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Worldwide

prevalence of anaemia19932005who Gb db

ai

Editors

Bruno de Benoist

w h ogizi

G, siz

Erin McLean

w h ogizi

G, siz

Ines Egli

Ii si nii,

eth Zi, siz

Mary Cogswellc di c pi

a, Ggi

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World Health Organization 2008

All rights reserved. Publications o the World Health Organization can be obtained rom WHO Press, World Health Organization, 20 Avenue Appia,1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; ax: +41 22 791 4857; e-mail: bookorders@who.int). Requests or permission to reproduce ortranslate WHO publications whether or sale or or noncommercial distribution should be addressed to WHO Press, at the above address (ax: +41

22 791 4806; e-mail: permissions@who.int).The designations employed and the presentation o the material in this publication do not imply the expression o any opinion whatsoever on the part othe World Health Organization concerning the legal status o any country, territory, city or area or o its authorities, or concerning the delimitation o itsrontiers or boundaries. Dotted lines on maps represent approximate border lines or which there may not yet be ull agreement.

The mention o specic companies or o certain manuacturers products does not imply that they are endorsed or recommended by the World HealthOrganization in preerence to others o a similar nature that are not mentioned. Errors and omissions excepted, the names o proprietary products aredistinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to veriy the inormation contained in this publication. However, thepublished material is being distributed without warranty o any kind, either expressed or implied. The responsibility or the interpretation and use o thematerial lies with the reader. In no event shall the World Health Organization be liable or damages arising rom its use.

The named authors alone are responsible or the views expressed in this publication.

Cover photographs by Virot Pierre, Armando Waak, Carlos Gaggero

Designed by minimum graphicsPrinted in Spain

WHO Library Cataloguing-in-Publication Data

Worldwide prevalence o anaemia 19932005 : WHO global database on anaemia / Edited by Bruno de Benoist,Erin McLean, Ines Egli and Mary Cogswell.

1.Anemia prevention and control. 2.Anemia epidemiology. 3.Prevalence. I.World Health Organization.

ISBN 978 92 4 159665 7 (NLM classication: WH 155)

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Contents

Preace v Acknowledgements Abbreviations

1. Introduction 1

1.1 Anaemia: a public health problem 1

1.1.1 Etiology 11.1.2 Health consequences 11.1.3 Assessing anaemia 1

1.2 Control o anaemia 11.2.1 Correcting anaemia 1

2. Methods 3

2.1 Data sources The WHO Global Database on Anaemia 32.2 Selection o survey data 3

2.2.1 Administrative level 32.2.2 Population groups 4

2.3 Dening anaemia 4

2.3.1 Haemoglobin threshold 42.3.2 Estimated anaemia prevalence or countries with no survey data 52.3.3 Uncertainty o estimates 52.3.4 Combining national estimates 52.3.5 Global anaemia prevalence 52.3.6 Classication o anaemia as a problem o public health signicance 6

2.4 Population coverage, proportion o population, and the number o individuals with anaemia 62.4.1 Population coverage 62.4.2 Proportion o population and the number o individuals aected 6

3. Results and Discussion 7

3.1 Results 7

3.1.1. Population coverage 73.1.2 Proportion o population and number o individuals with anaemia 73.1.3 Classication o countries by degree o public health signicance o anaemia 8

3.2 Discussion 83.2.1 Population coverage 83.2.2 Strengths o estimates 83.2.3 Limitations o estimates 83.2.4 Proportion o population and the number o individuals with anaemia 123.2.5 Classication o countries by degree o public health signicance o anaemia, based on

haemoglobin concentration 123.2.6 Comparison to previous estimates 12

3.3 Conclusion 12

References 14

iiicontents

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Annexes

Annex 1 WHO Member States grouped by WHO and UN regions 15Table A1.1 WHO Member States grouped by WHO regions 15Table A1.2 WHO Member States grouped by UN regions and subregions 16

Annex 2 Results by UN region 18Table A2.1 Population coverage by anaemia prevalence surveys (national or subnational)

conducted between 1993 and 2005 by UN region 18Table A2.2 Anaemia prevalence by UN region 18

Annex 3 National estimates o anaemia 20Table A3.1 Country estimates o anaemia prevalence in preschool-age children 20Table A3.2 Country estimates o anaemia prevalence in pregnant women 25Table A3.3 Country estimates o anaemia prevalence in non-pregnant women o reproductive age 30Table A3.4 Country reerences 35

Tables

Table 2.1 Haemoglobin thresholds used to dene anaemia 4Table 2.2 Prediction equations used to generate anaemia estimates or countries without survey data 5Table 2.3 Classication o anaemia as a problem o public health signicance 6

Table 3.1 Population coverage (%) by anaemia prevalence surveys (national or subnational) conductedbetween 1993 and 2005 7

Table 3.2 Global anaemia prevalence and number o individuals aected 7Table 3.3 Anaemia prevalence and number o individuals aected in preschool-age children, non-pregnant

women and pregnant women in each WHO region 8Table 3.4 Number o countries categorized by public health signicance o anaemia 8

Figures

Figure 3.1 Anaemia as a public health problem by country(a) Preschool-age children 9(b) Pregnant women 10(c) Non-pregnant women o reproductive age 11

worldwIde prevalence o anaemIa 19932005iv

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Preface

Anaemia is a public health problem that aects populationsin both rich and poor countries. Although the primarycause is iron deciency, it is seldom present in isolation.More requently it coexists with a number o other causes,such as malaria, parasitic inection, nutritional deciencies,

and haemoglobinopathies.Given the importance o this pathology in the world, nu-

merous countries conduct interventions to reduce anaemia;particularly in the groups most susceptible to its devastat-ing eects: pregnant women and young children. In orderto assess the impact o these interventions, the adequacyo the strategies implemented, and the progress made inthe ght against anaemia, inormation on anaemia preva-lence must be collected. This is the primary objective o theWHO Global Database on Anaemia. However, estimateso anaemia prevalence by themselves are only useul i they

are associated with a picture o the various causal actorsthat contribute to the development o anaemia in specicsettings. Indeed these actors are multiple and complex, andit is critical to collect accurate inormation about them toprovide the basis or developing the best interventions oranaemia control.

In the last three decades, there have been various at-tempts to produce estimates o the prevalence o anaemiaat dierent levels including at the global level, but untilthe present time, there has never been a systematic reviewo all o the data collected and published with the objec-tive o deriving regional and global estimates. The WHO

Global Database on Anaemia has lled this gap: data rom93 countries, representing as much as 76% o the popula-tion in the case o preschool-age children, were analysedand used to develop statistical models to generate nationalprevalence estimates or countries with no data within thetime rame specied.

It is surprising that given the public health importanceo anaemia, there are numerous countries lacking nationalprevalence data. Moreover, most survey data are relatedto the three population groups: preschool-age children,pregnant women, and non-pregnant women o reproduc-

tive age, which is why the report ocuses on these groups.

The data available or school-age children, men, and theelderly were not sucient to generate regional or country-level estimates or these groups, and thereore only globalestimates or these groups are presented.

In addition, despite the act that iron deciency is con-

sidered to be the primary cause o anaemia, there are ewdata on the prevalence o this deciency. The likely reasonis that iron assessment is dicult because the available in-dicators o iron status do not provide sucient inormationalone and must be used in combination to obtain reliableinormation on the existence o iron deciency. Further-more, there is no real consensus on the best combination oindicators to use. Another reason is that the role o actorsother than iron deciency in the development o anaemiahas been underestimated by public health ocials, becauseor a long time anaemia has been conused with iron de-

ciency anaemia, and this has infuenced the development ostrategies and programmes designed to control anaemia.In this report, the prevalence o anaemia is presented by

country and by WHO regions. Because these prevalencedata may be used to identiy programme needs by otherUnited Nations agencies, we have presented the estimatesclassied by United Nations regions in the annexes. In ad-dition, one chapter is dedicated to the criteria used to iden-tiy, revise, and select the surveys, and the methodologydeveloped to generate national, regional, and global esti-mates.

A lesson learned rom producing this report is that in

order or the database to reach its ull potentia l, data shouldbe collected on other vulnerable population groups such asthe elderly and school-age children, and surveys should bemore inclusive and collect inormation on iron status andother causes o anaemia.

This report is written or public health ocials, nutri-tionists, and researchers. We hope that readers nd it useuland eel ree to share any comments with us.

Bruno de Benoist

Coordinator, Micronutrient Unit

World Health Organization

vpreace

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Acknowledgements

WHO wishes to thank the numerous individuals, insti-tutions, governments, non-governmental, and internationalorganizations or providing data or the database. Withoutcontinual international collaboration in keeping the data-base up-to-date, this compilation on the global situation

and trends in anaemia prevalence would not have been pos-sible. Special thanks are due to ministries o health o theWHO Member States, WHO regional oces, and WHOcountry oces.

worldwIde prevalence o anaemIa 19932005vi

The WHO Global Database on Anaemia was developed bythe Micronutrient team in the Department o Nutrition orHealth and Development with the nancial support o theCenters or Disease Control and Prevention.

The estimates or the database were produced by Erin

McLean, Mary Cogswell, Ines Egli, and Daniel Wojdyla with contributions rom Trudy Wijnhoven, LaurenceGrummer-Strawn, and Bradley Woodru, under the co-ordination o Bruno de Benoist. Grace Rob and Ann-BethMoller assisted in data management.

