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2016

DAILY IRONSUPPLEMENTATIONin adult women andadolescent girls

GUIDELINE


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Guideline:DAILY IRON SUPPLEMENTATIONIN ADULT WOMEN

AND ADOLESCENT GIRLS


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WHO Guideline: Daily iron supplementation in adult women and adolescent girlsIV

WHO Library Cataloguing-in-Publicaon Data

Guideline: Daily iron supplementaon in adult women and adolescent girls

1.Iron - administraon and dosage. 2.Anaemia - prevenon and control. 3.Adolescent girls. 4.Adult women.

5.Menstruang women. 6.Guideline. I.World Health Organizaon.

ISBN 978 92 4 151019 6 (NLM classicaon: WH 160)

© World Health Organizaon 2016

All rights reserved. Publicaons of the World Health Organizaon are available on the WHO web site ( www.

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The designaons employed and the presentaon of the material in this publicaon do not imply the expression

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Cover design and layout: Chris Yuen ([email protected])

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Printed by the WHO Document Producon Services, Geneva, Switzerland

SUGGESTED CITATION

Guideline: Daily iron supplementaon in adult women and adolescent girls. Geneva: World Health Organizaon;

2016.

http://www.who.int/http://www.who.int/mailto:[email protected]://www.who.int/about/licensing/copyright_form/en/index.htmlhttp://www.who.int/about/licensing/copyright_form/en/index.htmlhttp://../.pdfhttp://../.pdfhttp://www.who.int/about/licensing/copyright_form/en/index.htmlhttp://www.who.int/about/licensing/copyright_form/en/index.htmlmailto:[email protected]://www.who.int/http://www.who.int/


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WHO Guideline: Daily iron supplementation in adult women and adolescent girls VI

ACKNOWLEDGEMENTS

This guideline was coordinated by the World Health Organizaon (WHO) Evidence and Programme Guidance

Unit, Department of Nutrion for Health and Development. Dr Pura Rayco-Solon, Dr Lisa Rogers and Dr Juan

Pablo Peña-Rosas oversaw the preparaon of this document. WHO acknowledges the technical contribuons

of the following individuals (in alphabecal order): Dr Andrea Bosman, Ms Hala Boukerdenna, Dr Carmen

Casanovas, Dr Camila Chaparro, Dr Maria Nieves García-Casal, Dr Viviana Mangiaterra, Ms Zita Weise Prinzo

and Mr Gerardo Zamora. We also thank the peer-reviewers Ms Solange Durao, Dr Tran Khanh Van and Ms

Terrie Wefwafwa.

We would like to express our gratude to Dr Susan Norris from the WHO Guidelines Review Commiee

Secretariat and members of the Guidelines Review Commiee for their technical support throughout the

process. Thanks are also due to Ms Alma Alic from the Department of Compliance and Risk Management and

Ethics, for her support in the management of the conicts of interests procedures. Ms Jennifer Volonnino,

from the Evidence and Programme Guidance Unit, Department of Nutrion for Health and Development,

provided logisc support.

WHO gratefully acknowledges the technical input of the members of the WHO Steering Commiee for

Nutrion Guidelines Development and the WHO guidelines development groups, especially the chairs of the

meeng concerning this guideline, Ms Deena Alaasor and Dr Maria Elena del Socorro Jeerds.

Financial support WHO thanks the Bill & Melinda Gates Foundaon for providing nancial support for this work. The

Micronutrient Iniave and the Internaonal Micronutrient Malnutrion Prevenon and Control Program of

the United States Centers for Disease Control and Prevenon (CDC) provided nancial support to the Evidence

and Programme Guidance Unit, Department of Nutrion for Health and Development, for the commissioning

of systemac reviews of nutrion intervenons. Donors do not fund specic guidelines and do not parcipate

in any decision related to the guideline development process, including the composion of research quesons,

membership of the guideline groups, conduct and interpretaon of systemac reviews, or formulaon of

recommendaons.


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WHO Guideline: Daily iron supplementation in adult women and adolescent girls 1

WHO GUIDELINE1: DAILY IRON SUPPLEMENTATION IN ADULT WOMEN AND ADOLESCENT GIRLS

EXECUTIVE SUMMARYGlobally, one in three non-pregnant women, corresponding to almost 500 million women, were anaemic in

2011. Iron deciency is thought to contribute to at least half of the global burden of anaemia. Iron deciency

occurs following prolonged negave iron balance, the major causes of which include inadequate intake

(owing to insucient bioavailable iron in the diet or decreased iron absorpon), increased iron requirements

(for instance, during periods of growth) and chronic blood loss (from heavy hookworm infecon or menstrual

bleeding). In adolescent girls, menstrual blood losses, accompanied by rapid growth with expansion of the

red cell mass and increased ssue iron requirements, make them parcularly vulnerable to iron deciency

compared to male counterparts. This guideline reviews the evidence and updates the recommendaon for

daily iron supplementaon in menstruang adult women and adolescent girls.

Purpose of the guideline This guideline aims to help Member States and their partners in their eorts to make informed decisions onthe appropriate nutrion acons to achieve the Sustainable Development Goals (SDGs) ( 1 ), the global targets

set in the Comprehensive implementaon plan on maternal, infant and young child nutrion (2) and the

Global strategy for women’s, children’s and adolescent’s health (2016–2030) (3). The recommendaon in this

guideline is intended for a wide audience, including policy-makers, their expert advisers, and technical and

programme sta at organizaons involved in the design, implementaon and scaling-up of programmes for

anaemia prevenon and control, and in nutrion acons for public health. The recommendaon supersedes

those of previous WHO guidelines on iron supplementaon in menstruang adult women and adolescent

girls.

Guideline development methodology WHO developed the present evidence-informed recommendaon using the procedures outlined in the WHO

handbook for guideline development (4). The steps in this process included: (i) idencaon of priority quesonsand outcomes; (ii) retrieval of the evidence; (iii) assessment and synthesis of the evidence; (iv) formulaon

of recommendaon, including research priories; and planning for (v) disseminaon; (vi) implementaon,

equity and ethical consideraons; and (vii) impact evaluaon and updang of the guideline. The Grading

of Recommendaons Assessment, Development and Evaluaon (GRADE) methodology was followed ( 5 ), to

prepare evidence proles related to preselected topics, based on up-to-date systemac reviews.

The guideline development group consisted of content experts, methodologists and representaves of

potenal stakeholders and beneciaries. One guideline group parcipated in a meeng concerning this

guideline, held in Geneva, Switzerland, on 20–25 February 2010, where the guideline was scoped. A second

guideline group parcipated in a meeng held in Geneva, Switzerland, on 14–18 March 2011, to discuss

the safety of iron supplementaon in menstruang adult women and adolescent girls living in areas of high

malaria transmission, and a third meeng was convened in Geneva, Switzerland, on 23–26 June 2014, wherethe guideline was nalized. Three experts served as technical peer-reviewers of the dra guideline.

