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Methods
Results
Discussion
References
Almaz Sharmanov
Almaz Sharmanov is a health specialist in the Demographic and Health Research Division (Demographic and Health Survey) of Macro International in Calverton, Maryland, USA.
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Abstract
Nationally representative anaemia levels among women and children were recently determined in conjunction with the Demographic and Health Surveys in Kazakstan (1995), Uzbekistan (1996), and the Kyrgyz Republic (1997). Anaemia was assessed by measuring the haemoglobin level in capillary blood of women aged 15 to 49 and their children under the age of 3 using the photometric Hemocue technique. The numbers of women tested were 3,658, 4,333, and 3,760 in Kazakstan, Uzbekistan, and the Kyrgyz Republic, respectively. All three Central Asian republics had a high prevalence of anaemia. The highest overall rates were in the regions of Kazakstan and Uzbekistan near the Aral Sea, which are characterized by severe agrochemical pollution and other environmental and socio-economic problems. Approximately half (49%) of the women in Kazakstan, 60% of the women in Uzbekistan, and 40% of the women in the Kyrgyz Republic suffered from some degree of anaemia. Mild anaemia (haemoglobin level, 10.0-11.9 g/dl; 10.0-10.9 g/dl for pregnant women) was diagnosed in 37%, 45%, and 28% of the women in Kazakstan, Uzbekistan, and the Kyrgyz Republic, respectively. Eleven percent of the women in Kazakstan, 14% in Uzbekistan, and 9% in the Kyrgyz Republic had moderate anaemia (haemoglobin level 7.0-9.9 g/dl). Severe anaemia (haemoglobin level less than 7.0 g/dl) was found among 1% of the women in all three Central Asian republics.
In Kazakstan, 69% of the children under the age of three suffered from some degree of anaemia. About the same number of children had mild (30%) and moderate (34%) anaemia. A smaller, but substantial, proportion of children (5%) were severely anaemic. In Uzbekistan and the Kyrgyz Republic, 61% and 50% of children, respectively, suffered from anaemia. The percentages of children with mild, moderate, and severe anaemia were 34%, 26%, and 1%, respectively, for Uzbekistan, and 24%, 24%, and 1%, respectively, for the Kyrgyz Republic.
There is sufficient evidence to suggest that negative iron balance is probably a major cause of anaemia among both women and children in Central Asia. Our findings provide important information for the development of health intervention programmes to prevent iron-deficiency anaemia among women of certain ethnic, educational, and residential groups in this region. Based on the results of the Demographic and Health Survey as well as other geographically focused studies, the UNICEF Area Office for the Central Asian Republics and Kazakstan proposed an integrated strategy of education, supplementation, fortification, and research to address the problem and called for donors’ support. It is expected that this approach can considerably improve maternal and child health in Central Asia.
Introduction
Anaemia is a condition characterized by a reduction in red blood cell volume and a decrease in the concentration of haemoglobin in the blood. Commonly, anaemia is the final outcome of nutritional deficiencies of iron, folate, vitamin B12, and other nutrients. Although many other causes of anaemia have been identified, such as haemorrhage, infection, genetic disorders, and chronic disease, nutritional deficiency due primarily to a lack of bioavailable dietary iron accounts for the majority of cases [1-4].
Anaemia is known to have detrimental health implications, particularly for mothers and young children. Unfavourable pregnancy outcomes are more common in anaemic than in non-anaemic mothers [2,5]. Women with severe anaemia can have difficulty meeting oxygen transport requirements near and at delivery, especially if significant haemorrhage occurs. This may be an underlying cause of maternal death and of prenatal and perinatal infant loss [6-8]. Iron-deficiency anaemia among children has been associated with impairment of cognitive performance, motor development, coordination, language development, and scholastic achievement [5,9]. Anaemia increases morbidity from infectious diseases, because several immune mechanisms are affected [10].
Anaemia due to iron deficiency is recognized as a major public health problem throughout the world. According to the epidemiological data collected from multiple countries by the World Health Organization, some 35% of women and 43% of young children have anaemia [5, 11]. In developing countries, about half of the women and young children are anaemic [5, 12, 13]. In the United States and Europe, the prevalence of anaemia is 7% to 12% among women and children [14,15]. The highest overall rates of anaemia have been reported in southern Asia and certain regions of Africa.
