ADDRESSING ADOLESCENT ANAEMIA We Must Act Now Dr. Sheila Vir

Iron Deficiency and Iron Deficiency Anaemia (Global Scenario) Iron Deficiency - 3 out of 4 persons Iron Deficiency Anaemia - 1 out of every 3 persons or IDA (2 billion)

Anaemia Prevalence (%) in Adolescent Girls  Anaemia prevalence in developing countries Adolescent girls - 27% (6% in developed world) non pregnant women (WRA) years - 43% pregnant women - 56%

Causative Factors Significant increase in requirements of iron Low intake of bioavailable iron

Prevention of IDA Dietary diversification Fortification of food Iron supplements

Prevention of IDA – Both Health and Economic Issue Iron Folic Acid Supplementation – Benefits  Investment not limited to pregnancy  Positive influence on cognitive development  Enhanced concentration in school and work  Increased physical output  Improved growth (10-14 years)  Improved appetite  Decreased morbidity  Overcome irregularity in menstruation  Investment in pregnancy (Iron supplementation during pregnancy might be too late!)  Overcome large prepregnancy deposits  Reduces chances of LBW and MMR  Reduces chances of neural tube defects (NTD)  Improves iron status of infants

Prevention of Anaemia Daily or Weekly Dose of IFA ?  Global Efficacy and Effectiveness Trials  Meta Analysis

Weekly Iron Folic Acid Supplementation (WIFS) is Effective for Prevention of Anaemia in adolescent girls

Meta analysis (3 India + 6 others) - CONCLUSION – Weekly supplementation should be considered only in situations where there is strong assurance of supervision and high compliance (Beaton et al, 1999) India – Impact of Daily and Weekly IFA Administration to adolescent Girls ( )

Indonesia Adolescent Study Haemoglobin < 120 g/L Daily – 60 mg Fe, 750 µg retinol, 250mg folic acid and 60 mg vitamin C Weekly – 60 mg Fe, 6000 µg retinol, 500mg folic acid and 60 mg vitamin C Placebo - 0 mg Fe, 0 µg retinol, 0 mg folic acid and 0 mg vitamin C Prevalence of anaemia at baseline and after 12 weeks of supplementation Angeles-Agdeppa et al, 1997

Sri Lanka Adolescent Study Intervention Iron Folic Acid Supplements 6 monthly Deworming done Jayatissa and Piyasena, 1999

India Experience – Weekly Iron and Folic Acid Supplementation (WIFS) – 100 mg Fe µg Folic Acid  13 states (8.7 m girls)  Age group between 10 – 19 years  In School Girls (SG) and Non School Going Girls (NSG)  Anaemia prevalence 54-99% Source: Dwivedi and Schultink, 2006 SCN News # 31

Change in Anemia Prevalence by States (Hb<12 g/dl) * statistically significant difference (Chi square test, p<0.001, CI 95%) (a) Baseline is the ICMR estimation of anemia (Chi Square Test not possible) (b) out of school non participants represent baseline and school going participants represent assessment (Chi Square Test not possible) WIFS – compliance 75-90%

Change in Mean Hb levels (g/dl) * Statistical t test confirmed significant difference

Benefits Reported (all states) Benefits% Range Less fatigue25.5 – 65 More concentration24.2 – 85.5 Less breathlessness0.7 – 83.5 Feel healthy7.2 – 87.9 Able to work21 – 24.2 Good appetite18.2 – 88 Menstrual cycle regularReported

UP State - A Case Study UMANG (Uplifting Marriage Age, Nutrition & Growth)

Gorakhpur Lucknow Coverage Two Districts : Adolescent Girls0.5 m Coverage : ICDS Centres3762 Schools1028

AgeNo. InterviewedMarried% % % % Total % Age of Marriage (Gorakhpur district)

UMANG Project, LUCKNOW district, UP 10 Administrative rural and urban blocks Population covered 3,647,834 Included Non School Going (NSG) girls (11-18 years) and School Going (SG) girls (10-19 years) Implemented in 3 phases (2001 – 2006) Intervention Package Weekly IFA tablets (Fe 100 mg, Folic acid 500 µg) Six monthly deworming tablets (400 mg Albendezole) Family life education (FLEd), Counseling delay conception > 18 years

Reaching Adolescent Girls * Non School Going (NSG) School Going (SG) Health (RCH)+ ICDS (Adolescent Girls Scheme)+ PRI Health + Education (Middle and Senior school)+ PRI * NGO (Vatsalya) facilitated district programme implementation Non - supervised Supervised Intervention package (Deworming, WIFA, FLEd)

Coverage of NSG and SG adolescent girls in Lucknow district Phase (implementation period) No. of blocks (total population) Age group (years) No. of ICDS centres No. of schoolsAdolescent girls (NSG+SG) covered I (Sept 2001 – Dec 2002) 1 Block (85, 383) 11 – (only NSG) II (Jan 2003 – Dec 2004) 2 Blocks (3, 24, 087) 11 – , 695 (NSG = 12695) (SG = 10, 000) III (Jan 2005 – Dec 2007) 10 Blocks (rural and urban in the district) (3, 647, 834) 10 – , 50, 700 (NSG = 73, 700) (SG = 77, 000)

Non School Going (NSG) girls AWW + Adolescent Girl Scheme (3 girls / AWC) incharge of supply, monitoring / record UMANG group (20-25 girls), (kitty ?) girl to girl approach additional 20 – 25 girls (1:2) Deworming IFA Counseling on benefits Diet + FLEd (Fixed theme) + Q box Recording in registers (4 th Saturday / month) 73,700 NSG

