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THE PREVALENCE OF NUTRITIONAL LA PREVALENCE DE L'ANEMIE ANAEMIA IN WOMEN IN DEVELOPING NUTRITIONNELLE CHEZ LES FEMMES DES COUNTRIES•: A CRITICAL REVIEW OF PAYS EN DEVELOPPEMENT•: ETUDE CRITIQUE AVAILABLE INFORMATION DES DONNEES

E. Roystonb E. Roystonb

INTRODUCTION INTRODUCTION

Anaemia is one of the most frequently observed diseases Actuellement, l'anemie est l'une des maladies les plus in the world today. It is especially prevalent in young chil­ frequemment observees dans le monde. Elle sevit tout par­ dren, women of reproductive age, and during pregnancy. ticulierement chez les jeunes enfants, les femmes en §ge de The causes of anaemia are multiple, but there is no doubt procreer, et pendant Ia grossesse. Ses causes sont multi­ that young children and women are specially affected ples mais il est indeniable que les jeunes enfants et les because of their relatively high requirements for iron. The femmes sont particulierement touches en raison de leurs amounts needed to cover the requirements for growth dur­ besoins relativement eleves en fer. Les quantites de fer ing childhood or of the fetus during pregnancy and to necessaires pour couvrir les besoins de Ia croissance pen­ replace the losses of blood due to menstruation often dant l'enfance ou Ia vie fretale, ainsi que pour remplacer les exceed the quantities of iron available from the daily diet. pertes de sang consecutives aux regles depassent souvent This is especially true when the latter contains few animal celles qui peuvent etre obtenues de !'alimentation quoti­ products or is even entirely vegetarian, as is the case in dienne. C'est particulierement vrai lorsque cette derniere some populations. This, compounded with the high para­ contient peu de produits d' origine animale ou est meme sitic load observed in tropical and subtropical areas, ex­ entierement vegetarienne, comme c'est le cas dans certai­ plains the high prevalence of iron-deficiency anaemia in nes populations. Cette situation, combinee a Ia charge para­ developing countries. The populations of developed coun­ sitaire elevee que I' on observe dans les regions tropicales et tries are not by any means completely free of anaemia, and subtropicales, explique Ia prevalence elevee de l'anemie a small but significant percentage of women of childbearing ferriprive dans les pays en developpement. Les populations age, especially young women and those on a reducing diet, des pays developpes ne sont en aucun cas absolument suffer from iron-deficiency anaemia. indemnes d'anemie et un pourcentage, faible mais revela­ teur, de femmes en ilge de procreer particulierement de jeunes femmes et de celles qui suivent un regime amaigris­ sant souffrent d'anemie ferriprive. Anaemia in its severest form can lead to death, but this is Sous sa forme Ia plus grave, l'anemie peut entrainer Ia rare. It does, however, have a profound effect on the psy­ mort, mais ce cas extreme est rare. Toutefois, Ia maladie a chological and physical behavtour of the individual. The mild un profond retentissement sur le comportement psycholo­ and moderate degrees of anaemia which are much more gique et physique de l'individu. Les anemies legeres et frequent are under normal circumstances, more or less well moyennes qui sont beaucoup plus frequentes sont, dans tolerated. Nevertheless they lessen the resistance to fa­ des circonstances normales, plus ou moins bien tolerees. ttgue and affect work capacity under conditions of stress. Ouoi qu'il en soit, elles diminuent Ia resistance a Ia fatigue et Even very mild forms influence the sense of wellbeing. In alterent Ia capacite de travail dans des conditions de ten­ pregnancy, anaemia has been shown to be associated with sion. Me me des formes tres legeres d' anemie influent sur le an increased risk of maternal and fetal morbidity and mor­ sentiment de bien-etre. Pendant Ia grossesse, on a montre tality. que l'anemie est associee a un risque accru de morbidite et de mortalite maternelle et fretale.

WHAT IS NUTRITIONAL ANAEMIA? QU'EST-CE QUE L' AN EM IE NUTRITION NELLE?

Nutnttonal anaemia is not a disease entity, it is rather a L'anemie nutritionnelle n'est pas une entite morbide, syndrome caused by malnutrition in its widest sense. WHO c'est plutot un syndrome provoque par Ia malnutrition has defined it as follows : entendue au sens le plus large. L'OMS l'a detinie de Ia fa<;on suivante: "Nutritional anaemia is a condition in which the haemo­ « L'anemie nutritionnelle est un etat pathologique dans globtn content of the blood is lower than normal as a lequel Ia teneur du sang en hemoglobine est devenue result of a deficiency of one or more essential nutrients, anormalement faible par suite d'une carence en un ou regardless of the cause of such deficiency 300" plusieurs nutriments essentiels, abstraction faite de Ia cause de cette carence. 300 ». Anaemia is the end-result of severe nutrient deficiency of L'anemie est le resultat final d'une carence grave en nutri­ one or more haematopoietic factors, usually iron, less fre­ ments d'un ou plusieurs facteurs hematopoi"etiques, gene­ quently folate or vitamin 8 12 . Haemoglobin concentration, ralement le fer, moins souvent l'acide folique ou Ia vitamine by which anaemia is diagnosed, is a relatively insensitive 8 12 . La concentration hemoglobinique, qui permet de dia­ index of milder degrees of nutrient depletion, so that by the gnostiquer l'anemie, est un indice relativement peu sensible

• This article IS based on a report bearing the same title which g1ves fuller • Le present article se fonda sur un rapport portant le m~me titre qui donne details of the fmdings of the studies cited. It IS ava1lable on request from the davantage de precisions sur les resultats des etudes citees. II peut Atre DIVISIOn of Fam1ly Health, World Health Organ1zat1on, 1211 Geneva 27, obtenu sur demande aupres de Ia Division de Ia Sante de Ia Familia, Organi­ Switzerland. sation mond1ale de Ia Sante, 1211 Geneve 27 Suisse. b Stat1stic1an, Div1sion of Fam1ly Health, WHO, Geneva b Stat1stic1enne, Division de Ia Sante de Ia Famille, OMS, Geneve. - 53 - time a person becomes anaemic he or she is already suf­ des formes plus legeres de deperdition de I")Utriments, de fering from a marked degree of nutrient deficiency. Because telle sorte qu'au moment ou une personne devient anemi­ anaemia is so much more easily detected than the underly­ que, elle souffre deja d'une nette carence en nutriments. ing deficiencies, it has come to be used as an index of Etant donne que l'anemie est beaucoup plus facilement haematopoietic nutritional status. decelee que les carences sous-jacentes, on en est venu a l'utiliser comme indice de l'etat nutritionnel hematoporeti­ que. The diagnosis of anaemia poses a number of problems, Le diagnostic de l'anemie pose un certain nombre de chief among them being the problem of defining what is problemes dont le principal est celui de Ia definition de Ia "normal haemoglobin concentration". It is recognized that «concentration normale d'hemoglobine». On sait que dans there is a homoeostatic mechanism that sets the haemo­ chaque organisme. un mecanisme homeostatique deter­ globin level in each individual. Whereas it is not known mine le taux d'hemoglobine. On ignore si ce taux corres­ whether this is the optimum level for health, it is accepted as pond ou non a un optimum pour Ia sante du sujet, mais on "normal" for the individual. This distribution of normal ad met qu'il constitue le taux «normal» chez celui-ci. Jusqu'a values was until lately thought to be the same throughout ces derniers temps, on pensait que Ia distribution des the world when allowance is made for such factors as age, valeurs normales etait partout Ia meme dans le monde. sex, pregnancy, and altitude 301 . Recent findings in the Uni­ compte tenu des facteurs age, sexe. gravidite. altitude 301 . ted States of America and elsewhere, however, have led Toutefois, des constatations recentes faites aux Etats-Unis scientists to question the assumption that there are no d' Amerique et ailleurs ont conduit les scientifiques a mettre racial differences in haemoglobin levels 86• en doute !'hypothese selon laquelle il n'existe pas de diffe­ rences raciales en matiere de taux d'hemoglobiness. Nevertheless, a group of WHO experts meeting in Neanmoins, un groupe d'experts de I'OMS reuni en 1968 300 laid down a set of norms below which ··anaemia or 1968 300 a fixe un ensemble de normes en dessous desquel­ deficiency should be considered to exist''. The values of les il convient «de considerer qu'il y a anemie». Les valeurs these norms which have been used throughout this report, de ces normes, qui ont ete utilisees tout au long du present are given in the Annex. rapport, figurent en annexe.

Harmful effects of anaemia Effets nefastes de I' anemie

From the public health and social point of view, anaemia is Du point de vue de Ia sante publique et du point de vue important because it may affect productivity and work social. l'anemie est importante car elle peut alterer Ia pro­ capacity and may lead to the aggravation of many other ductivite et Ia capacite de travail tout en contribuant a I' ag­ disorders. It contributes to the overall mortality associated gravation de nombreux autres troubles. Elle contribue a Ia with malnutrition and, in the case of anaemia in pregnancy, morbidite globale associee a Ia malnutrition et, dans le cas it poses at threat to the life and health of the mother at the de l'anemie de grossesse. elle fait peser une menace sur Ia time of delivery and may affect the viability of the infant. vie et Ia sante de Ia mere au moment de I' accouchement et peut egalement etre prejudiciable a Ia viabilite du nourris­ son. There are individuals who can function seemingly nor­ II est des individus qui peuvent vivre de fa<;:on apparem­ mally with even severe degrees of anaemia, but most can­ ment normale tout en souffrant de formes d' anemies me me not. Severe anaemia manifests itself clinically in anorexia, graves. mais Ia plupart ne le peuvent pas. L'anemie grave se lassitude, giddiness, breathlessness, oedema of the legs, manifeste cliniquement par differents troubles: anorexie, and soreness of the tongue and of the corners of the mouth. lassitude, vertiges, essoufflement, redeme des jambes et At the other end of the scale, even mild anaemia may impair endolorissement de Ia langue et des commissures des wellbemg, may reduce near-maximal work capacity and levres. A I' autre extremite de l'eventail, une anemie meme adversely affect work performance. benigne peut alterer le bien-etre, reduire Ia capacite de tra­ vail quasi maximale et etre prejudiciable a !'execution du travail.

Causes of nutritional anaemia Causes de I' anemie nutritionnelle

The overall cause of nutritional anaemia or rather of the La cause generale de l'anemie nutritionnelle ou plutot des nutrient deficiencies which are manifested in low haemo­ carences en nutriments qui se manifestent par une faible globin concentration is an imbalance between the absorp­ concentration en hemoglobine est un desequilibre entre tion of nutrient factors and the body's needs. Such an !'absorption des facteurs de nutriments et les besoins du imbalance can arise in a number of ways: corps humain. Un tel desequilibre peut se produire de dif­ ferentes fa<;:ons:

by low nutrient intake; par un faible apport de nutriments; by poor absorption; par une mauvaise absorption; by increased nutrient losses and/or demands; par une augmentation des pertes et/ou demandes de nutriments; by poor utilization. par une mauvaise utilisation.

In many developing countries nutrient intake is low simply Dans de nombreux pays en developpement, !'apport de because total food intake is low. In addition to those who nutriments est faible pour Ia bonne raison que !'apport ali­ actually go hungry there are millions more who suffer a lack mentaire total est lui-meme faible. Outre ceux qui ont effec­ of specific nutrients in their diet. tivement faim, il yen a des millions d'autres qui, dans leur alimentation, ne se procurent pas certains nutriments par­ ticuliers. The amount of a nutrient absorbed by the body depends La quantite d'un nutriment absorbee par l'organisme not only on the amount ingested, but also on its absorba- depend non seulement de Ia quantite ingeree, mais egale- -54-

bility. Iron absorption, for example, is higher from most ment de son absorbabilite. L'absorption de fer, par exem­ foods of animal origin and not all folate is in a form in which it ple, est plus forte a partir de Ia plupart des aliments d'origine is absorbable by the body. Diseases of the intestine such as animale et tout l'acide folique ne se presente pas sous une coeliac disease, tropical sprue and the widely prevalent forme absorbable par l'organisme. Les maladies de l'intes­ parasitic enteropathies probably all decrease nutrient ab­ tin telles que Ia maladie creliaque, Ia sprue tropicale et les sorption. enteropathies parasitaires tres frequentes diminuent proba­ blement !'absorption des nutriments. Normal physiological losses of body iron occur in the Les pertes physiologiques normales de fer corpore! se gastrointestinal tract and in urine. Minute amounts of folate produisent dans les voies gastro-intestinales et dans and vitamin B 12 are lost in urine and faeces. Larger losses of l'urine. Des quantites minimes d'acidefolique et de vitamine iron occur when any type of bleeding occurs (as in men­ 8 12 sont perdues dans l'urine et les selles. Des pertes plus struation) and/or as a result of parasitic diseases. importantes de fer se produisent a !'occasion des saigne­ ments de tous genres (comme pendant les regles) et/ou a Ia suite de maladies parasitaires.

ANAEMIA AND WOMEN L' ANEMIE ET LES FEMMES

Women in the reproductive ages form one of the two En ce qui concerne l'anemie, les femmes en age de pro­ main vulnerable groups with regard to anaemia, the second creer torment l'un des deux principaux groupes vulnerables, group being very young children. They are vulnerable pri­ le deuxieme etant constitue par les tres jeunes enfants. Elles marily because of their great nutritional needs, and in the sont vulnerables essentiellement a cause de leurs grands case of young children also because of their complete besoins nutritionnels et, les jeunes enfants le sont egale­ dependence on the support of others. When this inherent ment parce qu'ils sont entierement dependants du soutien vulnerability is combined with socioeconomic stress fac­ d'autrui. Lorsque cette vulnerabilite essentielle est associee tors, such as poverty, ignorance and primitive living condi­ a des facteurs de tension socio-economique tels que Ia tions, the situations of these groups may become truly pre­ misere, !'ignorance et les conditions de vie primitives, Ia carious. situation de ces groupes peut devenir veritablement precaire. Women in the reproductive years are at special risk in two Les femmes en age de procreer sont tout particuliere­ ways: when not pregnant or lactating, regular menstrual ment exposees, et cela de deux fac;:ons: lorsqu'elles ne sont blood loss constitutes a continuing drain of nutrients which pas enceintes ou n'allaitent pas, Ia perte de sang reguliere have to be replaced, while pregnancy increases the require­ occasionnee par les regles constitute une deperdition cons­ ments of the woman's body to meet the needs of the tante de nutriments qui doivent etre remplaces, tandis que growing fetus. During lactation, iron and folate are passed Ia grossesse augmente les exigences de I' organisme femi­ to the baby via the breastmilk, to the detriment of the nin afin de fa ire face aux besoins du fretus qui se developpe. mother. Pendant Ia lactation, le fer et l'acide folique sont transmis au nourrisson par l'intermediaire du lait maternel, au detriment de Ia mere.

Menstrual blood loss Perte de sang menstruelle

On average a healthy woman loses about 40 ml of blood En moyenne, une femme en bonne sante perd environ 40 each month. This is equivalent to an average daily iron loss ml de sang chaque mois. Ceci equivaut a une perte quoti­ of 0.6 mg. A small proportion of women have monthly iron dienne de fer de 0,6 mg. Chez une petite proportion de losses which are considerably higher 96 . The daily iron femmes, les pertes de fer menstruelles sont beaucoup plus requirements to cover such losses, which are over and elevees 96 . Les besoins quotidiens de fer permettant de above the physiological losses sustained by both sexes compenser ces pertes, qui s'ajoutent aux pertes physiolo­ equally, have to be increased to cover this amount. From a giques eprouvees de Ia meme fac;:on par les deux sexes, frequency distribution of menstrual blood losses, a WHO doivent etre majores pour compenser cette quantite. A expert group has calculated that in order to ensure that partir d'une distribution de frequence des pertes menstruel­ 97.5% of women remain in iron balance, a daily absorption les, un groupe d'experts de I'OMS a calcule que, pour faire of 2. 7 mg of iron is required compared to the 0.9 mg en sorte que 97,5% des femmes preservent un bilan terri­ required by an adult man3o2. que positif, une absorption quotidienne de 2, 7 mg de fer est necessaire- contre 0,9 mg pour un homme adulte 302 .

Contraception and anaemia Contraception et anemie

Menstrual blood loss is affected by two of the most Deux des methodes de contraception les plus largement widely used methods of contraception. utilisees influent sur les pertes menstruelles:

Intrauterine devices (IUDs) Les dispositifs intra-uterins (DIU)

IUDs have been shown to increase the average menstrual On a montre que les DIU augmentent les pertes mens­ blood loss by between 35% and 146% 91 103, depending on truelles moyennes dans une proportion entre 35 a 146% 91 · the type of device. In terms of iron losses, this means an 103, selon le type de dispositif utilise. Du point de vue des increase of the average daily iron loss due to menstruation pertes de fer, cela a pour effet de faire passer Ia deperdition from 0.6 mg to between 0.8 mQ and 1.5 mg. In a healthy quotidienne moyenne de fer par menstruation de 0,6 mg a well-nourished population, such increases may only have a entre 0,8 et 1,5 mg. Dans une population bien nourrie et en marginal effect, although one study 92 showed that in Den­ bonne sante, de telles augmentations ne peuvent avoir mark the prevalence of anaemia increased from 3% to 16% qu'un effet marginal, meme si une etude 92 a montre qu'au in women using an IUD. In a malnourished population with Danemark Ia prevalence de l'anemie augmente de 3 a 16% -55- low iron stores, the effect of the increased losses could be chez les femmes utilisatrices de DIU. Dans une population dramatic. mal nourrie dont les reserves de fer sont peu importantes, une telle augmentation des pertes pourrait avoir des effets dramatiques.

