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A Strategic Approach

to Anemia Control

This publication was made possible through support provided by the Office of Health, Infectious Disease and Nutrition, of the Bureau for Global Health, U.S. Agency for International Development (USAID).

MOST is managed by the International Science and Technology Institute, Inc.(ISTI) under the terms of Cooperative Agreement No. HRN-A-00-98-0047-00.Partners are the Academy for Educational Development (AED), Helen KellerInternational (HKI), the International Food Policy Research Institute (IFPRI), andJohns Hopkins University (JHU). Resource institutions are CARE, the InternationalExecutive Service Corps (IESC), Population Services International (PSI), Programfor Appropriate Technology in Health (PATH), and Save the Children.

The opinions expressed in this document are those of the author(s) and do notnecessarily reflect the views of the U.S. Agency for International Development.

Suggested Citation:MOST, USAID Micronutrient Program. 2004. A Strategic Approach to AnemiaControl Programs. Arlington, Virginia, USA: MOST, USAID Micronutrient Program.

Photo: Vicki MacDonald

A Strategic Approach

to Anemia Control

M a r c h 2 0 0 4

Philip Harvey

MOST, The USAID Micronutrient Program

Anemia is a huge public health and nutrition problem with serious consequences.

Anemia is particularly common in pregnant women and young children in developing

countries. Anemia increases maternal and perinatal mortality, has adverse effects on

cognitive development, and reduces physical capacity and work productivity in adults.

Anemia Control 1

Table of Contents

List of Acronyms .................................................................................................2

Executive Summary.............................................................................................3

Introduction ........................................................................................................5

Basic Information for Developing an Anemia Control Program........6

What is anemia?............................................................................................6

What are the causes of anemia? .....................................................................6

What are the consequences of anemia?...........................................................6

When is anemia a public health problem? ......................................................7

How are the target groups for an anemia control program determined? ............7

What interventions should be selected? ..........................................................8

Developing a Country Strategy and Program.........................................9

An Anemia Control Program Model ................................................................9

Program Components...................................................................................12

Increasing Iron and Folate Intake..................................................................12

Supplementation..........................................................................................12

Supplementation Issues Relevant to Specific Target Groups ............................14

A Food-based Approach: Fortification of Staple Foods....................................15

Other Food-based Approaches ......................................................................16

Malaria Control............................................................................................17

Parasitic Worms ...........................................................................................18

Advocacy and Behavior Change Communications..........................................20

Implementing Priority Interventions..............................................................20

Monitoring and Evaluation ...........................................................................21

Endnotes .....................................................................................................22

Figures

Figure 1: Anemia Control Program Model......................................................10

Figure 2: Iron/Folate Supplementation Program Framework ...........................13

Figure 3: Fortification Program Framework....................................................16

2 MOST, The USAID Micronutrient Program

List of Acronyms

AIDS Acquired immune deficiency syndrome

ANC Antenatal care

BCC Behavior change communication

GAIN Global Alliance for Improved Nutrition

CIDA Canadian International Development Agency

HIV Human immune deficiency virus

IDA Iron deficiency anemia

IEC Information, education and communication

IFA Iron and folic acid

IMCI Integrated management of childhood illnesses

INACG International Nutritional Anemia Consultative Group

IPT Intermittent preventive treatment

ITM Insecticide-treated materials

MOH Ministry of Health

MOST USAID Micronutrient Program

NGO Non-governmental organization

PZQ Praziquantel

RBM Roll Back Malaria Program

USAID United States Agency for International Development

WHO World Health Organization

Anemia Control 3

Executive Summary

Anemia is a huge public health and nutrition problem with serious

consequences. Anemia is particularly common in pregnant women

and young children in developing countries. Anemia increases

maternal and perinatal mortality, has adverse effects on cognitive develop-

ment, and reduces physical capacity and work productivity in adults.

Despite its significance to public health and nutrition, anemia often has

been a low priority on the agendas of ministries of health and of donors.

Few countries have been able to reduce the anemia problem on a large

scale. This brief describes a strategic approach to reducing anemia that is

based on addressing comprehensively its major preventable causes in the

target population. It draws on the experiences that MOST, the USAID

Micronutrient Program, has had in supporting the ministries of health in

the Democratic Republic of the Congo, Ghana, Uganda, and Nicaragua in

developing approaches to address anemia.

Anemia has multiple causes—including the inadequate intake of iron

and other nutrients, poor absorption of iron, malaria, parasitic worms,

infections, and genetic disorders. Over recent years, awareness has grown

that success in reducing anemia will require coordinated, and even inte-

grated, interventions that address its major preventable causes in popula-

tions, i.e., that reducing anemia is about more than food and nutrition.

Such an approach requires collaboration across units within ministries,

even across sectors, and there is limited programmatic experience of such

collaboration.

An anemia control program framework is presented; it starts with

high-level advocacy and the creation of an anemia task force. The anemia

task force guides a situational analysis that compiles what is known of

anemia prevalence and causes, related policies and programs, the econom-

ic context of anemia, and the political commitment to address it. Finally

this analysis assesses the capacity of institutions that may become

involved in program implementation. The information from the situational

analysis is used in writing a strategy to guide the coordinated implementa-

tion of selected interventions. This strategy will include increasing iron and

folate intakes, and where necessary, controlling malaria and parasitic

worms. Each of these interventions is described in detail in this brief.

Ministries of health can use this framework to design a well-coordinated

anemia strategy with the goal of decreasing anemia prevalence.

Despite its significance to

public health and nutri-

tion, anemia often has

been a low priority on the

agendas of ministries of

health and of donors. Few

countries have been able

to reduce the anemia

problem on a large scale.


Successful implementation of the anemia strategy must be built

upon a foundation of four key elements:

� Effective advocacy with policy makers and community leaders. To

raise the profile of anemia as a significant public health problem,

such advocacy is the critical first step in building the political will

and accessing the resources to sustain any action.

� Increasing the overall quality and coverage of health careservices. Motivating staff, strengthening logistics, and improving

training and supervision. In many situations, community-based dis-

tribution mechanisms will be necessary to extend the reach of health

services.

