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Why tackle anemia?
Anemia is ignored in most developing countries even though it is one of the most prevalent public health problems and has serious consequences for national development. Iron deficiency causes at least 50% of all anemia, and almost a million deaths a year; three-quarters of the deaths occur in Africa and South-East Asia. Iron deficiency anemia (IDA) is in the "top ten" risk factors contributing to the global burden of disease. One study estimates the economic costs of IDA at 4.05% of gross domestic product (GDP)—US$2.32 per capita in lost productivity and US$14.46 per capita in lost cognitive function (IDA reduces IQ by half a standard deviation). Worldwide, $50 billion in GDP is lost annually in low-Estimates of Economic Losses from Iron Deficiency Anemia (Cognitive & Productive) as % of GDP income countries due to IDA's effect on productivity.
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What causes anemia?
Anemia is defined as a low level of hemoglobin in red blood cells. Iron in the hemoglobin molecule fixes oxygen in the lungs and releases it in the tissues where oxygen generates energy for the body. The major clinical symptom of anemia and iron deficiency is pallor and its physical symptom is fatigue resulting in reduced capacity to work. There are three major causes of anemia:
insufficient red blood cell production due to inadequate intake or poor utilization of dietary iron (due to poor diet and helminth infections);
excessive red blood cell destruction due to malaria which displaces hemoglobin and prevents the transport of oxygen to the tissues;
excessive red blood cell loss due to helminth infections (mainly hookworm and schistosomiasis and in some cases trichuriasis) leading to iron deficiency, and blood loss in women during their reproductive years.
Other significant causes of anemia include nutritional deficiencies other than iron deficiency (i.e. folic acid, vitamins A and B-12), genetic conditions (e.g. thalassemia in parts of the Mediterranean, sickle
cell in Africa), factors related to reproduction (e.g. high fertility, obstetric complications, contraceptives or practices that increase blood loss such as not breastfeeding), and infections (e.g. HIV/AIDS, tuberculosis, diarrhea) that increase requirements for iron and other micronutrients.
Energy, vitamin A and zinc deficiencies can increase the severity of malaria infection, which may cause or exacerbate anemia. The relative importance of different causes varies by region. Malaria is a major cause of anemia in Sub-Saharan Africa. Iron deficiency is a major cause of anemia in all developing countries, including Africa, where consumption of iron is limited because dietary sources of iron are not affordable by most families.
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Anemia prevalence
National anemia surveys have been conducted in only 25 developing countries, but WHO estimates that more than 2 billion people worldwide are anemic. A severe public health problem exists when anemia prevalence is >40% in any group.
Children <2 years and pregnant women are most at risk for anemia because their requirements for iron are higher than any other group and they are most susceptible to malaria. For pregnant women,
anemia prevalence is highest in Nepal (75%) and is />40% in 16 of 19 countries with data. For children <2, anemia prevalence is highest in Benin, the Gambia and Nepal (88%) and />40% in 19 of 20 countries with data. School children, adolescents, the elderly and reproductive-age women also suffer from anemia. Anemia can be a problem in men with helminth infections that cause blood loss or who engage in heavy labor. Anemia affects productivity and incomes, but is usually life threatening
only in pregnant or newly delivered women and young children.
Severe anemia (hemoglobin < 7 g/dL) is a public health problem if prevalence exceeds 2%. Where severe anemia prevalence has been investigated, it is a problem in most countries in Africa and South Asia and some countries in East Asia and the Pacific (e.g., Cambodia). (For country data, see DHS and Galloway, 2003 in Resources and References).
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The main ways to combat anemia
The three major causes of anemia (iron deficiency, malaria and helminth infections) can be addressed during contacts with vulnerable groups using a combination of key interventions, as needed.