Hormonal contraceptives Contraceptifs hormonaux

Hormonal contraceptives, on the other hand, decrease En revanche, les contraceptifs hormonaux reduisent les menstrual blood loss by about 50% 91 . The Royal College of pertes menstruelles d'environ 50% 91 . L'etude du Royal Col­ General Practitioners' study 226 found that in the United lege of General Practitioners 226 a etabli qu'au Royaume-Uni Kingdom the risk of iron-deficiency anaemia was almost le risque d'anemie ferriprive etait presque deux fois moins halved in oral contraceptive users, from 9. 7 per 1 000 grand chez les utilisatrices de contraceptifs oraux, passant women years to 5.7 per 1 000 women years. de 9,7 pour 1 000 annees/femmes a 5,7 pour 1 000 annees/femmes. There have been some suggestions that hormonal con­ D'aucune ont avance que les contraceptifs hormonaux traceptives reduce the absorption of vitamin B12 and folic reduisent !'absorption de vitamine 8 12 et d'acide folique. acid. This could be important in a population with low Cela pourrait avoir son importance dans une population a nutrient stores, but as yet the evidence is inconclusive. The faibles reserves de nutriments mais, jusqu'a present, les study mentioned above concludes, ''while there is evidence constatations faites sont peu concluantes. L'etude sus­ that oral contraceptives have complex reactions on iron mentionnee conclut que «s'il ressort de certains elements metabolism and red cell formation, the predominant clinical que les contraceptifs oraux agissent de fa<;:on complexe sur effect is a reduced incidence of iron deficiency anaemia due le metabolisme du fer et Ia formation des globules rouges, le to diminished menstrual loss" 226. principal effet clinique est une reduction de !'incidence de l'anemie ferriprive due a une diminution des pertes mens­ truelles »226 .

Pregnancy Grossesse

In pregnancy there is a dramatic increase in nutrient Pendant Ia grossesse, il se produit une augmentation requirements. Iron is required not only to replace basal phy­ spectaculaire des besoins en nutriments. Le fer est neces­ siological losses but also to allow for the expansion of the saire non seulement pour compenser les pertes physiologi­ red cell mass and to provide for the needs of the fetus and ques, mais aussi pour couvrir l'accroissement de Ia masse placenta. When pregnancy occurs, the haemoglobin iron of erythrocytaire et les besoins du fretus et du placenta. En cas the mother increases by about 500 mg. At term, the fetus de grossesse, le fer hemoglobinique augmente d'environ contains about 290 mg of iron and the placenta contains 500 mg. A terme, le fcetus contient environ 290 mg de fer about 26 mg, excluding that in the entrapped maternal et le placenta environ 26 mg, non compris celui du sang blood. The basal losses (urine, faeces, sweat, etc.) during maternel qu'il renferme. Les deperditions de base (urine, pregnancy are similar to those of a non-menstruating wo­ selles, sueur, etc.) ne sont pas modifiees par Ia gravidite et man, amounting to 0.8 mg per day or about 220 mg for the s' elevent a 0,8 mg/jour, soit environ 220 mg pour Ia totalite whole of pregnancy. Thus, the total iron needed during the de Ia grossesse. Par consequent, Ia quantite totale de fer whole of pregnancy is about 1 000 mg. necessaire pendant cette periode est d'environ 1 000 mg. The daily requirement for iron, as well as folate, is six Le besoin quotidien de fer, ainsi que d'acide folique, est times greater for a woman in the last trimester of pregnancy six fois plus eleve pour une femme au dernier trimestre de sa than for a non-pregnant woman. This need cannot be met grossesse que pour une femme qui n'est pas enceinte. Ce by diet alone, but is derived at least partly from maternal besoin ne peut ~tre satisfait par le seul regime alimentaire reserves. In a well-nourished woman about half the total mais est obtenu, au moins en partie, des reserves mater­ requirement of iron may come from iron stores. When these nelles. Chez une femme bien nourrie, environ Ia moitie du reserves are already low-from malnutrition and/or fre­ besoin total de fer peut provenir des reserves ferriques. quent pregnancies-anaemia resultslo2. Quand celles-ci sont deja faibles - par suite de malnutrition et/ou de grossesses frequentes - cela entraine l'ane­ mieJo2. There is also an increased requirement for vitamin B12 in Au cours de Ia grossesse, il se produit egalement une pregnancy, at least partly due to the fetal drain on maternal augmentation des besoins en vitamines 8 12, due partielle­ stores. Stillborn infants contain approximately 30 mg of ment au moins a Ia spoliation des reserves maternelles par vitamin 8 12 1n their tissues, which corresponds to the le feet us. Les enfants mort-nes possedent environ 30 mg de removal of 0.2 mg per day from the maternal stores in the vitamines 8 12 dans leurs tissus, ce qui correspond a un latter half of pregnancy. In addition, there is an increased prelevement de 0,2 mg par jour au cours de Ia deuxieme metabolic demand in pregnancyJo2. moitie de Ia grossesse. En outre, celle-ci s'accompagne d'une augmentation de Ia demande metaboliqueJo2. Severe anaemia during pregnancy can have serious re­ Pendant Ia grossesse, l'anemie severe peut avoir des sults. In India, 20% to 40% of maternal deaths taking place resultats graves. En lnde, 20 a 40% des deces maternels at the Medical College Hospital Nagpur between 1955 and qui se sont produits a l'hopital universitaire de Nagpur entre 1964 were due to anaemia 56 . It was found that conditions 1955 et 1964 etaient dus a I' anemie 56 . On a constate que such as abortions, premature births, postpartum haemor­ des affections telles que les avortements, les naissances rhage and low birth weight were especially associated with prematurees, les hemmoragies post-partum et insuffisan­ low haemoglobin levels in pregnancy. In Pakistan, a study ces de poids a Ia naissance etaient particulierement asso­ of 2 500 pregnant women with pregnancy anaemia 157 in ciees a de faibles taux d'hemoglobine pendant Ia gros­ Karachi between 1957 and 1960, showed a marked differ­ sesse. Au Pakistan, une etude portant sur 2 500 femmes ence in maternal morbidity between those who had been enceintes souffrant d'anemie pendant Ia grossesse 157, me­ treated for anaemia during pregnancy and those who never nee a Karachi, entre 1957 et 1960, a revele une nette dif­ attended the antenatal clinics. ference de Ia morbidite et de Ia mortalite maternelles entre celles qui avaient ete soignees pour l'anemie pendant Ia 56 -

grossesse et celles qui ne s'etaient jamais rendues au cen­ tre de soins prenatals. In Multan, also Pakistan, the gross maternal mortality rate A Multan, egalement au Pakistan, le taux brut de mortalite at Nishtar Medical College between 1954 and 1965 238 was maternelle a I'Ecole de Medecine Nishtar entre 1954 et 19 per 1 000 live births, of which 13 per 1 000 were due to 1965 238 eta it de 19 pour 1 000 naissances vivantes, dont severe anaemia, while at Lahore 80% of maternal deaths 13 pour 1 000 etaient dus a une anemie severe, alors qu'a were attributed to anaemia 10• In Kuala Lumpur, Malaysia, Lahore 80% des deces maternels etaient attribues a l'ane­ between 1953 and 1962 the maternal death rate among mie 10. A Kuala Lumpur (Malaisie), entre 1953 et 1962, le women with severe anaemia was 15.5 per 1 000 compared taux de mortalite maternelle chez les femmes souffrant d'a­ with 3.5 per 1 000 among non-anaemic women 152. nemle severe etait de 15,5 pour 1 000 par rapport a 3,5 pour 1 000 chez les femmes non anemiques.

Diet Regime alimentaire

Women have higher requirements of iron, vitamin 8 12 Les femmes ont davantage besoin de fer, de vitamine 8 12 and folic acid than men and yet in most societies in devel­ et d'acide folique et, pourtant, dans Ia plupart des societes oping countries women's diets, at a given level of poverty, des pays en developpement, les regimes alimentaires des are frequently more deficient than men's. In addition, in femmes, a un niveau donne de pauvrete, sont souvent plus many societies food taboos, especially those that apply carences que ceux des hommes. En outre, dans de nom­ during pregnancy and the puerperium, aggravate malnutri­ breuses societes, des tabous alimentaires, notamment tion. ceux qui s'appliquent pendant Ia grossesse et Ia periode puerperale, aggravent Ia malnutrition.

AGGRAVATING FACTORS FACTEURS AGGRAVANTS

In many tropical areas, anaemia can be caused or aggrav­ Dans de nombreuses regions tropicales, l'anemie peut ated by parasitic diseases; the two chief culprits being etre provoquee ou aggravee par des maladies parasitaires; intestinal parasites and malaria. les deux principaux coupables etant les parasites intesti­ naux et le paludisme.

Intestinal parasites Parasites intestinaux

Layrisse & Roche 148, in a review of the literature and the Layrisse & Roche 148, dans une analyse de Ia documenta­ report of a study carried out in Venezuela, reached the fol­ tion et du rapport d'une etude effectuee au Venezuela, en lowing conclusions concerning hookworm infection: sont arrives aux conclusions suivantes en ce qui concerne l'ankylostomiase: Provided a sufficient number of cases are studied and a condition que I' etude porte sur un nombre suffisant de cases of heavy infection (2 000 eggs per gram of faeces) cas et que Ia serie com porte des cas de forte infestation are included in the series, a significant relationship (2 000 ceufs par gramme de selles). il existe une relation between hookworm load and anaemia exists. significative entre Ia charge parasitaire et l'anemie; Infestations below 2 000 eggs per gram of faeces are les infestations inferieures a 2 000 ceufs par gramme de usually not associated with anaemia. selles ne sont generalement pas associees a I' ane­ mie; In the infected area studied in Venezuela, one-third of dans Ia region infestee etudiee au Venezuela, on estime anaemias were deemed to be directly attributable to qu'un tiers des anemies est directement imputable a hookworm infection. l'ankylostomiase. A WHO expert group 300 attempted to quantify blood and Un groupe d'experts de I'OMS 300 a tente de chiffrer les iron losses due to hookworm and other intestinal parasites. pertes de sang et de fer dues a l'ankylostome eta d'autres It concluded that faecal blood loss due to Necator ameri­ parasites intestinaux. II a conclu que les pertes fecales de canus is about 0.03 ml per worm per day, and 2.1 ml per sang dues a Necatoramericanus sont d'environ 0,03 ml par 1 000 eggs per gram of faeces. An infection of 250 worms jour et par ver, ou voisines de 2,1 ml pour 1 00 ceufs par (5 000 eggs per gram of faeces) would result in an intestinal gramme de selles. Une infestation par 250 vers (ou 5 000 haemoglobin iron loss about 5 mg per day, of which about ceufs par gramme de selles) provoque une deperdition 70-80% would be eliminated in faeces. It concluded that intestinale de fer hemoglob~nique d'environ 5 mg par jour, infections with more than 5 000 eggs would undoubtedly dont 70 a 80% seulement sont eli mines dans les selles. II a cause an imbalance in iron metabolism and induce, in the conclu que toute infestation par plus de 5 000 ceufs dese­ long run, iron-deficiency anaemia. In Ancylostoma duoden­ quilibre le metabolisme du fer et fait apparaTtre, a longue ale infection blood loss is greater (0. 15-0.26 ml per worm echeance, une anemie ferriprive. Dans les infestations a per day) and about 4.5 ml of blood are lost per 1 000 eggs. Ancylostoma duodenale les pertes de sang sont plus im­ Infection with 100 ancylostoma worms will be sufficient to portantes (0, 15 a 0,26 ml par ver et par jour) et pour 1 000 induce anaemia under comparable conditions. ceufs, le sujet perd approximativement 4,5 ml de sang. Dans le cas d'une infestation a Ancylostoma 100 vers suf­ fisent a provoquer l'anemie dans des conditions compara­ bles.

Malaria Paludisme

There is also a strong association between anaemia and II existe egalement uneforte association entre l'anemie et malaria. The characteristic features in the pathology of mal­ le paludisme. La pathologie du paludisme se caracterise par aria are the destruction of red cells and the localization of Ia destruction des globules rouges et Ia localisation des -57- parasites in the capillaries of several internal organs. A parasites dans les vaisseaux capillaires de plusieurs orga­ number of studies have found a close association between nes internes. Plusieurs etudes ont montre une association malaria and the prevalence of anaemia, especially in the etroite entre le paludisme et Ia prevalence de l'anemie, par­ coastal areas of Africa but also in some inland areas. In ticulierement dans les regions littorales d' Afrique, mais Chad in a study of five villages the average haemoglobin egalement dans certaines zones de l'interieur du pays. Au concentration found in the only village where malaria was Tchad, dans une etude portant sur cinq villages, Ia concen­ not endemic was nearly 15 g/1 higher than in the four other tration hemoglobinique moyenne observee dans le seul vil­ villages 33 · 34 . lage ou le paludisme n'etait pas endemique etait de pres de 15 g/1 supeneure a celle des quatre autres villages 33· 34 .

Age Age

In women in the reproductive ages the influence of age on Chez les femmes en age de procreer, !'influence de I' age haemoglobin concentration is often difficult to separate sur le taux d'hemoglobine est souvent difficile a distinguer from the effect of parity. In a WHO-sponsored family for­ de l'effet de Ia parite. Dans le cadre d'une etude patronnee mation study 187 the two factors were analysed separately par I'OMS portant sur Ia formation de Ia fa mille 187 • les deux and no discernible relationship between age and haemoglo­ facteurs ont ete analyses separement et aucune relation bin concentration was found. In Kenya 292 a high prevalence discernable n'a ete observee entre I' age et le taux d'hemo­ of anaemia was found in young primiparae, possibly be­ globine. Au Kenya 292 , on a observe une prevalence elevee cause pregnancy at a time when a woman has herself not de I' anemie chez les jeunes primipares, probablement parce stopped growing adds an extra strain on nutrient stores. que Ia grossesse qui survient a une epoque ou Ia croissance Another theory put forward is that it is not until pregnancy de Ia femme elle-meme n'est pas encore terminee sollicite that a young African woman makes her first contact with davantage encore les reserves de nutriments. Selon une the health services and this may be the first opportuny for autre theorie, ce n'est que lorsqu'une jeune femme africaine the diagnosis of anaemia. If treated, she is less likely to be est enceinte qu'elle a ses premiers contacts avec les servi­ anaemic at subsequent examinations. A similar pattern, ces de sante et que c'est Ia premiere occasion qui s'offre de i.e., a higher prevalence of pregnancy anaemia among lui poser le diagnostic d'anemie. Si elle est soignee, elle a younger women, was also reported in Dacca (Banglad­ moins de chances d'etre anemique lors des examens ulte­ esh)113. rieurs. Des observations analogues, c'est-a-dire une preva­ lence plus elevee de ,. anemie de grosse sse chez les femmes plus jeunes, a egalement ete signalee a Dacca (Bangla­ desh) 113 . A nutrition survey in Ghana 52 found that haemoglobin Une enquete nutritionnelle me nee au Ghana 52 a montre concentration in women rose from age 15 to age 20, que chez Ia femme, le taux d'hemoglobine s'eleve de 15 a remained constant until age 39 and then declined, the same 20 ans, demeure constant jusqu'a 39 ans et diminue ensui­ pattern was observed in the Caribbean 183. te; Ia me me evolution a ete observee dans les Cara'i­ bes 183.

Parity Parite

A vast amount has been written about the deleterious On a beaucoup ecrit sur les effets netastes de Ia gros­ effect of continuous childbearing on maternal health and sesse quasi permanente sur Ia sante maternelle et l'anemie. anaemia. Most, although not all, the surveys examined con­ La plupart. mais non Ia totalite, des enquetes examinees firm this. The family formation survey mentioned above 187 , confirment cette opinion. L'enquete sur Ia formation des which was carried out on a very large number of women in families mention nee plus haut 187 qui porte sur un tres grand five countries found, after controlling for age, a definite nombre de femmes dans cinq pays a revele, apres correc­ decline in haemoglobin concentration with parity in only tion pour l'age, une nette diminution de Ia concentration three of the countnes. hemoglobinique avec Ia parite dans trois des pays seule­ ment. Among pregnant women the relationship was a little Chez les femmes enceintes, Ia relation etait un peu plus more clear-cut. In Bangkok, (Thailand). for example, the nette. A Bangkok (Tharlande). par exemple, Ia prevalence prevalence of anaemia in pregnant women doubled after the de l'anemie chez les femmes enceintes etait deux fois plus third pregnancy and increased fivefold after the fifth preg­ elevee apres Ia troisieme grossesse et cinq fois plus elevee nancy39. apres Ia cinquieme grossesse 39 .

Lactation Lactation

Lactation imposes an added strain on a woman at a time La lactation impose une sollicitation supplementaire a Ia when her reserves are at their lowest, although the actual femme a un moment ou ses reserves sont a leur niveau le extent of the strain it imposes is not clear-cut. In most plus bas, bien que l'etendue reelle de cette sollicitation ne surveys the haemoglobin concentration of lactating wo­ soit pas nette. Dans Ia plupart des enquetes, le taux d'hem­ men, as shown in Table 1, is somewhere between that of moglobine des femmes qui allaitent, comme on le voit au pregnant and that of non-pregnant women. The percentage Tableau 1, se situe quelque part entre celle de Ia femme "anaemic" is probably not very meaningful; imposing a enceinte et de Ia femme qui ne l'est pas. Le pourcentage norm equal to that for non-pregnant women regardless of «d'anemiques» n'a probablement pas beaucoup de sens; il the time that has elapsed since parturition tends to be mis­ sera it probablement fallacieux d'imposer une norme egale a leading. celle valable pour les femmes non enceintes, independam­ ment du temps qui s'est ecoule depuis !'accouchement. A woman feeding a 6-month-old baby passes on may be Une femme qui allaite un nourrisson de six mois secrete 0.3 mg of iron per day. Folate also is passed on in human environ dans le Ia it 0,3 mg de fer par jour. De l'acide folique milk, at the rate of about 11 g per day for a 6-month-old est egalement secrete dans le lait humain, a raison d'envi­ baby, hence the slow recovery of women suffering from ron 11 g par jour pour un enfant de six mois, d'ou Ia lente megaloblastic anaemia of pregnancy. In Algiers in a group recuperation des femmes souffrant d'anemie megaloblasti- -58- of women with megaloblastic anaemias linked with preg­ que de grossesse. Dans un groupe de femmes algeroises nancy, one-tenth of the cases were mothers who had been souffrant d'anemie megaloblastique liee a Ia grossesse, un lactating for some time, i.e., whose folate-deficiency dixieme des cas etaient des meres qui avaient nourri pen­ anaemia had not disappeared after parturition 45 . dant un certain temps, c'est-a-dire dont l'anemie par carence d'acide folique n'avait pas disparu apres l'accou­ chement45. In Trinidad and Tobago mothers whose infants were A Ia Trinite-et-Tobago, des meres dont les nourrissons entirely breast-fed had a mean haemoglobin concentration etaient entierement nourris au sein presentaient une con­ of 119 g/1 whereas those who supplemented breast-feed­ centration hemoglobinique moyenne de 119 g/1 alors que, ing had a concentration of 130 g/1 41 . In the Philippines the pour celles dont l'allaitement s'accompagnait d'une com­ mean haemoglobin concentration among mothers whose plementation alimentaire, cette concentration etait de 130 infants were entirely breast-fed did not differ significantly g/1 41 . Aux Philippines, Ia concentration hemoglobinique from that of those practising mixed feeding or of the con­ moyenne chez les meres dont les nourrissons etaient entie­ trols who bottle-fed their babies. Haemoglobin concentra­ rement nourris au sein ne se differenciaient pas notable­ tion rose with the duration of lactation, from 115 g/1 at 0-3 ment de celles des meres pratiquant l'allaitement mixte ou months to 124 g/1 at 7-9 months, thus confirming the need des sujets temoins qui nourrissaient leurs enfants au bibe­ for special norms for lactating women, based on the time ron. Le taux d'hemoglobine s' eleva it en fonction de Ia duree elapsed since parturition. de l'allaitement, passant de 115 g/1 entre 0-3 mois a 124 g/1 entre 7-9 mois, ce qui confirme Ia necessite de normes speciales pour les femmes qui allaitent, en fonction du delai ecoule depuis !'accouchement.

