Calcium Deficiency, Anemia in Asia and Middle East: Impact on Maternal and Neonatal Mortality

Dr Tahmeed Ahmed
Director, Centre for Nutrition & Food Security, ICDDR,B
Professor, Public Health Nutrition, James P. Grant School of Public Health, BRAC University

Outline of Presentation
• Calcium deficiency and anemia burden in Asia and Middle East
• Evidence of impact on maternal and neonatal morbidity and mortality • Program constraints • Research agenda

Definition of Anemia at Sea Level

Stoltzfus & Dreyfuss; INACG/UNICEF/WHO 1998

Consequences of Anemia: All
• Poor immune function and increased morbidity from infection • Fatigue and lower physical work capacity

• Poor concentration and impaired cognitive function
• Poor quality of life

Brabin BJ 2001, Grantham-McGregor S 2001

Consequences of Anemia: Infant, Preschool and School Age Children
• Poor physical growth, cognitive development and school achievement • Increased risk of infant and child death • Low or depleted iron stores for future pregnancies in adolescent girls

Brabin BJ 2001, Grantham-McGregor S 2001

Consequences of Anemia: During Pregnancy
• Increased risk of complications during delivery, including prolonged labor, preterm delivery, LBW and maternal and neonatal death • Infants of mothers with iron deficiency anemia are more likely to have low iron stores and to become anemic

Brabin BJ 2001, Steer P 1995

Consequences of Anemia: During Pregnancy
• Increased risk of maternal death: 1.35 times for moderate anemia & 3.5 times for severe anemia
• An odds ratio of 0·8 (95% CI 0·70–0·91) for maternal mortality was found for a 10 g/L increase in mean Hb in late pregnancy

Rasmussen K 2001, Black RE 2008

Consequences of Anemia: During Pregnancy

Rasmussen K 2001

Child Development: Long Term Effects of Iron Deficiency Anemia

Lozoffet al, NEJM 1991

Effect of Anemia on Child Cognition
• Combined analysis of the five available trials found 1·73 (95% CI 1·04–2·41) lower IQ points per 10 g/L decrease in Hb • Another meta-analysis of iron supplementation trials found an overall benefit of 1–2 IQ points in children receiving iron

Black RE 2008

Anemia and Work Capacity

Stoltzfus RJ; J Nutr 2001

Consequences of Anemia: Economic Loss
• Productivity losses due to iron deficiency

• Losses to GNP estimated from 6 countries range from 0.85% to 1.27%
• South Asia, where ID is high, loses $ 5 billion annually • Economic cost of anemia in Bangladesh is 7.9% of national GDP

Christian P 2005 UN/SCN 2004

Causes Of Anemia
• • • • • • • Iron deficiency Hookworm Vitamin A deficiency Malaria infection Chronic infections: TB, HIV Vitamins B12, folic acid Hemoglobinopathies: Thalassemia

Iron Deficiency Anemia
• ID: Serum ferritin levels of <12 µg/L or <20 µg/L, and serum transferrin receptor levels of >8.5 mg/L or >5.0 mg/L • Iron deficiency is the single most important cause of anemia • 60% of all anemia is due to iron deficiency • Prevalence of IDA was 55% (sFt <12 µg/L & sTfR >8.5 mg/L) among anemic pregnant women in rural Bangladesh
Stoltzfus & Dreyfuss 1998 Black RE 2008 Hyder SMZ 2004

Recommended Cut-off Points of Hb and Criteria for Public Health Significance
Group Cut-off Hb (g/L) Category Severe Public-health Significance Mild-moderate anemia (Hb:70- 109g/L) (%) > 40 Severe Anemia (Hb <70 - g/L) (%) >10

Children 05-59 mo < 110 5-11 yrs <115 12-13 yrs <120 Women NPW Preg Men <120 <110 <120

Moderate

20-39.9

1.0-9.9

Mild

5-19.9

0.1-0.9
WHO 1997 WHO 1992

Anemia Prevalence Trends in Bangladesh
Infant NPNL w om en Pre school Pregnant Wom en Adolescent Lactating Wom en

100 90 80 70 60 50 40 30 20 10 0

92
74.1 67.9

Percent

48.3
46.7 35 33 30

46
46 39.7 38.8

2001

2003

2004

NSP (HKI) 2004, Anemia prevalence survey unicef/BBS 2003, NSP (HKI) 2002, WHO global database on anemia

