1. NATIONAL IRON PLUS INITIATIVE
DR.S.DINESH BABU
PG REGISTRAR
DEPARTMENT OF COMMUNITY HEALTH,
CHRISTIAN MEDICAL COLLEGE, VELLORE
24-10-2020 1
2. SYNOPSIS
• Introduction
• Global burden
• National scenario of anemia trends
• Causes and consequences of anaemia
• Mile-stones
• Strategies of Anaemia Mukt Bharat
• Institutional mechanisms including NCEAR-A
• Conclusion-new changes and recommendation
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3. INTRODUCTION
• Anemia results as a manifestation
of various underlying deficiency
and disease conditions.
• It is associated with overall
development of children and also
associated with increased maternal
mortality, reduces work efficiency in
adults.
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4. ANEMIA
• Anemia is a condition in which the
number of red blood cells or their
oxygen-carrying capacity is insufficient
to meet the body’s physiological
requirements, which vary by age, sex,
altitude, smoking habits, and during
pregnancy.
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5. Symptoms
• The manifestations of anemia
vary by its severity and range
from fatigue, weakness,
dizziness and drowsiness to
impaired cognitive
development of children and
increased morbidity.
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6. Anemia in pregnancy
• Anemia in pregnancy is
associated with post-partum
haemorrhage , neural tube
defects, low birth weight,
premature births, stillbirths
and maternal deaths.
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7. Malaria endemic
regions
• In malaria endemic regions,
anemia is one of the most
common preventable causes of
maternal and child deaths.
• In its most severe form,
anemia can also lead to death.
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8. Iron deficiency
• There are many causes of
anemia, out of which iron
deficiency accounts for about
50 % of anemia in school
children and among women of
reproductive age-group, and
80 % in children 2–5 years of
age.
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9. Nutritional deficiencies
• Other nutritional deficiencies
besides iron, such as
• vitamin B12,
• folate and
• vitamin A,
can cause anemia although the
magnitude of their contribution
is unclear.
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10. Infectious diseases
• Other than malaria - helminth
infections, tuberculosis and
haemoglobinopathies - are other
important contributory causes to
the high prevalence of anemia.
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11. DEFINITIONS:
• The World Health Organization (WHO) and the
American College of Obstetricians and
Gynecologists (ACOG) define anemia in pregnancy
as follows :
• First trimester – Hemoglobin <11 g/dL
(approximately equivalent to a hematocrit <33
percent)
• Second trimester – Hemoglobin <10.5 g/dL
(approximate hematocrit <31 or 32 percent)
• Third trimester – Hemoglobin level <11 g/dL
(approximate hematocrit <33 percent)
# Obstet Gynecol. 2008 Jul;112(1):201-7. doi: 10.1097/AOG.0b013e3181809c0d.
ACOG Practice Bulletin No. 95: anemia in pregnancy
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12. What is to be
expected?
