Addressing Anemia Full Spectrum_Klemm_5.11.11


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  • Note to presenter:Good afternoon. Thank you to the Core Group for organizing this concurrent session and highlighting a problem which is one of the most widespread disorders worldwide, one whose burden and consequences falls mostly on women and children, one whose solution requires critical points of synergy and integration across life stages, disciplinary silos, interventions and service delivery channels. As far as I can see, there is no global champion leading the charge in a comprehensive way, but new initiatives and ways of think create opportunities to do things better.In some ways, the problem of anemia lacks a palpable face, not just among global and national leaders, but also within communities, households and mothers. The most common symptoms of anemia—fatigue, dizziness, shortness of breath—are often viewed as a fact of life for most women, and not necessarily symptoms of anemia. Many women know all too well the foolishness characterized in this poster from Bangladesh. While some woman may not be part of the formal and recognized workforce, any one who exchanges places and perform the multiple demanding tasks ofso-called “non-working” women would feel fatigued, dizzy and be short of breath without being anemic.
  • The most common symptoms of anemia—fatigue, dizziness, shortness of breath—are often viewed as a fact of life for most women, and not necessarily symptoms of anemia. Many women know all too well the foolishness characterized in this poster from Bangladesh. While some woman may not be part of the formal and recognized workforce, any one who exchanges places and perform the multiple demanding tasks of so-called “non-working” women would feel fatigued, dizzy and be short of breath without being anemic. So how can we give anemia a palpable face? This question was posed to women and health workers in Nepal and here’s what they came up with. I’m going to put you through a participatory and experiential exercise. On the count of 3, please hold your breath until I say “Breath”.
  • This exercise was used in health worker and mother trainings to provide a face to anemia and convey that anemia results in a decreased amount of oxygen that the body is able to carry and that is available to the fetus of a pregnant women, to a developing child’s brain, and to the woman herself as she multi-tasks and cares for her children.
  • While iron deficiency is responsible for a large proportion of anemia in pregnancy, it is not the only cause. This graphic depicting intersection circles of anemia, iron deficiency anemia and iron deficiency illustrates 3 main points:Iron deficiency anemia a major but NOT the only cause of anemia. The proportion of anemia due to iron deficiency is likely to vary across geography, population morbidity profile, socioeconomic and other factors.Individuals can be iron deficient without exhibiting anemia. The prevalence of iron deficiency (without anemia) is estimated to be twice that of iron deficiency anemia. Iron deficiency, even without anemia, is associated with health risks.Anemiahas multiple precipitating factors that can occur in isolation but more frequently co-occur. In addition to poor bioavailability of dietary iron, intestinal worm infections and particularly blood loss from hookworm infections compound the problem of anemia in many areas. Other important etiologic factors include vitamin deficiencies such as folate and vitamin A deficiency; a variety of infections, including malaria and HIV infection; and hemoglobinopathies. HIV infection is particularly prevalent in sub-Saharan Africa and has been shown to be associated with a median hemoglobin decrease of 5.5 g/l in asymptomatic pregnant women. These factors may be genetic, such as hemoglobinopathies; infections, such as malaria, intestinal helminths and chronic infection; or nutritional, which includes iron deficiency as well as deficiencies of other vitamins and minerals, such as folate, vitamins A and B12, and copper. Because iron deficiency makes a large contribution to anemia, global efforts to reduce the anemia burden have largely been directed towards increasing intake of iron through supplementation, food fortification and diversification of the diet.
  • Nutritional iron deficiency is highest in population segments that are at peak rates of growth, namely, infants, young children and pregnant women. Pregnancy is a time in which the risk for developing iron deficiency anemia is highest, because iron requirements are substantially greater than average absorbable iron intakes. Physiologic demands for iron increase from 0.8 to ≤7.5 ,g absorbed Fe/d. Such demands result in a decline in iron stores during pregnancy and ultimately can produce iron-deficient erythropoiesis (def: process of making RBCs) and anemia because a positive or even nIn order to understand how to prevent iron deficiency anemia, it is important to understand its causes and risk factors. 1. Iron deficiency is caused by high iron requirements during critical periods in the life cycle that are not met by iron absorption in diet, especially in populations where with a diet consisting of low dietary bioavailability from monotonous plant-based diets with little meat.The graph shows the iron requirements in miligrams per 1000 kcals (y-axis) by life stages (x-axis). Three life stages have a particularly high demand for iron, and a high risk for iron deficiency if bioavailable iron intake does not meet the high physiologic requirements. Infants—The growth requirements of infants rapidly exhaust the iron accumulated by the fetus during gestation. Infants born to iron deficiency mothers and low birth weight infants are particularly at risk for iron deficiency because they accumulate less iron during gestation and therefore their iron stores are more quickly depleted.Adolescents-- Menstrual blood losses superimposed with increased iron requirements due to the adolescent growth in teenage girls, put them at a higher risk for iron deficiency.Pregnant Women—Iron increases three-fold due to the expansion of the maternal red-cell mass and the growth of the placenta and fetus, yielding a net increase in the requirement for iron of 1 gram which is equivalent to 4 units of blood. This high requirement for iron places pregnant women at a high risk for iron deficiency.