For decades anaemia has been one of the leading public health problems in Central Asia. According to the 1988 nutrition survey conducted by the Nutrition Institute in four regions of Kazakstan, 60% of non-pregnant and non-lactating women and 60% to 80% of pregnant women had anaemia on the basis of haemoglobin and haematocrit, measurements [16]. The 1993 study by the Crosslink group in the Muynak District of adjoining Uzbekistan found anaemia levels of over 60% for women of reproductive age and approximately 80% for children under the age of three [17]. Because of correspondingly low serum levels of iron and ferritin, iron deficiency was recognized as a major cause of anaemia among women and young children in that area. In a study of women and children in Kazalinsk District of the Kzyl-Orda Region of Kazakstan in July 1994, the prevalence of anaemia was estimated as 46% among women aged 15 to 45 years and 64% among children aged 6 to 60 months [18].
With the socio-economic changes that have taken place in the former Soviet Union in the last few years, the probability that the prevalence of anaemia may have increased in Central Asia is of great public health concern. Testing women and children for iron-deficiency anaemia was one of the major efforts of the Demographic and Health Surveys conducted in Kazakstan in 1995, Uzbekistan in 1996, and the Kyrgyz Republic in 1997. These were the first anaemia studies done in Central Asian republics on nationally representative samples. This paper summarizes the results of anaemia testing and examines the systematic differences in haemoglobin concentrations between certain population groups in these three countries.
Kazakstan survey sample design
The Kazakstan survey was conducted between 15 May and 30 August 1995 by the Institute of Nutrition of the Kazakstan National Academy of Sciences. A detailed description of the survey design has been published elsewhere [19]. The survey employed a nationally representative and multistage probability sample of women between the ages of 15 and 49. The primary information for. the sampling was obtained from the 1989 census, data from the National Statistical Office, and the Ministry of Health of Kazakstan. The country was divided into five survey regions. With the exception of the capital city, Almaty, which constituted a survey region by itself, the other four survey regions were groups of contiguous oblasts located in south, west, central, and northeast Kazakstan.
A total of 4,480 households were selected from 176 sampling areas, which yielded 3,899 women who were eligible for anaemia testing (all women 15 to 49 years of age who were either usual residents or visitors and who had spent the previous night in the household). Anaemia testing was done on 3,658 of these women and 739 of their children born since January 1992.
Uzbekistan survey sample design
The Uzbekistan survey was conducted between 24 June and 12 October 1996 by the Institute of Obstetrics and Gynaecology, Ministry of Health of Uzbekistan. A detailed description of the survey design has been published elsewhere [20]. The survey employed a nationally representative and multistage probability sample of women between the ages of 15 and 49. The primary information for the sampling was obtained from the National Statistical Office and the Ministry of Health of Uzbekistan. The country was divided into five survey regions. With the exception of the capital city, Tashkent, which constituted a survey region by itself, the other four survey regions were groups of contiguous oblasts located in the Aral Sea area and in the central, eastern, and Ferghana Valley regions.
A total of 3,945 households were selected from 164 sampling areas, which yielded 4,544 women who were eligible for anaemia testing; 4,333 of these women and 1,106 of their children born since January 1993 were tested.
Kyrgyz survey sample design
The Kyrgyz survey was conducted between 8 August and 8 November 1997 by the Research Institute of Obstetrics and Paediatrics of the Ministry of Health of the Kyrgyz Republic. A detailed description of the survey design has been published [21]. The primary information for the sampling was obtained from the National Statistical Office and the Ministry of Health of the Kyrgyz Republic. The Kyrgyz survey employed a representative probability sample of women aged 15 to 49. Selected survey estimates were to be produced for four survey regions. The capital city of Bishkek and Narynskaya Oblast, which is located in the mountainous eastern part of the Kyrgyz Republic, constituted two survey regions by themselves (Bishkek City and East). The remaining two survey regions consisted of groups of contiguous oblasts located in the north and south of the Kyrgyz Republic.
A total of 3,821 households were selected from 168 sampling areas, which yielded 3,954 women who were eligible for anaemia testing. Testing was done on 3,760 of these women and 980 of their children born since January 1994.
The Kazakstan, Uzbekistan, and Kyrgyz surveys were funded by the United States Agency for International Development (USAID), and technical assistance was provided by Macro International (Calverton, Md, USA) through its contract with USAID.
Informed consent
Prior to participating in the study, women in the Kazakstan, Uzbekistan, and Kyrgyz surveys were asked to sign a consent form giving permission for the collection of a blood droplet from themselves and their children under the age of three years. In addition, if a woman was diagnosed as having severe anaemia (haemoglobin level less than 7 g/dl), she was asked to sign another consent form giving permission to the study team to inform the local health care facility about her condition.
Blood collection and Hemocue analyses
For haemoglobin measurement, capillary blood was taken from the finger using Tenderlett lancets (sterile disposable instruments that allow a relatively painless skin puncture). Haemoglobin was measured with the Hemocue system, which detects the level of haemoglobin within a minute. This system consists of a battery-operated portable photometer and a disposable cuvette, which serves as both the blood-collection device and the site where the reaction occurs. The procedure was performed by specially trained medical personnel and was confirmed to be accurate, precise, and suitable for the various field conditions.
