maternal and child anemia- why, what works, what needs more work?
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Maternal and Child Anemia- Why, what works, what needs more work? - Rolf Klemm, Johns HopkinsTRANSCRIPT
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Maternal and Child Anemia-Why, what works, what needs more
work?
Rolf Klemm Johns Hopkins School of Public Health and A2Z
Micronutrient and Child Blindness Project
Pre-Session: Maternal & Child AnemiaCore Group Spring Meeting-April 26, 2010
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Anemia Control Interventions– Weakest Links in the Chain of Maternal Nutrition and Health?
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Overview
• Anemia “101”
• Public Health Rationale—Old and New Findings
• Interventions: What works? Effective? Safe?
• Interventions: What needs more work?
• Opportunities for Integration
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Anemia “101”
The Basics
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–Defined as… Hemoglobin (Hb) concentration <2 standard deviations of the age- and sex specific normal reference–Hb binds to oxygen and carries it to tissues–Red blood cells (RBCs) consist mostly of Hb.–Commonly used indicator to screen for iron deficiency in population-based surveys but not specific for iron deficiency
Anemia
Normal RBCs Anemic RBCs
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Not all anemia is caused by iron deficiency. But iron deficiency is a major cause of anemia in many developing countries.
Ane
mia Iron deficiency
Iron Deficiency
Anemia
Other vitamin deficiencies
Hookworm
Malaria
HIV/AIDS
Anemia of Inflammatory Conditions
Hemoglobin-opathies
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Overlapping causes of Anemia
Malaria Anemia Hookworm
Severe: ≥40%
Moderate: 20-39%
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Causes of Anemia – Relative Importance by Region
Iron Deficiency
Malaria Hookworm High Fertility HIV/AIDS
Sub-Saharan Africa
South and South East Asia
North Africa
Americas
Central Asia/Caucasus
Western Pacific (includes China)
Adapted from: Galloway, R. Anemia Prevention and Control: What Works. Washington, DC: USAID, June 2003.
Relative Importance by Region High Medium Low
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• Physiologic needs not met by iron absorption in diet• Low dietary bioavailability from monotonous plant-
based diets with little meat
Anemia is NOT all caused by iron deficiency. BUT ~50% of anemia in developing countries is due to iron deficiency
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Institute of Medicine, 2001
Increased growth needs exhaust stores accumulated during gestation
Menstrual losses superimposed with needs for rapid growth
Iron requirement increases 3 x’s due to expansion of maternal red-cell mass & growth of fetal-placental unit.Net iron requirement is 1 g (~4 units of blood)
Iron requirement at different life stages
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Public Health Rationale for
Controlling Iron Deficiency Anemia?
Old and New Findings
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WHO, World Health Report, 2002
Iron Deficiency ranks 9th on the list of risk factors for global disease burden
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McLean et al. Public Health Nutr, 2008, 12: 444-454
Anemia is one the most widespread disorders in the world!
~50% pre-school children~42% pregnant~30% non-pregnant
~50% haveIDA
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New analysis suggests a continuous risk relationship between Hb and maternal mortality
• Low Hb level is associated with an increased risk of maternal and perinatal mortality 0
500100015002000
2500300035004000
5 7 9 11
Hemoglobin (g/ dL)
mort
ality
Stoltzfus, et al, Comparative Quantification of health risks: Global and regional burden of disease attributable to selected major risk factors:, WHO, 2004
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Zeng L, BMJ 2008;337:a2001doi:10.1136/bmj.a2001
Maternal IFAS associated with 0.23 wks longer gestation & 54% ↓ early neonatal mortality
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Folic Acid + Iron
Control
Maternal Iron+folic acid ↓ mortality among Nepalese children by 31% between birth & 7 years
Christian et al Am J Epidemiol, 2009, 170: 1127-1136
0 1 y 2 y 3 y 4 y 5 y 6 y 7y 8 y
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Developmental risk factors with sufficient evidence to recommend intervention
Walker et al. Lancet 2007; 369: 145-57
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Economic Loss Associated Iron Deficiency
Estimated Loss
Physical productivity loss $2.32/per capita
Loss in GDP 0.6%
Dollar value of losses $4.2 billion
Including cognitive losses $16.78/per capita
Loss in GDP 4.0%
Horton S The Economics of Iron Deficiency, Food Policy, 2003, 51-75
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Women play critical role in agricultural production, esp. in subsistence agriculture
The World Bank, Gender in Agriculture Sourcebook, 2009
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Increases or little change in Anemia Prevalence
0 10 20 30 40 50 60 70 80Anemia Prevalence
LAC
S/SE Asia
N Africa/Middle East
West Africa
East Africa
Haiti 2005-06Haiti 2000
India 2005/2006India 1998-99
Cambodia 2005Cambodia 2000
Jordan 2007Jordan 2002
Egypt 2005Egypt 2000
Senegal 2008-09Senegal 2005
Mali 2006Mali 2001
Ghana 2008Ghana 2003
Uganda 2006Uganda 2000-01
Source: Demographic and Health Survey Compiler Data 2004-2008
Anemia Prevalence among Pregnant Women Over Time By Country
Severe Moderate
Mild
Klemm R, et al. Unpublished
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↑ Maternal Mortality
↑Perinatal Mortality
↑ Low birth weight
↑ Neonatal mortality
↑ Post-neonatal, child mortality
↑Negative effects on child cognition and behavior
↓Productivity and economic gains
Summary of Health Risks of Iron Deficiency Anemia
Pregnancy
Childhood
Adults
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Interventions to reduce iron
deficiency anemia-What works?
