Dr.

Ranganath T S
Professor and Head
Community Medicine
BMCRI , Bangalore

1
 ANEMIA MUKT BHARAT TRAINING

• Reena’s story Reena is a 13-year-old girl. She lives with her parents,
two brothers and a younger sister in Bangalore. Reena goes to school
and also helps her mother with all the household work. Her normal
diet is rice and watery dal twice a day, and vegetables once a while.
She is very fond of noodles and burgers which she frequently enjoys in
the school canteen during recess. She feels very weak and is always
exhausted. Her grades are falling as she cannot concentrate in the
class. She feels irritable and does not like playing as she starts panting
even on slight effort

• What has happened to Reena?

• What other signs and symptoms might Reena be having?

2
 Outline

1. Introduction
2. Burden of anemia
3. Causes of Anemia
4. Anemia Mukt Bharat
5. National Centre of Excellence and Advanced Research
on Anemia Control (NCEAR–A)
6. Diagnosis of Anemia
7. Approaches to address Anemia
8. Partnership for Anemia Control

3
 Introduction

• Anemia affects 1.9 billion population globally

• Anemia is a severe public health problem in India, with

prevalence of >40% across all vulnerable groups

• All States and Districts in India are affected by anemia

• Anemia has significant consequences for human health as

well as social and economic development

4
 Introduction
• Control of anemia is a global and national priority

• There is a need to accelerate efforts to achieve control of

anemia in India by strengthening:
1. Nutrition specific interventions (promotion of dietary diversity,
micronutrient supplementation and food fortification)
2. Nutrition sensitive interventions (control of infection,
infestations and improvement in WASH practices)
3. A multi-sectoral partnership involving government
departments, academic institutions, bilateral agencies, civil
society and food industry

5
 Outline

1. Introduction
2. Burden of anemia
3. Causes of Anemia
4. Anemia Mukt Bharat
5. National Centre of Excellence and Advanced Research
on Anemia Control (NCEAR–A)
6. Diagnosis of Anemia
7. Approaches to address Anemia
8. Partnership for Anemia Control

6
 Definition of Anemia

RBC in healthy individual RBC in anemic individual

Anemia is a condition in which the number of red blood cells

and their oxygen-carrying capacity is insufficient to meet the
body’s physiological needs
WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information
7
System. Geneva, World Health Organization, 2011.
 Anemia in Ayurveda

• Anemia is referred as ‘Pandu Rog’ meaning

disease with pallor1

• Treatment for Anemia prescribed in Ayurveda

include iron formulations2

1. Shukla V, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana; Pandu Roga Chikitsa Adhyayay. 1st
ed., Vol. 2, Ch. 16. Varanasi: Chowkambha; 2007. p. 395‑414.
2. Tubaki B, Benni J, Rao N, Prasad UR. Effect of Ayurveda Medications (Kasīsa Bhasma and Dhārī
Avaleha) on Iron Deficiency Anaemia: A Randomized Controlled Study. Anc Sci Life. 2016;36(1):48.

8
 History of Anemia

• The word "anemia” is derived from the Greek

word which means "without blood.”

• William Hewson (1739-74), "the father of

hematology’’ highlighted the importance of red blood
cells

• In the beginning of 19th century, “Anemia" was used

as a clinical term referring to pallor of the skin and
mucous membranes
9
 History of Anemia

• Gabriel Andral (1843) postulated that clinical

anemia is due to inadequate numbers of red
blood cells

• In 1852 Karl Vierordt, developed a technical

method for counting blood cells

10
 Landmark Studies in India

Toteja et al; 2006 reported high prevalence of

anemia in the country (84.9% in pregnant
women and 90.1% in adolescent girls) in 16
districts of India.
Toteja GS, Singh P, Dhillon BS, Saxena BN, Ahmed FU, Singh RP, Prakash B, Vijayaraghavan K, Singh Y, Rauf A,
Sarma UC. Prevalence of anemia among pregnant women and adolescent girls in 16 districts of India. Food and
Nutrition Bulletin. 2006 Dec;27(4):311-5.

