Pre-conference Nutrition WorkshopJohannesburg, South Africa, 14 April 2013

Anemia Prevalence, Burden of Disease and Programmatic Considerations

Rolf Klemm, DrPH Johns Hopkins Bloomberg School of Public Health

Hold your breath

Breath!!!

Anemia 101
The Basics

Anemia

Normal RBCs

Anemic RBCs

Decrease in normal number of Red Blood Cells (RBCs) or less than normal quantity of hemoglobin

Anemia is one the most widespread disorders in the world!

~50% pre-school children ~42% pregnant ~30% non-pregnant

~50% have IDA

McLean et al. Public Health Nutr, 2008, 12: 444-454

Not all anemia is caused by iron deficiency. But iron deficiency is a major cause of Hookworm anemia in many developing countries.
Other vitamin deficiencies

Iron deficiency

Malaria HIV/AIDS Inflammatory Conditions

Anemia

Iron Deficiency Anemia

Hemoglobinopathies

Overlapping causes of Anemia

Malaria

Anemia

Hookworm

Severe: 40%

Moderate: 20-39%

Iron requirement at different life stages

Nutritional iron deficiency highest in groups experiencing peak growth rates

Institute of Medicine, 2001

Public Health Rationale for Controlling Iron Deficiency Anemia?

Old and New Findings

Public Health Rationale

Iron deficiency ranks 15th among selected risk factors for preventable death and disability (WHO, Global Health Risks, 2009)
Women: Increase maternal mortality risk and reduces quality of life Children: Suboptimal mental and motor development in young children leading to potentially irreversible cognitive deficits during school years.

Continuous risk relationship between Hb & maternal & perinatal mortality

4000 3500 3000 2500 2000 1500 1000 500 0 Hemoglobin (g/dL)
Stoltzfus, et al, Comparative Quantification of health risks: Global and regional burden of disease attributable to selected major risk factors:, WHO, 2004

Risk reduction associated with each 1 g/dL increase in hemoglobin.. Maternal 20% mortality Perinatal mortality (Africa) Perinatal mortality (other)
11 7 9

mortality

28%

16%

Daily iron supplementation during pregnancy

(Cochrane Review, 2012) Based on 60 studies, >27,000 pregnant women

birth weight (31 g) prevalence of LBW (19%) of maternal anemia at term (70%) of maternal iron deficiency at term (57%) No evidence th at Fe placental malaria

Daily iron supplementation during pregnancy

(Cochrane Review, 2012)

Preterm births: 13 studies (10,000 women) RR: 0.88 (95% CI: 0.77, 1.01)
of preterm births (12%) but not statistically significant

Neonatal mortality: 4 studies (7,500 participants)

RR: 0.90 (95% CI: 0.68, 1.19) of neonatal mortality (10%) but not statistically significant

Recent RCTs FA-Fe in pregnancy

Baseline Levels Place (Study) Nepal
(BMJ 2003)

Anemia High

LBW High

~N per group

Control

FA-Fe vs. Control

Context matters! ~1,000 Control BW (40 g)

(VA)

(44%)

USA-WIC
(AJCN, 2003)

None or Low

BW (206 g) (17%) GA (0.6 wk) Environmental factors SGA (50%) Baseline nutritional status Preterm LBW Med Low/Med (5%)

SESFA 135 Diet FA 2,000

LBW (16%) SGA (9%)

W China
(BMJ 2008)

Med

N China
(JAMA Int Med, 2013)

Low

Underlying risks for Interpregnancy interval Low 6,000 FA No effect on birth weight, birth Others (2%) length, perinatal mortality

GA (0.23 wk) Early preterm (<34 wk) outcomes Early neonatal morality(54%)

Maternal Iron+folic acid mortality among Nepalese children by 31% between birth & 7 years

Folic Acid + Iron

Control
0 1y 2y 3y 4y 5y 6y 7y 8y

Christian et al Am J Epidemiol, 2009, 170: 1127-1136

Developmental risk factors with sufficient evidence to recommend intervention

Walker et al. Lancet 2007; 369: 145-57

Economic Loss Associated Iron Deficiency

Estimated Loss Physical productivity loss Loss in GDP Dollar value of losses Including cognitive losses Loss in GDP $2.32/per capita 0.6% $4.2 billion $16.78/per capita 4.0%

Horton S The Economics of Iron Deficiency, Food Policy, 2003, 51-75

Summary of Health Risks of Iron Deficiency Anemia

Maternal Mortality Perinatal Mortality

Pregnancy

Childhood

Adults

Low birth weight Neonatal mortality Post-neonatal, child mortality Negative effects on child cognition and behavior Productivity and economic gains

Interventions to reduce iron deficiency anemiaWhat works?

Intervention strategies-Iron Deficiency

Dietary modification? Iron Supplements?

Home fortification?

Central fortification? Delayed cord clamping?