  • As many of you know, anemia is one of the most widespread disorders in the world. In Asia and Africa alone >50 million pregnant women are anemic corresponding to a prevalence of 55% in Africa and 42% in Asia. The high anemia prevalence among non-pregnant women shows that many women begin their pregnancy in an already compromised anemic state which can affect red blood cell expansion and growth of the placent and fetus. Across Africa and Asia alone, there are 450 million anemic women, and globally > ½ billion women are anemic. Yet these massive figures have not rung strong bells for effective action in maternal health.
  • From DHS surveys which measured anemia prevalence in pregnant women across two surveys, we see that there have been either increases or little change in most countries. The only three countries which observed substantial reductions are Nepal, Haiti and Cambodia. All others registered increases or virtually no change in prevalence across a 5 year interval. Why is this the case?
  • In addition to knowing the various causes of anemia in a target population, it is important to understand the relationship between the risks of iron deficiency across the critical phases of the life cycle and integrate appropriate interventions into service packages and contact points for each phase. This graphic shows the health risks and potential solutions as a continuum from pre-conception to pregnancy to child birth to early infancy and young childhood.Many reproductive age women in developing countries consume diets of low iron bioavailability and therefore enter pregnancy with no iron stores and less than optimal hemoglobin concentrations. There is a need to increase the iron status of women before pregnancy. This can be accomplished through iron fortification by adding an adequate amount of bioavailable iron to commonly consumed foods or through weekly iron+folic acid supplementation. In areas where hookworm is prevalent, women should receive an appropriate deworming regimen.During the second half of pregnancy, iron requirements begin to increase and continue to do so throughout the pregnancy because of the expansion of the red blood cell mass and the transfer of increasing amounts of iron to both the growing fetus and the placental structures. Iron deficiency anemia during pregnancy increases the risk of maternal mortality possibly through decreased resistance to infection which may contribute to uterine dysfunction or inertia, or through decreased uterine blood flow or low uterine muscle strength which may lead to inefficient uterine contractions and increased blood loss. Antenatal care offers an important platform for providing critical preventive interventions to pregnant women—specifically, iron and folic acid supplementation, deworming and interventions to reduce the risk of giving birth to a low birth weight infant. Maternal iron deficiency also increases the risk of giving birth to a low birth weight infant, delivering a preterm infant, and increases the risk of a maternal, neonatal and child death. At the time of delivery, new evidence indicates that delaying the clamping of the umbilical cord by ~2 minutes can significantly increase the blood flow, and therefore iron stores, to the newborn. The risk of iron deficiency is high during infancy because only about 50% of the iron requirement of a normal six month old can be obtained from breast milk, and by this age the stores received at birth are likely to have been used to support normal functions and growth even in children born at term of well nourished mothers. If the mother is anemic and/or the child is of low birth weight, the stores are depleted much earlier. Continued breastfeeding alone will supply only half of the infant’s iron needs, while the other half, approximately 4 mg/day, must come from complementary foods or an iron containing supplement if iron deficiency anemia is to be avoided. Iron deficiency anemia in infancy is associated with developmental and cognitive delays. Iron supplements, in the form of micronutrient powders, drops or iron-fortified complementary foods (including lipid-based nutrition supplements) can be used to reduce the risk of iron deficiency anemia in infants above 6 months of age.
  • The major global health initiatives that have relevance for iron deficiency anemia are Making Pregnancy Safe, Saving Newborn Lives, Infant and Young Child Feeding and Iron Fortification. Two other initiatives are important for other causes of anemia. The Presidential Malaria Initiative is essential for reducing the risk of malaria-induced anemia in malaria-endemic areas, and the Neglected Tropical Disease initiative is vital for addressing anemia caused by hook worm and schistosomiasis.
  • Diagram of FTF goal and objectives and indicators for illustration purposes
  • This exercise was used in health worker and mother trainings to provide a face to anemia and convey that anemia results in a decreased amount of oxygen that the body is able to carry and that is available to the fetus of a pregnant women, to a developing child’s brain, and to the woman herself as she multi-tasks and cares for her children.
  • Addressing Anemia Full Spectrum_Klemm_5.11.11

    1. 1. Core Group Spring Meeting-May 11, 2011<br />Addressing Anemia Full Spectrum<br />Recent scientific findings, implementation issues & opportunities for integration <br />Rolf Klemm, DrPH<br /> Johns Hopkins School of Public Health and A2Z: The USAID Micronutrient and Child Blindness Project<br />
    2. 2.
