The recently released NFHS-5 findings reveal that the prevalence of anaemia has increased among children, women of all age groups including pregnant women, and men. This increase in prevalence was observed in almost all the states barring a few exceptions. However, there are questions over the cutoffs and how these might be resulting in over-diagnosis.
Haemoglobin in the blood is necessary to carry oxygen to the tissues in the body. Anaemia is the condition in which the number of red blood cells or the concentration of haemoglobin within the blood cells is less than normal, which causes a decreased capacity of blood to carry oxygen in the body. As a result, the person experiences symptoms such as weakness, dizziness, fatigue, shortness of breath, etc. The required optimal concentration of haemoglobin in the blood varies with age, sex, altitude, pregnancy, and smoking behaviour. The common causes of the condition are nutritional deficiency such as deficiency of iron, vitamin B12, vitamin A, & folates, infectious diseases including malaria, tuberculosis & HIV, acquired disorders, and parasitic infections.
Anaemia is a serious global public health problem
Globally, anaemia is considered a serious global public health problem that particularly affects young children and pregnant women. According to the World Health Organization (WHO), the prevalence of anaemia among women of reproductive age (aged 15−49 years) is calculated as the percentage of women in the said age group with a haemoglobin concentration less than 120 grams per Litre (g/L) or 12 grams per decilitre (g/dL) for non-pregnant and lactating women, and less than 110 g/L or 11 g/dL for pregnant women, adjusted for altitude and smoking. Similarly, the prevalence among children (aged 6 – 59 months) is calculated as percentage of children in the said age group with a haemoglobin concentration less than 110 g/L or 11 g/dL, adjusted for altitude. Prevalence of 40% and above is considered severe.
WHO estimated that the prevalence of anaemia worldwide in 2019 was 39.8% among children aged 6 to 59 months and 36.5% among pregnant women. 29.9% of the women of reproductive age were anaemic in 2019. According to WHO’s dashboard, it is seen that the prevalence of anaemia in women of reproductive age in India was 53% in 2019, the fifth-highest globally, after Yemen, Mali, Benin, and Nigeria. In the case of children (6 to 59 months), the prevalence in India was 53.4%.
NFHS Survey records prevalence of anaemia
The Union Health Ministry recently released the key findings of both the phases of the National Family Health Survey that was conducted between 2019 & 2021. This is the fifth edition of the NFHS covering 6.1 Lakh sample households across the country. The sample size for the survey varies from state to state because of the differences in population & age composition. The representative survey also records the prevalence of anaemia among men, women, and children by collecting blood samples of all men (15 to 54 years of age) and women (15 to 49 years of age) who voluntarily give consent to the testing. For children (6 to 59 months), parents or their guardians will have to give consent.
The NFHS’s classification of anaemia is as follows:
Those who are diagnosed with severe anaemia during testing are referred to local health facilities for assessment and treatment.
The prevalence of anaemia among women and children has increased in the last five years
At the national level, the findings of the NFHS-5 reveal that there has been an increase in the prevalence of anaemia among women and children compared to the previous NFHS-4 survey that was conducted in 2015-16, about 4 years ago. The increase in anaemia among pregnant women is by 1.8 percentage points, among all women in the reproductive age is 3.9 percentage points, and among adolescent women by 5 percentage points. Among children, the increase is the highest of 8.5 percentage points and is now closer to the levels recorded in NFHS-3 from 2005-06 when the prevalence was 70%.
8 out of 10 children in Gujarat are anaemic
Among children aged 6 to 59 months, anaemia is the most prevalent in Gujarat among the larger states with nearly 80% of the children in the age group diagnosed with anaemia. The prevalence in Gujarat increased by 17.1 percentage points compared to 62.6% recorded in NFHS-4.
Madhya Pradesh, Rajasthan, Punjab, Haryana, and Telangana are the major large states with a prevalence of more than 70% among children. Kerala is the only state to have recorded a prevalence of less than 40% (39.4%), though it has registered an increase of 3.7 percentage points compared to NFHS-4. The prevalence in four south Indian states except for Telangana and 6 north-eastern states except Assam is below the national average as per NFHS-5.
The increase in the prevalence of anaemia is the greatest for Assam where the prevalence has gone up from 35.7% in NFHS-4 to 68.4% in NFHS-5, an increase of 32.7 percentage points. Mizoram and Chhattisgarh both have also recorded an increase of more than 25 percentage points each.
Only 4 states recorded a reduction in prevalence, though small in magnitude. These are Uttarakhand (by 1 percentage point), Haryana (1.3), Jharkhand (2.4), and Meghalaya (2.9).
