Iron deficiency anemia among
rural population attending tertiary care teaching hospital
Sharadamani. G.S 1
1Dr. Sharadamani. G.S., Associate Professor, Department of Pathology,
Vinayaka missions medical college Hospital, Karaikal
-609609 Puducherry, India
Address for correspondence:
Dr. Sharadamani.G.S, Email: smanibmc@gmail.com
Abstract
Background:
Nutritional anemia is a major public health problem in India and is
primarily due to iron deficiency which is more common among rural
population. The present study aimed at evaluating iron deficiency
anemia among rural population attending our tertiary care teaching
hospital. Materials and
Methods: Patients having hemoglobin level below 11g/dl
with Serum Iron level <30 ug/dl and/or serum TIBC>400
ug/dl were enrolled in the study. A total of 259 patients were included
in the study. Hemoglobin estimation and other investigations were
performed as per standard protocol in pathology laboratory. Results: Majority of
patients were females (58.69%) and preponderance of iron deficiency
anemia was seen in the age group of 21-30(28.96%) followed by
31-40(25.09%). Majority of male patients had mild anemia (55.14%)
whereas majority of females had moderate anemia (57.24%). Conclusion: Iron
deficiency anemia is significantly high among women of reproductive age
group. Among females moderate anemia was predominant. Mild anemia was
commonly observed in males.
Key words: Iron
deficiency anemia, Rural population, Reproductive age group
Manuscript received: 7th
January 2017, Reviewed:
13th January 2017
Author Corrected:
21st January 2017,
Accepted for Publication: 30th January 2017
Introduction
Anemia is an abnormal physiological and hematological condition
concerned with reduction in oxygen carrying capability of the blood due
to decline in Red Blood Cell (RBC) count, Packed Cell Volume (PCV) and
Hemoglobin (Hb) concentrations than normal ranges [1]. Anemia is a
major global health problem, especially in developing countries like
India. Anemia can be of various types based on the morphology of the
RBCs depending on etiology and clinical aspect. 30% or nearly one third
of world’s population is suffering from anemia due to various
causes [2]. The most common being deficiency of essential elements for
the synthesis of hemoglobin (Iron, Vitamin B12 and Folic Acid), blood
loss, repeated pregnancies in females of reproductive age, worm
infestation, hemolysis due to known or unknown causes and bone marrow
conditions causing suppression of red cell synthesis. Chronic diseases
such as chronic renal failure, rheumatoid arthritis and tuberculosis
are also known causes [3]. Iron deficiency anemia is a major
nutritional problem in India and many other developing countries. The
importance of iron-deficiency as cause of anemia varies by region.
Prevalence of iron deficiency anemia is higher in India than other
developing countries [4].
According to the statistics of the World Health Organization (WHO) [5],
the prevalence of anemia is 48% in preschool-age children (less than 5
years of age), 25% in school-age children (5 to 14 years), 13% in males
(15 to 59 years), 42% in pregnant females, 30% in women of reproductive
age (15 to 49 years), and 24% in the elderly (＞60 years). It is of note
that anemia is particularly prevalent among three population groups,
i.e., preschool-age children, pregnant females, and women of
reproductive age [4].
Consequences among pregnant women include, abortions, premature births,
post-partum hemorrhage and low birth weight were especially associated
with low hemoglobin. Anemia among pre school children and school going
age group is predominantly due to parasitic diseases such as maiaria
and worm infestations. Iron deficiency anemia may impair the activity
of host defense mechanisms and make host more prone to infections.
Further it causes decrease in working capability of the individual [4].
Hence, we aimed at evaluating anemia among various age groups and
proportion of iron deficiency anemia in mild, moderate and severe
anemic patients.
Materials
and Methods
This is a prospective, observational study conducted in the department
of pathology, Vinayaka Mission’s Medical College and
Hospital. A total of 259 iron deficiency anemia patients were included
in the study. Venous blood collected from the patients included in the
study after obtaining verbal consent. Hb level, total erythrocyte
count, red cell indices such as mean corpuscular volume (MCV), mean
corpuscular haemoglobin (MCH) and mean corpuscular haemoglobin
concentration (MCHC); and white cell indices such as total leucocyte
count (TLC) and differential leucocyte count, as well as platelet
count, packed cell volume and reticulocyte count were performed using
automated analyser (HORIBA MICROS ES 60). Further bone marrow study was
also performed by using Prussian blue reaction. Peripheral smear was
made and examined for microscopic findings. Iron studies included serum
iron and total iron binding capacity (TIBC).
Inclusion criteria:
Hemoglobin level below 11g/dl with Serum Iron level <30 ug/dl
and/or serum TIBC>400 ug/dl were included in the study.
