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ADDRESSING ADOLESCENT ANAEMIA We Must Act Now Dr. Sheila Vir. Iron Deficiency and Iron Deficiency Anaemia (Global Scenario). Iron Deficiency - 3 out of 4 persons Iron Deficiency Anaemia - 1 out of every 3 persons

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We Must Act Now

Dr. Sheila Vir


Iron Deficiency and Iron Deficiency Anaemia

(Global Scenario)

  • Iron Deficiency - 3 out of 4 persons
  • Iron Deficiency Anaemia - 1 out of every 3 persons
  • or IDA (2 billion)

Anaemia Prevalence (%) in Adolescent Girls

  • Anaemia prevalence in developing countries
  • Adolescent girls - 27% (6% in developed world)
  • non pregnant women (WRA) 15-49 years - 43%
  • pregnant women - 56%

Causative Factors

  • Significant increase in requirements of iron
  • Low intake of bioavailable iron

Prevention of IDA

  • Dietary diversification
  • Fortification of food
  • Iron supplements

Prevention of IDA – Both Health and Economic Issue

  • Iron Folic Acid Supplementation – Benefits
  • Investment not limited to pregnancy
  • Positive influence on cognitive development
  • Enhanced concentration in school and work
  • Increased physical output
  • Improved growth (10-14 years)
  • Improved appetite
  • Decreased morbidity
  • Overcome irregularity in menstruation
  • Investment in pregnancy (Iron supplementation during pregnancy might be too late!)
  • Overcome large prepregnancy deposits
  • Reduces chances of LBW and MMR
  • Reduces chances of neural tube defects (NTD)
  • Improves iron status of infants

Prevention of Anaemia

Daily or Weekly Dose of IFA ?

  • Global Efficacy and Effectiveness Trials
  • Meta Analysis

Weekly Iron Folic Acid Supplementation (WIFS)

is Effective for Prevention of Anaemia

in adolescent girls


India – Impact of Daily and Weekly IFA Administration to adolescent Girls (1996-1998)

Meta analysis (3 India + 6 others) - CONCLUSION – Weekly supplementation should be considered only in situations where there is strong assurance of supervision and high compliance

(Beaton et al, 1999)


Indonesia Adolescent Study

Haemoglobin < 120 g/L

Prevalence of anaemia at baseline and after 12 weeks of supplementation

Daily – 60 mg Fe, 750 µg retinol, 250mg folic acid and 60 mg vitamin C

Weekly – 60 mg Fe, 6000 µg retinol, 500mg folic acid and 60 mg vitamin C

Placebo - 0 mg Fe, 0 µg retinol, 0 mg folic acid and 0 mg vitamin C

Angeles-Agdeppa et al, 1997


Sri Lanka Adolescent Study

  • Intervention
  • Iron Folic Acid Supplements
  • 6 monthly Deworming done

Jayatissa and Piyasena, 1999


India Experience – 2000-2005

Weekly Iron and Folic Acid Supplementation (WIFS) – 100 mg Fe + 500 µg Folic Acid

  • 13 states (8.7 m girls)
  • Age group between 10 – 19 years
  • In School Girls (SG) and Non School Going Girls (NSG)
  • Anaemia prevalence 54-99%

Source: Dwivedi and Schultink, 2006 SCN News # 31


Change in Anemia Prevalence by States (Hb<12 g/dl)

* statistically significant difference (Chi square test, p<0.001, CI 95%)

(a) Baseline is the ICMR estimation of anemia (Chi Square Test not possible)

(b) out of school non participants represent baseline and school going participants represent assessment (Chi Square Test not possible)

WIFS – compliance 75-90%


Change in Mean Hb levels (g/dl)

* Statistical t test confirmed significant difference






UMANG Project, LUCKNOW district, UP

  • 10 Administrative rural and urban blocks
  • Population covered 3,647,834
  • Included Non School Going (NSG) girls (11-18 years) and School Going (SG) girls (10-19 years)
  • Implemented in 3 phases (2001 – 2006)
  • Intervention Package
  • Weekly IFA tablets (Fe 100 mg, Folic acid 500 µg)
  • Six monthly deworming tablets (400 mg Albendezole)
  • Family life education (FLEd), Counseling delay conception > 18 years

Reaching Adolescent Girls*

Intervention package (Deworming, WIFA, FLEd)

Non School Going (NSG)

