Anemia - Case Discussion in Community Medicine

CASE VIGNETTE

• Breathlessness on walking short distances (3 months)
• Easy fatigability and weakness
• Pallor of palms and conjunctivae
• No fever, no bleeding episodes, no jaundice

PART 1: DIAGNOSIS

WHO Diagnostic Cut-offs for Anaemia

• Hb 10-11 g/dL = Early (mild) anaemia
• Hb < 10 g/dL = Marked (moderate-severe) anaemia

Working Diagnosis

PART 2: DEFINITION

"A condition in which the haemoglobin content of blood is lower than normal as a result of a deficiency of one or more essential nutrients, regardless of the cause of such deficiency."

PART 3: THE EPIDEMIOLOGICAL PROBLEM

Global Burden

• Affects nearly two-thirds of pregnant and one-half of non-pregnant women in developing countries
• Even in developed countries, 4-12% of reproductive-age women are anaemic

India - A National Emergency

• Iron deficiency anaemia is the most widespread micronutrient deficiency in India, cutting across all age groups, castes, and religions
• 72.7% of urban children under 3 years are anaemic; 81.2% of rural children are anaemic
• Prevalence increased from 74.2% (1998-99) to 79.2% (2005-06) for children
• 19% of maternal deaths in India are due to anaemia
• Adolescent girls: 72.6% prevalence (DLHS 2002-04); severe anaemia 21.1%
• Bihar had the highest prevalence (87.6%); Punjab the lowest

High-Risk Groups

1. Pregnant and lactating women
2. Women of reproductive age (15-49 years)
3. Children 6-35 months
4. Adolescent girls (10-19 years)
5. Low socio-economic strata

PART 4: CAUSES / ETIOLOGY

Primary Cause in Community Settings

Key point: Poor bioavailability of iron from the habitual Indian diet (cereal-based, high in phytates) is considered a major reason for widespread iron deficiency even when total intake appears adequate.

PART 5: EVALUATION OF IRON STATUS

PART 6: DETRIMENTAL EFFECTS (Consequences)

(a) Pregnancy

• Increased risk of maternal and fetal mortality and morbidity
• 19% of maternal deaths in India attributable to anaemia
• Abortions, premature births, postpartum haemorrhage, low birth weight

(b) Infection

• Anaemia can be caused/aggravated by malaria and intestinal parasites
• Iron deficiency impairs cellular immunity and immune function
• Increased susceptibility to infections

(c) Work Capacity & Productivity

• Even mild anaemia causes significant impairment of maximal work capacity
• More severe anaemia = greater reduction in productivity
• Major economic impact on the country

PART 7: MANAGEMENT (Community Level)

Eligibility Criteria for IFA Supplementation

• Hb 10-12 g/dL: Daily IFA supplementation
• Hb < 10 g/dL: Refer to nearest PHC for further management

National Nutritional Anaemia Prophylaxis Programme (NNAPP)

IFA Dosage Schedule

• Haemoglobin should be re-checked every 3-4 months
• If Hb < 10 g/dL (severe): refer for blood transfusion or high-dose parenteral iron

PART 8: NATIONAL PROGRAMMES

1. National Nutritional Anaemia Prophylaxis Programme (NNAPP) - 4th Five Year Plan

2. National Iron Plus Initiative (NIPI)

3. Weekly Iron and Folic Acid Supplementation (WIFS)

4. Anaemia Mukt Bharat (AMB) Programme - 2018 (6×6×6 Strategy)

1. Pre-school children (6-59 months)
2. Children 5-9 years
3. Adolescent boys and girls (10-19 years)
4. Pregnant women
5. Lactating women
6. Women of reproductive age (15-49 years)

1. Prophylactic IFA supplementation (age-specific)
2. Periodic deworming (bi-annual)
3. Intensified year-round behaviour change and communication (BCC)
4. Testing of anaemia with point-of-care devices
5. Mandatory provision of IFA in programmes (ICDS, mid-day meal, NHM)
6. Addressing non-nutritional causes (malaria, haemoglobinopathies, fluorosis)