� Enhancing communication materials. These materials are needed

both to assist health workers in counseling clients and to aid clients

in complying with the advice they receive.

� Collecting and using information about program implementationto strengthen the management and increase the quality of service

provided.

The anemia task force guides a

situational analysis that compiles

what is known of anemia preva-

lence and causes, related policies

and programs, the economic con-

text of anemia, and the political

commitment to address it.

Anemia Control 5

Anemia is a huge public health and nutrition problem in developingcountries. The World Health Organization (WHO) estimates that anemiaaffects between one-quarter to one-third of the world’s population or up

to 2 billion people. Iron deficiency affects many more people. Most of the ane-mic population lives in developing countries, where high anemia prevalence isseen, particularly in pregnant women, young children, female adolescents, andwomen of childbearing age.

Overall, anemia contributes to about 20 percent of maternal and perinataldeaths in developing countries. A recent WHO World Health Report noted thatthe risks of both maternal and perinatal mortality were reduced by 25 percentand 28 percent, respectively, for each gram increase in hemoglobin levelbetween 50 and 120 g/L. This is contrary to the previous generally acceptedunderstanding that only severe anemia resulted in death. This finding is veryimportant because the numbers of women and children with mild and moder-ate anemia are vastly greater than the number with severe anemia. It followsthen that the great majority of anemia-related maternal and perinatal deaths aredue to mild and moderate anemia rather than severe anemia.

Anemia’s other serious negative consequences include poor pregnancy out-comes such as low birth weight and premature birth. Anemia also has adverseimplications for social and economic development. There is now strong evi-dence that anemia can reduce cognitive development and limit a child’s learn-ing in schools. This will lower the effectiveness of investments in education.Anemia’s role in reducing physical capacity and work productivity in adults hasbeen long established.

Nevertheless, anemia continues to have a relatively low priority in healthpolicies and programs, compared to other nutrition-related health problemswith more obvious life-threatening implications. Difficulties are posed by ane-mia’s multiple causes and by the still-limited programmatic experience in andinsufficient evidence on effective intervention approaches and best practices tocontrol anemia. These are major constraints for policy formulation and programdevelopment. A better understanding of the etiology or causes of anemia andthe identification of critical issues related to effective anemia program designand implementation are key to developing more successful actions. Recentprogress in understanding the nature of the problem and the achievements andlimitations of existing programs provides a firm basis for designing effectivestrategies and interventions.

MOST, the USAID Micronutrient Program, has supported ministries of health in the Democratic Republic of the Congo, Ghana, Uganda, andNicaragua to develop approaches to address anemia. This brief describes theMOST Project’s experiences together with the options now available foraddressing anemia in developing countries. A strategic approach to reducinganemia is presented that is based on addressing comprehensively its major preventable causes in the target population.

Introduction

Overall, anemia con-

tributes to about 20

percent of maternal

and perinatal deaths in

developing countries. A

recent WHO World

Health Report noted

that the risks of both

maternal and perinatal

mortality were reduced

by 25 percent and 28

percent, respectively,

for each gram increase

in hemoglobin level

between 50 and 120 g/L.

What is anemia?

Anemia occurs when there is an inadequate number of red blood cells or

an inadequate amount of hemoglobin for the body to function properly.

Hemoglobin is a protein in red blood cells that carries oxygen to the

brain, muscular system, immune system, and other parts of the body. Without

adequate oxygen, the physical and mental capacities of individuals are reduced.

What are the causes of anemia?

Anemia has many causes. The most common are the following:

� Inadequate intake of iron and other nutrients, resulting largely from con-suming too little iron in a form that is poorly absorbed. Other nutrient defi-ciencies that contribute to anemia include vitamins A and C, folate,riboflavin, and B12.

� Poor absorption of iron, because dietary components such as phytates incereal foods bind with the little iron present in plant foods making much ofit unavailable for absorption. As a result, iron taken into the body cannot bereadily absorbed and used.

� Malaria, particularly in young children and pregnant women.

� Parasitic worms (e.g., hookworm) and other parasites (schistosomiasis).

� Infections, both chronic and systemic (e.g., HIV/AIDS).

� Genetic disorders such as hemoglobinopathies and sickle cell trait.

The relative contributions of these causes of anemia vary in different countries.To reduce anemia prevalence in a population, it is important to select interven-tions that address the primary causes in that population, as listed above.

What are the consequences of anemia?

Strong evidence links anemia to health and development problems.

� Overall, about 20 percent of maternal and perinatal mortality in developingcountries can be attributed to anemia (World Health Report, 20021). Recentwork has shown that most of this impact is in the mild and moderate gradesof anemia, rather than being limited to severe anemia.2

� Anemia in pregnant women results in lower birthweight babies who have ahigher risk of death.

� Iron deficiency with or without anemia reduces work productivity in adultsand limits cognitive development in children,3 thus limiting their achievementin school and ultimately reducing investment benefits in education.


Basic Information for Developing an Anemia Control Program

Anemia occurs when

there is an inadequate

number of red blood

cells or an inadequate

amount of hemoglobin

for the body to function

properly. Hemoglobin is

a protein in red blood

cells that carries oxygen

to the brain, muscular

system, immune sys-

tem, and other parts of

the body.

When is anemia a public

health problem?

The following WHO-proposed hemo-globin cutoffs for defining anemia inpeople living at sea level are widelyused:

WHO has also proposed a classifica-tion of anemia’s public health signifi-cance in populations based on theprevalence estimated from hemoglo-bin levels as follows:

Estimated regional prevalence ratesin pregnant women are as high as 75percent in Southeast Asia, 55 percent in the Eastern Mediterranean region,50 percent in Africa, and 40 percentin the Western Pacific region and inLatin American and the Caribbean.In children aged 6–59 months, therates are about 65 percent inSoutheast Asia, 45 percent in theEastern Mediterranean region andAfrica, and 20 percent in the EasternPacific and the Latin American andCaribbean regions. Countries with>10 percent anemia prevalence inone or more of the vulnerable groupsshould consider anemia as a signifi-cant public health problem requiring-priority attention.