National Strategy for Anemia Control
Target (2015) Baseline (2001-3)
46 35 33 25 30 23 42 32 64 48 Pregnant NPW Adolescent Girls Children 24-59 mo Children 6-23

The overall goal is to reduce 1/4th of anemia among high risk groups by 2015

0

20

40

60

80

Anemia Prevalence (%)

National Strategy for Anemia Prevention and Control in Bangladesh, MOHFW 2007

National Strategy for Anemia Control
Target (2015) Pregnant NPW Adolescent Girls Children 24-59 mo Children 6-23 0 20 Baseline (2001-3) 38.8 46 35 25 23 33 30 46 39.7 58 Current (2004)

The overall goal is to reduce 1/4th of anemia among high risk groups by 2015

32

42

48

64

87

40 60 80 Anemia Prevalence (%)

100

National Strategy for Anemia Prevention and Control in Bangladesh, MOHFW 2007 ; NSP 2006

Priority Strategies for Anemia Prevention and Control
• Micronutrient supplementation
• Dietary improvement • Parasitic disease control • Food fortification • Family planning and safe motherhood

National Strategy for Anemia Prevention and Control in Bangladesh, MOHFW 2007

IFA Supplementation Program in Bangladesh
• Policy: 2001(National Guideline)
• Strategy: 2007

• Political Support: Favorable
• Implementation: DGFP, DGHS, NNP, NGOs

Existing Program on Iron Supplementation According to Age group
Age-group Infants & children Key Players No program existed NNP started piloting of MMN sprinkles (Including IFA) at 3 uz in Sylhet division targeting all under 2 year children DGFP, NNP (Only girls)

Adolescents

PLW NPW
Other

DGFP, DGHS, NNP, NGO (BRAC) DGFP, NNP
NNP (NPW, Newly married women)

Dose of Existing Iron Supplementation Program
Target group Doses

Adolescent girl

02 tablets/week (Only NNP)

Newly wed 02 tablets/week (Only NNP) women Pregnant women 01 tablet daily up to delivery

Lactating mother 01 tablets/day for 90 days

Health Worker Training
BHW DGHS HA, AHI No Training 23500 Some basic training

DGFP FWV,FW 21000 Well trained (18 months A training for FWV) NNP CNP 23246 Short training and refreshers training BRAC SS 7000 2 weeks basic training
*No training manual is particularly intended for anemia or IFA supplementation

Procurement
Availability

DGFP

DGHS

NNP

Central procurement 8000 IFA tablets/ union per month From EDCL through civil surgeon 65-70 million IFA tablets purchased yearly Self procurement funded by GOB, CIDA etc Self procurement

Enough, no stock-out

Available

Passing through major stock out

BRAC

Available

Packaging of IFA Tablets
DGFP DGHS Uncoated and wrapped in polythene paper Uncoated and wrapped in normal paper Chances of destruction Chances of destruction

NNP
BRAC

Uncoated and wrapped in normal paper
Started to use blister pack tablet

They will use blister pack very soon
Cost (14 Tk/100 compare to 12 Tk/100)

BCC & Communication
DGFP
DGHS NNP BRAC Others

Posters
No IEC materials Posters & flip charts Posters & flip charts Agriculture and social marketing sectors are also using some IEC material

HH level FWA does all BCC Advised by doctors during routine visit Use by CNPs
SS done all BCC No co-ordination with health sector

Coverage of IFA Supplementation
1-100 tablets >100 tablets No Supplementation

46

38.6

15.4
Pregnant women (n= 937) NSP April 2004

Anemia Prevalence Among IFA Supplemented Pregnant Mothers
No supplem entation 100 1-100 tab >100 tab

Proportion anemic

80

60 40

52.5

49.3

43.8

20

0

Pregnant women (n= 937)

Supplem entation

NSP April 2004

Reasons for Not Taking Iron Tablet Regularly
Indicator Did not consider necessary Objection of family members Side-effect of tablet Lack of supply Forget to take Do not receive enough tablets Lost tablets Economic constrains Others Total no of pregnant women 11.5 1.8 27.5 11.5 29.8 8.3 0.5 2.3 6.9 775 Survey Area BINP(%) NNP & Comparison(%) All (%) 19.3 2.2 24.3 12 23.2 4.7 .0 5.9 8.4 966 16.3 1.9 25.5 12.0 19.5 6.1 0.2 4.5 7.8 1741

