Program launched by GOI

1. Dr SEEMA VERMA
Department of Community medicine
PGIMS Rohtak Haryana INDIA

2. • Introduction
• Global burden
• National scenario , Haryana 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
Outline…

3. • Our nation is on the cusp of writing history in terms of its economic
development. The young population of our country carries the
responsibility of leading the nation towards prosperous future with
better social and economic standing.
• However, Anemia remains a major public health issue with high
prevalence across the country irrespective of gender, age and
geography. It is time to intensify our fight against anemia in terms of
its prevention and control leading to better health outcomes.
Introduction

4. • Anemia- manifestation of various underlying deficiency and disease
conditions.
• It - overall development of children, associated with increased
maternal mortality, reduces work efficiency in adults.
• Reducing anemia- important objectives of the POSHAN Abhiyaan
launched in March 2018. 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 percentage points per year among
children, adolescents and women in the reproductive age
group(WRA).
Introduction

5. • Anemia is a condition –no of RBCs 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.
• Haemoglobin concentration below established cut-off levels are used
for diagnosing anemia across different ages as described
Introduction
Source: WHO- Nutritional Anemia: Tools for Effective Prevention and Control, 2017

10. Reduced physical
development
Impact on
pregnancy
outcomes
Reduced cognitive
development
Economic impact
• Diminished concentration, disturbance in perception,
• delayed psychomotor development
• Impaired language and motor skills,
• Diminished IQ equivalent to a 5–10 point
• About 20 % of maternal deaths are caused by Anemia worldwide
• NTD, low birth weight and still births
• Anemic pregnant women are more prone to increased morbidity ;
• three times greater incidence of premature delivery in severely anemic
women
• Decreased work output and work capacity
• Physical and cognitive losses due to IDA in South Asia are staggering:
close to $ 4.2 billion annually in Bangladesh, India and Pakistan
• 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.
Public Health Implications of Anemia

12. Current – close to 1% Committed to achieve target – 3%
Short term, Long term and Intergenerational benefits
Enhances
health &
nutrition of
women and
children
World Health Assembly has proposed a target of 50% reduction in Anemia
among women by 2025 and
NHP 2017 commits to reduce anemia prevalence by 3% per year
Annual average rate of reduction (AARR) of anemia prevalence
Why Should We Address Anemia?
Improvements
enhance human
capital
Contribute to a
virtuous cycle by
fostering economic
development

13. 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
58.5
52 55.2 53.1
0
20
40
60
80
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

14. State-wise burden of anemia amongst Pregnant women in India

15. 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, P
unjab, 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)

16. WRA
Under- five children
81
75 76
69
77
84
63
78
74
63 64
61
72 70
64
69
54
51
60
72
36
20
30
40
50
60
70
80
90
Bihar Madhya P. Maharashtra Tamil Nadu Uttarakhand Haryana Assam
NFHS-2 (1998-99) NFHS-3 (200-06) NFHS-4 (2015-16)
63
54
49
57
46 47
70
67
56
48
53
55 56
70
60
52
48
55
45
63
46
30
35
40
45
50
55
60
65
70
75
Bihar Madhya P. Maharashtra Tamil Nadu Uttarakhand Haryana Assam
NFHS-2 (1998-99) NFHS-3 (200-06) NFHS-4 (2015-16)
Anemia trend in WRAAnemia trend in U5
Bottom 3
Mizoram – 22.5%
Nagaland – 23.9%
Manipur – 26.4%
Top 3
DNH – 79.5%
Chandigarh – 75.9%
A & N – 65.7%
Bottom 3
Mizoram – 17.7%
Nagaland – 21.6%
Manipur – 23.9%
Top 3
Chandigarh – 73.1%
Haryana – 71.7%
Jharkhand – 61.9%

17. HARYANA SCENARIO
0
10
20
30
40
50
60
70
80
6 - 59 m 11 - 19 yr 15 - 49 yr Pregnant
Trend of Anemia Prevalence
NFHS 3 NFHS 4

