Initiatives in addressing Anemia in Assam Dr. Priyakshi Borkotoky Consultant Nutrition, NHM, Assam

Significant reduction in all categories Status of Anemia Significant reduction in all categories 34% reduction among WRA. ( India-4.1%) 49% reduction in among children under 5 years. ( India-6.85%) 27.2% reduction among PW. ( India – 7.6%)

Vulnerable Communities Tea Garden Community Minority Community

Causes of Anaemia in vulnerable Communities of Assam How to Prevent Nutritional Anaemia Well Balance Diet IFA Supplementation . Deworming Proper introduction of complementary feeding. Habit of taking black tea with salt instead of water in Tea Garden Community Low protein diet. Poor dietary iron source in diet and iron absorption enhancers STH Late complementary feeding Multiple pregnancies

Poor compliance among PW Poor compliance among Pre schoolers Interventions NIPI 6 months to 59 months : NIPI 5-10 & 10-19 years : NIPI Pregnant Mothers Deworming Malaria at eradication phase Special Initiatives such as Mission Tejaswee Mission Rupjyoti Focus on tea gardens by UNICEF, Assam Focus on riverine areas by Boat Clinics Issue of departmental directives for IFA supplementation from department of Education & Social Welfare Poor compliance among PW Poor compliance among Pre schoolers Resistant Schools

Mission Tejaswee-A month long Programme Anaemia Free Assam Special drive for prevention and awareness of anemia Lauched in October, 2015 Initially Launched centrally at Guwahati by Hon’ble Chief Minister followed by District level Launching by MPs/MLAs and Deputy Commissioners. It is annually implemented across the state with equal focus in all 27 districts Branding: Wearing of Red Apparels by all on the day of launching. Implementation steps are analogous to NDD & IDCF

Mission Tejaswee-A month long Programme Anaemia Free Assam Objectives: To improve compliance for IFA in all age group. Capacity building and regular sensitization of all services providers who deals with IFA supplementation on anaemia effects and its prevention. Intensive awareness generation on effects of anaemia and its prevention as well as food diversification.

Mission Tejaswee-A month long Programme Anaemia Free Assam Process: Month long targeted approach against anaemia to reduce anaemia prevalence in Assam. Demand generation through awareness. Identification of High Risk Pregnant Women and their referral. Strengthening and streamlining of drugs distribution system. To extend weekly iron folic acid supplementation programme in all school & AWCs of Assam Awareness generation on danger signs of pregnancy due to anaemia. This increased identification and referral of HRP.

Demand Generation for NIPI 6 months to 59 months (Target: Parents) Poor physical development Poor attentiveness Poor memory Poor academic performances in future Delayed psychomotor development IFA supplementation is important Raising Healthy Children

Demand Generation NIPI 5-10 & 10-19 years Advantages of IFA Supplementation (Academic) Target: School Teachers Increase in IQ leading to better academic performance of the students. Increase in learning ability. Increase in concentration. Increase in energy levels and output in day to day work. Increase in overall capacity to work and earn. Physically more active facilitating increased participation in extra curricular activities. Reduction in school absenteeism.

Target: adolescence girls & parents Health Benefits of IFA Supplementation Increase in Hemoglobin level thus reduction in anemia. Reduction of occurrence of dysmenorrhea Increase appetite. Reduced fatigue. Regular Menstrual cycle. Better sleep. Improved Skin Appearance. Building pre-pregnancy health. Feeling stronger and less tired.

Demand Generation for Pregnant mothers Target : PW , Husband & family members for safe delivery and healthy baby Low birth weight Premature birth IFA supplementation is safe and essential during pregnancy Target of HRPW (anaemia)/ASHA - ensuring identification & IFA compliance. Involvement of CHO using MCTS work plan.

There are some harmless but expected mild side effects of IFA Epigastric discomfort–nausea, diarrhoea or constipation Dark stools Metallic taste Side effects are not universal, not frequent (<1%) and never lead to any adverse event (disability or death) These happen most when is taken for the first time, since the body may find it little difficult to digest and disappear once IFA is regularly used for a few days or weeks. Dark stools are harmless. The body takes the iron it needs and the extra iron comes out of body through feces.