11
 Signs of Anemia

Pale skin Pallor of the hands Pallor of inner

eyelids

Sore tongue (Glossitis) Brittle concave nails

(Koilonychia)
Mild anemia may be asymptomatic 1
 HEALTH CONSEQUENCES OF ANEMIA
Consequences of Anemia
ADULTS
CHILDREN AND - Low work productivity
ADOLESCENTS
- Low physical activity,
- Poor cognition, Increased fatigue, LACTATING WOMEN
ncentration, memory Impaired muscle
and school strength - Decreased quality of
performance - Increased disability, life
Depressed immunity, Greater risk of falls - Increased tiredness,
Repeated infections - Irritability/ Mood breathlessness,
- Poor motor swings palpitations
velopment outcomes - Increased risk of
- Increased fatigue/ - Higher risk of infections
hortness of breath, dementia - Increased stress,
Low endurance higher risk of
- Irregular cardiac depression
- Irregular rhythm, Cardiac arrest
menstruation -Increased
- Child mortality hospitalizations, Higher
risk of death

COGNITION – PRODUCTIVITY- DEATH 13

 Consequences of
Reduced Anemia in Reduced
physical Adolescents/ cognitive
develop develop
ment
Women of ment
reproductive age

Decrease
Decreas Poor learnin
d work
ed work Pregnanc Diminished ability
capacity
output y related concentratio
outcomes n

Low pre- LBW babies

Repeated
pregnancy and preterm
infections
iron stores delivery
Severity of Consequences
of Anemia
Severe consequences:
1. Pregnant women: Premature birth, Low birth weight,
Maternal, Perinatal and Neonatal mortality
2. Child mortality
3. Adults: Increased risk of death due to Irregular
heartbeats (arrhythmias), heart murmur, cardiac
arrest/ congestive heart failure

Moderate consequences:
1. Children: Poor cognition, physical development
2. Adults: Poor work productivity

Mild consequences:
1. Fatigue, irritability and weakness, shortness of breath
2. Decreased appetite
3. Orthostatic hypotension
Mild anemia may be asymptomatic
15
 Deaths due to Anemia
• In Asia, anemia is the second highest cause of maternal mortality 1.

• Mortality due to anemia contributes to-

• 22% (n=115,000) of the total maternal deaths every year 2

• 24% (n=591,000) of the total perinatal deaths every year 2

• 90,000 deaths in both sexes and all age groups were due to iron
deficiency anemia alone 3
1. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a
systematic review. Lancet 2006;367:1066–74.
2. Worldwide prevalence of anemia 1993-2005. WHO Global Database on Anemia. Geneva, World Health
Organization. 2008
3. Global health estimates 2014 summary tables: deaths by cause, age and sex, by WHO region, 2000–2012.
16
Geneva: World Health Organization; 2014
 Anemia and
Human Development

• 1.9 billion people affected by anemia globally1

• 58.2 million Years Lived with Disability (YLD) due to

anemia – leading cause of impairment globally2

• Loss of 4% of Gross Domestic Product (GDP) due to

anemia globally3

• 1 g/dL increase in hemoglobin level associated with

1.
2.
increase in 1.7 IQ points2
Global Burden of Disease 2017.
Stoltzfus RJ, Mullany L, Black RE. Iron deficiency anaemia. Comparative quantification of health risks: global and
regional burden of disease attributable to selected major risk factors. 2004;1:163-209.
3. Horton S, Ross J. Corrigendum to: “The Economics of iron deficiency”. Food Policy. 2007;32(1):141–3.
1
7
 Consequences of Anemia

Pasricha SR. Anemia: a comprehensive global estimate. Blood. 2014 Jan

30;123(5):611-2. 18
 Disability due to Anemia

Iron deficiency is the number one cause of disability across populations

Global burden of diseases, India 2018. 19

 Vulnerable groups
• Infants and Under 5
children

• School age children (5-9

yrs)

• Adolescent girls (10-19

yrs)

• Women of reproductive
age group (15-49 yrs)

• Pregnant and Lactating

women
20
 Intergenerational Life Cycle
of Anemia

UNCORRECTED ANEMIA

Anemia in Anemia
Anemiain
Anemia in Infants, children
Young women Infants a
Pregnancy and adolescents
and adolescents

Low stores of
iron in Newborn

Pregnancy Birth weight

Birth
Erythropoiesis Pre term birth
Fetal needs
Post partum Blood loss
 Outline

1. Introduction
2. Burden of anemia
3. Causes of Anemia
4. Anemia Mukt Bharat
5. National Centre of Excellence and Advanced Research
on Anemia Control (NCEAR–A)
6. Diagnosis of Anemia
7. Approaches to address Anemia
8. Partnership for Anemia Control

22
 Global Burden of Anemia

Anemia is a severe public health

problem in India
Anemia. Global Scenario; WHO data base, 1993-2005 2
 Global Burden Anemia

• Anemia is the most common public health problem

affecting around 1.9 billion population of the
world1

• 90% of the cases of anemia were in developing

countries2

• Africa and Asia accounted for 85% of anemia cases 2

1. Global, regional, and national incidence, prevalence,

and years lived with disability for 354diseases and injuries for 195 countries and territories, 1990-2017:
a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018 Nov 10;392(10159):1789-1858.
2. Worldwide prevalence of anemia 1993-2005. WHO Global Database on Anemia. Geneva, World Health 24
Organization. 2008.
Global and Regional Prevalence
of Anemia
Global Nutrition Targets 2025
Stunting: 40% reduction in the number of children
under-5 who are stunted

