Anemia issue and challenges

Presenter - Akash RanjanModerator- Dr Ranjan Solanki

Anemia- The number of Red Blood Cells, and consequently their Oxygen carrying capacity, is insufficient to meet the body’s physiological need

Age groupNo Anaemia

Mild

Moderate

Severe

Children 6-59Mth ≥11 10-10.9 7- 9.9 <7

Children 5-11 Yr. ≥11.5 11- 11.4 8- 10.9 <8

Children 12-14Yr ≥12 11-11.9 8- 10.9 <8

Non pregnant women (≥ 15Yr) ≥12 11-

11.9 8- 10.9 <8

Pregnant women ≥11 10- 10.9 7- 9.9 <7

Men ≥13 11- 12.9 8- 10.9 <8

Source: : Haemoglobin concentration for the diagnosis of anaemia any assessment of severity. WHO

Diagnosis:

Aetiology-

Iron Deficiency: Commonest cause of anaemia

in developing countries.

Among the most vulnerable groups (pregnant women and preschool age children)

Iron Deficiency:

Other micronutrient deficiencies Vit B12

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

Magnitude of problemWorld:

Country

Proportion of population with Anaemia (Hb<11gm/dl)

Public Health problem

Bangladesh 47.0 Severe

Bhutan 80.6 Severe

India 74.3 Severe

Nepal 78.0 Severe

Pakistan 50.9 Severe

Sri Lanka 29.9 Moderate

Magnitude of problem

South- East Asia Region:

Source: WHO Global Database on Anaemia

Age group Prevalence of Anaemia(%)

Children (6-35 months) 79All 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

Urban Rural Total Urban Rural TotalNFHS-2 NFHS-3

0102030405060708090

Graph 1: Prevalence of anemia among children 6-

35mth (%)

MildModSevAny

Source: NFHS-2, NFHS-3

12-14 Yr

15-19Yr 20-29 Yr

12-14 Yr

15-19Yr 20-29 Yr

12-14 Yr

15-19Yr 20-29 Yr

12-14 Yr

15-19Yr 20-29 Yr

Any Mild Moderate severe

01020304050607080

68.6

55.8 56.1

27

39.1 38.5

20.514.9 16

1.1 1.7 1.7

Graph2: Prevalence of anemia among Adolescent girls (12-19 Yr) and young women (20-29Yr)

Source: NFHS-3, NNMBS 2006

Prevalence of anaemia among pregnant women, men and women of reproductive Age:

Mild Moderate Severe Any0

10

20

30

40

50

60

70

2631

2

58

Graph4: Prevalence of anemia among pregnant women

Percentage

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  

About 1 million deaths a year worldwide, of which 3/4th 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.

Impact of Anaemia on pregnancy Outcomes

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

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

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

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 IronIn 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

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

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.

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.

Bi-weekly for preschool children 6 months to 5 years. Weekly supplementation for children from 1st to 5th

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

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?

 

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 CycleSix Months – 60 Months

 

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:

 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, 20124.  WHO. Guideline: Intermittent iron and folic acid supplementation in non-anaemic       pregnant women. Geneva, World Health Organization, 20125.  WHO. Guideline: Intermittent iron and folic acid supplementation in menstruating women. Geneva, World Health Organization, 20116.  WHO. Guideline: Intermittent iron supplementation in preschool and school-age children. Geneva, World Health Organization, 20117.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.pdf9. 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): 8-1612.  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:

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.