Exclusion criteria:
Patients having history of taking supplemental iron during previous
year, history of blood transfusion, family history of anemia, history
of receiving oral contraceptive pills were excluded from the study.
The level of Hb in different categories of anemia was defined as
follows: (i) severe anemia < 7 g/dl, (ii)moderate anemia 7-9.9
g/dl, (ii) mild anemia in pregnant women 10-10.9 g/dl, and (iv) mild
anemia in non-pregnant women 10-11.9 g/dl.[5].
Statistical analysis: Analysis
of results was performed by simple percentage method.
Results
A total of 259 patients were included in the study. Out of them
107(41.31%) were males and 152(58.69%) were females. Majority of
patients were belonged to the age group of 21-30(28.96%) followed by
31-40(25.09%). The average hemoglobin was 7.5gms. The lowest hemoglobin
recorded in our study was 3.5gms. In males, the prevalence of iron
deficiency was 4.25% in ages 1 to 10 years, 5.02% in 11 to 20 years.
Majority of male patients were belonged to the age group of 31-40 and
accounted for 10.42%. In females, the prevalence of iron deficiency was
highest in the age group of 21-30 and accounted for (28.96%). (Table.1)
Table-1: Age and gender
wise distribution of Iron deficiency anemia
|
S. No
|
Age
|
Males (%)
|
Females (%)
|
Total (%)
|
|
1
|
0-10
|
11(4.25)
|
6(2.31)
|
17(6.56)
|
|
2
|
11-20
|
13(5.02)
|
14(5.40)
|
27(10.42)
|
|
3
|
21-30
|
19(7.34)
|
56(21.62)
|
75(28.96)
|
|
4
|
31-40
|
27(10.42)
|
38(14.67)
|
65(25.09)
|
|
5
|
41-50
|
12(4.63)
|
17(6.56)
|
29(11.20)
|
|
6
|
51-60
|
7(2.70)
|
14(5.40)
|
21(8.10)
|
|
7
|
>60
|
14(5.40)
|
11(4.25)
|
25(9.65)
|
Severity of anemia was categorized into mild, moderate and severe.
Majority of male patients had mild anemia whereas moderate anemia was
predominated among females. Least number of patients had severe anemia
in both males and females. (Table.2)
Table-2: Distribution of
iron deficiency anemia in males and females
|
S. No
|
Category
|
Males
|
Females
|
|
1
|
Mild
|
59(55.14%)
|
47(30.92%)
|
|
2
|
Moderate
|
35(32.71%)
|
87(57.24%)
|
|
3
|
Severe
|
13(12.15%)
|
18(11.84%)
|
In our study, 69 pregnant women were identified with iron deficiency
anemia. Majority of pregnant women were belonged to the age group of
21-25 which accounted for 52.17%. Iron deficiency anemia was 40.28% in
Primi gravida and 59.42% in multi gravid. Majority of pregnant women
(46.38%) in third trimester had anemia (Table.3)
Table-3: Profile of iron
deficiency anemia in pregnant women
|
Age
|
No.
of patients (%)
|
|
15-20
|
10(14.49)
|
|
21-25
|
36(52.17)
|
|
26-30
|
17(24.64)
|
|
31-35
|
6(8.70)
|
|
Gravida
|
|
|
Primi
|
28(40.58)
|
|
Multi
|
41(59.42)
|
|
Trimester
|
|
|
First
|
15(21.74)
|
|
Second
|
22(31.88)
|
|
Third
|
32(46.38)
|
Discussion
Anemia can be of various types, but most common in developing countries
is nutritional anemia. Globally anemia due to iron deficiency is
perhaps the most widespread clinical nutritional deficiency disease
especially among rural population. In our study, the age group of 21-40
years had highest prevalence of anemia. This is in agreement with the
studies conducted previously [6,7]. However, another study from South
India reported 40-45 years age group as predominant [8]. Another study
conducted by Lamsal, showed highest prevalence in 40-49 years age group
[9]. In the present study anemia were in elderly 9.65%, in contrast
another community based study conducted by Swami et al. showed high
prevalence of anemia among elderly(68.5%), this difference may be due
to our study is hospital based[10]. Similarly other Indian studies also
showed varying degree of anemia depending on difference in various
variables.
The relation of anemia and age was different for various locations. In
the present study, females were predominated and accounted for
152(58.69%) whereas males accounted only for 107(41.31%). This is in
accordance with the study conducted by Reena kouli et al[11], who
reported 39.92% males and 60.08% females. However, other studies showed
no statistical difference between both genders [12,13]. This is in
contrast with the study conducted by Chul won choi et al [14].