18. Iron deficiency,
Haemoglobinopathies,
Malaria are three leading
causes Of anemia Globally.

20. 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
5-10 yrs age group
added
2013
Wkly and biwkly
supplementation.
Test and treat (NIPI)
Life cycle approach
2018
I-NIPI Program
intensification
(Anemia Mukt Bharat)
P & LW 60mgX180
days, IFA for WRA
6X6X6 strategy
Life cycle approach
• Anemia control efforts in India started in 1970 with supplementation of Iron
and folic acid in PW,LW,PSC.(NNACP)
• Anemia level in various population groups remained high(NNACP)
• More than 50% cases of anemia are IFA.

21. State-wise burden of anemia amongst Pregnant women in India

22. > = 3 0 % d e c l i n e1 4 - 2 8 % d e c l i n e5 - 9 % d e c l i n e
55
45
35
25
15
-5
5
-15
-25
-35
-45
55
65
%decline
comparing NFHS-4,2015-16AND NFH-3,2005-06
D
elhi
H
.P.Punjab
U
.P.
BiharTripura
M
.Pardesh
U
ttarkhand
M
eghalayaJharkhand
India
W
.B.
M
ah.G
ujaratT.N
aduH
aryanaR
ajasthanKarnataka
G
oaM
anipurO
disha
J&K
Kerala
C
hhattisgarh
Ar.Pradesh
AssamM
izoram
Sikkim
Eight states >=30% decline (6 are eastern states)
Two States >=25% increase
Decadal change | Anemia in Pregnancy
Learning from Best Performing States/ Districts

23. States with
≥30% anemia
decline
What did they do
differently?
1 2
3
4
5
6
7 No stock outs/ un-interrupted
supply chain
Special strategies for Malaria zones:
Screening, Tracking high-risk/anemia cases
and treatment
Monitoring and
strengthening outreach
service coverage
IEC/ BCC
Inter-personal
counseling, mass
and mid media
Target setting, convergence and
reviews at highest level
Highest Political Commitment
Combination of
interventions:
• Dietary diversification
(iron-rich foods
including foods from
animal origin)
• IFA, deworming and
malaria interventions
Assam, Chattisgarh,
Odisha
Learning from field

24. Objectives of Anemia Mukt Bharat strategy
Reduction in morbidity and mortality due to anemiaImpact
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

25. To reduce the prevalence of anemia by 3 percentage points per annum targets
Beneficiary WiseTargets of AMB for 2022

26. Anemia Mukt Bharat
6x6x6 strategy to
combat anemia
6
interventions
institutional
mechanisms
6X6X6
strategy
6
6
Anemia Mukt Bharat

27. 6
adolescent boys
and girls
(10-19 years)
Children
(6-59 months)
124
million
115
million
children
(5-9 years)
134
million
pregnant
women
30
million
lactating
mothers
27
million
women of
reproductive
age
(20-24 years)
17
million
Estimated
450 million
beneficiaries
Reaching nearly 50% of
the country’s population
Six Beneficiaries

28. Six Interventions
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
HOSPITAL
6
Addressing non-nutritional causes
of anemia in endemic
pockets, with special focus on
malaria, haemoglobinopathies and
fluorosis

29. 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

30. 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)
• To be 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

32. IPCs for women

33. • 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.
• All WRA- 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, - reduce the incidence of NTD.
Contraindication …

35. Focus on Social mobilization and behaviour change: 4 key behaviours
1. Compliance to Iron Folic Acid supplements and deworming
2. Appropriate Infant and Young Child Feeding (IYCF)
3. Increase intake of iron-rich, protein-rich and vitamin C rich foods
through diet diversification and consumption of fortified foods.
4. Practice of delayed cord clamping in all health facility deliveries
followed by early initiation of breastfeeding within 1 hour of birth
Intervention 3
IEC/ BCC for Anemia Prevention &
BehaviourChange
Solid Body,
Smart Mind

