Ahmed_Calcium Deficiency, Anemia in Asia and Middle East_Impact on Maternal and Neonatal Mortality

7/31/2019 Ahmed_Calcium Deficiency, Anemia in Asia and Middle East_Impact on Maternal and Neonatal Mortality

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Calcium Deficiency, Anemia in Asia and

Middle East: Impact on Maternal and

Neonatal Mortality

Dr Tahmeed AhmedDirector, Centre for Nutrition &Food Security, ICDDR,B

Professor, Public Health Nutrition,James P. Grant School of PublicHealth, BRAC University


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Outline of Presentation

Calcium deficiency and anemia burden in Asia

and Middle East

Evidence of impact on maternal and neonatalmorbidity and mortality

Program constraints

Research agenda


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Definition of Anemia at Sea Level

Stoltzfus & Dreyfuss; INACG/UNICEF/WHO 1998


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Consequences of Anemia: All

Poor immune function and increased

morbidity from infection

Fatigue and lower physical work capacity Poor concentration and impaired cognitive

function

Poor quality of life

Brabin BJ 2001, Grantham-McGregor S 2001


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Consequences of Anemia: Infant,

Preschool and School Age Children

Poor physical growth, cognitive development

and school achievement

Increased risk of infant and child death

Low or depleted iron stores for future

pregnancies in adolescent girls

Brabin BJ 2001, Grantham-McGregor S 2001


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Consequences of Anemia: During Pregnancy

Increased risk of complications during delivery,

including prolonged labor, preterm delivery,

LBW and maternal and neonatal death

Infants of mothers with iron deficiency anemia

are more likely to have low iron stores and to

become anemic

Brabin BJ 2001, Steer P 1995


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Increased risk of maternal death: 1.35 times

for moderate anemia & 3.5 times for severe

anemia

An odds ratio of 08 (95% CI 070091) for

maternal mortality was found for a 10 g/Lincrease in mean Hb in late pregnancy

Rasmussen K 2001, Black RE 2008



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Rasmussen K 2001



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Child Development: Long Term Effects ofIron Deficiency Anemia

Lozoffet al, NEJM 1991


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Black RE 2008

Effect of Anemia on Child

Cognition Combined analysis of the five available trials

found 173 (95% CI 104241) lower IQ

points per 10 g/L decrease in Hb Another meta-analysis of iron

supplementation trials found an overall benefit

of 12 IQ points in children receiving iron


11/47Stoltzfus RJ; J Nutr 2001

Anemia and Work Capacity


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Christian P 2005UN/SCN 2004

onsequences of Anemia: Economic Los

Productivity losses due to iron deficiency

Losses to GNP estimated from 6 countries

range from 0.85% to 1.27%

South Asia, where ID is high, loses $ 5 billion

annually

Economic cost of anemia in Bangladesh is

7.9% of national GDP


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Causes Of Anemia

Iron deficiency

Hookworm

Vitamin A deficiency

Malaria infection Chronic infections: TB, HIV

Vitamins B12, folic acid

Hemoglobinopathies: Thalassemia


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Iron Deficiency Anemia

ID: Serum ferritin levels of 5.0 mg/L

Iron deficiency is the single most important causeof anemia

60% of all anemia is due to iron deficiency

Prevalence of IDA was 55% (sFt 8.5 mg/L) among anemic pregnant women in rural

BangladeshStoltzfus & Dreyfuss 1998

Black RE 2008H der SMZ 2004


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Recommended Cut-off Points of Hb andCriteria for Public Health Significance

WHO 1997WHO 1992

Group Cut-off

Hb (g/L)

Public-health Significance

Category Mild-moderate anemia(Hb:70- 109g/L) (%)

Severe Anemia

(Hb


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0

10

20

30

40

50

60

70

80

90

100

Percent

Infant Pre school Adolescent

NPNL women Pregnant Women Lactating Women

200420032001

74.1

92

67.9

48.3

39.7

30

46

3338.8

46.7

35

46

NSP (HKI) 2004, Anemia prevalence survey unicef/BBS 2003, NSP (HKI)2002, WHO global database on anemia

Anemia Prevalence Trends in Bangladesh


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National Strategy for Anemia Control

