Anemia among children and women in the Eastern Mediterranean Region: A Technical Guide

Anemia, a condition defined by deficiency in the size or number of red blood cells (RBCs), or a lower-than-normal level of hemoglobin within the RBCs, is a multifactorial condition whereby numerous factors may contribute to its development. The main factors include inadequate nutrition, poor nutrient absorption, deficiencies in essential micronutrients, nutritional interactions, infections, inflammation, chronic diseases, gynecological factors, heavy menstrual cycles, hemorrhage, pregnancy complications, family history of anemia and inherited disorders affecting RBCs. Anemia remains a significant public health concern, with the most vulnerable being children under five, specifically infants and young children below the age of 2 years, adolescent girls, women of reproductive age (WRA) and pregnant women. While symptoms of anemia vary depending on its severity, common symptoms include fatigue, dizziness, shortness of breath, chills at the extremities (hands and feet), headache, palpitations, decreased physical endurance, inadequate nutrition, and reduced productivity. Anemia predominantly affects low-income and middle-income countries with the heaviest burden, specifically populations residing in rural areas, economically disadvantaged households, and those lacking formal education. In 2019, the World Health Organization (WHO) estimated that approximately 40% of under five children, 37% of pregnant women, and 30% of WRA (15–49 years of age) worldwide are anemic. In the Eastern Mediterranean Region (EMR), the prevalence among under five children ranged between 11.9% and 79.5%. Among WRA, the prevalence ranged from 23.7% to 61.5%, while the prevalence among pregnant women was estimated between 19.1% and 57.5% in countries of the region. When the prevalence was assessed based on income, data from the region showed that in general, as income increased, the prevalence of anemia, and subsequently its severity, decreased, even though some exceptions were present in few countries. When the severity of anemia was assessed, the majority of EMR countries fell into the moderate category for anemia, with a prevalence rate ranging between 20% and 39.9% among under five children, WRA and pregnant women. The majority of EMR countries are therefore off track when compared with the World Health Assembly (WHA) global target of reducing anemia by 50% among WRA in 2025. The management and prevention of anemia should be specific in targeting the underlying nutritional and non-nutritional causes of anemia. This includes following a healthy, nutritious and diversified diet; improving infant feeding practices and promoting exclusive breastfeeding; considering supplementation if necessary; implementing food fortification policies; implementing nutrition education and awareness programs; enforcing food security and ensuring adequate access to a healthy, nutritious and diversified diet, across the population; targeting non-nutritional causes of anemia through specific programs pertinent to malaria, HIV, tuberculosis, soil-transmitted parasitic worms, genetic blood disorders, water, sanitation and hygiene (WASH), environmental and social aspects, delayed cord clamping, birth spacing, and menstrual bleeding and hemorrhage. Therefore, multifaceted, holistic and comprehensive approaches to address the key contributors to anemia are a must, along with frequent monitoring, evaluating and impact assessment. Key recommendations highlighted in the regional expert consultation 2023, on prevention and management of anemia in the EMR, focused on the following: defining a holistic approach; advocacy, coordination and communication; nutrition, dietary habits and preferences; nutrition education; providing support; school-based approaches; data collection, assessment, revision and monitoring; data quality/reporting and analysis; and coverage of interventions.