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viiaBBrevIatIons

Abbreviations

CDC Centers or Disease Control and PreventionHb HaemoglobinHDI Human Development Index: a composite indicator o wealth, lie expectancy and education developed by

the United Nations Development Programme.IDA Iron deciency anaemia

NHANES National Health and Nutrition Examination SurveyNPW Non-pregnant women (15.0049.99 yrs)PreSAC Preschool-age children (0.004.99 yrs)PW Pregnant womenSD Standard deviationUN United NationsVMNIS Vitamin and mineral nutrition inormation system WHO World Health OrganizationCRP C-reactive protein

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1

1. Introduction

1.1 Anaemia: a public health problem

Anaemia is a global public health problem aecting bothdeveloping and developed countries with major conse-quences or human health as well as social and economicdevelopment. It occurs at all stages o the lie cycle, but

is more prevalent in pregnant women and young children.In 2002, iron deciency anaemia (IDA) was considered tobe among the most important contributing actors to theglobal burden o disease (1).

1.1.1 Etiology

Anaemia is the result o a wide variety o causes that can beisolated, but more oten coexist. Globally, the most signi-cant contributor to the onset o anaemia is iron deciencyso that IDA and anaemia are oten used synonymously, andthe prevalence o anaemia has oten been used as a proxyor IDA. It is generally assumed that 50% o the cases oanaemia are due to iron deciency (2), but the proportionmay vary among population groups and in dierent areasaccording to the local conditions. The main risk actors orIDA include a low intake o iron, poor absorption o ironrom diets high in phytate or phenolic compounds, and pe-riod o lie when iron requirements are especially high (i.e.growth and pregnancy).

Among the other causes o anaemia, heavy blood loss asa result o menstruation, or parasite inections such as hook-worms, ascaris, and schistosomiasis can lower blood haemo-globin (Hb) concentrations. Acute and chronic inections,

including malaria, cancer, tuberculosis, and HIV can alsolower blood Hb concentrations. The presence o other micro-nutrient deciencies, including vitamins A and B12, olate,ribofavin, and copper can increase the risk o anaemia. Fur-thermore, the impact o haemoglobinopathies on anaemiaprevalence needs to be considered within some populations.

1.1.2 Health consequences

Anaemia is an indicator o both poor nutrition and poorhealth. The most dramatic health eects o anaemia, i.e.,increased risk o maternal and child mortality due to severeanaemia, have been well documented (35). In addition,

1. IntroductIon

the negative consequences o IDA on cognitive and physi-cal development o children, and on physical perormance particularly work productivity in adults are o majorconcern (2).

1.1.3 Assessing anaemiaHb concentration is the most reliable indicator o anae-mia at the population level, as opposed to clinical meas-ures which are subjective and thereore have more room orerror. Measuring Hb concentration is relatively easy andinexpensive, and this measurement is requently used as aproxy indicator o iron deciency. However, anaemia canbe caused by actors other than iron deciency. In addition,in populations where the prevalence o inherited haemo-globinopathies is high, the mean level o Hb concentrationmay be lowered. This underlines that the etiology o anae-

mia should be interpreted with caution i the only indicatorused is Hb concentration. The main objective or assess-ing anaemia is to inorm decision-makers on the type omeasures to be taken to prevent and control anaemia. Thisimplies that in addition to the measurement o Hb concen-tration, the causes o anaemia need to be identied consid-ering that they may vary according to the population.

1.2 Control of anaemia

1.2.1 Correcting anaemia

Given the multiactorial nature o this disease, correctinganaemia oten requires an integrated approach. In order

to eectively combat it, the contributing actors must beidentied and addressed. In settings where iron deciencyis the most requent cause, additional iron intake is usuallyprovided through iron supplements to vulnerable groups;in particular pregnant women and young children. Food-based approaches to increase iron intake through oodortication and dietary diversication are important, sus-tainable strategies or preventing IDA in the general pop-ulation. In settings where iron deciency is not the onlycause o anaemia, approaches that combine iron interven-tions with other measures are needed.

Strategies should include addressing other causes o

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worldwIde prevalence o anaemIa 199320052

anaemia (6,7),1.2 and should be built into the primaryhealth care system and existing programmes. These strat-egies should be tailored to local conditions, taking intoaccount the specic etiology and prevalence o anaemia ina given setting and population group.

1 http://www.who.int/malaria/docs/TreatmentGuidelines2006.pd2 http://www.who.int/wormcontrol/documents/en/Controlling%20

Helminths.pd

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3

2. Methods

2.1 Data sources The WHO Global Databaseon Anaemia

The estimates presented are based on data rom the WHOGlobal Database on Anaemia; a part o the Vitamin andMineral Nutrition Inormation System (VMNIS), main-

tained at WHO.Data are collected rom the scientic literature and

through collaborators, including WHO regional andcountry oces, United Nations organizations, ministrieso health, research and academic institutions, and non-governmental organizations. MEDLINE and WHO re-gional databases were searched systematically, and manualsearches were conducted to nd articles published in non-indexed medical and proessional journals. For inclusion inthe database, Hb must be measured in capillary, venous,or cord blood using quantitative photometric methods or

automated cell counters. In addition, anaemia prevalence ormean Hb concentrations have to be reported. Surveys wereexcluded i they measured only clinical signs o anaemia orhaematocrit. Data are included in the database i they arerepresentative o any administrative level within a country,including nationally representative data and surveys repre-sentative o a region, the rst administrative level bound-ary, second administrative level boundary or local surveys.As o December 31, 2005, 696 surveys were available in thedatabase; the majority o these in women or preschool-agechildren.

2.2 Selection of survey dataThe time rame or the current estimates is 19932005 andsurvey data or WHOs 1921 Member States were extractedrom the database. Data on anaemia were selected or each

country using two variables: the administrative level or which the survey was representative, and the populationgroup surveyed.

2.2.1 Administrative level

Surveys were selected based on the administrative levelthey represented. Surveys were classied as national whenthey were based on a nationally representative sample. Sub-national surveys were also available in the database andwere classied according to the population that they rep-resented as regional (multiple states), state (representativeo the rst administrative level boundary), district (repre-sentative o the second administrative level boundary), orlocal surveys.

Data rom the most recent national survey was used inpreerence to subnational surveys. For one country, where

an area had been let out o a national survey because osecurity concerns, available data rom the missing regionwas pooled with the national data and weighted by the gen-eral population estimate or that area to provide a nationalestimate or that country. This proportion was determinedby using the most recent census data rom the country. Itwo national surveys were conducted in the same year, sur-vey results were pooled into a single summary measure andweighted by the survey sample size.

In the absence o national data, surveys representative oat least the rst administrative level boundary were used itwo or more surveys at this level were available or the pop-

ulation group and country concerned within the accept-able time rame. Results were pooled into a single summarymeasure, weighted by the total general population or thatregion or state, and based on the most recent and availablecensus data between 1993 and 2005. Local- and district-level surveys were not used in these estimates since theyhave the potential or more bias.

Surveys with prevalence data based on a sample size oless than 100 subjects were excluded in most cases. Thiswas done because with a sample size o 100 and a con-dence level o 95%, the error around an estimate o anae-

mia prevalence o 50% would be +/-10 percentage points. Asmaller sample size would have an even larger error. How-

1 On 3 June 2006, the Permanent Representative o the Republic o Serbiato the United Nations and other International Organizations in Genevainormed the Acting Director-General o the WHO that the member-ship o the state union Serbia and Montenegro in the United Nations,including all organs and the organizations o the United Nations sys-tem, is continued by the Republic o Serbia on the basis o Article 60 othe Constitutional Charter o Serbia and Montenegro, activated by theDeclaration o Independence adopted by the National Assembly o Mon-tenegro on 3 June 2006. Estimates used or reerred to in this documentcover a period o time preceding that communication.

2. methods

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worldwide prevalence of anaemia 199320054

ever, a ew exceptions were made. National surveys with

ewer than 100 subjects but more than 50 subjects were

only accepted where the results were being extrapolated to

ewer than 500,000 people; or to pregnant women, since

the numbers in this group are requently small, especially in

populations with a lower rate o reproduction.

2.2.2 Population groups

Population groups are as ollows: preschool-age children

(04.99 yrs), school-age children (5.0014.99 yrs), preg-

nant women (no age range defned), non-pregnant women

(15.0049.99 yrs), men (15.0059.99 yrs), and elderly (both

sexes >60 yrs). Wherever possible, children below 0.5 yrs

were excluded rom the estimate or preschool-age children

since the cut-o or anaemia is not defned in this age group.

However, the estimate was applied to the entire popula-

tion o children less than 5 yrs o age. Occasionally, in the

non-pregnant women group, pregnant women could not beexcluded because all women were included in the fgure pro-

vided in the country report; but pregnant women were oten

a small proportion o the group and their exclusion would

not be expected to change the fgure signifcantly. I a sur-

vey reported results by physiological status, lactating women

were combined with non-pregnant non-lactating women to

provide the estimate or non-pregnant women.

Data disaggregated by age closest to the defned age

range or the population groups were used. I the age range

overlapped two population groups, the survey was placed

with the group with the greatest overlap in age. When theage range was unavailable, the mean age o the sample was

used to classiy the data. I this was unavailable or i the age

range equally spanned two population groups, the popula-

tion-specifc Hb concentration threshold was used to clas-

siy the data. I data represented less than 20% o the age

range o a population group, the survey was excluded.

