Anemia is a critical global public health challenge affecting a significant portion of the world’s population, predominantly in low- and lower-middle-income countries. Its impact is particularly pronounced among vulnerable groups such as young children, pregnant and postpartum women, and menstruating adolescent girls and women.
The World Health Organization estimates that in 2019, 30 percent (571 million) of women aged 15–49 years, 37 percent (32 million) of pregnant women, and 40 percent (269 million) of children 6-59 months of age were affected by anemia. In India, according to the National Family Health Survey 5 (2019-2021), one in every two women and one in every four men aged between 15-49 years are anemic.
Anemia screening: A key to early intervention
Screening serves as a critical tool for early detection and management of anemia, allowing health care providers to intervene swiftly, thwarting health issues such as extreme fatigue, weakness, an increased risk of infections and death, cognitive impairment, poorer growth and development.
The effectiveness of any screening strategy at the population level depends on a scientific, accurate, reliable, and cost-effective mechanism.
Haemoglobin concentration is widely considered the most common biomarker at both the individual and population levels, typically measured through traditional invasive methods involving blood sample collection. Accurate measurement of haemoglobin concentration is crucial for diagnosing and managing anemia effectively.
With advancements in technology, there has been a proliferation of minimally invasive and non-invasive screening devices suitable for population-level use. Offering alternatives to traditional methods of haemoglobin (Hb) estimation, these innovative approaches enhance the accessibility and scale of anemia reduction interventions.
From invasive to non-invasive: The evolution of haemoglobin measurement
From the early invasive techniques to the cutting-edge non-invasive technologies of today, haemoglobin measurement techniques have significantly evolved.
In the twentieth century, the hemoglobincyanide method, which involves converting haemoglobin to cyanmethemoglobin by adding a potassium cyanide reagent to measure haemoglobin concentration in the blood, was the dominant technique. However, it was fraught with challenges like hazardous waste disposal, prompting the need for innovation. In response, the first generation of point-of-care diagnostics emerged, championing cyanide-free alternatives like azide methemoglobin.
As the landscape of hemoglobin estimation continued to evolve, so did the exploration for non-invasive methods. Diverse technologies, from photoplethysmography to smartphone-based applications, were developed to transform anemia screening.
Emerging technologies such as near-infrared spectroscopy and photoplethysmography based devices offer promising avenues for non-invasive haemoglobin measurement, aiming to transcend the limitations of invasive techniques.
Advancements in screening under the Anemia Mukt Bharat program
To combat anemia across India, the Government of India launched the Anemia Mukt Bharat (AMB) program to implement comprehensive strategies for anemia prevention, detection, and management.
Under the AMB program, the widespread adoption of digital haemoglobinometers for anemia screening has revolutionised the approach to haemoglobin testing.
As part of the AMB program, school-going adolescents and pregnant women now undergo routine screening using these digital meters, marking a significant stride in proactive health care. This initiative not only ensures timely detection of anemia but also fosters awareness on anemia status among diverse stakeholders, from health care workers to policymakers.
Despite these achievements, challenges remain as the scope of screening through digital haemoglobinometers is currently limited to specific beneficiary groups, though a few states plan to expand to other beneficiaries as well. Expanding the reach of screening to encompass a broader demographic is crucial for comprehensive anemia control efforts.
“The RBSK team was clinically identifying mild, moderate, and severe anemia cases and referring them to PHCs for exact Hb estimation. Now, digital Hb meters are enabling anemia screening, saving time and covering more beneficiaries.”— RBSK team
Persistent challenges hinder progress
Overcoming hurdles to effective health care delivery requires addressing a multitude of challenges. Despite efforts to improve anemia screening and treatment, significant gaps persist.
Shortages in screening devices hinder the scale of screening efforts, limiting the number of individuals who can be screened. Insufficient stocks of test strips disrupt screening activities, undermining the effectiveness of screening programs due to consumable shortages. The lack of device-specific consumables, combined with compatibility issues, compromises the further use of devices and screening.
Moreover, a disconnect between screening reports and treatment interventions often leads to untreated cases of anemia, highlighting the crucial need for integrated referral systems to ensure individuals identified with anemia receive appropriate treatment.
In addition, the limited availability and high cost of digital haemoglobinometers, especially recurring consumables, such as strips, cuvettes, batteries, and lancets for pricking, pose significant challenges. This is particularly acute in resource-constrained settings, hampering the widespread deployment and use of these advanced screening devices.
The proliferation of screening devices without adequate quality assurance undermines the reliability of screening outcomes, as multiple devices may vary in accuracy.
The market is saturated with numerous brands of digital haemoglobinometers, including those listed on the Government e-Marketplace portal. Ensuring the quality, sensitivity, and specificity of these devices is challenging. Furthermore, there are significant training gaps for the use of hemoglobinometers, leading to underutilization of these devices. Additionally, there are deficiencies in troubleshooting mechanisms at the ground level and insufficient systems for accessing biomedical maintenance and recalibration services.
The fear of needle pricks among adolescents presents yet another obstacle, deterring participation in screening efforts. To address this, non-invasive screening methods based on scientific evidence should be explored to ensure greater participation among this demographic.
Addressing these challenges require a comprehensive approach encompassing strategic planning, forecasting for procurement and supply of devices and consumables based on coverage needs, capacity building, stakeholder collaboration, and resource mobilization.
While non-invasive hemoglobinometers are available in the market, it is crucial to ensure that these devices possess scientifically acceptable levels of sensitivity and specificity for public health deployment. The technology behind non-invasive haemoglobinometers needs to be enhanced to improve their accuracy in anemia screening, and appropriate evidence must be generated to support their use.
By overcoming these obstacles, anemia screening programs can effectively identify and address the burden of anemia, ultimately improving health outcomes and enhancing the wellbeing of communities.
“Early detection of anemia using digital Hb meters enables timely treatment. Enhancing the accuracy of non-invasive Hb meters across anemia levels, and generating evidence for public health implementation, can accelerate these efforts.”— Jayendra Kasar, Senior Program Officer, PATH
Driving anemia reduction
PATH, with its expertise and evidence-based interventions, plays a significant role in reducing the burden of anemia. Through diagnostic evaluations, PATH guides policymakers and manufacturers in developing suitable point-of-care devices for anemia screening.
Conducting comprehensive assessments of the AMB program across 15 states in collaboration with The Inclen Trust International, UNICEF, and the Institute of Economic Growth, PATH provided critical insights into facilitators, barriers, and enablers of the program.
Employing living lab methodologies and human-centered design approaches, PATH collaborates with end-users to co-create effective solutions for AMB implementation. This collaborative effort has led to an operational feasibility study for non-invasive Hb meters for anemia screening, demonstrating PATH's commitment to innovative, user-driven improvements in health care.
Accredited Social Health Activist workers at the human-centered design (Living Labs) workshop in Bihar for anemia and AMB program. Photo: PATH
Moreover, PATH conducts training sessions to enhance the capacity of district-level health officials and stakeholders in implementing effective AMB strategies. PATH is also working on district saturation models to strengthen anemia interventions at the district level, developing strategic documents for anemia reduction, rolling out innovative IEC/BCC activities, and improving screening and treatment for anemia.
Through its multifaceted approach and collaborations, PATH drives progress towards achieving anemia-free communities and improving overall health outcomes for vulnerable populations.