• Normal pregnancy is
characterized by profound
changes in almost every organ
system to accommodate the
growing and developing
fetoplacental unit
• Expanded plasma volume
• Physiologic anemia
• Mild neutrophilia
• Mildly prothrombotic state
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13. Plasma Volume:
• Increases by 10 to 15 percent at 6
to 12 weeks of gestation, expands
rapidly until 30 to 34 weeks
• Increased metabolic demands of
the uterus and placenta
• Facilitate delivery of nutrients to
the developing fetus and removal
of waste
• Protect against the effects of
impaired venous return when the
mother is supine or standing, and
• Protect the mother from excessive
blood loss during delivery
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14. Red blood cells
• Red blood cell (RBC) mass begins
to increase at 8 to 10 weeks of
gestation
• Reaches levels 20 to 30 percent
higher than in nonpregnant
women by the end of pregnancy
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18. Approach to IDA in
pregnancy
• Cumulative total requirements are:
• 300 to 350 mg for the fetus and
placenta,
• 500 mg for the expansion of the
maternal red blood cell (RBC) mass, and
• 250 mg associated with blood loss
during labor and delivery
• Decreased Absorption in pregnancy
• Nausea and vomiting of pregnancy,
inflammatory bowel disease, bariatric
surgery (e.g., gastric bypass)
• Bioavailability of compound
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22. • Examples of available preparations (with the amount of elemental
iron per dose) include:
• FERRIC MALTOL – 30 mg tablet contains 30 mg elemental iron
• FERROUS FUMARATE – 324 or 325 mg tablet (contains 106 mg
elemental iron per tablet)
• FERROUS GLUCONATE
• 240 mg tablet (contains 27 mg elemental iron per tablet)
• 324 mg tablet (contains 38 mg elemental iron per tablet)
• 325 mg tablet (contains 36 mg elemental iron per tablet)
• FERROUS SULFATE
• 325 mg tablet (contains 65 mg elemental iron per tablet)
• 220 mg/5 mL oral elixir (contains 44 mg elemental iron per 5 mL)
• 75 mg/mL oral solution (contains 15 mg elemental iron per mL)
• Polysaccharide iron complex
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23. Iron sucrose:
• Each mL contains 20 mg
elemental iron as iron sucrose in
water for injection
• 200 mg administered on 5
different occasions within a 14-day
period (total cumulative dose:
1,000 mg in 14-day period)
• May repeat treatment if clinically
indicated.
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24. GLOBAL BURDEN OF ANEMIA
• Anemia is the most common public health problem affecting
around 1.9 billion population in the world.
• 90% of the cases of anemia were in the developing countries
• Asia and Africa accounts for 85 % of anemia cases.24-10-2020 24
25. PUBLIC HEALTH IMPLICATIONS OF ANEMIA
• It decreases the work output and work capacity.
• Physical and cognitive losses due to IDA in South Asia are close to $ 4.2
billion annually in Bangladesh, India and Pakistan.
• About 20 % of maternal deaths are caused by Anemia worldwide
• Anemic pregnant women are more prone to increased morbidity ; three
times greater incidence of premature delivery in severely anemic women.
• Diminished concentration, disturbance in perception, delayed
psychomotor development, Impaired language and motor skills,
Diminished IQ equivalent to a 5–10 point
• In the WHO/World Bank rankings, Iron Deficiency Anemia contributes
1.18 % of Gross Domestic Product (GDP) loss.
• Median total loss (physical and cognitive) combined are 4.05 % of GDP
in developing countries.
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26. ANEMIA AND SUSTAINABLE DEVELOPEMENTAL GOALS - 2030
SDG GOALS ROLE OF ANEMIA
GOAL 1: NO
POVERTY
Anemia is estimated to contribute to 17% lower productivity in heavy manual labour and 5 % lower
productivity in other manual labour.
GOAL 2: ZERO
HUNGER
Target 2.2 -Anemia is a part of all forms of malnutrition which is committed to be end by 2030 and
addressing by 2025, the nutritional needs of adolescent girls, pregnant and lactating women and older
persons.
GOAL 3: GOOD
HEALTH &
WELLBEING
Target 3.1 (Maternal mortality)- Iron reduces maternal anemia,20% maternal deaths are due to
anemia, Iron prevents maternal deaths during perinatal period
Target 3.2 (child mortality) – Iron prevents IUGR,LBW and prematurity. Iron enhances immunity,
reduces frequency and severity of infections and decreases childhood mortality and mortality .
Target 3.3 – Malaria causes hemolysis and anemia
GOAL 4 :
QUALITY
EDUCATION
Iron reduces frequency and severity of infections, morbidity and mortality.
Improves school attendance, retention, learning abilities and school achievements
GOAL 5:
GENDER
EQUALITY
Anemia in girls is often more severe than boys.
Anemia adversely influences school attendance and achievement.
