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 INTERVENTIONS

1st Intervention out of 6

Prophylactic Iron and Folic Acid (IFA) supplementation

A key intervention is to give IFA to children, adolescents and women of reproductive age and pregnant women irrespective of anemia, under Anemia Mukt Bharat.

The below table delineates the dose and regime of Iron Folic Acid supplementation to be followed.

Prophylactic dose and regime for Iron Folic Acid supplementation

Age group Dose and regime
Children 6-59 months of age Bi-weekly 1ml Iron and Folic Acid syrup. Each ml Iron and Folic Acid syrup containing 20 mg elemental Iron + 100 mcg of Folic Acid. Bottle (50ml) to have an ‘auto-dispenser’ and information leaflet as per MoHFW guidelines in the mono-carton
Children 5-9 years of age Weekly, 1 Iron and Folic Acid tablet. Each tablet containing 45 mg elemental Iron + 400 mcg Folic Acid, sugar-coated, pink-colour.
School-going Adolescent Girls and Boys, 10-19 years of age Out-of-school Adolescent Girls, 10-19 years of age Weekly, 1 Iron and Folic Acid tablet. Each tablet containing 60 mg elemental Iron + 500 mcg Folic Acid, sugar-coated, blue-colour.
Women of Reproductive Age (non-pregnant, non-lactating) 20-49 years (Under Mission Parivar Vikas) Weekly, 1 Iron and Folic Acid tablet. Each tablet containing 60 mg elemental Iron + 500 mcg Folic Acid, sugar-coated and red-colour.
Pregnant Women and Lactating Mothers (of 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) and to be continued for 180 days, post-partum Each tablet containing 60 mg elemental Iron + 500 mcg Folic Acid, sugar-coated and red-colour.
 

Note 1: Prophylaxis with iron should be withheld in case of acute illness (fever, diarrhoea, pneumonia, etc.), and in a known case of thalassemia major/history of repeated blood transfusion. In case of SAM children, IFA supplementation should be continued as per SAM management protocol.

Note 2: 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, to reduce the incidence of neural tube defects in the foetus.

2nd Intervention out of 6

Deworming

Bi-annual mass deworming for children in the age groups between 1-19 years is carried out on designated dates – 10th February and 10th August every year under National Deworming Day (NDD) programme. The Anemia Mukt Bharat, also integrates deworming of women of reproductive age and for pregnant women as part of the NDD strategy.

The below table reiterates the deworming dose and regime to be followed

Dose and regime for deworming

Age group Deworming
Children 6-59 months of age Biannual dose of 400 mg Albendazole (½ tablet to children 12-24 months and 1 tablet to children 24-59 months).
Children 5-9 years of age Biannual dose of 400 mg Albendazole (1 tablet).
School-going Adolescent Girls and Boys, 10-19 years of age Out-of-school Adolescent Girls, 10-19 years of age Biannual dose of 400 mg Albendazole (1 tablet).
Women of Reproductive Age (non-pregnant, non-lactating) 20-49 years Biannual dose of 400 mg Albendazole (1 tablet).
Pregnant Women and Lactating Mothers (0-6 months) One dose of 400 mg Albendazole (1 tablet), after the first trimester, preferably during the second trimester.

3rd Intervention out of 6

Intensified year-round Behaviour Change Communication Campaign (Solid Body, Smart Mind) including ensuring delayed cord clamping in newborns

There is sufficient evidence that repeated engagement using consistent key messaging is required for any behaviour to change, or to initiate new behaviour so that it becomes a practice. The various behaviour change communication activities of the strategy will address four key behaviours:

  • 1. Compliance to Iron Folic Acid supplements and deworming
  • 2. Appropriate Infant and Young Child Feeding (IYCF) with emphasis on adequate and age-appropriate complementary foods for children 6 months and above
  • 3. Increase intake of iron-rich, protein-rich and vitamin C-rich foods through dietary diversification/quantity/frequency and food fortification
  • 4. Promoting practice of delayed cord clamping (by atleast 3 minutes or until cord pulsations cease) in all health facility deliveries followed by early initiation of breastfeeding within 1 hour of birth

Various activities prepared for behaviour change include sensitization meetings for the media, school teachers and administration, faith leaders, panchayat leaders, Village Health Sanitation and Nutrition Committee (VHSNC), etc.