48

32

23

25

35

64

42

30

33

46

0 20 40 60 80

Children 6-23

Children 24-59

mo

AdolescentGirls

NPW

Pregnant

Target (2015) Baseline (2001-3)

Anemia Prevalence (%)

National Strategy for Anemia Prevention and Control inBangladesh, MOHFW 2007

The overall goal isto reduce 1/4th of

anemia amonghigh risk groups

by 2015


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National Strategy for Anemia Control

48

32

23

25

35

64

42

30

33

46

87

58

39.7

46

38.8

0 20 40 60 80 100

Children 6-23

Children 24-59

mo

AdolescentGirls

NPW

Pregnant

Target (2015) Baseline (2001-3) Current (2004)

Anemia Prevalence (%)

National Strategy for Anemia Prevention and Control inBangladesh, MOHFW 2007 ; NSP 2006

The overall goal isto reduce 1/4th of

anemia amonghigh risk groups

by 2015


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Priority Strategies for Anemia

Prevention and Control Micronutrient supplementation

Dietary improvement

Parasitic disease control

Food fortification

Family planning and safe motherhood

National Strategy for Anemia Prevention and Control inBangladesh, MOHFW 2007


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IFA Supplementation Program in

Bangladesh Policy: 2001(National Guideline)

Strategy: 2007 Political Support: Favorable

Implementation: DGFP, DGHS, NNP, NGOs


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Existing Program on Iron Supplementation

According to Age groupAge-group Key Players

Infants &

children

No program existed

NNP started piloting of MMN sprinkles

(Including IFA) at 3 uz in Sylhet division

targeting all under 2 year children

Adolescents DGFP, NNP (Only girls)

PLW DGFP, DGHS, NNP, NGO (BRAC)NPW DGFP, NNP

Other NNP (NPW, Newly married women)


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Dose of Existing Iron SupplementationProgram

Target group Doses

Adolescent girl 02 tablets/week (Only NNP)

Newly wedwomen

02 tablets/week (Only NNP)

Pregnant women 01 tablet daily up to delivery

Lactating mother 01 tablets/day for 90 days


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Health Worker Training

*No training manual is particularly intended for anemia or IFA supplementation

BHW No Training

DGHS HA, AHI 23500 Some basic training

DGFP FWV,FW

A

21000 Well trained (18 months

training for FWV)

NNP CNP 23246 Short training and

refreshers training

BRAC SS 7000 2 weeks basic training


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Procurement

AvailabilityDGFP Central procurement

8000 IFA tablets/ union

per month

Enough, no stock-out

DGHS From EDCL through civil

surgeon 65-70 million IFA

tablets purchased yearly

Available

NNP Self procurement fundedby GOB, CIDA etc

Passing through majorstock out

BRAC Self procurement Available


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DGFP Uncoated and wrapped in

polythene paper

Chances of destruction

DGHS Uncoated and wrapped innormal paper

Chances of destruction

NNP Uncoated and wrapped in

normal paper

They will use blister

pack very soon

BRAC Started to use blister packtablet

Cost (14 Tk/100compare to 12 Tk/100)

Packaging of IFA Tablets


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BCC & Communication

DGFP Posters HH level FWA does all

BCC

DGHS No IEC materials Advised by doctors

during routine visit

NNP Posters & flip charts Use by CNPs

BRAC Posters & flip charts SS done all BCC

Others Agriculture and socialmarketing sectors are also

using some IEC material

No co-ordination withhealth sector


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Coverage of IFA Supplementation

NSP April 2004

Pregnant women (n= 937)

15.4

4638.6

1-100 tablets >100 tablets No Supplementation


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Anemia Prevalence Among IFASupplemented Pregnant Mothers

NSP April 2004

Pregnant women (n= 937)

52.549.3

43.8

0

20

40

60

80

100

Supplementation

P

roportionanem

ic

No supplementation 1-100 tab >100 tab


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Reasons for Not Taking Iron Tablet

RegularlyIndicator Survey AreaBINP(%) NNP & Comparison(%) All (%)

Did not consider necessary

Objection of familymembersSide-effect of tabletLack of supplyForget to takeDo not receive enough tabletsLost tabletsEconomic constrainsOthers

