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7/30/2019 Klemm_Anemia Prevalence, Burden of Disease and Programmatic Considerations
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Anemia Prevalence, Burden of Diseaseand Programmatic Considerations
Rolf Klemm, DrPHJohns Hopkins Bloomberg School of
Public Health
Pre-conference Nutrition
Workshop-
Johannesburg, South Africa,
14 April 2013
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Hold your
breath
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Breath!!!
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Anemia 101
The Basics
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Decrease in normalnumber of Red Blood Cells(RBCs) or less than normalquantity of hemoglobin
Anemia
Normal RBCs Anemic RBCs
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McLean et al. Public Health Nutr, 2008, 12: 444-454
Anemia is one the most widespread disordersin the world!
~50% pre-school children~42% pregnant
~30% non-pregnant
~50% have
IDA
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Not all anemia is caused by iron
deficiency.
But iron deficiency is a major cause ofanemia in many developing countries.
An
emia I
ro
n
deficiency
Iron
Deficiency
Anemia
Other vitamin
deficiencies
Hookworm
Malaria
HIV/AIDS
Inflammatory
Conditions
Hemoglobin-
opathies
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Overlapping causes of Anemia
Malaria Anemia Hookworm
Severe: 40%
Moderate: 20-39%
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Institute of Medicine, 2001
Iron requirement at different life stages
Nutritional iron deficiencyhighest in groupsexperiencing peak growth
rates
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Public HealthRationale for
Controlling IronDeficiency Anemia?
Old and New Findings
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Public Health Rationale
Iron deficiency ranks 15th amongselected 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 motordevelopment in young children leading topotentially irreversible cognitive deficitsduring school years.
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Continuous risk relationship between Hb &maternal & perinatal mortality
0
500
1000
1500
2000
2500
3000
35004000
5 7 91
1
Hemoglobin (g/dL)
mo
rtality
Stoltzfus, et al, Comparative Quantification ofhealth risks: Global and regional burden of
disease attributable to selected major riskfactors:, WHO, 2004
Risk reduction
associated with each 1
g/dL increase in
hemoglobin..Maternalmortality
20%
Perinatalmortality (Africa)
28%
Perinatalmortality (other)
16%
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Daily iron supplementation during pregnancy(Cochrane Review, 2012)
birth weight (31 g)
prevalence of LBW (19%)
of maternal anemia at term (70%)
of maternal iron deficiency at term (57%)
No evidence that Fe placental malaria
Based on 60 studies, >27,000 pregnant women
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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 statisticallysignificant
Neonatal mortality: 4 studies (7,500 participants)
RR: 0.90 (95% CI: 0.68, 1.19)
of neonatal mortality (10%) but not statisticallysignificant
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Recent RCTs FA-Fe in pregnancy
Baseline Levels
Place
(Study)
Anemia LBW ~N per
group
Control FA-Fe vs. Control
Nepal(BMJ 2003)
High High(44%)
~1,000 Control(VA)
BW (40 g) LBW (16%)SGA (9%)
USA-WIC(AJCN, 2003)
None orLow
Med(17%)
135 FA BW (206 g) GA (0.6 wk)SGA (50%) Preterm LBW
W China(BMJ 2008)
Med Low/Med(5%)
2,000 FA GA (0.23 wk) Early preterm (
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Folic Acid + Iron
Control
Maternal Iron+folic acid mortality among Nepalesechildren by 31% between birth & 7 years
Christian et al Am J Epidemiol, 2009, 170: 1127-1136
0 1 y 2 y 3 y 4 y 5 y 6 y 7y 8 y
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Developmental risk factors with sufficientevidence to recommend intervention
Walker et al. Lancet 2007; 369: 145-57
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Economic Loss Associated Iron Deficiency
Estimated Loss
Physical productivity loss $2.32/per capita
Loss in GDP 0.6%
Dollar value of losses $4.2 billion
Including cognitive losses $16.78/per capita
Loss in GDP 4.0%
Horton S The Economics of Iron Deficiency, Food Policy, 2003, 51-75
S f H lth Ri k f I
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Maternal Mortality
Perinatal Mortality
Low birth weight
Neonatal mortality
Post-neonatal, child mortalityNegative effects on child cognition
and behavior
Productivity and economic gains
Summary of Health Risks of Iron
Deficiency Anemia
Pregnancy
Childhood
Adults
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Interventions toreduce iron
deficiency anemia-What works?
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Home
fortification?
Centralfortification?
Delayed cord clamping?
Dietary modification? IronSupplements?