MATERIALS AND METHODS MATERIELS ET METHODES

Sources of information Sources d'information

The present survey is based on information readily avail­ La presente etude se fonde sur des informations qui pou­ able in 1979 at WHO, in the WHO Library, in various internal vaient IHre obtenues facilement a I'OMS en 1979, a Ia documentation centres and in the possession of individual Bibliotheque de I'OMS, dans differents centres de docu­ members of the staff. All sources are either published docu­ mentation interne, ainsi qu'aupres des membres du person­ ments, in the sense of being printed and available to the nel. Toutes les sources sont des documents publies (c'est­ general public, or they are WHO documents, for example a-dire imprimes et a Ia disposition du grand public) ou des assignment reports. No confidential data or verbal esti­ documents OMS, par exemple des rapports de mission. On mates have been used. The information is as complete as it ne s'est pas servi de donnees confidentielles ou d'estima­ was possible to make it with the resources available. tions verbales. Les informations sont aussi completes qu'il a ete poss1ble de les etablir avec les moyens d1sponibles. The following criteria were used in deciding whether to Dans le choix de chaque element d'information, on a include a given piece of information: applique les criteres suivants:

(a) Date. For countries for which there was plenty a) Date. Pour les pays au sujet desquels on dispo­ of information no information published before 1958 was sait d'une masse d'informations, aucun renseignement included. Exceptions were made where there was very little publie avant 1958 n'a ete utilise. Des exceptions ont ete information on a country or if the report was especially faites lorsqu'on disposait de tres peu de renseignements interesting. sur un pays ou lorsque le rapport etait particulierement interessant.

(b) Size of sample. The general rule was to include b) Dimensions de J'echanti/lon. La regie generale a only information from samples of at least 300 women if ete de n'inclure que des renseignements provenant they were heterogeneous or 100 women if they were d'echantillons d'au moins 300 femmes si elles etaient hete­ homogeneous. But the shortage of data was such that in the rogenes ou de 100 femmes si elles etaient homogenes. event only very small, unrepresentative samples were re­ Mais le manque de donnees a ete tel qu'en realite seuls de jected. Sample size IS given as an indication of reliability. tres petits echantillons peu representatifs ont ete rejetes. La taille de l'echantillon est donnee comme une indication de Ia fiabilite. (c) Geographic coverage. Information on all devel­ c) Couverture geographique. Des rense1gnements oping countries was included. It was not possible to obtain ont ete donnes sur tousles pays en developpement. II n'a Information on China. pas ete possible d'obtenir des informations sur Ia Chine.

(d) Methods of measurement. More reliance should d) Methodes de mesure. II convient de se fier be placed on the result of surveys where methods of hae­ davantage aux resultats des enquetes utilisant des metho­ moglobinometry and nutnent assessment were standar­ des normalisees et controlees d'hemoglobinometrie et dized and controlled, e.g., the WHO collaborative studies, d'evaluation des nutnments (etudes concertees de I'OMS, ICNND and INCAP studies. Survey results were only ex­ etudes de I'ICNND et de I'INCAP). Seuls ont ete exclus les cluded if they were based on the Tallquist method or on resultats d' enquetes se fondant sur Ia methode de Tallquist clinical assessment such as "pallor". Any exceptions to ou sur une evaluat1on clinique telle que Ia « paleur». Toutes this rule are noted. les exceptions a ce principe sont mentionnees.

Definitions of anaemic and deficient Definitions de I' anemie et de Ia carence

The indices suggestive of anaemia and nutritional defi­ Tout au long de cette etude, et sauf stipulations contrai­ ciencies used by WHO have been taken as "the norm" res, les indices revelateurs d'anemie et de carences nutri- -59- throughout this study, unless otherwise stated. The indices tionnelles utilises par I'OMS ont ete pris comme normes. are3o•: . Ces indices sont les suivants301 Haemoglobin concentrations below which anaemia is likely Taux d'hemglobine en dessous desquels l'an{]mie risque to be present at sea-level d'etre presente, au niveau de Ia mer.

Children aged 6 months to 6 years 110 g/1 Enfants - 6 mois a 6 ans 110 g/1 Children aged 6-14 years 120 g/1 Enfants - 6-14 ans 120 g/1 Adult males 130 g/1 Adultes - hommes 130 g/1 Adult females, non-pregnant 120 g/1 Adultes - femmes non enceintes 120 g/1 Adult females, pregnant 110 g/1 Adultes - femmes enceintes 110 g/1

Serum iron concentrations Concentrations de fer s{]rique

Normal range Probable deficiency Fourchette normale Carence probable Serum iron (mg/1) 0.80-1.80 <0.50 Fer serique (mg/1) . . . . 0,80-1,80 <0.50

Serum vitamin 8 12 and serum folate concentration Concentration en vitamines 8,2 serique et en acide folique serique

Normal range Probably deficiency Fourchette normals Carence probable Serum vitamin 8 12 (pg/ml) 150-1 000 <100 Vitamine 8,2 serique (pg/ml) 150-1000 <100 Serum folate (ng/ml) . . . 6-20 <3 Acide folique serique (ng/ml) 6-20 <3

Haemoglobin concentration and serum iron concentra­ Le taux d'hemoglobine et Ia concentration en fer serique tion have been converted to g/1 and mg/1 respectively as an ont ete convertis respectivement en g/1 et mg/1 a titre de interim step to the adoption of the Sl units3o4 . mesure interimaire menant a !'adoption des uniMs SJ304 .

Methods of estimation Methodes d'estimations

All estimates made in this paper tend to be conservative; T outes les estimations du present document se veulent under-rather than over-estimates. prudentes; ce sont des sous-estimations plutOt que des surestimations.

(a) Percentage below the norm. Where a survey a) Pourcentage en dessous de Ia norme. Lorsqu'un report quoted a mean and standard deviation and/or the rapport d'enqu~te faisait etat d'un ecart moyen et type proportion below some given level, it was possible to esti­ et/ou de Ia proportion en dessous d'un niveau donne, il a ete mate the percentage falling below another given level by possible d' estimer le pourcentage de ceux qui se trouvaient assuming that the values were normally distributed. In prac­ en dessous d'un autre niveau donne en raisonnant sur une tice, the distribution of most haematological values is nega­ distribution normale des valeurs. Or, en pratique, Ia distri­ tively skewed, which would tend to make estimates based bution de Ia plupart des valeurs hematologiques est nega­ on the normal value slightly biased. tivement asymetrique, ce qui tendrait a fausser legerement les estimations basees sur Ia valeur normale. Occasionally a report gave percentages below or above Occasionnellement, un rapport donnait des pourcenta­ certain levels without giving a mean or a frequency distri­ ges inferieurs ou superieurs a certains niveaux sans donner bution. Where possible an estimate ofthe mean was made, une moyenne ou une distribution de frequence. Dans Ia using the above reasoning. mesure du possible, on a precede a une estimation de Ia moyenne, grace au raisonnement indique plus haut.

(b) Percentage anaemic by country or continent. b) Pourcentage d'anemiques par pays ou continent. Ideally, before generalizing from a sample to the country as Pour bien faire, avant de generaliser a I' ensemble d'un pays a whole, due consideration should be given to such factors en partant d'un echantillon, il conviendrait d'accorder toute as the distribution of the population by socioeconomic !'attention voulue a des facteurs tels que Ia repartition class, by urban/rural density, by climatic region, by altitude socio-economique de Ia population par classe, par densiM of residence, etc. Such an approach would require very urbaine/rurale, par region climatique, par altitude de resi­ much more time than was available and would not be fea­ dence, etc. Une telle fac;on de faire necessiterait beaucoup sible for more than a very small number of countries. The plus de temps qu'on en a dispose et ne serait realisable que percentages appearing in Table 4 are thus very much "best pour un tres petit nombre de pays. Aussi, les pourcentages guesses" based on the size of samples, recentness of the qui figurent au Tableau 4 sont-ils, dans une large mesure, survey and general reliability. It follows, therefore, that the les meilleures estimations possibles en fonction des dimen­ estimates for groups of countries and continents are even sions des echantillons, de l'actualite de l'enqu~te et de Ia less reliable and should be taken as useful guides or orders fiabilite generale. II s'ensuit done que les estimations vala­ of magnitude rather than as precise figures. bles pour des groupes de pays et des continents sont encore moins fiables et doivent ~tre considerees comme des chiffres guides ou des ordres de grandeur utiles plutOt que des chiffres precis.

(c) Demographic data. The total number of women c) Donnees demographiques. Le nombre total de (Tables 4 and 5) are taken from United Nations estimates femmes (Tableaux 4 et 5) provient des estimations des for 1975 263 . The number of pregnant women was esti­ Nations Unies pour 1975263 . Le nombre de femmes encein­ mated thus: tes a ete estime de Ia fac;on suivante:

GFR TPG Wp=W1s_49 x-- x0.75xPWF FE = F15-49 X-- X 0,75 FM 1000 1000 60 - where: dans laquelle: w number of pregnant women FE Nombre de femmes enceintes w,5-49 number of women aged 15-49 years F15_49 Nombre de femmes de 15 a 49 ans

GFR general fertility rate TFG Taux de fecondite general

PWF pregnancy wastage factor (estimated at FM Facteur de mortalite avant terme et perinatale 10%)187. (estime a 10%) 187

(d) Corrections of haemoglobin concentration for d) Corrections du taux d'hemoglobine pour tenir differences in altitude. In conformity with the WHO colla­ compte des differences d'a/titude. Conformement aux etu­ borative studies 46 the corrections used were those devel­ des concertees menees par I'OMS 46 , les corrections utili­ oped by Hurtado 112 . The mean values appearing in Table 1 sees ont ete celles mises au point par Hurtado 112 . Les are non-adjusted values, but the percentages falling below valeurs moyennes figurant au Tableau 1 sont des valeurs the norm are based on adjusted norms. non corrigees, mais les pourcentages inferieurs de Ia norme se fondent sur des normes corrigees.

(e) Means versus medians. When dealing with skew e) Moyenne ou medianes. En presence de distribu­ distributions such as that of haemoglobin levels it is more tions asymetnques telles que celles des taux d'hemoglobi­ meaningful to use the median as a representative measure. ne, il est plus rationnel d'utiliser Ia mediane comme mesure In practice, however, very few reports, other than the representative. Toutefois, en pratique, tn3s peu de rap­ PAHO collaborative study report 46 give medians, so that in ports, autres que l'etude concertee OPS 46 donnent des order to give a comparative measure the mean value has medianes, si bien que, dans un souci de comparaison, on been used throughout this paper. s'est servi de Ia valeur moyenne tout au long du present document.

Geographic grouping of countries Regroupement geographique des pays

Countries are arranged according to geographic and cli­ Les pays sont disposes par regions geographiques et matic regions rather than by WHO regions. The classifica­ climatiques et non par regions OMS. La classification utili­ tion used is that employed by the United Nations263. see est celle qu'emploie les Nations Unies 263 . Taus les pays Included are all developing countries other than China, for en developpement y figurent, sauf Ia Chine pour laquelle which no Information was found. Other countries for which aucun renseignement n'a ete obtenu. Les autres pays pour no information was found were included in Table 4 and lesquels aucun renseignement n'a ete trouve ont ete places assumed to be like the other countries in their groupings. dans le Tableau 4 et on les a assimiles aux pays avec les­ quels ils sont regroupes.

THE DIMENSIONS OF THE PROBLEM LES DIMENSIONS DU PROBLEME

The prevalence picture 3oe Panorama de Ia prevalence309

In 1975 there were some 1 800 million females 1n the En 1975, il y avait environ 1,8 milliard de femmes dans le world, roughly half of them women in their reproductive monde, dont grosso modo Ia moitie etait en age de pro­ years. Over two-thirds of them live in developing countries creer. Plus des deux tiers des femmes vivant dans des pays where their life expectancy at birth is on average 55 years, en developpement ou I' esperance de vie a Ia naissance est compared to a life expectancy at birth of 75 years of the de 55 ans en moyenne, par rapport a une esperance de vie a women in developed countries. They have, on average, Ia naissance de 75 ans pour les femmes des pays develop­ over twice as many children. At any point in time every sixth pes. Elles ont, en moyenne, plus de deux fois plus d'en­ woman aged 15-49 years living in a developing country3o8 fants. A tout moment, une femme sur six de 15 a 49 ans is pregnant, compared with 1 in 17 such women in devel­ v1vant dans un pays en developpement308 est encemte, par oped countries. rapport a une sur 17 dans les pays developpes. This report is concerned with the nearly 500 million La presente etude a trait aux 500 millions de femmes ou women living in developing countries other than China (Ta­ presque qui vivent dans les pays en developpement autres ble 5). About 70 million ofthem are pregnant and at least as que Ia Chine (Tableau 5). Environ 70 millions d'entre elles many lactating. From the information collated it would seem sont enceintes et au mains autant d'autres allaitent. D'apres that about half the non-pregnant women and nearly two­ les renseignements recueillis, il semblera1t que Ia moitie thirds of the pregnant women have haemoglobin concen­ environ des femmes non enceintes et pres des deux tiers trations below those laid down by WHO as being indicative des femmes enceintes presentent des taux d'hemoglobine of anaemia; making a total of some 230 million "anaemic" inferieurs a ceux definis par I' OMS comme etant revelateurs women (country-by-country findings are summarized in d'anemie; ce qui aboutit a un total de 230 millions de fem­ T abies 1-4). mes «anem1ques » (les resultats pays par pays sont recapi­ tules aux Tableaux 1 a 4). The overall proportion of women With haemoglobin con­ La proportion globale de femmes dont le taux d'hemo­ centration below the norms IS highest in Asia and Oceania, globine est inferieur aux normes est Ia plus forte en Asie et followed in descending order of magnitude by Africa and en Oceanie, suivies dans I' ordre decroissant par I' Afrique et Latin America. For pregnant women the order is also Asia, I' Amerique latine. Pour les femmes enceintes, I' ordre est Africa and Latin America (Oceania seems to be slightly egalement: Asie, Afrique et Amerique latine (I'Oceanie lower than Asia, but this difference is probably due to the semble se situer legerement en dessous de I' Asie, mais smaller numbers and is of significant). cette difference est probablement due a des effectifs plus petits et n'est pas significative). - 61

In both the areas where the proportion of all women with Dans les deux regions ou Ia proportion de I' ensemble des haemoglobin concentration below the norm is highest the femmes a taux d'hemoglobine inferieur a Ia norme est Ia proportion of non-pregnant women with haemoglobin con­ plus elevee, Ia proportion des femmes non enceintes a taux centration below the norm is nearly as high or higher than d'hemoglobine inferieur a Ia norme est presque aussi elevee the proportion of pregnant women with haemoglobin con­ ou plus elevee que Ia proportion des femmes enceintes dont centration below the norm. In the two other continents it is le taux d'hemoglobine est inferieur a Ia norme. Une theorie very much lower. One theory that might explain this differ­ susceptible d'expliquer cette difference veut que Ia malnu­ ence is that malnutrition and hence depleted nutrient stores trition et, par consequent, l'epuisement des reserves de are more widespread in Asia than in Africa and Latin Amer­ nutriments soient plus frequents en Asie qu' en Afrique et en ica, so that women do not fully replenish their haemoto­ Amerique latine, de telle sorte que les femmes ne recons­ poietic nutrient stores between pregnancies. A glance at tituent pas completement leurs reserves de nutriments Table 3, which shows the proportions of women found hematoporetlques entre les grossesses. Un coup d'ooil au deficient in iron, folate and vitamin 8 12 tends to bear out this Tableau 3, qui indique les proportions de femmes chez qui theory. l'on a observe une carence en fer, en acide folique et en vitamine 8,2, tend a JUStifier cette theorie. As is to be expected, the proportion of women with a Comme on peut s'y attendre, Ia proportion des femmes a haemoglobin concentration below the norm is closely re­ taux d'hemoglobine infeneur a Ia norme est etroitement liee lated to affluence as measured by GNP31o: a l'abondance mesuree par le PN831o.

PNB par hab1tanrs Pourcentage GNP per capita (m US$) Percentage anaemic (en dollars EUA) d"anem1ques Asia 280 58 Asie ...... 80 58 Afnca 390 40 Afnque ..... 90 40 Latin Amenca 1025 17 Amerique latine 1 025 17

This type of relationship seems to hold even within con­ Ce type de relation semble se verifier, m~me a l'interieur tinents, although there is, of course, considerable variation des continents, bien qu'il y ait naturellement des differences within continents and even within countries. considerables au sein des continents et m~me au sein des pays.