Available evidence The available evidence comprised a systemac review (6) that followed the procedures of the Cochrane

1 This publicaon is a World Health Organizaon (WHO) guideline. A WHO guideline is any document, whatever its tle, containing WHOrecommendaons about health intervenons, whether they be clinical, public health or policy intervenons. A standard guideline is

produced in response to a request for guidance in relaon to a change in pracce, or controversy in a single clinical or policy area, andis not expected to cover the full scope of the condion or public health problem. A recommendaon provides informaon about whatpolicy-makers, health-care providers or paents should do. It implies a choice between dierent intervenons that have an impact onhealth and that have ramicaons for the use of resources. All publicaons containing WHO recommendaons are approved by theWHO Guidelines Review Commiee.

https://sustainabledevelopment.un.org/topicshttps://sustainabledevelopment.un.org/topicshttps://sustainabledevelopment.un.org/topicshttps://sustainabledevelopment.un.org/topicshttp://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1http://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1http://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://www.who.int/kms/handbook_2nd_ed.pdf,http://www.who.int/kms/handbook_2nd_ed.pdf,http://www.who.int/kms/handbook_2nd_ed.pdf,http://www.who.int/kms/handbook_2nd_ed.pdf,http://www.gradeworkinggroup.org/http://www.gradeworkinggroup.org/http://www.gradeworkinggroup.org/http://www.gradeworkinggroup.org/http://community.cochrane.org/handbookhttp://community.cochrane.org/handbookhttp://www.gradeworkinggroup.org/http://www.gradeworkinggroup.org/http://www.who.int/kms/handbook_2nd_ed.pdf,http://www.who.int/kms/handbook_2nd_ed.pdf,http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1https://sustainabledevelopment.un.org/topicshttps://sustainabledevelopment.un.org/topics


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WHO Guideline: Daily iron supplementation in adult women and adolescent girls2

handbook for systemac reviews of intervenons (7) and assessed the eects of daily iron supplementaon

in menstruang adult women and adolescent girls. The reviews included individually randomized and cluster-

randomized controlled trials. All studies compared a group of non-pregnant adolescent girls and menstruangadult women who received daily oral iron supplementaon to a group that did not receive iron. The overall

quality of the available evidence for daily iron supplementaon in menstruang adult women and adolescent

girls was moderate for the crical outcomes of anaemia and iron deciency. No evidence was available for

the outcomes of iron deciency anaemia and malaria-related morbidity. The WHO Secretariat conducted an

addional search for evidence prior to the nalizaon of the guideline (November 2015), and did not idenfy

any addional relevant studies.

Recommendation 1

Daily iron supplementaon is recommended as a public health intervenon in menstruang adult women

and adolescent girls, living in sengs where anaemia is highly prevalent (≥40% anaemia prevalence),2 for the

prevenon of anaemia and iron deciency (strong recommendaon, moderate quality of evidence).

Suggested scheme for daily iron supplementation in adult women and adolescent girls

TARGET GROUP Menstruang adult women and adolescent girls (non-pregnant females in thereproducve age of group)

SUPPLEMENT COMPOSITION 30–60 mg elemental irona

SUPPLEMENT FORM Tablets

FREQUENCY Daily

DURATION Three consecuve months in a year

SETTINGSWhere the prevalence of anaemia in menstruang adult women and adolescent

girls is 40% or higherb

a 30–60 mg of elemental iron equals 150–300 mg of ferrous sulfate heptahydrate, 90–180 mg of ferrous fumarate or 250–500 mg offerrous gluconate.

b In the absence of prevalence data in this group, consider proxies for hig h risk of anaemia. For the most recent esmates, visit theWHO - hosted Vitamin and Mineral Nutrion Informaon System (VMNIS) ( 8 ).

Remarks The remarks in this secon are intended to give some consideraons for implementaon of the

recommendaon, based on the discussion of the guideline development group.

• Daily oral iron supplementaon is a prevenve strategy for implementaon at the populaon level.

If a menstruang woman or adolescent girl is diagnosed with anaemia, naonal guidelines for the

treatment of anaemia should be followed.

• Daily iron supplementaon should be considered in the context of other intervenons containing

iron (fored foods, mulple micronutrient powders, lipid-based nutrient supplements).

1 This recommendaon supersede those of previous WHO guidelines on iron supplementaon in menstruang adult women andadolescent girls.

2 Where the prevalence of anaemia is 40% or higher in this age group. For the latest esmates, please refer to the WHO-hosted Vitaminand Mineral Nutrion Informaon System (VMNIS) ( 8 ).

http://community.cochrane.org/handbookhttp://community.cochrane.org/handbookhttp://www.who.int/vmnis/enhttp://www.who.int/vmnis/en/http://www.who.int/vmnis/enhttp://www.who.int/vmnis/enhttp://www.who.int/vmnis/enhttp://www.who.int/vmnis/enhttp://www.who.int/vmnis/enhttp://www.who.int/vmnis/en/http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://www.who.int/vmnis/en/http://www.who.int/vmnis/en/http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://www.who.int/vmnis/en/http://www.who.int/vmnis/enhttp://community.cochrane.org/handbook


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• The selecon of the most appropriate delivery plaorm should be context specic, with the aim

of reaching the most vulnerable populaons and ensuring a mely and connuous supply of

supplements.

• All women, from the moment they begin trying to conceive unl 12 weeks of gestaon, should

take a folic acid supplement. Daily oral iron and folic acid supplementaon should be part of

roune antenatal care, begun as early as possible and connued throughout pregnancy. Where

the prevalence of anaemia in pregnant women is high (40% or more), supplementaon should

connue for 3 months in the postpartum period ( 10 , 11 ).

Research priorities Discussions between the members of the WHO guideline development group and the external review group

highlighted the limited evidence available in some knowledge areas, mering further research on iron

supplementaon in menstruang adult women and adolescent girls, parcularly in the following areas:

• the opmal dose, schedule and duraon of iron supplementaon; the eect of dierent doses and

duraon of iron supplementaon on dierent severity, prevalence or causes of anaemia in all WHO

regions;

• addional data on the safety of iron supplementaon (liver damage; iron overload aer connuing

the supplementaon programme for a number of years; iron supplementaon given in conjuncon

with other intervenons; insulin resistance; eects on non-anaemic or non-iron-decient women

and adolescent girls);

• the eect of adding other micronutrients to the iron supplement on haemoglobin concentraons

and the prevalence of anaemia;

• implementaon research on eecve behaviour-change strategies for sustained adherence andinnovave delivery mechanisms for iron supplements;

• addional long-term studies on funconal outcomes (e.g. exercise performance and producvity);

• cost, cost–benet and feasibility analysis of the distribuon of iron supplementaon to be taken

daily or intermiently among menstruang adult women and adolescent girls.

http://apps.who.int/iris/bitstream/10665/69735/1/a91272.pdfhttp://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf?ua=1http://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf?ua=1http://apps.who.int/iris/bitstream/10665/69735/1/a91272.pdf


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WHO GUIDELINE1: DAILY IRON SUPPLEMENTATION IN ADULT WOMEN AND ADOLESCENT GIRLS

SCOPE AND PURPOSEThis guideline provides a global, evidence-informed recommendaon on daily iron supplementaon in menstruang

adult women and adolescent girls, as a public health intervenon for the prevenon of anaemia and iron deciency.

The guideline aims to help Member States and their partners in their eorts to make informed decisions on

the appropriate nutrion acons to achieve the Sustainable Development Goals (SDGs) ( 1 ), in parcular, Goal

2: End hunger, achieve food security and improved nutrion and promote sustainable agriculture. It will also

support Member States in their eorts to achieve the global targets set in the Comprehensive implementaon

plan on maternal, infant and young child nutrion, as endorsed by the Sixty-h World Health Assembly in

2012, in resoluon WHA65.6 ( 2 ), and the Global strategy for women’s, children’s, and adolescent’s health

(2016–2030) (3).