How are the target groups

for an anemia control pro-

gram determined?

Anemia is so common in developingcountries that difficult choices arerequired to determine the appropriateallocation of scarce resources. Targetgroups for anemia control could bedetermined by considering:

� The strength of evidence for asso-ciations between anemia and itsconsequences (maternal and peri-natal mortality, poor pregnancyoutcome, impaired cognitive devel-opment and learning performancein children, and reduced physicalcapacity and work productivity inadults). These need to be consid-ered separately in different demo-graphic groups.

� An intervention’s likely effective-ness and costs.

� An intervention’s feasibility in aparticular country.

In some populations almost everygroup is affected adversely by anemia,but almost always priorities will needto be established. The most commonpriority target groups are, by rank, asfollows:

1 Pregnant women

2 Young children 6–24 months ofage

3 Female adolescents, eventually aspart of a school-aged childrenapproach

4 Women of childbearing age, main-ly to ensure that women have thebest possible iron status beforethey become pregnant

Anemia Control 7

Age group Hemoglobin level (g/L)

6–59 months 110

5–11 years 115

12–14 years 120

Non-pregnant women 120

Pregnant women 110

Adult males 130

Category of public Prevalence

health significance of anemia

Severe > or = 40%

Moderate 20-39%

Mild 5.0 – 19.9%

Normal < 5.0%

In some populations

almost every group is

affected adversely by

anemia, but almost

always priorities will

need to be established.

What interventions

should be selected?

A central principle of the MOSTapproach to develop anemia reduc-tion strategies is that the interven-tions should be linked to the primarycauses of anemia in a population orpopulation group. This statementmay sound so obvious as to bealmost trivial, but it is often neglect-ed. In particular, uncertainty overiron deficiency’s contribution to over-all anemia is common and, reflectingthis, the terms “anemia” and “irondeficiency anemia” (IDA) have oftenbeen used interchangeably. The lackof clarity in these terms has been abarrier to developing programs withmeasurable impacts. For example,iron supplementation programs willnot reduce anemia caused primarilyby malaria.

Unfortunately, it is difficult to assessthe relative contributions of differentetiologic factors or causes leading toanemia, even in carefully controlledresearch studies. A practical approachto this information gap is to base

planning on the common assumptionthat 50 percent of anemia is causedby iron deficiency. Where malariaand/or parasitic worms are recog-nized as public health problems, theyare also likely to be important causesof anemia.

Anemia has often been positioned asthe responsibility of nutrition units inthe Ministry of Health and, in somecases, this has been a barrier todeveloping a comprehensive approachto anemia as a health problem ratherthan using a more limited approachto anemia as a nutrition problem.Usually, developing interventionsthat target all of anemia’s major pre-ventable causes rather than restrict-ing interventions to only those thataddress inadequate iron intake willgenerate more political support.Coordinating the interventions thataddress anemia’s major causes willresult in the most effective outcomesin terms of reducing anemia preva-lence. However, coordination of inter-ventions is a substantial challenge inmost countries.


A central principle of the

MOST approach to develop

anemia reduction strategies is

that the interventions should

be linked to the primary caus-

es of anemia in a population

or population group.

An Anemia Control Program Model

Figure 1, on the next page, illustrates the model that MOST found use-

ful in helping ministries of health to develop anemia control program

strategies. The program components are as follows:

1 Conduct high-level advocacy with key policymakers and administratorsin government ministries, donors, universities, and the private sector

who have a stake in reducing anemia. A key out-come will be national-level political commitmentthat will make the anemia program intrinsicallymore stable.

2 Facilitate the creation of an anemia taskforce, a core group of stakeholders that isresponsible for overseeing the process of devel-oping the strategy and then implementing anational anemia program. Obtaining the genuinecollaboration of leaders in reproductive health,malaria, nutrition, parasite control, and educa-tion may be the most important challenge inimplementing integrated anemia programs.

3 Support a situational analysis that includes anassessment of the anemia problem (prevalenceand distribution), current policies and programs,institutional resources available, and the existingcapacity to implement interventions. Identify andengage appropriate stakeholders in the situation-al analysis to develop program ownership.

A situational analysis should:

� Establish what is known about the causes of anemia (i.e., diet,malaria, helminthes, inherited traits).

� Describe the health status and also the policies and programs relatedto these causes and how well they are conceived and managed.

� Describe the political commitment to and economic context withinwhich anemia programs might be implemented, as these two factorsare critically important to program sustainability.

� Assess the resources and capacity of institutions that may becomeinvolved in program implementation. There is a broad range of activ-ities that the private sector can become involved in as a partner. Forexample, small retail outlets could receive a supply of treatments for

Anemia Control 9

Developing a Country Strategy and Program

Basic Assumptions Underlying

Anemia Control Strategy

� Unless otherwise documented, iron deficien-cy causes about half of all anemia cases indeveloping countries.

� Wherever malaria and parasitic worms(mostly hookworm) are significant publichealth problems, they are likely to make animportant contribution to anemia prevalence.

� In countries where other micronutrient defi-ciencies exist, particularly those of vitaminsA and C, folate, riboflavin, and B12, thesedeficiencies may play a defined although not-yet-quantified contribution to anemia inthose countries.

� Therefore, anemia’s multiple causes call forintegrated public health and cross-sectoralstrategies, with multiple interventions toaddress factors in addition to iron deficiency.

Anemia Control

StrategyDevelopment


Figure 1: Anemia Control Program Model

Creation of an Anemia Task Force

Advocacy

Country Situation Analysis

Health Status and

Health Care

Environment� Political

� Economic� Geographic

InstitutionalResources &

Capacity� Industry� NGOs

Anemia

Distributionand

Causes

I N F O R M A T I O N

Develop and BuildCommitment to

an Anemia Control Strategy

Malaria

� IntermittentPreventive Treatment

� Insecticide-TreatedMaterials

� Case Management

Inadequate Fe/folate,Vitamin A

� Supplementation

� Fortification

� Nutrition Education

Parasitic Worms

� Chemotherapy

� Improved Sanitation

� Health Education

Supply of Services and Products:

Advocacy, training, logistics, IEC, BCC, social marketing

Public Demand Creation:

IEC, BCC, social marketing, community mobilization

Monitoring and Evaluation

iron deficiency, malaria, and para-sitic worms through improved dis-tribution chains. Non-governmen-tal organizations (NGOs) alsohave enormous potential, particu-larly in implementing small-scaleinitiatives that often act as cata-lysts to convince governments thatit is worthwhile to scale up pro-grams to the national level.