    3. 3. Hold your breath<br />
    4. 4. Breath!!!<br />
    5. 5. Overview<br /><ul><li>Anemia “101” & the case for integration
    6. 6. New Scientific Findings
    7. 7. Interventions: What works? Effective? Safe?
    8. 8. Implementation: What needs more work?
    9. 9. Opportunities for Integration</li></li></ul><li>Anemia “101”<br />The Basics<br />
    10. 10. Anemia<br />Defined as… Hemoglobin (Hb) concentration <2 standard deviations of the age- and sex specific normal reference<br />Hb binds to oxygen and carries it to tissues<br />Red blood cells (RBCs) consist mostly of Hb.<br />Commonly used indicator to screen for iron deficiency in population-based surveys but not specific for iron deficiency<br />Normal RBCs<br />Anemic RBCs<br />
    11. 11. Not all anemia is caused by iron deficiency….<br />but iron deficiency is a major cause in many dev’g countries. <br />Hookworm<br />Other vitamin deficiencies<br />Malaria<br />HIV/AIDS<br />Anemia of <br />Inflammatory Conditions<br />Hemoglobin-<br />opathies<br />
    12. 12. Overlapping causes of Anemia<br />Malaria<br />Anemia<br />Hookworm<br />Severe: ≥40%<br />Moderate: 20-39%<br />
    13. 13. Institute of Medicine, 2001<br />Iron requirement at different life stages<br />
    14. 14. New Scientific Findings<br />
    15. 15. Anemia is one of the most widespread disorders in the world.<br />More than half a billion women are anemic worldwide<br />McLean et al. Public Health Nutr, 2008, 12: 444-454<br />
    16. 16. New Scientific Evidence<br />Improving Hb by 1 g/dL in pregnancy is associated with a 20% decreased risk of maternal mortality (Murray-Kolb, 2010, unpublished)<br />Maternal IFAS associated with 50% ↓ in very pre-term births & 54% ↓ early neonatal mortality (Zeng L, BMJ 2008)<br />Nepalese women receiving IFA in pregnancy had 16% ↓ in LBW & 60 g ↑in birth weight(Christian P; BMJ, 2003)<br />Maternal IFA ↓ mortality among Nepalese children by 31% between birth & 7 years (Christian P; Am J Epidemiol, 2009) <br />IFA during ANC associated with 90% ↓ in early neonatal deaths in Indonesia (Titaley CR, Bull World Health Organ, 2009)<br />IFA + IPTp in mothers associated with 24% ↓ in neonatal deaths 19 countries Sub-Saharan Africa (Titaley CR et al, AJCN, 2010)<br />
    17. 17. 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<br />
    18. 18. Are we making progress on reducing maternal anemia?<br />
    19. 19. Increases or little change in anemia prevalence in most countries over 5 years based on DHS <br />Klemm R, et al. Unpublished<br />
    20. 20. Interventions to reduce iron deficiency anemia-What works?<br />Effectiveness and Safety?<br />
    21. 21. Woman-Mother-Newborn-Young Child<br />Continuum of Care<br />Breast<br />Feeding<br />Complementary<br />Feeding<br />Birth &<br />Colostrum<br />Pre-<br />conception<br />Pregnancy<br />Focused Antenatal Care (FANC)<br />Delivery &<br /> Newborn Care<br />Infant and Young Child<br />Feeding (IYCF)<br />Fortification<br />↑ iron intake, prevent LBW<br />Treat hookworm<br />IPT, ITN for malaria<br />↑ iron intake (WIFS)<br />Treat hookworm,<br />ITN for malaria<br />Delayed Cord<br />Clamping<br />↑ iron intake<br />ITN<br /><ul><li>Anemia
    22. 22. ↑ maternal mortality
    23. 23. ↑ LBW
    24. 24. ↑ neonatal and child mortality
    25. 25. Anemia
    26. 26. Altered development and behavior
    27. 27. High risk of iron deficiency
    28. 28. Anemia
    29. 29. Constrained productivity
    30. 30. Less well baby</li></li></ul><li>Cautionary Comments for iron supplementation in malaria-endemic areas”<br />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”<br />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”<br />
    31. 31. Implementation-What needs more work?<br />
    32. 32. Use of iron tablets by ANC attendees, Uganda, n=612<br />High proportion of women have at least 1 ANC visit<br />~40% who had an ANC visit did NOT receive ANY IFA tablets<br />AND….<10% consumed ≥30 tablets<br />A2Z Survey (2009) of ANC platforms, unpublished data<br />
    33. 33. Use of iron tablets by ANC attendees in Jharkhand, India, 2008 n=955<br />Only ~55% attend ANC<br />78% who attend ANC get iron<br />80% who get iron take all they get<br />Only 12% take ≥90 tablets<br />A2Z Project, Jharkhand MARP Baseline Survey, 2008, n=954<br />
    34. 34. But SOME women will experience difficulties. They need to be found, listened to & counseled.<br />