West Bengal and Gujarat had the highest prevalence of anaemia among adolescent girls
Almost 97% of the adolescent women in Ladakh in the 15 to 19 age group were found to be anaemic, an increase from 81.6% during NFHS-4. Among large states, the prevalence was the highest in West Bengal with 70.8%, up from 62.2% during NFHS-4, followed by Gujarat with 69%.
Mizoram (34.9%), Nagaland (33.9%), Kerala (32.5%), and Manipur (27.9%) recorded a prevalence of less than 40%.
Assam with a prevalence of 67% saw an increase of 24.3 percentage points from 42.7% recorded during NFHS-4 while the states of Haryana, UP, Andhra Pradesh, Tamil Nadu, Sikkim, Delhi, Kerala, and Uttarakhand saw a decline in prevalence.
More than 60% of pregnant women were anaemic in Bihar, Gujarat, West Bengal, Odisha, and Tripura
The prevalence of anaemia among pregnant women was the highest in Bihar among large states with 63.1%, followed by Gujarat and West Bengal with more than 62% each. Odisha and Tripura too recorded a prevalence of more than 60%.
On the other side, Mizoram (34%), Manipur (32.4%), Kerala (31.4%), Arunachal Pradesh (27.9%), and Nagaland (22.2%) recorded less than 40% prevalence.
Uttarakhand, Rajasthan, MP, Delhi, Maharashtra, UP, Jharkhand, Himachal Pradesh, Meghalaya, Arunachal Pradesh, and Nagaland have recorded a drop in prevalence as per NFHS-5 compared to NFHS-4 while Sikkim, Odisha, and Gujarat have recorded an increase in prevalence by more than 10 percentage points each.
AP, Telangana, TN, UP, and Delhi have witnessed reduction in prevalence among all women
The prevalence of anaemia among all women in the reproductive age (15 to 49 years) reveals that West Bengal had the highest prevalence of 71.4%. Assam, Jharkhand, and Gujarat have a prevalence of 65% and above. Meanwhile, just like in the case of adolescent women, Kerala (36.3%) and the north-eastern states of Mizoram (34.8%), Manipur (29.4%), and Nagaland (28.9%) had a prevalence of less than 40%.
In terms of change in prevalence compared to NFHS-4, Assam witnessed an increase by 19.9 percentage points while Himachal Pradesh, Andhra Pradesh, Tamil Nadu, UP, Haryana, Meghalaya, Uttarakhand, Meghalaya, and Delhi have recorded a drop in prevalence.
Anaemia Mukt Bharat was launched by GoI in 2018
On the whole, findings of NFHS-5 reveal that the states of Gujarat, Assam, and West Bengal witnessed a significant increase in prevalence in anaemia among children and women respectively, compared to NFHS-4. Though Kerala and some north-eastern states have recorded a low prevalence across categories, these states have also witnessed an increase in prevalence since NFHS-4.
At the same time, in the states of Uttarakhand, Jharkhand, and Haryana, there has been a decline in prevalence or only a marginal increase in prevalence in certain categories. In Jharkhand, the Health Department of the state rolled out an action plan covering pregnant women, lactating women, infants and children in order to tackle anaemia in the state. The plan was taken up prioritizing the Centre’s Anaemia Mukt Bharath program that was launched in 2018 under National Health Mission as part of Intensified National Iron Plus Initiative (NIPI) Program. The action plan aimed to provide micronutrient drugs like IFA, Calcium, Vitamin A and Albendazole, to the last mile.
Likewise, Haryana launched the Anaemia Mukt Haryana program under state scheme ‘Atal Abhiyaan’ (Assuring total Anaemia Limit Abhiyaan) to reduce anaemia in all age group across Haryana, in line with the Centre’s Anaemia Mukt Bharat program in 2019.
More comprehensive data on epidemiology of anaemia will help in addressing the problem
To accelerate anaemia reduction, measures such as awareness, improved dietary choices and nutrition, education, and IFA supplementation during pregnancy and lactation are required. However, though the most common cause of anaemia is iron deficiency, there are other causes which require diagnosis and health interventions. For this, it is important that there is data on the epidemiology of the condition, which would help in understanding the burden of the condition and ensure that necessary health interventions are made.
Questions remain over the cutoffs & resultant over-diagnosis
As reported in ‘The Hindu’, a group of a team of researchers multiple institutions across India said it is possible that anaemia is being over-diagnosed in India due to a wrong (higher than appropriate) haemoglobin diagnostic cut-off. They argued for a re-examination of WHO haemoglobin cut-offs to define anaemia, in their recent paper published in the Lancet. They also highlighted the difference in sampling methods between the NFHS and the Comprehensive National Nutrition Survey (CNNS) 2016-18. For instance, the CNNS reported significantly lower figures of anaemia prevalence among children.
Featured Image: Increase in Anaemia