Transcript Slide 1

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
Norway
4
USA
5.9
England
10.5
Thailand
17
Bhutan
26.4
Indonesia
30
Sri Lanka
40
Bangladesh
40
Myanmar
45.2
Nepal
46
Maldives
50
India
90
0
5
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95
Percentage (%)
Anaemia prevalence in developing countries
• Adolescent girls
- 27% (6% in developed world)
• non pregnant women (WRA) 15-49 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
India – Impact of Daily and Weekly IFA Administration to
adolescent Girls (1996-1998)
WEEKLY [Baseline anaemia prevalence (%)]
DAILY [Baseline anaemia prevalence (%)]
66.2
Percentage (%)
70
60
WEEKLY [Final anaemia prevalence (%)]
DAILY [Final anaemia prevalence (%)]
65
63.5
61.6
53.8
50
44.4
49
48.2 47
40
30.9
33.9
26.2
30
20
10
0
n=438
n=441
Baroda
n=506
Delhi
n=617
n=680
n=558
Mumbai
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)
Indonesia Adolescent Study
25
Daily (n=64)
Weekly (n=70)
Placebo (n=75)
21.3
20
20
17.3
15.6
15
10
7.8
5.7
5
0
12 week
0 week
Haemoglobin < 120 g/L
Prevalence of anaemia at baseline and after 12 weeks of supplementation
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
Angeles-Agdeppa et al, 1997
Sri Lanka Adolescent Study
Before treatment anaemia prevalence (%)
Before treatment ferritin level (µg/L)
After treatment anaemia prevalence (%)
After treatment ferritin level (µg/L)
92.3
100
82.7
80
66.6
60
40
25
20
0
59.1 56.3
54.1
9.5
n=220
19.8
18.5
8.6
n=9
Weekly
n=222
Daily
n=22
13.4
n=217
n=11
Placebo
Prevalence of anaemia and serum ferritin level
(in a sub sample) before and after 8 weeks of treatment
Intervention
• Iron Folic Acid Supplements
• 6 monthly Deworming done
Jayatissa and Piyasena, 1999
India Experience – 2000-2005
Weekly Iron and Folic Acid Supplementation (WIFS) –
100 mg Fe + 500 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)
120
Baseline
1 year post
2 years post
99.4
100
90
82.9
87.4
80
85
87.3
74.2
80
95
92.6
89
73.3
65.2
60
58
54.7
53.4
49.4
40.2
40.2
39.1
40
20
13
G
)
(b
)W
B
-S
G
G
(L
-S
P
*U
*U
P
(L
-N
G
SG
G
-S
*U
P
(G
-N
(G
P
*U
)
G
)
)
SG
G
SG
G
&N
-S
G
-N
*M
ah
ra
sh
tra
*M
P
-S
ka
nd
(a
)J
ha
r
tS
uj
ar
a
*G
SG
G
G
G
G
G
G
G
PS
*A
G
0
* 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)
13
12.5
12.6
1 year post
2 years post
12.1
12
11.7
12
11.5
Baseline
11.1
11.1
11
10.5
11.7
10.9
11.4
11.1
11.25
10.5
10.4
10.12
10
9.5
9
8.5
8.5
(L
P
U
(L
P
U
* Statistical t test confirmed significant difference
-S
G)
)
-N
SG
(G
)
P
U
M
ah
*M
P
uj
*G
A
P
8
Benefits Reported (all states)
Benefits
Less fatigue
% Range
25.5 – 65
More concentration
24.2 – 85.5
Less breathlessness
0.7 – 83.5
Feel healthy
7.2 – 87.9
Able to work
21 – 24.2
Good appetite
18.2 – 88
Menstrual cycle regular
Reported
UMANG (Uplifting Marriage Age, Nutrition & Growth)
UP State - A Case Study
Coverage
Two Districts :
Adolescent Girls
0.5 m
Coverage :
ICDS Centres
3762
Schools
1028
Gorakhpur
Lucknow
Age of Marriage (Gorakhpur district)
Age
No. Interviewed
Married
%
10 -13
876
97
11%
14-16
630
103
16%
17-19
283
180
64%
Total
1789
380
21%
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*
Intervention package
(Deworming, WIFA, FLEd)
Non School Going (NSG)
School Going (SG)
Supervised
Non - supervised
Health (RCH)+ ICDS
(Adolescent Girls
Scheme)+ PRI
Health + Education (Middle and Senior
school)+ PRI
* NGO (Vatsalya) facilitated district programme implementation
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 schools
Adolescent girls
(NSG+SG)
covered
I (Sept 2001 –
Dec 2002)
1 Block
(85, 383)
11 – 18
95
-
3800
(only NSG)
II (Jan 2003 –
Dec 2004)
2 Blocks
(3, 24, 087)
11 – 18
169
100
22, 695
(NSG = 12695)
(SG = 10, 000)
III (Jan 2005 –
Dec 2007)
10 Blocks
(rural and
urban in the
district)
(3, 647, 834)
10 – 19
1275
351
1, 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
Selected Schools
School Going (SG) girls
Block PHC
ICDS (CDPO Office)
Anganwadi Centres
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 years
1.