Diagnostic criteria
Levels of anaemia were classified as severe, moderate, or mild based on the haemoglobin concentration in the blood and according to criteria developed by the World Health Organization [12]. Haemoglobin concentrations less than 7.0 g/dl were considered severe anaemia; concentrations of 7.0 to 9.9 g/dl were considered moderate anemia; concentrations of 10.0 to 11.9 g/dl (10.0-10.9 g/dl for pregnant women and children under the age of three years) were considered mild anaemia.
Haemoglobin high-altitude adjustments
The haemoglobin concentration in the blood is negatively regulated by the level of saturation of arterial blood with oxygen. The decline in the partial pressure of oxygen with altitude is accompanied by a decline in the saturation of arterial blood with oxygen and an increased concentration of haemoglobin in the blood. On the basis of these relationships, Hurtado et al. developed adjustments of haemoglobin levels according to altitude for the Centers for Disease Control Pediatric Nutrition Surveillance System [22].
For the population of the Kyrgyz Republic, which lives at altitudes that range from 488 m (1,600 feet) in the Ferghana Valley to more than 3,000 m (10,000 feet) in some areas of Narynskaya Oblast, altitude is an important factor that could affect the level of haemoglobin in the blood and therefore should be considered in calculating anaemia rates. For this reason, in the Kyrgyz survey the rates of anaemia were calculated using high-altitude adjustment equations. According to these equations:
Adjusted level of altitude = observed level - adjustment coefficient
The adjustment coefficient is calculated as
Adjustment coefficient = (-0.032 × altitude) + (0.022 × altitude2)
Altitude is measured as
(Altitude in metres/1,000) × 3.3
Ferritin assessment
To evaluate body iron stores, the level of serum ferritin was tested in a small subsample of women from Almaty City with haemoglobin values less than 10 g/dl. The blood for ferritin testing was taken by venipuncture. The serum ferritin was determined in duplicate with a commercially available enzyme immunoassay (ELISA) kit (Ramco Laboratories, Houston, Texas, USA) using a Titertek Multiscan R plus (EFLAB, Labsystems, Helsinki, Finland).
Statistical procedures
Data were entered and edited on microcomputers using the software package Integrated System for Survey Analysis (ISSA). Tabulations also used the ISSA package. To correct for differences in selection probabilities between the different survey regions, sampling weights have been applied to the data.
Table 1 shows the results of testing of women for anaemia in Kazakstan. Almost half (49%) of those tested were anaemic. More than 11% of them had moderate or severe anaemia with haemoglobin levels less than 10 g/dl. The highest prevalence of anaemia was in the western region of Kazakstan, where 19% were diagnosed with moderate or severe anaemia The rates of moderate and severe anaemia were higher among ethnic Kazaks than ethnic Russians and among rural women than urban. Women with higher education were less likely to be anaemic than those with primary or secondary education. There were no significant differences in rates of anaemia among different age groups, except for a low frequency of moderate anaemia among women 15 to 19 years old.
Table 1. anaemia among women in Kazakstan: Percentage of women classified as having iron-deficiency anaemia according to background characteristics, Kazakstan Demographic and Health Survey, 1995
|
Background characteristic |
Percentage of women with: |
Women measured |
||||
|
Severe anaemiaa |
Moderate anaemiab |
Mild anaemiac |
Weighted |
Unweighted |
||
|
Age (yr) |
||||||
|
|
15-19 |
0.4 |
6.4 |
38.8 |
657 |
650 |
|
|
20-24 |
0.6 |
11.4 |
39.0 |
557 |
566 |
|
|
25-29 |
0.9 |
10.5 |
35.8 |
514 |
518 |
|
|
30-34 |
2.1 |
11.8 |
39.4 |
539 |
536 |
|
|
35-39 |
1.5 |
12.2 |
37.4 |
552 |
546 |
|
|
40-44 |
0.8 |
10.1 |
34.0 |
521 |
486 |
|
|
45-49 |
2.0 |
13.8 |
33.0 |
344 |
356 |
|
Residence |
||||||
|
|
Urban |
0.7 |
9.0 |
36.5 |
2,058 |
1,958 |
|
|
Rural |
1.7 |
12.6 |
37.8 |
1,626 |
1,700 |
|
Region |
||||||
|
|
Almaty City |
1.1 |
9.4 |
27.7 |
249 |
564 |
|
|
South |
0.8 |
10.6 |
38.9 |
1,177 |
901 |
|
|
West |
2.5 |
16.4 |
40.0 |
459 |
801 |
|
|
Central |
0.7 |
8.0 |
35.1 |
354 |
718 |
|
|
North-east |
1.1 |
9.5 |
36.8 |
1,445 |
674 |
|
Education |
||||||
|
|
Primary/secondary |
1.3 |
11.6 |
37.8 |
1,352 |
1,364 |
|
|
Special education |
1.0 |
10.7 |
37.9 |
1,681 |
1,584 |
|
|
Higher |
1.1 |
8.2 |
33.5 |
651 |
710 |
|
Ethnicity |
||||||
|
|
Kazak |
1.9 |
14.3 |
40.7 |
1,654 |
1,885 |
|
|
Russian |
0.7 |
7.2 |
33.8 |
1,283 |
1,141 |
|
|
Other |
0.3 |
8.2 |
34.7 |
747 |
632 |
|
|
Total |
1.1 |
10.6 |
37.1 |
3,684 |
3,658 |
As seen in table 2, 60% of the women tested in Uzbekistan had some degree of anaemia, mostly mild (45%) or moderate (14%). One percent had severe anaemia. Differences in anaemia status of women according to age, residence, ethnicity, and education were minor. However, regional differences were more marked. High rates of moderate and severe anaemia were found in the Aral Sea region and in Ferghana Valley (23% and 25%, respectively), whereas Tashkent City had the lowest rate of moderate anaemia (7%) and no cases of severe anaemia.