� Identify information gaps thatcould hinder strategy and programdevelopment.

4 Assist the anemia task force todraft an anemia strategy througha process that builds ownership ofand hence commitment to its suc-cessful implementation. In addi-tion to specifying goals and specif-ic time-bound objectives, the strat-egy should include the mecha-nisms by which different govern-ment and non-government institu-tions will coordinate efforts in anintegrated program.

5 Update protocols, guidelines,communication materials, andtraining programs needed tostrengthen the separate programsthat are strategic components. Insub-Saharan Africa, likely programcomponents will be interventionsto:

1) increase iron and folateintake,

2) control malaria, and

3) control parasitic worms.(Each intervention is describedbelow in more detail.)

6 Supply: The program componentsinvolve delivery of services and, in many cases, of products. The

supply of these services and products requires:

a) Advocacy at all levels to ensureadequate political and financialsupport for the products andservices

b) Training of health personnelwho will deliver the servicesand products

c) Logistics to ensure that theproducts are available in suffi-cient quantities where andwhen they are needed

d) Adequate communication andsocial marketing support tofacilitate delivery of the servic-es and products. It is prudentpolicy to begin implementationin a limited area to resolveoperational supply issuesbefore scaling up to nationalimplementation.

7 Increase demand: Once the provi-sion of quality anemia controlservices and products are in placeand ensured, public demand mustbe created. Information, educationand communication (IEC), behav-ior change communication (BCC),social marketing, and communitymobilization are strategies used toincrease correct knowledge, forgepositive attitudes, and improvedesired practices that lead to bet-ter anemia control.

8 Develop a monitoring and evalu-ation system that provides infor-mation needed for efficient pro-gram coordination and manage-ment and ensures that programeffectiveness is assessed in a time-ly manner.

Anemia Control 11

Information, education

and communication

(IEC), behavior change

communication (BCC),

social marketing, and

community mobiliza-

tion are strategies used

to increase correct

knowledge, forge

positive attitudes, and

improve desired

practices that lead to

better anemia control.

Program Components

The three major program componentsare:

1 Increasing iron intake

2 Malaria control

3 Reducing parasitic worm loads

Increasing Iron and Folate Intake

Inadequate consumption of absorbableiron and folate are the major causes ofanemia worldwide. Supplementationand food-based approaches are basicto increasing iron and folate intake.The food-based approach includes for-tification and interventions to improvethe overall diet.

Supplementation

Background: Supplementationwith iron and folate, at a minimum,targeted to pre-selected prioritygroups is required almost universally

in developing countries as a keycomponent of an anemia control program (see figure 2). Virtually allpregnant women in developing coun-tries require substantially more ironthan is available from their diet tomeet their nutritional needs. Dailyiron supplements, usually togetherwith folic acid, are recommended forall pregnant women, so there is noneed to screen women individuallyfor anemia to determine whether ornot to give them supplements.

Policies describing IFA supplementationare almost always an integral compo-nent of antenatal/postnatal care serv-ices, but in many developing coun-tries pregnant women do not accessthese services or do not have ade-quate access to the services to reduceanemia prevalence; they do not attendantenatal care clinics early or frequent-ly enough. Understanding and thenaddressing the determinants of thesebehaviors is essential to enhancinganemia services for pregnant women(see box 2). Even for women whoattend antenatal care services regular-ly, it is important to address issuesthat affect their compliance with IFAsupplements.

Implementation: Evidence is nowavailable from effective large-scalesupplementation programs in Indonesiaand Thailand.4 For many years suchevidence was lacking, but this waslargely because of either weak programimplementation or because the pro-grams were being implemented in pop-ulations where iron/folate deficiencywas not the sole cause of anemia.Examples of common “system failures”include: inadequate supply ofiron/folate tablets and other drugs;inadequate supervision; poor trainingand motivation of health workers; and


Is it safe to give iron supplementation to clients with

anemia in areas where malaria is common?

Yes, it is. Oral iron supplementation is the most effective and com-monly used approach to treat anemia resulting from iron deficien-cy. Yet in areas where malaria is common, some argue that usingiron supplements is not a good idea because it will increase therisk of malarial infections. These people argue that it is better notto treat the anemia.

To arrive at a more definitive answer, an analysis of 13 researchstudies addressing this question was conducted. The analysis pro-vided a clear conclusion: in malaria-endemic regions, iron supple-mentation’s known benefits outweigh the small risk of adverseeffects that malaria causes. The practical implication is that ironsupplementation should continue to be recommended in malaria-endemic areas where iron deficiency anemia is common.

An INACG Consensus Statement on this issue provides a summaryof the methods, results and conclusions of the meta-analysis. It isavailable at: http://www.ilsi.org/malaria.pdf.

Inadequate consumption

of absorbable iron and

folate are the major caus-

es of anemia worldwide.

Supplementation and

food-based approaches are

basic to increasing iron

and folate intake.

lack of appropriate counseling on sup-plementation’s side-effects, provision ofmemory aides, and follow-up toenhance compliance.

Given the need for frequent distributionof supplements to be consumed eitherdaily or intermittently, iron/folate sup-plementation is generally not amenableto a campaign-style approach. Rather,supplementation should become anintegral component of routine healthservices and/or make use of comple-mentary or alternative distributionchannels (e.g., traditional birth atten-dants, community health volunteers,

family planning programs, NGOs,community workers) and social/com-mercial marketing options (e.g., localpharmacies).