Year-round broadcast of messages for ‘Anemia Mukt Bharat’ should be carried out through mass media and social media (Whatsapp and Twitter).

For community- and school-level communication, morning assemblies at schools will be utilized to discuss ‘nutrition and anemia’. Youth festivals organized at school platform will also be utilized to generate discussions and dialogue on anemia and nutrition. Monthly meeting of ASHA and mothers’ group will also be held at the existing platforms such as monthly Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) sites, monthly meetings as planned under Mother’s Absolute Affection (MAA) programme, weekly Self Help Groups (SHGs) meeting under the State Rural Livelihood Mission (Maitri Baithaks), etc.

Special press advertisements on occasions such as National Nutrition Week, National Deworming Day, Women’s Day, World’s Breastfeeding Week, and World Health Day including engagements with celebrities (local, national and international) will be used to amplify the communication strategy.

A comprehensive communication package for the strategy is available for use by the States which may be adapted as per requirement. These can be downloaded from the Anemia Mukt Bharat portal: www.anemiamuktbharat.info

States can develop appropriate behaviour change communication plans through a range of communication channels such as using mass media through mobile phones, out-bound calls or text messages and interactive voice response system (IVRS), etc. as a need-based communication strategy.

Promotion and monitoring of delayed clamping of the umbilical cord for at least 3 minutes (or until cord pulsations cease) for newborns across all health facilities will be carried out for improving the infant’s iron reserves up to 6 months after birth. Simultaneously, all birth attendants should make an effort to ensure early initiation of breastfeeding within 1 hour of birth.

4th Intervention out of 6

Testing and treatment of anemia, with focus on pregnant women and school-going adolescents

Screening and testing of anemia is important in all age groups so that appropriate treatment may be initiated as per the haemoglobin level of the individual. The current method of haemoglobin estimation in the field uses SAHLI’s method, which needs to be replaced with newer advanced technologies for the available haemoglobin estimation.

Therapeutic Management of Anemia

Anemia management protocol for children

Target group A Children 6–59 months
Who will screen and place of screening ANM: VHND/sub-centre/session site
RSBK team: AWC/school
Medical Officer: health facility
Periodicity • RBSK/ANM: as per scheduled microplan
• MO: opportunistic
If Haemoglobin is 7–10.9 g/dl (mild and moderate anemia)
First level of treatment (at all levels of care) 3 mg of iron/kg/day for 2 months
• For children 6–12 months (6–10.9 kg): 1 ml IFA syrup, once a day
• For children 1–3 years (11–14.9 kg): 1.5 ml IFA syrup, once a day
• For children 3–5 years (15–19.9 kg): 2 ml IFA syrup, once a day
Line listing for all anemic children to be maintained by the ANM/ ASHA/ AWW
Follow-up • Every month by ANM at VHND
• Hb estimation after 2 months for completing 2 months of treatment to document Hb>= 11g/dl
• Monitoring by ASHA for compliance of IFA syrup every 14 days for a period of 2 months
If haemoglobin levels have improved to normal level, discontinue the treatment, but continue with the prophylactic IFA dose
If no improvement after first level of treatment In case the child has not responded to the treatment of anemia with daily dose of iron for 2 months, refer the child to the FRU/DH medical offi cer/paediatrician/physician for further investigation
If Haemoglobin is <7 g/dl (severe anemia)
Treatment • Refer urgently to District Hospital/First Referral Unit
• Management of severe anemia in children of 6–59 months is to be done by the medical offi cer at the First Referral Unit/District Hospital based on investigation
Target group B Children 5–9 years
Who will screen and place of screening RSBK teams will screen in-school and out-of-school children for anemia. All children with clinical signs and symptoms of anemia will be referred to SC/PHC for Hb estimation and further management
Periodicity • Once a year
• Opportunistic screening, e.g., routine Hb assessment of sick children presented to health facility
If Haemoglobin is 8–11.4 g/dl (mild and moderate anemia)
First level of treatment (at all levels of care) 3 mg of iron/kg/day for 2 months Line listing of all anemic cases to be maintained in the school register for Iron Folic Acid supplementation and given to the ANM/LHV/Multiple Purpose Health Worker for designated area
Follow-up • Class teacher/ Nodal teacher at school to orient parents during Parent Teacher Meeting (PTM) for compliance of treatment
• Parents to ensure follow-up of child after 30 days and 60 days at nearest SC/health facility
• Follow-up by ANM/LHV/MPW of designated area, as feasible.
• Hb estimation after completing 2 months of treatment to document Hb>=11.5 g/dl
• If haemoglobin levels have improved to normal level, discontinue the treatment, but continue with the prophylactic IFA dose
If no improvement after first level of treatment In case the child has not responded to the treatment of anemia with daily dose of iron for 2 months, refer the child to the FRU/DH medical offi cer/paediatrician/physician for further investigation
If Haemoglobin is <8 g/dl (severe anemia)
Treatment • Refer urgently to District Hospital/First Referral Unit
• Management of severe anemia in children of 5–9 years is to be done by the medical offi cer at the First Referral Unit/District Hospital based on investigation