Iron improves women’s health ,increases work performance and productivity
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27. 58%
of children
(6-59 months)
54%
of adolescent
girls
(15-19 years)
29%
of adolescent
boys
(15-19 years)
53%
of women in their
reproductive age
50%
of pregnant women
58%
of breastfeeding
mothers
High Prevalence
across all ages
Slow progress in
most of the States
74 69.4
52 55.2
58.5
53.1
80
60
40
20
0
100
NFHS 2 NFHS 3 NFHS 4
Children
WRA (15-49 yrs)
Trend in
Prevalence of
Anemia among
Children and
Women
A Snapshot of Anemia in India
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29. Anemia prevalence among
Pregnant Women
(15-49 yrs) States/ UTs
More than 50%
11 States and 2 UTs
Bihar, Himachal Pradesh, Jharkhand, Madhya Pradesh, Uttar Pradesh,
Meghalaya Tripura, Andhra Pradesh, Gujarat, Haryana, West Bengal, A & N
islands and D & N Haveli
40% to 50%
10 States and 1 UT
Chattishgarh, Odisha, Rajasthan, Uttarakhand, Assam, Karnataka,
Maharashtra, Punjab, Tamil Nadu, Telangana
Delhi
Less than 40%
8 States and 2 UTs
Jammu & Kashmir, Arunachal Pradesh, Manipur, Mizoram, Nagaland,
Sikkim, Goa, Kerala Lakhwadeep and Puducherry
Anemia Prevalence among Pregnant Women (NFHS-4)
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31. CAUSES OF ANEMIA
Iron deficiency,
Haemoglobinopathies,
Malaria are three leading
causes Of anemia Globally.
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32. SEVERITY OF CONSEQUENCES OF ANEMIA
SEVERE CONSEQUENCES :
1) PREGNANT WOMEN : MATERNAL MORTALITY
2) CHILDREN : PREMATURE BIRTH,LOW BIRTH WEIGHT,PERINATAL,
NEONATAL,CHILD MORTALITY
3) ADULT : INCREASED RISK OF DEATH DUE TO IRREGULAR HEART BEATS,
MURMUR,CARDIAC ARREST , CONGESTIVE HEART FAILURE
MODERATE CONSEQUENCES :
1) CHILDREN : POOR COGNITION,PHYSICAL DEVELOPMENT
2) ADULTS : POOR WORK PRODUCTIVITY
MILD CONSEQUENCES :
1) FATIGUE,IRRITABILTY AND WEAKNESS,DYSPNOEA
2) DECREASED APPETITE
3) ORTHOSTATIC HYPOTENSION
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33. Milestones in Control of Anemia in India
1970
60 mg IFA for PW
20 mg for 1-5 yr X100 days
1991
60 mg Iron
changed to
100mg
2007
6-10 yrs age group &
Adolescents added
2013
Weekly and biweekly
supplementation.
Test and treat (NIPI)
Life cycle approach
2018
(Anemia Mukt
Bharat)
P & LW 60mgX180
days, IFA for WRA
6X6X6 strategy
Life cycle approach
NATIONAL NUTRITIONAL ANEMIA PROPHYLAXIS
PROGREMME (NNAPP) (1970)
TO
INTENSIFIED NATIONAL IRON PLUS INITIATIVE AND
ANEMIA MUKT BHARAT (2019)
NNAPP
NNACP
NIPI
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I-NIPI
38. WHY THERE IS NEED FOR
STRENGTHENING OF NIPI
PROGRAMME..
• Need to be revised for dose,
frequency and duration of IFA,
based on global scientific
evidence.
• The iron doses administered to
the pregnant mothers for the
prevention and treatment of
anaemia are high.
• There is a need to lower the iron
doses in view of adverse effects.
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39. NUTRITION
COUNSELLING
• The beneficiaries do not collect or
consume supplements regularly
simply because the majority of them
are not given proper nutrition
counselling.
• There is a need to improve the
compliance in the consumption of
IFA tablets by giving high priority to
interpersonal counselling to
beneficiaries.
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40. HEALTH BUDGET
• The budget provision for the
scheme should be increased.
• The State-level programme
officers should be trained to
calculate the requirement of IFA
for each group of beneficiaries
and cost of supportive activities
of NIPI so that they can make
provision in the PIP submitted to
MoHFW for sanctioning of the
budget accordingly.
