1. Anemia issue and challenges Presenter - Akash Ranjan Moderator- Dr Ranjan Solanki

2. Anemia- The number of Red Blood Cells, and consequently their Oxygen carrying capacity, is insufficient to meet the body’s physiological need Age group No Anaem ia Mil d Mo de rat e Se ve re Children 6-59Mth≥1110-10.97- 9.9<7 Children 5-11 Yr.≥11.511- 11.48- 10.9<8 Children 12-14Yr≥1211-11.98- 10.9<8 Non pregnant women (≥ 15Yr) ≥1211- 11.98- 10.9<8 Pregnant women≥1110- 10.97- 9.9<7 Men≥1311- 12.98- 10.9<8 Source: : Haemoglobin concentration for the diagnosis of anaemia any assessment of severity. WHO Diagnosis:

3. Aetiology-  Iron Deficiency: Commonest cause of anaemia in developing countries. Among the most vulnerable groups (pregnant women and preschool age children)

4.  Iron Deficiency:

5.  Other micronutrient deficiencies Vit B 12 Follic Acid  Helminthic infection Hookworm Flukes  Malaria  Sickle cell disease and Thalassemia  Infections Chronic diseases, such as cancer, HIV/AIDS, rheumatoid arthritis, Crohn’s disease. Kidney failure

6. Magnitude of problem World:

7. Country Proportion of population with Anaemia (Hb<11gm/dl) Public Health problem Bangladesh47.0Severe Bhutan80.6Severe India74.3Severe Nepal78.0Severe Pakistan50.9Severe Sri Lanka29.9Moderate Magnitude of problem South- East Asia Region: Source : WHO Global Database on Anaemia

8. Age group Prevalence of Anaemia( %) Children (6-35 months) 79 All women (15-49 years) 55.3 Pregnant women (15-49 Years) 58.7 Lactating women (15-49 Years) 63.2 Adolescent Girls 12-14 Years 68.6* 15-17 Years 69.7* 15- 19 Years 55.8 India: Table3: Prevalence of Anaemia among different age groups Source: NFHS 3 *National Nutrition Monitoring Bureau Survey (NNMBS), 2006 Source: NFHS-2, NFHS-3

9. Source: NFHS-3, NNMBS 2006

10. Prevalence of anaemia among pregnant women, men and women of reproductive Age: Source: NFHS-3, 2005-06 According to NFHS-3 Anemia affecting:  55 % of women  58 % of pregnant women  24 % of men  56 % Ever married women

11.  About 1 million deaths a year worldwide, of which 3/4 th occur in Africa and SEA.  World’s second leading cause of disability.  Responsible for 2.4 per cent of the total DALYs worldwide.  Delayed psychomotor development and impaired performance in children equivalent to a 5–10 point deficit in IQ.  Physical and cognitive losses due to IDA cost up to 4 % loss in GDP for developing countries while 1.18 % of GDP in India. Impact of Anaemia on Health Outcomes: The WHO 2002 Report titled “Preventing Risks and Promoting Healthy Life”, mentioned iron deficiency as one of the top 10 preventable risks to disease disability and death in the world today.

12. Impact of Anaemia on pregnancy Outcomes

13.  Worldwide, 20 % of maternal deaths are due to anemia.  In addition, contributes partly to 50 % of all maternal deaths.  Threaten household food security and income.  Severe anemia in pregnancy leads to intrauterine growth retardation, stillbirth, LBW and neonatal deaths. Impact of Anaemia on pregnancy Outcomes

14. Results in to Because that Why Anemia control? Improve school achievement Increases earning potential Raise ability to care for family More work capacity so more income More energy and better health Better mental concentration Improve learning ability

15.  1968: Nutrition Society of India recommended an anaemia prophylaxis programme for the eradication of anaemia of pregnancy and childhood.  1970: GoI had set up the National Anaemia Prophylaxis Programme (NAPP) in all States of the country. Target population-Pregnant & lactating women, family planning acceptor women (of terminal methods and I.U.D.s) and children between 1- 11 years. Supplementation- 60 & 20mg elemental Fe, 500 &100µg Follic acid for pregnant women & children respectively. Duration- For 100 days, once a year /Year/ beneficiary  1985-86: ICMR conducted the evaluation of programme in 11 states yielded the following depressing conclusions No significant impact on the prevalence of anaemia Supply, distribution & compliance of tablets were poor poor quality of the tablets How India is addressing Anaemia

16.  Recommendations of the lCMR Task Force on Evaluation of NAAP: Education of the health functionaries involved in implementation Periodic checking of the quality of tablets. Pilot study to find out the best strategy for delivery of the supplement Ensuring adequate and regular supply of the supplement to PHC To consider alternate strategies as additional measures to control nutritional anaemic  But surprisingly nothing has been said about the dosage of Iron In 1990, Dr B S Narsinga Rao (Former Director of NIN ) suggested “Iron dosage to anaemic pregnant women should be 120 mg/day, improve the appearance of the tablet, Better linkages between the ICDS and the health system, selected groups at risk & need to augment dietary intake of iron