Effectiveness and Safety?
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Home fortification?
Central fortification?
Delayed cord clamping?
Dietary modification?
Screen?
Iron Supplements?
Intervention strategies-Iron Deficiency
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Intervention strategies-Malaria & Hookworm
Use of insecticide treated nets (ITN)
Intermittent Preventive Treatment (IPT)
Quality Focused Antenatal Care (FANC)
De-worming for hookworm
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Increased consumption of iron rich foodsUse of iron cooking pots
Increased iron bioavailability of traditional foods– Germination (50-64% ↓ phytate)– Microbial fermentation (up to 90% ↓ phytate)– Soaking (47-98%↓ phytate)– Adding ascorbic acid containing foods– Use of iron cooking pots
Dietary Modification
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Dietary modification--Effective and safe?
• Traditional food processing may increase Fe bioavailability but does not sufficiently increase Fe intake of young children• Dietary diversification, while important for overall dietary quality, is generally unsuccessful at closing the Fe gap for young children• Fe-rich animal source foods are expense and often unavailable• Use of Fe pots has had limited success. Excess Fe content (e.g. fermented beverages) may be a risk.
Summary: It is unlikely that dietary modification strategies alone will be sufficient in most low-income populations
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Food Fortification
Addition of Fe to commonly consumed foods, beverages, condiments– Centrally fortified: Fe added at time of processing– Home or “point-of-use”: Fe added to meals just before consumption
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Centrally-processed iron-fortified foods
Effective and safe?
• With careful choice of the Fe compound and amount added, fortification can improve Fe status of all at-risk groups
• However, products have not been developed for pregnant women and the higher Fe level needed may cause sensory changes
• It is difficult to meet Fe needs for all children in the target range with a single formulation
• There is no evidence that these foods are not safe, but no studies have focused on safety in malarial areas
• There are few examples of widespread application of the approach in developing countries.
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Home fortification:Effective and safe?
Home fortification mixtures with appropriate amounts of absorbable Fe compounds can be formulated to improve or maintain the Fe status of infants, children, pregnant and non-pregnant women
In children, highly effective at reduction Fe deficiency (RR 0.44 [0.22, 0.86]) and anemia (RR 0.54 [0.46, 0.64]) There is no evidence that home fortification is not safe, but no studies have focused on safety in malaria
endemic areas
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Innovative Approaches to Iron and micronutrient “supplementation”
CrushableTablet
“Foodlet”
Fat-based ProductsPowders
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Iron supplementation
• Delivery of medicinal Fe orally in the form of pills or liquids, usually consumed in the absence of food.
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Routine iron supplementation in pregnancy prevents anemia at delivery
Kulier et al, Int J Gyn & Obst 1998, 63: 231-246
Reduces Risk
IncreasesRisk
Consistent results showing reduction of anemia risk
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Iron SupplementationSafe and effective?
• Fe supplementation prevents and ameliorates nutritional Fe-deficiency in children and pregnant women• However, providing Fe supplements in liquid or table form may increase the incidence, and possibly the severity, of malaria (and other infections)
among Fe-replete children• In pregnant women, increased placental malaria has been demonstrated with intravenous infusions and is suspected with Fe supplements but has
not been demonstrated with the few studies available.
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Delayed chord clamping
• Delay clamping of umbilical cord by 2-3 minutes• Results in greater transfusion of placental blood to the infant• Increases the total body Fe content of the infant at birth (+~75 mg Fe) which helps to
prevent Fe deficiency during the first years of life
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Delayed cord clamping—Effective and safe?
