klemm_anemia prevalence, burden of disease and programmatic considerations

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:1


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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

klemm_anemia prevalence, burden of disease and programmatic considerations

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