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    National Iron Plus Initiative: Current status & future strategy

    Anaemia is a severe public health problem amongst all vulnerable age groups in India. The National Nutritional Anaemia Prophylaxis Programme initiated in 1970, was revised and expanded to include beneficiaries from all age groups namely children aged ...

    Indian J Med Res. 2019 Sep; 150(3): 239–247.

    doi: 10.4103/ijmr.IJMR_1782_18

    PMCID: PMC6886130 PMID: 31719294

    National Iron Plus Initiative: Current status & future strategy

    Umesh Kapil,1 Radhika Kapil,3 and Aakriti Gupta2

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    Abstract

    Anaemia is a severe public health problem amongst all vulnerable age groups in India. The National Nutritional Anaemia Prophylaxis Programme initiated in 1970, was revised and expanded to include beneficiaries from all age groups namely children aged 6-59 months, 5-10 yr, adolescents aged 10-19 yr, pregnant and lactating women and women in reproductive age group under the National Iron Plus Initiative (NIPI) programme in 2011. The dose of iron, frequency and duration of iron supplementation and roles and responsibilities of the functionaries were described. At present, the coverage of beneficiaries with iron and folic acid has been poor at the national level. The prevalence of anaemia has continued to remain high during the last 60 years, and there has been no significant change in the scenario due to various reasons. The constraints in implementation and measures to improve the NIPI programme are discussed in the current article.

    Keywords: Anaemia, haemoglobin, iron, National Family Health Survey, National Iron Plus Initiative Programme

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    Introduction

    High prevalence of anaemia has been reported amongst all vulnerable age groups, especially mothers and children. According to the National Family Health Survey (NFHS)-4, 53 per cent of non-pregnant women, 50.3 per cent of pregnant women (in the age group of 15-49 yr) and 58.5 per cent of children in the age group of 6-59 months had anaemia1. Another study conducted in 16 districts of the country reported the prevalence of anaemia as high as 84.9 per cent among pregnant women and 90.1 per cent among adolescent girls2.

    The prevalence of anaemia has continued to remain high during the last 30 yr, possibly due to the provision of iron and folic acid (IFA) supplementation as the main intervention for the management of anaemia1,3,4. This was based on the assumption that the main cause of anaemia is iron deficiency. However, the proportion of anaemia associated with iron deficiency is reported to be only 14 per cent for preschool children and 16 per cent for women of reproductive age (WRA). The contribution of iron deficiency in the aetiology of anaemia is lower in countries where the prevalence of anaemia is more than 40 per cent, such as India and especially in rural populations5. In addition, the impact of IFA supplementation on the increase in haemoglobin (Hb) levels of anaemic individuals has been documented to be marginal as iron supplementation has been suggested to increase the mean blood Hb concentration by 8.0 g/l in children, 10.2 g/l in pregnant women and 8.6 g/l in non-pregnant women6.

    Deficiencies of other mineral and vitamins such as folate, vitamin B12, vitamin A, and copper interfere with erythropoiesis7,8. The genetic Hb disorders also play an important role in the development of anaemia. The inflammation caused due to infections leads to poor nutrient absorption and increased nutrient losses. Infectious diseases such as malaria, tuberculosis, fevers, diarrhoea, parasitic infestations and other infections common in developing countries alsocontribute to anaemia9. Recent evidence suggests that unsafe water, sanitation and hygiene (WASH) in resource-poor settings promote the transmission of enteric pathogens, leading to diarrhoeal diseases and chronic inflammation10,11,12. Environmental enteric dysfunction due to poor WASH practices reduces the absorption of nutrients including iron10,11,12.

    In view of the multifactorial aetiology of anaemia, there is a need to undertake the prevention of vitamins and mineral deficiencies along with the prevention of communicable diseases and subclinical infections to control and reduce the prevalence of anaemia in the country.