• Reduces the risk of anemia (RR=0.53 [0.40, 0.70]) at 2-6 months of age• Increases indices of Fe status (Ferritin concentration and stored Fe)• Guidelines have been developed for implementation and uptake of this strategy in low-resource settings• There are no data on safety in the context of malarial endemic areas
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Conclusions:NIH Technical Working Group
• When there is comprehensive surveillance and prompt malaria diagnosis and treatment there is no increased risk
• When health care is insufficient there is an increased risk of malaria with Fe supplementation
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Conclusions:NIH Technical Working Group
• At this time, the provision of Fe via tablets of liquids requires caution and may be the least desirable approach in malaria endemic areas• Fortified foods may be the most viable alternative intervention. This includes Fe fortification (central or home) of complementary foods for infants and
young children and of staple foods or condiments of women and older children• Assuming that the Fe from these foods is absorbed more slowly than Fe from supplements, and that this leads to little or no excess NTBI formation or
associated harmful effects, Fe-fortified foods are expected to be safe in such areas.
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What needs more work?
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Barriers to Effective Implementation-
2008 Innocenti Process
• Inadequate political support• Low priority for IFA within maternal health programs• Inadequate supplies, low utilization, and weak demand• Community-based delivery platforms to complement the ANC platform are missing• Insufficient bundling of interventions to address the multiple causes of anemia
Klemm R et al Micronutrient Programs: What Works and What Needs More Work? A Report of the 2008 Innocenti Process. July 2009, Micronutrient Forum, Washington, DC.
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First Visit Re-visit
Current Practice
(minutes)
Desiredbased on
FANC(minutes)
Current Practice
(minutes)
Desiredbased on
FANC(minutes)
Registration 2:10 5:00 1:30 0:00History taking 4:20 10:00 1:20 5:00Examination 3:30 8:00 3:00 8:00Drug Administration 1:00 3:00 1:40 3:00Immunization 1:40 1:00 1:00 1:00Health education & counseling 1:30 15:00 0:00 15:00Total time direct activities 12:20 42:00 6:30 32:00Welcoming the client 1:00 1:00 1:00 1:00Documentation of findings 2:00 3:00 1:30 3:00Total contact time 15:20 46:00 9:00 36:00
Comparison of current performance and anticipated standard of focused ANC model,
Tanzania
Von Both, BMC Pregnancy and Childbirth, 2006, 6:22
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Reasons given by women based on exit interviews
1. Obtain an ANC card.
2. When mother is sick/suspects a pregnancy complication
3. When mother is close to delivery time
4. When mother wants to know if her baby is well
5. If referred by TBAs or lower health unit
6. When mother is unsure of pregnancy and wants confirmation
MOST, Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda, 2002
Reasons given for using ANC services, Uganda
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Reasons given by women based on exit interviews
1. Long waiting hours
2. Fear of being asked to pay a fee for services
3. Perception that they would not be given drugs/medicines or services
4. Have no wish to deliver in a health unit
5. Fear of being referred to other health centers away from home with no transport or assistance
6. Health workers are rude (“They shout at us especially when we are tired”)
Modified from MOST, Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda, 2002
Reasons given for NOT using ANC services, Uganda
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Use of iron and folic acid tablets by ANC attendees, Uganda, n=612
High proportion of women have at least 1 ANC visit
A2Z Survey (2009) of ANC platforms, unpublished data
~40% who had an ANC visit did NOT receive ANY
IFA tablets
AND….<10% consumed ≥30 tablets
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Opportunities for Integration
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Delivery & Newborn Care
BreastFeeding
ComplementaryFeeding
Delayed CordClamping
↑ iron intakeITN
•Anemia•↑ maternal mortality•↑ LBW•↑ neonatal and child mortality
•Anemia•Altered development and behavior
Birth &Colostrum
Infant and Young ChildFeeding (IYCF)
Pre-conception
↑ iron intakeTreat hookwormIPT, ITN for malaria
•High risk of iron deficiency
Fortification
Pregnancy
↑ iron intakeTreat hookwormIPT, ITN for malaria
•Anemia•Constrained productivity•Less well baby
Focused Antenatal Care (FANC)
Woman-Mother-Newborn-Young ChildContinuum of Care
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• Making Pregnancy Safe (MPS)– Focused Antenatal Care (FANC)
• Saving Newborn Lives (SNL)• Infant and young child feeding (IYCF)• Fortification• Presidential Malaria Initiative (PMI)• Neglected Tropical Disease (NTD)• Global Health Initiative (GHI)• Feed the Future
Major global health initiatives relevant to iron and anemia
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Maternal Anemia “Brief” for Policy Makers
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Additional Resources with Weblinks
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Thank You