Steps of implementation State workshop District workshop Block & micro level Training of Teachers/ANMs/Health Supervisors/LHVs/ASHAs/ ASHA supervisors SC & Block micro planning District Micro planning meeting Mission Tejaswee Implementation Review by state NHM IEC- BCC Activities (7 days prior to the campaign)

Communication planning (IEC/BCC) Leaflets Miking with special focus on hard to reach & tea garden areas. Audio jingles developed by state HQ . Audio-visual spots generated for local cable TV & community radio. Banners/ Posters Group SMS to all citizens of Assam on the day of launching. Rally Street play by ASHAs in community meetings. Media briefing

Mission Rupjyoti Special IEC and BCC initiative for prevention and awareness of anemia

Out Comes Group 2016-17 2017-18 2018-19 (1st quarter) NIPI for 6-59 months 46% 54% 63% NIPI for 5-10 years not started 56% 84% NIPI for 10-19 years 23.11% 58.90% 42% NIPI for Pregnant Lady  91% 93% 94% Mission Tejaswee 72.60% 76.80% Nov, 2018 Progressive improvement in coverage in case of all age group. Improved awareness on anaemia among students, teachers, other beneficiaries and community. Periodic sensitization during Mission Tejaswee, strengthening the NIPI programme by boosting confidence, ownership of ASHA, AWW & Teachers. Enhance cooperation among Heath, Social Welfare and Education department. Awareness generation on danger signs of pregnancy due to anaemia. This increased identification and referral of High Risk Pregnancy cases contributing to reduced MMR & IMR. Optimum supply and use of IFA syrup and tablets. Better acceptance of IFA in the community.

Case Study Patient name: Devi Doley History: During the 1st ANC was detected with a Hemoglobin level less than 9 mg/dl and identified as severely anaemic. Management: Regular home visits with counselling to Doley as well as to her family members on ANC, importance of institutional delivery, balance diet, dietary diversification and compliance of 180 IFA tablets though home visits. AWC has ensured regular supply of take home ration also creating awareness on locally available iron rich food. Out come: Hb level increased to 11 mg/dl at delivery and she delivered a healthy child weighing 3.9 Kg at Govt. Hospital. Presently she is in the 1st trimester of 2nd pregnancy with Hb -10mg/dl. She get registered herself to take all ANC facilities.

Actions to Sustain Good Coverage

Robust Monitoring Plan At Sub Center (SC) Level: The MPW (M) and ANM visit schools and AWC under their jurisdiction and monitor the school/ AWC reporting register on WIFS/ WIFS Junior fortnightly. At Block Level: All BMO, BPM, BCM, HE, BEE, LHV, BPA ABPM visit one school and one AWC per week regularly to monitor WIFS programme. Each person will visit separate institutions every time. At District Level: SDM&HO ( School Health)/ i/c SDM&HO ( School Health), DPM, DME, DCM, RBSK Coordinator, Urban Health Coordinator will visit one schools and one AWC per month regularly to monitor WIFS programme.

Drug Supply State District Block Sub centre IFA tablet are available up to the Sub Centre level. Nodal teachers has to submit their requirement and collect medicine from sub centre. Furthermore MPW will be responsible for estimation of requirement of IFA, stock enquiry and availability of IFA at school/AWC. In absence of MPW indent may be submitted to the respective ANM. In SCs where no MPW or ANM is posted, medicine may be distributed by the RBSK team or ASHA , CRCC may be also be involved in such cases.

Reporting Formats Reporting format of NIPI-Under 5 & PW Simplified SN School / AWC SN Name of the Format Person Responsible Submitted to A Monthly School Reporting Format Nodal Teacher/ AWW To be prepared in duplicate one copy to MPW/ ANM of nearest SC and one copy to parent Department B Sub Centre Level Reporting Format MPW/ANM Sector C Class Monthly Register/ Monthly AWC Register To be maintained at School/ AWC E Block Reporting Format for Education BPA or block level in charge of WIFS programme CDPO/BEEO/School Inspector F Individual Compliance Card Class Teacher To be maintained against each student & filled by class teacher Monthly AWC Register : Initiative of the State

Special focus on riverine areas 13 lakh people in 13 districts IFA supplementation through boat clinics in riverine areas IFA stock maintained by ASHA

Key drivers Enhanced outreach through MMUs specially in Tea Gardens Strong communication campaign – Mission Tejaswee Focus on vulnerable pockets Supply issues effectively addressed Convergence – A monthly meeting regularly held in O/o of MD, NHM and DSW is the convenor of the meeting. Improved access to food and feeding behaviors – ration for tea garden areas. Bottlenecks addressed – auto-dispenser. ASHA incentive payment for IFA supplementation streamlined.

Thank You

Caused nutritional anemia in 6 – 5 years children Poor Iron store in the body Other micronutrient deficiency Worm Infestation Malaria Infection How to prevent anemia in preschool children 6 months to 5 years ntation for Biannual Deworming Hand washing habit of the mother and child at the later part of the life. Introduction of Complementary Food at 6 months of age. Introduction of common family food from 1 year age. Maintenance of proper personal and environmental hygiene.

Hand Washing Benefits of Hand Washing Wash hands before holding a neonate or infant. Wash hands before serving foods to children. Start hand washing training of a pre school child as soon as possible. Benefits of Hand Washing Protects from Diarrhea, Pneumonia, Worm infestation and other infections.