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41. DEWORMING
• In regions with high prevalence of
anaemia, regular mass deworming
of under-five children should be
undertaken for the prevention of
anaemia.
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42. Malaria & anemia
• Malaria, being an important
cause of anaemia, requires
an efficient implementation
of National Vector Borne
Control Programme in
malaria-hyperendemic
regions.
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43. Other causes of
anemia
• Interventions for other
causes of anaemia such as
1) Haemoglobinopathies-
sickle cell anaemia and
thalassaemia
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46. IFA DOSAGE
• IFA administration to children aged 5-10 yr
should be initiated in the majority of States.
• More than 50 per cent of pregnant mother
suffer from anaemia; however, under NIPI,
almost all are provided prophylactic dose of
IFA tablets for 100 days.
• This will possibly improve their Hb level but
not make them non-anaemic.
• In actual practice, all beneficiaries are given
the same number of tablets irrespective of
the degree of anaemia.
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47. Test and treat
strategy
• The test-and treat strategy of the
programme requires estimation
of Hb. However, the
functionaries are not provided
with facilities to carry out the Hb
estimation.
• Supervision and monitoring of
programme are given a low
priority at all the levels: central,
state, district, block and PHC
levels.
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48. PROPER REPORTING..
• The performance reporting of the programme requires
improvement.
• The States submit reports about the number of individuals
who initiated the prophylaxis course rather than who have
completed the consumption of 100 tablets. This type of
format of reporting does not reflect the correct status of
performance achievements.
• The status of compliance and supervision issues of weekly
IFA administration with IFA tablets in schools has not been
documented in detail to improve the programme.
• There is a need to document this process.
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49. Initiation of complementary
foods..
• All beneficiaries or their care givers
need to be counselled on appropriate
infant and young child feeding with
emphasis on timely initiation of
complementary foods.
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50. INTENSIVE NATIONAL
IRON PLUS INITIATIVE
• Reducing anemia- important objectives
of the POSHAN Abhiyaan launched in
March 2018.
• In 2019, The Ministry of health and
family welfare after Complying with the
targets of POSHAN Abhiyaan and
National Nutrition Strategy set by NITI
Aayog, the Anemia Mukt Bharat
strategy has been designed to reduce
prevalence of anemia by 3 % points per
year among children, adolescents and
women in the reproductive age
group(WRA).
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51. Objectives of Anemia Mukt Bharat strategy
Reduction in morbidity and mortality due to
anemia
To reduce anemia prevalence by 3 percent per annum in
all age groups (children, adolescents, pregnant women
and WRA)
Impact
To increase the proportion of eligible target beneficiaries
who consumed IFA tablet as per protocol by 50% (by
NFHS-5)
Output
To increase community knowledge and risk perception
through improved social support.
To ensure that state governments have enhanced capacity
to deliver services and supplies for prevention and
management of anemia
Process
Outcome
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52. To reduce the prevalence of anemia by 3 percentage points per annum targets
Beneficiary Wise Targets of AMB for 2022
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53. Anemia Mukt Bharat
6 x 6 x 6 strategy to
fight anemia
6
6X6X6
strategy
6
interventions
6
institutional
mechanisms
Anemia Mukt Bharat- STRATEGY
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55. 1
Prophylactic iron folic acid
supplementation
3 Intensified year-round Behavior
Change Communication
Campaign "Solid Body Smart
Mind" ,delayed cord clamping
5
Mandatory provision of iron
public health programmes
ANGANWADI
2
Periodic deworming of children,
adolescents, pregnant women
4
Testing of anemia using digital
methods and point of care
treatment
HOSPTIAL
6
Addressing non-nutritional causes
of anemia in endemic
pockets, with special focus on