AFRICA AFRIQUE

Nonhern Africa Afrique septentrionale

Northern Africa has one-quarter of the population but L' Afrique septentrionale possede un quart de Ia popula­ one-third of the wealth of Africa. This relative affluence tion mais un tiers des richesses de I' Afrique. Toutefois, does not. however, seem to have affected the health of the cette abondance relative ne semble pas avoir influe sur Ia women. Documentation is poor, but the information avail­ sante des femmes. On manque de documentation, mais les able tends to indicate that anaemia among women is a renseignements disponibles tendent a indiquer que l'ane­ major health problem. In Algeria three-quarters of all hos­ mie feminine pose un probleme de sante important. En pitalized women were anaemic. Data from Egypt show a Algerie, les trois quarts de I' ensemble des femmes hospi­ very high prevalence of anaemia, especially in pregnancy.ln talisees etaient anemiques. Des donnees en provenance the Libyan Arab Jamahiriya, according to the Interdepart­ d'Egypte indiquent une tres forte prevalence de l'anemie, mental Committee on Nutrition for National Defense, about notamment pendant Ia grossesse. Dans Ia Jamahiriya arabe half the pregnant women were anaemic. The only reliable libyenne, selon le Comite interministeriel de Ia Nutrition pour data from this area relate to Tunisia, where 31% of non­ Ia Defense nationale (ICNND) environ Ia moitie des femmes pregnant, 46% of lactating, and 38% of pregnant women etaient anemiques. Les seules donnees fiables provenant had haemoglobin concentration below the norms. There de cette region ont trait a Ia Tunisie ou 31% des femmes was a high frequency of iron deficiency, especially in preg­ non enceintes, 46% des femmes allaitantes et 38% des nant women. Two studies from hospitals indicated that femmes enceintes presentaient des taux d'hemoglobine megaloblastic anaemia of pregnancy due to folate defi­ inferieurs aux normes. La carence martiale etait tres fre­ ciency was common. quente, particulierement chez les femmes enceintes. Deux etudes faites dans les hopitaux indiquaient que l'anemie megaloblastique de Ia grosse sse due a une carence en acide folique etait courante.

Western Africa Afrique occidentale

The prevalence of anaemia in Western Africa seems to be En Afrique occidentale, Ia prevalence de l'anemie semble higher than in Eastern Africa, possibly owing to climatic and ~tre superieure ace qu'elle est en Afrique orientale, proba­ altitude factors, which in turn affect the prevalence of para­ blement en raison de facteurs tenant au climat eta I' altitude sitic diseases. Haemoglobinopathies, not dealt with in this qui, a leur tour, modifient Ia prevalence des maladies para­ document, are also widespread. sitaires. Les hemoglobinopathies, dont il n'est pas question dans ce document, sont egalement tres repandues. The studies carried out in this area show that between Les etudes effectuees dans cette region montrent que 24 24% and 99% of pregnant women were anaemic. The a 99% des femmes enceintes etaient anemiques. Lesane­ coastal anaemias tended to be hypochromic whereas the mies cotieres avaient tendance a ~tre hypochromes alors inland form was norma- or hyperchromic. About one-third qu'a l'interieur du pays elles prenaient une forme norma­ of all severe pregnancy anaemias were megaloblastic, chrome ou hyperchrome. Environ un tiers de I' ensemble des mostly owing to folate deficiency. The majority of the mild anemies de grossesses graves etaient megaloblastiques, le anaemias were due to iron deficiency. plus souvent par suite d'une carence en acide folique. Dans leur majorite, les anemias benignes etaient dues a une carence en fer. 62 -

Eastern Africa Afrique orientale

At first glance it would seem that mean haemoglobin Au premier abord, il semblerait que les concentrations concentrations are high in Eastern Africa, particularly in hemoglobiniques moyennes soient elevees en Afrique Ethiopia and Kenya. This is mostly due to the high altitudes orientale, particulierement en Ethiopie et au Kenya. Cela est at which people live. Apart from the known effect of barom­ essentiellement dO aux altitudes elevees auxquelles vit Ia etric pressure, other factors associated with altitude also population. Hormis l'effet bien connu de Ia pression atmo­ play a part, e.g., the lower prevalence of malaria and other spherique, d'autres facteurs lies il !'altitude jouent egale­ parasitic diseases. Thus in Kenya anaemia is more preval­ ment un role, par exemple Ia prevalence moins elevee du ent in the coastal belt than inland, even after correction of paludisme et d'autres maladies parasitaires. Ainsi, au Ke­ haemoglobin concentration for altitude. On the coast one­ nya, l'anemie est plus frequente dans Ia zone littorale qu'il quarter of admissions of women to hospital were due to l'interieur du pays, m~me apres correction du taux d'hemo­ severe anaemia. The prevalence of megaloblastic anaemia globine pour tenir compte de !'altitude. Sur Ia cote, un quart was seasonal. des hospitalisations de femmes etait dO i1 une anemie gra­ ve. La prevalence de l'anemie megaloblastique etait saison­ niere. In the United Republic of Tanzania, as in Zambia, the Dans Ia Republique-Unie de Tanzanie, de m~me qu'en prevalence of anaemia is high among both pregnant and Zambie, Ia prevalence de l'anemie est elevee tant chez les non-pregnant women, especially in the rural coastal areas. femmes enceintes que chez celles qui ne le sont pas, par­ Anaemia is associated with hookworm infection, malaria ticulierement dans les zones rurales du littoral. L'anemie est and low dietary iron intake. associee il l'ankylostomiase, au paludisme et au faible apport alimentaire de fer.

Middle Africa Afrique centrale

The prevalence of anaemia in Middle Africa, which en­ La prevalence de l'anemie en Afrique centrale, qui en­ compasses some of poorest nations in Africa, is the least globe certaines des nations les plus pauvres d' Afrique, est well-documented of all the African regions. The little infor­ celle sur laquelle on possede le moins de documents ecrits mation that exists would seem to indicate that anaemia is de toutes les regions d' Afrique. Le peu de renseignements widespread and that about half the women are anaemic by dont on dispose semblerait indiquer que l'anemie est fre­ the standards used in this study. Anaemia is thought to be quente et que Ia moitie environ des femmes est anemique closely allied to malaria. No information is available on the selon les normes retenues dans cette etude. On pense que types of anaemia. l'anemie est etroitement liee au paludisme mais ne dispose pas de renseignements sur les types d'anemies.

Southern Africa Afrique australe

The only information on this area, which relates to Bot­ Les seuls renseignements dont on dispose sur cette swana and South Africa, tends to indicate that anaemia is region, relatifs au Botswana et ill' Afrique du Sud, tendent il not as serious a problem here as elsewhere in Africa. In indiquer que l'anemie n'y est pas un probleme aussi grave South Africa the prevalence of anaemia differs between the qu'ailleurs en Afrique. En Afrique du Sud, Ia prevalence de races. The Indian women have a fairly high prevalence of l'anemie differe selon les races. La prevalence de l'anemie anaemia; about half of the pregnant women and one-third est assez elevee chez les femmes indiennes; Ia moitie envi­ of the others have haemoglobin concentrations below the ron des femmes enceintes et un tiers des autres presentent norm. The mean haemoglobin concentrations of South Afri­ des taux d'hemoglobine inferieurs il Ia norme. Les taux car Bantu women are higher. South African Bantus on the d'hemoglobine moyens des femmes bantoues sud-africai­ whole do not suffer from iron deficiency. Their dietary iron nes sont plus eleves. Dans !'ensemble, les Bantous sud­ intake is high because they use iron pots for cooking and africains ne souffrent pas de carence martiale. L'apport de brewing beer. As a result some of the adult men, but not fer alimentaire est eleva parce qu'ils utilisent des recipients usually the younger women, suffer from iron overload. In de fer pour Ia cuisine et le brassage de Ia biere. II s 'ensuit que pregnancy a small proportion of Bantu women suffer from certains des hommes adultes, mais generalement pas les iron-deficiency anaemia. The proportion of all pregnancy femmes plus jeunes, souffrent m~me de surcharge en fer. anaemias due to folate deficiency is higher than usual, as is Pendant Ia grossesse, une faible proportion de femmes to be expected in a population where iron deficiency is rare. bantoues souffre d'anemie ferriprive. La proportion des Anaemia among non-pregnant Bantu women is rare. anemies de grossesse dues il une carence en acide folique est plus forte que Ia normale, comme on peut s'y attendre dans une population ou Ia carence martiale est rare. Chez les Bantous, l'anemie est rare chez les femmes non encein­ tes.

AMERICA AMERIQUE

Middle America Amerique centrale

In Mexico anaemia among pregnant women was found to Au Mexique, on s ·est aperc;u que chez les femmes encein­ be most prevalent among the urban poor, followed by tes r anemia sevissait le plus parmi les populations pauvres women living in rural areas and least prevalent among the des villes, suivies en cela par les femmes vivant en milieu not quite so poor in an urban area. In rural areas more rural, et qu'elle etait en revanche Ia plus rare chez celles qui, women were anaemic in coastal areas than in the Altiplano, en milieu urbain, n'etaient pas tout il fait aussi pauvres. En 33% against 23%. milieu rural, il y avait davantage d'anemiques dans les regions littorales que dans I' Altiplano, 33 contra 23%. - 63

The INCAP surveys, which covered most of this area, Les enquiHes de I'INCAP, qui ont couvert Ia plus grande found a high prevalence of anaemia in some countries; over partie de cette region, ont permis d'observer une preva­ 40% of pregnant women in Costa Rica and Honduras were lence elevee de l'anemie dans certains pays; plus de 40% deemed deficient, 15% in El Salvador, and 20% in Nicara­ des femmes enceintes du Costa Rica et du Honduras ont ete gua. The prevalence of anaemia was said to be highest at jugees carencees, 15% au Salvador et 20% au Nicaragua. altitudes below 750 m. The prevalence of iron deficiency La plus forte prevalence de Ia carence martiale eta it elevee, was high, probably as a result of low availability of dietary probablement par suite de Ia faible disponibilite en fer ali­ iron. A high prevalence of low serum folate levels was mentaire. Une prevalence elevee de faibles concentrations found in both rural and urban areas. Vitamin B12 deficiency en acide folique serique a ete observee tant en milieu rural was rare. qu'urbain. La carence en vitamine B12 etait rare.

Caribbean Caraibes

Haemoglobin levels in this area seem to be somewhat Dans cette region, les taux d'hemoglobine semblent etre lower than in Middle America. In Trinidad and Tobago over quelque peu inferieurs a ceux de I' Amerique centrale. A Ia half the pregnant women had levels below the norm. For Trinite-et-Tobago, plus de Ia moitie des femmes enceintes non-pregnant women the proportions varied between 74% presentaient des taux interieurs a Ia norme. Pour les fem­ on St. Helena and about 20% in Haiti, although this latter mes non enceintes, les proportions allaient de 74% a Sa1nt figure is questionable. Most of the anaemia is due to iron Helena a environ 20% a Harti, bien que ce dernier chiffre soit deficiency and in Jamaica, for example, anaemia due to sujet a caution. La plupart des cas d'anemie sont dus a une folate deficiency is said to be uncommon. carence martiale et, a Ia Jamarque par exemple, l'anemie due a Ia carence en acide folique est reputee peu couran­ te. Serum vitamin B12 levels were low in pregnant Indian Les concentrations en vitamine B12 serique etaient faibles women in Port-of-Spain, but otherwise levels of this vitamin chez les femmes enceintes indiennes a Port-of-Spain, mais seem to be quite high. sinon les concentrations de cette vitamine semblent etre assez eleves.

Tropical South America Amerique du Sud tropicale

The PAHO collaborative study, analysing results ob­ L'etude concertee de I'OPS, analysant les resultats obte­ tained from four countries in this area, together with those nus de quatre pays de ce secteur, ainsi que ceux de I' Ar­ from Argentina, Guatemala and Mexico, concluded that iron gentine, du Guatemala et du Mexique, a conclu que Ia deficiency and iron-deficiency anaemia were widespread carence martiale et l'anemie ferriprive etaient largement not only in low but also in high socioeconomic classes. repandues non seulement dans les classes socio-economi­ Serum folate deficiency was found in about 10% of women, ques inferieures mais egalement dans les classes superieu­ but was correlated with low haemoglobin concentrations res. Une carence en acide folique serique a ete observee only in pregnant women. Serum vitamin B12 deficiency was chez environ 10% des femmes, mais n'etait correlee avec observed only in pregnant women. de faibles taux d'hemoglobine que chez les femmes encein­ tes. La carence en vitamine B12 serique n'a ete observee que chez les femmes ence1ntes. Average haemoglobin concentrations in this area range Dans cette region, les concentrations hemoglobiniques around 120 g/1 for pregnant women, with between one­ moyennes se situent aux alentours de 120 g/1 pour les quarter and one-third of women below the norm and around femmes enceintes, avec une proportion d'un quart a un t1ers 130 to 135 g/1 for non-pregnant women with slightly fewer de femmes en dessous de Ia norme, et aux alentours de 130 below the norm. In Brazil iron deficiency was frequent in a 135 g/1 pour les femmes non enceintes, avec une propor­ pregnant women. In Rio de Janeiro, megaloblastic anaemia tion legerement plus faible de taux inferieurs a Ia norme. Au was rare. In Sao Paulo, serum vitamin B12 levels found in Bresil, Ia carence martiale etait frequente chez les femmes pregnant women were very low. In Colombia, the preval­ enceintes; a Rio de Janeiro, l'anemie megaloblastique etait ence of anaemia was said to be low in Cali, but in Medellin rare. A Sao Paulo, les concentrations de vitamine B12 seri­ about one-quarter of pregnant women had haemoglobin que observees chez les femmes enceintes etaient tres fai­ concentrations below the norm. Serum iron and serum bles. En Colombie, Ia prevalence de l'anemie est reputee folate concentrations were low. The status of non-pregnant faible a Cali, mais a Medellin environ un quart des femmes women was considerably better. enceintes presentait des taux d'hemoglobine inferieurs a Ia norme. Les concentrations de fer serique et d'acide folique serique etaient faibles. L'etat des femmes non enceintes etait bien meilleur. In Peru the situation was found to be much worse in rural Au Perou, Ia situation a ete jugee bien pire en milieu rural, areas, where 50% of women had haemoglobin concentra­ ou 50% des femmes presentaient des taux d'hemoglobine tions below the WHO norm, than in Lima, where 35% of inferieurs a Ia norme, qu'a Lima ou 35% des femmes encein­ pregnant and 22% of non-pregnant women were below the tes et 22% des femmes non enceintes se situaient en des­ norm. Most of the anaemia was due to iron deficiency. sous de Ia norme. La plupart des cas d'anemie etaient Folate and vitamin B, 2 deficiency were only present in preg­ imputables a Ia carence martiale. II n'y avait de carences en nant women. In Venezuela about 18% of non-pregnant acide folique et en vitamine B12 que chez les femmes encein­ women had haemoglobin concentrations below the norms; tes. Au Venezuela, environ 18% des femmes non enceintes in hookworm-infested areas the proportion was double. In presentaient des taux d'hemoglobine interieurs a Ia norme; Caracas, folate and vitamin B12 deficiencies were found only dans les zones infestees par les ankylostomes, Ia propor­ in pregnant women, always coupled with iron deficiency. tion doublait. A Caracas, les carences en acide folique et en The lowest haemoglobin concentrations of this area were vitamine B,2 etaient observees uniquement chez les fem­ found in Guyana, one of the poorest countries of the mes enceintes, toujours associees a une carence martiale. region. Les plus faibles taux d' hemoglobine dans ce secteur etaient observes en Guyane, l'un des pays les plus pauvres de Ia region. 64 -

Temperate South America Amerique du Sud temperee

The prevalence of anaemia found in Corrientes City (Ar­ Au cours d'une etude menee par I'OPS, on a observe une gentina) in the PAHO study was high. Hookworm was sa1d prevalence elevee de l'anemie dans Ia ville de Corrientes to be an important contributory cause. Folate deficiency (Argentine). L'ankylostomiase y a ete consideree comme was more common than vitamin B12 deficiency. The situa­ une cause contributive importante. La carence en acide foli­ tion in Uruguay seems to be somewhat better. que etait plus courante que Ia carence en vitamine B12 . II semble que Ia situation soit quelque peu meilleure en Uru­ guay.

ASIA AS IE

Western South Asia Aste meridionale occidentale

Th1s area comprise most of the oil-producing countries of Cette region comprend Ia plupart des pays producteurs the Middle East, but no information on anaemia was found de petrole du Moyen-Orient, mais on n'a pas obtenu d'in­ for these countries. The ICNND surveys of Jordan and Leba­ formations sur l'anemie dans ces pays. Les enquEltes de non included only a very small number of women; the aver­ I'ICNND sur Ia Jordanie et le Liban n'ont retenu qu'un tres age haemoglobin concentrations in Jordan were somewhat petit nombre de femmes; les concentrations hemoglobini­ higher than in Lebanon, 125 g/1 against 120 g/1 for non­ ques moyennes en Jordanie etaient quelque peu supeneu­ pregnant women. In Turkey one-quarter of pregnant wo­ res a celle du Liban, 125 g/1 contre 120 g/1 pour les femmes men had haemoglobin concentrations below the norm. In non enceintes. En Turquie, un quart des femmes enceintes Israel average haemoglobin concentrations were closely presentait des taux d'hemoglobine inferieurs a Ia norme. En related to ethnic origin, being highest for women of Euro­ Israel, les concentrations hemoglobiniques moyennes pean origin and lowest for those from Asia. Much of the eta1ent etroitement liees a l'origine ethnique. Les plus ele­ anaemia was associated with iron deficiency; folate and vees s'observaient chez des femmes d'origine europeenne vitamin B12 deficiency were relatively rare. et les plus faibles chez celles originaires d' Asie. La plupart des cas d'anemie etaient assoc1es a une carence martiale; Ia carence en acide folique et en vitamine B12 etait relative­ ment rare.

