Test and Treat Strategy for Point of Care Management Of Anemia   “Anemia Mukt Bharat and Home-based Young Child Care” National Dissemination Workshop for State Programme Managers, 18 &19 September, 2018 Test and Treat Strategy for Point of Care Management Of Anemia Dr. Kapil Yadav, Associate Professor, and Dr Shashi Kant, Professor and Head, Centre for Community Medicine and National Centre of Excellence and Advanced Research on Anemia Control (NCEAR-A), All India Institute of Medical Sciences (AIIMS), New Delhi

Take Home Message Hb estimation essential for management & follow up Test and Treat strategy -key paradigm shift for AMB POCT by digital hemoglobinometer a feasible option Need for scaling up & universalising “Test and Treat” Future research for validating non-invasive hemoglobinometer

Prevalence of Anemia in India ( High prevalence across all age groups Source: NFHS 4 2015-16

State-wise burden of anemia amongst Pregnant women in India

Ministry of Health and Family Welfare Government of India INTENSIFIED NATIONAL IRON PLUS INITIATIVE April, 2018 Ministry of Health and Family Welfare Government of India

Objectives of Anemia Mukt Bharat To reduce in morbidity and mortality due to anemia 2. To reduce anemia prevalence by 3 percent per annum in all age groups (children, adolescents, pregnant women and WRA) 3. To increase the proportion of eligible target beneficiaries who consumed IFA tablet as per protocol by 50% (by NFHS-5) 4.To increase community knowledge and risk perception through improved social support 5. To ensure that state governments have enhanced capacity to deliver services and supplies for prevention and management of anemia

Targets of Anemia Mukt Bharat Age Group Anemia prevalence (%) (NFHS-4) National target 2022 Children (6-59 months) 58 40 Adolescent girls (15-19 yrs) 54 36 Adolescent boys (15-19 yrs) 29 11 WRA (15-49 years) 53 35 Pregnant women 50 32 Lactating women To reduce the prevalence of anemia by 3 percentage points per annum as per POSHAN Abhiyaan targets

How will this be done? 6 6X6X6 strategy institutional interventions mechanisms 6X6X6 strategy

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.

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.”

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

6 Interventions Point of Care Testing of anemia and Treatment Anemia testing using invasive digital hemoglobinometers, for In school adolescents and Pregnant women Testing of adolescents by RBSK teams, follow up by ANM/MPW/States to decide Testing of PW at VHNDs/ANC clinics For non-nutiritonal causes of anemia- focus on Malaria, Fluorosis and hemoglobinopathies through reiterating preventive/promotive activities as per the respective programmes and fluorosis

Why Point of Care Test and Treatment Strategy? Equipped laboratory may not be available / accessible Enables screening in outreach and community setting Beneficiary may be lost to follow up if called again for laboratory tests Faster access to test results Rapid clinical decision making Rapid treatments and interventions Improved health outcome Paradigm shift from earlier clinical examination or laboratory based tests

Hemoglobin Estimation included in WHO Essential Diagnostic List

Other Advantages of POCT Small volume of blood sample required Rapid turnover time, more beneficiaries covered Overcomes need for health facility visit No loss to follow up Ease of obtaining the sample (capillary vs venous) Laboratory technicians & phlebotomists not required

POCT for Hemoglobin Estimation Invasive methods: Indirect cyanmethemoglobin method Sahli’s method Hb color scale method Copper sulphate method Vanzetti’s method and modifications (HemoCue 201, HemoControl, TrueHb) Invasive methods with reagent free cuvettes: HemoCue 301 DiaSpect Non-invasive methods: Occlusion spectroscopy (NBM 200) Pulse co-oximetry Trancutaneous Reflection Spectroscopy (HemoSpect) Sahli’s method is commonly used as a POCT in India, but it has poor sensitivity and specificity.

Poor sensitivity and specificity of Sahli’s and WHO Colour Scale Anand H, Mir R, Saxena R. Hemoglobin color scale a diagnostic dilemma. Indian Journal of Pathology and Microbiology. 2009 Jul 1;52(3):360.

Validation of Digital Hemoglobinometer as compared to gold standard AIIMS, New Delhi assessed validity of two digital hemoglobinometer devices (Device A and Device B) compared with autoanalyzer Device B: Reagent free microcuvettes, not affected by moisture, temperature , no specific storage conditions Device B is being used for “Test and Treat” camps during Poshan Maah Indicator Device A Device B Mean (SD) difference of Hb -0.53 (1.01) -0.25 (0.85) sensitivity 93% 90% specificity 76% 80%

Validation of Digital Hemoglobinometer as compared to gold standard Agreement between Device B and Gold Standard Scatter plot between Device B and Gold Standard

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

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

Management of Mild and Moderate Anemia amongst Adolescent

Management of Severe Anemia amongst Adolescent

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

Prophylactic IFA supplementation during Pregnancy – No anemia Daily One IFA tablet Each tablet containing 100 (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

Testing and treating of anemia in pregnant women under AMB – Mild anemia

Testing and treating of anemia in pregnant women under AMB – Moderate anemia

Testing and treating of anemia in pregnant women under AMB – Severe anemia

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

Take Home Message Hb estimation essential for management & follow up Test and Treat strategy -key paradigm shift for AMB POCT by digital hemoglobinometer a feasible option Need for scaling up & universalising “Test and Treat” Future research for validating non-invasive hemoglobinometer

THANK YOU NCEAR-A Team, AIIMS, New Delhi

Test and treat intervention for anemia in Adolescent Screening for anemia No anemia > 12 g/dl Mild / moderate anemia 8-11.9 g/dl Severe anemia <8g/dl 60 gm elemental Fe tablet – twice daily orally for 3 months (under observation by school teacher) Weekly, 1 IFA tablet (100 mg elemental Fe + 500 mcg folic Acid) Sugar coated blue colour Management by MO at FRU 1st follow-up*: after 45 days 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