Supplementation for infants andyoung children (6-24 months) is effi-cient, but to our knowledge, has neverbeen scaled up to become an effectiveprogram in a large population. Twoexperimental products hold greatpotential to address anemia in youngchildren: sprinkles and spreads.Sprinkles, as the name implies, aresprinkled onto prepared foods. Theyare packaged in small single-serve

Anemia Control 13

Figure 2: Iron/Folate Supplement Program Framework

� Routine antenatal care� Traditional birth attendants� NGOs, community

volunteers� Social/Commercial marketing

Formative Research

Nationalsupplementation

policies/plansdeveloped

Nationaltask force on

supplementationformed

Iron/Folate Supplementation

Infants and young children

Pregnant/lactatingwomen

Schoolchildren/adolescents and

adult women

� Routine infant and childcare� NGOs, community volunteers� Sprinkles, spreads� Social/Commercial marketing

� School system� Routine health services� Organized youth and women

groups� Social/Commercial marketing

Program planning: Supply of services & products and demand creation/compliance issues addressed, responsibilities assigned, financial

resources secured, operational guidelines prepared.

� Managers and workers� Logistic personnel� Community workers� Volunteers� NGOs� Pharmacists

Training IEC/BCCLogistics

� Health workers� Community, Politicians� Decision-makers� Awareness-raising� Promotion of services &

products

� Technical guidance� Estimating needs� Procurement� Transport� Storage� Distribution� Follow-up


Supplementation Issues Relevant To Specific Target Groups

Pregnant women. Supplementation for pregnant women should be an integral component ofstrengthened antenatal care. Expected coverage goals for iron/folate supplementation for pregnantwomen may not exceed the coverage of antenatal care. Unless this coverage can be increased,expanded supplementation coverage for pregnant women will have to be achieved through alterna-tive delivery channels, such as traditional birth attendants, community health volunteers, familyplanning programs, NGO community workers, and social and commercial marketing.

Infants and young children. Supplementation for infants and children aged 6-24 months should bean integral part of preventive health care; it should be linked to regular infant and child check-ups,immunizations, growth monitoring, and other opportunities for contact with health services targetedto children within the specified age, as well as within the Integrated Management of ChildhoodIllnesses (IMCI). Best practices with iron/folate supplementation of infants and young children havenot been fully established, as experience and evidence of effectiveness is even more limited than forsupplementation for pregnant women. Liquid supplements (syrup, drops) seem the best option atpresent, although little is known about compliance. Distribution of the liquids is more costly becauseof their weight. Dispersible tablets are a relatively new technology that has been well accepted in sev-eral field trials and offer the potential for scaling up. Sprinkles and spreads are recently developedprogram options with demonstrated efficacy that may soon be available for implementation and pos-sible subsequent scaling up. To the extent allowed by the resources available, infants and young chil-dren deserve high priority in view of the exceedingly high anemia prevalence rates and its develop-mental and learning implications. And addressing anemia in young children may have a further impactamong older children.

Schoolchildren and adolescents. Iron supplementation for schoolchildren and adolescents may usedelivery strategies in or outside the health system. High coverage of iron supplementation in school-children is more achievable than in non-secluded population groups (pregnant women, infants, chil-dren). Large-scale programs are not common, probably because anemia prevalence is often lower inpre-adolescent schoolchildren than in other more vulnerable groups (pregnant women, infants, ado-lescent girls) and because of the relatively high overall program costs of covering a significant pro-portion of the large school-aged population. Iron supplementation of schoolchildren is becomingincreasingly popular with growing evidence that it benefits cognitive and learning outcomes inschoolchildren and strong evidence that intermittent, less costly programs are effective. Moreover,international donors may be more interested in supporting nutrition programs that will achieve highcoverage and have demonstrated effectiveness. A disadvantage is that those adolescents not attend-ing school cannot be reached in this approach. Preventive iron/folate supplementation of femaleadolescents makes sense for increasing iron and folate stores to reduce the risk of anemia. Folatesupplements will reduce the incidence of neural tube defects in future pregnancies only if the sup-plements are taken daily.

Women of childbearing age. Preventive supplementation for women of childbearing age may bedelivered through either health service systems or other channels (e.g., factories, labor, and religiousgroups). Experience in this area is growing and looks promising. Cost is clearly a key consideration.Intermittent supplementation through places of employment also has major advantages.Furthermore, the health system may not be the most efficient delivery channel, thus alternativedelivery channels, including social and commercial marketing, need to be explored.

packets. Spreads combine an energysupplement with micronutrients andthus also help in addressing general-ized malnutrition. Both sprinkles andspreads are entirely flexible in terms ofthe composition of the added micronu-trients, i.e., they need not be limited toiron and folate. These “food-based”products bring advantages over tradi-tional supplements as they are notseen as “medicine” and so it is believedthat mothers might be more willing touse them as often as needed (i.e.,almost daily). Some have termed thesetechnologies “home fortification,” butfrom a program viewpoint, they arerelatively expensive and require sub-stantial behavior change among thetarget group. Thus, they do not havethe key advantage of fortification—especially mandatory fortification—itdoes not require behavior change.

A Food-based Approach:Fortification of Staple Foods

Fortification of processed staple foodsor condiments with iron and othernutrients is often considered a goodlong-term strategy to address inade-quate iron intake (see figure 3),although it is widely acknowledgedthat supplementation is required tomeet the iron needs of pregnantwomen. In developed countries, forti-fying wheat flour and breakfast cere-als has been practiced for many yearsand some claim that it has resulted insubstantial anemia reductions. Thefortification approach’s major advan-tage is that it addresses anemia on apopulation basis without requiringchanges in the target group’s dietarybehavior.

The Global Alliance for ImprovedNutrition (GAIN) plans to provide animpetus to the development of fortifi-

cation initiatives. Initiated by the Bill& Melinda Gates Foundation, USAID,and the Canadian InternationalDevelopment Agency (CIDA) andbacked by United Nations agencies aswell as researchers and private sectorconcerns, GAIN was launched at theUnited Nations General AssemblySpecial Session on Children on May 9,2002. GAIN aims to reduce micronu-trient malnutrition through fortifica-tion of mostly staple foods that areconsumed by poor and deficient pop-ulations. GAIN will work through newnational fortification alliances, pursu-ing a public/private partnershipapproach.