Middle South Asia Asie meridionale centrale

This is one of the poorest and most populous regions of II s'agit de l'une des regions les plus pauvres et les plus the world. It is the home of 188 million women, who make peuplees du monde. c· est Ia que vivent 188 millions de up about 40% of all the women in the developing world femmes qui constituent environ 40% de !'ensemble des (excluding China). Of all the countries of the world for which femmes du monde en developpement (Chine exclue). A the Information was available, India has probably the high­ I' exception de l'lran, le PNB par hab1tant en 1975 eta it inte­ est prevalence of nutritional anaemia in women. In southern rieur a 200 dollars des Etats-Unis d' Amerique dans tousles India between 60% and 80% of pregnant women were pays de ce secteur. De tous les pays du monde pour les­ anaemic; the prevalence of megaloblastic changes 1n the quels on dispose d'informations, l'lnde est probablement bone marrow was found, in the few studies that measured celui ou Ia prevalence de l'anemie nutritionnelle chez Ia this, to be extremely high. In northern India the haemoglobin femme est Ia plus elevee. En lnde meridionale, 60 a 80% concentration was marginally higher than in the south. des femmes enceintes etaient anemiques. Dans les rares etudes pour lesquelles on l'a mesuree, Ia prevalence des modifications megaloblastiques de Ia moelle osseuse etait extrElmement elevee. En lnde septentrionale, Ia concentra­ tion hemoglobinique etait marginalement plus elevee que dans le sud. In Pakistan and Bangladesh anaemia is also very common Au Pakistan et au Bangladesh, l'anemie est egalement among pregnant women, and average haemoglobin con­ tres courante chez les femmes enceintes, et Ia concentra­ centration is extremely low, usually under 100 g/1. Accord­ tion hemoglobinique moyenne est extrElmement faible, ge­ ing to most authors, most of the anaemia is due to iron neralement inferieure a 100 g/1. Selon Ia plupart des au­ deficiency, but little work seems to have been reported on teurs, les cas d'anemie sont le plus souvent dus a une folate and vitamin B12 concentration. In Sri Lanka over half carence martiale, ma1s il semble que I' on fasse peu etat de the women were found to have a haemoglobin concentra­ travaux sur Ia concentration en acide fohque et en vitam1ne tion below the norm. In a survey of tea estate workers, 80% B12. Au Sn Lanka, on a constate que plus de Ia moitie des of the anaemias were due to iron deficiency, 12% to iron femmes presentaient un taux d'hemoglobine inferieur a Ia and folate deficiency, 3% to iron and vitamin B12 deficiency, norme. Dans une enquElte sur le personnel des plantations and 6% to all three. de the, 80% des cas d'anemie etaient dus a une carence en fer, 12% a une carence en fer et en acide folique, 3% a une carence en fer et en vita mine B12 et 6% a une carence de ces trois elements reunis. In Iran the mean haemoglobin concentration found in two En Iran, Ia concentration hemoglobinique moyenne ob­ recent surveys was 122 g/1 for all women and 111 g/1 for servee a !'occasion de deux enquEltes recentes etait de pregnant women. 122 g/1 pour I' ensemble des femmes et de 111 g/1 pour les femmes enceintes.

Eastern South Asia Asie meridionale orientale

Overall prevalence rates are high in this area. In most Dans cette region, les taux de prevalence globale sont countries in this region over half the pregnant women are eleves. Dans Ia plupart des pays, plus d'une femme en­ anaemic; 1n fact most of the mean haemoglobin values, for ceinte sur deux est anemique; en fait, Ia plupart des con- - 65- pregnant and non-pregnant women alike, are below the centrations hemoglobiniques moyennes, pour les femmes norms. In Burma about 40% of non-pregnant village women ence1ntes ou non, se situent en dessous des normes. En were anaemic, as were over half the pregnant women. In Birmanie, environ 40% des villageoises non enceintes Indonesia between one-half and all pregnant village women etaient anemiques, comme l'etaient plus de Ia moitie des were anaemic, in a Jakarta hospital 70% of women deliv­ femmes enceintes. En Indonesia, de Ia moitie a Ia totalite ered were anaemic. des villageoises enceintes etaient anemiques et, a l'hopital de Djakarta, 70% des femmes accouchees etaient anemi­ ques. Interesting ethnic differences were found in Malaysia and D'interessantes differences ethniques ont ete observees Singapore, with Indian women having significantly lower en Malaisie et a Singapour, les femmes indiennes presen­ haemoglobin concentrations than Malay women, who in tant des concentrations hemoglobiniques nettement lnfe­ turn had lower levels than the Chinese women. This is rieures a celles des femmes malaises dont les taux etaient a assumed to be due to differences in diet and cooking habits. leur tour inferieurs a ceux des femmes chi noises. On estime In addition, in Kuala Lumpur the proportion of anaemias that que ces differences sont imputables au regime alimentaire were megaloblastic was 36% for north Indian women, 27% et aux habitudes culinaires. En outre, a Kuala Lumpur, Ia for south Indian women, 10% for Chinese women and 9% proportion des anemie megaloblastiques etait de 36% pour for Malay women. In the Philippines about half the pregnant les femmes originaires d'lnde du Nord, de 27% pour les women and one-third of the rest had a haemoglobin con­ femmes originaires d'lnde du Sud, de 10% pour les femmes centration below the norm. chinoises et de 9% pour les femmes malaises. Aux Philip­ pines, les taux de prevalence etaient legerement interieurs. La mo1tie envion des femmes enceintes et un tiers des autres presentaient une concentration hemoglobinique infe­ rieure a Ia norme. Thai women tend to be Iron-deficient rather than folate­ Les femmes tha'is tendent a etre carencees en fer plutot deficient, although there have been (rare) reports of folate qu'en acide folique, bien que l'on ait signale quelques cas deficiency in pregnancy. Vitamin 8 12 deficiency anaemia (rares) de carence en acide folique pendant Ia grossesse. On has also been found. a egalement observe des cas d'anemie de carence en vita­ mine 81 2 .

East Asia Asie orientale

There is very little information on this relatively more On possede peu de renseignements sur cette region rela­ affluent area. In Hong Kong 14% of pregnant Chinese tivement plus riche. A Hong-Kong, 14% des Chinoises women had haemoglobin concentrations below 100 g/1. enceintes presentaient des concentrations hemoglobini­ Women in China (province of Taiwan only) had fairly high ques inferieures a 100 g/1. En Chine (province de Ta'iwan haemoglobin concentrations. uniquement), les femmes presentaient des concentrations hemoglobiniques assez elevees.

OCEANIA OCEANIE

In most of the islands anaemia seems to be widespread, Dans Ia plupart des lies, l'anemie semble etre largement especially at sea level. In Fiji the prevalence of anaemia repandue, particulierement au niveau de Ia mer. Aux Fidji, Ia among Indian women was somewhat higher than among prevalence de l'anemie chez les femmes indiennes eta1t the Fij1ans; most of the megaloblastic anaemia was in Indian quelque peu superieure ace qu' elle eta it chez les Fidjiennes; women and was due to folate deficiency rather than vitamin Ia plupart des cas d'anemie megaloblastique etaient obser­ 8 12 deficiency. About three-quarters of the women sur­ ves chez les femmes indiennes et dus a une carence en veyed had haemoglobin concentrations below the norm. In acide folique plutot qu'en vitamine 8 12 . Les trois quarts Kiribati the proportions were much the same. environ des femmes enquetees presentaient des concen­ trations hemoglobiniques inferieures a Ia norme. Aux Kiri­ bati, les proportions etaient sensiblement les memes. There is a surprisingly vast amount of information on II existe une masse etonnante de renseignements sur anaemia in Papua New Guinea, whose total population is l'anemie en Papouasie-Nouvelle-Guinee, pays qui compte less than 3 million. Most of the studies have demonstrated au total moins de trois millions d'habitants. La plupart des that anaemia is widespread, especially in the coastal areas, etudes ont fait Ia preuve que l'anemie est largement repan­ where megaloblastic anaemias have also been found. In the due, particulierement dans les zones littorales ou I' on ob­ lowlands between 50% and 100% of women were found serve egalement des cas d'anemie megaloblastique. Dans with haemoglobin concentrations below the norm. Higher les terres basses, on a observe que 50 a 100% des femmes haemoglobin concentrations at higher altitudes were partly presentaient des concentrations hemoglobiniques inferieu­ caused by the lower incidence of malaria. Vitamin 8 12 defi­ res a Ia norme. Les concentrations hemoglobiniques plus ciency seemed to be almost as common, if not more com­ elevees observees a des altitudes superieures etaient en mon, than folate deficiency. partie dues a !'incidence plus faible du paludisme. La carence en vitam~ne 8 12 semblait etre presque aussi cou­ rante, sinon plus courante, que Ia carence en acide foli­ que.

The yardstick-the developed countries L'etalon: les pays developpes

In order to assess the gravity or significance of the find­ A fin de mesurer Ia gravite ou !'importance des constata­ ings with regard to nutritional anaemias in developing coun­ tions faites a propos des anemies nutritionnelles dans les tries some sort of yardstick becomes necessary. pays en developpement, il est necessaire de choisir une sorte d' etalon. - 66

Given the natural variation in haemoglobin levels in heal­ Etant donne Ia variation naturelle des taux d'Mmoglobine thy subjects and the fact that the norms are arbitrarily fixed chez les sujets en bonne sante et le fait que les normes sont at a level "below which anaemia is likely to exist", even a arbitrairement fixees a un niveau en dessous duquel il con­ survey of completely healthy individuals will turn up a few vient «de considerer qu' il y a anemie », une enquete portant people with haemoglobin concentrations below these meme sur des individus absolument sains decouvrira quel­ norms. Moreover, nutritional anaemia is not confined to ques personnes presentant des concentrations hemoglobi­ developing countries but exists also, although to a niques inferieures a ces normes. markedly lesser extent, in developed countries. De plus, l'anemie nutritionnelle ne se limite pas aux pays en developpement mais existe egalement, bien que dans une mesure nettement moindre, dans les pays develop­ pes. It is useful, therefore, as a measure of comparison, to Par consequent, il est utile, a titre de comparaison, d'exa­ look at a few findings from developed countries. miner quelques resultats obtenus de pays developpes. A collaborative study in several European countries 65 Une etude concertee, entreprise dans plusieurs pays found between 4% and 7% of women with haemoglobin d'Europe 65 , a permis de constater que 4 a 7% des femmes concentrations below the norms. presentaient des taux d'hemoglobine inferieurs aux nor­ In the USA, The Health and Nutritional Examination Sur­ mes. Aux Etats-Unis d' Amerique, I' enquete sur Ia sante et Ia vey264 found a mean haemoglobin concentration for wo­ nutrition 264 a perm is de fixer a 138 g/1 Ia concentration men aged 18-44 years of 138 g/1 with 6% below the norm. hemoglobinique moyenne pour les femmes de 18 a 44 ans, There were marked variations between different groups. eta 6% Ia proportion des valeurs inferieures a Ia norme. II y Women with an income level below the "poverty line", avait de nettes disparites entre les differents groupes de who comprised about 10% of all women, had a mean hae­ femmes. Celles dont les revenus se situent en dessous de Ia moglobin concentration of 132 g/1, with 12% of them «barre de pauvrete», soit environ 10% de !'ensemble des below the mean. In Poland, the mean haemoglobin concen­ femmes, ont une concentration hemoglobinique moyenne tration of pregnant women in Warsaw was 121 g/1, with de 132 g/1, 12% d'entre elles presentant une concentration 22% below the norm 300. In Australia 5% of pregnant inferieure a Ia moyenne. En Pologne, Ia concentration Mmo­ women had haemoglobin concentrations below the globinique moyenne des femmes enceintes a Varsovie etait norm 114. de 121 g/1, avec une proportion de 22% en dessous de Ia norme 300. En Australie, 5% des femmes enceintes presen­ taient des taux d'hemoglobine inferieurs a Ia norme 114.

A comparison of these data with those presented above La comparaison de ces donnees avec celles presentees conf1rms that nutritional anaemia in women is a major public avant montre assez clairement chez Ia femme que l'anemie health problem in most developing countries. Because of its nutritionnelle pose un grave probh~me de sante publique deleterious consequences and because it is so widespread, dans Ia plupart des pays en developpement. Or, en raison nutritional anaemia in women is one of the nutritional defi­ de ses consequences nefastes et parce qu'elle est si large­ ciency diseases that must be given high priority if countries ment repandue, l'anemie nutritionnelle de Ia femme est are to make significant progress toward the goal of "health rune des maladies de carence nutritionnelle auxquelles il for all''. Intervention strategies and methodologies for com­ convient d'accorder un niveau eleva de priorite si les pays bating nutritional anaemia have already been developed 307 veulent faire des progres decisifs vers l'instauration de Ia and most nutritional anaemia can be prevented. sante pour taus. Les strategies et les methodologies d'in­ tervention permettant de combattre l'anemie nutritionnelle ont deja ete elaboree 307 et Ia plupart des anemies nutrition­ nelles peuvent etre evitees. - 67-

ANNEX ANNEXE

Symbols and abbreviations Symboles et abreviations

< less than < interieur a less than or equal to interieur au egal a > more than > superieur a more than or equal to ;;;;. superieur au egal a a zero means none un zero s1gnif1e : neant a blanc space means no information un espace en blanc signifie: pas de rense1gnements the date g1ven in the tables 1s either the date of the survey or, if Ia date donnee dans les tableaux est soit Ia date de l'en­ this is not known, the date of publication qul!te, soit si on ne Ia connai't pas, Ia date de publication g, g/1 grams, grams per litre g, g/1 grammes, grammes par litres mg, mg/1 milligrams, milligrams per litre mg, mg/1 milhgrammes, milligrammes par litre pg, pg/ml p1cograms, picograms per millilitre pg, pg/ml picogrammes, p1cogrammes par m1llilitre mg micrograms ug microgrammes ng, ng/ml nanograms, nanograms per millilitre ng, ng/ml nanogrammes, nanogrammes par milhhtre an. anaemia, anaem1c an. anem1e, anem1que D. or Dem. Democratic D. au Dem. democratique E. estimate E. estimation FAO Food and Agriculture Organization of the United FAO Organisation des Nations Unies pour I' Alimenta­ Nat1ons tion et I' Agriculture GNP Gross national product PNB Produit nat1onal brut Hb haemoglobin concentration Hb Concentration hemoglobinique hasp. hospital, hospitalized hasp. hopital, hospitalise ICNND Interdepartmental Committee on Nutrition for ICNND Com1te interm1msteriel de Ia Nutrition pour Ia National Defense Defense nationals (Etats-Unis d' Amerique) INCAP Institute of Nutrition of Central America and Panama INCAP lnstitut de Ia Nutrition d' Amerique centrale et du Panama lact. w. lactatmg women f. all. femmes allaitantes m metres m metres MCH maternal and child health SMI sante maternelle et infantile neg I. negligible neg I. negligeable non-lact. w. non-lactating women f non-all. femmes non-allaitantes non-p.w. non-pregnant women f. non-e. femmes non-enceintes P. People's p populaire PCV Packed cell volume PCV volume globula1re total p.w. pregnant women f.e. femmes enceintes PAHO Pan American Health Organization OPS Organisation panamericame de Ia Sante Port. Portuguese Port. Portugais post-meno. post-menopausal post-meno post-menopause port.p. postpartum post.p postpartum R. or Rep. Republics R. au Rep Republique s South S. Sud soc. econ. socioeconomic group soc.econ. groupe soc1o-economique th. thousands m. milliers U. United U. Unie UN United Nat1ons NU Nat1ons Un1es UNICEF Un1ted Nations Children's Fund UNICEF Fonds des Nat1ons Unies pour I'Enfance V1t. V1tam1n Vit. V1tamine w. women f. femme wt we1ght pd poids WHO World Health Orgamzation OMS Organisation mond1ale de Ia Sante yrs years a. annees - 68-

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302 WORLD HEALTH ORGANIZATION. Requirements of 305 VII, C. Y. A study of endemic anaemia in a rural popu­ ascorbic acid, vitamin D, vitamin 8 12, folate and iron. lation of Taiwan. Journal of the Formosan Medical Technical Report Series, No. 432, Geneva, WHO, Association, 68: 392 (1969). 1970. 306 YUSUFJI, D. eta/. Iron, folate and vitamin 8 in nutrition ORGANISATION MONDIALE DE LA SANT~. 8esoins en 12 in pregnancy a study of 1 000 women from Southern acide ascorbique, vitamine D, vitamine 8 12 acide folique et fer. St!Jrie de Rapports techniques, N° 452, Geneve, India. Bulletin of the World Health Organization, 48: 15 (1973). OMS, 1970. 303 WORLD HEALTH ORGANIZATION. Scientific Group on 307 USA. International Nutritional Anaemia Consultative Research in Nutritional Anaemias (Latin America and the Group. Guidelines for the eradication of iron deficiency Caribbean). Report to the Director-General, Caracas, anaemia. The Nutrition Foundation. Washington, DC, 1963. (Unpublished document No. MHO/PA/48.64- INACG, 1977. Document non publi~ N° MHO/PA/48.64). 308 Excluding China - A !'exclusion de Ia Chine. 304 WORLD HEALTH ORGANIZATION. The Sl for the health 309 professions. Geneva, WHO, 1977. And: The Use of Sl For sources of information, see the tables - Pour Ia units in public health. WHO Chronicle, 32: 99 (1978). source des informations voir les tableaux. ORGANISATION MONDIALE DE LA SANTt Le Sl pour 310 GNP data from source 121, estimated percentage les professions de Ia sant~. Geneve, OMS, 1977. Et anaemic from Table 5- Les donn~es du PN8 provien­ L'emploi des unit~s Sl en sanM publique. Chronique nent de Ia source 121, le pourcentage estim~ d'an~mi­ OMS, 32: 108 (1978). ques provient du Tableau 5. TABLE 1. HAEMOGLOBIN CONCENTRATION TABLEAU 1. CONCENTRATION HEMOGLOBINIQUE

Pregnant women Lactating women Non-pregnant women All women Total Femmes encemtes Femmes alla1tantes Femmes non enceintes Ensemble des femmes sample Reg1on-Country Year Altitude SIZ8 Source Below Below Below Below R6gion-Pays Ann6e (m) D•mens1ons Mean Hb the norm Mean Hb the norm Mean Hb the norm Mean Hb the norm totales de Hb En dessous Hb En dessous En dessous En dessous I' 6chantlllon Moyenne de Ia Moyenne de Ia Hb de Ia Hb de Ia Moyenne Moyenne norma norma norme nor me (g/1) (%) (g/1) (%) (g/1) (%) (g/1) (%) --