To explain the variations in prevalence rates of anemia, few
researchers argued that estrogens act as inhibitors of erythropoiesis
and make women more vulnerable to the development of anemia. However,
while postmenopausal estrogen levels decrease, there is an increase in
red cell mass to levels that are similar to those in males, which makes
it unreasonable to use different criteria for anemia in each gender
[15].
In our study, majority of male patients had mild anemia 59(55.14) and
majority of females had moderate anemia 87(57.24). Prevalence of severe
anemia was least in both genders. According to Agarwal et al[16]. Who
reported prevalence of moderate anaemia to be maximum (50.9%) followed
by mild (34%) and severe anaemia (7.3%). Taseer et al [17] reported
only mild and moderate anaemia cases and no severe anaemia case.
Majority of pregnant women with iron deficiency had moderate category
of anaemia. According to Abel et al [18], maximum number of cases were
classified as moderate anemia (35.8%) and minimum number of cases were
classified as severe anemia (3.3%) which is in agreement with the
present study. Similarly, Ahmad et al [19], reported maximum number of
cases were classified as moderate anemia(50.9%) and minimum number of
cases were classified as severe anemia(18.9%). In India, special
attention is given towards moderate to severe forms of anemia because
of its high prevalence and the public health significance of moderate
and severe anemia [20]. In the present study, demographic data obtained
was limited. However, previous studies showed significant association
between low education and socio economic strata. According to Shweta
rajput et al [21], 98.9% women in lower socioeconomic strata had iron
deficiency anaemia as compared to 14.3% women in upper socioeconomic
strata. Females belongs to lower socioeconomic strata have limited
access to nutritious diet. They generally follow normal diet and normal
activity schedule despite in pregnant state. Ignorance, poverty and
gender bias significantly contribute to this high prevalence [21].
In our study, majority of patients complained generalized weakness,
breathlessness and puffiness of face, nail brittleness. In a study
conducted by Ratre et al[22], most common symptoms were fatigability
(100%), decreased work performance (80%), breathlessness on exertion
(60%), other important presenting symptoms were swelling over body
(40%), pain in abdomen (40%), bodyache (28%), giddiness (20%),
palpitation (20%), headache (12%), anorexia (10%), worms in stool
(10%), PICA (8%) and chest pain (5%).
Weakness, fatigability, decreased work performance and dyspnea on
exertion were common symptoms, which were because of cardiovascular
compromise. Work capacity is assessed by aerobic capacity, endurance,
energetic efficiency, voluntary activity and work productivity. The
presumed mechanism for this effect is the reduced oxygen transport
associated with anemia; tissue iron deficiency may also play a role
through reduced cellular oxidative capacity. Iron plays an essential
role in oxidative energy production [22].
Higher rate of parasitic infestations were observed in our study. Stool
examination was performed for the detection of intestinal parasites in
95 patients, but not in all which remained as one of the limitations of
the study. In 27 stool specimens ova of hook worm was seen .Cysts of
Entamoeba histolytica were seen in 8 stool specimens and two stool
specimens with Giardia lamblia trophozoites were seen. No other
intestinal parasites were detected .But previous studies reported,
Ascaris lumbricoides and Trichuris trichiura[23]. Ancylostoma duodenale
and Necator americanus are two important species of hook worm which
contribute to iron deficiency anemia [23]. In the present study, hook
worm Ancylostoma duodenale alone was reported. However, stool
concentration techniques are more accurate than routine stool
examination for the diagnosis of intestinal parasites. Other infectious
diseases commonly associated with anemia, like leishmaniasis and
schistosomiasis, are nonexistent in the area. Least number of malaria
cases has been reported from this region. In our study, two cases of
Plasmodium vivax were seen in peripheral smear. Few studies associated
urinary tract infections with anemia and an elevated s-CRP [24].
Various studies reported anemia as a common complication of pulmonary
tuberculosis [25]. A number of studies in India, Indonesia, South
Korea, Nigeria have documented anemia in patients with TB, however, all
the studies involved only small numbers of patients and the results
were not uniform[26].
Conclusion
Iron deficiency anemia is significantly high among women of
reproductive age group. Preponderance of moderate anemia was seen in
females and mild anemia was commonly observed in males. Effective
public health education, school based deworming and promoting cost
effective iron rich diet among rural population would help in reducing
the incidence of iron deficiency anemia.
Funding:
Nil, Conflict of
interest: None initiated
Permission from IRB:
Yes
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How to cite this article?
Sharadamani. G.S. Iron deficiency anemia among rural population
attending tertiary care teaching hospital. Trop J Path Micro
2017;3(1):03-08.doi: 10.17511/jopm.2017.i1.01.