The recommendaon in this guideline is intended for a wide audience, including policy-makers, their expertadvisers, and technical and programme sta at government instuons and organizaons involved in the design,

implementaon and scaling-up of programmes for anaemia prevenon and control, and in nutrion acons for public

health. This guideline is intended to contribute to discussions among stakeholders when selecng or priorizing

intervenons to be undertaken in their specic context. This document presents the key recommendaon and a

summary of the supporng evidence.

BACKGROUND

Globally, one in three non-pregnant women, corresponding to almost 500 million women, were anaemic in

2011 ( 12 ). Iron deciency is thought to contribute to at least half of the global burden of anaemia, though this

proporon can vary widely and is very context specic. Iron deciency occurs following prolonged negave

iron balance, the major causes of which include inadequate intake (owing to insucient bioavailable iron in

the diet or decreased iron absorpon), increased iron requirements (for instance, during periods of growth)

and chronic blood loss (from heavy hookworm infecon or menstrual bleeding) ( 13 ).

From the me that girls enter menarche unl menopause, women are at high risk of iron deciency, owing

to menstrual blood losses. In adolescent girls, menstrual blood losses, accompanied by rapid growth with

expansion of the red cell mass and increased ssue iron requirements, make them parcularly vulnerable to

iron deciency compared to their male counterparts (14).

Public health intervenons that improve iron status in populaons include nutrion counselling that promotes

diet diversity and food combinaons that improve iron absorpon; forcaon of staple or rounely

consumed foods with iron; point-of-use forcaon with mulple micronutrients including iron; treatment of

preventable causes of iron losses such as hookworm infestaon; and iron supplementaon.

In 2001, WHO recommended prevenve supplementaon of 60 mg/day iron for three months for non-pregnant

women of reproducve age in sengs where the prevalence of anaemia is above 40% ( 13 ). This guideline

reviews the evidence and updates the recommendaon for daily iron supplementaon in menstruang adult

women and adolescent girls.

1 This publicaon is a World Health Organizaon (WHO) guideline. A WHO guideline is any document, whatever its tle, containing WHOrecommendaons about health intervenons, whether they be clinical, public health or policy intervenons. A standard guideline is

produced in response to a request for guidance in relaon to a change in pracce, or controversy in a single clinical or policy area, and isnot expected to cover the full scope of the condion or public health problem. A recommendaon provides informaon about what policy-makers, health-care providers or paents should do. It implies a choice between dierent intervenons that have an impact on health andthat have ramicaons for the use of resources. All publicaons containing WHO recommendaons are approved by the WHO GuidelinesReview Commiee.

http://sustainabledevelopment.un.org/topics,%20accessed%204%20December%202015http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_11-en.pdf?ua=1http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_11-en.pdf?ua=1https://sustainabledevelopment.un.org/topicshttp://who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://www.who.int/nutrition/publications/micronutrients/global_prevalence_anaemia_2011/en/http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1http://www.who.int/nutrition/publications/micronutrients/global_prevalence_anaemia_2011/en/http://who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1https://sustainabledevelopment.un.org/topicshttp://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_11-en.pdf?ua=1http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_11-en.pdf?ua=1http://sustainabledevelopment.un.org/topics,%20accessed%204%20December%202015


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OBJECTIVES

The recommendaon in this guideline supersedes those of previous WHO guidelines on iron supplementaon,

such as Iron deciency anaemia: assessment, prevenon, and control. A guide for programme managers ( 13 ),

where they pertain specically to daily oral iron supplementaon among menstruang adult women and

adolescent girls (non-pregnant females in the reproducve age group). This guideline complements the WHO

Guideline: intermient iron and folic acid supplementaon in menstruang women ( 9 ), which is applicable to

sengs where the prevalence of anaemia among non-pregnant women of reproducve age is 20% or higher.

SUMMARY OF AVAILABLE EVIDENCE

The evidence that informed the recommendaon on daily iron supplementaon in menstruang adult women

and adolescent girls is based on a systemac review of women and adolescent girls beyond menarche and

prior to menopause who were not pregnant or lactang and did not have any condion that impedes the

presence of menstrual periods (6). The systemac review also included studies for which results for girls and

women aged between 12 and 50 years (plausible age range for menstruaon) could be extracted separately, orin which more than half of the parcipants fullled this criterion. The review excluded studies on populaons

with condions aecng iron metabolism, intesnal malabsorpon condions, ongoing excessive blood loss

(including ongoing blood donaons), inammatory bowel disease, cancer, chronic congesve cardiac failure,

chronic renal failure, chronic liver failure or chronic infecous disease, or hospitalized or il l paents.

The review included randomized controlled trials comparing daily iron supplementaon (with or without a

co-intervenon such as folic acid or vitamin C) to placebo or supplementaon without iron. Daily

supplementaon was dened as receiving iron for at least 5 days in a week.

The systemac review searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE,

Embase (Ovid), CINAHL (EBSCOHost), Conference Proceedings Citaon Index – Science (CPCI-S), Science

Citaon Index (SCI), POPLINE, IMSEAR, LILACS, IMERMR, African Index Medicus, and the following databasesfor grey literature: WorldCat, DART-Europe E-theses Portal, Australasian Digital Theses Program, Theses

Canada Portal, and ProQuest-Dissertaons and Theses. The search for evidence was done in September 2014.

The review included 62 trials involving 7523 women and adolescent girls (3951 in the intervenon arm and

3572 in the control arm). These studies were conducted in 24 countries with representaon from low-, middle-

and high-income countries. The sample size ranged between 10 and 1390 parcipants. Overall, the sample

size tended to be small; 96% of the studies included fewer than 400 women and adolescent girls.

Menstruang women and adolescent girls who received daily iron supplementaon had a lower risk for the

crical outcomes of anaemia (risk rao [RR]: 0.34; 95% condence interval [CI]: 0.20 to 0.57; 9 trials, n = 2905)

and iron deciency (RR: 0.61; 95% CI: 0.47–0.77; 6 trials, n = 1033) compared to menstruang women and

adolescent girls receiving placebo or supplementaon without iron. No trials reported on the outcome of irondeciency anaemia.

There were 48 studies that reported on haemoglobin concentraon. The large number of studies and parcipants

for this outcome allowed for evaluaon of subgroup dierences. Haemoglobin levels were signicantly higher

among those given iron supplementaon compared to those given placebo or supplementaon without iron

(mean dierence [MD]: 5.61 g/L; 95% CI: 4.44 to 6.79; 48 trials, n = 6390). There was no evidence of dierence

in the eect of iron supplementaon compared to placebo or supplementaon without iron on haemoglobin

by dose (100 mg; test for subgroup dierence χ 2 = 1.32; P = 0.72) or duraon

(3 months; test for subgroup dierence χ 2 = 4.12; P = 0.13).