The strategy thus proposes the use of digital haemoglobinometers for haemoglobin level estimations (specifi cations at Annexure 4) in two benefi ciaries groups namely;

a) adolescent girls and boys 10–19 years, in government and government-aided schools

b) pregnant women registered for antenatal check-ups. This may be extended to all age groups later.

In-school adolescents will be screened by the Rashtriya Bal Swasthya Karyakram (RBSK) mobile teams using digital haemoglobinometers.

Schools should plan to sensitize the students and parents during Parent Teacher Meetings, about the planned health check-up by the RBSK teams, test and treat strategy for anemia and importance of diagnosis and control of anemia in adolescents for improvement in health and overall performance at schools. If needed, private schools should opt for informed consent of parents for Hb testing of adolescents.

After the visit of RBSK team and screening of adolescents, a line list of identifi ed anemic adolescents prepared by RBSK teams will be shared with Nodal teacher/class teacher, so that the school can inform the parents as well as the nearby Sub-Centre/Primary Health Centre/Health and Wellness Centre for treatment, followup and dietary counselling. Parents should be counselled on the importance of compliance to treatment and regular followup along and adhere to the dosage regime, as well as Dos and Don’ts as advised by the medical offi cer/nurse/ANM.

Testing of anemia in pregnant women will be done using digital haemoglobinometers at all ANC contact points. At all high case load facilities at the block level and above, haemoglobin level estimation will be done using Semi-Auto Analyzers.

 

Anemia management protocol for adolescents

Target group All school-going adolescents 10–19 years in government/government-aided schools
Who will screen and place of screening In school premises by RSBK team
Periodicity Annually
Mild and Moderate Anemia (Hb cut-off as per Table 1)
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, orally after meals.
Follow-up • Line listing of all anemic cases to be maintained in the school register for Iron Folic Acid supplementation and given to the ANM/LHV/MPHW of designated area
• Follow-up by ANM/LHV/MPHW of designated area, as feasible for the state
• Parents to ensure follow-up of adolescent after 45 days to 90 days at the nearest sub-centre/ health facility
• If haemoglobin levels have improved to normal level, discontinue the treatment, but continue with the prophylactic IFA dose
If no improvement after first level of treatment If no improvement after three months of treatment (i.e., still in mild/moderate category), ANM/MO of nearest facility to refer adolescent to First Referral Unit (FRU)/District Hospital (DH)
If Haemoglobin is <8 g/dl (severe anemia)
First dose of treatment Management of severe anemia in adolescents 10–19 years is to be done by the medical offi cer at FRU/DH based on investigation and subsequent diagnosis

 

