Recent scientific findings, implementation issues & opportunities

for integration

Rolf Klemm, DrPH Johns Hopkins School of Public Health and A2Z: The

USAID Micronutrient and Child Blindness Project

Addressing Anemia Full Spectrum

Core Group Spring Meeting-May 11, 2011

Hold your breath

Breath!!!

Overview

• Anemia “101” & the case for integration

• New Scientific Findings

• Interventions: What works? Effective? Safe?

• Implementation: What needs more work?

• Opportunities for Integration

Anemia “101”

The Basics

–Defined as… Hemoglobin (Hb) concentration <2 standard deviations of the age- and sex specific normal reference–Hb binds to oxygen and carries it to tissues–Red blood cells (RBCs) consist mostly of Hb.–Commonly used indicator to screen for iron deficiency in population-based surveys but not specific for iron deficiency

Anemia

Normal RBCs Anemic RBCs

Not all anemia is caused by iron deficiency….but iron deficiency is a major cause in many dev’g countries.

Ane

mia Iron deficiency

Iron Deficiency

Anemia

Other vitamin deficiencies

Hookworm

Malaria

HIV/AIDS

Anemia of Inflammatory Conditions

Hemoglobin-opathies

Overlapping causes of Anemia

Malaria Anemia Hookworm

Severe: ≥40%

Moderate: 20-39%

Institute of Medicine, 2001

Iron requirement at different life stages

New Scientific Findings

Anemia is one of the most widespread disorders in the world.

Africa Asia

No. Affected(million)

Prevalence (%)

No. Affected(million)

Prevalence (%)

Pregnant 19.3 55.8 31.7 41.6

Non-Pregnant 82.9 44.4 318.3 33.0

Total 102.2 350.0

More than half a billion women are anemic worldwide

McLean et al. Public Health Nutr, 2008, 12: 444-454

New Scientific Evidence• Improving Hb by 1 g/dL in pregnancy is associated with a

20% decreased risk of maternal mortality (Murray-Kolb, 2010, unpublished)

• Maternal IFAS associated with 50% ↓ in very pre-term births & 54% ↓ early neonatal mortality (Zeng L, BMJ 2008)

• Nepalese women receiving IFA in pregnancy had 16% ↓ in LBW & 60 g ↑in birth weight (Christian P; BMJ, 2003)

• Maternal IFA ↓ mortality among Nepalese children by 31% between birth & 7 years (Christian P; Am J Epidemiol, 2009)

• IFA during ANC associated with 90% ↓ in early neonatal deaths in Indonesia (Titaley CR, Bull World Health Organ, 2009)

• IFA + IPTp in mothers associated with 24% ↓ in neonatal deaths 19 countries Sub-Saharan Africa (Titaley CR et al, AJCN, 2010)

Growing body of evidence that maternal anemia interventions are not only important for the

health of the mom, but also for her neonate, and child

Are we making progress on

reducing maternal anemia?

Increases or little change in anemia prevalence in most countries over 5 years based on DHS

0 10 20 30 40 50 60 70 80Anemia Prevalence

Uganda 2006Uganda 2000-01Senegal 2008-09

Senegal 2005Philippines 2008Philippines 1998

Mali 2006Mali 2001

Jordan 2007Jordan 2002

India 2005-06India 1998-99

Ghana 2008Ghana 2003Egypt 2005Egypt 2000

Source: Demographic and Health Survey Compiler Data 2004-2008

Anemia Prevalence among Pregnant Women Over Five Years By Country

Severe Moderate Mild

Klemm R, et al. Unpublished

Interventions to reduce iron

deficiency anemia-What works?

Effectiveness and Safety?

Delivery & Newborn Care

BreastFeeding

ComplementaryFeeding

Delayed CordClamping

↑ iron intakeITN

• Anemia• ↑ maternal

mortality• ↑ LBW• ↑ neonatal

and child mortality

• Anemia• Altered

development and behavior

Birth &Colostrum

Infant and Young ChildFeeding (IYCF)

Pre-conception

↑ iron intake (WIFS)Treat hookworm,ITN for malaria

• High risk of iron deficiency

Fortification

Pregnancy

↑ iron intake, prevent LBWTreat hookwormIPT, ITN for malaria

• Anemia• Constrained

productivity• Less well

baby

Focused Antenatal Care (FANC)

Woman-Mother-Newborn-Young ChildContinuum of Care

Cautionary Comments for iron supplementation in malaria-endemic areas”

• WHO (2007): “Universal iron supplementation (i.e. use of medicinal iron as pills or syrups) should not be implemented without the screening of individuals for iron deficiency, because this mode of iron administration may cause severe adverse events in iron-sufficient children”

• Cochrane review (2009): “Iron supplementation does not increase risk of clinical malaria or death, when regular malaria surveillance and treatment services are provided. There is no need to screen for anemia prior to iron supplementation”

Implementation-What needs more work?