Table 3 presents anaemia rates for women in the Kyrgyz Republic, 38% of whom had some degree of anaemia. Nine percent of these women had moderate anaemia and 2% had severe anaemia There was a high rate of moderate and severe anaemia in the south (12%). The rates of moderate and severe anaemia were higher among rural women than urban women, and higher among ethnic Kyrgyz and Uzbek women than among ethnic Russians or women of other ethnic groups.
Figure 1 shows the prevalence of moderate and severe anaemia among pregnant, breastfeeding, and non-pregnant, non-breastfeeding women. In all three countries, moderate and severe anaemia was almost two to three times more prevalent among pregnant women than among non-pregnant women (breastfeeding or non-breastfeeding).
Table 2. Anaemia among women in Uzbekistan: Percentage of women classified as having anaemia according to background characteristics, Uzbekistan Demographic and Health Survey, 1996
|
Background characteristic |
Percentage of women with: |
Women measured |
||||
|
Severe anaemiaa |
Moderate anaemiab |
Mild anaemiac |
Weighted |
Unweighted |
||
|
Age (yr) |
||||||
|
|
15-19 |
0.6 |
10.4 |
45.3 |
964 |
916 |
|
|
20-24 |
0.9 |
16.6 |
45.0 |
792 |
791 |
|
|
25-29 |
0.6 |
16.4 |
45.5 |
697 |
679 |
|
|
30-34 |
1.2 |
16.3 |
45.8 |
615 |
603 |
|
|
35-39 |
1.6 |
14.6 |
47.0 |
551 |
557 |
|
|
40-44 |
0.8 |
11.5 |
45.4 |
414 |
423 |
|
|
45-49 |
1.1 |
13.3 |
41.5 |
300 |
305 |
|
Residence |
||||||
|
|
Urban |
0.9 |
12.8 |
45.5 |
1,625 |
2,181 |
|
|
Rural |
0.9 |
15.1 |
45.2 |
2,709 |
2,093 |
|
Region |
||||||
|
|
Aral Sea region |
2.1 |
21.3 |
48.1 |
461 |
961 |
|
|
Central |
0.3 |
10.0 |
33.7 |
1,049 |
922 |
|
|
East |
0.4 |
8.5 |
44.7 |
1,243 |
751 |
|
|
Ferghana Valley |
1.8 |
23.1 |
53.4 |
1,224 |
909 |
|
|
Tashkent City |
0.0 |
6.7 |
50.2 |
357 |
731 |
|
Education |
||||||
|
|
Primary/secondary |
1.0 |
13.8 |
45.8 |
2,787 |
2,478 |
|
|
Special education |
0.8 |
16.6 |
44.7 |
1,095 |
1,247 |
|
|
Higher |
0.5 |
10.8 |
43.7 |
451 |
549 |
|
Ethnicity |
||||||
|
|
Uzbek |
0.9 |
14.6 |
45.9 |
3,594 |
3,259 |
|
|
Other |
0.8 |
12.1 |
42.3 |
739 |
1,015 |
|
|
Total |
0.9 |
14.2 |
45.3 |
4,333 |
4,274 |
Figure 2 shows haemoglobin concentrations in non-pregnant and non-lactating women. The entire haemoglobin distribution for women in each of the three Central Asian countries is shifted downward (to the left) as compared with the distribution for healthy non-anaemic women in the United States according to the sample of the US National Health and Nutrition Examination Survey (NHANES-II). The NHANES-II distribution can be used as a reference, since individuals with abnormal mean cell volume and transferrin saturation were excluded from the distribution [11].
