anaemia

Anaemiaisaconditioninwhichthenumberofredbloodcells(and

conquentlytheiroxygen-carryingcapacity)isinsufficienttomeetthe

body’icphysiologicneedsvarywithaperson’s

age,gender,residentialelevationabovealevel(altitude),smoking

behaviour,ficiencyisthoughtto

bethemostcommoncauofanaemiaglobally,butothernutritional

deficiencies(includingfolate,vitaminB12andvitaminA),acuteandchronic

inflammation,parasiticinfections,andinheritedoracquireddisordersthat

affecthaemoglobinsynthesis,redbloodcellproductionorredbloodcell

survival,lobinconcentrationalonecannot

r,theconcentrationof

haemoglobinshouldbemeasured,eventhoughnotallanaemiaiscaud

valenceofanaemiaisanimportanthealth

indicatorandwhenitisudwithothermeasurementsofironstatusthe

haemoglobinconcentrationcanprovideinformationabouttheverityof

irondeficiency(1).

Inside

Background

Scopeandpurpo

ThisdocumentaimstoprovideursoftheVitaminandMineralNutrition

InformationSystem(VMNIS)withinformationabouttheuof

ompilationof

currentWorldHealthOrganization(WHO)recommendationsonthetopic

andsummarizesthecut-offsfordefininganaemiaanditsverityatthe

populationlevel,aswellasthechronologyoftheirestablishment.

Theuofthecut-offpointsderivedfromthereferencedpublications

permitstheidentificationofpopulationsatgreatestriskofanaemiaand

priorityareasforaction,so

facilitatethemonitoringandasssmentofprogresstowardsinternational

goalsofpreventingandcontrollingirondeficiencyandfurtherprovidethe

basisforadvocacyforthepreventionofanaemia.

Haemoglobin

concentrationsforthe

diagnosisofanaemiaand

asssmentofverity

VMNIS|VitaminandMineralNutritionInformationSystem

WHO/NMH/NHD/MNM/11.1

Background1

Descriptionof

technicalconsultation

2

Recommendations3

Summary

development

Acknowledgements

5

Plansforupdate5

References6

4

Scopeandpurpo1

VMNIS|1

Haemoglobinconcentrationsforthediagnosisofanaemia

andasssmentofverity

VMNIS|2

MicronutrientsIndicators

Descriptionoftechnical

consultation

ThisdocumentcompilescurrentWHOguidelines

fromfivedocuments:

Nutritionalanaemias(2),isareportofaWHO

ScientificGroupthatconsistedofaninternational

groupofexpertsconvenedinGeneva,Switzerland

sultationwascalled

threeyearsafterthestartofaworldwidemulti-

countrycollaborativestudyinIndia,Israel,Mexico,

Poland,SouthAfrica,theUnitedKingdom,theUnited

StatesofAmerica,dy

investigatedironmetabolisminpregnancyaswell

astheroleofhookworminanaemiaduring

pregnancy,andfurthertestedtheproceduresfor

1967

consultationreviewedoverallprogressofthe

studiesandalsodiscusdnutritionalrequirements

ofiron,folate,andvitaminB12.

Preventingandcontrollinganaemiathrough

primaryhealthcare(3)waspublishedafteraMay1987

meetingoftheInternationalNutritionalAnaemia

ConsultativeGroup(INACG)inQuito,

publicationaimstohelphealthadministratorsand

programmemanagerstodevelopandimplement

suitablestrategiesforpreventingandcontrollingiron

considerssomeofthe

practicalaspectsofintegratingprimarycareat

variouslevelsoforganizationlearntfromtheJNSP

(WHO/UNICEFJointNutritionSupportProgramme),

whichwasactivein18countriesatthattime.

Themanagementofnutritioninmajoremergencies

(4)waspublishedbyWHOinrespontotheWorld

DeclarationandPlanforActioninNutrition(5)that

urgedgovernmentstoprovidesustainableassistance

torefugees,displacedandwar-affectedpopulations

wherehighratesofmalnutritionandmicronutrient

deficienciesoccur.