11.5

1.827.511.529.88.30.52.36.9

19.3

2.224.312

23.24.7.05.98.4

16.3

1.925.512.019.56.10.2

4.57.8

Total no of pregnant women 775 966 1741

NNP Baseline Survey 2004


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Why Fortification

The Copenhagen Consensus 2004 concluded

that the returns of investing in micronutrient

programs are second only to those of fighting

HIV/AIDS

The benefit-to-cost ratio of iron interventions

was estimated to be as high as 200:1

Behrmann JR, Alderman H, Hoddinott J. Hunger andmalnutrition. Copenhagen Consensus Challenge Paper, 2004


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Review: Effect of MMN and single micronutrient fortification (Version 01)

Comparison: 08 Effect of iron fortification on the prevalance of anaemia in two age subcatagories

Outcome: 01 preva lance of anaemia(%)

Study RR (random) Weight RR (random)

or sub-category 95% CI % 95% CI

01 Prevalance of anaemia i n chi ldren aged between 0-5yrs age

Carlos Alberto,2005 11.96 1.82 [1.00, 3.31]

Villalpando,2006 9.71 0.49 [0.21, 1.13]

Subtotal (95% CI) 21.67 0.98 [0.27, 3.52]

Total events: 30 (Intervention group), 27 (Control group)

Test for heterogeneity: Chi = 6.28, df = 1 (P = 0.01), I = 84.1%

Tes t for overall effect: Z = 0.04 (P = 0.97)

02 Prevalance of anaemia i n chi ldren aged between 6-15 yrs age

Nadiger,1980 14.51 0.37 [0.27, 0.52]

Nadiger,1980(G) 8.54 0.14 [0.05, 0.36]

Walter(BH),1993 2.50 0.51 [0.05, 5.55]

Walter(BH-g),1993 2.76 0.36 [0.04, 3.42]

Deborah M Ash,2003 15.33 0.74 [0.60, 0.92]

Zimmermann,2004 8.16 0.19 [0.07, 0.51]

Moretti, 2006 11.72 0.56 [0.30, 1.05]

Pattanee,2006 14.80 1.01 [0.75, 1.36]

Subtotal (95% CI) 78.33 0.47 [0.30, 0.73]


Test for heterogeneity: Chi = 37.24, df = 7 (P < 0.00001), I = 81.2%


Total (95% CI) 100.00 0.55 [0.36, 0.83]


Test for heterogeneity: Chi = 48.71, df = 9 (P < 0.00001), I = 81.5%


0.1 0.2 0.5 1 2 5 10

Favours treatment Favours control

Effect of Iron Fortification on thePrevalence of Anaemia in Children

Ahmed T 2008


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Review: Effect of MMN and single micronutrient fortification (Version 01)

Comparison: 03 Effect of iron fortification on women of child bearing age

Outc ome: 01 Hb l evel (g/L)

Study WMD (random) Weight WMD (random)

or sub-category 95% CI % 95% CI

Ballot,1989 40.15 2.90 [0.38, 5.42]

Viteri,1995 23.47 3.00 [-3.18, 9.18]

Pham Van Thuy,2003 36.38 8.70 [5.38, 12.02]

Total (95% CI) 100.00 5.03 [0.80, 9.27]


Test for overall effect: Z = 2.33 (P = 0.02)

-10 -5 0 5 10

Favours c ontrol Favours treatment

Effect of Iron Fortification on the Hb

level of Women of Childbearing Age

Ahmed T 2008


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Multiple Micronutrient Sprinkles


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Home Fortification: Micronutrient

Sprinkles

Ahmed T (unpublished)

Review: Effect of spr inkles (Version 01)

Comparison: 04 Effect of sprinkles on the Hb conc. in general untargeted population

Outcome: 02 gm/L

Study Sprinkles placebo WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

01 According to age (< 2 years of age)

Giovannini, 2006 65 107.60(11.00) 60 99.70(10.30) 30.47 7.90 [4.17, 11.63]

Menon, 2007 254 104.40(12.70) 161 100.50(13.90) 34.55 3.90 [1.24, 6.56]

Subtotal (95% CI) 319 221 65.01 5.68 [1.78, 9.57]



02 According to age (> 2 years of age)

Sharieff, 2005 109 128.00(10.00) 108 128.00(9.00) 34.99 0.00 [-2.53, 2.53]

Subtotal (95% CI) 109 108 34.99 0.00 [-2.53, 2.53]