malaria, haemoglobinopathies and
fluorosis
SIX INTERVENTIONS
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56. Age group Dose
6 – 59 months
of age
• Biweekly, 1 ml Iron and Folic Acid syrup
• Each ml of Iron and Folic Acid syrup containing 20 mg elemental Iron +
100 mcg of Folic Acid
• Bottle (50ml) to have an ‘auto-dispenser’ and information leaflet as per
MoHFW guidelines in the mono-carton
5- 10 years
children
• Weekly, 1 Iron and Folic Acid tablet
• Each tablet containing 45 mg elemental Iron + 400 mcg Folic Acid
• Sugar-coated, pink colour
Intervention- 1
Prophylactic IFA supplementation- Regime
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57. Age group Dose
Adolescent
girls and boys,
10-19 years of age
• Weekly, 1 Iron and Folic Acid tablet
• Each tablet containing 60 mg elemental iron + 500 mcg Folic Acid
• Sugar-coated, blue colour
Women of
reproductive age
(non-pregnant,
non-lactating)
20-49 years
• Weekly, 1 Iron and Folic Acid tablet
• Each tablet containing 60 mg elemental Iron + 500 mcg Folic Acid,
• sugar-coated, red colour
All women in the reproductive age group in the pre-conception period and
up to the first trimester of the pregnancy are advised to have 400 mcg of
Folic Acid tablets, daily
Pregnant women and
lactating mothers
(0-6 months child)
• Daily, 1 Iron and Folic Acid tablet starting from the fourth month of
pregnancy (that is from the second trimester), continued
• Throughout pregnancy (minimum 180 days during pregnancy)
• Tobe continued for 180 days, post-partum
• Each tablet containing 60 mg elemental Iron + 500 mcg Folic Acid
• Sugar-coated, red colour
Cont...
Prophylactic IFA Supplementation- Regime
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58. CONTRAINDICATIONS
Prophylaxis with iron should be
withheld in case of acute illness
(fever, diarrhoea, pneumonia, etc.),
and in a known case of thalassemia
major/history of repeated blood
transfusion.
In case of SAM children, IFA - per
SAM management protocol.
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59. Deworming (Dose and regime)
AGE GROUP DOSE AND REGIME
Children 12–59 months of age Biannual dose of 400 mg albendazole (½ tablet
to children 12–24 months and 1 tablet to
children 24–59 months)
Children 5–9 years of age Biannual dose of 400 mg albendazole (1 tablet)
School-going adolescent girls and boys 10–19
years of age
Out-of-school adolescent girls 10–19 years of age
Biannual dose of 400 mg albendazole (1 tablet)
Women of reproductive age (non-pregnant, non-
lactating) 20–49 years
Biannual dose of 400 mg albendazole (1 tablet)
Pregnant women One dose of 400 mg albendazole (1 tablet), after
the first trimester, preferably during the second
trimester24-10-2020 59
60. INTERVENTION-3
IEC/ BCC FOR ANEMIA PREVENTION & BEHAVIOUR CHANGE
Focus on Social mobilization and behaviour change: 4 key
behaviours
• Compliance to Iron Folic Acid supplements and deworming
• Appropriate Infant and Young Child Feeding (IYCF)
• Increase intake of iron-rich, protein-rich and vitamin C rich foods
through diet diversification and consumption of fortified foods.
• Practice of delayed cord clamping in all health facility deliveries
followed by early initiation of breastfeeding within 1 hour of birth
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61. INTERVENTION 4
TEST AND TREAT STRATEGY
TESTING:
• Use of digital hemoglobinometers among School-going
Adolescent girls and boys 10-19 years, WIFS beneficiaries
using RBSK mobile teams
• Pregnant women at all ANC contact points.
• At all high case load facilities at block level and above,
hemoglobin level estimation will be done using Semi-Auto
Analyzers
• This may be extended to all age groups, later
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62. Test and treat intervention for anemia in Adolescent
Mild / moderate anemia
8-11.9 g/dl
Severe anemia
<8g/dl
Screening for anemia
No anemia
> 12 g/dl
1st follow-up*: after 45 days
Weekly, 1 IFA
tablet (60 mg
elemental Fe
+ 500 mcg
folic Acid)
Sugar coated
blue colour
Refer urgent
to MO at FRU
or DH
2 IFA tablet (60 mg elemental Fe +
500 mcg folic Acid) daily orally for
3 months (under observation by
school teacher)
2nd: follow-up*: after 90 days
Hb ≤ 12g/dl
Hb > 12g/dl
*Follow up by RBSK team / ANM based on the feasibility of the state24-10-2020 62
63. Prophylactic IFA supplementation
during Pregnancy – No anemia
• Daily One IFA tablet.
