1. Anemia Mukt Bharat -An Intensified National Iron Plus Initiative
18th September, 2018
Ministry of Health and Family Welfare
Government of India

2. High Prevalence across all ages Slow progress in most of the States
A Snapshot of Anemia in India v
High Prevalence across all ages
Slow progress in most of the States
Trend in Prevalence of Anemia among Children and Women
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

3. among Pregnant Women (15-49 yrs)v
Anemia Prevalence among Pregnant Women (NFHS-4)
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

4. Causes of High Burden of Anemiav
Causes of High Burden of Anemia
Low Iron Stores
During pregnancy in anemic mothers
Poor iron stores from infancy, childhood deficiencies and adolescent Anemia
Dietary
Inappropriate IYCF esp. Complementary Feeding Practices
Excessive consumption of ‘Iron Inhibitors’ (tea, coffee, calcium-rich foods) and low intake of ‘Iron Enhancers’ (Vitamin C etc.)
Low bioavailability of dietary iron
50% of the population is consuming < 50% RDA
Iron Loss
Due to parasitic load (malaria, intestinal worms)
Poor environmental sanitation, unsafe drinking water and inadequate personal hygiene
Maternal Anemia
Increased iron requirement due to tissue, blood formation and energy requirement during pregnancy
Iron loss from post-partum haemorrhage
Teenage pregnancy
Repeated pregnancies with less than 2 years interval

5. Public Health Implications of Anemiav
Reduced physical development
Impact on pregnancy outcomes
Reduced cognitive development
Economic impact
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
About 20 % of maternal deaths are caused by Anemia worldwide
tube defects, infants of low birth weight and still births
AnemiNeuralc pregnant women are more prone to increased morbidity and ; there is a 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 is the third leading cause of DALYs lost for females aged 15–44 years and % of Gross Domestic Product (GDP) loss. Median total loss (physical and cognitive) combined are 4.05% of GDP in developing countries.

6. Why Should We Address Anemia?
Improvements enhance human capital
Contribute to a virtuous cycle by fostering economic development v
Why Should We Address Anemia?
Short term, Long term and Intergenerational benefits
Enhances health & nutrition of women and children
Contribute to a virtuous cycle by fostering economic development
Improvements enhance human capital
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
poor growth, development and cognition in children,
increased risk of preterm delivery,
low birth weight and reduction in neonatal iron stores during pregnancy
reduction in work efficiency and productivity in general
It is estimated anemia contributes to around 0.4 per cent of Global DALYs.
Evidence is that anemia elimination can increase productivity by up to 17 per cent.
Reduction of anemia prevalence by 50 percent has been stated as one of the goals in 12th Action Plan.
The National Health Policy 2017 also lays a special focus on the health challenges of adolescents and Children as one of the key policy intervention for achieving the RCH outcomes.
Annual average rate of reduction (AARR) of anemia prevalence
Current – close to 1%
Committed to achieve target – 3%

7. Milestones in Control of Anemia in Indiav
Milestones in Control of Anemia in India
Anemia control efforts in India started in 1970 with supplementation of Iron and folic acid across age groups
Anemia level in various population groups remained high
IFA coverages remained less than 30%
More than 50% cases of anemia attributed to Iron deficiency
2018
I-NIPI Program intensification (Anemia Mukt Bharat) PLW 60mgX180 days, IFS for WRA 6X6X6 strategy
Life cycle approach
2013
Wkly and biwkly supplementation.
Test and treat (NIPI)
Life cycle approach
2007
5-10 yrs age group added
1991
60 mg Iron changed to 100mg
1970
60 mg Iron supplementation for PW and 20 mg for 1-5 yr X100 days

8. Learning from Best Performing States/ Districtsv

9. States with >=30% Anemia Decline What Did They Do?v
States with >=30% Anemia Decline What Did They Do?

10. Anemia Mukt Bharat v 6
interventions
institutional
mechanisms
6X6X6
strategy
Anemia Mukt Bharat will use a 6x6x6 strategy to combat anemia

11. Six Beneficiaries Estimated 450 million beneficiariesv
Estimated
450 million beneficiaries
Reaching nearly 50% of the country’s population

12. Beneficiary-wise Targetsv
To reduce the prevalence of anemia by 3 percentage points per annum

13. Six Interventions v 2 1 4 3 6 5 Prop h ylactic iron folic acid
supplementation 3
Intensified year-round Behavior
Change Communication Campaign Solid Body Smart Mind ,delayed cord clamping 5
Mandatory pr o
vision of iron
public health prog r
ammes
ANGAN W
ADI 2 P
eriodic deworming of children,
adolescents, pregnant women 4 T
esting of anemia using digital
methods and point of care
treatment
HOSPI AL 6
Addressing non-nutritional causes of anemia in endemic pockets, with special focus on malaria, haemoglobinopathies and fluorosis

14. Intervention- 1 Prophylactic IFA supplementation- Regime v 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 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 mcg Folic Acid
Sugar-coated, pink colour

15. Prophylactic IFA Supplementation- Regime
Cont...
Prophylactic IFA Supplementation- Regime v
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 mcg Folic Acid
Sugar-coated, blue colour
Women of
reproductive age
(non-pregnant, non-lactating)
20-49 years
Each tablet containing 60 mg elemental Iron 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 mcg Folic Acid
Sugar-coated, red colour

16. Intervention 3
Intensified 360 Degree IEC/ BCC for Anemia Prevention & BehaviourChange v
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
Solid Body, Smart Mind

17. Intervention 4 Test and Treat Strategy Testing: v
Use of digital hemoglobinometers
In two age groups- to begin with
School-going Adolescent girls and boys 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

18. Anemia Management Protocol for Adolescentsv
Mild/moderate
First level of treatment (at all levels of care)
Two IFA tablets (each with 60 mg elemental iron and 500 mcg
folic acid), once daily, for 3 months
Line listing of all anemic cases; Two Follow-ups
First follow-up after 45 days and second follow-up after 90 days at nearest health facility
If hemoglobin levels have come up to normal level, discontinue the treatment and continue with the prophylactic IFA dose
If no improvement after first level of treatment
If no improvement after three months of treatment, RBSK team will refer the adolescent to First Referral Unit (FRU)/District Hospital (DH)
Severe anemia
Management to be done by medical officer at FRU/DH based on investigation and diagnosis

19. Anemia Management Protocol forPregnant Womenv
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.
Management protocol for severe anemia contraindicated for patients of thalassemia major and sickle cell disease.

20. Six Institutional Mechanismsv

21. Target based monitoring SIX performance indicatorsv

22. What’s New? v
Coordinated management efforts – intra & inter ministerial Target based monitoring and KPI reviews and awards; Private schools; 60 mg instead of 100 mg prophylactic dose, sugar coated. Communication materials for extensive awareness, intensive 360 degree communication campaigns - Creating a Jan Andolan… Use of digital methods of hemoglobin estimation and point of care treatment, newer treatment strategies – IV Iron Sucrose and FCM Linkage with Malaria; mandating use of fortified food in public health programmes, specially double fortified salt (iron and iodine) Linkage with academic – national and regional networks- (re) learning and policy decisions

23. LET US MAKE INDIA ANEMIA-FREE