Five Key Interventions
- Iron supplements targeted to at-risk groups
- Fortification of staple foods with iron and other micronutrients that cause anemia for the general population and iron-fortified foods targeted to at-risk groups
- Prevent and treat malaria
- Use of insecticide-treated materials and bednets, particularly by at-risk groups, to prevent anemia
- Deworming (anthelminthics) in at-risk groups
Other important interventions to decrease anemia:
- Increase production and consumption of foods with iron and all micronutrients (folic acid, vitamins A, C, B-12 and zinc) that contribute to anemia and increase the severity of illness
- Supplementation with other micronutrients needed to prevent anemia, including "multi-micronutrients" as consensus develops on appropriate use, and if affordable
- Fully immunize children
- Prevent and treat communicable diseases
- Manage obstetric complications, particularly excessive bleeding
- Promote birth spacing through use of modern contraceptives and exclusive breastfeeding
- Promote use of contraceptives that decrease blood loss
- Improve water and sanitation facilities/practices
Where to combat anemia
Anemia should be addressed through health facilities (to reach young children and their mothers); schools (to reach children and their parents); and existing programs that work directly with communities and community workers, such as water and sanitation/environmental
health/ hygiene and infectious disease control programs. Agriculture extension/food security programs can help increase production and consumption of foods rich in iron and other micronutrients. The private sector can also help, especially food and pharmaceutical manufacturers, marketers and distributors. Specific interventions for each point of contact are in the Core Anemia Control Interventions Table.
Reaching the poor and most vulnerable
The poorest women, particularly when
pregnant, and children <5 years are the most anemic and have least access to services and interventions to mitigate anemia. In <br />women, anemia prevalence decreases with income in every region/country. Prevalence in the poorest compared to the richest quintile is 2 times higher in India and 1.4 times higher in Egypt, Cambodia, LAC and ECA. But anemia is high even in the richest groups, so programs should not be narrowly targeted. A similar scenario exists for anemia prevalence by
income group in children, with the greatest poor/rich differences in Egypt and LAC
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Program Manager's anemia interventions checklist
Know the problem: situation analysis
- Determine the public health significance and prevalence of anemia; identify priority target groups, areas of greatest anemia prevalence and its causes
- Determine what people know about anemia and their experience with anemia prevention and control programs
Raise awareness and develop partnerships
- Raise awareness across sectors: advocate and educate to prevent and control anemia
- Build partnerships in health, agriculture, food and pharmaceutical sectors, among government ministries and agencies, NGOs, donors, industry, and commerce Develop interventions and implement plans
- Identify priorities, responsibilities, and time frames
- Identify specific objectives
- Identify collaborating groups (universities, government agencies, NGOs, civil groups, commercial entities)
- Review existing programs and determine and develop anemia prevention and control activities
- Determine and secure staffing, funding and other resources to implement activities
- Develop a monitoring and evaluation plan and indicators, using reduction of anemia as a benchmark for program success in IDA, malaria and helminth control programs
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Core anemia interventions: Core Interventions, Beneficiaries and Indicators
Core Interventions | Beneficiaries | Indicators |
COMBAT THE THREE MAIN CAUSES OF ANEMIA | ||
Prevent anemia in women during anenatal, delivery and postpartum care contacts
| Women during pregnancy, delivery and postpartum periods and their breastfed infants <6 mos.</font /> |
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Prevent anemia in children 0-5 years during well and sick child visits
| Children 6-24 mos. (normal birthweight) or children 2-24 mos. (low birth-weight) or children 2-5 years |
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Behavior change communications (BCC) are needed during contacts with women and children to improve compliance in use of iron, effective antil-malarials and anthelminthics. Other messages should promote the following: women receiving a dose of vitamin A within 60 days after they deliver and children 6-29 mos. receiving vitamin A twice-yearly (see Vitamin A at a glance); good breastfeeding practies; full immunization for women and children; increased consumption of energy, iron-high foods (meat), other micronutrients (vitamins A and B-12 and folic acid) and iron enhancers (vitamin C, germinated/fermented foods); decreased consumption of iron inhibitors (tea and coffee at meals); nightly use of ITB (bednets); modern family planning methods that reduce iron loss; good water and santiation practices; and awareness about danger signs in pregnancy, delivery, postpartum (bleeding) and from childhood diseases and what to do about them. | ||