Irondeficiencyanaemia:asssment,preventionand

control,aguideforprogrammemanagers(6),a

documentpublishedin2001,ismainlybadona

consultationorganizedbyWHO,UNICEF,andthe

UnitedNationsUniversity(UNU)heldinGeneva,

Switzerland,poofthis

consultationwastoprovidescientistsandnational

authoritiesatimelyandauthoritativereviewofiron

deficiencyanaemia,andalsotohelpmanagersof

nationalmicronutrientmalnutritionpreventionand

controlprogrammestoidentifyeffectivemeasuresfor

clusionsof

theconsultationwerecomplementedwithadditional

scientificliteraturethatappearedbefore2000.

Asssingtheironstatusofpopulations(1)isthe

reportofajointWHOandUSCentersforDia

ControlandPrevention(CDC)TechnicalConsultation

heldinGeneva,Switzerland,6-8April2004,withthe

eultimategoalof

planningeffectiveinterventionstocombatbothiron

deficiencyandanaemia,theobjectivesofthe

Consultationweretoreviewtheindicatorscurrently

availabletoasssironstatus,tolectthebest

indicatorsforasssingtheironstatusofpopulations,

tolectthebestindicatorstoevaluatetheimpactof

interventionstocontrolirondeficiencyin

populations,andtoidentifyprioritiesforrearch

relatedtoasssingtheironstatusofpopulations.

ThisConsultationwasprecededbyashortWHO/CDC

workinggroupmeetingheldinJanuary2004to

reviewtheliteratureonindicatorsofironstatusand

l2004,the

Consultationwasprovidedwithliteraturereviewson

indicatorsofironstatus,includingredbloodcell

(RBC)parameters,ferritin,freeerythrocyte

protoporphyrin,rumandplasmairon,totaliron

bindingcapacity,transferrinsaturationandrum

transferrinreceptoraswellasareviewonthe

interpretationofindicatorsofironstatusduringan

ourreviewsare

availableinthecondedition,publishedin2007.

Haemoglobinconcentrationsforthediagnosisofanaemia

andasssmentofverity

VMNIS|3

MicronutrientsIndicators

Table1

Haemoglobinlevelstodiagnoanaemiaatalevel(g/l)±

Theanaemiacut-offsprentedinTable1were

publishedin1968byaWHOstudygroupon

nutritionalanaemias(2),whilethecut-offsdefining

mild,moderateandvereanaemiawerefirst

prentedinthe1989guidePreventingand

controllinganaemiathroughprimaryhealthcare(3)

andthenmodifiedforpregnantwomen,non-

pregnantwomen,andchildrenlessthanfiveyearsof

ageinThemanagementofnutritioninmajor

emergencies(4).Theoverallanaemiacut-offshave

beenunchangedsince1968,withtheexceptionthat

theoriginalagegroupofchildren5-14yearsofage

wassplit,andacut-offof5g/llowerwasappliedto

children5-11yearsofagetoreflectfindingsamong

non-irondeficientchildrenintheUSA(6).Although

thecut-offswerefirstpublishedinthelate1960s,

theyhavebeenincludedinnumeroussubquent

WHOpublications(3,4,6)andwereadditionally

validatedbyfindingsamongparticipantsinthe

SecondNationalHealthandNutritionExamination

Survey(NHANESII)whowereunlikelytohaveiron

deficiencybadonanumberofadditional

biochemicaltests(7).

Thehaemoglobincut-offof110g/lforpregnant

womenwasfirstprentedinthe1968reportalong

withresultsofthefivestudiesmentionedpreviously.

Inhealthy,iron-sufficientwomen,haemoglobin

concentrationschangedramaticallyduring

Recommendations

Population

Anaemia*

Non-Anaemia*

MildaModerateSevere

Children6-59monthsofage110orhigher100-10970-99lowerthan70

Children5-11yearsofage115orhigher110-11480-109lowerthan80

Children12-14yearsofage120orhigher110-11980-109lowerthan80

Non-pregnantwomen

(15yearsofageandabove)

120orhigher110-11980-109lowerthan80

Pregnantwomen110orhigher100-10970-99lowerthan70

Men(15yearsofageandabove)

130orhigher110-12980-109lowerthan80

pregnancytoaccommodatetheincreasingmaternal

bloodvolumeandtheironneedsofthefetus(3).

