Maternal and Child Anemia- Why, what works, what needs more work?

Maternal and Child Anemia- Why, what works, what needs more work ? Rolf Klemm Johns Hopkins School of Public Health and A2Z Micronutrient and Child Blindness Project Pre-Session: Maternal & Child Anemia Core Group Spring Meeting-April 26, 2010

Anemia Control Interventions– Weakest Links in the Chain of Maternal Nutrition and Health?

Overview
Anemia “101”
Public Health Rationale—Old and New Findings
Interventions: What works? Effective? Safe?
Interventions: 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 of anemia in many developing countries.
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%

Causes of Anemia – Relative Importance by Region
Adapted from: Galloway, R. Anemia Prevention and Control: What Works. Washington, DC: USAID, June 2003. Iron Deficiency Malaria Hookworm High Fertility HIV/AIDS Sub-Saharan Africa South and South East Asia North Africa Americas Central Asia/Caucasus Western Pacific (includes China) Relative Importance by Region High Medium Low

Physiologic needs not met by iron absorption in diet
Low dietary bioavailability from monotonous plant-based diets with little meat
Anemia is NOT all caused by iron deficiency. BUT ~50% of anemia in developing countries is due to iron deficiency

Iron requirement at different life stages
Institute of Medicine, 2001 Increased growth needs exhaust stores accumulated during gestation Menstrual losses superimposed with needs for rapid growth Iron requirement increases 3 x’s due to expansion of maternal red-cell mass & growth of fetal-placental unit. Net iron requirement is 1 g (~4 units of blood)

Public Health Rationale for Controlling Iron Deficiency Anemia? Old and New Findings

Iron Deficiency ranks 9 th on the list of risk factors for global disease burden
WHO, World Health Report, 2002

Anemia is one the most widespread disorders in the world!
McLean et al. Public Health Nutr, 2008, 12: 444-454 ~50% pre-school children ~42% pregnant ~30% non-pregnant ~50% have IDA

New analysis suggests a continuous risk relationship between Hb and maternal mortality
Low Hb level is associated with an increased risk of maternal and perinatal mortality
Stoltzfus, et al, Comparative Quantification of health risks: Global and regional burden of disease attributable to selected major risk factors:, WHO, 2004

Maternal IFAS associated with 0.23 wks longer gestation & 54% ↓ early neonatal mortality
Zeng L, BMJ 2008;337:a2001 doi:10.1136/bmj.a2001

Maternal Iron+folic acid ↓ mortality among Nepalese children by 31% between birth & 7 years
Christian et al Am J Epidemiol, 2009, 170: 1127-1136 0 1 y 2 y 3 y 4 y 5 y 6 y 7y 8 y Folic Acid + Iron Control

Developmental risk factors with sufficient evidence to recommend intervention
Walker et al. Lancet 2007; 369: 145-57

Economic Loss Associated Iron Deficiency
Horton S The Economics of Iron Deficiency, Food Policy, 2003, 51-75 Estimated Loss Physical productivity loss $2.32/per capita Loss in GDP 0.6% Dollar value of losses $4.2 billion Including cognitive losses $16.78/per capita Loss in GDP 4.0%

Women play critical role in agricultural production, esp. in subsistence agriculture
The World Bank, Gender in Agriculture Sourcebook, 2009

Increases or little change in Anemia Prevalence
Klemm R, et al. Unpublished

↑ Maternal Mortality
↑ Perinatal Mortality
↑ Low birth weight
↑ Neonatal mortality
↑ Post-neonatal, child mortality
↑ Negative effects on child cognition and behavior
↓ Productivity and economic gains
Summary of Health Risks of Iron Deficiency Anemia Pregnancy Childhood Adults

Interventions to reduce iron deficiency anemia -What works? Effectiveness and Safety?

Intervention strategies-Iron Deficiency
Home fortification? Central fortification? Delayed cord clamping? Dietary modification? Screen? Iron Supplements?

Intervention strategies-Malaria & Hookworm
Use of insecticide treated nets (ITN) Intermittent Preventive Treatment (IPT) Quality Focused Antenatal Care (FANC) De-worming for hookworm

Increased consumption of iron rich foods
Use of iron cooking pots
Increased iron bioavailability of traditional foods
Germination (50-64% ↓ phytate)
Microbial fermentation (up to 90% ↓ phytate)
Soaking (47-98%↓ phytate)
Adding ascorbic acid containing foods
Use of iron cooking pots
Dietary Modification

Dietary modification-- Effective and safe?
Traditional food processing may increase Fe bioavailability but does not sufficiently increase Fe intake of young children
Dietary diversification, while important for overall dietary quality, is generally unsuccessful at closing the Fe gap for young children
Fe-rich animal source foods are expense and often unavailable
Use of Fe pots has had limited success. Excess Fe content (e.g. fermented beverages) may be a risk.
Summary: It is unlikely that dietary modification strategies alone will be sufficient in most low-income populations

Food Fortification
Addition of Fe to commonly consumed foods, beverages, condiments
Centrally fortified: Fe added at time of processing
Home or “point-of-use”: Fe added to meals just before consumption

Centrally-processed iron-fortified foods
Effective and safe?
With careful choice of the Fe compound and amount added, fortification can improve Fe status of all at-risk groups
However, products have not been developed for pregnant women and the higher Fe level needed may cause sensory changes
It is difficult to meet Fe needs for all children in the target range with a single formulation
There is no evidence that these foods are not safe, but no studies have focused on safety in malarial areas
There are few examples of widespread application of the approach in developing countries.