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    Fallacy of evidence on reduction in anaemia

    The drastic reduction in the prevalence of anaemia among pregnant mothers in selected States of India such as Chhattisgarh (63 to 41%), Assam (72 to 44%), Haryana (71 to 51%), Odisha (68 to 47%) and Kerala (62 to 45%)has been recorded between NFHS-3 and -4 surveys, in a span of 10 years1,4. This high reduction in the prevalence of anaemia was possibly not valid as the coverage of IFA supplementation was poor [Chhattisgarh (30.3%), Assam (32.0%), Haryana (32.5%), Odisha (36.5%) and Kerala (67.1%)] and also on the fact that less than 50 per cent of the population was amenable to iron. HemoCue® digital haemoglobinometer used as the method for the estimation of Hb in the NFHS surveys provided inconsistent results13. Hence, the error in Hb estimations may have been responsible for a reduction in the prevalence of anaemia rather than improvement in the anaemia due to IFA supplementation. Furthermore, all the NFHS surveys (2, 3 and 4) in which Hb estimation was done using HemoCue machine documented the lower prevalence of anaemia in pregnant mothers compared to non-pregnant mothers1,3,4. This finding is in contradiction to the existing knowledge according to which the prevalence of anaemia among pregnant mothers is always higher due to haemodilution during pregnancy. The WHO also recommended lower 'cut-off' for Hb by 0.5 g/dl, for defining anaemia among pregnant mothers14.

    स्रोत : www.ncbi.nlm.nih.gov

    National nutritional anemia prophylaxis programme

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    National nutritional anemia prophylaxis programme

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    IFA supplementation

    The Ministry of Health and Family Welfare has revised the guidelines on IFA supplementation related to the National Nutritional anaemia Prophylaxis programme. This is the outcome of a long process, initiated with different consultations on anaemia in adolescent girls, the National Consultation on Micronutrients in end 2003 with ICMR/MHFW, work with the committee (chaired by DG ICMR) constituted subsequently and work with NRHM and different groups on the 11 th plan.

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    IFA supplementation - National Nutritional anaemia Prophylaxis programme

    Vitamin A & IFA supplementation 4 pages - 210 kb - download   pdf document

    The Ministry of Health and Family Welfare has revised the guidelines on IFA supplementation related to the National Nutritional anaemia Prophylaxis programme.

    This is the outcome of a long process, initiated with different consultations on anaemia in adolescent girls, the National Consultation on Micronutrients in end 2003 with ICMR/MHFW, work  with the committee (chaired by DG  ICMR) constituted  subsequently and work with NRHM and different groups on the 11 th plan.  Highlights of the same include the following

    The infants between 6-12 months should also be included in the programme as there is sufficient evidence that iron deficiency affects this age also.

    Children between 6 months to 60 months should be given 20mg elemental iron and 100 mcg folic acid per day per child as this regimen is considered safe and effective.

    National IMNCI guidelines for this supplementation to be followed.

    For children (6-60 months), ferrous sulphate and folic acid should be provided in a liquid formulation containing 20 mg elemental iron and 100mcg folic acid per ml of the liquid formulation. For safety reason, the liquid formulation should be dispensed in bottles so designed that only 1 ml cab be dispensed each time.

    Dispersible tablets have an advantage over liquid formulations in programmatic conditions. These have been used effectively in other parts of the world and in large scale Indian studies. The logistics of introducing dispersible formulation of Iron and Folic Acid should be expedited under the programme.

    The current programme recommendations for pregnant and lactating women should be continued.

    School children, 6-10 year old, and adolescents, 11-18 year olds, should also be included in the National Nutritional Anaemia Prophylaxis Programme  (NNAPP).

    Children 6-10 year old will be provided 30 mg elemental iron and 250 mcg folic acid per child per day for 100 days in a year.

    Adolescents, 11-18 years will be supplemented at the same doses and duration as adults. The adolescent girls will be given priority.

    Multiple channels and strategies are required to address the problem of iron deficiency anaemia. The newer products such as double fortified salts / sprinkles/ ultra rice and other micro nutrient candidates or fortified candidates should be explored as an adjunct or alternate supplementation strategy.

    14 September, 2019

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