Table 4 presents anaemia rates for children under the age of three years in Kazakstan. There is a high national rate of anaemia (69%) among children. One-third of all children were diagnosed with moderate anaemia and 5% with severe anaemia As in women, the highest prevalence of anaemia in children occurred in the western region, where almost half were moderately anaemic and 8% were severely anaemic The most pronounced differentials are observed in the rates of severe anaemia. Nine percent of ethnic Kazak children were severely anaemic in contrast to no ethnic Russian children and only 1% of children in other ethnic groups. Similarly, the rates of severe anaemia among children of mothers with a primary or secondary education and among children in the southern, western, and central regions were two to five times higher than the rates for other groups of children. Children living in rural areas had severe or moderate anaemia more frequently than urban children.
Table 5 presents anaemia rates for children under three years of age in Uzbekistan. Sixty-one percent had some degree of anaemia, 26% had moderate anaemia and 1% were severely anaemic. The differences in overall rates of anaemia according to the sex of the child, residence, and education of the mother were relatively minor. However, as is the case with women, the regional differences were substantial. More than half of the children (53%) living in the Aral Sea region had moderate or severe anaemia. The prevalence of moderate and severe anaemia was also high in the east and in Ferghana Valley (26% and 28%, respectively).
Table 3. Anaemia among women in the Kyrgyz Republic: Percentage of women classified as having anaemia according to background characteristics, Kyrgyz Demographic and Health Survey, 1997
|
Background characteristic |
Percentage of women with: |
Women measured |
||||
|
Severe anaemiaa |
Moderate anaemiab |
Mild anaemiac |
Weighted |
Unweighted |
||
|
Age (yr) |
||||||
|
|
15-19 |
0.7 |
5.9 |
25.2 |
720 |
718 |
|
|
20-24 |
0.8 |
8.9 |
24.3 |
642 |
631 |
|
|
25-29 |
1.3 |
7.4 |
28.4 |
525 |
543 |
|
|
30-34 |
2.7 |
11.2 |
30.3 |
618 |
605 |
|
|
35-39 |
1.0 |
10.3 |
30.3 |
566 |
549 |
|
|
40-44 |
2.8 |
10.2 |
26.1 |
396 |
402 |
|
|
45-49 |
1.5 |
10.5 |
31.1 |
300 |
312 |
|
Residence |
||||||
|
|
Urban |
0.8 |
6.5 |
24.8 |
1,250 |
1,430 |
|
|
Rural |
1.8 |
10.2 |
29.1 |
2,517 |
2,330 |
|
Region |
||||||
|
|
Bishkek City |
0.6 |
5.0 |
23.5 |
500 |
862 |
|
|
North |
1.4 |
8.5 |
26.6 |
1,157 |
997 |
|
|
East |
0.5 |
7.0 |
22.6 |
211 |
756 |
|
|
South |
1.9 |
10.5 |
30.0 |
1,898 |
1,145 |
|
Education |
||||||
|
|
Primary/secondary |
1.1 |
10.1 |
27.6 |
2,018 |
1,892 |
|
|
Special education |
2.3 |
8.4 |
28.9 |
1,128 |
1,156 |
|
|
Higher |
1.3 |
6.5 |
25.5 |
621 |
712 |
|
Ethnicity |
||||||
|
|
Kyrgyz |
1.9 |
9.6 |
27.6 |
2,347 |
2,518 |
|
|
Russian |
0.3 |
3.9 |
20.7 |
391 |
470 |
|
|
Uzbek |
1.1 |
10.8 |
34.2 |
680 |
432 |
|
|
Other |
0.7 |
7.1 |
23.3 |
349 |
340 |
|
|
Total |
1.5 |
9.0 |
27.7 |
3,767 |
3,760 |
Table 6 presents anaemia rates for children under three years of age in the Kyrgyz Republic. Fifty percent had some degree of anaemia 24% had moderate anaemia and 1% were severely anaemic. Differences in overall rates of anaemia according to sex of the child, ethnicity, residence, and education of the mother were relatively minor. However, as was the case with women, the regional differences were substantial; 32% of the children in the north and 24% percent of those in the south and east had moderate or severe anaemia In Bishkek City the prevalence of moderate anaemia among children was relatively low (13%).
