Anemia Testing in Population-Based Surveys Anemia Testing in Population-Based Surveys General Information and Guidelines for Country Monitors and Program Managers Almaz Sharman ORC Macro Calverton, Maryland, USA June 2000 This publication was prepared under the auspices of the MEASURE DHS+ project. The MEASURE DHS+ project assists developing countries in the collection and use of data to monitor and evaluate trends in population, health, and nutrition. Funded by the U.S. Agency for International Development (USAID), MEASURE DHS+ is administered by ORC Macro in Calverton, Maryland. The main objectives of the MEASURE DHS+ project are as follows: 1) to provide decisionmakers in survey countries with information that is useful for informed policy choices, 2) to expand the international population and health database, 3) to advance survey methodology, and 4) to develop in participating countries the skills and resources necessary to conduct high-quality demographic and health surveys. Information about the MEASURE DHS+ project can be obtained by contacting ORC Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705 USA (Telephone: 301-572-0200; Fax: 301-572-0999; E-mail: [email protected]; Internet: http://www.measuredhs.com). Recommended citation: Sharman, Almaz. 2000. Anemia testing in population-based surveys: General information and guidelines for country monitors and program managers. Calverton, Maryland USA: ORC Macro. CONTENTS Foreword ...................................................................................................................................................vii PART I GENERAL INFORMATION ON ANEMIA: CAUSES, PREVALENCE, CONTROL AND PREVENTION Chapter 1 Definition, Consequences, Clinical Manifestations and Prevalence of Anemia 1.1 Definition and Consequences of Anemia............................................................................ 3 Definition of Anemia .......................................................................................................... 3 Anemia and Maternal Health.............................................................................................. 3 Effects of Anemia on Mental Performance ........................................................................ 3 Anemia and Resistance to Infections.................................................................................. 4 Effect on Work Capacity .................................................................................................... 4 1.2 Clinical Manifestations of Anemia ..................................................................................... 4 1.3 Prevalence of Anemia in the World.................................................................................... 5 Chapter 2 Physiology of Iron Requirements and Main Causes of Anemia 2.1 Main Causes of Anemia......................................................................................................7 2.2 Physiologic Iron Requirements........................................................................................... 8 Iron Losses in Pregnancy and Lactation ........................................................................... 10 Iron Requirements in Infancy and Childhood................................................................... 11 2.3 Dietary Iron Content and Bioavailability of Iron.............................................................. 11 2.4 Anemia Caused by Deficiency of Folic Acid ................................................................... 13 Increased Demand............................................................................................................. 13 Inadequate Intake.............................................................................................................. 13 Impaired Absorption......................................................................................................... 14 2.5 Parasite Infestations and Anemia...................................................................................... 14 Hookworm Infestation ...................................................................................................... 14 Whipworm Infestation ...................................................................................................... 14 Schistosomiasis................................................................................................................. 14 2.6 Anemia Caused by Malaria............................................................................................... 15 Epidemiology of Malaria .................................................................................................. 15 Pathogenesis of Malarial Anemia ..................................................................................... 15 iii Chapter 3 Anemia Control and Prevention 3.1 Magnitude of the Problem and Importance of Anemia Control and Prevention .............. 17 Global Burden of Anemia and Effectiveness of Anemia Control and Prevention............ 17 Integrated Anemia Control and Prevention Strategy ........................................................ 17 3.2 Dietary Improvement........................................................................................................ 18 3.3 Iron Supplementation........................................................................................................ 18 Iron Supplementation in Pregnancy.................................................................................. 18 Iron Supplementation During Infancy and Early Childhood............................................ 19 Iron Supplementation to Other Population Groups........................................................... 20 Limitations of Iron Supplementation Programs................................................................ 21 3.5 Iron Fortification............................................................................................................... 21 Overall Approach to Anemia Control and Prevention...................................................... 22 3.6 Management and Treatment of Patients with Anemia...................................................... 22 Management of Patients with Anemia.............................................................................. 22 Protocols for Drug Therapy of Patients with Severe Anemia........................................... 23 PART II METHODOLOGY, TRAINING GUIDELINES, AND FIELD IMPLEMENTATION OF ANEMIA SURVEYS Chapter 4 Methods of Anemia Testing 4.1 Modern Methods of Anemia Testing................................................................................ 27 Modern Methods of Anemia Testing................................................................................ 27 HemoCue System ............................................................................................................. 28 4.2 Hemoglobin Cutoff Points................................................................................................ 28 Chapter 5 Methodological Issues of Population-Based Anemia Testing 5.1 Individual Variability of Capillary Hemoglobin Testing.................................................. 33 Physiologic Variation of Capillary Blood Sampling ........................................................ 33 Variability Caused by Improper Capillary Sampling ....................................................... 34 5.2 Capillary Blood Testing Versus Venous Blood Testing................................................... 34 5.3 Determining Iron Status.................................................................................................... 34 Clinical Approach............................................................................................................. 35 Population-Based Approach ............................................................................................. 36 iv Chapter 6 Anemia Training Guidelines 6.1 Personnel Requirements ................................................................................................... 39 6.2 Training Schedule............................................................................................................. 40 Day One ............................................................................................................................ 40 Day Two ........................................................................................................................... 40 Day Three ......................................................................................................................... 41 Day Four ........................................................................................................................... 41 6.3 Quality Assurance............................................................................................................. 41 Chapter 7 Procedures for Implementing an Anemia Survey 7.1 Planning a Population-based Anemia Survey................................................................... 43 7.2 Sampling Issues ................................................................................................................ 44 7.3 Field Supervision .............................................................................................................. 44 Field Checklist .................................................................................................................. 45 7.4 Referral System................................................................................................................