2.3 Defning anaemia

2.3.1 Haemoglobin threshold

Normal Hb distributions vary with age, sex, and physiolog-

ical status, e.g., during pregnancy (8). WHO Hb thresh-

olds were used to classiy individuals living at sea level asanaemic (Table 2.1) (2). Statistical and physiological evi-

dence indicate that Hb distributions vary with smoking (9)

and altitude (10), and thereore the prevalence o anaemia

corrected or these actors was used when provided by the

survey. No other corrections were accepted.

Some surveys did not present data using the WHO Hb

thresholds to defne anaemia. When this occurred, preva-

lence was estimated by assuming that the Hb concentration

was normally distributed within the population and esti-

mating anaemia prevalence by using one o the ollowing

methods in order o preerence:

1. The mean and standard deviation (SD) o the Hb con-

centration were used to estimate the proportion o in-

dividuals alling below the appropriate Hb cut-o or

the population group (n=20 surveys). The correlation

between the estimated and predicted prevalence o anae-

mia was determined using surveys rom the database

where a mean, an SD, and a prevalence or the WHO

age- and sex-specifc cut-o were provided. The relation-

ship was plotted (n=508 surveys), and or most surveys,

the two fgures were extremely close (r20.95, p

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52. methods

one non-WHO cut-o or anaemia where two should havebeen used; or 2) using two non-WHO cut-os. In the rstcase, the prevalence was adjusted or the WHO cut-o thatapplied to the group in the majority. In the second case,the prevalence was adjusted by assuming that the cut-oapplied to the group in the majority had been used or theentire group.

Data provided or separate groups requently had to becombined, such as data or women by physiological statusor any other population group disaggregated by age. Prev-alence estimates were combined and weighted by samplesize, and where this inormation was unavailable or oneo the groups, it was assumed to have the average numbero subjects o the other groups. I sample size inormationwas missing rom all data pooled, equal weight was givento each survey.

2.3.2 Estimated anaemia prevalence or countries withno survey data

Some countries did not have any survey data that met thecriteria or the estimates. Thereore, a regression model wasdeveloped using countries with anaemia prevalence dataand the 2002 United Nations Human Development Index(HDI) (11) which is a composite indicator o a lie expect-ancy index, an education index, and a wealth index (12) and health indicators rom the World Health StatisticsDatabase (13), so that anaemia prevalence could be pre-dicted or the countries without data.

Separate prediction equations or each population groupwere based on countries with anaemia prevalence data orthat group. Seventeen countries did not have an HDI, andso HDI was estimated using two o the components and aproxy indicator or education (average years o schoolingin adults) (1416). HDI and estimated HDI were used topredict the prevalence o anaemia using a multiple regres-sion model.

Anaemia prevalence was estimated by using the predic-tion equations (Table 2.2) in countries where only explana-tory variables were known. For one country, none o thecovariates were available and thereore, a country-level esti-mate was not generated.

2.3.3 Uncertainty o estimates

For estimates based on survey data, each estimate was con-sidered to be representative o the entire country whetherrom a national or subnational sample, and the variance wascalculated in the logit scale using the sample size. A designeect o 2 was applied since most surveys utilized clustersampling. From the prevalence, the variance and the de-sign eect, a 95% condence interval was generated in logitscale and then transormed to the original scale (17,18).

For regression-based estimates, a point estimate and95% prediction interval were computed by using the logit

transormations in the regression models (19) and thenback-transorming them to the original scale (20).

2.3.4 Combining national estimates

Country estimates were combined to provide estimates atthe global level as well as by WHO region or women andpreschool-age children by pooling the data and weightingit by the population that each estimate represented. Ninety-ve percent condence intervals were constructed using theestimated variance o the weighted average. For one coun-try without data, no proxy indicators were available and so

no country estimate was generated, but the UN subregionalestimate had to be applied to that country to make regionaland global estimates.

2.3.5 Global anaemia prevalence

The global prevalence o anaemia was calculated by com-bining the estimates or all population groups, which cov-ered the entire population except or one segment (women

Table 2.2 Prediction equations used to generate anaemia estimates or countries without survey data

Population Number of Equation R2 p-value

group countries for model

p-g 82 = 3.5979-4.9093*hdIb-0.0657*e 0.0003*e 0.550

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7

3. Results and Discussion

3.1 Results

3.1.1 Population coverage

Almost the entire population was covered by survey data

or regression-based estimates, since all countries except

or one had an estimate. The proportion o the population

covered by survey data was high or preschool-age children(76.1%) and pregnant (69.0%) and non-pregnant women

(73.5%), but lower or school-age children (33.0%), men

(40.2%), and the elderly (39.1%) (Table 3.1). By WHO

region, the coverage was highest in the Western Pacifc and

lowest in Europe. Based on this population coverage, it was

decided that there were insufcient data in school-age chil-

dren, men, and the elderly to generate regional estimates.

Table 3.1 Population coverage (%) by anaemia prevalence surveys (national or subnational) conducted between1993 and 2005

WHO region PreSACa PW NPW SAC Men Elderly All

a (46)b 74.6 (26) 65.8 (22) 61.4 (23) 13.2 (8) 21.9 (11) 0.0 (0) 40.7

as (35) 76.7 (16) 53.8 (15) 56.2 (13) 47.1 (9) 34.3 (2) 47.6 (1) 58.0

Sth-est as (11) 85.1 (9) 85.6 (8) 85.4 (10) 13.6 (3) 4.1 (2) 5.2 (1) 14.9

e (52) 26.5 (12) 8.3 (4) 28.0 (12) 9.3 (3) 14.1 (3) 8.0 (2) 22.9

est mt (21) 67.4 (11) 58.7 (7) 73.5 (11) 15.5 (6) 27.5 (6) 3.2 (3) 84.3

wst pf (27) 90.4 (10) 90.2 (8) 96.9 (13) 83.1 (7) 96.2 (10) 93.3 (6) 13.8

Global (192) 76.1 (84) 69.0 (64) 73.5 (82) 33.0 (36) 40.2 (34) 39.1 (13) 48.8

pt gs: pSac, sh-g h (0.004.99 ys); pw, gt ( g g f); npw, -gt (15.0049.99 ys), Sac, sh-g

h (5.0014.99 ys), m (15.0059.99 ys), ey (60.00 ys).b

nb ts h gg. Tt b ts th t, fg s v a s h ty y b ty v by s t gs, bt ts hv t 6 -

t gs ts hv t 5059 ys g.

Table 3.2 Global anaemia prevalence and number of individuals affected

Population group Prevalence of anaemia Population affected

Percent 95% CI Number (million) 95% CI

psh-g h 47.4 45.749.1 293 283303

Sh-g h 25.4 19.930.9 305 238371

pgt 41.8 39.943.8 56 5459

n-gt 30.2 28.731.6 468 446491

m 12.7 8.616.9 260 175345

ey 23.9 18.329.4 164 126202

Total population 24.8 22.926.7 1620 15001740

3.1.2 Proportion of population and number of

individuals with anaemia

Globally, anaemia aects 1.62 billion people (95% CI:

1.501.74 billion), which corresponds to 24.8% o the pop-

ulation (95% CI: 22.926.7%) (Table 3.2). The highest

prevalence is in preschool-age children (47.4%, 95% CI:45.749.1), and the lowest prevalence is in men (12.7%,

95% CI: 8.616.9%). However, the population group with

the greatest number o individuals aected is non-pregnant

women (468.4 million, 95% CI: 446.2490.6).

WHO regional estimates generated or preschool-age

children and pregnant and non-pregnant women indi-

cate that the highest proportion o individuals aected

are in Arica (47.567.6%), while the greatest number a-

3. reSulTS and diScuSSion

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worldwIde prevalence o anaemIa 199320058

ected are in South-East Asia where 315 million (95% CI:291340) individuals in these three population groups areaected (Table 3.3).

3.1.3 Classifcation o countries by degree o public

health signifcance o anaemia

There are almost no countries where anaemia is not at least

a mild public health problem in all three o the populationgroups or which country-level estimates were generated(Table 3.4). For pregnant women, over 80% o the coun-tries have a moderate or severe public health problem.

The level o the public health problem across countries isillustrated by maps or preschool-age children and pregnantand non-pregnant women in Figure 3.1.

3.2 Discussion

3.2.1 Population coverage

The population covered by survey data is high or the threepopulation groups considered to be the most vulnerable;preschool-age children, pregnant women, and non-pregnantwomen o childbearing age. A greater number o countrieshave undertaken surveys to assess anaemia in non-pregnant

women than in pregnant women. However, since some othe surveys conducted in pregnant women are rom coun-tries with a large population, the proportion o the globalpopulation covered by these surveys is similar between thetwo population groups.

3.2.2 Strengths o estimates

These estimates are based on a high proportion o nation-ally representative survey data. For the three most vulner-able population groups, preschool-age children, pregnantwomen, and non-pregnant women, nationally representative

data covered more than two thirds o the population in eachgroup. This eliminates the bias that comes rom local data, which may greatly over- or under-represent the nationalsituation.

Regression-based estimates were used or countries with-out data, and these estimates explained a large amount othe variation in anaemia prevalence among countries withsurvey data (3258%).