Test for heterogeneity: not applicable


Total (95% CI) 428 329 100.00 3.75 [-0.46, 7.97]

Test for heterogeneity: Chi = 12.45, df = 2 (P = 0.002), I = 83.9%Test for overall effect: Z = 1.75 (P = 0.08)

-10 -5 0 5 10

Favours placebo Favours sprinkles


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Acceptability of Sprinkles for Children

12-24 Months: Mothers Opinion

Hyder Z 2004

Extremely liked 60%

Liked 30%Somewhat liked 10%

n= 140


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12-24 Months: Major Health BenefitsPerceived

General improvement of childs health 100%

Increased childrens appetite 29%

Playfulness 28%

Faster intellectual development 28%

n= 140

Hyder Z 2004


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12-24 Months: Mixing With WeaningFood

Did not change normal food

SmellColourTaste

91%98%99%

n= 140

Hyder Z 2004


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Problems & Possible Solution

Coverage Burden of anemia is highestamong infants (~ 90%), but no

program existed in the country

targeting infant and pre-school

children

No or little coverage in urban

areas

Infant and young childrenshould come under coverage

NNP recently started piloting

Use of multiple micronutrient

sprinkles (Including IFA) at 3

upazillas in Sylhet division

targeting all under 2 year

children

Policy National policy & strategy presentbut need to more effective

Anemia prevention controlshould be included in other

relevant guidelines


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Political

Support

Favorable, but their perception

regarding anemia is poor

Political persons need to

be informed about anemia

and IFA supplementation

Logistic NNP is passing through a majorstock out. There is no system of

back up when there is an acute

shortage

Proper planning and co-ordination among different

stake holders is necessary

Characteri

stics of Iron

tablet

Uncoated and wrapped in

paper, chances of disintegration

in humid climate

Blister pack is a solution


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Healthworker

training

No training manual isparticularly intended for anemia

or IFA supplementation

Inclusion of anemia andIFA supplementation in

the training manual of

health workers

Manpower Lack of sufficient number ofhealth workers (Only 3000

FWA present (40%) for

domiciliary services for DGFP,

no recruitment of FWV since

1992)

Increase manpower andkeep right people in the

right place

Co-ordination Duplication of work done in the

same area regularly

Improve co-ordination


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Vehicles for

iron in children

There are lack of proper

vehicles to supplement Iron

formulation among infants

MMN Sprinkle could be

used

BCC and

Communication

No mass media coverage Starting TV coverage

Mothers

awareness

Mothers have no

perception on role of iron

tablet on anemia

reduction

Lesson could be learned

from SUZY project for

using TV and other media



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Monitoring and

evaluation

No or ineffective

monitoring cell

Effective monitoring cell

is essential

Others No alternativestrategy

Food fortification

Contextual

factors

Breast feeding, Infection control, Food security

Final

suggestion to

anemia control

Supplementation

Fortification

Deworming

Breast feeding


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Role of Anemia Control to Achieve MDGs

MDG Goal 1: Eradicate extreme poverty and hunger

Increase work capacity and intellectual potential of children

lead to higher earnings

MDG Goal 2: Achieve Universal Primary Education

cognitive development & intellectual potential of children will

improve school performance & drop out rates

MDG Goal 3: Promote gender equality and empower womenReduce child care burden will allow women more time for

income generating work

Adapted from National Strategy for Anemia Preventionand Control in Bangladesh, MOHFW 2007


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Role of Anemia Control to Achieve MDGs

MDG Goal 4: Reduce child mortality

Increased child survival reduces child mortality

MDG Goal 5: Improve maternal health

Decreased preterm delivery, pregnancy complications and

peri-natal mortality will improve the health and survival of

adolescent girls and women of reproductive age

Adapted from National Strategy for Anemia Preventionand Control in Bangladesh, MOHFW 2007


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Pirgacha

Trishal


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Daily Calcium Intake of Women inPirgacha and Trishal, Bangladesh

Age (years) Daily calciumintake (mg)

Pirgacha 26.26.7 157 (103, 227)

Trishal 29.68.8 144 (97, 226)

Documents

Ahmed_Calcium Deficiency, Anemia in Asia and Middle East_Impact on Maternal and Neonatal Mortality