    35. 35. Demand<br />Outcomes<br />Supply<br />Use of Health Services offered at Distribution Point/Platform<br />Health Services Offered at Distribution Point/Platform<br />(ANC, CHW Visits, Care Groups, ITN delivery, etc)<br />Health System<br />Awareness & Motivation to Use Services<br />(risks & benefits)<br />Reduced Maternal Anemia<br />Access to care<br />(i.e. distribution points/<br />delivery channel)<br />Availability of supplies <br />(Iron tablets, deworming & antimalaria drugs & ITNs)<br />Enabling Social & Policy Environment<br />Practices<br />(ANC, iron tablets, IPTp, ITNs, deworming)<br />Quality<br />(of counseling about need for iron supplementation, deworming & IPTp & ITNs; benefits & managing side-effects)<br />Increased:<br /> IFAS<br />Deworming<br />IPT<br />ANC use<br />Knowledge<br />(management of side-effects, # of supplements to take, when to start)<br />Satisfaction with Service <br />Enabling Social Environment<br />(support of husband, mother-in-law, etc)<br />CHW=Community Health Worker<br />ANC=Antenatal Care<br />IPTp=Intermittant Preventive Treatment in pregnancy<br />ITN=Insecticide Treated bedNets<br />
    36. 36. Opportunities for Integration<br />
    37. 37. Major global health initiatives relevant to iron and anemia<br /><ul><li>Making Pregnancy Safe (MPS)</li></ul>Focused Antenatal Care (FANC)<br /><ul><li>1000 Days-Window of Opportunity
    38. 38. Saving Newborn Lives (SNL)
    39. 39. Infant and young child feeding (IYCF)
    40. 40. Fortification
    41. 41. Presidential Malaria Initiative (PMI)
    42. 42. Neglected Tropical Disease (NTD)
    43. 43. Global Health Initiative (GHI)
    44. 44. Feed the Future</li></li></ul><li>Feed the Future Goal: Sustainably Reduce Global Poverty and Hunger<br />Indicators: Prevalence of poverty & Prevalence of underweight children<br />First Level Objective:<br />Improved nutritional status esp. of women & children<br />First Level Objective:<br />Inclusive agriculture sector growth<br />Prevalence of anemia among women and children<br />Indicators: -Agriculture sector GDP<br />- Per capita expenditures of rural households <br />(proxy for incomes)<br />Indicators: -Prevalence of stunted children-Prevalence of wasted children-Prevalence of underweight women<br />Second-Level Objectives<br />Improved agriculture productivity<br />Expanding Markets & Trade<br />Increased resilience of vulnerable communities and households<br />Increased agricultural value chain productivity leading to greater on- and off-farm jobs<br />Increased private sector investment in agriculture and nutrition-related activities <br />Improved access to diverse and quality foods<br />Improved nutrition-related behaviors<br />Improved use of maternal and child health and nutrition services<br /><ul><li>Percent change of value of intra-regional trade in targeted agricultural commodities
    45. 45. Value of incremental sales (farm-level)</li></ul>-Gross margins per unit of land or animal of selected product<br />-Women’s Dietary Diversity<br />-Percent of Children 6-23 months that received a MAD<br />-Prevalence of exclusive breastfeeding under six months<br />-Value of new private sector investment in agriculture sector or value chain<br />-Prevalence of households with moderate to severe hunger<br />-Prevalence of anemia among women and children<br />-Number of jobs attributed to FTF implementation<br />Second-Level Objective Indicators<br />Programs and policies to reduce inequities<br />Programs and policies to support agriculture sector growth<br />Programs and policies to support positive gains in nutrition<br />Programs and policies to increase access to markets and facilitate trade<br />AVAILABILITY<br />ACCESS<br />UTILIZATION<br />STABILITY<br />Definition of Food Security<br />27<br />
    46. 46. Actions Needed<br />Most countries have MMR reduction goals: Is maternal anemia and iron and folic acid (IFA) supplementation given high priority? <br />ANC guidelines include preventive IFA: But is the implementation being monitored? effective? <br />Varied causes of anemia, e.g. Iron-deficiency, hookworm, malaria: Is there an integrated package of services? Is there “buy in” & agreement across sectors?<br />Essential Drugs Lists have IFA, deworming, malaria drugs: How can “stock outs” be eliminated?<br />Basic health worker training covers anemia: How adequate is counseling and compliance follow-up?<br />
    47. 47. Thank You!<br />