3.2.3 Limitations o estimates

There were ewer surveys that collected data in school-agechildren, men, and the elderly, and in some cases there were

no data or an entire region. Thus, country- or regional-

Table 3.3 Anaemia prevalence and number o individuals aected in preschool-age children, pregnant women,and non-pregnant women in each WHO region

WHO region Preschool-age childrena Pregnant women Non-pregnant women

Prevalence # affected Prevalence # affected Prevalence # affected(%) (millions) (%) (millions) (%) (millions)

ai 67.6 83.5 57.1 17.2 47.5 69.9

(64.371.0)b (79.487.6) (52.861.3) (15.918.5) (43.451.6) (63.975.9)

ai 29.3 23.1 24.1 3.9 17.8 39.0

(26.831.9) (21.125.1) (17.330.8) (2.85.0) (12.922.7) (28.349.7)

s-e 65.5 115.3 48.2 18.1 45.7 182.0

ai (61.070.0) (107.3123.2) (43.952.5) (16.419.7) (41.949.4) (166.9197.1)

e 21.7 11.1 25.1 2.6 19.0 40.8

(15.428.0) (7.914.4) (18.631.6) (2.03.3) (14.723.3) (31.550.1)

e 46.7 0.8 44.2 7.1 32.4 39.8

mi (42.251.2) (0.41.1) (38.250.3) (6.18.0) (29.235.6) (35.843.8)

w 23.1 27.4 30.7 7.6 21.5 97.0

pif (21.924.4) (25.928.9) (28.832.7) (7.18.1) (20.822.2) (94.0100.0)

Global 47.4 293.1 41.8 56.4 30.2 468.4

(45.749.1) (282.8303.5) (39.943.8) (53.859.1) (28.731.6) (446.2490.6)

pi bg: p-g i (0.004.99 y); pg ( g g f); n-g (15.0049.99 y).b 95% cf I.

Table 3.4 Number o countries categorized by publichealth signifcance o anaemia

Public Preschool-age Pregnant Non-pregnanthealth childrenb women womenproblema nb i nb i nb i

n 2 0 1

mi 40 33 59

m 81 91 78

s 69 68 54

t i bi b i giz :

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Figure 3.1a Anaemia as a public health problem by country: Preschool-age children

Category of public health

significance (anaemia prevalence)

Normal (40.0%)

No data

3.resultsanddIscussIon

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Figure 3.1b Anaemia as a public health problem by country: Pregnant women

Category of public health

significance (anaemia prevalence)

Normal (40.0%)

No data

worldwIdepreval

enceofanaemIa19932005

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Figure 3.1c Anaemia as a public health problem by country: Non-pregnant women o reproductive age

Category of public health

significance (anaemia prevalence)

Normal (40.0%)

No data

3.resultsanddIscussIon

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worldwIde prevalence o anaemIa 1993200512

level estimates or these population groups were not pre-sented. Even the global estimates should be interpretedwith caution since they are based primarily on regression-based estimates or these population groups.

Furthermore, the estimates generated or women (5059yrs) were not based on any data rom this population groupsince it is not routinely collected. It is why this estimate wasused or the global gure only and not as an estimate orthis group o women.

These estimates were based on a number o assumptions.All surveys were treated equally, although in act their qual-ity varied greatly. For example, some surveys used samplingproportionate to the population distribution within thecountry, while others did not, and in some national sur-veys, specic areas had to be let out due to security or ac-cessibility issues. Furthermore or some population groups(e.g., children 0.54.99 yrs), the population sampled cov-

ered only a portion o the desired age range (e.g., children11.99 yrs). For the purpose o our analysis, these surveyswere considered equal to those that covered the entire agerange. However, an estimate rom children in only the low-er or higher end o the range would signicantly impactthe prevalence estimate, since children below two years oage are much more likely to be anaemic than those abovethis age.

While there were only three countries or which sub-national data were used to generate prevalence estimates inpreschool-age children, these data may result in an over- or

under-estimation o anaemia prevalence or those coun-tries.In some cases, anaemia prevalence was calculated us-

ing Hb concentration and assuming that it was distributednormally. This may have lead to a slight over-estimationo anaemia prevalence, since Hb distributions tend to benegatively skewed in populations with a high prevalence odeciency.

The estimates or pregnant women did not account orthe trimester o pregnancy since this inormation is notroutinely reported in publications. Prevalence would beexpected to vary by trimester, and thus the estimates or

pregnant women may have been biased i there was not aneven distribution o women at various stages o pregnancy.Furthermore, we do not have prevalence gures or thethird trimester when anaemia is most likely to aect therisk o maternal mortality.

3.2.4 Proportion o population and the number o

individuals with anaemia

One in our people is aected by anaemia, and pregnantwomen and preschool-age children are at the greatest risk.The WHO regions o Arica and South-East Asia have

the highest risk, where about two thirds o preschool-agechildren and hal o all women are aected. In numbers,

the main burden is concentrated in South-East Asia, whereabout 40% o anaemic preschool-age children and non-pregnant women, and about 30% o pregnant women re-side.

3.2.5 Classifcation o countries by degree o public

health signifcance o anaemia, based on

haemoglobin concentration

Anaemia is a public health problem or pregnant womenin all o WHOs Member States. Given the consequenceso anaemia during pregnancy, this problem urgently needsto be addressed. The situation is similar in preschool-agechildren and non-pregnant women or whom only one ortwo countries do not have an anaemia public health prob-lem. For women and young children, the majority o WHOMember States (132 to 159, depending on the populationgroup) have a moderate-to-severe public health problem

with anaemia; meaning that over 20% o the populationgroup in these countries is aected. This should draw theattention o the public health authorities on the need tore-evaluate current strategies to control anaemia by mak-ing sure that the various actors contributing to anaemiahave been identied and addressed properly through an in-tegrated approach.

3.2.6 Comparison to previous estimates

It is a challenge to assess global progress in the control oanaemia, since the methodology used or these estimates

is so dierent rom those used in previous estimates. Pre-vious global estimates made by DeMaeyer in 1985 indi-cated that approximately 30% o the worlds populationwas anaemic (23). These estimates seem to be based on anextrapolation o the prevalence in preschool-age children,school-age children, women, and men. These estimates,which excluded China where 20% o the global populationresides, indicated that 43% o preschool-age children, 35%o all women, and 51% o pregnant women were anaemic.Current estimates, excluding China, are 52%, 34%, and44%, respectively. Variations in the methods employed,and a larger proportion o nationally representative data,

are more likely to account or the dierences between theseestimates than a change in anaemia prevalence.

In 1992, WHO estimates or the year 1988 indicatedthat 37%, 51%, and 35% o all women and pregnant andnon-pregnant women were anaemic (24). These estimatesincluded subnational data or China. The current estimateswhich use nationally representative data or China (31%,42%, and 30%) may or may not be lower, since the meth-odologies used are substantially dierent.

3.3 Conclusion

The data available or these estimates are the most repre-sentative data to date, and we can consider that these esti-

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133. results and dIscussIon

mates are the most accurate refection o the global anaemiaprevalence published so ar. However, countries withoutsurvey data should be encouraged to collect data, since re-gression-based estimates are good at the regional and globallevel, but may not be the most accurate refection o thesituation or an individual country.

The generation o these estimates and the maintenanceo the anaemia database provide a reliable tool to trackthe global progress towards the elimination o anaemiaand the eectiveness o the current strategies or anaemiacontrol. However, since inormation on causal actors is

not routinely collected, the database does not provide in-ormation on the ability o the strategies to address theseactors. Hopeully, these estimates will encourage countriesto plan surveys which assess the prevalence o actors thatcontribute to anaemia not only iron deciency, but alsoinectious diseases and other micronutrient deciencies.The understanding o how these actors vary by geography,level o development, and other social and economic actorswill make it easier to design interventions that are more e-ective and integrative in addressing multiple contributingactors at the same time.

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References

1. World Health Organization. The World Health Report 2002: Reducing risks, promoting healthy lie. Geneva,World Health Organization, 2002.

2. Iron deciency anaemia: assessment, prevention, and con-trol. A guide or programme managers. Geneva, WorldHealth Organization, 2001 (WHO/NHD/01.3).

3. Macgregor M. Maternal anaemia as a actor in prema-turity and perinatal mortality. Scottish Medical Journal,1963, 8:134.

4. Scholl TO, Hediger ML. Anemia and iron-deciencyanemia: compilation o data on pregnancy outcome.

American Journal o Clinical Nutrition , 1994, 59:492S500S.

5. Bothwell T, Charlton R, eds. Iron deciency in women.Washington DC, Nutrition Foundation, 1981.

6. Guidelines or the treatment o malaria. Geneva, RollBack Malaria Department, World Health Organiza-tion, 2006 (WHO/HTM/MAL/2006.1108).

7. Crompton DWT et al., eds. Controlling disease due tohelminth inections. Geneva, World Health Organiza-tion, 2003.

8. Koller O. The clinical signicance o hemodilutionduring pregnancy. Obstetrical and Gynecological Survey,1982, 37:649652.

9. Nordenberg D, Yip R, Binkin NJ. The eect o ciga-rette smoking on hemoglobin levels and anemia screen-ing.Journal o the American Medical Association, 1990,264:15561559.

10. Hurtado A., Merino C, Delgado E. Infuence o anox-emia on haematopoietic activities. Archives o Internal

Medicine, 1945, 75:284323.

11. Human Development Report 2002, Deepening democ-racy in a ragmented world. New York, United NationsDevelopment Programme, 2002.

12. Human Development Indicators. In: Cait Murphy BR-L, ed. Human Development Report 2004. New York,United Nations Development Programme, 2004: 139250.

13. World Health Organization. World Health Statistics2005. Geneva, World Health Organization, 2005.

14. Mathers CD, Loncar D. Projections o global mortalityand burden o disease rom 2002 to 2030. PLoS Medi-cine, 2006, 3:e442.