17.  1991 -National Nutritional Anemia Control Program Aim- To decrease the incidence of anemia among the vulnerable sections of the population  1993 - National Nutrition Policy  Objective- operationalizing multi-sectoral strategies to address the problem of under-nutrition/malnutrition Studies recommended:  Liquid IFA supplementation instead of Tablets in young children (<3 Yr).  IFA supplementation even in < 1yr.  Both recommendation endorsed in GoI’s policy in 2007 NNMB 2003 documented prevalence of Anemia in children:  Any Anemia 67%  Mod-Sev Anemia 43%  The lack of monitoring system

18.  The WHO strongly advocate when there is a prevalence of anemia above 40%, a universal supplementation is required and it is not cost-effective to screen children for anemia. However, technical experts believe that to differentiate severe anemia, a screening is desirable. Issues in management of anemia What is important and needs to be emphasized is that universal intervention need not wait until this screening, and that screening is done primarily with the aim of finding children afflicted with severe anaemia that may not be corrected with the current program and would need specific treatment.

20.  2013: Taking cognizance of ground realities the MoHFW took a policy decision to develop the National Iron+ Initiative.  Bring together existing programmes of IFA supplementation and introduce new age group.  A minimums service of packages for treatment and management of anaemia.

21.  Bi-weekly for preschool children 6 months to 5 years.  Weekly supplementation for children from 1 st to 5 th grade in Govt. & Govt. Aided schools  Weekly supplementation for out of school children (5–10 yr) at AWC  Weekly supplementation for adolescents (10–19 years)  Pregnant and lactating women  Weekly supplementation for women in reproductive age  IFA tablet has been made blue (‘Iron ki nili goli’) to distinguish it from the red IFA tablet for pregnant and lactating women. National Iron+ Initiative will reach the following age groups for supplementation The campaign has been built around benefits of IFA supplementation and healthy eating

22.  A multi-factorial disorder that requires a multi-pronged approach for its prevention and treatment  The benefit-to-cost ratio of iron interventions is as high as 200:1  Ministry of Health and Family Welfare’s Revised Strategy for control and prevention of IDA would be Provision of IFA supplementation Therapeutic management of mild, moderate and severe anaemia in the most vulnerable groups Approach – What Would It Take to Fight Iron Deficiency and IDA More Effectively?

25. ASHAs and ANMs will screen children from 6 months up to 5 years of age for signs of anaemia throug opportunistic screening at VHNDs Immunisation sessions House-to-house visits by ASHAs for biweekly IFA supplementation Sick child coming to health facility (SC/PHC) Therapeutic Approach through the Life Cycle Six Months – 60 Months

32.  It is disheartening, that In India, where the program is in place for more than four decades, it is not being implemented at any significant level.  The small amount of data that exists regarding the program points to poor implementation.  There is also a brighter side to anemia control, that although long awaited, it is now getting the recognition and attention it rightfully deserves  MDG’s aimed at the reduction of infant and maternal mortality will have to address anemia as it is a common problem with serious consequences for both these groups Conclusion:

33. 1. Guideline for Control of Iron Deficiency Anaemia, National Iron+ Initiative. In: Division A, editor. New Delhi: Ministery of Health and Family Welfare, Government of India; 2013. 2. Iron Deficiency Anaemia Assessment, Prevention and Control: A guide for Programme managers. Geneva: World Health Organization; 2001. 3. WHO. Guideline: Daily iron and folic acid supplementation in pregnant women. Geneva, World Health Organization, 2012 4. WHO. Guideline: Intermittent iron and folic acid supplementation in non-anaemic pregnant women. Geneva, World Health Organization, 2012 5. WHO. Guideline: Intermittent iron and folic acid supplementation in menstruating women. Geneva, World Health Organization, 2011 6. WHO. Guideline: Intermittent iron supplementation in preschool and school-age children. Geneva, World Health Organization, 2011 7.Vijayaraghavan K, Brahmam GN, Nair KM, Akbar D, Rao NP. Evaluation of national nutritional anemia prophylaxis programme. Indian journal of pediatrics. 1990 Mar-Apr;57(2):183-90. PubMed PMID: 2246014. 8.http://nutritionfoundationofindia.res.in/pdfs/BulletinArticle/Pages_from_nfi_04_91_2.pdfhttp://nutritionfoundationofindia.res.in/pdfs/BulletinArticle/Pages_from_nfi_04_91_2.pdf 9. Sood SK, Ramachandran K, Mathur M, et al. WHO sponsored collaborative studies on nutritional anaemia in India. Q J Med. 1975; 44:241–258. 10. ICMR (1989); Report of a Task Force Studies on the evaluation of National Anaemia Prophylaxis Programme. 11. Kotecha PV, Nutritional Anemia in Young Children with Focus on Asia and India. Indian J Community Med. 2011 Jan-Mar; 36(1): 8-16 12. Hyderabad, India: Indian Council of Medical Research; 2003. NNMB. National Nutrition Monitoring Bureau: Prevalence of Micronutrient Deficiencies: NNMB Technical Report No. 22, National Institute of Nutrition. References:

34.  We need to bridge the gap between our desire to control/ reduce the anemia and our lack of action and apathy toward implementing an effective program in anemia control.  We need to emphasize, train, support, and effectively monitor the program's implementation, and systematically and realistically plan out logistics, supply, monitoring, and implementation of the program at the regional, national, state, and district levels.  Only then will this curse, that is, anemia, be adequately controlled and the fruits that the program promises will actually be delivered.