AFRICA - AFRIQUE Northern Africa - Afrique septentrionale 26 Algeria - Algerie 1960s 65 E 55 Algeria - Algene 1974 56 107 60 287 Egypt - Egypte 1954 50 90 95 E 174 Egypt - Egypte 1954 220 90 124b 1 Egypt - Egypte 1956-57 1 5ooa 83 E 99 E 93 E 99 E 64 Egypt - Egypte 1960 132 80 100 68 Egypt - Egypte 1964 300 110 46 199 Egypt - Egypte 1965 115 E 273 Libyan Arab Jamahiriya 1957 72 111 47 129 24 Jamah1nya arabe hbyenne 212 Libyan Arab Jamahiriya .. 1971 355 100E Jamah1nya arabe libyenne -...J 106 Morocco - Maroc 1964 80E O'l 55 Morocco - Maroc 1971 43 46 128 Tunisia - Tunis1e 1978 660 111 38 118 46 124 31 Western Africa - Afrique occidentale 259 Cape Verde - Cap-Vert 1950s 149 109 42 296 Gambia - Gambie 1955 188 91 80 E 101 80E 52 Ghana 1962 5 589 109 153 Ghana 1967 400 100 119 115 241 Ghana 1970 1098 64 30 Ghana 1973 113 E 260 Gu1nea-B1ssau - Guinee-Bissau 1952 95 93 99 78 GU1nea-B1ssau - Gu1nee-Bissau 1957 1 538 soc 85 E 100 85 E 214 Ivory Coast - COte d'lv01re 1978 198 109 34 195 Mali 1964 86 110 50E 223 Mah 1973 48 102 65 E 117 58 E 224 Mali 1974 334 128 26 176 Mali 1977-78 258 20 181 Mauritania - Mauritanie 1975 419 121 24 178 N1ger 1978 70 108 57 E 123 36 82 N1gena - N1gena . 1959-60 4324 90 E 90 E 282 Nigeria - N1gena . 1965 165 109 c 50 E 121 50E 62 Nigena - N1gena . 19€ 118 50E 150 Senegal - Senegal 195us 150 123 d 13d 139 d 105 Senegal - Senegal 1972 113 297 Sierra Leone ... 1977 45 e 281 Togo ...... 1977 1141 47 30 35 124 32 Eastern Africa - Afrique orientale 270 EthiOpia - EthiOpie 1958 1 700+ 140 132 33 E 137 50 E 128 65 E 108 Ethiopia - Ethiopie ...... 1968 2400 174 133 7 142 8 108 Eth1op1a - Ethiopie 1968 1 850 100 121 126 54 222 Eth1op1a - Ethiopie 1972 2400 597 143 5 152 87 Ethiopia - Ethiop1e 1976 2400 236 137 6E 139 1 3 I 140 Kenya 1967 42 127 38 E 25 Kenya 1964-68 700-2000 126 40E 149 Kenya 1969 2000 231 137 17 E 149 Kenya 1969 1400 155 129 36 E 149 Kenya 1969 Sea level 217 99 89 E Niveau de Ia mer 292 Kenya 1969 1600 211 120 48 E 145 f 37 Malaw1 1970 391 110 E 49 107 247 Mauritius - Maurice 1957 147 98 70 E 105 57 78 MauritiUS - Maurice 1960 1073 89 80E 70E 107 79 Seychelles ..... 1961 490 127 40E 89 Uganda - Ouganda 1958 294 121 35 E 122 46 E 220 U. R. Tanzania - R.-U. de Tanzame 1961 1 100 162 102 77 E 76 U. R. Tanzania - R.-U. de Tanzanie 1964-65 Sea level 270 111 70 E Niveau de Ia mer 76 U. R. Tanzama - R.-U. de Tanzan1e 1966-67 Sea level 201 91 95 E N1veau de Ia mer 225 U. R. Tanzania - R.-U. de Tanzanie 1966 Sea level 204 88 N1veau de Ia mer 20 U. R. Tanzania - R.-U. de Tanzan1e 1966-67 81 117 E 285 U. R. Tanzania - R.-U. de Tanzanie 1971 500 E 103 90E 182 U. R. Tanzania - R.-U. de Tanzanie 1971 Sea level 117 93 79 E Niveau de Ia mer 179 U. R Tanzania - R.-U. de Tanzan1e 1971 Sea level 1 317 106 59 N1veau de Ia mer 215 U. R. Tanzania - R -U. de Tanzanie 1974 387 809 72 -....! 155 Zambia - Zambie 1958 1200 33 124 50 E -....! 24 Zambia - Zamb1e 1966 943 105 65 E 141, 142 Zambia - Zamb1e 1970-71 1200 1063 108 60 E 119 60 E 53 E 67 Zambia - Zamb1e 1972 1200 239 110 50 E 31 Zimbabwe .... 1968 125 122 45 E 137 Zimbabwe ... 1968 175 116 27 Middle Africa - Afrique centrale 166 Angola 1956 129 194 Chad- Tchad ...... 1965 365 122 130 33,34 Chad - Tchad ...... 1968 873 121 50 E Southern Africa - Afrique australe 172 Botswana ...... 1969 900 122 125 140 ]h 140 6h 50 Botswana ...... 1971 111 50 E 36 Botswana ...... 1971 386 140 E 3 145 E 10 E 135 E 20E 218 South Afnca - Afrique du Sud ...... 1964 102 61 South Africa: Bantu - Afnque du Sud: bantoues 1966 285 129 25' 139 140 1 167 South Africa: Bantu - Afrique du Sud: bantoues 1966 75 122 12 E 167 South Africa: lnd1an - Afnque du Sud: indiennes 1966 75 108 32 E 167 South Afnca. White - Afrique du Sud. blanches 1966 50 119 8E 18 South Afnca · Bantu - Afnque du Sud: bantoues 1970 1 750 51 131 J 27 169, 170 South Afnca: Indian - Afrique du Sud: 1ndiennes 1972 1610 124 38

AMERICA - AMERIQUE Middle America - Amerique centrale 115 Costa Rica 1969 800 124 44h oh 136 30 E 193 El Salvador 1969 <750 93 15 135 193 Guatemala 1968 1 850 95 122 34 E 117 Guatemala 1969 1 100 90 141 118 Honduras 1969 800 81 132 TABLE 1. HAEMOGLOBIN CONCENTRATION (Continued) TABLEAU 1. CONCENTRATION H~MOGLOBINIQUE (Suite) ------Pregrwnt women Lectettng women Non-pregnant women All women Total Femmes ence1ntes Femmes 1llaitantes F"mmes non enceintes Ensembltt des femmes ••mple Reg1on-Country Ye•r Altitude size Source Below Below Below Below R6gion-P•v• Ann6e (ml Oim.n••ons Mean Hb the norm Me•n Hb the norm the norm thft norm Mean Hb Me•n Hb tot•les de Hb Hb En dessous En dessous Hb En dessous Hb En dessous 1'6chantillon Moyenne de Ia Moyenne dft le de Ia I• Moyenne Moyenne de norme no nne norme norme (g/0 ('JI.I (g/11 (%1 (g/11 (%1 (g/11 (%1 ---

229 Mexico - Mexique . . 1957 2250 9 951 35 E 151 Mexico - Mexique 1960 148 129 25 15 Mexico - Mexique . 1966 2060 157 137 23 15 Mexico - Mexique 1966 Sea level 320 124 33 Niveau de Ia mer 11 Mexico - Mexique 1968 1 600 600 SOE 193 Mexico - Mexique 1968 2500 495 126 38 E 143 17 E 201 Mexico - Mexique 1978 2250 68 159 k 119 Nicaragua 1969 <750 89 20 138 0 6 131 120 Panama • • 0 • • • • 1969 90 0

Ceribbeen - Cereibes 45E 191 Barbados - Barbade ••••••••• 0 1969 121 122 236 Dominican Rep. - Rllpublique dominicaine 1969 229 46 60E -....! 235 Haiti - HaTti ...... 1958 150 128 22 135 17 (X) 19 Haiti - Halli ..... 1970 102 64 1 173 Jamaica - Jamarque 1962-66 798 125m 33 E 198 Jamaica - Jamarque 1967 1000 117 24 4 Jamaica - JamaTque 1968 205 129 n 17 202 Puerto Rico - Porto Rico 1961 119 69 Puerto Rico - Porto Rico 1966 176 137 183 St. Helena - Saint Helena 1958 61 111 75 E 279 St. Kitts-Nevis - Saint-Christophe-et-Nil!ves 1962 41 107 118 54 279 St. lucia - Sainte-lucie ...... 1962 36 114 121 43 279 Trinidad and Tobago- Trinitll-et-Tobago 1962 114 121 41 41 Trinidad and Tobago- Trinitll-et-Tobago 1964 93 126 JOE 42 Trinidad and Tobago- Trinit6-et-Tobago 1967 555 108 56 E 43 Trinidad and Tobago- Trinitll-et-Tobago 1968 116 104 57 E 132 21 Tropicel South Americe Am6rique du Sud tropicele 265 Bolivia - Bolivie 1964 2500 126 146 150 155 15 E

266 Brazil - Brllsil • 0 •• 1963 127 128 67 193 Brazil - Br6sil .... 1968 750 78 120 20E 135 BE 193 Colombia - Colombie 1968 1 500 148 127 22 142 6 269 Ecuador - Equateur . 1960 2000 59 135 35 E 192 Guyana - Guyana 1971 642 55 41 41 280 Paraguay .. 1965 175 122 127 130 28 Peru- P6rou 1960 144 115 32 Peru- P6rou 1965 1 300 282 124 50E 193 Peru- P6rou 1968 200 114 35 131 22 277 Venezuela 1964 194 121 124 30 129 20 148 Venezuela 1964 307 128 20 193 Venezuela 1968 900 217 111 54E 128 24 E 57 Venezuela ...... 1972 192 1231 133i 175 Venezuela ...... 1974 176 125 10 Temperate South America Amerique du Sud tempirite 193 Argentina - Argentine 1968 125 104 61 129 34 268 Chile - Chili 1961 166 129 22 294 Chile - Chili 1970 325 129 I 74 Ch1le- Chih 1976 552 112 32 137 3 276 Uruguay ...... 1962 265 126 136 3 134 7

ASIA- ASIE Western South Asia Asie mllridionale occidentale 124 Iraq ...... 1952 115 100E 132 Israel - lsra!!l 1958-59 3 578 112 44E 248 Israel - lsra!!l 1959-60 2498 116 23 207 Israel - lsra!!l 1963-65 890 112 58 66 Israel - lsra!!l 1964-66 2 768 118 29 E 300 Israel - lsra!!l 1968 200 109 47 125 29 271 Jordan - Jordanie 1962 116 117 124 33 125 25 272 Lebanon - Liban . 1962 100 110 50E 118 56 120 44 187 Lebanon - L1ban . 1971 689 127 187 Turkey - Turquie 1971 532 119 50E 139 Turkey - Turquie 1974 8000 74 Middle South Asia Asie meridionale centrale 298 Bangladesh . 1973 300 42' 69' 113 Bangladesh . 1973 157 102 66 ...... 16 Bangladesh . 1975-76 611 108 c 50° 111 70 tO 210 India- lnde 1958 201 110 81 233 India- lnde 1958 823 68 E 251 India- lnde 1958 938 109 50E 117 58 113 63 234 India- lnde 1958 830 72E 17 India- lnde 1959 449 88 98 E 209 lnd1a- lnde 1960 272 106 60E 239 India- lnde 1962 478 99 118 286 lnd1a- lnde 1962 394 112 47E 56 lnd1a- lnde 1966 5 725 80E 21 India- lnde 1967-68 374 102 80E 112 197 India- lnde 1968 743 22 300 India- lnde 1968 1 348 69 300 lnd1a- lnde 1968 195 98 80 105 64 300 India- lnde 1968 1 100 102 56 123 35 187 India- lnde 1971-75 2 837 74 100E 230 India- lnde 1973 415 73 67 245 India- lnde 1975 647 96 87 135 India- lnde 1977 2 795 62 93 Iran 1968-69 1500 639 127 34E 187 Iran ..... 1971 1100 2 125 122 80 Iran ..... 1978 1 100 108 111 56 E 80 Iran ..... 1978 1 100 86 138 4E 2 Nepal - N~pal 1972 1500 15 117 33 189 Pakistan 1962-64 375 114 44E 113 63 117 55 238 Pakistan 1965 98 E 104 Pakistan 1968-69 1 285 107 55 160 Pakistan 1969 200 97 58 E 101 Pak1~an 1970 509 99 73 102 Pakistan 1971 889 96 64 TABLE 1. HAEMOGLOBIN CONCENTRATION (Continued) TABLEAU 1. CONCENTRATION HtMOGLOBINIQUE (Suite)

~------Pregnant women Ll!lctating women Non-pregn1nt women All women Tot•l Femmes enceintes Femmes allaitantes Femmes non ence!ntes Ensemble des femmes sample ------Regton-Country Year Altitude SIZft Source Below Below Below Below R~gion-Pays AnnH (m) Dtmens1ons Me•n Hb the norm Mean Hb the norm the norm the norm totales de Mean flb Mean Hb Hb En dessous Hb En dessous En dessous En dessous Hb Hb r 6ch•nttllon Moyenne de Ia Moyenne de Ia de Ia de Ia Moyenno Moyenne nor me norme norme norme (gfl) (%) (gfl) (%) (g(l) (%) (g(l) (%) ------

158 Pakistan . 1976 105 54 243 Sri Lanka 1969-72 983 106 62 237 Sri Lanka 1974 213 50 244 Sri Lanka 1974 368 92. 244 Sn Lanka 1974 200 70

Eastern South Asia Asie meridionale orientale 17 Burma - B1rmanie 1957 263 108 9 Burma - B1rmanie 1966 1 167 106 65 E 7, Burma - Birmanre 1968-72 1 938 109 42 121 42 126 123 41 8, 136 290 Indonesia - lndonl§sie 1961 116 124 40E 81 Indonesia - lndonl§sie 1970 106 132 f 10 (X) 134 Indonesia - lndonl§sle 621 65 55 0 134 Indonesia - lndonl§sie 6203 70" 134 Indonesia - lndonl§sle 3 531 99 134 Indonesia - lndonl§sie 185 91 97 105 88 29,98 Lao Peop. Dem. Rep. - Rl§p. dem. pop. lao 1968-69 1 197 290 35 Lao Peop. Dem. Rep. - Rep. dem. pop. lao 1970 1 973 62 274 Malaysia - Malais1e 1962 145 125 132 154 Malaysia - Malaisie 1964 1000 100 77 38 Malaysia - Malais1e 1964 83 111 85 E 40 Malaysia - Malaisie 1968 102 120 22 E 6 Philippines 1960-65 1 695 114 46 126 34 E 128 31 E 162, 163 Philippines 1969 1248 109 48 22 122 37 212 Philippines 1971-75 3000 116 50E 253 Philippines 1976 437 118 143 Philippines 1978 252 109 50 146 Singapore - Singapour 1965-66 1000 102 73 107 Singapore - Singapour 1967 413 121 E 26 E 275 Thailand - Thanande 1960 68 102 68 114 55 283 Thailand - Thanande 1963 254 106 64 E 115 57 99 Thailand - Thanande 1964 194 93 99 84 102 91 249 Thailand - Thai1ande 1965 624 25 249 Thailand - Thanande 1965 150 109 44 180 Thailand - Thanande 1966 50 134 p 85 Thailand - Thai1ande 1970-71 207 120 50 E 99 Thailand - Thanande 1971 879 88 284 Thailand - Thanande 1971 154 111 31 284 Thailand - Thanande 1971 241 106 39 219 Thailand - Thanande 1971-72 39 915 112 q 48 E 144 Thailand - Thanande 1972 269 122 38 291 Thailand - Thanande 1973 2 041 119q 50 E 256 Thailand - Tha·11ande ..... 1973 3 230 21 278 VietNam ...... 1959 123 111 50 E 118 44 E•st Asi• - Asie orientale 305 China (Prov. of Taiwan) - Chine (prov. 1962 860 142 14 de Tarwan) ...... 257 Hong Kong - Hong-kong ...... 1961 1 915 14 t

OCEANIA - OCEANIE 147 Cook Islands - lies Cook 1953 74 132 213 Fiji- Fidji 1970 139 107 70 E 126 FIJI- Fldjl 1972 1089 103 68 102 72 208 Fiji- F1d11 1971-78 1 871 38 p 159 Guam 1956 70 105 70E 109 Kiribati 1953 300 116 36 E 124 38 E 124 38 E 127 K1ribati 1971 233 105 69 113 66 111 77 125 Pacific Islands - lies du Pacifique 1972 70 47 Papua New Gu1nea - Papouasie-Nouvelle-Guinl§e 1962 1 700 101 111 50E 110 288 Papua New Guinea - Papouasie-Nouvelle-Guinl§e 1963 1 200-2 400 299 137 30 E 129 Papua New Guinea - Papouasie-Nouvelle-Guin6e 1965 Sea level 802 108 55 E 117 50E Niveau de Ia mer 246 Papua New Guinea - Papouasie-Nouvelle-Guinl§e 1966 Sea level 54 102 Niveau de Ia mer 12 Papua New Guinea - Papouasie-Nouvelle-Guinee 1966 1 500-2 400 270 137 27 Papua New Guinea - Papouasie-Nouvelle-Guinl§e 1968 Sea level 58 101 125 t Niveau de Ia mer 48 Papua New Guinea - Papouasie-Nouvelle-Guinl§e 1973 1 000-1 600 300E 108 80E 49 Papua New Guinea - Papouasie-Nouvelle-Guinl§e 1974 150 47 96 100 110 Solomon Islands - lies Salomon ...... 1952 253 108 75 E 00 ~ For abbrev1at•ons see Methodology and Annex. "Non-pregnant women" may include ''lactating women" 1f these are not enumerated separately. Percentage below norm has been corrected for altitude, where this is known. -Pour las abr8v1at•ons, voir Mltthodolog1e et Annexa Les «femmes non ence1ntes » peuvent comprendre les «femmes allaltantes » s1 celles-c1 ne sont pas ltnum8r9es s8par8ment. Le pourcentage de femmes en dessous de Ia norma a 6t8 corrig8 pour temr compte de I' altitude, lorsque celle-c1 est connue