Certain relationships were observed between the prevalence of anaemia among mothers and their children. Figure 3 shows cumulative data from Kazakstan, Uzbekistan, and the Kyrgyz Republic on the prevalence of moderate or severe anaemia among children according to the anaemia status of their mothers. Among children of mothers with severe anaemia 68% were severely or moderately anaemic. The percentage of children with moderate or severe anaemia born to mothers with moderate anaemia was 46%, whereas for those children born to mothers with mild anaemia it was 30%. Only 24% percent of children born to non-anaemic mothers suffered from moderate or severe anaemia This is less than one-third of the rate among children born to mothers who were severely anaemic at the time of the surveys.
FIG. 2. Percent distribution of non-pregnant and non-lactating women age 15-19 years according to blood haemoglobin levels
Table 4. Anaemia among children in Kazakstan: Percentage of children under three years classified as having anaemia according to background characteristics, Kazakstan Health and Demographic Survey, 1995
|
Background characteristic |
Percentage of children with: |
Children measured |
||||
|
Severe anaemiaa |
Moderate anaemiab |
Mild anaemiac |
Weighted |
Unweighted |
||
|
Residence |
||||||
|
|
Urban |
4.5 |
26.9 |
32.3 |
293 |
275 |
|
|
Rural |
6.1 |
38.2 |
28.6 |
422 |
464 |
|
Region |
||||||
|
|
Almaty City |
1.5 |
20.0 |
26.2 |
29 |
65 |
|
|
South |
7.4 |
32.8 |
32.7 |
319 |
253 |
|
|
West |
7.7 |
47.3 |
26.0 |
93 |
173 |
|
|
Central |
5.1 |
40.0 |
21.7 |
73 |
153 |
|
|
North-east |
2.0 |
27.9 |
31.7 |
200 |
95 |
|
Education of mother |
||||||
|
|
Primary/secondary |
6.7 |
35.3 |
25.7 |
261 |
270 |
|
|
Special education |
5.3 |
32.9 |
33.8 |
340 |
346 |
|
|
Higher |
3.0 |
31.7 |
29.5 |
113 |
123 |
|
Ethnicity |
||||||
|
|
Kazak |
8.9 |
40.6 |
28.2 |
420 |
487 |
|
|
Russian |
0.0 |
27.5 |
31.0 |
159 |
137 |
|
|
Other |
1.3 |
19.0 |
35.1 |
135 |
115 |
|
|
Total |
5.5 |
33.6 |
30.1 |
714 |
739 |
Table 5. Anaemia among children in Uzbekistan: Percentage of children under three years classified as having anaemia according to background characteristics, Uzbekistan Demographic and Health Survey, 1996
|
Background characteristic |
Percentage of children with: |
Children measured |
||||
|
Severe anaemiaa |
Moderate anaemiab |
Mild anaemiac |
Weighted |
Unweighted |
||
|
Sex |
||||||
|
|
Mate |
1.8 |
27.5 |
31.8 |
557 |
512 |
|
|
Female |
0.6 |
23.7 |
36.2 |
549 |
506 |
|
Residence |
||||||
|
|
Urban |
0.9 |
23.8 |
32.8 |
310 |
400 |
|
|
Rural |
1.4 |
26.3 |
34.4 |
795 |
618 |
|
Region |
||||||
|
|
Aral Sea region |
5.2 |
48.2 |
27.5 |
122 |
251 |
|
|
Central |
0.5 |
17.6 |
29.6 |
294 |
249 |
|
|
East |
0.5 |
25.8 |
26.9 |
335 |
197 |
|
|
Ferghana Valley |
1.4 |
26.9 |
50.2 |
307 |
223 |
|
|
Tashkent City |
0.0 |
7.1 |
22.4 |
48 |
98 |
|
Education of mother |
||||||
|
|
Primary/secondary |
1.1 |
26.8 |
35.1 |
709 |
584 |
|
|
Special education |
1.9 |
23.6 |
31.4 |
293 |
322 |
|
|
Higher |
0.4 |
23.1 |
33.4 |
104 |
112 |
|
Ethnicity |
||||||
|
|
Uzbek |
1.0 |
25.0 |
34.6 |
980 |
840 |
|
|
Other |
3.2 |
30.2 |
29.3 |
126 |
178 |
|
|
Total |
1.2 |
25.6 |
34.0 |
1,106 |
1,018 |
Nationally representative anaemia levels among women and children were recently determined in conjunction with the three demographic and health surveys in Kazakstan (1995 Kazakstan survey) [19], Uzbekistan (1996 Uzbekistan survey) [20], and the Kyrgyz Republic (1997 Kyrgyz survey) [21]. Anaemia was assessed by measurement of the haemoglobin level in capillary blood of women aged 15 to 49 years and their children under the age of 3 years using the photometric Hemocue technique. The studies showed that approximately half (49%) of the women in Kazakstan, 60% of the women in Uzbekistan, and 40% of the women in the Kyrgyz Republic had some degree of anaemia. The percentages of children diagnosed as having anaemia in Kazakstan, Uzbekistan, and the Kyrgyz Republic were 69%, 61%, and 50%, respectively. There were some socio-economic, residential, demographic, and ethnic differentials in the prevalence of anaemia in each of these countries.