NNP Baseline Survey 2004

Why Fortification
The Copenhagen Consensus 2004 concluded that the returns of investing in micronutrient programs are second only to those of fighting HIV/AIDS The benefit-to-cost ratio of iron interventions was estimated to be as high as 200:1

Behrmann JR, Alderman H, Hoddinott J. Hunger and malnutrition. Copenhagen Consensus Challenge Paper, 2004

Effect of Iron Fortification on the Prevalence of Anaemia in Children
Review: Comparison: Outcome: Study or sub-category Effect of MMN and single micronutrient fortification (Version 01) 08 Effect of iron fortification on the prevalance of anaemia in two age subcatagories 01 prevalance of anaemia(%) RR (random) 95% CI Weight % RR (random) 95% CI 01 Prevalance of anaemia in children aged between 0-5yrs age Carlos Alberto,2005 Villalpando,2006 Subtotal (95% CI) T otal events: 30 (Intervention group), 27 (Control group) T est for heterogeneity: Chi² = 6.28, df = 1 (P = 0.01), I² = 84.1% T est for overall effect: Z = 0.04 (P = 0.97) 02 Prevalance of anaemia in children aged between 6-15 yrs age Nadiger,1980 Nadiger,1980(G) Walter(BH),1993 Walter(BH-g),1993 Deborah M Ash,2003 Zimmermann,2004 Moretti, 2006 Pattanee,2006 Subtotal (95% CI) T otal events: 231 (Intervention group), 316 (Control group) T est for heterogeneity: Chi² = 37.24, df = 7 (P < 0.00001), I² = 81.2% T est for overall effect: Z = 3.36 (P = 0.0008) T otal (95% CI) T otal events: 261 (Intervention group), 343 (Control group) T est for heterogeneity: Chi² = 48.71, df = 9 (P < 0.00001), I² = 81.5% T est for overall effect: Z = 2.87 (P = 0.004) 0.1 0.2 0.5 1 2 5

11.96 9.71 21.67

1.82 [1.00, 3.31] 0.49 [0.21, 1.13] 0.98 [0.27, 3.52]

14.51 8.54 2.50 2.76 15.33 8.16 11.72 14.80 78.33

0.37 0.14 0.51 0.36 0.74 0.19 0.56 1.01 0.47

[0.27, [0.05, [0.05, [0.04, [0.60, [0.07, [0.30, [0.75, [0.30,

0.52] 0.36] 5.55] 3.42] 0.92] 0.51] 1.05] 1.36] 0.73]

100.00

0.55 [0.36, 0.83]

10

Favours treatment

Favours control

Ahmed T 2008

Effect of Iron Fortification on the Hb level of Women of Childbearing Age
Review: Comparison: Outcome: Study or sub-category Ballot,1989 Viteri,1995 Pham Van Thuy,2003 Total (95% CI) Test for heterogeneity: Chi² = 7.81, df = 2 (P = 0.02), I² = 74.4% Test for overall effect: Z = 2.33 (P = 0.02) -10 -5 Favours control 0 5 Effect of MMN and single micronutrient fortification (Version 01) 03 Effect of iron fortification on women of child bearing age 01 Hb level (g/L) WMD (random) 95% CI Weight % 40.15 23.47 36.38 100.00 WMD (random) 95% CI 2.90 [0.38, 5.42] 3.00 [-3.18, 9.18] 8.70 [5.38, 12.02] 5.03 [0.80, 9.27]

10

Favours treatment

Ahmed T 2008

Multiple Micronutrient Sprinkles

Home Fortification: Micronutrient Sprinkles
Review: Comparison: Outcome: Study or sub-category Effect of sprinkles (Version 01) 04 Effect of sprinkles on the Hb conc. in general untargeted population 02 gm/L Sprinkles Mean (SD) placebo Mean (SD) WMD (random) 95% CI Weight % WMD (random) 95% CI N N

01 According to age (< 2 years of age) 65 107.60(11.00) Giovannini, 2006 254 104.40(12.70) Menon, 2007 319 Subtotal (95% CI) Test for heterogeneity: Chi² = 2.93, df = 1 (P = 0.09), I² = 65.8% Test for overall effect: Z = 2.86 (P = 0.004) 02 According to age (> 2 years of age) 109 Sharieff, 2005 109 Subtotal (95% CI) Test for heterogeneity: not applicable Test for overall effect: Z = 0.00 (P = 1.00)