Challenges to the wider use of foodfortification in developing countriesinclude:

a) The difficulty of identifying anappropriate fortification vehicle inmany countries, particularly thosewith predominantly rural popula-tions that consume little commer-cially processed foods and manyfoods that inhibit iron absorption.On the other hand, the urban poorare increasing as a proportion ofthe population in many countries,and they depend increasingly onprocessed staples.

b) The choice of fortificant5 remains achallenge—the bioavailability6 offorms of elemental iron, (this isthe form of iron that reacts leastwith food), has been questioned.Forms of iron that are more avail-able for absorption are moreexpensive and tend to react morewith foods.

Efforts to address these constraintsshould include the following:

a) Promoting technical and scientificexchange, e.g., identification ofhighly bioavailable iron fortificants.

Anemia Control 15

In developed countries,

fortifying wheat flour and

breakfast cereals has been

practiced for many years

and some claim that it

has resulted in substan-

tial anemia reductions.

The fortification

approach’s major advan-

tage is that it addresses

anemia on a population

basis without requiring

changes in the target

group’s dietary behavior.

b) Developing partnerships withother interested groups.

c) Developing instruments to facili-tate a systematic assessment of thetechnical, economic, and politicalfeasibility of fortifying commercial-ly processed food staples common-ly found in developing countriessuch as wheat or corn flour andmaize meal.

d) Establishing systematic monitoringand evaluation of iron fortificationprograms.

Other Food-based Approaches

Interventions that increase diet diver-sity are appealing because theyimprove overall food security and theintake of many, not single, micronu-trients. However, there is no strongevidence of their effectiveness oreven efficacy. This lack of evidencedoes not necessarily mean that theinterventions have no impact butrather that their impacts are extremelydifficult to measure. The market price


Figure 3: Fortification Program Framework

Identification of potential food vehiclesFortification

StrategyDeveloped

National task force forfortification with both

public & private representatives

Food Fortification

� Food consumption and impact analysis� Assessment of industry structure & capacity� Stability tests, if needed� Technical & economic feasibility

� Fortification� Technology� Quality assurance and

control

Production MarketingRegulation/enforcement

� Market analysis� Product specification� Price structure� Promotion

� Distribution

� Standards/labeling

� Monitoring andEnforcement

Selection of appropriate staple food vehiclesand fortificant levels

Field Implementation

Monitoring and Evaluation/Impact Assessment

DevelopStrengthenLegislation

of foods containing highly bioavail-able iron, most of them from animals,is a major constraint to food-basedapproaches other than fortification.Diet-based strategies hold enormouspotential for broadly-based benefitsand warrant further investments fortheir development and rigorous evalu-ation.

A promising approach is the effort tochange dietary practices away fromthose that result in a reduced absorp-tion of iron from foods consumed(e.g., drinking tea or coffee withmeals) and towards those that willincrease iron absorption (e.g., fer-menting and germinating selectedcereals). However, dietary behaviorsare usually influenced strongly by cul-tural and environmental factors andthus are difficult to change in sustain-able ways.

Malaria Control

Background: Malaria causes anemiaboth by destroying red blood cells(hemolysis) and also by suppressingthe production of new red blood cells.In many countries, particularly in sub-Saharan Africa, malaria is a majorcause of anemia in pregnant womenand young children. It may be themajor cause of severe anemia in someareas, especially in young children.

Malaria’s impact on anemia is deter-mined by whether malaria transmis-sion is high and year-round (stable)or low and seasonal (epidemic). Inareas where malaria is endemic,much of the population developsimmunity to the parasite and to someextent, this limits its impact on ane-mia. Women in their first and secondpregnancies and children less than 2or 3 years of age are at the greatestrisk of malarial infection and resulting

anemia. For the pregnant women,malarial infections cause anemia thatcan result in morbidity and mortalityand in low birth weight. Malariainfections in the first and second preg-nancies also reduce the integrity ofthe placenta, which results in reducednutrient transfer to the fetus; this fur-ther accentuates anemia’s impact onlow birth weight, a leading cause ofinfant mortality.

In areas of low or epidemic malariatransmission and for HIV-infectedwomen, malaria affects all pregnancies,not just the first two. It results in clini-cal illness, severe diseases, and highrisks to both the mother and the fetus.

Interventions: Over the last decadethree interventions—intermittent pre-ventive treatment (IPT), insecticide-treated materials (ITM), and casemanagement—have been establishedas simple and cost-effective strategiesto reduce both malaria and anemia inpregnancy. Intermittent therapyinvolves the administration of full cur-ative treatment doses of an effectiveanti-malarial drug at predefined timeintervals during pregnancy. This is aclinic-based intervention. Treating bed-nets and other household materialssuch as curtains has been shown toreduce the vector population andhence reduce exposure to malarialinfections not just in households usingITM, but also in other nearby housesthat have not used ITM. Together withteaching caregivers how to recognizeand treat promptly malaria infectionsymptoms, this intervention has beenimplemented successfully throughcommunity-based programs. Wheremalaria control programs are beingimplemented effectively, options tocoordinate them with other anemiacontrol efforts should be explored.

Anemia Control 17

Malaria causes anemia

both by destroying red

blood cells (hemolysis) and

also by suppressing the

production of new red

blood cells. In many coun-

tries, particularly in sub-

Saharan Africa, malaria is

a major cause of anemia in

pregnant women and

young children.

Over the last decade, WHO’s RollBack Malaria Program (RBM) hasmade major strides in strengtheningboth policy and programs to addressmalaria. RBM has made special effortsto establish links with the WHO SafeMotherhood program to addressmalaria in pregnancy and with IMCIfor case management of malaria inchildren. RBM’s technical strategiesinclude:

� Prompt access to treatment, especially for young children

� Prevention and control in preg-nant women

� Vector control

� Prediction and containment of epidemics

RBM field research has generatedcompelling evidence for the efficacyof these approaches, particularly insub-Saharan Africa. The approachestarget young children and pregnantwomen for immediate results in themost vulnerable groups, but alsoaddress the larger need for affordableand sustainable approaches to reducethe disease burden at the communityand country levels.