School Going (SG) Girls Map middle and senior schools Orientation to Panchayat + district and block education officers 2 teachers / school (trainers) Each Saturday (Anaemia Day) Deworming IFA Tablet (Supervised) Individual recoding cards FLEd 77, 000 girls

IFA Supply (6 months)* District Hospital (Kit A + UNICEF supply) District Education Department Block Education Department Block PHC ICDS (CDPO Office) Selected Schools Anganwadi Centres School Going (SG) girls Non School Going (NSG) girls * Identical to those provided to pregnant mothers by GOI, Cost = Rs 11.40/100 tablets (blister packs)

Monitoring Form

Phase I – Knowledge of NSG adolescent girls – baseline and following 6 months of Family Life Education intervention 11 – 14 years15 – 18 years Baseline (%) Post* (%) Baseline (%) Post * (%) 1.Awareness related to anaemia Yes Measures for prevention By taking IFA tablets Both diet and IFA tablets Medicines and tonic Improved diet Any other DNK * Following 6 months intervention

Phase I – Impact on haemoglobin levels following 6 and 12 months of weekly IFA consumption by non school going (NSG) adolescent girls

1 year Total Hb rise 2g/dl after 1 year of supervised consumption n = 600 girls Impact of WIFS on Hb Levels (NSG)

School Going Girls – Status of anaemia at baseline (596 girls) and following 6 months of weekly IFA supplementation (573 girls)

ParametersSchool Going (SG) Supervised Non School Going (NSG) Non Supervised Pre (n=299) Post (n=276) Pre (n=300)Post (n=297) Overall Hb level (g/dL) t=8.36 (p<0.01)*t=8.35 (p<0.01)* Overall % Anaemia (< 12 g/dL) t=8.545 (p<0.01)**t=6.373 (p<0.01)** Overall haemoglobin levels (g/dL) and anaemia prevalence (%) in SG (School Going – supervised) and NSG (Non – School Going – Non Supervised) adolescent girls * Mean haemoglobin (gm %) - t value for SG vs NSG < 1 (no significant difference) **Prevalence of anaemia (%) – t value for SG vs NSG < 1 (no significant difference)

Overall haemoglobin levels (g/dL) and anaemia prevalence (%) in SG (School Going – supervised) and NSG (Non – School Going – Non Supervised) adolescent girls

Change in anaemia status of combined NSG and SG adolescent girls in two selected blocks followed between (N=1173)(N=870) (N=301)

Percentage of girls (Numbers) Weekly consumption  Yes  No - Forget to take - health effects - other non specific 86 (129) 14 (21) 52.4 (11) 28.6 (6) 19.0 (4) Girls - perceived impact -Positive response -Negative response -No specific response 62.7 (94) 18.6 (28) 18.7 (28) Consumption time -any time -following dinner -empty stomach 16.7 (25) 82.7 (124) 0.6 (1) Method of consuming -with milk -with tea/coffee -with water (1) 99.4 (149) IFA consumption analysis undertaken in 150 NSG girls* * Girls with UMANG for minimum 24 months

Cost incurred in the programme per beneficiary YearNo. of Beneficiaries Cost (Rs) / head Cost ( US$) / head , ,50,

UMANG Project - Cost ($)/Adol. girl

Success Factors High priority (State / District / PRI) Integrated with ongoing programme Supply regular and streamlined Package presentation of IFA (blister packs) Distribution of IFA (fixed day approach) Family Life Education (Theme – fixed month) Multisectoral Training (Training Manual) IEC and Social Mobilisation (emphasis on benefits – increase compliance) Monitoring (NGO involved)

Preventing Adolescent Anaemia Access to dietary iron – long term strategy WIFS – short term strategy  effective preventive strategy for iron deficiency and iron deficiency anaemia  benefits in future outweigh the cost incurred  manageable in community settings (schools, factories, community organisation, mass media)  integrate with ongoing development programme (Education, ICDS, RCH)

From District Project to UP State Programme Weekly Iron and Folic Acid Supplementation (WIFS) intervention integrated with ongoing state efforts for reaching Adolescent girls  Health Sector (SG) - RCH II (UP) with Education sector (Every Saturday / week)  ICDS (NSG) - Mission Poshan (4th Saturday of Month)

Prevention of Iron Deficiency and Impact on MDGs MDG GoalsImpact of IDA Prevention MDG # 1 Eradicate Extreme Poverty and Hunger increases body’s capacity to do work (for every 10% increase in HB – 15% increase in physical work) Reduces low birth weight undernutrition in under 5 year MDG # 2 Achieve Universal Primary Education Reduces frequency and severity of infections / morbidity and mortality school attendance, retention, learning capacity and school achievement MDG # 3 Promote Gender Equality and Empower Women Anaemia in girls – often more severe than in boys. Adversely influences school attendance and achievement. gender disparity MDG # 4 Reduce Child Mortality Reduces serious consequences on child health, including LBW, still birth child mortality MDG # 5 Improve Maternal Health Reduction of maternal anaemia MMR (20% of these maternal deaths directly attributed to anaemia)

Moving Ahead 1991 – National Nutritional Anaemia Prophylaxis Programme (NNAPP) revised to National Anaemia Control Programme (NACP) 1998 – National Anaemia Consultation Report “Demonstrate large scale district level projects to study the effectiveness of WIFA supplementation to adolescent girls.” 2007 – Review of Policy – IFA (23 rd April 2007) “ Adolescents, 11 – 18 years will be supplemented at the same doses and duration as adults. The adolescent girls will be given priority.” 2008 – We all must act now Redefine specific cost effective dosage and strategy (WIFS and Nutrition Education) for addressing anaemia prevention in adolescent girls

Thank You