Only one study specically reported being performed in a malaria-endemic area (15). One of the two villages

http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=http://apps.who.int/iris/bitstream/10665/44648/1/9789241502009_eng.pdfhttp://apps.who.int/iris/bitstream/10665/44648/1/9789241502009_eng.pdfhttp://apps.who.int/iris/bitstream/10665/44648/1/9789241502009_eng.pdfhttp://apps.who.int/iris/bitstream/10665/44648/1/9789241502009_eng.pdfhttp://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1


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haemoglobin concentraon had high quality. The eect sizes of the intervenon on the outcomes

with data were large. There was no evidence presented for malaria-related morbidity.

• Adherence may be a concern if the intervenon is perceived as non-essenal. Barriers to

adherence may need to be addressed (for instance, with behaviour-change communicaon if

the intervenon is not perceived as necessary among the beneciaries). Among the studies that

measured compliance, between 65% and 98% of the tablets were consumed, with no dierence

between the iron supplementaon and control arms.

• Costs will largely be determined by operaonal challenges rather than the cost of the supplement

itself. Distribuon of daily iron supplementaon in this populaon, parcularly in sengs where

health-care intervenons do not specically target menstruang adult women and adolescent girls,

may entail operaonal challenges. The resources and investments needed should be considered in

designing programmes to reach this populaon.

REMARKSThe remarks in this secon are intended to give some consideraons for implementaon of the

recommendaon, based on the discussion of the guideline development group.

• Daily oral iron supplementaon is a prevenve strategy for implementaon at the populaon

level. If a menstruang woman is diagnosed with anaemia, naonal guidelines for the treatment of

anaemia should be followed.

• The prevalence of anaemia should be considered when determining the dose, duraon and

frequency of iron supplementaon among menstruang adult women and adolescent girls. If

the prevalence of anaemia is less than 40%, other guidelines are available for consideraon. For

instance, for anaemia prevalence of 20–40%, intermient regimens of iron supplementaon may

be an opon ( 9 ).

• Daily iron supplementaon should be considered in the context of other intervenons containing

iron (fored foods, mulple micronutrient powders, lipid-based nutrient supplements).

• The selecon of the most appropriate delivery plaorm should be context specic, with the aim

of reaching the most vulnerable populaons and ensuring a mely and connuous supply of

supplements.

• All women, from the moment they begin trying to conceive unl 12 weeks of gestaon, should

take a folic acid supplement. Daily oral iron and folic acid supplementaon should be part of

roune antenatal care, begun as early as possible and connued throughout pregnancy. Where

the prevalence of anaemia in pregnant women is high (40% or more), supplementaon shouldconnue for 3 months in the postpartum period ( 10 , 11 ).

Iron supplementaon is the customary intervenon that comes to mind to address anaemia but it should

ideally form only a part of a comprehensive, integrated programme for anaemia reducon and addressing

women’s health across the life-course. Intervenons for decreasing iron deciency or iron deciency anaemia

should include nutrion counselling that promotes diet diversity and food combinaons that improve iron

absorpon; malaria-control programmes, including intermient prevenve treatment of malaria in pregnancy

and in children, as well as use of inseccide-treated bednets; control of parasic infecons; and improvement

in sanitaon. Once, a woman is pregnant, antenatal programmes help promote adequate gestaonal weight

gain and other complementary measures for monitoring, prevenon and control of anaemia, such as screening

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for anaemia, deworming treatment and a referral system for the management of cases of severe anaemia.

Delayed umbilical cord clamping is eecve in prevenng iron deciency in infants and young children. Other

opons include forcaon of staple foods and provision of micronutrient powders, including iron.

RESEARCH PRIORITIES

Discussions between the members of the WHO guideline development group and the external review group

highlighted the limited evidence available in some knowledge areas, mering further research on iron

supplementaon in menstruang adult women and adolescent girls, parcularly in the following areas:

• the opmal dose, schedule and duraon of iron supplementaon; the eect of dierent doses and

duraon of iron supplementaon on dierent severity, prevalence or causes of anaemia in all WHO

regions;

• addional data on the safety of iron supplementaon (liver damage; iron overload aer connuing

the supplementaon programme for a number of years; iron supplementaon given in conjuncon

with other intervenons; insulin resistance; eects in non-anaemic or non-iron-decient

menstruang adult women and adolescent girls);

• the eect of adding other micronutrients to the iron supplement on haemoglobin concentraons

and the prevalence of anaemia;

• implementaon research on eecve behaviour-change strategies for sustained adherence and

innovave delivery mechanisms for iron supplements;

• addional long-term studies on funconal outcomes (e.g. exercise performance and producvity)

• cost, cost–benet and feasibility analysis of the distribuon of iron supplementaon to be takendaily or intermiently among menstruang adult women and adolescent girls.

DISSEMINATION, IMPLEMENTATION AND ETHICAL CONSIDERATIONS

Dissemination The current guideline will be disseminated through electronic media, such as slide presentaons and the

World Wide Web, through the WHO Nutrion mailing lists, social media, the WHO nutrion website

(18) or the

WHO e-Library of Evidence for Nutrion Acons (eLENA) (19). eLENA compiles and displays WHO guidelines

related to nutrion, along with complementary documents such as systemac reviews and other evidence

that informed the guidelines; biological and behavioural raonales; and addional resources produced by

Member States and global partners. In addion, the guideline will be disseminated through a broad network

of internaonal partners, including WHO country and regional oces, ministries of health, WHO collaborang

centres, universies, other United Naons agencies and nongovernmental organizaons. Derivave productssuch as summaries and collaon of recommendaons related to iron supplementaon will be developed for

a more tailored product that is useful for end-users.

Parcular aenon will be given to improving access to these guidelines for stakeholders that face more,

or specic, barriers in access to informaon, or to those who play a crucial role in the implementaon of

the guideline recommendaon, for example, policy-makers and decision-makers at subnaonal level that

disseminate the contents of the guideline, and health workers and educaon sta that contribute to the

delivery of the intervenon. Disseminated informaon may emphasize the benets of iron supplementaon

in menstruang adult women and adolescent girls in populaons or regions presenng an important risk of

anaemia and iron deciency. In addion, these guidelines and the informaon contained therein should be

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accessible to the nongovernmental organizaons working in coordinaon with naonal authories on the

implementaon of nutrion intervenons, especially those related to the prevenon and control of anaemia.

in menstruang adult women and adolescent girls.

Implementation As this is a global guideline, it should be adapted to the context of each Member State. Prior to implementaon,

a public health programme that includes the provision of iron supplements to menstruang adult women

and adolescent girls should have well-dened objecves that take into account available resources, exisng

policies, suitable delivery plaorms and suppliers, communicaon channels, and potenal stakeholders.

Ideally, iron supplementaon should be implemented as part of an integrated programme on adolescent and

reproducve health, which includes addressing micronutrient deciencies.

Considering the experiences of menstruang adult women and adolescent girls with the intervenon is

also a relevant implementaon consideraon: ongoing assessment of the accessibility and acceptability

of the intervenon can inform programme design and development, in order to increase adherence tosupplementaon and beer assess the impact of the programme. This is parcularly relevant in sengs where

the prevailing social norms and determinants may set unequal condions and opportunies for dierent

groups. For instance, in some sengs, social percepons around ethnicity and race intervene in how certain

populaon groups access and use an intervenon.