15. World Health Organization. The World Health Report2000: Health systems: improving perormance. Geneva,World Health Organization, 2000.

16. World Health Organization. The World Health Report:2004: Changing History. Geneva, World Health Or-ganization, 2004.

17. Wackerly D, Mendenhall W, Scheaer RL. Math-ematical Statistics with Applications, 6th edition. PacicGrove, CA, Duxbury Press, 2001.

18. Lohr SL. Sampling: Design and Analysis, 1st edition.Pacic Grove, CA, Duxbury Press, 1998.

19. Neter J et al.Applied Linear Statistical Models, 4th edi-tion. New York, McGraw-Hill/Irwin, 1996.

20. Allison PD. Logistic Regression using the SAS System. In-dianapolis, IN, WA (Wiley-SAS), 2001.

21. Whelan EA et al. Menstrual and reproductive charac-teristics and age at natural menopause.American Jour-nal o Epidemiology, 1990, 131:625632.

22. United Nations PD. World Population Prospects the2004 revision . New York, 2005.

23. DeMaeyer E, Adiels-Tegman M. The prevalence oanaemia in the world. World Health Statistics Quarterly,

1985, 38:302316.24. World Health Organization. The Prevalence o Anae-mia in Women: A Tabulation o Available Inormation.1992 (WHO/MCH/MSM/92.2).

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Annex 1

WHO Member States groupedby WHO region as of 2005

Table A1.1 WHO Member States grouped by WHO region

AfricaAlgeria

Angola

BeninBotswana

Burkina Faso

Burundi

Cameroon

Cape Verde

Central African Republic

Chad

Comoros

Congo

Cte dIvoire

Democratic Republic of

the CongoEquatorial Guinea

Eritrea

Ethiopia

Gabon

Gambia

Ghana

Guinea

Guinea-Bissau

Kenya

Lesotho

LiberiaMadagascar

Malawi

Mali

Mauritania

Mauritius

Mozambique

Namibia

Niger

Nigeria

Rwanda

Sao Tome and Principe

Senegal

Seychelles

Sierra Leone

South Africa

Swaziland

Togo

Uganda

United Republic of

Tanzania

Zambia

Zimbabwe

AmericasAntigua and Barbuda

Argentina

Bahamas

Barbados

BelizeBolivia

Brazil

Canada

Chile

Colombia

Costa Rica

Cuba

Dominica

Dominican Republic

Ecuador

El SalvadorGrenada

Guatemala

Guyana

Haiti

Honduras

Jamaica

Mexico

Nicaragua

Panama

Paraguay

Peru

Saint Kitts and NevisSaint Lucia

Saint Vincent and the

Grenadines

Suriname

Trinidad and Tobago

United States of America

Uruguay

Venezuela (Bolivarian

Republic of )

South-East AsiaBangladesh

Bhutan

Democratic Peoples

Republic of Korea

India

IndonesiaMaldives

Myanmar

Nepal

Sri Lanka

Thailand

Timor-Leste

Europe

Albania

Andorra

ArmeniaAustria

Azerbaijan

Belarus

Belgium

Bosnia and Herzegovina

Bulgaria

Croatia

Cyprus

Czech Republic

Denmark

Estonia

Finland

France

Georgia

Germany

Greece

Hungary

Iceland

Ireland

Israel

ItalyKazakhstan

Kyrgyzstan

Latvia

Lithuania

Luxembourg

Malta

Monaco

Netherlands

Norway

Poland

PortugalRepublic of Moldova

Romania

Russian Federation

San Marino

Serbia and Montenegro1

1 On 3 June 2006, the Permanent Representative of the Republic of Serbiato the United Nations and other International Organizations in Genevainformed the Acting Director-General of the WHO that the mem-bership of the state union Serbia and Montenegro in the United Na-tions, including all organs and the organizations of the United Nationssystem, is continued by the Republic of Serbia on the basis of Article60 of the Constitutional Charter of Serbia and Montenegro, activated

by the Declaration of Independence adopted by the National Assemblyof Montenegro on 3 June 2006. Estimates used or referred to in thisdocument cover a period of time preceding that communication.

Annex 1 15

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Slovakia

Slovenia

Spain

Sweden

Switzerland

Tajikistan

The former Yugoslav

Republic of Macedonia

Turkey

Turkmenistan

Ukraine

United Kingdom of Great

Britain and Northern

Ireland

Uzbekistan

Eastern Mediterranean

Afghanistan

Bahrain

Djibouti

Egypt

Iran (Islamic Republic of )

Iraq

Jordan

Kuwait

Lebanon

Libyan Arab Jamahiriya

Morocco

Oman

Pakistan

Qatar

Saudi Arabia

Somalia

Sudan

Syrian Arab Republic

Tunisia

United Arab Emirates

Yemen

Western Pacifc

Australia

Brunei Darussalam

Cambodia

China

Cook Islands

Fiji

Japan

Kiribati

Lao Peoples Democratic

Republic

Malaysia

Marshall Islands

Micronesia (Federated

States of)

Mongolia

Nauru

New Zealand

Niue

Palau

Papua New Guinea

Philippines

Republic of Korea

Samoa

Singapore

Solomon Islands

Tonga

Tuvalu

Vanuatu

Viet Nam

Table A1.2 WHO Member States grouped by UN region and subregion1

Gabon

Sao Tome and Principe

Northern Africa

Algeria

Egypt

Libyan Arab Jamahiriya

MoroccoSudan

Tunisia

Southern Africa

Botswana

Lesotho

Namibia

South Africa

Swaziland

Western Africa

Benin

Burkina Faso

Cape Verde

Cte dIvoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Mauritania

Niger

Nigeria

Senegal

Sierra Leone

Togo

Asia

Central AsiaKazakstan

Kyrgyzstan

Tajikistan

Turkmenistan

Uzbekistan

Eastern Asia

China

Democratic Peoples

Republic of Korea

JapanMongolia

Republic of Korea

Southern Asia

Afghanistan

Bangladesh

Bhutan

India

Iran (Islamic Republic of )

Maldives

Nepal

Pakistan

Sri Lanka

South-eastern Asia

Brunei Darussalam

Lao Peoples Democratic

Republic

MalaysiaMyanmar

Philippines

Singapore

Thailand

Timor-Leste

Viet Nam

Western Asia

Armenia

Azerbaijan

BahrainCyprus

Georgia

Iraq

Israel

Jordan

Kuwait

Lebanon

Oman

Arica

Eastern Africa

Burundi

Comoros

Djibouti

Eritrea

Ethiopia

KenyaMadagascar

Malawi

Mauritius

Mozambique

Rwanda

Seychelles

Somalia

Uganda

United Republic of

Tanzania

ZambiaZimbabwe

Middle Africa

Angola

Cameroon

Central African Republic

Chad

Congo

Democratic Republic of

The Congo

Equatorial Guinea

1 http://unstats.un.org/unsd/methods/m49/m49regin.htm

worldwide prevAlence of AnAemiA 1993200516

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Annex 1

Qatar

Saudi Arabia

Syrian Arab Republic

Turkey

United Arab Emirates

Yemen

Europe

Eastern Europe

Belarus

Bulgaria

Czech Republic

Hungary

Poland

Republic of Moldova

Romania

Russian Federation

SlovakiaUkraine

Northern Europe

Denmark

Estonia

Finland

Iceland

Ireland

Latvia

Lithuania

NorwaySweden

United Kingdom of Great

Britain and Northern

Ireland

Southern Europe

Albania

Andorra

Bosnia and Herzegovina

Croatia

Greece

Italy

Malta

Portugal

San Marino

Serbia and Montenegro

Slovenia

Spain

The former Yugoslav

Republic of Macedonia

Western Europe

AustriaBelgium

France

Germany

Luxembourg

Monaco

Netherlands

Switzerland

Americas

Latin America and

the Caribbean

Caribbean

Antigua and Barbuda

Bahamas

Barbados

Cuba

Dominica

Dominican Republic

Grenada

Haiti

Jamaica

Saint Kitts and Nevis

Saint Lucia

Saint Vincent and the

Grenadines

Trinidad and Tobago

Central America

Belize

Costa Rica

El Salvador

Guatemala

HondurasMexico

Nicaragua

Panama

South America

Argentina

Bolivia

Brazil

Chile

Colombia

EcuadorGuyana

Paraguay

Peru

Suriname

Uruguay

Venezuela (Bolivarian

Republic of )

Northern America

Canada

United States of America

Oceania

Australia-New Zealand

Australia

New Zealand

Melanesia

Fiji

Papua New Guinea

Solomon Islands

Vanuatu

Micronesia

Kiribati

Marshall Islands

Micronesia (Federated

States of)

Nauru

Palau

Polynesia

Cook IslandsNiue

Samoa

Tonga

Tuvalu

17

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annex 2

Results by UN region

Table A2.1 Population coverage (%) by anaemia prevalence surveys (national or subnational) conducted between

1993 and 2005, by UN region

UN region PreSACa PW NPW SAC Men Elderly All

ai (53)b 76.7 (30) 65.3 (25) 63.6 (26) 18.6 (10) 32.0 (14) 1.8 (1) 40.7

ai (47) 82.1 (30) 80.9 (21) 88.8 (34) 37.0 (11) 47.6 (13) 54.1 (7) 58.0

e (41) 19.2 (5) 0.9 (1) 23.9 (5) 12.9 (3) 15.9 (2) 8.7 (2) 14.9l a cibb (33) 70.5 (15) 38.4 (14) 37.5 (12) 28.9 (8) 0.1 (1) 0.0 (0) 22.9

n ai (2) 92.4 (1) 92.8 (1) 89.9 (1) 91.3 (1) 89.9 (1) 89.6 (1) 84.3

oi (16) 5.1 (3) 4.7 (2) 16.5 (4) 15.1 (3) 15.6 (3) 15.1 (2) 13.8

Global (192) 76.1 (84) 69.0 (64) 73.5 (82) 33.0 (36) 40.2 (34) 39.1 (13) 48.8

pi g: psac, -g i (0.004.99 y); pw, g ( g g f); npw, -g (15.0049.99 y), sac, -g

i (5.0014.99 y), m (15.0059.99 y), ey (60.00 y).b nb i i gig. t b i i . n fg i i a i y y b i y by i g, b i

6 i g i 5059 y g.