The highest overall rates of anaemia were found in the Aral Sea region of Uzbekistan, which includes the autonomous Republic of Karakalpakstan and Khorezm Oblast: 72% of women and 61% of children were anaemic. This region of Uzbekistan is considered part of the area of the Aral Sea environmental crisis, which is characterized by severe agrochemical Pollution, lack of water and food, and a number of other socio-economic problems. The rates of anaemia in the western region of Kazakstan, which is also close to the Aral Sea, were 59% among women and 81% among children.
Table 6. anaemia among children in the Kyrgyz Republic: Percentage of children under three years classified as having anaemia according to background characteristics, Kyrgyz Republic Demographic and Health Survey, 1997
|
Background characteristic |
Percentage of children with: |
Children measured |
||||
|
Severe anaemiaa |
Moderate anaemiab |
Mild anaemiac |
Weighted |
Unweighted |
||
|
Sex |
||||||
|
|
Male |
2.1 |
28.1 |
22.9 |
511 |
500 |
|
|
Female |
0.7 |
20.5 |
25.4 |
510 |
480 |
|
Residence |
||||||
|
|
Urban |
2.2 |
15.9 |
20.4 |
227 |
244 |
|
|
Rural |
1.2 |
26.7 |
25.2 |
793 |
736 |
|
Region |
||||||
|
|
Bishkek City |
0.8 |
12.7 |
17.8 |
69 |
118 |
|
|
North |
2.1 |
30.0 |
19.9 |
284 |
249 |
|
|
East |
3.6 |
20.0 |
24.9 |
69 |
245 |
|
|
South |
0.9 |
23.4 |
26.7 |
599 |
368 |
|
Education of mother |
||||||
|
|
Primary/secondary |
1.2 |
25.5 |
24.5 |
535 |
499 |
|
|
Special education |
1.8 |
24.0 |
24.4 |
359 |
344 |
|
|
Higher |
1.1 |
19.8 |
21.8 |
126 |
137 |
|
Ethnicity |
||||||
|
|
Kyrgyz |
1.4 |
25.5 |
26.0 |
664 |
709 |
|
|
Russian |
0.0 |
22.5 |
10.8 |
45 |
55 |
|
|
Uzbek |
0.9 |
20.3 |
24.4 |
240 |
151 |
|
|
Other |
3.5 |
27.4 |
13.8 |
71 |
65 |
|
|
Total |
1.4 |
24.3 |
24.1 |
1,021 |
980 |
Approximately half of the children in the Aral Sea region of Uzbekistan and the western region of Kazakstan had moderate anaemia. A significant proportion of these children (more than 5%) were severely anaemic. Patients with severe anaemia require medical assistance in clinical settings, whereas moderate anaemia can be treated by public health approaches such as iron- fortification or iron -supplementation programmes.
The high rates of anaemia found by the Demographic and Health Survey study in the Aral Sea areas of Uzbekistan and Kazakstan are in accordance with data from two other recent studies: the 1993 Crosslink study in Muynak District of Uzbekistan [17] and the study done by the London Institute of Tropical Diseases in Kzyl-Orda Oblast of Kazakstan [18]. Both studies showed similarly high rates of anaemia among women and children living in the area of environmental crisis around the Aral Sea.
Although many causes of anaemia have been identified, such as haemoglobinopathies, parasitic infestation, chronic bleeding, and deficiencies of folic acid and vitamin C, there is sufficient evidence to suggest that the majority of cases of anaemia in Kazakstan are due to negative iron balance. A special study conducted in a subsample of 44 women living in Almaty City with haemoglobin levels below 10 g/dl (data not shown) showed that 41 of these women also had low blood levels of ferritin (<12 ng/dl).
Anaemia represents only the severe end of iron deficiency, and the real magnitude of iron deficiency in a population is greater than that reflected by haemoglobin measurement alone. Iron deficiency is caused primarily by the low consumption of foods containing bioavailable iron and promoters of iron absorption, such as animal protein and ascorbic acid. In a series of dietary assessment studies done by the Kazakstan Nutrition Institute during the last decade, an overall decrease in consumption of animal protein, essential vitamins, and microelements by various population groups in Kazakstan has been documented [23]. Deficiencies of iron and other nutrients are especially critical during pregnancy and growth in early childhood.
