1. 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

2. 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

3. Prevalence of Anemia in India(
High prevalence across all age groups
Source: NFHS

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

5. 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

6. 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

7. 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

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

9. 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.

10. 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.”

11. 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

12. 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

13. 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

14. Hemoglobin Estimation included in WHO Essential Diagnostic List

15. 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

16. 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.

17. 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 Jul 1;52(3):360.

18. 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%

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

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

21. 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

22. Management of Mild and Moderate Anemia amongst Adolescent

23. Management of Severe Anemia amongst Adolescent

24. 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

25. Prophylactic IFA supplementation during Pregnancy –
No anemia
Daily One IFA tablet
Each tablet containing 100 (60) mg elemental iron 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

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

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

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

29. 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

30. 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

31. THANK YOU
NCEAR-A Team, AIIMS, New Delhi

32. Test and treat intervention for anemia in Adolescent
Screening for anemia
No anemia
> 12 g/dl
Mild / moderate anemia
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 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