Anemia: 50% reduction of anemia in women of

reproductive age

Low birth weight: 30% reduction in low birth weight

Childhood overweight: No increase in childhood

overweight

Breastfeeding: Increase the rate of exclusive

breastfeeding in the first 6 months up to at least 50%

Wasting: Reduce and maintain childhood wasting to

less than 5% 26
 Anemia and Sustainable
Development Goals (2030)

27
 Trends in prevalence of anemia in India: 1998-2021
Stagnation – increase ?

100

90 NHFS 2 (1998-99)

80 78.9
74.3 NFHS 3 (2005-06)
70 67
NFHS 4 (2015-16)
Prevalence of anemia

58
60 57.9 56.2 57
52 51.8 53 NFHS 5 (2019-
49.7 50
50 2021)

40

30
24.3
21.4
20 18.7

10

0
Under-five children Pregnant women WRA Men 15-49 years

NFHS 2 data in under five age group: data on anemia is available only for 6-35 months children,
NFHS 2 data for anemia among men – not available 28
 Outline

1. Introduction
2. Burden of anemia
3. Causes of Anemia
4. Anemia Mukt Bharat
5. National Centre of Excellence and Advanced Research
on Anemia Control (NCEAR–A)
6. Diagnosis of Anemia
7. Approaches to address Anemia
8. Partnership for Anemia Control

29
 Causes of Anemia
Biomedical

Politico
developmen
tal

30
 Biomedical, Socio-epidemiological and
Politico- developmental Causes of Anemia

31
 Causes of Anemia in
Indian children
• Low iron stores at birth due to maternal anemia

• Faulty Infant Young Child Feeding Practices

– Inappropriate, non-fortified substitutes of breast milk
– Inappropriate complementary food

• Insufficient quantity of iron and iron enhancers in

diet, and low bioavailability of dietary iron

• Iron loss due to parasitic infestations (e.g. malaria,

intestinal worms)
 Causes of Anemia in
Indian Women
• Insufficient quantity of iron-rich foods in diet

• Low bioavailability of dietary iron (non-heme iron)

• Deficiency of “iron enhancers” in diet and excess of “iron inhibitors”

in diet

• Iron loss during menstruation and child birth

• Poor iron stores due to infancy & childhood deficiency

• Teenage pregnancy and pregnancies with <2 year interval

• Parasitic infestations (e.g. malaria, intestinal worms)

33
 Development of Anemia
1. Ineffective erythropoiesis
(  RBC production )
• Aplastic anemia

2. Haemolysis ( RBC destruction)

• Anemia of chronic diseases
• Haemolytic anemia
• Thalassemia

34
 Development of Anemia
3. Blood loss
• Excessive bleeding during menstruation, childbirth, post
partum period
• Infections such as Malaria
• Worm infestation (Hook worm)
• Internal bleeding

4. Increased iron demand: During pregnancy, periods of

growth (infancy, adolescents)

5. Decreased dietary intake, Low/inadequate absorption of

iron 35
 Etiological framework
of Anemia

WHO. Strategies to prevent anaemia: Recommendations from an Expert Group Consultation. 2016
 Causes of Anemia

Iron deficiency, haemoglobinopathies and malaria are three leading

37
causes of anemia globally
 Anemia, Iron Deficiency and
Iron Deficiency Anemia (IDA)

Iron
Anemia IDA Deficiency

Worldwide prevalence of anaemia 1993-2005

.
50% of Anemia attributable to iron deficiency 38
 Iron Deficiency Anemia

• Approximately 50% of
cases of anemia are due
to iron deficiency

• The proportion of cases

of anemia due to iron
deficiency varies among
population groups and in
different areas

39
 Iron Metabolism
Iron in food
(heme (Fe2+)/non-heme(Fe3+))

Absorbed in duodenum Majority

(15-35% of heme/1-2% of non-heme ) 3 mg/day
of iron
excreted
1-2 mg/day
Other cells and tissues
400 mg
Transport
iron (0.1%)

Ferritin Plasma
(26- 30%) Iron -transferrin
Storage iron 20-25mg
Released iron in reticulo
endothelial system

*Highlighted text represents

RBC 1800 mg 300 mg
the distribution of iron in
Hemoglobin
the body Bone marrow
(70% iron)
 Iron Distribution in
Human Body
Details Man Woman
mg (%) mg (%)

Total 3450 (100) 2450 (100)

Functional
Hemoglobin (Blood) 2100 (61) 1750 (71)