• Each tablet containing 60 mg elemental
iron + 500 mcg folic acid, sugar-coated,
red-colour.
• Starting from the 4th month of
pregnancy/from the second trimester / at
14th week of gestation.
• Continued throughout pregnancy.
• Minimum 180 days during pregnancy.
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65. INDICATIONS OF
PARENTERAL IRON
• Severe anemia ( any time during
pregnancy )
• Moderate anemia in 2nd or 3rd trimester.
• Post-partum if oral iron not
suitable/effective.
• Requirement for rapid iron repletion
• Intolerance to oral iron.
• Co-morbidities affecting iron
absorption.
• Chronic Renal impairment
• Ongoing iron losses exceeding
absorptive capacity
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66. FOOD
FORTIFICATION
• Mandatory provision of iron and
folic acid fortified products in
government health programmes.
• Iron fortified whole wheat
flour/refined flour/rice (Sodium
federate NaFeEDTA @20 mg/kg.
• Iron fortified salt/ double
fortified salt (Fe @ 850-1100
ppm).
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67. Intervention – 6
Malaria and Anemia
• The testing of malaria and anemia will be
integrated in the identified malaria endemic
regions, e.g., the beneficiaries who report recent
fever and being screened for anemia will also be
tested for malaria as per NVBDCP guidelines, to
ascertain the co- occurrence of malaria.
• Similarly, patients who are being tested for malaria
will also be tested for anemia in these endemic
regions with increase in outreach under NVBDCP
• NVBDCP has provided Long Lasting Insecticide
Nets (LLINs) in all high endemic areas.
• Anaemia Mukt Bharat will play a key role for
utilization of these LLINs by all target groups
especially pregnant mothers and under-five
children by promoting IEC/ BCC.
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69. Intra-ministerial coordination
• Existing (RKSK) National Steering Committee will be expanded to include the
National Anemia Mukt Bharat Steering Committee.
• Steering Committee will have biannual convergent meetings in coordination
with the respective divisions within MoHFW
Existing (RKSK) National Steering Committee will be expanded to include the National
Anemia Mukt Bharat Steering Committe Steering Committee will have biannual
convergent meetings in coordination with the respective divisions within MoHFW.
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70. NCEAR-A
‘National Centre of Excellence and Advanced Research on
Anemia Control (NCEAR-A)’ established at Centre of
Community Medicine, All India Institute of Medical
Sciences (AIIMS), New Delhi.
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71. Vision of NCEAR-A
“ To develop and provide
technical support to the
Ministry of Health and Family
Welfare, Government of India, for
incorporating scientific, policy
and community perspective in
policy and programmatic
decisions for control of anemia.”
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5
1
74. Recommendations of Expert Group Technical Consultation
on ANEMIA (23rd-24th April 2018)
• Recommended prophylactic dosage for PW, WRA and Adolescents to be 60
mg IFA tablets daily instead of ongoing 100 mf IFA tablets
• IFA tablets to be sugar coated instead of enteric coated
• Recommended therapeutic dosage for mild and moderate anemia in PW,
WRA and Adolescents to be single dose of 120 mg IFA (two tablets of 60
mg) daily instead of two divided doses daily
• Recommended referral of severe anemia cases to higher facility level
for management on case by case basis
• Sahli’s or Color Scale method should not be utilized for hemoglobin testing
due to estimation errors. No specific recommendation on estimation method.
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75. Further suggested
readings
• AMB Operational Guidelines
for Programme Managers –
handbook
• Anemia Mukt Bharat Portal or
Digital Dashboard
• Achieving Anemia Free
India-NCEAR-A, Centre
of community
Medicine(AIIMS)-Red
book
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