8 Haematocnt <30% - Hematocnte <30% b Healthy controls - SuJets temo1ns en bonne sante. c Includes lactating women - Femmes alla1tantes incluses. d Moddle class - Classe moyenne 8 level not stated - N1veau non 1nd1que I Nurse contols - lnformieres temoons. g Talquost

h Not corrected for altotude - Sans correctoon pour l"altotude. 1 Below 12 g/1 - lnft\roeur ~ 12 g/1 J Medoan - Medoane. ~ Hogh soc econ. level controls - Temoons de noveau socio-economoque eleva Talquost, less than 102 g/1 - Talquost, onfeneur ~ 102 g/1. m Aged 35 yrs + - Agees de 35 ans et plus n Aged 40 yrs + - Agees de 40 ans et plus 0 Aged 10 yrs + - A gees de 10 ans et plus. P Healthy norms - Normes de bonne sante q Convened from haematocrot - Conversion ~ panor de l"hematocrote r No cntena spec1f1ed - Sans 1nd1cat1on de cnteres s Adolescent gorls - Adolescentes. t Below 100 g/1 - lnfeneur ~ 100 g/1 - 82-

TABLE 2. MEGALOBLASTIC ANAEMIA TABLEAU 2. ANEMIE MEGALOBLASTIQUE

Total sample Prevalence Region-Country Year size (%) Source Population Regoon-Pays An nee D1mensions Pr6valence totales de (en%) r echantollon

AFRICA - AFRIQUE Northern Africa Afrique septentrionale 203 Algeria - Algerie 1960 124 25 p.w. "anaemic" - f.e. canemiques» 45 Algeria - Algerie 1963-67 278 45 p.w. & lact. w. "anaemic"- f.e. etf.all. « anemiques » Western Africa Afrique occidentale 63 Nigeria - Nigeria 1958 76 25 p.w. (Hb <110 g/1) - f.e. (Hb <110 g/1) 185 Nigeria - N1geria 1961-62 136 41 p.w. (Hb <80 g/1) - f.e. (Hb <80 g/1) 82 Nigeria - N1geria 1959-60 76 p.w. (Hb <40g/l) - f.e. (Hb <40g/l) 82 Nigeria - Nigeria 1959-60 4324 46 p.w. (Hb 40-69 g/1) - f.e. (Hb 40-69 g/1) 82 N1geria - Nigeria 1959-60 4 p.w. (Hb 70-99 g/1) - f.e. Hb 70-99 g/1) 72 N1gena - Nigeria 1969 269 70 p.w. (PCV <23%)- f.e. (PCV <23%) 188 Nigeria - Nigeria 1970 864 42 all w. (Hb <80 g/1)- f. toutes (Hb <80 g/1) Eastern Africa Afrique occidentale 262 Kenya ...... 1960 125 25 hosp. an. 165 Kenya ...... 1967 70 43 p.w. hosp. an- f.e. hosp. an 247 Mauntius - Maurice 1957 47 13 p.w. (Hb <110 g/1) f.e. (Hb <110 g/1 247 Mauritius - Maurice 1957 43 0 non-p.w. (Hb <110g/l) - f.non e. (Hb < 110 g/1) 97 Uganda - Ouganda 1964 95 3 p.w. hosp. an. - f.e. hosp. an. 22 U. R. of Tanzania - R.-U. de Tanzania 1962 41 5 non-p.w. (Hb <73 g/1) - f.non e. (Hb <73 g/1) 22 U. R. of Tanzania - R.-U. de Tanzania 1962 43 30 p.w. (Hb <58 g/1) - f.e. (Hb <58 g/1) 75 Zimbabwe ...... 1958 20 18 all. w. hosp. an. -f. toutes hosp. an. Southam Africa Afrique australe 60 South Africa - Afrique du Sud 1967 100 78 post-p. (Hb <100 g/1) 59 South Africa - Afrique du Sud 1969 100 3 p.w. (Hb <80 g/1) - f.e. (Hb <80 g/1)

AMERICA - AMERIQUE Middle America Amerique centrale 193 Mexico - Mexique 1968 122 8-16 p.w.- f.e. Tropical South America Amerique du Sud tropicale 3 Venezuela 1958 400 4 p.w. "anaemic" - f.e. «anemique» 300 Venezuela 1968 95 15 p.w.- f.e.

ASIA- ASIE Middle South Asia Asie meridionale centrale 17 lnd1a- lnde 1959 449 1 p.w.- f.e. 133 India- lnde 1964 50 54 p.w.- f.e. 240 India- lnde 1967 1 271 49 p.w. (Hb <100 g/1) - f.e. (Hb <100 g/1) 83 India- lnde 1967-68 103 21 p.w.- f.e. 21 India- lnde 1967-68 320 4 p.w.- f.e. 300 India- lnde 1968 123 66 p.w. at term - f.e. il terme 100 Pakistan 1967-68 100 9 hosp. an. 160 Pakistan 1969 200 2 p.v.- f.e. 102 Pakistan 1971 889 3 p.w.- f.e. Eastern South Asia Asie meridionale orientale 232, 134 Indonesia - Indonesia 1970 3 531 29 p.w. (Hb <110g/l)­ f.e. (Hb < 110 g/1) 254 Malays1a - Mala1sie 1958 467 27 p.w. S. Indian - f.e. ind1ennes S. 254 Malays1a - Malaisie 1958 99 10 p.w. Chinese- f.e. chinoises 254 Malaysia - Malaisie 1958 27 36 p.w. N. Indian - f.e. indiennes N. 254 Malaysia - Mala1sie 1958 28 9 p.w. Malay- f.e. malaises 152 Malays1a - Mala1sie 1953-62 1066 35 p.w. (Hb <65 g/1) - f.e. (Hb <65 g/1) 255 Malaysia - Malaisie 1966 44 18 p.w.- f.e. 293 S1ngapore - Singapour 1961-63 4433 1 p.w.- f.e. 145 Singapore - Singapour 1965-66 1434 16 p.w. (Hb <100 g/1) - f.e. (Hb <100 g/1) - 83-

TABLE 2. MEGALOBLASTIC ANAEMIA TABLEAU 2. ANEMIE MEGALOBLASTIQUE

Total sample Prevalence Region-Country Year SIZ8 (%) Source Population Region-Pays Annee Dimensions Prevalence totales de (en%) 1'6chantillon

107 S1ngapore - Singapour 1967 331 7 p.w. (Hb <105 g/1) Chinese- f.e. (Hb < 105 g/1) chinoises 107 Singapore - Singapour 1967 53 30 p.w. (Hb <105 g/1) Malay f.e. (Hb < 105 g/1) malaises 107 Singapore - Singapour 1967 29 45 p.w. (Hb <105 g/1) Indian f.e. (Hb < 105 g/1) indiennes East Asia - Asie orientale

257 Hong-kong • • • • • • • • • • 0 1962 1 915 0 p.w.- f.e.

For obbrev1at1ons see Methodology and Annex. - Pour les •br6viotoons, volf Methodologie et Annexa TABLE 3. SERUM IRON, SERUM FOLATE AND SERUM VITAMIN B12 TABLEAU 3. FER, ACIDE FOLIQUE ET VITAMINE B12 SERIQUES

Serum 1ron Serum folate Serum votamon B 12 Fer s6nque Acide fohque s6nque Votemone B 12 s6rique Total sample Region-Country Year size Below Below Below Source Mean the norm Mean the norm Mean the norm Population R6gion·Pays Ann~e D1mensions totales de Moyenne En dessous Moyenne En dessous Moyenne En dessous l'~chantillon de Ia dela del• norme norme norma (mg/1) (96) (ng/ml) (96) (pg/ml) (96) --

AFRICA - AFRIQUE Northern Africa Afrique septentrionale 128 Tumsia - Tunisie 1978 277 0.95 7 non-p.w. - f.non e. 128 Tunisia - Tunisie ..... 1978 118 0.87 14 p.w.- f.e. 128 Tunisia - Tunisie ..... 1978 284 0.90 11 lact.w. - f.all Western Africa - Afrique occidentale 259 Cape Verde - Cap-Vert .. 1950s 149 1.06 1 p.w.- f.e. 214 Ivory Coast - COte d'lvoire 1978 198 0.69 35 post-p. 223 Mali ...... 1973 23 0.86 15 E 4.7 21 E non-p.w. - f.non e. 223 Mali ...... 1973 25 0.93 7E 5.4 10 E p.w.- f.e . 181 Mauritania - Mauritanie 1975 419 0.89 3 p.w.- f.e. 297 Niger ...... 1978 70 0.89 p.w.- f.e. 297 Niger ...... 1978 70 1.00 6 mth post-p. - 6 mois post-p. 72 Nigeria - Nigt§ria 1969 88 6.3 5 p.w. (PCV <23%)- f.e. (PCV <23%) (X) 72 Nigeria - Nigt§ria 1969 132 2.6 p.w. (PCV <23%) - f.e. (PCV <23%) .j:>. 186 Nigeria - Nigt§ria 1974-76 23 1.02 p.w. (PCV <30%) - f.e. (PCV <30%) 186 Nigeria - Nigt§ria 1974-76 17 1.78 p.w. (PCV >30%) - f.e. (PCV>30%) Eastern Africa - Afrique orientale 108 Ethiopia - Ethiop1e 1968 49 0.94 non-p.w. - f.non e. 108 Ethiopia - Ethiopie 1968 24 0.82 post-p. 87 Ethiopia - Ethiopie 1976 29 0.91 8.0 366 p.w.- f.e. 292 Kenya 1969 187 0.64 p.w.- f.e. 292 Kenya 1969 25 0.78 non-p.w. - f. non e. 53 Kenya 1975 24 5.0 1 298 pastoral men & w. 1 - hommes et femmes, socit§tt§ pastorale 8 53 Kenya 1975 24 6.1 608 non-pastoral men & w. • - hommes et femmes, socit§tt§ non pastorale" 22 U. R. of Tanzania - R.-U. de Tanzanie 1962 20 0.53 non-p.w. (Hb <73 g/1) - f.non e. (Hb <73 g/1) 22 U. R. of Tanzania - R.-U. de Tanzanie 1962 23 0.54 p.w. (Hb <58 g/1) - f.e. (Hb <58 g/1) 141 Zambia - Zamb1e 1970-71 61 1.02 p.w.- f.e. 10 141 Zambia - Zambie 1970-71 338 0.95 lact.w. - f.all. 67 Zambia - Zambie 1978 239 0.85 p.w.- f.e. 31 Zimbabwe ..... 1968 125 0.98 all w.- f.all. Zimbabwe ..... 1968 175 0.81 21 p.w.- f.e. Middle Africa - Afrique centrale 166 Angola ...... 1956 1.23 all w.- f.all. Southern Africa - Afrique Australe

172 Botswana • • • • • • • • • 0 • • 1969 38 0.91 12 b 9.5 3 790 0 young non-p.w. - jeunes f. non e. 172 Botswana ...... 1969 30 1.10 7b 8.1 17 810 0 lact. w. - f. toutes 172 Botswana ...... 1969 45 0.94 8b 9.2 2 840 0 post-meno. - post-mt§no. 61 South Africa - Afrique du Sud 1966 235 4.4 357 p.w.- f.e. 61 South Africa - Afrique du Sud 1966 50 9.7 25 650 non-p.w. c - f. non e. c 167 South Africa - Afrique du Sud 1966 75 0.47 p.w. Indian - f.e. indiennes 167 South Africa - Afrique du Sud 1966 75 0.92 p.w. Bantu - f.e. bantoues 167 South Africa - Afrique du Sud 1966 50 0.83 p.w. White - f.e. blanches 18 South Afnca - Afrique du Sud 1970 51 0.68d p.w. Bantu - f.e. bantoues 169, 170 South Africa - Afrique du Sud 1972 1610 41 8 all w. Indian - f. toutes indiennes 44 South Africa - Afrique du Sud 1975 144 44 p.w. (Hb> 110 g/1) - f.e. (Hb > 110 g/1) 44 South Africa - Afrique du Sud 1975 185 32 non-p.w. (Hb > 110 g/1) - f. non e. (Hb > 110 g/1)

AMERICA - AMERIQUE Middle America - Am6rique centrale 115 Costa Rica . 1969 124 0.81 20 2 non-p.w. - f. non e. 115 Costa Rica . 1969 20 65 0 lact. w - f.all. 116 El Salvador 1969 93 0.90 4.8 41 234 7 non-p.w. -f. non e. 193 Guatemala 1968 95 0.55 45 E 6.4 15 154 18 p.w.- f.e. 117 Guatemala 1969 90 0.89 6.1 25 262 non-p.w. - f. non e. 117 Guatemala 1969 65 45 0 lact. w. - f.all. 118 Honduras 1969 81 0.83 18 3 non-p.w. - f. non e. 118 Honduras 1969 32 23 0 lact. w. - f.all. 300 Mexico - Mexique 1967 110-122 0.88 22 9.1 6 426 0 non-p.w. - f. non e. 300 Mexico - Mexique 1967 85-128 0.74 31 6.2 7 292 13 E p.w.- f. e. 119 Nicaragua 1969 89 0.90 4.0 40 254 0 non-p.w. - f. non e. 119 Nicaragua ..... 1969 52 45 0 lact. w. - f.all. 120 Panama ...... 1969 69 0.80 41 0 non-p.w. - f. non e. Caribbean - Caraibes 191 Barbados ...... 1969 104 1.00 3.5 non-p.w. - f. non e. 173 Jama1ca - Jamarque . . . 1962-66 508 0.79 all 35 yrs + - toutes 35 ans et + 00 4 Jamaica - Jamarque . . . 1968 205 0.84 all w. 40 yrs + - toutes 40 ans et + U1 41 Tnnidad and Tobago- Trinit6-et-Tobago 1964 93 0.83 9 lact. w. - f.all. 42 Trinidad and Tobago- Trinit6-et-Tobago 1967 555 0.33 84 7.5 3 426 p.w. (Hb <100 g/1) - f.e. (Hb <100 g/1) 43 Trinidad and Tobago- Trinit6-et-Tobago 1968 87 0.75 38 4.8 23 220 26 1 p.w.- f.e. p.w. (Hb <100 g/1) - f.e. (Hb <100 221 Trinidad and Tobago- Trinit6-et-Tobago 6.0 176 g/1) 1976 109 221 Trinidad and Tobago- Trinit6-et-Tobago 6.0 211 p.w. (Hb > 100 g/1) - f.e. (Hb > 100 g/1) Tropical South America Am6rique du Sud tropicale 193 Brazil - Br6sil . . . . . 1968 131 1.12 7.3 239 p.w.- f.e .. 193 Colombia - Colombie 1968 94 0.64 30E 5.1 26 p.w.- f.e. 193 Colombia - Colombie 1968 54 0.85 9E 6.3 6 non-p.w. - f. non e. 193 Peru - P6rou 1968 100 1.02 7.1 6 154 36 p.w.- f.e. 193 Peru- P6rou 1968 100 1.20 7.3 8 462 1 non-p.w. - f. non e. 193 Venezuela 1968 114 0.73 30 E 5.3 19 135 53 p.w.- f.e. 193 Venezuela 1968 103 0.87 13 E 6.1 10 516 1 non-p.w. - f. non e. 57 Venezuela 1972 132 o.8od 28 5.0d 23 p.w.- f.e. 57 Venezuela 1972 31 0.94d 16 5.9d 13 non-p.w.9- f. non e.9 175 Venezuela 1974 88 0.89 5 14.8 14 p.w. medium soc. econ. - f.e. niveau socio-6conomique moyen 175 Venezuela 1974 88 0.89 17 10.4 29 p.w. low soc. econ. - f.e. niveau socio-6conomique interieur Temperate South America Am6rique du Sud temp6r6e 193 Argentina - Argent1ne 1968 100 0.96 25 7.0 40 347 28 p.w.- f.e. 294 Chile- Ch11i 1970 0.74 lact. w. - f.all. 325 294 Chile - Chili ...... 1970 0.82 non-lact. w. - f. non-all. TABLE 3. SERUM IRON, SERUM FOLATE AND SERUM VITAMIN B12 TABLEAU 3. FER, ACIDE FOLIQUE ET VITAMINE B12 SERIQUES

Serum iron Serum folate Serum vitamin B12 Fer serique Acode folique s6nque Vitamone B12 serique Total sample Region-Country Year size Below Below Below Source Mean the norm Mean the norm Mean the norm Populatoon R6goon-Pays Annee Dimensions totales de Moyenne En dessous Moyenne En dessous Moyenne En dessous 1'6chantillon dela de Ia dela norme norma norma (mg/1) (96) (ng/ml) (96) {pg/ml) (96) --

ASIA- ASIE Western South Asia Asia miridionale occidentale 122 Israel - Israel 1961 63 80 4.2 22 post-part. w. (Hb <100 g/1) - f. post.part. (Hb < 100 g/1) 122 Israel - Israel 1961 43 8.3 post-part. w. (Hb >100 g/1) - f. post-part. (Hb > 100 g/1) 207 Israel - Israel 1963-65 890 0.68 7.2 274 p.w.- f.e. 300 Israel - Israel 1968 50-100 0.60 36 6.2 6 246 4E p.w.- f.e. 300 Israel - Israel 1968 97-100 0.86 15 7.8 5 498 OE non-p.w. - f. non e.

Middle South Asia Asia m6ridionale centrale 126 0.79 40E all w. - toutes femmes co 211 India- lnde 1960 CJ) 133 India- lnde 1964 50 4.3 88 p.w.- f.e. 133 India- lnde 1964 50 6.8 130 non-p.w. - f. non e. 240 India- lnde 1967 47 53 b 85 E p.w. (Hb <100 g/1) - f.e. (Hb <100 g/1) 300 India- lnde 1968 1348 35 h p.w.- f.e. 300 India- lnde 1968 100 0.72 10 97 49 h p.w.- f.e. 300 India- lnde 1968 95 0.70 10 122 27 h non-p.w. - f. non e. 300 India- lnde 1968 1000 0.27 99 5.1 9 148 Oh p.w.- f.e. 300 India- lnde 1968 100 0.57 51 9.3 0 215 3h non-p.w. - f. non e. post-p. low soc. aeon. - post-p. niveau 1978 0.94 14 E socio-~conomique inMrieur 80 Iran 194 80 Iran 1978 1.16 7E post-p. higher soc. econ. - post-p. niveau socio-economique superieur 2 Nepal - Nepal 1972 151 42i 25i p.w. (Hb <115 gfl)k- f.e. (Hb <115 g/l)k 160 Pakistan 1969 200 1.95 17 e p.w.- f.e. 102 Pakistan 1971 889 0.86 243,242 Sri Lanka 1969-72 350 53 b 57 14 E p.w.- f.e.