Concentrationsdeclineduringthefirsttrimester,

reachingtheirlowestpointinthecondtrimester,

andbegintoriagaininthethirdtrimester.

Currently,therearenoWHOrecommendationson

theuofdifferenthaemoglobincut-offpointsfor

anaemiabytrimester,butitisrecognizedthatduring

thecondtrimesterofpregnancy,haemoglobin

concentrationsdiminishapproximately5g/l.

Residentialelevationabovealevelandsmoking

areknowntoincreahaemoglobinconcentrations

(6).Conquently,theprevalenceofanaemiamaybe

underestimatedinpersonsresidingathighaltitudes

andamongsmokersifthestandardanaemiacut-offs

2prentstherecommended

adjustmentstobemadetothemeasured

haemoglobinconcentrationamongpersonslivingat

altitudeshigherthan1000metresabovealevel,

andTable3prentstheadjustmentsforsmokers.

Theadjustmentsmustbemadetothemeasured

haemoglobinconcentrationfortheanaemiacut-offs

ion

adjustmentsarederivedusingdatafromtheUS

CentersforDiaControlandPrevention’s(CDC)

PediatricNutritionSurveillanceSysteminchildren

livinginmountainousstates,whilethesmoking

±Adaptedfromreferences5and6

*Haemoglobiningramsperlitre

a"Mild"isamisnomer:iciencyhasconquencevenwhennoanaemiais

clinicallyapparent.

Haemoglobinconcentrationsforthediagnosisofanaemia

andasssmentofverity

VMNIS|4

MicronutrientsIndicators

Table2

Altitudeadjustmentstomeasuredhaemoglobinconcentrations

Altitude

(metresabovealevel)

Measuredhaemoglobinadjustment(g/l)

<10000

1000-2

1500-5

2000-8

2500-13

3000-19

3500-27

4000-35

4500-45

Summarydevelopment

Themainbibliographicsourcesofthissummarywere

fiveWHOpublications(1-4,6)releadbetween1968

onsideredthateachofthem

providedinputsthathelpedtobuildtheknowledge

y,haemoglobincut-offswerefirst

prentedinthe1968document(2)andwerebad

onfourpublishedreferences(8-11)andonetof

tionsformild,

moderate,andvereanaemiawerefirstpublishedin

1989(3)andslightlymodifiedinasubquent

publicationonnutritioninemergencies(4),which

alsoproposaclassificationtodeterminethepublic

y,

the2001guideformanagerssplittheagegroupfor

children5-14yearsofageandappliedanew,lower

haemoglobincut-offforchildren5-11yearsofage

2001document

additionallyprovidedhaemoglobinadjustmentsfor

altitudeandsmoking.

adjustmentsareadditive,slivingathigher

additiontoelevationandsmoking,ithasbeen

suggestedthattherearesmalldifferencesinthe

distributionsofhaemoglobinvaluesamongdifferent

ethnicgroups(6),however,thedataisstillscarceand

theuofstandardcut-offsisrecommended

Boththemethodofhaemoglobinmeasurement

andbloodsamplesource(capillaryversusvenous

blood)canaffectthemeasuredhaemoglobin

nmethemoglobinandthe

HemoCue®systemarethemethodsgenerally

recommendedforuinsurveystodeterminethe

populationprevalenceofanaemia(6).Inthe

cyanmethemoglobinmethod,afixedquantityof

bloodisdilutedwithareagentandhaemoglobin

concentrationisdeterminedafterafixedtimeinterval

inanaccurate,

cyanmethemoglobinmeasurementisthereference

laboratorymethodforthequantitativedetermination

ofhaemoglobinandisudforcomparisonand

standardizationofothermethods(6).TheHemoCue®

systemisbadonthecyanmethemoglobinmethod

andhasbeenshowntobestableanddurableinfield

rceofthebloodsampleshouldalso

beconsideredwhenasssinghaemoglobin

udiessuggestthat

haemoglobinvaluesmeasuredincapillarysamplesare

higherthanthomeasuredinvenoussamples,

potentiallyleadingtofal-negativeresults(6).