36. Testing:
 Use of digital hemoglobinometers
 In two age groups- to begin with
 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
Intervention 4
Test and Treat Strategy

37. Target group for Test and Treat intervention
under Anemia Mukt Bharat
• Adolescent girls and boys of 10-19 years in government and
government aided schools
• Pregnant women registered for ANC check-up
• To be extended to other beneficiary groups subsequently

38. Test and Treat intervention for anemia
amongst Adolescent
Activity Details
Screening by Rashtriya Bal Swasthya
Karyakaram (RBSK) team
Tool Digital hemoglobinometer
Place of screening School premises
Periodicity Annual

39. 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 state

40. Test and Treat intervention for anemia
amongst Pregnant women
Activity Details
Screening by Health service provider at ANC contact,
including PMSMA
Tool Digital hemoglobinometer
(high load facilities like block health center and
above to use semi-autoanalyzer)
Place of
screening
Health facilities
Periodicity Every antenatal check-up (ANC) contact

41. • 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
Prophylactic IFA supplementation during Pregnancy –
No anemia

43. • Severe anemia
• 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.
• Ch. Renal impairment
• Ongoing iron losses exceeding absorptive capacity
Indications of parenteral iron

44. Management protocol for severe anemia contraindicated for patients of thalassemia major and sickle cell disease.
Anemia Management Protocol
for Pregnant Women
Mild/moderate
First level of treatment
(at all levels of care)
Two tablets of iron and folic acid tablet (60 mg elemental iron and
500 mcg folic acid) daily, orally given by the health provider
during the ANC contact.
* Parental iron (IV Iron sucrose or Ferric Carboxy Maltose may be
considered as the first line of treatment in pregnant women who
are detected to be anemic late in pregnancy or in whom
compliance is likely to be low (high chance of lost to follow-up).
Follow-up Every two months, during the ANC contact
If no improvement after first
level of treatment
If no Hb (<1g/dl) increase; Refer to FRU/DH (case may be
managed with IV Sucrose/FCM)
Severe anemia (5-6.9 g/dl) By medical officer, using IV Sucrose/FCM. Immediate
hospitalization if pregnant woman is in 3rd trimester.

45. Testing and treating of anemia
in pregnant women under AMB – Severe anemia
If Hb is <5 g/dl
Immediate hospitalization irrespective of period of gestation where round-the-
clock specialist care is available

47. • 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.
Intervention 6

48. 1
Intra-ministerial
coordination
2
National Anemia Mukt
Bharat Unit
3
National Centre
of Excellence and
Advanced Research on
Anemia Control
4
Convergence with
other ministries
5
Strengthening supply
chain and logistics 6
Anemia Mukt Bharat
dashboard and digital
Portal - one-stop shop
for anemia
Six Institutional Mechanisms

49. Intra-ministerial coordination
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

50. 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.

51. 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.”
5
1

52. Objectives
of
NCEAR
5
2
Objectives
Provision
of technical
inputs
Research
Monitoring
and
evaluation
Act as apex
reference
laboratory
Capacity
building
Mentor &
support
regional
centres for
excellence

55. Online tool kit and
programme
monitoring tool

56. All resources including
guidelines, quarterly
report cards for states and
districts, denominators
for services & stock and all
communication and
training materials can be
downloaded from the
Anemia Mukt Bharat portal
A one-stop shop for all anemia-related materials

57. 6-59
months
child 5-9
years
10-19
years
Pregnant
women
Lactating
women
Stock
available
WRA
Total indicator 2 2 11 6 2 6 2
HMIS 2 2 4 5 1 5 0
QPR 0 0 7 1 1 1 2

60. Quarterly
[HMIS]
KPIs
As %
• ALL States
• ALL Districts

63. One stop shop
for all
resources in
one place

64. State focal point
Anemia Mukt Bharat MIS
Platform
Enter your
own data
feature
Initially at
state level

66. Target based monitoring
SIX performance indicators

69. 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

70. 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
•

71. LET US MAKE
INDIA ANEMIA-FREE