• Ministry-level convergence, dashboards, real-time monitoring, AMB index

PART 9: PREVENTION STRATEGIES

1. Iron and Folic Acid Supplementation

2. Iron Fortification

• Addition of ferric orthophosphate or ferrous sulphate with sodium bisulphate to salt (double-fortified salt)
• When consumed for 12-18 months, significantly reduces anaemia prevalence
• Accepted by Government of India as a public health approach; commercial production since 1985
• Advantage: salt is universally consumed - benefits all segments; no special delivery system needed

3. Other Strategies (Long-term)

• Dietary diversification and nutrition education
• Control of intestinal parasites (deworming)
• Malaria control
• Behaviour change communication

PART 10: OTHER TYPES OF ANAEMIA IN COMMUNITY MEDICINE

Sickle Cell Anaemia

• Autosomal recessive disorder; point mutation in DNA causes abnormal Hb S
• Heterozygous = clinically healthy (sickle cell trait)
• Homozygous = chronic haemolytic anaemia; death often before puberty
• Prevalent in sub-Saharan Africa and certain regions of India
• Rate of sickling influenced by concentration of HbS in RBC
• Associated with malaria-endemic areas (malaria provides heterozygote advantage)
• Management: supportive; prenatal diagnosis available by DNA analysis; genetic counselling

Thalassaemia

• Hereditary disorder with reduced synthesis of globin chain (alpha or beta)
• Produces hypochromic microcytic anaemia due to defective haemoglobinization
• Community approach: carrier screening, genetic counselling, prenatal diagnosis

Megaloblastic / Folic Acid Deficiency Anaemia

• Folate deficiency anaemia occurs in pregnant women from low-income groups
• Sub-clinical folate deficiency reported in ~30% of pregnant women in rural North India
• Microcytic anaemia (from iron deficiency) can mask concurrent megaloblastic anaemia

PART 11: SUMMARY TABLE FOR EXAM - CASE APPROACH

RECENT EVIDENCE

• Park's Textbook of Preventive and Social Medicine (Park's PSM), pp. 719-720, 738-740
• Government of India - Anaemia Mukt Bharat (PIB)
• AMB Index Study, Global Health: Science and Practice, 2018-2023

• Column 1 - The 6 target population groups following a life cycle approach (from pre-school children to women of reproductive age)
• Column 2 - The 6 key programmatic interventions (IFA supplementation, deworming, BCC, point-of-care testing, mandatory IFA delivery, and addressing non-nutritional causes)
• Column 3 - The 6 institutional mechanisms (ministry convergence, real-time dashboards, AMB Index, POSHAN Abhiyaan linkage, and community mobilization via ASHA/AWC)
• Bottom banner - The core target (3% annual reduction in anaemia) and the T3 Approach: Test · Treat · Talk

Anaemia Mukt Bharat (AMB) Index - Latest State Performance

What is the AMB Index?

1. Children aged 6-59 months
2. Children aged 5-9 years
3. Adolescents aged 10-19 years
4. Pregnant women
5. Lactating mothers

AMB Scorecard 2025-26 - Annual Rankings (Published May 2025)

• Children 6-59 months: 80.4%
• Children 5-9 years: 95%
• Adolescents: 95%
• Pregnant women: 95%
• Lactating mothers: 95%

• Uttar Pradesh: 74 of 75 districts in incomplete/non-reporting category
• Rajasthan: Dropped from 19th to 23rd position

AMB Scorecard Q1 2025-26 (April-June 2025) - Quarterly Rankings

• Climbed from 3rd to 2nd place
• Children 6 months - 5 years coverage: 90.5% (vs. 87.2% previous year)
• More than double the national average of 38.7% for this group

National Trend: IFA Coverage 2018-2023 (Peer-Reviewed Data)

Summary: Top vs. Bottom Performers at a Glance

Key Insight