Parasitic Worms 7

Background: Several species of para-sitic worms—hookworms and schisto-somes in particular—cause blood lossand hence iron loss. Hookworms con-tribute to anemia in several ways:

� Feeding on blood

� Bleeding caused by damage fromtheir feeding; this is made worseby the effects of anticoagulants thatthe worms secrete when feeding

� Reducing iron absorption becausethe worms’ feeding damages theintestinal lining where most of theiron is absorbed

� Heavy worm burdens impair appetite

� Lastly, in a cyclical way, the ane-mia that hookworms contribute tomay reduce a person’s productivi-ty that, in turn, reduces the per-son’s food quantity and quality.This may happen either directly infarming communities—when afarmer with anemia is less able toproduce foodstuffs— or indirect-ly—when a person with anemia isless able to work and so earns lessmoney to purchase food.

Female schistosome worms lay eggsin blood vessels around the gut orbladder walls, depending on thespecies. The eggs have sharp spines tohelp them to penetrate tissue so thatthey can leave the body in the fecesor urine. The holes that are made bythese eggs cause bleeding and, as aresult, hemoglobin is lost into the gut(in the case of Schistosoma mansoniand S. japonicum) and into the blad-der (in the case of S. hematobium).

Parasitic worms contribute to irondeficiency and anemia when the ironloss from the body from infections is greater than the amount of ironabsorbed from the diet and iron storesare depleted. The amount of blood achild loses due to parasitic wormsdepends on the number of wormspresent, and worm loads usually buildup slowly. Parasitic worms generallydo not multiply within their host, i.e.,each worm is the result of separateinfection. Moderate to heavy wormloads typically result from exposure toworms over long periods. This under-lies the importance of reducing trans-mission though sanitation. The heavi-est hookworm infections tend tooccur in adolescents and adults andthus may make an important contri-bution to anemia in pregnant women.Hookworm infection in preschool


Parasitic worms contribute

to iron deficiency and ane-

mia when the iron loss from

the body from infections is

greater than the amount of

iron absorbed from the diet

and iron stores are depleted.

children may not be a major cause ofanemia because the loads are general-ly not heavy, but including preschoolchildren in de-worming programsearly on may delay substantially theonset of anemia, a major advantage.

Treatment: While traditionally,deworming treatment was given tochildren two years of age and older,there are several good reasons to de-worm preschool children, eventhough this may not reduce anemiameasurably in this age group. Studiesfrom India, Kenya, and South Africahave demonstrated that periodicanthelminthic treatment improvesgrowth, physical fitness, appetite, andalso enhances a child’s cognitive per-formance. A recent WHO consultationconcluded that it is both safe and rec-ommended to deworm children overone year of age8 in endemic areas.Worm-free children also have bettervitamin A status and better immuneresponses.

Communities usually place a highvalue on deworming and thus includ-ing deworming in a package of pre-ventive services will likely enhancecoverage for the entire package ofhealth services. Adding deworming tothe package of preventive services forchildren in the critical second year oflife will bring substantial benefits tothe children. For example, addingdeworming to twice-annual vitamin Adistribution rounds and immunizationcampaigns offers a unique opportunityto reach small children. Reasons foradding deworming to a package of pre-ventive services include the following:

� The drugs are safe, cheap, andeasy to administer.

� The drugs have almost no sideeffects and are effective againstmost parasitic worms (helminthes).

� Non-medics, such as schoolteach-ers, can be trained to give thedrugs.

� The health benefits are immediateand apparent (e.g., expulsion ofround worms).

� There is compelling evidence ofsubstantial health benefits in boththe short- and long-term.

Parasitic worm infections in pregnantwomen are likely to contribute strong-ly to anemia. WHO recommends asingle-dose, oral anthelminthic9 treat-ment for hookworm infection for allpregnant and lactating women inareas of high hookworm prevalence.10

During antenatal contacts in hook-worm endemic areas, health workersshould give pregnant women a treat-ment once in the second trimester. Ifhookworms are highly endemic—i.e.,greater than 50 percent prevalence—health workers should give women anadditional dose in the third trimester ofpregnancy.

Several safe and effective drugs areavailable to treat parasitic worms. Thechoice of these drugs depends on theirsafety record, therapeutic effect, curerate or efficacy, activity spectrum,experience of local health profession-als, staff training, and cost.

� The benzimidazoles (mebendazoleand albendazole) are the mostcommonly used drugs to treathookworm and other intestinalworms.

� Albendazole is recommended as asingle dose of 400 mg and meben-dazole either as a single dose of500 mg or as 100 mg twice dailyfor three days. Some are now dis-couraging the latter because ofconcern about compliance in com-pleting the full 3-day treatment.

Anemia Control 19

Several safe and effective

drugs are available to

treat parasitic worms.

The choice of these drugs

depends on their safety

record, therapeutic effect,

cure rate or efficacy,

activity spectrum, experi-

ence of local health pro-

fessionals, staff training,

and cost.

� Praziquantel (PZQ) is recommend-ed for treating schistosomiasis.11

The recent WHO informal consul-tation12 recommended that allinfected pregnant and lactatingwomen be offered PZQ treatmenteither individually or during treat-ment campaigns. PZQ is alsobeing given to school-aged chil-dren with the dose determined onthe basis of height.

Advocacy and BehaviorChange Communications

As mentioned above, advocacy andBCC interventions should always bepart of an integrated approach to ane-mia control programs. The advocacyand BCC interventions should havefive general objectives:

1 Create and raise awareness of ane-mia’s magnitude and its seriousimplications for the individual andthe nation’s social and economicdevelopment. The interventionshould target all levels of society,but particularly policymakers andadministrators from all sectors togenerate a firm political commit-ment to address anemia.

2 Improve health care workers’ moti-vation and ability to get activelyinvolved in iron/folate supplemen-tation programs. Enhance theirknowledge of the program’s impor-tance and the appropriate dosages,and upgrade their skills in counsel-ing and follow-up.