Table A2.2 Anaemia prevalence and number o individuals aected in preschool-age children, pregnant women,

and non-pregnant women in each UN region

UN regiona Preschool-age childrenb Pregnant women Non-pregnant women

Prevalence # affected Prevalence # affected Prevalence # affected(%) (millions) (%) (millions) (%) (millions)

ai 64.6 93.2 55.8 19.3 44.4 82.9

(61.767.5) (89.197.4) (51.959.6) (18.020.7) (40.947.8) (76.589.4)

ai 47.7 170.0 41.6 31.7 33.0 318.3

(45.250.3) (161.0178.9) (39.044.2) (29.733.6) (31.334.7) (302.0334.6)

e 16.7 6.1 18.7 1.4 15.2 26.6

(10.523.0) (3.88.4) (12.325.1) (0.91.8) (10.519.9) (18.434.9)

lac 39.5 22.3 31.1 3.6 23.5 33.0

(36.043.0) (20.324.3) (21.840.4) (2.54.7) (15.931.0) (22.443.6)

na 3.4 0.8 6.1 0.3 7.6 6.0

(2.04.9) (0.41.1) (3.48.8) (0.20.4) (5.99.4) (4.67.3)

oi 28.0 0.7 30.4 0.2 20.2 1.5

(15.840.2) (0.41.0) (17.043.9) (0.10.2) (9.530.9) (0.72.4)

Global 47.4 293.1 41.8 56.4 30.2 468.4

(45.749.1) (282.8303.5) (39.943.8) (53.859.1) (28.731.6) (446.2490.6)

un gi: ai, ai, e, li ai cibb (lac), n ai (na), oi.b pi g: psac, -g i (0.004.99 y); pw, g ( g g f); npw, -g (15.0049.99 y). 95% cf I.

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35annex 3

A3.4 Country references

Aghanistan

Ministry o Public Health o the Islamic Republic o Agha-nistan et al. Summary Report o the National Nutrition Sur-vey, Aghanistan, 2004. Ministry o Public Health o theIslamic Republic o Aghanistan, 2005. Re 5173.

Angola

Ministry o Health et al. Assessing vitamin A and iron de- ciency anaemia, nutritional anaemia among children aged060 months in the Republic o Angola [technical report].Ministry o Health, 2000. Re 2839.

Antigua and Barbuda

Micronutrient Working Group. Iron and vitamin A statusin ve Caribbean countries. Cajanus, 2002, 35 (1): 434.Re 3758.

Armenia

National Statistical Service et al.Armenia Demographic andHealth Survey 2000. Calverton, MD, National StatisticalService, 2001. Re 3208.

Azerbaijan

Serbanescu F et al., eds. Reproductive health survey Azerbai- jan, 2001. Atlanta, Centers or Disease Control and Pre-vention, 2003. Re 4682.

Bahrain

Al-Dallal ZS et al. Impact o the national four ortication program on the prevalence o iron deciency and anemiaamong women at reproductive age in the Kingdom o Bahrain.Kingdom o Bahrain, Ministry o Health, Public HealthDirectorate, Nutrition Section, 2003. Re 5391.

Bangladesh

Helen Keller International et al. Anemia: a severe publichealth problem in pre-school children and pregnant womenin rural Bangladesh. HKI-Nutrition Surveillance ProjectBulletin, 2002. Re 3256.

Belize

Ministry o Health et al. Study o iron deciency anaemiaamong pregnant women in Belize. Belmopan, Ministry oHealth, 1996. (BZ-NUT/F/003). Re 1062.

Benin

Institut National de la Statistique et de lAnalyse cono-mique et al. Enqute Dmographique et de Sant au Bnin,2001. Calverton, MD, Institut National de la Statistique etde lAnalyse conomique et ORC Macro, 2002. Re 3461.

Bhutan

Royal Government o Bhutan Ministry o Health andEducation.Anemia among men, women and children in Bhu-tan: How big is the problem? Bhutan, Ministry o Healthand Education, 2003. Re 5150.

Bolivia

Gutirrez Sardn M et al. Bolivia Encuesta Nacional de De-mograa y Salud 2003 [Bolivia National Demographic andHealth Survey 2003]. La Paz, Ministerio de Salud y Depor-tes, Instituto Nacional de Estadstica, 2004. Re 5095.

Botswana

Ministry o Health Botswana et al. Micronutrient malnu-trition in Botswana. A national survey to assess the status o iodine, iron, and vitamin A. Gaborone, Ministry o Health,1996. Re 2805.

Brazil

Governo de Sergipe et al. III Pesquisa de sade materno-in- antil e nutrio do estado de Sergipe. Pesmise 98. Brasilia,Governo de Sergipe, Secretaria de Estado da Sade, 2001.Re 614.

Torres MAA et al. Anemia em crianas menores de doisanos atendidas nas unidades bsicas de sade no Estado deSo Paulo, Brasil [Anemia in children under 2 years in basichealth care units in the State o So Paulo, Brazil]. Revistade Sade Pblica, 1994, 28 (4): 290294. Re 2375.

Osrio MM et al. Prevalence o anemia in children 659months old in the state o Pernambuco, Brazil. Revista Pa-namericana de Salud Pblica, 2001, 10 (21): 101107. Re

2843.

Brunei Darussalam

Ministry o Health. National Nutritional Status Survey,1997. Negara, Ministry o Health, 1997. Re 3334.

Nutritional status o children under ve years old and pre- gnant women in Brunei Darussalam. A collaborative studybetween Institute o Medical Research, Ministry o Health,

Malaysia, Ministry o Health, Brunei Darussalam, Ministryo Health, Lao PDR,19951996. Negara, Brunei Darussa-lam, 1996. Re 3328.

Burkina Faso

Institut National de la Statistique et de la Dmographie[Burkina Faso] et al. Burkina Faso Enqute Dmographiqueet de Sant 2003 [Burkina Faso Demographic and HealthSurvey 2003]. Calverton, MD, ORC Macro, 2004. Re4948.

Burundi

Kimboka S. Burundi National Anaemia Survey. Bujumbura,Burundi, Ministere de la Sante Publique, 2004. Re5782.

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Cambodia

Ministry o Health et al. Cambodia Demographic and HealthSurvey 2000. Phnom Penh, Ministry o Health, 2001. Re

3206.

Cameroon

Institut National de la Statistique et al. Enqute Dmogra-phique et de Sant: Cameroon 2004. [Demographic HealthSurvey: Cameroon 2004]. Calverton, MD, ORC Macro,2005. Re 5214.

Central Arican Republic

Ministere Delegue a lEconomie au Plan et a la Coopera-tion Internationale et al. Enqute nationale sur lavitaminose

A, la carence en er et la consommation du sel iode. Republi-que Centraricaine, 2000. Re 1722.

ChileMinisterio de Salud. Resultados 1: Encuesta de Salud, Chile2003. Santiago, Departmento de Epidemiologa, Ministe-rio de Salud, 2003. Re 5783.

China

Chinese Center or Disease Control and Prevention. Theprevalence o anemia in China, 2002, by age and gender. Bei- jing, Chinese Center or Disease Control and Prevention,2005. Re 5287.

Costa Rica

Ministerio de Salud. Encuesta Nacional de Nutricin: 2 Fasc-culo Micronutrientes [National nutrition survey: Part 2 micro-nutrients]. San Jos, Ministerio de Salud, 1996. Re 1634.

Cunningham L et al. Prevalencia de anemia, deciencia dehierro y olatos en nios menores de siete aos: Costa Rica,1996 [Prevalence o anemia, iron and olate deciency inchildren smaller than seven years: Costa Rica, 1996]. Ar-chivos Latinoamericanos de Nutricin, 2001, 51 (1): 3743.Re 3555.

Rodriguez S et al. Prevalencia de las anemias nutricionalesde mujeres en edad rtil, Costa Rica: encuesta nacional denutricin, 1996 [Prevalence o nutritional anemia in womeno reproductive age, Costa Rica: national nutrition survey,1996]. Archivos Latinoamericanos de Nutricin, 2001, 51(1): 1924. Re 3556.

Blanco A et al. Anemias nutricionales en mujeres lactantesde Costa Rica [Nutritional anemia in nursing women inCosta Rica].Archivos Latinoamericanos de Nutricin, 2003,53 (1): 2834. Re 4524.

Democratic Peoples Republic o Korea

UNICEF et al. The Multiple Indicator Cluster Survey in theDemocratic Peoples Republic o Korea, 1998. Pyongyang,United Nations Childrens Fund, 1998. Re 3090.

