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

90

50

46

45.2

40

40

30

26.4

17

10.5

5.9

4

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95

India

Maldives

Nepal

Myanmar

Bangladesh

Sri Lanka

Indonesia

Bhutan

Thailand

England

USA

Norway

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

53.849

6566.2

48.2

33.9

63.5

47

61.6

44.4

30.926.2

0

10

20

30

40

50

60

70

Baroda Delhi Mumbai

Percen

tag

e (

%)

WEEKLY [Baseline anaemia prevalence (%)] WEEKLY [Final anaemia prevalence (%)]

DAILY [Baseline anaemia prevalence (%)] DAILY [Final anaemia prevalence (%)]

n=438 n=441 n=506 n=617 n=680 n=558

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 (1996-1998)

Indonesia Adolescent Study

15.6

7.8

20

5.7

17.3

21.3

0

5

10

15

20

25

0 week 12 week

Daily (n=64) Weekly (n=70) Placebo (n=75)

Haemoglobin < 120 g/L

Daily – 60 mg Fe, 750 µg retinol, 250mg folic acid and 60 mg vitamin CWeekly – 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

Prevalence of anaemia and serum ferritin level (in a sub sample) before and after 8 weeks of treatment

2518.5 19.8

9.5 8.6 13.4

66.6

54.159.1

82.792.3

56.3

0

20

40

60

80

100

Weekly Daily Placebo

Before treatment anaemia prevalence (%) After treatment anaemia prevalence (%)Before treatment ferritin level (µg/L) After treatment ferritin level (µg/L)

n=220 n=9 n=222 n=22 n=217 n=11

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

82.9

74.2

90 87.4

65.2

99.4

87.3

73.3

92.6 95

40.2

53.4

8580

54.749.4

40.2 39.1

58

89

13

0

20

40

60

80

100

120

*AP- S

GG

*Guja

rat-

SGG

(a) J

hark

and

- SG

G

*MP -

NSGG

*Mahr

asht

ra -

SGG&NSG

G

*UP (G

- NSGG

)

*UP (G

- SG

G)

* UP (L

-NSG

)

* UP (L

-SG

G)

(b) W

B - SG

G

Baseline 1 year post 2 years post

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%

11.1 11.1

10.12

11.1

8.5

10.4 10.5

12.111.7

10.9

11.4 11.25

1211.7

12.6

8

8.5

9

9.5

10

10.5

11

11.5

12

12.5

13 Baseline 1 year post 2 years post

Change in Mean Hb levels (g/dl)

* Statistical t test confirmed significant difference

Benefits Reported (all states)

Benefits % Range

Less fatigue 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

UP State - A Case Study

UMANG (Uplifting Marriage Age, Nutrition & Growth)

Gorakhpur

Lucknow

Coverage Two Districts :

Adolescent Girls 0.5 m

Coverage :

ICDS Centres 3762

Schools 1028

Age No. Interviewed Married %

10 -13 876 97 11%

14-16 630 103 16%

17-19 283 180 64%

Total 1789 380 21%

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 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 (4th Saturday / month)

73,700 NSG

School Going (SG) Girls

Map middle and senior schoolsOrientation 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 years 15 – 18 years

Baseline (%)

Post* (%)

Baseline (%)

Post * (%)

1. Awareness related to anaemia

• Yes 44.0 94.7 64.1 98.9

2. Measures for prevention

• By taking IFA tablets

• Both diet and IFA tablets

• Medicines and tonic

• Improved diet

• Any other

• DNK

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

* Following 6 months intervention

10

11

12

13

11 12 13 14 15 16 17 18 overall

Age

Mea

n H

aem

og

lob

in (

gm

%)

Pre (N=437) 6 months (N=413)12 months (N=216) Cut off point

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

10.4

11.3

12

9.5

10

10.5

11

11.5

12

12.5

Baseline 1st 6 months Next 6 months

Hb

(g

/dl)

1 year

Total Hb rise 2g/dl after 1 year of supervised consumption

n = 600 girls

Impact of WIFS on Hb Levels (NSG)

73.2

0.1

19.4

53.7

26.8

46.3

0 1.4

44.9

53.7

05

1015202530354045505560657075

Anaemic (Hb%<12g/dL) Severe (Hb%<7g/dL) Moderate (Hb%7-10g/dL) Mild (Hb%10-11.9g/dL) Non Anaemic(Hb%12g/dl)

Type of anaemia

Perce

ntage

(%)

baseline follow 6 months of IFA supplementation

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

Parameters School 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)

10.5 11.7 11.3 12.0t=8.36 (p<0.01)* t=8.35 (p<0.01)*

Overall % Anaemia (< 12 g/dL)

92.6 58.0 73.3 39.0

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)

10.5 11.7 11.3 12

92.6

58

73.3

39

0

10

20

30

40

50

60

70

80

90

100

Presupplementation

Postsupplementation

Presupplementation

Postsupplementation

Overall Hb levels (g/dL) Overall % anaemia (<12 g/dL)

SCHOOL GOING (Supervised)

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

73.3

39

25.4

0 0 1.6

7.9

1.1

6.5

65.4

37.9

17.3

26.7

61

74.6

0

10

20

30

40

50

60

70

80

2003 2004 2006

Per

cent

age

(%)

Total % anaemic Severely anaemic Moderately anaemic Mildly anaemic Non Anaemic

Change in anaemia status of combined NSG and SG adolescent girls in two selected blocks followed between 2003-2006

(N=1173) (N=870) (N=301)

Percentage of girls (Numbers)

Weekly consumptionYesNo - 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)

IFA consumption analysis undertaken in 150 NSG girls*

* Girls with UMANG for minimum 24 months

Cost incurred in the programme per beneficiary

Year No. of Beneficiaries

Cost (Rs) / head

Cost ( US$) / head

2003 3800 119.62 2.96

2004 22,695 58.60 1.45

2006 1,50,700 14.60 0.36

2.96

1.45

0.42 0.36

0

0.5

1

1.5

2

2.5

3

3.5

2003 2004 2005 2006

Co

st

($ /

gir

l) 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 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 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 (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