Use of iron tablets by ANC attendees, Uganda, n=612

≥1 ANC visit Received ANY IFA tablets

Consumed ≥30 tablets

Consumed ≥90 tablets

0

10

20

30

40

50

60

70

80

90

100 High proportion of women have at least 1 ANC visit

A2Z Survey (2009) of ANC platforms, unpublished data

~40% who had an ANC visit did NOT receive ANY

IFA tablets

AND….<10% consumed ≥30 tablets

Use of iron tablets by ANC attendees in Jharkhand, India, 2008 n=955

A2Z Project, Jharkhand MARP Baseline Survey, 2008, n=9540

10

20

30

40

50

60

Attended ANC

Rec’d IFA Cosumed

IFA given

Consumed ≥90 iron tablets

Precent

Only ~55% attend ANC

78% who attend ANC get iron

80% who get iron take all they get

Only 12% take ≥90 tablets

0

10

20

30

40

50

60

Consumed All IFA received

Did not consume all IFA received

%

A2Z Mirocnutrient Project, Jharkhand MARP Baseline Survey, 2007-08, n=597, unpublished

But SOME women will experience difficulties. They need to be found, listened to & counseled.

Health Services Offered at Distribution

Point/Platform(ANC, CHW Visits, Care Groups, ITN

delivery, etc)

Access to care(i.e. distribution points/

delivery channel)

Availability of supplies

(Iron tablets, deworming & antimalaria drugs & ITNs)

Quality(of counseling about need for iron supplementation,

deworming & IPTp & ITNs; benefits & managing side-

effects)

Health System

Awareness & Motivation to Use

Services(risks & benefits)

Supply DemandUse of Health

Services offered at Distribution Point/Platform

Practices(ANC, iron tablets,

IPTp, ITNs, deworming)Knowledge

(management of side-effects, # of supplements to

take, when to start)

Enabling Social Environment

(support of husband, mother-in-law, etc)

Enabling Social & Policy

Environment

Outcomes

Increased: IFAS

DewormingIPT

ANC use

Reduced Maternal Anemia

Satisfaction with Service

CHW=Community Health WorkerANC=Antenatal CareIPTp=Intermittant Preventive Treatment in pregnancyITN=Insecticide Treated bedNets

Opportunities for Integration

• Making Pregnancy Safe (MPS)– Focused Antenatal Care (FANC)

• 1000 Days-Window of Opportunity• Saving Newborn Lives (SNL)• Infant and young child feeding (IYCF)• Fortification• Presidential Malaria Initiative (PMI)• Neglected Tropical Disease (NTD)• Global Health Initiative (GHI)• Feed the Future

Major global health initiatives relevant to iron and anemia

27

First Level Objective:Improved nutritional status esp. of women &

children

Increased resilience of vulnerable

communities and households

Increased agricultural value chain productivity leading to

greater on- and off-farm

jobs

Programs and policies to reduce inequities

Improved agriculture productivity

Expanding Markets &

Trade

Increased private sector investment in agriculture and nutrition-related

activities

Improved access to

diverse and quality foods

Improved nutrition-related

behaviors

Improved use of

maternal and child health and nutrition

services

Programs and policies to support agriculture sector

growth

Programs and policies to support

positive gains in nutrition

Feed the Future Goal: Sustainably Reduce Global Poverty and Hunger

AVAILABILITY ACCESS UTILIZATIONSTABILITY

Programs and policies to increase access to

markets and facilitate trade

First Level Objective:Inclusive agriculture sector growth

Indicators: Prevalence of poverty & Prevalence of underweight children

Indicators: -Agriculture sector GDP- Per capita expenditures of rural households

(proxy for incomes)Indicators: -Prevalence of stunted children

-Prevalence of wasted children-Prevalence of underweight women

-Gross margins per unit of land or animal of selected product

- Percent change of value of intra-regional trade in targeted agricultural commodities

- Value of incremental sales (farm-level)

-Value of new private sector investment in agriculture sector or value chain

-Number of jobs attributed to FTF implementation

-Prevalence of households with moderate to severe hunger

-Women’s Dietary Diversity

-Percent of Children 6-23 months that received a MAD

-Prevalence of exclusive breastfeeding under six months

-Prevalence of anemia among women and children

Second-Level Objectives

Second-Level Objective Indicators

Definition of Food Security

Prevalence of anemia among

women and children

Actions Needed• Most countries have MMR reduction goals: Is maternal

anemia and iron and folic acid (IFA) supplementation given high priority?

• ANC guidelines include preventive IFA: But is the implementation being monitored? effective?

• Varied causes of anemia, e.g. Iron-deficiency, hookworm, malaria: Is there an integrated package of services? Is there “buy in” & agreement across sectors?

• Essential Drugs Lists have IFA, deworming, malaria drugs: How can “stock outs” be eliminated?

• Basic health worker training covers anemia: How adequate is counseling and compliance follow-up?

Thank You!