Central Bureau o Statistics et al. DPRK 2004 Nutrition

assessment report o survey results. The Democratic PeoplesRepublic o Korea, Central Bureau o Statistics, Institute oChild Nutrition, 2005. Re 5068.

Democratic Republic o Congo

Ministre du Sant, Programme National de NutritionPRONANUT. Enquete sur la prevalence de lanemie enRpublique Dmographique du Congo. Rpublique D-mocratique du Congo, Programme National de NutritionPRONANUT, 2005. Re 5764.

Dominica

Micronutrient Working Group. Iron and vitamin A statusin ve Caribbean countries. Cajanus, 2002, 35 (1):434. Re

3758.

Egypt

El-Zanaty F et al. Egypt Demographic and Health Survey.Calverton, MD, Ministry o Health and Population, Egypt,National Population Council and ORC Macro, 2001. Re1940.

El Salvador

Salvadoran Demographic Association (ADS) et al. EncuestaNacional de Salud Familiar FESAL-98. [National FamilyHealth Survey FESAL-98]. San Salvador, Salvadoran De-mographic Association, 2000. Re 3107.

Salvadoran Demographic Association (ADS) et al. EncuestaNacional de Salud Familiar FESAL 20022003: Inorme -nal. San Salvador, 2004. Re 5171.

Fiji

Saito S. 1993 national nutrition survey. Suva, National Foodand Nutrition Committee, 1995. Re 2699.

France

Galn P et al. Determining actors in the iron status oadult women in the SU.VI.MAX study. European Journal oClinical Nutrition, 1998, 52 (6): 383388. Re 2392.

Gambia

Bah A et al. Nationwide survey on the prevalence o vitaminA and iron deciency in women and children in the Gambia.Banjul, National Nutrition Agency, 2001. Re 2806.

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37annex 3

Ghana

Ghana Statistical Service (GSS) et al. Ghana Demographicand Health Survey 2003. Calverton, MD, ORC Macro,2004. Re 4943.

Guatemala

Ministerio de Salud Publica y Asistencia Social et al. Gua-temala, Encuesta Nacional de Salud Materno Inantil 2002.Guatemala, Ministerio de Salud Publica y Asistencia So-cial, 2003. Re 4586.

Guinea

Ministre de la Sant Publique. Enqute nationale sur lan-mie erriprive en Guine. Rapport Final: rsum. Guinee,2001. Re 2780.

Guyana

Ministry o Health [Guyana] et al. Executive summary micro-nutrient study report Guyana. An assessment o the vitaminA, E, beta-carotene, iron and iodine status in the population.Georgetown, Ministry o Health, 1997. Re 3094.

Haiti

Republique dHaiti et al. Enqute Mortalit, Morbidit etUtilisation des Services EMMUS-III Hati 2000. Republi-que dHaiti, 2001. Re 3264.

Honduras

Ministerio de Salud Pblica et al. Encuesta Nacional de Mi-

cronutrientes Honduras, 1996. Tegucigalpa, Secretaria deSalud, Ministerio de Salud Pblica, 1997. Re 3095.

Secretara de Salud et al. Encuesta Nacional de Salud Mascu-lina ENSM-2001. Tegucigalpa, Secretara de Salud, 2002.Re 3096.

India

International Institute or Population Sciences et al. Na-tional Family Health Survey (NFHS-2), 19981999: India.Mumbai, International Institute or Population Sciences,2000. Re 2972.

International Institute or Population Sciences et al. Na-tional Family Health Survey (NFHS-2), India, 19981999,Northeastern States: Arunachal Pradesh, Manipur, Megha-laya, Mizoram, Nagaland and Tripura. Mumbai, Interna-tional Institute or Population Sciences, 2002. Re 3780.

Iran (Islamic Republic o)

Ministry o Health and Medical Education et al. Multi-centre study on iron deciency anemia among 15 to 49 year oldwomen in the Islamic Republic o Iran . Islamic Republic oIran, Nutrition Department, Ministry o Health and Me-

dical Education, 1995. Re 3015.

Jamaica

WHO Pan American Health Organization et al.Micronu-trient study report: an assessment o the vitamin A, E, beta-carotene, and iron status in Jamaica. Kingston, WHO, PanAmerican Health Organization, Caribbean Food and Nu-trition Institute, 1998 (PAHO/CFNI/98.J1). Re 3093.

Micronutrient Working Group. Assessment o the iron sup- plementation programme or pregnant women in Jamaica.Cajanus, 2002, 35 (1): 3549. Re 3759.

Japan

National Institute o Health and Nutrition. National Nu-trition Survey o Japan in 2001 and 2002. Japan, NationalInstitute o Health and Nutrition, 2002. Re 5177.

Jordan

Department o Statistics et al. Jordan Population and Fa-

mily Health Survey 2002. Calverton, MD, Department oStatistics Jordan, ORC Macro, 2003. Re 3389.

Ministry o Health Jordan et al. National baseline survey oniron deciency anemia and vitamin A deciency. Amman,Ministry o Health, 2002. Re 4382.

Kazakhstan

Academy o Preventive Medicine Kazakhstan et al. Ka-zakhstan Demographic and Health Survey 1999. Calverton,MD, Academy o Preventive Medicine and Macro Interna-tional Inc, 1999. Re 2675.

Kenya

Mwaniki DL et al. Anaemia and status o iron, vitamin Aand zinc in Kenya. The 1999 National Survey. Nairobi, Mi-nistry o Health, 2002. Re 3442.

Kuwait

Jackson RT et al. Gender and age dierences in anemiaprevalence during the liecycle in Kuwait. Ecology o Foodand Nutrition, 2004, 43 (12):6175. Re 4375.

Kyrgyzstan

Research Institute o Obstetrics and Pediatrics et al. KyrgyzRepublic Demographic and Health Survey, 1997. Calverton,MD, Research Institute o Obstetrics and Pediatrics, Mi-nistry o Health o the Kyrgyz Republic and Macro Inter-national Inc, 1998. Re 2295.

Lao Peoples Democratic Republic

Ministry o Health, Lao Peoples Democratic Republic. Re-port on national health survey: health status o the People o LAO PDR. Vientiane, Ministry o Health, 2001. Re 770.

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worldwIde prevalence o anaemIa 1993200538

Lebanon

Hwalla N et al. Prevalence and selected determinant o irondeciency anemia in women and under ve children in Leba-non. Beirut, 1998. Re 3221.

Lesotho

Ministry o Health and Social Welare et al. Lesotho De-mographic and Health Survey 2004. Calverton, MD, ORCMacro, 2005. Re 5356.

Liberia

Mulder-Sibanda M et al. National Micronutrient Survey. Anational prevalence study on vitamin A deciency, iron de-

ciency anemia, iodine deciency. Monrovia, Ministry oHealth and Social Welare, Family Health Division, Uni-ted Nations Childrens Fund, 1999. Re 1242.

MadagascarInstitut National de la Statistique et al. Enqute Dmogra-phique et de Sant de Madagascar 20032004. Calverton,MD, ORC Macro, 2005. Re 5190.

Malaysia

Ministry o Health Malaysia. Family Health. Sub SystemHealth Management Inormation System, 2004. Malaysia,Ministry o Health, 2005. Re 5795.

Malawi

National Statistical Oce et al. Malawi Demographic and

Health Survey 2004. Calverton, MD, ORC Macro, 2005.Re 5201.

Maldives

Ministry o Health and Welare et al. Nutritional status andchild eeding practices o Maldivian children Report o theNational Nutrition Survey. Mal, 1994. Re 831.

Minister o Health, Republic o Maldives.Multiple Indica-tor Cluster Survey (MICS 2), Maldives. Mal, Ministry oHealth, 2001. Re 2987.

MaliCellule de Planication et de Statistique du Ministre dela Sant et al. Enqute Dmographique et de Sant au Mali

2001. Calverton, MD, ORC Macro, 2002. Re 3446.

Mauritius

Ministry o Health Mauritius.A survey o nutrition in Mau-ritius and Rodrigues (1995). Port Louis, Ministry o Health,1995. Re 395.

Mexico

Instituto Nacional de Salud Publica. Encuesta Nacional de

Nutricin 1999. Mexico City, Instituto Nacional de SaludPublica, 1999. Re 2997.

Micronesia (Federated States o)

Auerbach SB.Maternal-Child Health Survey: Pohnpei, Fe-derated States o Micronesia, 1993 [summary table]. Palikir,Pohnpei, US Public Health Service/Department o HealthServices [Federated States o Micronesia], 1999. Re 4942.

Socorro P et al. Results o vitamin A, anemia and blood leadsurvey among 24 year old children and reproductive-agedwomen in Yap proper and Kosrae State, Federated States o

Micronesia. Atlanta, Centers or Disease Control and Pre-vention, 2000. Re 2548.

Mongolia

Enkhbat S. Third National Nutrition Survey 2004 [perso-nal communication]. Mongolia, Ministry o Health, 2004.Re 5247.

Morocco

Ministre de la Sant Maroc. Enqute nationale sur la ca-rence en er lutilisation du sel iod et la supplmentation parla vitamine A, 2000. Morocco, 2000. Re 3469.

Mozambique

Ministrio da Sade et al. Inqurito nacional seovre a de-cincia de vitamina A, prevalncia de anemia e malria emcrianas dos 659 meses e respectivas mes. Maputo, InstitutoNacional de Sade, 2003. Re 589.

Myanmar

National Nutrition Center et al.A study on hemoglobin statusand ood practices o Myanmar women. Myanmar, NationalNutrition Center, Department o Health, 2001. Re 5246.