Intervention strategies-Malaria & Hookworm

De-worming for hookworm

Quality Focused Antenatal Care (FANC)

Intermittent Preventive Treatment (IPTp) Use of insecticide treated nets (ITN)

Dietary Modification
Germination, Fermentation, Soaking, Adding Ascorbic Acid Dietary diversification & modification is important Increased consumption of iron for rich foods Use of iron cooking pots improving dietary quality, but. .BUT not sufficient to close Fe gap for young children and pregnant women in most lowincome populations

Food Fortification
Central fortification of staples:
Can improve Fe status of all risk groups

Home or Point-of-Use:
Highly effective at reducing Fe deficiency (RR=0.44) & anemia (RR=0.54) in children

Iron-folic acid supplementation in pregnancy

60 mg Fe+ 400 ug FA to pregnant women

of maternal anemia at term (70%) of maternal iron deficiency at term (57%) No evidence th at Fe placental malaria
(Cochrane Review, 2012)

Iron supplementation in children in Malaria endemic populations

When there is comprehensive surveillance and prompt malaria diagnosis and treatment there is no increased risk When health care is insufficient there is an increased risk of malaria with iron supplementation
NIH Technical Working Group

Delayed chord clamping

Delay clamping of umbilical cord by 2-3 minutes Results in greater transfusion of placental blood to the infant Increases the total body Fe content of the infant at birth (+~75 mg Fe) which helps to prevent Fe deficiency during the first years of life

What needs more work?

Increases or little change in Anemia Ghana 2003 Prevalence Ghana2008

East Africa West Africa

Uganda 2000-01 Uganda2006

Anemia

Mali 2001 Mali2006 Senegal2005 Prevalence among Senegal2008-09

Pregnant Women Over Time By Country

Egypt 2000 Egypt2005 N Africa/Middle East Uganda Jordan 2002 2000-01 East Africa Uganda2006 Jordan2007 Cambodia2000 Ghana 2003 Cambodia2005 Ghana2008 Mali 2001 India 1998-99 Mali2006 India2005/2006 Senegal2005 Haiti 2000 Senegal2008-09 Haiti2005-06 Egypt 2000 Egypt2005 0 Jordan 2002 Jordan2007

S/SE Asia West Africa LAC

N Africa/Middle East

10

20

30 40 50 Anemia Prevalence

60

70

80

Severe Moderate Cambodia2000 Mild Cambodia2005 S/SE Asia India 1998-99 Source: Demographic and Health Survey Compiler Data 2004-2008 India2005/2006 Klemm R, et al. Are we making progress on reducing anemia in Women? A2Z, 2011 Haiti 2000

Use of iron and folic acid tablets by ANC attendees, Uganda, n=612
100 90 80 70 60 50 40 30

High proportion of women have at least 1 ANC visit ~40% who had an ANC visit did NOT receive ANY IFA tablets

20
10 0

AND.<10% consumed 30 tablets

1 ANC visit

Received ANY Consumed 30 Consumed 90 IFA tablets tablets tablets

A2Z Survey (2009) of ANC platforms, unpublished data

Comparison of current performance and anticipated standard of focused ANC model, Tanzania
First Visit
Current Practice (minutes) 2:10 4:20 3:30 1:00 1:40
Desired based on FANC (minutes) 5:00 10:00 8:00 3:00 1:00

Re-visit
Current Practice (minutes) 1:30 1:20 3:00 1:40 1:00
Desired based on FANC (minutes) 0:00 5:00 8:00 3:00 1:00

Registration History taking Examination Drug Administration Immunization

Health education & counseling

Total time direct activities Welcoming the client Documentation of findings

1:30
12:20 1:00 2:00

15:00
42:00 1:00 3:00

0:00
6:30 1:00 1:30

15:00
32:00 1:00 3:00

Total contact time

15:20

46:00

9:00

36:00

Von Both, BMC Pregnancy and Childbirth, 2006, 6:22

Barriers to Effective Implementation2008 Innocenti Process

Inadequate political support Low priority for IFA within maternal health programs Insufficient bundling of interventions to address the multiple causes of anemia Inadequate supplies, low utilization, and weak demand Community-based delivery platforms to complement the ANC platform are missing
Klemm R et al Micronutrient Programs: What Works and What Needs More Work? A Report of the 2008 Innocenti Process. July 2009, Micronutrient Forum, Washington, DC.

Actions Needed
Most countries have MMR reduction goals: Is maternal anemia and iron and folic acid (IFA) supplementation given high priority? ANC guidelines include preventive IFA: But is the implementation being monitored? effective? Varied causes of anemia, e.g. Iron-deficiency, hookworm, malaria: Is there an integrated package of services? Essential Drugs Lists have IFA, deworming, malaria drugs: How can stock outs be eliminated? Basic health worker training covers anemia: How adequate is counseling and compliance followup?

Thank You

Siyabonga
Dankie Ke a leboga