Thehaemoglobincut-offsprentedinTable1are

udtodiagnoanaemiainindividualsina

screeningorclinicaltting,butthepublichealth

significanceofanaemiainapopulationcanthenbe

determinedbyapplyingthecriteriashowninTable4.

Haemoglobinconcentrationsforthediagnosisofanaemia

andasssmentofverity

VMNIS|5

MicronutrientsIndicators

Smokingstatus

Measuredhaemoglobin

adjustment(g/l)

Non-smoker0

Smoker(all)-0.3

½-1packet/day-0.3

1-2packets/day-0.5

≥2packets/day-0.7

Table3

Adjustmentstomeasuredhaemoglobin

concentrationsforsmokers

Table4

Classificationofpublichealthsignificanceof

anaemiainpopulationsonthebasisofprevalence

estimatedfrombloodlevelsofhaemoglobin

Categoryofpublic

healthsignificance

Prevalenceofanaemia

(%)

Severe40orhigher

Moderate20.0–39.9

Mild5.0–19.9

Normal4.9orlowerPlansforupdatingthissummary

TheWHOMicronutrientsUnit,Departmentof

NutritionforHealthandDevelopment,isresponsible

forreviewingthisdocumentandifneededwill

updateitby2014,followingthenewlyadoptedWHO

Handbookforguidelinedevelopment(12)procedures.

Acknowledgements

ThissummarywascoordinatedbyDrLuzMariade

RegilwithtechnicalinputfromDrJuanPabloPena-

Rosas,DrSarahCusickandDrSeanLynch.

WHOwishestothanktheGovernmentof

Luxembourgfortheirfinancialsupport.

Suggestedcitation

lobinconcentrationsforthediagnosisof

nand

,World

Health

Organization,2011(WHO/NMH/NHD/MNM/11.1)

(/vmnis/indicators/haemoglobin.

pdf,accesd[date]).

FORFURTHERINFORMATIONPLEASECONTACT

DepartmentofNutritionforHealthandDevelopment(NHD)

WorldHealthOrganization

20,AvenueAppia,1211Geneva,Switzerland

Email:micronutrients@

WHOhomepage:

©WorldHealthOrganization2011

Haemoglobinconcentrationsforthediagnosisofanaemia

andasssmentofverity

VMNIS|6

MicronutrientsIndicators

References

ingtheironstatusofpopulations:reportofajointWorldHealthOrganization/CentersforDiaControlandPreventiontechnical

consultationontheasssmentofironstatusatthepopulationlevel,2nded.,Geneva,WorldHealthOrganization,bleat

/nutrition/publications/micronutrients/anaemia_iron_deficiency/

,WorldHealthOrganization,1968.(WHOTechnicalReportSeries,No.

405).Availableat/trs/WHO_TRS_

tingandcontrollinganaemiathroughprimaryhealthcare:,

WorldHealthOrganization,bleat

/nutrition/publications/micronutrients/anaemia_iron_deficiency/

,WorldHealthOrganization,bleat

/publications/2000/

,,FoodandAgriculture

OrganizationoftheUnitedNations,bleat/hq/1992/

,UNICEF,ficiencyanaemia:asssment,preventionandcontrol,,WorldHealth

Organization,bleat

/nutrition/publications/micronutrients/anaemia_iron_deficiency/WHO_NHD_01.3/en/

ityandMortalityWeeklyReport,1989,38(22):400-404.

obinconcentrationandhematocritinmenaged15–21years.

ActaMedicaScandinavica,1966,180:613–620.

rickGS,yofarandomsampleofthepopulation.

BritishMedicalJournal,1961,5228:778–782.

wNK,LowensteinL,ne(Baltimore),1966,45:291–315.

nceofsupplementalironduringnormalpregnancyonmotherandinfant.

hJournalofHaematology,1959,5:31–44.

,WorldHealthOrganization,March2010.