Nepal

Ministry o Health Nepal et al. Nepal Micronutrient StatusSurvey 1998. Kathmandu, Ministry o Health, 1999. Re1083.

New Zealand

Russell D et al. NZ Food: NZ People: key results o the 1997National Nutrition Survey. New Zealand, Ministry o

Health, 1999. Re 3192.

Nicaragua

Ministerio de Salud. Encuesta nacional de micronutrien-tes (ENM 2000) [National survey o micronutrients (ENM

2000)]. Managua, Ministerio de Salud, 2002. Re 3109.

Ministerio de Salud. Sistema integrado de vigilancia de inter-venciones nutricionales (SIVIN): primer inorme de progreso

20022003 [Integrated system o monitoring nutrition inter-ventions (SIVIN): rst progress report 20022003]. Mana-gua, Ministerio de Salud, 2004. Re 4466.

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39annex 3

Nigeria

Federal Ministry o Health and Social Services et al. Nige-ria National Micronutrient Survey, 1993. Nigeria, FederalMinistry o Health and Social Services, 1996. Re 50.

Oman

Al-Riyami A et al. National Health Survey, 2000. Volume II Reproductive Health Study. Ministry o Health the Sulta-nate o Oman, 2000. Re 4218.

Al-Riyami A et al. Genetic Blood Disorders Survey in theSultanate o Oman. Journal o Tropical Pediatrics, 2003, 49(Suppl 1): i120. Re 5204.

Pakistan

Pakistan Institute o Development Economics et al. Natio-nal Nutrition Survey 20012002. Islamabad, Governmento Pakistan, Planning Commission, 2003. Re 4640.

Panama

Ministerio de Salud, et al. Encuesta nacional de vitamina Ay anemia por deciencia de hierro [National survey o vitaminA and iron deciency anemia]. Panama City, Ministerio deSalud, 2000. Re 3097.

Peru

Ministerio de Salud Publica et al. Monitoreo nacional deindicadores nutricionales 2004. Lima, Ministerio de SaludPublica, Instituto Nacional de Salud, 2004. Re 5359.

Philippines

Food and Nutrition Research Institute, Philippines. TheSixth National Survey 2003 [personal communication].Manila, 2003. Re 5242.

Qatar

Amine EK. Nutritional assessment in Qatar; 1995 Oct 20Nov 3 [assignment report]. Qatar, WHO Regional Oceor the Eastern Mediterranean, 1995. Re 820.

Republic o Korea

WHO Regional Oce or the Eastern Mediterranean.1995 National Nutrition Survey Report. Republic o Korea,Ministry o Health and Welare, 1997. Re 3327.

Korean Ministry o Health and Welare. National Healthand Nutrition Survey, 2001. Seoul, Korean Ministry oHealth and Welare, 2005. Re 5249.

Romania

Alred Rusescu Institute or Mother and Child Protec-tion. Nutritional status o pregnant women, children under5 years and school children aged 67 years. Alred Rusescu

Institute or Mother and Child Protection, 2005. Re 164.

Rwanda

Ministre de la Sant et al. National Nutrition Survey o Wo-men and Children in Rwanda in 1996 [nal report]. Kigali,Ministre de la Sant, 1997. Re 2558.

Samoa

Mackerras D et al. Samoa national nutritional survey 1999,part 1: anaemia survey [technical report]. Apia, Departmento Health, 2002. Re 3226.

Serbia and Montenegro1

Petrovic O et al. Multiple Indicator Cluster Survey II. Thereport or the Federal Republic o Yugoslavia. Belgrade,UNICEF, 2000. Re 2441.

Singapore

Department o Nutrition et al. National Nutrition Survey

1998. Singapore, Ministry o Health, 2001. Re 760.

South Arica

South Arican Vitamin A Consultation Group (SAVACG).Children aged 6 to 71 months in South Arica, 1994: theiranthropometric, vitamin A, iron and immunisation coveragestatus. Johannesburg, South Arican Vitamin A Consulta-tive Group, 1995. Re 48.

Sri Lanka

Piyasena C et al. Assessment o anaemia status in Sri Lanka2001 [survey report]. Colombo, Ministry o Health, Nutri-

tion and Welare, Department o Health Services, MedicalResearch Institute, 2003. Re 4972.

Sudan

Federal Ministry o Health et al. Comprehensive NutritionSurvey. Khartoum, Federal Ministry o Health, NationalNutrition Department, 1997. Re 1443.

Elnour A et al. Endemic goiter with iodine suciency: apossible role or the consumption o pearl millet in the etio-logy o endemic goiter.American Journal o Clinical Nutri-tion, 2000, 71 (1): 5966. Re 1553.

1 On 3 June 2006, the Permanent Representative o the Republic o Ser-bia to the United Nations and other International Organizations inGeneva inormed the Acting Director-General o the W HO that themembership o the state union Serbia and Montenegro in the UnitedNations, including all organs and the organizations o the United Na-tions system, is continued by the Republic o Serbia on the basis o Article 60 o the Constitutional Charter o Serbia and Montenegro,activated by the Declaration o Independence adopted by the NationalAssembly o Montenegro on 3 June 2006. Estimates used or reerred

to in this document cover a period o time preceding that communica-tion.

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worldwIde prevalence o anaemIa 1993200540

Switzerland

Hess SY et al. A national survey o iron and olate status inpregnant women in Switzerland. International Journal orVitamin and Nutrition Research, 2001, 71 (5): 268273. Re

3402.

Tajikistan

Branca F et al. Micro-nutrient status survey in Tajikistan.Rome, National Institute or Research on Food and Nutri-tion, Kazakh Academy o Nutrition, 2004. Re 4182.

Thailand

Ministry o Public Health et al. The Fourth National Nutri-tion Survey o Thailand 1995. Bangkok, Ministry o PublicHealth, Department o Health, 1998. Re 3961.

The ormer Yugoslav Republic o Macedonia

Branca F et al. Multiple indicator cluster survey in FYRMacedonia with micronutrient component. Rome, NationalInstitute o Nutrition, 2000. Re 1609.

Timor-Leste

Ministry o Health Timor-Leste et al. Timor Leste 2003Demographic and Health Survey. Newcastle, Australia, Mi-nistry o Health/University o Newcastle, 2003. Re 5050.

Tunisia

Ministre de la Sant Publique et al. Rapport national:valuation de l tat nutritionnel de la population tunisienne

[National report: evaluation o the nutritional status o theTunisian population]. Tunis, Ministre de la Sant Publi-que, 1996. Re 2485.

Turkmenistan

Gurbansoltan Eje Clinical Research Center or Maternaland Child Health et al. Turkmenistan Demographic andHealth Survey 2000. Calverton, MD, ORC Macro, 2001.Re 3209.

Uganda

Uganda Bureau o Statistics (UBOS) et al. Uganda Demo- graphic and Health Survey 20002001. Calverton, MD,ORC Macro, 2001. Re 3207.

Ukraine

Academy o Medical Science o Ukraine et al. Report o theNational Micronutrient Survey Ukraine. Ukraine, Academyo Medical Science o Ukraine, 2004. Re 5172.

United Kingdom o Great Britain and Northern Ireland

Gregory JR et al. National Diet and Nutrition Survey: chil-dren aged 1 to 4 years. Volume 1: report o the diet and

nutrition survey. London, Her Majestys Stationery Oce,1995. Re 3279.

Ruston D et al. The National Diet & Nutrition Survey:adults aged 19 to 64 years. Volume 4: nutritional status (an-thropometry and blood analytes), blood pressure and physicalactivity. London, Her Majestys Stationery Oce, 2004.Re 4154.

United Republic o Tanzania

National Bureau o Statistics (NBS) Tanzania et al. Tan-zania Demographic and Health Survey 200405. Dar esSalaam, National Bureau o Statistics, ORC Macro. 2005.Re 5221.

United States o America

Centers or Disease Control and Prevention. NationalHealth and Nutrition Examination Survey 19992000,

20012002[personal communication], 2002. Re 4738.

Uzbekistan

Institute o Obstetrics and Gynecology et al. UzbekistanDemographic and Health Survey, 1996. Calverton, MD,Institute o Obstetrics and Gynecology, Macro Internatio-nal Inc, 1997. Re 2293.

Analytical and Inormation Center et al. Uzbekistan HealthExamination Survey 2002. Calverton, MD, Analytical andInormation Center, State Department o Statistics, ORCMacro, 2004. Re 4950.

Vanuatu

Harvey P et al. Report o the second national nutrition survey1996. Port Vila, Department o Health, 1998. Re 3196.

Viet Nam

Khoi HH et al. Report on Vietnam National anemia Sur-vey, 2000. Hanoi, National Institute o Nutrition, 2001.Re 3408.

Zambia

Luo C et al. National baseline survey on prevalence and aetio-logy o anaemia in Zambia: a random cluster community sur-vey involving children, women and men. Lusaka, National

Food and Nutrition Commission, 1999. Re 2477.Micronutrient Operational Strategies and Technologies(MOST) et al. Report o the national survey to evaluatethe impact o vitamin A interventions in Zambia, July andNovember 2003. Zambia, Micronutrient Operational Stra-tegies and Technologies, United States Agency or Inter-national Development (USAID) Micronutrient Program,2003. Re 5098.

Zimbabwe

Ministry o Health and Child Welare, Nutrition Unit.

Zimbabwe National Micronutrient Survey: 1999. Harare,Ministry o Health and Child Welare, 2001. Re 2641.

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