Supplementaon programmes in menstruang adult women and adolescent girls need to be carefully

designed, based on locally available evidence and experience. These can include data that can inform

the implementaon strategies on procurement and supply-chain issues, opmal distribuon channels,

behaviour-change communicaon and specic strategies to idenfy and reach the most vulnerable adult

women and adolescent girls. These are parcularly important in the absence of a well-funconing health-care

system that reaches this populaon.

Accessing hard-to-reach populaon groups is extremely important during implementaon stages, as it

contributes to prevenng or tackling health inequies. Appropriate surveillance and monitoring systems can

thus provide informaon on the impact of the disseminated guidelines and their implementaon (including

informaon on the adequacy of funding and the eecveness of the supply chain and distribuon channels).

Regulatory considerations The WHO Essenal Medicines List (EML) compiles medicines that sasfy the priority health-care needs of

populaons and are selected with due regard to disease prevalence, evidence on ecacy and safety, and

comparave cost-eecveness ( 20 ). Hence, the WHO EML is used by countries for the development of their

own naonal essenal medicines lists. The quality criteria for vitamins and minerals included in the WHO EML

take into account Food and Agriculture Organizaon of the United Naons/WHO standards ( 21 ).

Monitoring and evaluation of guideline uptake and adaptation A plan for monitoring and evaluaon with appropriate indicators, including equity-oriented indicators,

is encouraged at all stages ( 22 ). The impact of this guideline can be evaluated within countries (i.e.

monitoring and evaluaon of the programmes implemented at naonal or regional scale) and across

countries (i.e. adopon and adaptaon of the guideline globally). The WHO Department of Nutrion for

Health and Development, Evidence and Programme Guidance Unit, jointly with the United States Centers

for Disease Control and Prevenon (CDC) Internaonal Micronutrient Malnutrion Prevenon and Control

(IMMPaCt) programme, and with input from internaonal partners, has developed a generic logic model

for micronutrient intervenons in public health ( 23), to depict the plausible relaonships between inputs

and expected SDGs, by applying the micronutrient programme evaluaon theory. Member States can adjust

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the model and use it in combinaon with appropriate indicators, for designing, implemenng, monitoring

and evaluang the successful escalaon of nutrion acons in public health programmes. Addionally, the

WHO/CDC eCatalogue of indicators for micronutrient programmes

(24), which ulizes the logic model, has beendeveloped as a user-friendly and non-comprehensive web resource for those acvely engaged in providing

technical assistance in monitoring, evaluaon and surveillance of public health programmes implemenng

micronutrient intervenons. Indicators for iron supplementaon are currently being developed and, once

complete, will provide a list of potenal indicators with standard denions that can be selected, downloaded

and adapted to a local programme context. The eCatalogue will serve as a repository of indicators to monitor

and evaluate micronutrient intervenons. While it does not provide guidance for designing or implemenng

a monitoring or evaluaon system in public health, some key indicators may include useful references for that

purpose.

Since 1991, WHO has hosted the VMNIS micronutrients database ( 8 ). Part of WHO’s mandate is to assess

the micronutrient status of populaons, monitor and evaluate the impact of strategies for the prevenon

and control of micronutrient malnutrion, and track related trends over me. The Evidence and Programme

Guidance Unit of the Department of Nutrion for Health and Development manages the VMNIS micronutrient

database, through a network of regional and country oces, and in close collaboraon with naonal health

authories.

For evaluaon at the global level, the WHO Department of Nutrion for Health and Development has

developed a web-based WHO Global Targets Tracking Tool that allows users to explore dierent scenarios

to achieve the rates of progress required to meet the 2025 global nutrion targets, including target 2: 50%

reducon of anaemia in women of reproducve age, as well as a centralized plaorm for sharing informaon

on nutrion acons in public health pracce implemented around the world. By sharing programmac

details, specic country adaptaons and lessons learnt, this plaorm will provide examples of how guidelines

are being translated into acons. The Global database on the Implementaon of Nutrion Acon (GINA) (25)

provides valuable informaon on the implementaon of numerous nutrion policies and intervenons. The

use of GINA has grown steadily since its launch in November 2012.

An ecient system for the roune collecon of relevant data, including relevant determinants of health,

therapeuc adherence, and measures of programme performance, is crical to ensure supplementaon

programmes are eecve and sustained, and drivers to the achievement of the right to health for all populaon

groups. Monitoring dierences across groups in terms of accessibility, availability, acceptability and the quality

of the intervenons contributes to the design of beer public health programmes. The creaon of indicators

for monitoring can be informed by the approaches of social determinants of health ( 26), so inequies can

be idened and tackled. Appropriate monitoring requires suitable data, so eorts to collect and organize

informaon on the implementaon are also fundamental.

GUIDELINE DEVELOPMENT PROCESS

This guideline was developed in accordance with the WHO evidence-informed guideline-development

procedures, as outlined in the WHO handbook for guideline development (4).

Advisory groups The WHO Steering Commiee for Nutrion Guidelines Development (see Annex 3), led by the Department

of Nutrion for Health and Development, was established in 2009 with representaves from all WHO

departments with an interest in the provision of scienc nutrion advice. The WHO Steering Commiee for

Nutrion Guidelines Development met twice yearly and both guided and provided overall supervision of the

guideline development process. Two addional groups were formed: a guideline development group and an

external review group.

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One guideline development group parcipated in the development of this guideline (see Annex 4). Its role

was to advise WHO on the choice of important outcomes for decision-making and on interpretaon of the

evidence. The WHO guideline development group – nutrion acons includes experts from various WHOexpert advisory panels and those idened through open calls for specialists, taking into consideraon a

balanced mix of sex, mulple disciplinary areas of experse, and representaon from all WHO regions. Eorts

were made to include content experts, methodologists, representaves of potenal stakeholders (such as

managers and other health professionals involved in the health-care process), and ministries of health from

Member States. Representaves of commercial organizaons may not be members of a WHO guideline group.

The nal dra guideline was peer-reviewed by three content experts, who provided technical feedback. These

peer-reviewers (see Annex 7) were idened through various expert panels within and outside WHO ( 5 , 18,

27 ).

Scope of the guideline, evidence appraisal and decision-making

An inial set of quesons (and the components of the quesons) to be addressed in the guideline formed thecrical starng point for formulang the recommendaon. The quesons were draed by technical sta at

the Evidence and Programme Guidance Unit, Department of Nutrion for Health and Development, based on

the policy and programme guidance needs of Member States and their partners. The populaon, intervenon,

control, outcomes (PICO) format was used (see Annex 8). The quesons were discussed and reviewed by

the WHO Steering Commiee for Nutrion Guidelines Development and the guideline development group –

nutrion acons, and were modied as needed.

A meeng of the guideline development group – nutrion acons was held on 14–16 March 2010, in Geneva,

Switzerland, to nalize the scope of the quesons and rank the outcomes and populaons of interest for the

recommendaon on iron supplementaon. The guideline development group discussed the relevance of the

quesons and modied them as needed. The group scored the relave importance of each outcome from 1

to 9 (where 7–9 indicated that the outcome was crical for a decision, 4–6 indicated that it was important and1–3 indicated that it was not important). The nal key quesons on this intervenon, along with the outcomes

that were idened as crical for decision-making, are listed in PICO format in Annex 8.

