Anaemia is characterized by a decrease in the number of red blood cells in the blood (or

haemoglobin [Hb] concentration) to a level that impairs the normal physiological capacity
of the blood to transport oxygen to cells around the body. WHO defines mild anaemia as a
Hb of between 10 g/dL and 10.9 g/dL, moderate anaemia as between 7 g/dL and 9.9 g/dL
and severe anaemia as below 7 g/dL. Deficiency in iron is thought to be the most common
cause of anaemia. Additional important causes of anaemia include infections, other
nutritional deficiencies (e.g. in folate, and vitamins B12, A and C), genetic conditions and
haemoglobinopathies (e.g. sickle cell disease and thalassaemia) and chronic kidney disease
(23). Anaemia is highly prevalent globally, and is particularly prevalent in sub-Saharan
Africa. Malaria infections cause anaemia through multiple mechanisms (direct destruction
of red blood cells, clearance of infected and uninfected red cells by the spleen, and
impaired red cell production by bone marrow), and individuals who are anaemic are at a
greater risk of mortality, including from malaria. Single or repeated episodes of malaria
may result in lifethreatening anaemia, metabolic acidosis (24) and death. Severe anaemia
has been estimated to account for more than half of all childhood deaths from malaria in
Africa (25). In communities where blood transfusions are not available, anaemia deaths are
likely to be a particular problem (26).
Pregnant women and children aged under 5 years are most vulnerable to anaemia. In sub-
Saharan Africa, iron deficiency and malaria infection often coexist, but the relationship
between them is complex. Even measuring iron status in someone with current or recent
past P. falciparum malaria infection is complicated by the inflammatory response to
malaria infection (27).
Anaemia was once a key indicator of progress with malaria control, and was used as part
of the evaluation of interventions. Recent years have seen a decline in awareness of the
burden of malaria-related anaemia.
Despite its importance as a direct and indirect consequence of malaria infection and
disease, the prevalence of anaemia among populations at risk of malaria has not been
reported consistently as a metric of malaria transmission and burden. Data from household
surveys implemented in 16 high malaria burden countries between 2015 and 2017 were
analyzed. The Hb concentration in children aged under 5 years was examined in relation to
malaria infection, the results showed a median Hb concentration of 9.4 g/dL among
children who were positive for malaria (by RDT) and 10.7 g/dL among those who were
negative. Hb concentration increased with age, regardless of malaria infection status, but
median concentration was lower in each age group among those who were positive for
malaria compared with those who were negative for malaria (Fig. 6.9). Based on WHO
definitions, the prevalence of any anaemia was 61%, mild anaemia 25%, moderate
anaemia 33% and severe anaemia 3%. Of children who tested positive for malaria, the
prevalence of any, mild, moderate and severe anaemia was 79%, 21%, 50% and 8%,
respectively (Fig. 6.10). According to WHO recommendations, up to 13% of these children
would qualify for blood transfusion and would probably be at an increased risk of malaria
mortality.