Awareness related
to anaemia
•
Yes
2.
Measures for
prevention
•
•
•
•
•
•
By taking IFA tablets
Both diet and IFA tablets
Medicines and tonic
Improved diet
Any other
DNK
* Following 6 months intervention
15 – 18 years
Baseline
(%)
Post*
(%)
Baseline
(%)
Post *
(%)
44.0
94.7
64.1
98.9
4.2
1.5
26.0
12.5
0.8
56.6
38.0
35.3
6.5
16.8
0.5
7.3
10.3
3.6
27.9
21.8
1.2
39.1
37.3
22.8
4.6
31.4
0.3
4.4
Pre (N=437)
12 months (N=216)
6 months (N=413)
Cut off point
Mean Haemoglobin (gm %)
13
12
11
10
11
12
13
14
15
16
17
18
overall
Age
Phase I – Impact on haemoglobin levels following 6 and 12 months of
weekly IFA consumption by non school going (NSG) adolescent girls
Impact of WIFS on Hb Levels (NSG)
12.5
n = 600 girls
12
Hb (g/dl)
12
11.3
11.5
11
10.5
10.4
10
9.5
Baseline
1st 6 months Next 6 months
1 year
Total Hb rise 2g/dl after 1 year of supervised consumption
Percentage (%)
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
baseline
73.2
follow 6 months of IFA supplementation
53.7
46.3
53.7
44.9
26.8
19.4
0.1
Anaemic (Hb%<12g/dL)
0
1.4
Severe (Hb%<7g/dL) Moderate (Hb%7-10g/dL) Mild (Hb%10-11.9g/dL)
Non Anaemic
(Hb%12g/dl)
Type of anaemia
School Going Girls – Status of anaemia at baseline (596 girls) and
following 6 months of weekly IFA supplementation (573 girls)
Overall haemoglobin levels (g/dL) and anaemia prevalence (%) in SG (School Going
– supervised) and NSG (Non – School Going – Non Supervised) adolescent girls
Parameters
Overall Hb
level (g/dL)
Overall %
Anaemia (<
12 g/dL)
School Going (SG)
Supervised
Pre
Post
(n=299)
(n=276)
10.5
11.7
Non School Going (NSG)
Non Supervised
Pre (n=300)
Post
(n=297)
11.3
12.0
t=8.36 (p<0.01)*
t=8.35 (p<0.01)*
92.6
58.0
t=8.545 (p<0.01)**
73.3
39.0
t=6.373 (p<0.01)**
* 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)
100
92.6
Overall Hb levels (g/dL)
Overall % anaemia (<12 g/dL)
90
80
73.3
70
58
60
50
39
40
30
20
10.5
11.7
12
11.3
10
0
Pre
supplementation
Post
supplementation
SCHOOL GOING
(Supervised)
Pre
supplementation
Post
supplementation
NON SCHOOL GOING
(Non Supervised)
Overall haemoglobin levels (g/dL) and anaemia prevalence (%) in SG (School Going
– supervised) and NSG (Non – School Going – Non Supervised) adolescent girls
80
Total % anaemic
Severely anaemic
Moderately anaemic
Mildly anaemic
Non Anaemic
74.6
73.3
70
65.4
Percentage (%)
61
60
50
39
40
37.9
26.7
30
25.4
17.3
20
7.9
10
6.5
0
0 1.1
2003
2004
1.6
0
(N=1173)
(N=870)
2006
(N=301)
Change in anaemia status of combined NSG and SG adolescent
girls in two selected blocks followed between 2003-2006
IFA consumption analysis undertaken in 150 NSG girls*
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
0.6 (1)
99.4 (149)
* Girls with UMANG for minimum 24 months
Cost incurred in the programme per beneficiary
Year
No. of
Beneficiaries
Cost (Rs) / Cost ( US$)
head
/ head
2003
3800
119.62
2.96
2004
22,695
58.60
1.45
2006
1,50,700
14.60
0.36
UMANG Project - Cost ($)/Adol. girl
3.5
Cost ($ / girl)
3
2.96
2.5
2
1.45
1.5
1
0.5
0.42
0.36
2005
2006
0
2003
2004
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 Goals
Impact 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 • Anaemia in girls – often more severe than in
Empower Women
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 (23rd 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