A systemac review (6) was used to summarize and appraise the evidence using the Cochrane methodology

( 7 ) for randomized controlled trials and observaonal studies. Evidence summaries were prepared according

to the (GRADE) approach to assess the overall quality of the evidence ( 5 , 16, 17). GRADE considers the

study design; the limitaons of the studies in terms of their conduct and analysis; the consistency of the

results across the available studies; the directness (or applicability and external validity) of the evidence with

respect to the populaons, intervenons and sengs where the proposed intervenon may be used; and the

precision of the summary esmate of the eect.

Both the systemac review and the GRADE evidence proles for each of the crical outcomes were used fordraing this guideline. The dra recommendaon was discussed by the WHO Steering Commiee for Nutrion

Guidelines Development and in consultaons with the WHO guideline development group – nutrion acons,

held on 14–18 March 2011 and 23–26 June 2014 in Geneva, Switzerland.

The procedures for decision-making are established at the beginning of the meengs, including a minimal set

of rules for agreement and decision-making documentaon. At least two thirds of the guideline development

group should be present for an inial discussion of the evidence and proposed recommendaon and

remarks. The members of the guideline development group secretly noted the direcon and strength of

the recommendaon, using a form designed for this purpose that also included a secon for documenng

their views on (i) the desirable and undesirable eects of the intervenon; (ii) the quality of the available

evidence; (iii) values and preferences related to the intervenon in dierent sengs; and (iv) the cost of

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opons available to health-care workers in dierent sengs (see Annex 2). Abstenons were not allowed.

The process was improved with the availability of a predened link to an online form prepared using survey

soware. Subsequent deliberaons among the members of the guideline development group were of privatecharacter. The WHO Secretariat collected the forms and disclosed a summary of the results to the guideline

development group. If there was no unanimous consensus (primary decision rule), more me was given for

deliberaons and a second round of online vong took place. If no unanimous agreement was reached, a two-

thirds vote of the guideline development group was required for approval of the proposed recommendaon

(secondary decision rule). Divergent opinions could be recorded in the guideline. The results from vong

forms are kept on le by WHO for up to 5 years. Although there was no unanimous consensus, more than 80%

of the vong members of the guideline development group decided that the recommendaon was strong.

WHO sta present at the meeng, as well as other external technical experts involved in the collecon and

grading of the evidence, were not allowed to parcipate in the decision-making process. Two co-chairs

with experse in managing group processes and interpreng evidence were nominated at the opening of

the consultaon, and the guideline development group approved the nominaon. Members of the WHO

Secretariat were available at all mes, to help guide the overall meeng process, but did not vote and did not

have veto power.

MANAGEMENT OF COMPETING INTERESTS

According to the rules in the WHO Basic documents ( 28 ) and the processes recommended in the WHO

handbook for guideline development ( 4 ), all experts parcipang in WHO meengs must declare any interests

relevant to the meeng, prior to their parcipaon. The responsible technical ocer and the relevant

departments reviewed the declaraons-of-interests statements for all guideline development group members

before nalizaon of the group composion and invitaon to aend a guideline development group meeng.

All members of the guideline development group, and parcipants of the guideline development meengs,

submied a declaraon-of-interests form, along with their curriculum vitae, before each meeng. Parcipants

of the guideline development group meengs parcipated in their individual capacity and not as instuonalrepresentaves. In addion, they verbally declared potenal conicts of interests at the beginning of each

meeng. The procedures for management of compeng interests strictly followed the WHO guidelines for

declaraon of interests. The management of the perceived or real conicts of interests declared by the

members of the guideline group is summarized next.1

Dr Beverley-Ann Biggs declared that the University of Melbourne received funding from the Naonal Health

and Medical Research Council and Australian Research Council for research on intermient iron and folic

acid supplementaon in pregnancy, conducted in collaboraon with the Research and Training Center for

Community Development, the Key Centre for Women’s Health and the Murdoch Children’s’ Research Instute.

It was agreed that she could parcipate fully in the deliberaons and decision-making on this guideline.

Dr Luz Maria De-Regil declared that her present employer is an internaonal nongovernmental organizaondevoted to the improvement of micronutrient status among infants, children and women. These acvies

are primarily nanced by the government of Canada. The Micronutrient Iniave is a leading organizaon

working exclusively to eliminate vitamin and mineral deciencies in the world’s most vulnerable populaons.

It was decided that Dr De-Regil could be a member of the guideline development group and would disclose

her interests and the interests of her organizaon in the relevant guidelines related to micronutrient

intervenons. She parcipated in the deliberaons related to the recommendaon for iron supplementaon

but recused herself from vong on this guideline.

1 A conict-of-interest analysis must be performed whenever WHO relies on the independent advice of an expert in order to take adecision or to provide recommendaons to Member States or other stakeholders. The term “conict of interest” means any interest

declared by an expert that may aect, or be reasonably perceived to aect, the expert’s objecvity and independence in providingadvice to WHO. WHO’s conict-of-interest rules are designed to avoid potenally compromising situaons that could undermine orotherwise aect the work of the expert, the commiee or the acvity in which the expert is involved, or WHO as a whole. Consequently,

the scope of the inquiry is any interest that could reasonably be perceived to aect the funcons that the expert is performing.

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Dr Lynnee Neufeld declared that her current employer has received funding in the past 4 years for research

and programming related to iron supplementaon. At the moment she is not leading any of these iniaves. In

a prior posion she held with MI, she commissioned research related to iron supplementaon. It was decided

that Dr Neufeld could be a member of the guideline development group and had to disclose her and her

organizaon’s interests in the relevant guidelines related to micronutrient intervenons. She could parcipate

in the deliberaons but she recused herself from the decision-making (vong) on the recommendaon related

to iron supplementaon.

Dr Héctor Bourges Rodriguez declared being chair of the execuve board of the Danone Instute in Mexico

(DIM), a non-prot organizaon promong research and disseminaon of scienc knowledge in nutrion,

and receiving funds as chair honorarium from DIM. Some of the acvies of DIM may generally relate to

nutrion and are funded by Danone Mexico, a food producer. It was agreed that he could parcipate fully in

the deliberaons and decision-making on this guideline.

All other members made a verbal declaraon of their interests and it was considered that they were not

relevant for this guideline on iron supplementaon in adult women and adolescent girls. External resource

persons also declared their interests but did not parcipate in the deliberaons or decision-making process.

PLANS FOR UPDATING THE GUIDELINE

The WHO Secretariat will connue to follow the research development in the area of oral iron supplementaon

in menstruang adult women and adolescent girls in malaria-endemic and non-malaria endemic sengs,

parcularly for quesons in which the quality of evidence was found to be low or very low. If the guideline

merits an update, or if there are concerns about the validity of the guideline, the Department of Nutrion for

Health and Development will coordinate the guideline update, following the formal procedures of the WHO

handbook for guideline development (4).

As the guideline nears the 10-year review period agreed by the guideline development group, the Departmentof Nutrion for Health and Development at the WHO headquarters in Geneva, Switzerland, along with its

internal partners, will be responsible for conducng a search for new evidence.

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19. World Health Organizaon, e-Library of Evidence for Nutrion Acons (eLENA) Guideline development process (hp://www.who.int/elena/about/guidelines_process/en/, accessed 4 December 2015).