Intervention strategies-Iron Deficiency
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Intervention strategies-Malaria & Hookworm
Use of insecticide treated
nets (ITN)
IntermittentPreventiveTreatment (IPTp)
Quality Focused AntenatalCare (FANC)
De-worming for
hookworm
http://images.google.com/imgres?imgurl=http://www.gsk.com/common/img/infocus/v-lf-albendazole.jpg&imgrefurl=http://www.gsk.com/infocus/lf.htm&usg=__5YCqhDrz0DIVihl2gosdxiQvlf8=&h=225&w=189&sz=11&hl=en&start=6&um=1&itbs=1&tbnid=OI7hXDh1OY3ZKM:&tbnh=108&tbnw=91&prev=/images?q=albendazole&um=1&hl=en&sa=N&rlz=1T4GGLL_en___US336&tbs=isch:17/30/2019 Klemm_Anemia Prevalence, Burden of Disease and Programmatic Considerations
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Increased consumption of iron rich foodsUse of iron cooking pots
Dietary Modification
Germination, Fermentation,Soaking, Adding Ascorbic Acid
Dietary diversification &modification is important forimproving dietary quality, but.
.BUT not sufficient to close Fe
gap for young children andpregnant women in most low-income populations
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Food Fortification
Central fortification ofstaples:
Can improve Fe status of all
risk groups
Home or Point-of-Use:
Highly effective at reducingFe deficiency (RR=0.44) &anemia (RR=0.54) in children
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Iron-folic acidsupplementation in pregnancy
60 mg Fe+ 400 ugFA to pregnantwomen
of maternal anemia at
term (70%) of maternal iron deficiency
at term (57%)No evidence that Fe placental malaria
(Cochrane Review, 2012)
I l t ti i hild i
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Iron supplementation in children inMalaria endemic populations
When there is comprehensivesurveillance and prompt malariadiagnosis and treatment there is noincreased risk
When health care is insufficient thereis an increased risk of malaria withiron supplementation
NIH Technical Working Group
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Delayed chord clamping
Delay clamping of umbilicalcord by 2-3 minutes
Results in greater transfusion
of placental blood to theinfant
Increases the total body Fecontent of the infant at birth
(+~75 mg Fe) which helps toprevent Fe deficiency duringthe first years of life
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What needs more work?
I littl h i A i
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0 10 20 30 40 50 60 70 80Anemia Prevalence
Source: Demographic and Health Survey Compiler Data 2004-2008
Severe Moderate
Mild
West Africa
East Africa
Senegal 2008-09Senegal 2005
Mali 2006Mali 2001
Ghana 2008Ghana 2003
Uganda 2006Uganda 2000-01
Anemia Prevalence among Pregnant Women Over Time By Country
Increases or little change in AnemiaPrevalence
Klemm R, et al. Are we making progress on reducing anemia in Women? A2Z, 2011
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Use of iron and folic acid tablets by
ANC attendees, Uganda, n=612
0
10
20
30
40
50
60
70
80
90
100
1 ANC visit Received ANY
IFA tablets
Consumed 30
tablets
Consumed 90
tablets
High proportion of womenhave at least 1 ANC visit
A2Z Survey (2009) of ANC platforms, unpublished data
~40% who had an ANC
visit did NOT receive ANYIFA tablets
AND.
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First Visit Re-visit
Current
Practice
(minutes)
Desired
based on
FANC
(minutes)
Current
Practice
(minutes)
Desired
based on
FANC
(minutes)
Registration 2:10 5:00 1:30 0:00
History taking 4:20 10:00 1:20 5:00
Examination 3:30 8:00 3:00 8:00
Drug Administration 1:00 3:00 1:40 3:00
Immunization 1:40 1:00 1:00 1:00
Health education &counseling 1:30 15:00 0:00 15:00
Total time direct activities 12:20 42:00 6:30 32:00
Welcoming the client 1:00 1:00 1:00 1:00
Documentation of findings 2:00 3:00 1:30 3:00
Total contact time 15:20 46:00 9:00 36:00
Comparison of current performance and
anticipated standard of focused ANC model,
Tanzania
Von Both, BMC Pregnancy and Childbirth, 2006, 6:22
Barriers to Effective Implementation
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Barriers to Effective Implementation-
2008 Innocenti Process
Inadequate political support Low priority for IFA within maternal health
programs
Insufficient bundling of interventions toaddress the multiple causes of anemia
Inadequate supplies, low utilization, andweak demand
Community-based delivery platforms tocomplement 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.
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Actions Needed
Most countries have MMR reduction goals: Ismaternal 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 integratedpackage of services?
Essential Drugs Lists have IFA, deworming, malariadrugs: How can stock outs be eliminated?
Basic health worker training covers anemia: Howadequate is counseling and compliance follow-
up?
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Thank You
SiyabongaDankie
Ke a leboga