3 Enhance demand and compliancewith iron/folate supplements in thepopulation.

4 Promote specific changes in dietarypractices that are aimed at reducingthe consumption of inhibitors ofiron absorption or removing themfrom the diet (e.g., through soaking

and/or fermenting cereals), andincreasing the intake of enhancersof iron absorption (e.g., fruit, juicesand other sources of vitamin C).Another approach to increasingabsorption is to encourage the con-sumption of tea and coffee at timesother than when sources of ironare consumed.

5 To the extent possible, promoteincreased consumption of foodsources of bioavailable iron, includ-ing fortified foods.

A recent International NutritionalAnemia Consultative Group (INACG)publication describes in detail the roleof communication in a comprehensiveanemia control program.13

Implementing PriorityInterventions

Because financial and human resourcesare always limited, interventions mustbe prioritized. Issues to be consideredin determining intervention prioritiesinclude:

� Existing Ministry of Health priori-ties and policymakers’ interests

� Operational feasibility

� Availability of resources (this maybe in the donor’s interest)

� Opportunities to build on existingprograms and/or capacities ofhealth care and other services. For example, the training pro-grams required to introduce IPT inpregnancy could incorporate revi-sions and training for the ironfolate supplementation programwhere appropriate

� Evidence of the costs and effec-tiveness of selected interventions

In many countries, the Ministry ofHealth places the highest priority onreducing anemia in pregnant women.


In many countries, the

Ministry of Health places

the highest priority on

reducing anemia in preg-

nant women. This priority

is justified by the strength

of evidence linking anemia

to maternal mortality and

because antenatal care

(ANC) services are often

well established and

accepted and have the

potential to provide a range

of interventions.

This priority is justified by thestrength of evidence linking anemia tomaternal mortality and because ante-natal care (ANC) services are oftenwell established and accepted andhave the potential to provide a rangeof interventions. ANC services providethe contact point for health workersand pregnant women and thus theANC anemia component is key toreducing anemia in this target group.Reproductive health or maternal andchild health units have the primaryresponsibility for implementing ANCservices, but traditionally there hasnot been a strong link between repro-ductive health, malaria control, andnutrition.

It is a very challenging task to coordi-nate and/or integrate the programs ofvarious health units, perhaps the mostchallenging task of this anemia controlapproach. The government units thatare responsible for the programs thataddress preventable causes of anemiawill need to strengthen logistics, develop communication materials,and provide training and supervisionin a collaborative manner. Often,donors and their technical representa-tives can facilitate this cooperationand these opportunities should not be missed.

Monitoring and Evaluation

Monitoring the process of implementinganemia control interventions, evalu-ating the program outcomes, andeventually evaluating their long-termimpact in reducing anemia should be a defined program componentfrom the outset. Monitoring and evaluation activities may provide amechanism to assist the various unitsof the Ministry of Health in coordi-nating their programs. Certainly

cooperation gaps will become quick-ly apparent through monitoring activ-ities. For example, indicators mightinclude activities in district work-plans to coordinate program compo-nents, and the extent to which repro-ductive health, malaria control, andnutrition units have established com-mon or shared budgets or resourcesor have produced communicationand training materials that covermore than one cause of anemia.

Hemoglobin concentration is theaccepted anemia indicator in popula-tions, but there are some controver-sies associated with its interpretation.The cutoff points that WHO hasdefined (see above) are widely usedbut are not clearly linked to specificfunctional outcomes. Because of thissome argue that ‘mild’ anemia is nota public health concern and thusresources should be focussed solelyon treating severe anemia. Anothercontroversy concerns the need toadjust hemoglobin concentrations inpopulations of African extraction.Hemoglobin concentrations are stan-dardly adjusted for altitude andsmoking and WHO also recommendsthat the cutoff for populations ofAfrican extraction be adjusted down-ward by 1 g/dL irrespective of age.14

Anemia Control 21

It is a very challenging

task to coordinate and/or

integrate the programs

of various health units,

perhaps the most

challenging task of this

anemia control approach.

1 World Health Report 2002. World Bank.<http://www.who.int/whr/2002/en/>(2002).

2 Stoltzfus, R. J., L. Mullany, and R. E. Black. Iron deficiency anemia.Comparative quantification of health risks: The global burden of diseasedue to 25 selected major risk factors. Cambridge: Harvard UniversityPress (In Press).

3 A WHO/INACG group reviewed the strength of the evidence linking irondeficiency or anemia to health and development outcomes in May 2000.The proceedings of this meeting were published in the Journal ofNutrition Supplement, February 2001, Volume 131, No. 2S-II, and areavailable online at www.nutrition.org.

4 Galloway, R. 2003. Anemia Prevention and Control: What Works, Part I-Program Guidance. Population, Health and Nutrition Information Project.Washington, DC, 2003.

5 Prescribed compound which provides the micronutrients.

6 The degree to which a drug or other substance becomes available to thebody or target tissue after it is ingested.

7 Material in this section cites information presented by Andrew Hall et al.,“Public health measures to control helminth infections,” in RamakrishnanU., Ed. Nutritional Anemias, CRC Press, (New York, 2001), 215-239.

8 “Report of the Informal Consultation on the Use of Praziquantel duringPregnancy/Lactation and Albendazole/Mebendazole in Children less than24 Months.” World Health Organization. Geneva (DocumentWHO/CPE/PVC 2002/4).

9 A compound that kills or expels parasitic intestinal worms (helminthes).

10 “Report of the WHO Informal Consultation on Hookworm Infection andAnemia in Girls and Women.” World Health Organization. Geneva(Document WHO/CTD/SIP/ 96.1).

11 An infestation with or a resulting infection caused by a parasite of thegenus Schistosoma; it is common in the tropics and Far East; symptomsdepend on the part of the body infected.

12 “Report of the Informal Consultation on the Use of Praziquantel duringPregnancy/Lactation and Albendazole/Mebendazole in Children less than24 Months.” World Health Organization. Geneva (DocumentWHO/CPE/PVC 2002/4).

13 Hyde et al., “The role of communication in comprehensive anemia con-trol: a framework for planning and implementing a strategic communica-tion plan,” INACG, http://inacg.ilsi.org/publications.

14 Described in INACG brief “Adjusting hemoglobin values in program surveys,” available at http://inacg.ilsi.org/publications.


Endnotes

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