Prevalence of Anemia Among Children Under 5 Years of Age – Uganda, 2009

Abstract 4262

Anemia in children under 5 years of age, defined by the World Health Organization as a hemoglobin (hb) level < 11g/L, is a global public health problem, affecting a significant percentage of the world's children. In addition to its contribution to childhood mortality, the role of anemia in cognitive impairment and educational attainment is also well recognized. According to the 2000-01 Demographic Health Survey (DHS), the prevalence of anemia in Uganda was 64% among children <5, similar to other countries in the region. A subsequent 2006 DHS noted that the prevalence of anemia had increased to 72% in Uganda. Although it is estimated that nearly half of all cases of anemia are due to iron deficiency, the causes of anemia, which disproportionately affect children and pregnant woman, are multifactorial and include nutritional deficiencies and parasitic infections. In endemic regions, the causative role of malaria is particularly important.

The 2009 Uganda Malaria Indicator Survey (UMIS) is a nationally representative household survey which collects demographic data and measurements of hemoglobin and testing for malaria in addition to coverage estimates of malaria prevention and control activities. Hemoglobin measurements were collected via the HemoCue®, a point of use test. Malaria was detected both by peripheral blood smear and via the rapid diagnostic test, Paracheck-Pf^®, which detects the presence of histidine rich protein 2 (HRP2). For this analysis, we utilized the results of the rapid diagnostic test, which is characterized by high sensitivity but lower specificity as the tests detect HRP2 which persists in the bloodstream after clearance of the parasite.

The UMIS collected data on household assets. Using principal component analysis, a wealth index was created and households were stratified into wealth quintiles. We analyzed data on hemoglobin levels (adjusted for altitude) among children under 5 years. We assessed various risk factors and performed both univariate and bivariate analyses. Those variable which were significantly associated with anemia (p <0.05) were included in the multivariate analysis.

The UMIS utilized a two-stage sample design; 4,421 households were randomly selected (response rate 97.5%) from 170 clusters. Half (51%) of the sampled children were female and over 80% were between 12 and 59 months. Of the 4,065 children under 5 in the sample, hemoglobin measurements were obtained on 3,878 children (95%). Of these, 61% of children <5 had a hb level less than 11 g/L; nearly 10% were severely anemic with a hb less than 8 g/L. On bivariate analysis, anemia was more common in children between 12–59 months (p =.001), living in rural areas (p=.001), in households in the poorest wealth quintiles (p<.001), in those households having problems in satisfying their food needs (p<.001) and among those with concomitant malaria infection (p <.001). The prevalence of anemia among children who tested negative for malaria was 45% (versus 77% among those who tested positive). Maternal education was inversely associated with anemia (p=.009). Neither household size nor distance to the nearest health facility were associated with anemia. The sex of the child was also not associated with anemia. Using a logistic regression model, only simultaneous malaria infection (p <.001) and living in poorer households (p <.001) were associated with anemia.

While the prevalence of anemia has decreased in Uganda since the most recent national household survey in 2006, the burden of anemia remains unacceptably high. In this analysis, the detection of malaria via Paracheck-Pf^® was significantly associated with anemia. Clearly, malaria prevention and effective treatment measures have expanded and as such have reduced the prevalence of malaria during this interim. While these control efforts are likely responsible for the observed downward trend in anemia prevalence, such public health endeavors are unlikely to be sufficient to reduce the burden of anemia. Although the UMIS did not collect data on nutritional deficiencies, previous studies have documented the high percentage of anemia attributed to iron deficiency globally. Therefore, prevention of anemia via iron supplementation and antihelmintics, in conjunction with malaria prevention and treatment strategies, will likely be necessary to halt the global toll of anemia.