60 161 221

99.70(10.30) 100.50(13.90)

30.47 34.55 65.01

7.90 [4.17, 11.63] 3.90 [1.24, 6.56] 5.68 [1.78, 9.57]

128.00(10.00)

108 108

128.00(9.00)

34.99 34.99

0.00 [-2.53, 2.53] 0.00 [-2.53, 2.53]

428 Total (95% CI) Test for heterogeneity: Chi² = 12.45, df = 2 (P = 0.002), I² = 83.9% Test for overall effect: Z = 1.75 (P = 0.08)

329

100.00

3.75 [-0.46, 7.97]

-10

-5 Favours placebo

0

5 Favours sprinkles

10

Ahmed T (unpublished)

Acceptability of Sprinkles for Children 12-24 Months: Mother’s Opinion
Extremely liked Liked 60% 30%

Somewhat liked
n= 140

10%

Hyder Z 2004

Acceptability of Sprinkles for Children 12-24 Months: Major Health Benefits Perceived
General improvement of child’s health 100%

Increased children’s appetite Playfulness
Faster intellectual development
n= 140

29% 28%
28%

Hyder Z 2004

Acceptability of Sprinkles for Children 12-24 Months: Mixing With Weaning Food
Did not change normal food Smell Colour Taste
n= 140

91% 98% 99%

Hyder Z 2004

Problems & Possible Solution
Coverage Burden of anemia is highest among infants (~ 90%), but no program existed in the country targeting infant and pre-school children Infant and young children should come under coverage NNP recently started piloting Use of multiple micronutrient sprinkles (Including IFA) at 3 upazillas in Sylhet division targeting all under 2 year children

No or little coverage in urban areas
Policy

National policy & strategy present Anemia prevention control but need to more effective should be included in other relevant guidelines

Problems & Possible Solution
Political Support Logistic Favorable, but their perception regarding anemia is poor Political persons need to be informed about anemia and IFA supplementation

NNP is passing through a major Proper planning and costock out. There is no system of ordination among different back up when there is an acute stake holders is necessary shortage

Characteri Uncoated and wrapped in Blister pack is a solution stics of Iron paper, chances of disintegration tablet in humid climate

Problems & Possible Solution
Health worker training Manpower No training manual is Inclusion of anemia and particularly intended for anemia IFA supplementation in or IFA supplementation the training manual of health workers Lack of sufficient number of health workers (Only 3000 FWA present (40%) for domiciliary services for DGFP, no recruitment of FWV since 1992) Increase manpower and keep right people in the right place

Co-ordination Duplication of work done in the same area regularly

Improve co-ordination

Problems & Possible Solution
Vehicles for iron in children BCC and Communication Mothers’ awareness There are lack of proper vehicles to supplement Iron formulation among infants No mass media coverage MMN Sprinkle could be used Starting TV coverage

Mothers have no perception on role of iron tablet on anemia reduction

Lesson could be learned from SUZY project for using TV and other media

Problems & Possible Solution
Monitoring and evaluation
Others Contextual factors Final suggestion to anemia control

No or ineffective monitoring cell
No alternative strategy

Effective monitoring cell is essential
Food fortification

Breast feeding, Infection control, Food security Supplementation Fortification Deworming Breast feeding

Role of Anemia Control to Achieve MDGs
MDG Goal 1: Eradicate extreme poverty and hunger

Increase work capacity and intellectual potential of children
lead to higher earnings MDG Goal 2: Achieve Universal Primary Education cognitive development & intellectual potential of children will

improve school performance & drop out rates
MDG Goal 3: Promote gender equality and empower women Reduce child care burden will allow women more time for income generating work
Adapted from National Strategy for Anemia Prevention and Control in Bangladesh, MOHFW 2007

Role of Anemia Control to Achieve MDGs
MDG Goal 4: Reduce child mortality
Increased child survival reduces child mortality MDG Goal 5: Improve maternal health

Decreased preterm delivery, pregnancy complications and
peri-natal mortality will improve the health and survival of adolescent girls and women of reproductive age

Adapted from National Strategy for Anemia Prevention and Control in Bangladesh, MOHFW 2007

Pirgacha

Trishal

Daily Calcium Intake of Women in Pirgacha and Trishal, Bangladesh
Age (years) Daily calcium intake (mg)

Pirgacha
Trishal

26.2 ±6.7
29.6 ±8.8

157 (103, 227)
144 (97, 226)