Anemia management protocol for pregnant women

Target group Pregnant women registered for antenatal care
Who will screen and place of screening Health service provider at any ANC contact, including Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)5
Periodicity At every ANC contact
If Haemoglobin is 10–10.9 g/dl (mild anemia)
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 (FCM) may be considered as the fi rst line of management 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 2 months for compliance of treatment by health provider during the contact
• If haemoglobin 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 in haemoglobin (<1 g/dl increase) after one month of treatment, refer to First Referral Unit (FRU)/District Hospital (DH) by health provider
The case to be referred to FRU/DH for further investigations for cause of anemia and may be managed with IV Iron Sucrose/FCM
If Haemoglobin is 7–9.9 g/dl (moderate anemia)
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 FCM) may be considered as the fi rst line of management 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 2 months for compliance of treatment by health provider at regular ANC clinics/PMSMA/VHND platform.
• The contact is to be utilized by the health provider to also conduct haemoglobin estimation of the anemic cases every month. If haemoglobin 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 in haemoglobin (<1 g/dl increase) after two month of treatment, refer to First Referral Unit (FRU)/District Hospital (DH) by health provider
The case to be referred to FRU/DH for further investigations for cause of anemia and may be managed with IV Iron Sucrose/FCM
If Haemoglobin is 5.0–6.9 g/dl (severe anemia)
First level of treatment Management of severe anemia in pregnant women will be done by the medical offi cer at PHC/CHC/FRU/DH
The treatment will be done using IV Iron Sucrose/Ferric Carboxy Maltose (FCM) by the medical officer
*Immediate hospitalization recommended in the third trimester of pregnancy at a health facility where round-the-clock specialist care is available
Follow-up after first level of treatment After the fi rst level of treatment, monthly or as prescribed by the medical officer
Treatment protocol if no improvement As prescribed by the medical officer
Note For severely anemic pregnant women with haemoglobin less than 5 g/dl, immediate hospitalization irrespective of period of gestation where round-the-clock specialist care is available. This is to be done till normal level of haemoglobin is achieved.

 

Management protocol for severe anemia mentioned in Tables 6–8 is contraindicated for patients with thalassemia major and sickle cell disease. Treatment of anemia through folic acid is recommended in thalassemia major cases.

5th Intervention out of 6

Mandatory provision of Iron and Folic Acid fortified foods in government-funded health programmes

The Government of India has mandated the use of fortified salt, wheat fl our and oil in foods served under Integrated Child Development Services (ICDS) and Mid-day Meal (MDM) schemes to address micronutrient deficiencies. In addition, all health facility-based programmes where food is being provided are mandated to provide fortifi ed wheat, rice (with iron, folic acid and vitamin B12), and double fortifi ed salt (with iodine and iron), and oil (with vitamin A and D) as per standards for fortification of staple foods (salt, wheat, rice, milk and oil) prescribed and notifi ed by the Food Safety and Standard Authority of India (FSSAI, 2016).

6th Intervention out of 6

Intensifying awareness, screening and treatment of non-nutritional causes of anemia in endemic pockets, with special focus on malaria, haemoglobinopathies and fluorosis

The strategy attempts to intensify awareness and integrate screening and treatment for following non-nutritional causes of anemia with special focus on malaria, haemoglobinopathies and fluorosis.

Malaria:

As the country is committed towards malaria elimination by 2030, States have identifi ed high malaria-endemic districts/ blocks/sub-centres and villages for intensification of malaria prevention and control activities.

The prevention and control strategy for nutritional anemia is to be integrated with active and passive case detection and management protocols as per the guidelines of National Vector Borne Disease Control Program (NVBDCP), MoHFW, GoI. The testing of malaria and anemia will be integrated in the identified malaria endemic regions, e.g., the beneficiaries who report recent fever and being screened for anemia will also be tested for malaria as per NVBDCP guidelines, to ascertain the co- occurrence of malaria. Similarly, patients who are being tested for malaria will also be tested for anemia in these endemic regions with increase in outreach under NVBDCP programme.

Fixed days for screening of anemia at Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) sites and annually by Rashtriya Bal Swasthya Karyakram teams in schools will be utilized to provide screening for malaria as per NVBDCP, MoHFW guidelines. The treatment protocol for management of anemia in malaria-endemic regions will be the same as given in Tables 6 and 7 for children and adolescents. For treating malaria in pregnant women, the protocol issued by NVBDCP will be followed including Artemisinin Combination Therapy (ACT) for treatment of P. falciparum malaria as per drug policy of NVBDCP for treatment of malaria.