School Going (SG)


Non - supervised

Health (RCH)+ ICDS (Adolescent Girls Scheme)+ PRI

Health + Education (Middle and Senior school)+ PRI

* NGO (Vatsalya) facilitated district programme implementation


Non School Going (NSG) girls

AWW + Adolescent Girl Scheme (3 girls / AWC)incharge of supply,

monitoring / record

UMANG group (20-25 girls), (kitty ?)

girl to girl approach

additional 20 – 25 girls (1:2)

Deworming IFA

Counseling on benefits Diet + FLEd (Fixed theme) + Q box

Recording in registers (4th Saturday / month)

73,700 NSG


School Going (SG) Girls

Map middle and senior schools

Orientation to Panchayat + district

and block education officers

2 teachers / school (trainers)

Each Saturday (Anaemia Day)

Deworming IFA Tablet (Supervised)

Individual recoding cards FLEd

77, 000 girls


IFA Supply (6 months)*

District Hospital (Kit A + UNICEF supply)

District Education Department

Block Education Department Block PHC ICDS (CDPO Office)

Selected Schools Anganwadi Centres

School Going (SG) girls Non School Going (NSG) girls

* Identical to those provided to pregnant mothers by GOI, Cost = Rs 11.40/100 tablets (blister packs)


Phase I – Knowledge of NSG adolescent girls – baseline and following 6 months of Family Life Education intervention

* Following 6 months intervention


Phase I – Impact on haemoglobin levels following 6 and 12 months of weekly IFA consumption by non school going (NSG) adolescent girls


Impact of WIFS on Hb Levels (NSG)

n = 600 girls

1 year

Total Hbrise2g/dl after 1 yearof supervisedconsumption


School Going Girls – Status of anaemia at baseline (596 girls) and following 6 months of weekly IFA supplementation (573 girls)


Overall haemoglobin levels (g/dL) and anaemia prevalence (%) in SG (School Going – supervised) and NSG (Non – School Going – Non Supervised) adolescent girls

* Mean haemoglobin (gm %) - t value for SG vs NSG < 1 (no significant difference)

**Prevalence of anaemia (%) – t value for SG vs NSG < 1 (no significant difference)


Overall haemoglobin levels (g/dL) and anaemia prevalence (%) in SG (School Going – supervised) and NSG (Non – School Going – Non Supervised) adolescent girls





Change in anaemia status of combined NSG and SG adolescent girls in two selected blocks followed between 2003-2006


IFA consumption analysis undertaken in 150 NSG girls*

* Girls with UMANG for minimum 24 months


Success Factors

  • High priority (State / District / PRI)
  • Integrated with ongoing programme
  • Supply regular and streamlined
  • Package presentation of IFA (blister packs)
  • Distribution of IFA (fixed day approach)
  • Family Life Education (Theme – fixed month)
  • Multisectoral Training (Training Manual)
  • IEC and Social Mobilisation (emphasis on benefits – increase compliance)
  • Monitoring (NGO involved)

Preventing Adolescent Anaemia

  • Access to dietary iron – long term strategy
  • WIFS – short term strategy
  • effective preventive strategy for iron deficiency and iron deficiency anaemia
  • benefits in future outweigh the cost incurred
  • manageable in community settings (schools, factories, community organisation, mass media)
  • integrate with ongoing development programme (Education, ICDS, RCH)

From District Project to UP State Programme

Weekly Iron and Folic Acid Supplementation (WIFS) intervention integrated with ongoing state efforts for reaching Adolescent girls

  • Health Sector (SG)- RCH II (UP) with Education sector

(Every Saturday / week)

  • ICDS (NSG) - Mission Poshan

(4th Saturday of Month)


Moving Ahead

  • 1991 – National Nutritional Anaemia Prophylaxis Programme (NNAPP) revised to National Anaemia Control Programme (NACP)
  • 1998 – National Anaemia Consultation Report
  • “Demonstrate large scale district level projects to study the effectiveness of WIFA supplementation to adolescent girls.”
  • 2007 – Review of Policy – IFA (23rd April 2007)
  • “ Adolescents, 11 – 18 years will be supplemented at the same doses and duration as adults. The adolescent girls will be given priority.”
  • 2008– We all must act now
  • Redefine specific cost effective dosage and strategy (WIFS and Nutrition Education) for addressing anaemia prevention in adolescent girls