Treat anemia in women (particularly severe anemia which can be identified using clinical signs for pallor of the palm or conjuctiva or, if available, a test for hemoglobin) | ||
| Pregnant women |
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Treat anemia in children (particularly severe anemia which can be identified using clinical signs for pallor of the palm [conjuctiva cannot be used in children] or, if available, a test for hemoglobin) | ||
| Children 0-5 yrs | |
Behavior change communications are needed during these contacts to ensure compliance in use of iron supplementation, anti-malarials and anthelminthics and to ensure women and children return for follow up when messages to improve health and nutrition behaviors and practices should be given (including prompt treatment of fever). | Pregnant women and caregivers of children <5 yrs</font /> |
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PREVENT ANEMIA IN THE OTHER VULNERABLE GROUPS | ||
Primary and secondary schools
| Children 6-11 years attending primary school, adolescents attending secondary school |
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Daycare centers and pre-schools | Children 0-5 years | See indicators under well child, sick child care |
School committees and parent-teacher associations | All memebers of the community but particularly vulnerable groups |
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OTHER ACTIVITIES TO CONTROL ANEMIA | ||
Micronutrients Community-based distribution (home visits, growth monitoring and promotion) of iron and other micronutrient supplements to the most vulnerable groups, particularly where health services are not well utilized, and other high-risk groups (i.e., all reproductive age women, heavy laborers, children not attending school). | Vulnerable groups |
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Water and sanitation /hygience Promote good water and sanitation facilities and practicies. | All households |
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Infectious disease control Promote immunization. Promoted home-based care for diarrhea, respiratory infections and other communicable diseases (HIV/AIDS). Promote use of ITB (bednets). Behavior change communications (BCC) to prevent and treat infectious diseases including HIV/AIDS and refer serious cases. | Children 0-5 years and women |
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Family Planning Promote breastfeeding for lactatioinal amenorrhea method (LAM) and modern methods of contraceptives including those that reduce blood loss. | Reproductive age women |
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Reproductive Health Promote the care of women (raising awareness about danger signs during pregnancy and postpartum periods and what to do about them; the need for antenatal and postpartum care, adequate diet for women). | Reproductive age women |
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Private Sector (food and pharmaceutical manufacturers, marketers, distributors) Promote production and sale of iron and micronutrient supplements, fortified foods, ITB (bednets) and family planning by private vendors, marketers, distributors. | Private sector vendors, marketers, distributors |
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For More Information
Nutrition Advisory Service
Resources and References
FRESH (Focusing
Resources on Effective School Health) World Bank, 2001. //www.freshschools.org/whatisFRESH.htm
DHS (Demographic and Health Surveys).
//www.measuredhs.com/
Galloway, R, 2003. Anemia prevention and control - What works? Part 1 | Part 2 USAID, World Bank, PAHO/WHO, Micronutrient Initiative, FAO, and UNICEF.
Horton, S & J Ross, 2003. The economics of iron deficiency, Food Policy 28:51-75. Available: World Bank Library Resources, e-journals
INACG - International Nutritional Anemia Consultative Group - provides
information and publications on iron and iron deficiency's contribution to anemia. //inacg.ilsi.org/
The Micronutrient Initiative provides information and publications on iron and other micronutrients.
//www.micronutrient.org/
MOST provides information and publications on iron and other micronutrients. //www.mostproject.org/
SCN (2004). Nutrition for improved development
outcomes. 5th Report on the World Nutrition Situation. United Nations Standing Committee on Nutrition.
//www.unsystem.org/scn/Publications/AnnualMeeting/SCN31/SCN5Report.pdf
Stoltzfus, R & M Dreyfuss, 1998. Guidelines for the use of iron supplements to prevent and treat iron deficiency anemia. INACG, WHO, UNICEF.
//inacg.ilsi.org/
WHO 2002. World Health Report, World Health Organization, Geneva. //www.who.int/publications/en/ This site also includes useful publications on malaria, helminths and
nutrition.
World Bank 2004. Poverty and Income. The Poverty Group. //devdata.worldbank.org/hnpstats/pvd.asp
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PDF Version
English (December 2004)(PDF 278kb)
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