Date Published: March 14, 2017
Publisher: Public Library of Science
Author(s): Taye Gari, Eskindir Loha, Wakgari Deressa, Tarekegn Solomon, Hanibale Atsbeha, Meselech Assegid, Alemayehu Hailu, Bernt Lindtjørn, Jacobus P. van Wouwe.
As part of a field trial (PACTR201411000882128) to provide evidence on the combined use of long-lasting insecticidal nets and indoor residual spray for malaria prevention, we measured haemoglobin values among children aged 6 to 59 months. The aim of this study was to estimate the prevalence of anaemia, and to determine the risk factors of anaemia and change in haemoglobin value in Adami Tullu district in south-central Ethiopia.
Repeated cross-sectional surveys among 2984 children in 2014 and 3128 children in 2015; and a cohort study (malaria as exposure and anaemia as outcome variable) were conducted. The study area faced severe drought and food shortages in 2015. Anaemia was diagnosed using HemoCue Hb 301, and children with haemoglobin <11 g/dl were classified as anaemic. Multilevel and Cox regression models were applied to assess predictors of anaemia. The prevalence of anaemia was 28.2% [95% Confidence Interval (CI), 26.6–29.8] in 2014 and increased to 36.8% (95% CI, 35.1–38.5) in 2015 (P<0.001). The incidence of anaemia was 30; (95% CI, 28–32) cases per 100 children years of observation. The risk of anaemia was high (adjusted Hazard Ratio = 10) among children with malaria. Children from poor families [Adjusted Odds Ratio (AOR); 1.3; 95% CI, 1.1–1.6)], stunted children (AOR 1.5; 95% CI; 1.2–1.8), and children aged less than 36 months (AOR; 2.0; 95% CI, 1.6–2.4) were at risk of anaemia compared to their counterparts. There was no significant difference in risk of anaemia among the trial arms. Young age, stunting, malaria and poverty were the main predictors of anaemia. An increase in the prevalence of anaemia was observed over a year, despite malaria prevention effort, which could be related to the drought and food shortage. Therefore, conducting trials in settings prone to drought and famine may bring unexpected challenges.
Anaemia is a common childhood health problem in Africa, and its prevalence among children under the age of five years is estimated at 62%, which is above the cut off points (40%) of the World Health Organization (WHO) classification of anaemia as a severe public health problem . Anaemia has a serious effect on child health, and could result in impaired cognitive function, poor school performance, poor growth and development, and threatens the life of children [2–4]. The risk factors of anaemia are multiple, and vary across geographical areas. Iron deficiency anaemia is the leading (50%) cause of childhood anaemia in developing countries [5, 6]. In such countries, increased risks for childhood anaemia are protein energy malnutrition  and infections such as malaria, diarrhoea and intestinal helminths [7–12]. In addition, poverty [9, 13], illiteracy , and poor hygiene and sanitation  are among the contributing factors for the occurrence of anaemia.
This study was a part of a trial to prevent malaria; and showed that low age, stunting, malaria and poverty were the main predictors of anaemia. Although we had expected a reduction of anaemia due to the effect of the malaria prevention trial, we observed an increase in anaemia prevalence among children aged 6 to 59 months from 28% in 2014 to 37% in 2015. Our study took place during a period when there was 60% less rain. The population experienced severe food shortage followed by an increase in the prevalence of stunting. The prevalence of anaemia and stunting were particularly high among children in the poor families, or among families who moved out of the area, probably because of lack of food. Many (36.5%) of the children who were anaemic in 2014 were also anaemic a year later. This could indicate that children remained chronically anaemic, or that they suffered from recurrent anaemia.
In conclusion, young age, stunting, malaria and poverty were the main predictors of anaemia. An unexpected increase in the prevalence of anaemia was observed over a year period, and anaemia prevalence was particularly high among people who moved from the area due to lack of food. We did not observe statistical significant difference in risk of anaemia among malaria intervention arms. Therefore, conducting trials in settings prone to drought and food shortage is a serious challenge. Further study could be needed to measure serum ferritin value to establish the proportion of iron deficiency anaemia among the children.