Background - Malaria is a leading cause of morbidity in Ethiopia. However, its transmission varies in both space and time, and large areas of the country are hypoendemic and epidemic-prone. The Ethiopia National Malaria Indicator Survey 2007 is a cross-sectional, nationally-representative household survey. The objective of the analyses presented here were to use the survey's data to identify factors associated with anemia presence in children under 6 years of age (U6); specifically, investigate the association between malaria and anemia; and discuss using anemia as a malaria proxy biomarker in the Ethiopian hypo-endemic transmission setting.

Methods The survey sampled 4185 households in 347 enumeration areas =2500 m above sea level. Primary outcome was increasing anemia severity in sampled children: no anemia (Hb: =11g/dl); mild anemia (Hb: =8g/dl and <11g/dl); and moderate–severe anemia (Hb: <8g/dl). Secondary outcomes were positive malaria rapid diagnostic test (RDT) or blood slide microscopy.

Results The analysis included 6054 (92.0%) children U6 in 3962 households. The proportion of children with no anemia, mild anemia, and moderate-severe anemia was 63.6%, 31.3%, and 5.1%, respectively. The overall prevalence of anemia (Hb <11g/dl) was 36.4% (95% CI 34.4–38.4). Factors independently associated with reduced relative odds of anemia categories were age (OR=0.7, 95% CI 0.7–0.7) and female sex (OR=0.9, 95% CI 0.8–1.0); malaria RDT positivity was associated with increased relative odds of a more severe anemia category (OR=5.8, 95% CI 3.7–9.2).

Conclusions We conclude that at altitudes =2500 m malaria appears to be a significant risk factor for anemia; potentially anemia could be used as a useful proxy biomarker for malaria and its control in Ethiopia