Indoor Residual Spray (IRS) before and after the monsoon season will be carried out with the appropriate insecticides in school premises and residential areas as per the malaria burden as decided by NVBDCP. To prevent malaria, NVBDCP has provided Long Lasting Insecticide Nets (LLINs) in all high endemic areas. Anaemia Mukt Bharat will play a key role for utilization of these LLINs by all target groups especially pregnant mothers and under-five children by promoting IEC/BCC.

Haemoglobinopathies:

An integrated strategy for comprehensive prevention, screening and management of haemoglobinopathies should be provided at the existing service delivery platforms. Pre-marital and pre-conception screening and counselling services for informing the community about appropriate preventive options will be provided in the endemic districts of the country. Existing platforms such as AWCs, SCs and Health and Wellness Centres and events such as VHNDs, Nutrition week, Breastfeeding week, Women’s Day, World Thalassemia Day, etc. will be utilized to generate discussions and dialogue on nonnutritional causes of anemia in the endemic districts.

Activities such as quizzes and assisted educative talks (with distribution of informative booklets) can be done during Adolescent Health Days to engage adolescents. Screening for haemoglobinopathies should be integrated with ANC services during the first trimester of pregnancy in the endemic districts. Women identified with severe anemia should be referred to higher centres for further investigations and if found positive, the husband is to be screened for carrier status. If the couple is found positive, they are to be referred to a higher centre for prenatal diagnosis before twenty weeks of pregnancy.

Appropriate treatment should be provided as per the National Guidelines on Prevention and Control of Haemoglobinopathies (2016).6 The treatment of anemia using parental iron administration is contraindicated in sickle cell disease patients.

Fluorosis:

High fluoride concentration in food and water leads to destruction of gastrointestinal mucosa, thus reducing the nutrient absorption, including iron and folic acid. The National Programme for Prevention and Control of Fluorosis (NPPCF)7 is coordinating action on the fluorosis issue across the country. The programme recognizes the linkages of fluoride, anemia and malnutrition, and recommends a combined approach of safe drinking water and nutritional therapy to treat the people affected with problems of anemia due to fluorosis.

Addressing anemia due to fluorosis will need sustained communication, behaviour change and a combined approach of safe drinking water along with nutritional improvements. This can be achieved through the existing implementation framework of the NPPCF under NHM and through convergence with other departments such as the PHE at the district level.

The 3 key interventions are:

1. Identification of fluoride-affected habitations: States should
identify the habitations with high anemia and fluorosis prevalence. List of fluorosis-endemic districts/blocks of the country as available with the NPPCF Division, MoHFW is at Annexure 5. States should converge with the PHED departments to produce local mapping of high fluoride-affected habitations through this process for planning purpose.

2. Activities for anemia control due to fluorosis: The recommended activities for anemia prevention and control due to fluorosis is to be taken up in these habitations through counselling services in the community, such as use of safe drinking water, focus on diet corrections (Calcium, Magnesium, Vitamin C) by dietary diversity, etc. These counselling process to be made systemic within the district level by establishing local protocols for anemia and fluorosis control. Counselling services should also include periodic check-up of haemoglobin in affected habitations and seek appropriate treatment for the same. Subsequently, IFA supplementation is to be initiated after correction of anemia status through these fluorosis control activities.

3. Capacity building: Within fluoride-affected blocks, training of all public health staff, such as MO in PHC/CHC, field workers (ASHA, ANM and AWW) and others should be conducted on aspects of communication and behaviour change of anemia and fluoride control, with the broad message of “Accha Paani, Takatvar Paani” signifying health and nutritional improvements through water.

5 Pradhan Mantri Surakshit Matritva Abhiyan – https://pmsma.nhp.gov.in

6 National Guidelines on Prevention and Control of Haemoglobinopathies (2016) – http://nhm.gov.in/images/pdf/programmes/RBSK/Resource_Documents/Guidelines_on_Hemoglobinopathies_in%20India.pdf

7 National Guidelines on Fluorosis Management (2014)- https://MoHFW.gov.in/sites/default/fi les/569857456332145987456.pdf