Eastern South Asia Asia orientale m6ridionala 136 Burma - Birmanie 1968 37 p.w. (Hb < 110 g/1) - f.e. (Hb < 110 g/1) 136 Burma - Birmanie 1968 648 45 lact. w. (Hb <110 g/1)- f.all. (Hb <110 g/1) 136 Burma - Birmanie 1968 54 non-p., non-lact. w. (Hb < 110 g/1) - f. non e. non-all. (Hb < 11 0 g/1) all w. (Hb < 110 g/1) - ensemble f. (Hb 8 Burma - Birmanie 1972 40 <110 g/1) 1 491 8 Burma - Birmanie 1972 4 all w. (Hb ;;..140 g/1) -ensemble f. (Hb ;;..140 g/1) p.w. (Hb < 110 g/1) - f.e. (Hb < 110 8 Burma - Birmanie 1972 3b g/1) 447 8 Burma - Birmanie 1972 7 all w. (Hb ;;..140 g/1) - toutes f. (Hb ;;..140 g/1) 8 Burma - Birmanie 1972 1491 0.84 all w. - toutes f. 8 Burma - Birmanie 1972 447 1.16 p.w.- f.e. 9 Burma - Birmanie 1966 157 0.96 6.2 p.w.- f.e. 134 Indonesia - lndon~sie . 1970 90 0.64 23 p.w.- f.e. 40 Malaysia - Malaisie 1968 102 0.98 19 p.w.- f.e. 162, 163 Philippines 1969 289 0.74 26 4.9 25 368 1 h p.w.- f.e. 162, 163 Philippines 1969 522 0.72 38 6.6 11 non-p., non-lact. w. - f. non e., f. non all. 163,253 Philippines 1969 437 0.76 30 4.4 21 lact. w. - f.all. 143 Philippines 1978 252 0.84 24 6.8 0 p.w.- f.e. 107 Singapore - Singapour 1967 4.5 9 267 3 p.w. (Hb <105 g/1) Chinese - f.e. (Hb < 105 g/1) chi noises 107 Singapore - Singapour 1967 413 4.1 15 293 6 p.w. (Hb <105 g/1) Malay - f.e. (Hb <105 g/1) Malaises 107 Singapore - S1ngapour 1967 3.3 43 219 11 p.w. (Hb <105 g/1) Indian - f.e. (Hb < 105 g/1) indiennes 249 Thailand - Thal1ande 1965 150 0.59 post-p. 250 Thailand - Thal1ande 1967-68 94 11 410 1m p.w.- f.e. 284 Thailand - Thal1ande 1971 154 21 p.w. (Hb <110 g/1) - f.e. (Hb <110 g/1) 284 Thailand - Thal1ande 1971 241 35 p.w. (Hb <110 g/1) - f.e. (Hb <110 g/1) 144 Thailand - Tha11ande 1972 269 43 7 all w. - toutes f. 00 OCEANIA - OCEANIE -..I 49 Papua New Guinea - 1974 47 0.51 69 n 6.0 13 ° 492 OP Papouasie-Nouvelle-Guin~e

For abbrev1at1ons see Methodology and Annex - Pour les abrev1ations VOir Methodolog1e et Annexa. a Allegedly no sex differences - Pretendument sans difference tenant du saxe. b Below 0. 70 mg/1 - lnfllneur ~ 0, 70 mg/1. c Healthy nurse controls - lnf1rm1itres te\mo1ns. d Med1an - Mlld1ane. 8 Below 0 60 mg/1 - lnfllneure ~ 0,60 mg/1. f Below 120 pg/ml - lnfeneure ~ 120 pg/ml g Healthy controls - Sujets temo~ns en bonne sante. h Below 80 pg/ ml - lnfeneure ~ 80 pg/ ml 1 Below 60 ng/ml - lnfeneure ~ 60 ng/ml. J Below 140 pg/ml- lnfeneure ~ 140 pg/ml. k Equivalent to 110 g/1 at sea-level - EqUivalant ~ 110 g/1 au n1veau de Ia mer

I Below 5 ng/ml - lnfeneur ~ 5 ng/ml. m Below 150 pg/ml - lnfeneur ~ ~ 150 pg/ml. n Below 0.45 mg/1 - lnfllneur ~ 0.45 mg/1 0 Below 3 5 ng/ml - lnfeneur ~ 3,5 ng/ml P Below 190 pg/ml - lnfllneur ~ 190 pg/ml. - 88-

TABLE 4. POPULATION AT RISK. WOMEN AGED 15 TO 49 YEARS, NUMBERS AND ESTIMATED PERCENTAGE WITH HAEMOGLOBIN CONCENTRATION BELOW THE NORM TABLEAU 4. POPULATION EXPOSEE AU RISQUE. FEMMES AGEES DE 15 A 49 ANS, NOMBRE ET POURCENTAGE ESTIMATIFS DECELLES QUI PRESENTENT UN TAUX D'HEMOGLOBINE INFERIEUR A LA NORME

Pregnant women Non-pregnant women All women Femmes enceantes Femmes non-enceintes T outes femmes

Percentage Percentage Percentage w1th Hb below With Hb below w1th Hb below Reg1on-Country the norm the norm the norm Reg1on-Pays Number Number Number (in thousands! Pourcentage (in thousands) Pourcentage (in thousands) Pourcentage presentant un presentant un presentant un Nombre Nombre Nombre (en m1lhers) taux (en milliers) taux (en milhers) taux d'hemoglobine d'hemoglob~ne d'hemoglobine 1nfeneur ~ 1nteneur ~ interieur ~ Ia norma Ia norma Ia norma

AFRICA - AFRIQUE Northern Africa - Afrique septentionale Algeria - Algllrie . . . . . 654 65 3040 3 694 Egypt - Egypte ...... 1 087 75 7 784 8 871 Libyan Arab Jamahinya . . 82 47 402 24 484 Jamahiriya arabe libyenne Morocco - Maroc 635 46 3 218 3 853 80 Sudan - Soudan 719 3 340 4059 Tunisia - Tunisia ..... 190 38 1 100 31 1290 Total. 3367 18884 22251

Western Africa - Afrique occidentale Bemn - Ben1n ...... 124 581 705 Cape Verde - Cap-Vert 8 42 67 75 Gambia - Gambie 18 80 102 80 120 Ghana ...... 389 64 1818 2 207 Guinea - Guinee 169 858 1027 Gu1nea-Bissau - Guinee-Bissau 17 85 105 85 122 Ivory Coast - C6te d'lv01re 183 34 929 1 112 Liberia - Libllria . . . . . 63 344 407 Mall ...... 234 50 1083 1 317 20 Mauntania - Mauritanie 47 24 257 304 Niger ..... 197 57 847 36 1044 36 Nigeria - Nigllria 2 561 65 11 692 50 14 253 50 Senegal - Sllnllgal 173 856 1029 S1erra Leone 110 45 588 698 Togo ...... 93 47 427 520 32 Upper Volta - Haute-Volta 240 1 153 1 393

Total. 4626 21707 26333

Eastern Africa - Afrique orientale Burundi ...... 148 736 884 Comoro - Comores 11 60 71 Eth1op1a - Ethiop1e 1 133 6 5 258 8 6 391 Kenya ...... 529 48 2 411 2 940 Madagascar . . . . 329 1 511 1 840 Malawi ...... 187 49 977 1 164 Mauritius - Maurice 15 80 208 70 223 Mozambique . . 316 1 901 2 217 Reun1on . 10 103 113 Rwanda .... 180 795 975 Somalia - Somalle 125 628 753 Uganda - Ouganda 421 35 2 149 46 2 570 U. R. of Tanzania - R.-U. de Tanzanie 634 59 2 911 3 545 72 Zambia - Zambie 204 60 934 1 139 53 Zimbabwe ...... 248 27 1 151 1399 45

Total. 4490 21 733 26223

Middle Africa - Afrique centrale Angola ...... 249 1 210 1459 Central Afncan Rep. - Rep. centrafricaine 64 374 438 Chad- Tchad ...... 147 893 1040 50 Congo ...... 50 272 322 Equatonal Gumea - Guinee equatoriale 9 63 72 Gabon ...... 12 129 141 U. R. of Cameroon - R.-U. du Cameroun 216 1 358 1 574 Za1re - Za'ire ...... 911 4 853 5 764

Total. 1658 9 152 10810 - 89-

TABLE 4. POPULATION AT RISK. WOMEN AGED 15 TO 49 YEARS, NUMBERS AND ESTIMATED PERCENTAGE WITH HAEMOGLOBIN CONCENTRATION BELOW THE NORM TABLEAU 4. POPULATION EXPOSEE AU RISQUE. FEMMES AGEES DE 15 A 49 ANS!. NOMBRE ET POURCENTAGE ESTIMATIFS DECELLES QUI PRESENTENT UN TAUX D'HEMOGLOBINE INF£RIEUR A LA NORME

Pregnant women Non-pregnant women All women Femmaa encemt•• Femmea non-ence1ntee Toutes femmes

Percentage Percentage Percentege wnh Hb below withHbbelow woth Hb below Regoon-Country the norm the norm the norm Regoon-Pays Number Number Number (In thousands) Pourcentage (on thouaanda) Pourcentage (in thouaanda) Pourcent•g• pr6sentant un pr6aentant un prtaentant un Nombre Nombre Nombre taux (en molhers) taux (enmolloera) taux (en mtlhera) d"h6moglobtne d"h6moglobine d"h6moglobtne anf6neur I onf6roeur i onf6neur i Ia norma Ia norma Ia norme

Southern Afric•- Afrique •uatr•le Botswana 27 139 20 166 Lesotho ...... 38 238 276 Namibia - Namibia ...... 26 136 162 South Africa - Afrique du Sud 882 25 5009 12 5891 Swaziland ...... 19 90 109 Total. 992 5612 6604

AMERICA - AMERIQUE Middle Americ• - Amerique centr•le Costa Rica 52 44 417 30 469 27 El Salvador 137 15 759 896 Guatemala .... . 209 34 1 188 1 397 Honduras ...... 116 543 659 Mextco - Mexique 2021 38 10961 17 12 982 25 Nicaragua 89 20 420 509 Panama ...... 48 323 371 Total. 2672 14 611 17 283

C•rribean - C•r•ibea Barbados - Barbade ...... 4 53 45 57 Cuba ...... 212 1 916 2128 Dominican Republic - R~publique dominicaine 188 46 921 60 1 109 56 Guadeloupe 8 74 82 Haiti - Harti . . . . . 136 1 017 1 153 Jamaica - Jamarque 50 24 352 402 Martinique ...... 8 76 84 Puerto Rico - Porto Rico 50 687 737 Trinidad and Tobago - Trinit~-et-Tobago 19 56 218 21 237 24 Other - Autres ...... 26 205 50 231 Total. 701 5 519 6220

Tropic•l South Americ• Amerique du Sud tropic•le Bolivia - Bolivia . . . . 197 1055 15 1 252 Brazil - Br~sil . . . . . 3254 20 22523 8 25 777 10 Colombia - Colombie 809 22 5023 6 5 832 8 Ecuador - Equateur . 230 1 334 1564 35 Guyana - Guyane 20 55 160 41 180 43 Paraguay ... 85 506 591 Peru- P~rou 493 35 3004 22 3497 18 Suriname 14 73 87 Venezuela 351 52 2406 18 2 757 22 Total. 5453 36084 41537

Temper•te South Americ• Amerique du Sud tempirie Argentina - Argentine 452 61 5 769 34 6 221 36 Chile - Chili 226 32 2 339 3 2 565 Uruguay ...... 51 692 7 743 Total. 729 8800 9529

ASIA- ASIE Western South Aai• Aaie meridion•le occident•le Cyprus - Chypre ...... 12 125 137 Dem. Yemen- Y~men d~m. 67 304 371 Iraq ...... 432 1 984 2 416 Israel - Israel . . . 75 29 729 29 804 29 Jordan - Jordanie 45 529 25 574 Kuwait - Koweit 40 174 214 Lebanon - Liban 95 50 532 44 627 45 - 90-

TABLE 4. POPULATION AT RISK. WOMEN AGED 15 TO 49 YEARS, NUMBERS AND ESTIMATED PERCENTAGE WITH HAEMOGLOBIN CONCENTRATION BELOW THE NOIIM TABLEAU 4. POPULATION EXPOSEE AU RISQUE. FEMMES AGEES DE 16 A. 49 ANSi. NOMBRE ET POURCENTAGE ESTIMATIFS DECELLES QUI PRESENTENT UN TAUX D'HEMOGL081NE INFI:IIIEUR A LA NORME

Pregnant women Non-pregnant women AM women Femmes ence.ntes Femmes non-encemtea Toutes femmes

Percontogo Porcentego Porcontoge woth Hb below with Hb below with Hb below Regoon-Country the norm the norm the norm R6goon-Pays Number Number Number (on thousondo) Pourcentoge (on thouAnds) Pourcentage (on thousondo) Pourcentage presentontun pr6sentont un pntaentant un Nombre Nombro Nombro (on molloers) tiUX (on milhoro) taux (enmolloors) taux d"h6moglobono d"h6moglobone d"h,moglobmo onftrltlur. 1nf6neur 6 ln,.rteur • 11 norme Ia norme Ia norm•

Saudi Arabia - Arabie saoudite 358 1640 1 998 Syrian Arab Republic 329 1 225 1 554 Rl§publique arabe syrienne Turkey - Turquie 1 250 74 7 806 50 9056 53 Yemen - Y !§men 267 1222 1 489 Other - Autres 64 234 298 Total. 3034 16 504 19538

Middle South Aai• Aaie m6ridion•le centr•l• Afghanistan 776 3 536 4 312 Bangladesh . . . . 3001 66 12 862 70 15 863 Bhutan - Bhoutan 42 227 269 India- lnde 19 515 68 119 708 60 139 223 61 Iran ...... 1 211 50 5 943 7 154 34 Nepal - Nl§pal 453 33 2488 2 941 Pakistan 2 728 65 12 213 14941 Sri Lanka ... 290 62 2 997 3 287 60 Total. 28016 159 974 187 990

E•atem South Aai• Aaie miridion•le orienule Burma - Birmanie ...... 1008 55 6 384 7 392 41 Dem. Kampuchea- Kampuchea dl§m. 311 1 516 1 827 East Timor - Timor oriental ...... 24 132 156 Indonesia - lndonl§sie ...... 4603 65 28431 55 33034 Lao Peop. Dem. Rep. - Rl§p. dem. pop. lao 120 62 651 771 Malaysia - Malaisie . . 371 77 2 366 2 737 Philippines ...... 1 501 47 8 182 37 9683 Singapore - Singapour 33 26 467 500 Thailand - Thallande 1 441 48 8024 9465 50 VietNam ...... 1448 50 8430 44 9 878 Total. 10860 64583 75443

E•at Asi• - Aaie orient•l• Dem. Peop. Rep. of Korea - Rl§p. pop. dem. de 422 3 373 3 795 Corl§e ...... Hong Kong - Hong-kong 66 969 1035 Rep. of Korea - Rep. de Coree 738 7 576 8 314 Mongolia - Mongolia ...... 44 286 330 Total. 1270 12204 13474

OCEANIA - OC~ANIE Fiji- Fidji ...... 13 68 135 72 148 70 Papua New Guinea - 110 55 490 600 Papouasie-Nouvelle-Guinee Other - Autres ...... 17 70 239 70 256 70 Total. 140 864 1004

For abbreviatoons and method of estimatong the number of pregnant women see Methodology and Annex. - Pour les obr6viations et Ia m6thode d"estimation du nombre de femmes enceintes. voor M6thodologoe et Annexa

Source Total number of women, for 1975, from reference 263 Anaemia data are estomates booed on Table 1 - Nombre total de femmes, pour 1975, provenont de Ia r6f6rence 263. Les donn6es relatives 6 l'an6mie sont des estomations se fondant sur le Tableau 1. - 91 -

TABLE 5. POPULATION AT RISK. WOMEN AGED 15 TO 49 YEARS, NUMBERS AND ESTIMATED PERCENTAGE WITH HAEMOGLOBIN CONCENTRATION BELOW THE NORM. SUMMARY BY CONTINENTS AND STATE OF DEVELOPMENT TABLEAU 5. POPULATION EXPOSEE AU RISQUE. FEMMES AGEES DE 15 A 49 ANS, NOMBRE ET POURCENTAGE ESTIMATIFS PRESENTANT DES TAUX D'HEMOGLOBINE INFERIEURS A LA NORME. RECAPITULATION PAR CONTINENT ET STADE DE DEVELOPPEMENT

Pregnant women Non-pregnant women All women Femmes ence1ntes Femmes non-enceintes Toutes femmes

Percentage Percentoge Percentage Continents woth Hb below wnh Hb below with Hb below Stage of development the norm the norm the norm Number Number Number Contments Pourcentage Pourcentoge Pourcentage Stode de d6veloppement (millions) (molloons) (molhons) pr6sentant un pr6sentant un pr6sentant un Nombre Nombre Nombre (en mollions) taux (en millions) taux (en molhons) t8U)( d'h6moglobine d'h6moglobine d'h6moglobine inf6rieur 6 inf6roeur 6 onf6rieur 6 Ia norme lo norma I• norme

Developing countries in: P•ys en diveloppement: Africa - Afrique ...... 15.1 63 77.1 40 92.2 40

America - Aml!rique 0 ••• ...... 9.6 30 65.0 15 74.6 17 Asia (excluding China) - Asia (Chine exclue) 43.2 65 253.2 57 296.4 58 Oceania - Ocl!anie ...... 0.1 58 0.9 71 1.0 70 Total. 68.0 60 396.2 47 464.2 49 China ...... 17.0 186.0 203.0

All developing countries 85.0 582.2 667.2 Ensemble des p•ys en diveloppement All developed countries ...... 16.3 258.7 275.0 Ensemble des p•ys diveloppis

WORLD - MONDE ...... •• 0. 0 •• 101.3 840.9 942.2

All data on anaemia are best guesses based on data in Table 4. For obbreviatoons and method of estimating the number of pragnont women see Methodology and Annex. - T outes les donn6es sur l'an6moe sont las meolleures hypothbes fond6es sur las donn6es du Tableau 4. Pour les abr6viations at lo m6thode d'estomation du nombre des femmes enceintes, voor M6thodologoe at Annexo.

Source: Table 4 and reference 263. - Tableau 4 et r616rence 263.