Home fortification: Effective and safe?
Home fortification mixtures with appropriate amounts of absorbable Fe compounds can be formulated to improve or maintain the Fe status of infants, children, pregnant and non-pregnant women
In children, highly effective at reduction Fe deficiency (RR 0.44 [0.22, 0.86]) and anemia (RR 0.54 [0.46, 0.64])
There is no evidence that home fortification is not safe, but no studies have focused on safety in malaria endemic areas

Innovative Approaches to Iron and micronutrient “supplementation”
Crushable Tablet “ Foodlet” Fat-based Products Powders

Iron supplementation
Delivery of medicinal Fe orally in the form of pills or liquids, usually consumed in the absence of food.

Routine iron supplementation in pregnancy prevents anemia at delivery
Kulier et al , Int J Gyn & Obst 1998, 63: 231-246 Reduces Risk Increases Risk Consistent results showing reduction of anemia risk

Iron Supplementation Safe and effective?
Fe supplementation prevents and ameliorates nutritional Fe-deficiency in children and pregnant women
However, providing Fe supplements in liquid or table form may increase the incidence, and possibly the severity, of malaria (and other infections) among Fe-replete children
In pregnant women, increased placental malaria has been demonstrated with intravenous infusions and is suspected with Fe supplements but has not been demonstrated with the few studies available.

Delayed chord clamping
Delay clamping of umbilical cord by 2-3 minutes
Results in greater transfusion of placental blood to the infant
Increases the total body Fe content of the infant at birth (+~75 mg Fe) which helps to prevent Fe deficiency during the first years of life

Delayed cord clamping— Effective and safe?
Reduces the risk of anemia (RR=0.53 [0.40, 0.70]) at 2-6 months of age
Increases indices of Fe status (Ferritin concentration and stored Fe)
Guidelines have been developed for implementation and uptake of this strategy in low-resource settings
There are no data on safety in the context of malarial endemic areas

Conclusions: NIH Technical Working Group
When there is comprehensive surveillance and prompt malaria diagnosis and treatment there is no increased risk
When health care is insufficient there is an increased risk of malaria with Fe supplementation

Conclusions: NIH Technical Working Group
At this time, the provision of Fe via tablets of liquids requires caution and may be the least desirable approach in malaria endemic areas
Fortified foods may be the most viable alternative intervention. This includes Fe fortification (central or home) of complementary foods for infants and young children and of staple foods or condiments of women and older children
Assuming that the Fe from these foods is absorbed more slowly than Fe from supplements, and that this leads to little or no excess NTBI formation or associated harmful effects, Fe-fortified foods are expected to be safe in such areas.

What needs more work?

Barriers to Effective Implementation-
2008 Innocenti Process
Inadequate political support
Low priority for IFA within maternal health programs
Inadequate supplies, low utilization, and weak demand
Community-based delivery platforms to complement the ANC platform are missing
Insufficient bundling of interventions to address the multiple causes of anemia
Klemm R et al Micronutrient Programs: What Works and What Needs More Work? A Report of the 2008 Innocenti Process. July 2009, Micronutrient Forum, Washington, DC.

Comparison of current performance and anticipated standard of focused ANC model, Tanzania Von Both, BMC Pregnancy and Childbirth, 2006, 6:22 First Visit Re-visit Current Practice (minutes) Desired based on FANC (minutes) Current Practice (minutes) Desired based on FANC (minutes) Registration 2:10 5:00 1:30 0:00 History taking 4:20 10:00 1:20 5:00 Examination 3:30 8:00 3:00 8:00 Drug Administration 1:00 3:00 1:40 3:00 Immunization 1:40 1:00 1:00 1:00 Health education & counseling 1:30 15:00 0:00 15:00 Total time direct activities 12:20 42:00 6:30 32:00 Welcoming the client 1:00 1:00 1:00 1:00 Documentation of findings 2:00 3:00 1:30 3:00 Total contact time 15:20 46:00 9:00 36:00

Reasons given for using ANC services, Uganda
MOST, Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda, 2002 Reasons given by women based on exit interviews 1. Obtain an ANC card. 2. When mother is sick/suspects a pregnancy complication 3. When mother is close to delivery time 4. When mother wants to know if her baby is well 5. If referred by TBAs or lower health unit 6. When mother is unsure of pregnancy and wants confirmation

Reasons given for NOT using ANC services, Uganda
Modified from MOST, Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda, 2002 Reasons given by women based on exit interviews 1. Long waiting hours 2. Fear of being asked to pay a fee for services 3. Perception that they would not be given drugs/medicines or services 4. Have no wish to deliver in a health unit 5. Fear of being referred to other health centers away from home with no transport or assistance 6. Health workers are rude (“They shout at us especially when we are tired”)

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

Opportunities for Integration

Woman-Mother-Newborn-Young Child
Continuum of Care
Delivery & Newborn Care Breast Feeding Complementary Feeding Delayed Cord Clamping ↑ iron intake ITN
Anemia
↑ maternal mortality
↑ LBW
↑ neonatal and child mortality
Anemia
Altered development and behavior
Birth & Colostrum Infant and Young Child Feeding (IYCF) Pre- conception ↑ iron intake Treat hookworm IPT, ITN for malaria
High risk of iron deficiency
Fortification Pregnancy ↑ iron intake Treat hookworm IPT, ITN for malaria
Anemia
Constrained productivity
Less well baby
Focused Antenatal Care (FANC)

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

Maternal Anemia “Brief” for Policy Makers

Additional Resources with Weblinks

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Maternal and Child Anemia- Why, what works, what needs more work?

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Maternal and Child Anemia- Why, what works, what needs more work? — Presentation Transcript