When iron deficiency is the main cause of anaemia, population groups with a high iron requirement are disproportionately affected and more frequently develop anaemia. Negative iron balance due to an imbalance of iron requirements versus iron intake often occurs during pregnancy and growth. For this reason, when iron deficiency is highly prevalent in a population, pregnant women, who provide the foetus with a considerable amount of iron, are at greater risk of developing anaemia than non-pregnant women. In Central Asia the prevalence of anaemia among pregnant women is two to three times greater than among non-pregnant and non-lactating women. Our data also showed that the percent distribution of non-pregnant and non-lactating women according to the level of haemoglobin shifted towards the lower concentration of haemoglobin in the blood as compared with the corresponding reference sample population of healthy US women.
Negative iron balance is probably also a major cause of anaemia among young children in Central Asia. The highest rate of anaemia among children in Kazakstan is found among those 12 to 24 months of age, which can be explained by a rapid rate of growth. during this period and the relatively low iron content of the diet. This is in accordance with several physiological studies showing that the iron stores are more likely to become depleted between six months and two to three years of age [2, 24-26]. In addition, the relatively low consumption of meat products, a major source of bioavailable iron, plus the Central Asian custom of giving children tea, which inhibits iron absorption, could also lead to the depletion of iron stores and the development of anaemia For example, according to a supplemental foods assessment done in the Kazakstan, Uzbekistan, and Kyrgyz surveys, tea was given in the 24 hours before the interview to 21%, 49%, and 34% of infants 0 to 3 months of age in Kazakstan, Uzbekistan, and the Kyrgyz Republic, respectively [19-21].
Some demographic predisposing factors increase the likelihood of anaemia in children: being 12 to 23 months of age, a high birth order, and a birth interval of 24 to 47 months (data not presented). Our results also show that having an anaemic mother increases the risk of moderate and severe anaemia among children.
It is unlikely that haemoglobinopathies contribute substantially to the high prevalence of anaemia in these regions. In the study by the Crosslink group, only 0.14% of people in the Muynak District of Karakalpakstan had haemoglobinopathy (thalassaemia was not determined) [17]. Considering common genetic features of people of Kazak and Karakalpak origin, the prevalence of haemoglobinopathies among the Kazaks is also probably low. However, without focused studies of the prevalence of haemoglobinopathies and thalassaemias, it is difficult to exclude their role as aetiologic factors of anaemia in such regions as the Ferghana Valley and Samarkand Oblast of Uzbekistan, as well as the southern region of the Kyrgyz Republic, which is characterized by high ethnic admixture and a historically intensive migration process and therefore a high chance of blood disorders among the population.
The Kazakstan, Uzbekistan, and Kyrgyz surveys, as well as other geographically focused studies, provide an important information base for the development of health intervention programmes to prevent many severe complications of pregnancy and delivery related to iron-deficiency anaemia among women of certain ethnic, educational, and residential groups in these countries. These data are important as a background for public health policy decisions with regard to the iron fortification of food.
Since anaemia represents only the severe end of the iron-deficiency spectrum, it is assumed that the total proportion of iron-deficient persons in the population is greater than that reflected by the prevalence of anaemia detected by haemoglobin measurement alone. It can be assumed that in Central Asia, where the prevalence of anaemia according to haemoglobin measurement is higher than 40% among both women and their children, the real magnitude of iron deficiency is greater, and therefore universal iron fortification or supplementation may be justified. Another solution would be to provide certain population groups, such as pregnant women and young children, with selective supplementation of iron.
Based on the results of Demographic and Health Survey anaemia studies in Kazakstan and Uzbekistan, the UNICEF Area Office for the Central Asian Republics and Kazakstan (UNICEF CARK) proposed an integrated strategy of education, supplementation, fortification, and research to address the problem and called for donors’ support. The proposed strategy considered an intervention approach and includes the following elements:
· National and area-wide education and training efforts aimed at affordable and acceptable change in the environments of economic transition;Acknowledgements· Fortification of cereal flour with iron;
· A major expansion for a period of two years of iron supplementation (weekly) to encompass women of reproductive age, pregnant women, and children 6 to 24 months of age;
· Retention of current treatment practices for all per sons found to be suffering from severe anaemia
· A research agenda of key studies and monitoring activities by the Ministries of Health and other institutions, beginning with a study of the effectiveness of weekly supplementation in all groups and action research on channels, messages, and other factors that will be developed as part of the programme.
I thank Dr. Jeremiah M. Sullivan for his help in analysis of the anaemia data, Mr. Trevor Croft for assistance with the tabulations, Ms. Thanh Lê for the Kazakstan survey sampling design, and all Kazakstan, Uzbekistan, and Kyrgyz survey field staff for the anaemia testing.
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