20. World Health Organizaon. Essenal medicines and health products (hp://www.who.int/medicines/services/essmedi-

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21. World Health Organizaon (WHO) and Food and Agriculture Organizaon of the United Naons (FAO). Codex Alimentarius:

Guidelines for vitamin and mineral food supplements. Geneva: World Health Organizaon and the Food and Agriculture

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Health Organizaon; 2013 (WHO/EMP/MPC/2013.1; hp://apps.who.int/medicinedocs/documents/s20188en/s20188en.

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23. Centers for Disease Control and Prevenon (CDC). Division of Nutrion, Physical Acvity, and Obesity. Internaonal Micronu-

trient Malnutrion Prevenon and Control (IMMPaCt) (hp://www.cdc.gov/immpact/, accessed 4 December 2015).

24. World Health Organizaon. eCatalogue of indicators for micronutrient programmes ( hps://extranet.who.int/indcat/, ac-

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26. Handbook on health inequality monitoring: with a special focus on low- and middle-income countries. Geneva: World Health

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bd/, accessed 4 December 2015).

http://www.who.int/nutrition/enhttp://www.who.int/elena/about/guidelines_process/enhttp://www.who.int/elena/about/guidelines_process/enhttp://www.who.int/medicines/services/essmedicines_def/enhttp://www.who.int/medicines/services/essmedicines_def/enhttp://www.who.int/medicines/services/essmedicines_def/enhttp://www.codexalimentarius.org/standards/list-of-standards/en/?provide=standards&orderField=fullReference&sort=asc&num1=CAChttp://www.codexalimentarius.org/standards/list-of-standards/en/?provide=standards&orderField=fullReference&sort=asc&num1=CAChttp://apps.who.int/medicinedocs/documents/s20188en/s20188en.pdfhttp://apps.who.int/medicinedocs/documents/s20188en/s20188en.pdfhttp://www.cdc.gov/immpacthttps://extranet.who.int/indcathttp://www.who.int/nutrition/gina/enhttp://www.who.int/nutrition/gina/enhttp://www.who.int/nutrition/gina/enhttp://apps.who.int/iris/bitstream/10665/85345/1/9789241548632_eng.pdfhttp://www.unscn.org/http://apps.who.int/gb/bdhttp://apps.who.int/gb/bdhttp://apps.who.int/gb/bdhttp://apps.who.int/gb/bdhttp://www.unscn.org/http://apps.who.int/iris/bitstream/10665/85345/1/9789241548632_eng.pdfhttp://www.who.int/nutrition/gina/enhttp://www.who.int/nutrition/gina/enhttps://extranet.who.int/indcathttp://www.cdc.gov/immpacthttp://apps.who.int/medicinedocs/documents/s20188en/s20188en.pdfhttp://apps.who.int/medicinedocs/documents/s20188en/s20188en.pdfhttp://www.codexalimentarius.org/standards/list-of-standards/en/?provide=standards&orderField=fullReference&sort=asc&num1=CAChttp://www.codexalimentarius.org/standards/list-of-standards/en/?provide=standards&orderField=fullReference&sort=asc&num1=CAChttp://www.who.int/medicines/services/essmedicines_def/enhttp://www.who.int/medicines/services/essmedicines_def/enhttp://www.who.int/elena/about/guidelines_process/enhttp://www.who.int/elena/about/guidelines_process/enhttp://www.who.int/nutrition/en


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ANNEX 2. SUMMARY OF THE CONSIDERATIONS OF THE MEMBERS OF THE GUIDELINE DEVELOPMENT GROUP FOR DETER-MINING THE STRENGTH OF THE RECOMMENDATION FOR DAILY ORAL IRON SUPPLEMENTATION IN MENSTRUATING ADULT

WOMEN AND ADOLESCENT GIRLS

QUALITY OF EVIDENCE: Anaemia and iron deciency had moderate-quality evidence. Theeect sizes of the intervenon on these outcomes were large.

The quality of the evidence for the eect on haemoglobin is high

though there is currently no evidence on the outcome of iron

deciency anaemia. Although the evidence of either loose or hard

stools is of high quality, the quality of the evidence for adverse ef -

fects or gastrointesnal eects in general is low or very low.

VALUES AND PREFERENCES: Adherence may be a concern. If the intervenon is perceived as

non-essenal, there may be lile demand for it.

Where access to health facilies is limited, as in many rural areas,

the problem may be more prevalent. Inequies in access may thus

negavely aect successful implementaon.

TRADE-OFF BETWEEN BENEFITS ANDHARMS:

Benets include improved haemoglobin and lower risk of anaemia

or iron deciency, which have funconal consequences such as im-

proved exercise performance. Potenal harms include gastrointes-

nal eects, but evidence is of low quality. There is increased risk of

either diarrhoea or conspaon, with high quality of evidence.

Not enough data are available on adverse events, or long-term

harm, for instance on overdose, specically for those who are iron

replete.

COSTS AND FEASIBILITY: The cost will largely be determined by the operaonal challengesrather than the cost of the supplementaon itself. The diculty will

lie in aempng to set up vercal programmes, which can prove

very costly. Health services that do not have prevenve health care

in menstruang adult women and adolescent girls may be more

likely to nd this intervenon infeasible.


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ANNEX 3. WHO STEERING COMMITTEE FOR NUTRITION GUIDELINES DEVELOPMENT

Dr Najeeb Mohamed Al Shorbaji

Director, Deparment of Knowledge Management andSharingWorld Health OrganizaonAvenue Appia 20, 1211 Geneva 27 Switzerland

Dr Douglas Becher

Director, Department of Prevenon of NoncommunicableDiseasesWorld Health Organizaon

Avenue Appia 20, 1211 Geneva 27,Switzerland

Dr Ties Boerma

Director, Department of Health System Policies andWorkforceWorld Health OrganizaonAvenue Appia 20, 1211 Geneva 27 Switzerland

Dr Francesco Branca

Director, Department of Nutrion for Health andDevelopmentWorld Health OrganizaonAvenue Appia, 20, 1211 Geneva 27

Switzerland

Dr Richard Brennan

Director, Department of Emergency Risk Managementand Humanitarian ResponseWorld Health OrganizaonAvenue Appia 20, 1211 Geneva 27 Switzerland

Dr Goried Oo Hirnschall

Director, Department of HIV/AIDSWorld Health OrganizaonAvenue Appia 20, 1211 Geneva 27Switzerland

Dr Knut Lonnroth

Medical Ocer, Global TB ProgrammeWorld Health OrganizaonAvenue Appia 20, 1211 Geneva 27Switzerland

Dr Elizabeth Mason

Director, Director of Maternal, Newborn, Child andAdolescent Health World Health OrganizaonAvenue Appia 20, 1211 Geneva 27

Switzerland

Dr Kazuaki Miyagishima

Director, Department of Food Safety, Zoonoses and

Foodborne Diseases

World Health Organizaon

Avenue Appia 20, 1211 Geneva 27

Switzerland

Dr Maria Puricacion Neira

Director, Department of Public Health, Environmental and

Social Determinants of Health

World Health OrganizaonAvenue Appia 20, 1211 Geneva 27

Switzerland

Dr Jean-Marie Okwo-Bele

Director, Department of Immunizaon, Vaccines and

Biologicals



Switzerland

Professor John Charles Reeder

Director, Special Programme for Research and Training in

Tropical Diseases

World Health OrganizaonAvenue Appia 20, 1211 Geneva 27

Switzerland

Dr Isabelle Romieu

Secon Head, Nutrional Epidemiology Group

Internaonal Agency for Research on Cancer

150, cours Albert Thomas

69372 Lyon Cedex 08

France

Dr Nadia Slimani

Group Head, Nutrional Epidemiology Group

Internaonal Agency for Research on Cancer

150, cours Albert Thomas

69372 Lyon Cedex 08

France

Dr Marleen Temmerman

Director, Department of Reproducve Health and

Research



Switzerland


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ANNEX 4. WHO GUIDELINE DEVELOPMENT GROUP

