Implications of inconsistent anaemia policies for children and adolescents in Africa

Summary of published study¹

Location: Sub-Saharan Africa

What we know: There are many interdependent factors that cause anaemia (infectious and chronic disease, micronutrient deficiencies), which challenges the development of relevant clear, consistent policies and their adaptation to resource-poor settings.

What this article adds: A review to identify international anaemia policies relevant for children in Africa identified some agreement but many inconsistencies, including a wide variety of diagnostic methods, treatment approaches and prevention programmes; inconsistent definitions and target groups; and poor description of the evidence base. These factors limit harmonisation. Anaemia policy development is fragmented and evidence from resource poor settings is lacking. Contextual adaptations of global recommendations are necessary. A single body within WHO should be responsible for devising and implementing a coherent approach to anaemia policy development and access. 

In sub-Saharan Africa, the high prevalence of infectious diseases such as malaria, helminthiasis and HIV; chronic diseases including haemoglobinopathies and deficiencies of micronutrients such as iron, cobalamin, folate and vitamin A, are responsible for causing anaemia in an estimated 47% of children and adolescents. This array of interdependent factors is a major challenge for developing clear, cohesive and evidence-based policies for anaemia diagnosis, prevention and treatment. Adapting policies to apply to resource-poor settings in Africa presents an additional challenge. 

International anaemia policies relevant for children in Africa are produced by several agencies and by different units within single agencies, for example those dealing with malaria, HIV, nutrition and neglected tropical diseases including helminthiasis. The wide variety of diagnostic methods, treatment approaches and prevention programmes for anaemia in various risk groups that are practised in Africa suggest that the guidance offered by current policies may be inconsistent, or difficult to apply in the Africa setting. An additional complication is the fact that the definition of anaemia in countries varies with age and gender; for example, from Hb<94g/l in infants aged two months to Hb<130g/l in male adolescents. 

A recent study identified and compared international policies concerning anaemia diagnosis, treatment and prevention in children. It evaluated the quality of these policies and the extent to which they are based on evidence relevant to the African contexts making recommendations for improvements to the policy making process. The study used the WHO definition for ‘guidelines’ to identify relevant policies and therefore included documents that contain recommendations about health interventions, whether they be clinical, public health or policy interventions. Databases and websites of international policy-making organisations were searched for documents relevant for the diagnosis, treatment and prevention of anaemia in children and non-pregnant adolescents (i.e. less than 18 years old) in Africa. No restrictions on language or time period were applied. The search was completed in May 2013.

Results

Several areas of agreement between policies were noted especially in relation to iron supplements and transfusions and the need to treat co-morbidities. It was generally agreed that although there are continued concerns about potential increased risk of infections, iron supplements are generally beneficial for treating anaemia, especially in combination with other anaemia interventions. Iron given with foods was speculated to be safe, although safety when administered as a fortificant has been questioned. There was consensus that blood transfusions are indicated in children with severe anaemia who are clinically unstable. However, there were also examples of ambiguities within individual policies and inconsistencies between policies on key issues concerning anaemia diagnosis, treatment and prevention. For example, the definitions for categories of anaemia severity were inconsistent, many policies did not specify the age group for which the policy had been developed and where target age groups were specified, they varied between policies.  

As so few policies explicitly described the evidence on which they had been based, it was not possible to draw conclusions about whether publication of evidence was related to any revision of existing policies or to the development of new policies. Some of the contradictory findings in the evidence are likely to reflect differences in populations or population sub-groups and their environment, which may limit the generalisability of some policies. However, for others, particularly those concerning diagnostics, there is insufficient available evidence to inform recommendations. The anomalies within and between policies and in some cases their lack of generalisability, mean that information often cannot be pooled to harmonise the policies. Without more context specific research to fill current evidence gaps and to clarify any adaptations that are needed for specific contexts, clinicians will remain uncertain about selecting the best intervention for their own practice. The clear need to adapt global anaemia policies for each context highlights the importance of WHO headquarters restricting itself to making global anaemia policies and then WHO’s regional offices can support local adaptations depending on the local context.  

Although WHO recommend that its guidelines should specify the duration of their validity, when they should be reviewed and which department will be responsible for initiating the review, most of the policies identified in the study did not have any indication of their duration of validity, and few have undergone any documented process of updating. By analysing the strengths and weaknesses of international policies concerning anaemia in children and adolescents in Africa, the authors have been able to identify and prioritise areas for further work. The authors advise that in order to address the weakest aspects of existing anaemia policies, attention should be focussed on constituting appropriate guideline development and peer review groups and on more rigorous methods for updating and developing policies and incorporating evidence. Furthermore, a comprehensive review of existing research evidence concerning anaemia in African children is urgently needed so that knowledge gaps can be identified and prioritised and research commissioned to fill the gaps. Almost none of the current policies are specifically tailored to Africa, which raises concerns about the appropriateness of these policies in the Africa context. Research located in Africa and involvement of national stakeholders is essential to be able to answer context-specific questions concerning, for example, the risks and benefits of iron supplementation where other infections are prevalent or in groups at high risk of anaemia, such as those with HIV infection or sickle cell disease and young infants.  

Although the lack of policies concerning anaemia diagnosis is particularly worrying since effective anaemia screening and diagnosis is a critical entry point for many children into the health-care system, currently anaemia policy development is fragmented and those concerning iron requirements are based largely on estimates of nutritional requirements from food intake studies in healthy Western children. In areas with high infection exposure, there is a need to identify specific iron biomarkers which are not affected by concurrent inflammation. Hepcidin, an essential hormone which regulates iron metabolism, may be useful for differentiating anaemia due to iron deficiency from other causes. 

Although the review focuses on children, it is likely that a similar lack of harmonisation applies to policies concerning anaemia in other population subgroups, such as pregnant women and the elderly. A critical step towards reducing the high burden of anaemia in African children should be the establishment of a single body within WHO responsible for devising and implementing a coherent approach to revising and developing anaemia policies and for making these policies easily accessible.

¹ Hamdan M, Brabin B and Bates I (2014). Implications of inconsistent anaemia policies for children and adolescents in Africa. Public Health Nutrition 17 (11) pp2587-2594.