Ms Deena Alasfoor

Directorate of Training and Educaon

Ministry of Health

Oman

Health programme management, food legislaons,

surveillance in primary health care

Dr Beverley-Ann Biggs

Head, Internaonal and Immigrant Health Group

Department of Medicine

University of MelbourneAustralia

Micronutrients supplementaon, clinical infecous

diseases

Dr Norma Campbell

Professor

Departments of Medicine

Community Health Sciences and Physiology and

Pharmacology

University of Calgary

Canada

Physiology and pharmacology, hypertension prevenon

and control

Dr Mary Chea

Deputy Manager of Naonal Nutrion Programme

Naonal Maternal and Child Health Centre

Ministry of Health

Cambodia

Programme implementaon, midwifery

Dr Maria Elena del Socorro Jeerds

Behavioural Scienst, Division of Nutrion, Physical

Acvity and Obesity

Centers for Disease Control and Prevenon

United States of America

Behaviour science, programme evaluaon

Dr Luz Maria De-Regil

Director, Research and Evaluaon and Chief Technical

Adviser

Micronutrient Iniave

Canada

Epidemiology, systemac reviews, programme

implementaon

Dr Heba El Laithy

Professor of Stascs and Head of Stascal

Departments at Faculty of Economics

Cairo University

Egypt

Stascs, economics

Dr Rafael Flores-Ayala

Team lead, Internaonal Micronutrient Malnutrion

Prevenon and Control Programme

Centers for Disease Control and PrevenonUnited States of America

Nutrion and human capital formaon, nutrion and

growth, impact of micronutrient intervenons

Professor Davina Ghersi

Senior Principal Research Scienst

Naonal Health and Medical Research Council

Australia

Policy-making, systemac reviews, evidence

Professor Malik Goonewardene

Senior Professor and Head of Department

Department of Obstetrics and Gynaecology

University of RuhunaSri Lanka

Obstetrics and gynaecology, clinical pracce

Dr Rukhsana Haider

Chairperson

Training and Assistance for Health and Nutrion Foundaon

Bangladesh

Breaseeding, capacity-building on counselling and

nutrion

Dr Junsheng Huo

Professor

Naonal Instute for Nutrion and Food Safety

Chinese Centre for Disease Control and Prevenon

China

Food forcaon, food science and technology, standards

and legislaon

Dr Janet C King

Children’s Hospital Oakland Research Instute


Micronutrients, maternal and child nutrion, dietary

requirements


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Dr Carol Tom

Regional Food Forcaon Advisor

A2Z Project

East, Central and Southern African Health Community

United Republic of Tanzania

Food forcaon technical regulaons and standards,

policy harmonizaon

Dr Igor Veljkovik

Health and Nutrion Ocer

United Naons Children’s Fund (UNICEF) Oce in Skopje

The former Yugoslav Republic of Macedonia

Programme implementaon

Dr Maged Younes

Independent internaonal expert on global public health

ItalyFood safety, public health, programme management


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ANNEX 5. EXTERNAL RESOURCE EXPERTS

Dr Nancy Aburto

Nutrion Adviser

United Naons World Food Programme

Italy

Dr Guillermo Carroli

Director

Centro Rosarino de Estudios Perinatales

Argenna

Ms Nita DalmiyaNutrion Specialist, Micronutrients

United Naons Children’s Fund


Dr Maria Cecilia Dedios Sanguine

Independent consultant, Evaluaon


Dr Kathryn Dewey

Professor, Department of Nutrion

Director, Program in Internaonal and Community

Nutrion

University of California


Ms Mary-Anne Land

Research Associate

The George Instute for Global Health

Australia

Dr Sant-Rayn Pasricha

MRC Human Immunology Unit

Weatherall Instute of Molecular Medicine

University of Oxford

John Radclie Hospital

United Kingdom of Great Britain and Northern Ireland

Dr Usha Ramakrishnan

Program Director, Doctoral Program in Nutrion and

Health Sciences

Department of Global Health

Rollins School of Public Health

Emory University



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ANNEX 6. WHO SECRETARIAT

Ms Sanjhavi Agarwal

Intern, Evidence and Programme Guidance

Department of Nutrion for Health and Development

Ms Maryam Bigdeli

Technical Ocer

Alliance for Health Policy and Systems Research

Dr Carmen Casanovas

Technical Ocer, Evidence and Programme Guidance


Dr Laragh Gollogly

Editor, WHO Press

Department of Knowledge Management and Sharing

Dr Maria de las Nieves Garcia-Casal

Consultant, Micronutrients


Dr Eyerusalem Kebede Negussie

Medical Ocer, HIV Treatment and Care

Department of HIV/AIDS

Dr Suzanna McDonald (rapporteur)Consultant, Immunology, Evidence and Programme

Guidance


Ms Daniela Meneses (rapporteur)

Intern, Evidence and Programme Guidance


Dr Juan Pablo Peña-Rosas

Coordinator, Evidence and Programme Guidance


Dr Pura Rayco-Solon

Epidemiologist (infecous disease and nutrion), Evidence

and Programme Guidance


Dr Lisa Rogers

Technical Ocer, Evidence and Programme Guidance


Dr Nigel Rollins

Medical Ocer, Research and Development

Department of Maternal, Newborn, Child and

Adolescent Health

Ms Victoria Saint

Technical Ocer, Social Determinants of Health

Department of Public Health, Environmental and Social

Determinants of Health

Dr Eugenio Villar Montesinos

Coordinator, Social Determinants of Health

Department of Public Health, Environmental and Social

Determinants of Health

Ms Zita Weise PrinzoTechnical Ocer, Evidence and Programme Guidance


Mr Gerardo Zamora

Technical Ocer (implementaon research and equity),

Evidence and Programme Guidance


WHO regional offices Regional Office for Africa

Dr Mercy Chikoko

Acng Regional Adviser for NutrionWHO Regional Oce for Africa

Cité du Djoué, PO Box 06 Brazzaville,

Congo

Regional Office for the Americas/Pan American HealthOrganization

Dr Chessa Luer

Regional Adviser, Child and Adolescent Health

Pan American Health Organizaon

525 23rd Street, NW, Washington DC 20037


Regional Office for South-East Asia

Dr Kunal Bagchi

Regional Adviser – Nutrion and Food Safety

Healthy Ageing

WHO Regional Oce for South-East Asia

World Health House

Indraprastha Estate, Mahatama Gandhi Road

New Delhi 110002

India


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ANNEX 7. PEER-REVIEWERS

Ms Solange Durao

Senior Scienst

South Africa Cochrane Collaboraon Centre

South Africa

Dr Tran Khanh Van

Vice Head of Nutrion

Naonal Instute of Nutrion

Vietnam

Ms Terrie WefwafwaChief Execuve Ocer

Karibuni Kenya (Consultancy)

Kenya


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