Myoglobin (Muscles) 300 (9) 250 (10.2)

Enzymes (Catalase, 50 (1) 50 (2.5)

peroxidase )

Storage
Ferritin (Liver) 1000 (29) 400 (16.3)
41
 Iron Distribution in
Human Body
Details Man Woman
mg (%) mg (%)

Total 3450 (100) 2450 (100)

Functional
Hemoglobin (Blood) 2100 (61) 1750 (71)

Myoglobin (Muscles) 300 (9) 250 (10.2)

Enzymes (Catalase, 50 (1) 50 (2.5)

peroxidase )

Storage
Ferritin (Liver) 1000 (29) 400 (16.3)
42
 Recommended Daily Allowance
(RDA) of Iron
Age group Physiological group RDA (mg/day)

>18 years Adult man 17

>18 years Adult woman 21
Pregnant woman 35
Lactating woman (0-6 months) 21
0-6 months Infants 46*
6-12 months Infants 5
1-3 years Children 9
4-6 years Children 13
7-9 years Children 16

*Infants (0-6 m): microgram/kg/day

ICMR (2010). Nutrient Requirement and Recommended Dietary Allowances for Indians. A report43of
the expert group of ICMR
 RDA of iron in adolescent
age group
Age group Sex RDA
mg/day
10-12 years Boys 21
Girls 27
13-15 years Boys 32
Girls 27
16-17 years Boys 28
Girls 26

ICMR (2010). Nutrient Requirement and Recommended Dietary Allowances

44
for Indians. A report of the expert group of ICMR
Forms of Dietary Iron

45
 Forms of Dietary Iron

Heme iron
Non-heme iron
 Derived from  Found in plant
hemoglobin found sources and
in animal food fortified foods
sources - meat,
poultry, fish

46
 Iron Absorption Enhancers

• The absorption of iron from mixed cereal-pulse diet is

POOR (5% in men and children and 8% in all women)

• Food Enhancing Iron Absorption

– Foods containing Vitamin C:
- Citrus fruits like lemon, orange,
- Amla
- Tomatoes
- Sprouted pulse (Germinated pulse)

• Ascorbic acid: Iron ratio of 4:1 increases iron

absorption by 300 – 350% (NIN, 2010)
ICMR (2010). Nutrient Requirement and Recommended Dietary Allowances for Indians. A report47of
the expert group of ICMR
 Iron Absorption Inhibitors

• Calcium containing food - milk and milk

products

• Foods containing high fiber

• Foods rich in phytates - cereals and

pulses

• Foods rich in polyphenols, oxalates -

green leafy vegetables

• Tea and coffee containing tannin 48

Iron Rich Foods- Cereals

49
Iron Rich Foods- Pulses

50
Iron Rich Foods- Vegetables

51
Iron Rich Foods– Fruits

52
 Iron Rich Foods -
Nuts, Oilseeds and Sugar

53
Iron Rich Foods-
Eggs and Poultry

54
Percentage of Anemia amenable
to Iron Supplementation

• Iron supplementation can increase the mean blood haemoglobin

concentration by 0.8 g/dL in children, 1.02 g/dL in pregnant women
and 0.86 g/dL in non-pregnant women

• Only 42% of Anemia in children and about 50% of Anemia in

women amenable to iron supplementation
WHO. The global prevalence of anaemia in 2011. Geneva: World Health Organization; 2015.
Other Nutritional Deficiencies
Vitamin B2
Vitamin A Folate (riboflavin)

Vitamin B6 Vitamin B12

(pyridoxine) (cobalamin) Vitamin C

Vitamin D Vitamin E Copper

56
Mechanisms of Nutritional
Deficiencies in Anemia

57
Mechanisms of Nutritional
Deficiencies in Anemia

58
Mechanisms of Nutritional
Deficiencies in Anemia

59
 Types of Hemoglobinopathies
Hemoglobinopathies
Thalassemia syndromes Structural haemoglobin
α β variants
thalassemi thalassemi HbS- Sickle cell
a Thalasse
a disease
mia
major
Thalasse HbC
mia
Thalasse
interme
mia
dia
minor HbE
(BTT-
Beta
thalasse HbD
mia
state)

World Health Organization. Thalassaemia and other haemoglobinopathies.2006.

http://apps.who.int/gb/archive/pdf_files/EB118/B118_5-en.pdf 6
0
 Global Burden
of Hemoglobinopathies
• Hemoglobinopathies:
– Inherited disorders of red blood cells
– Major hemoglobinopathy types: thalassemia and
sickle cell disease

• Global:1
– Prevalence of Carriers - 5%
– 300,000 -500,000 children are born annually with
hemoglobinopathies
70% of hemoglobinopathies are due to Sickle cell
disease and 30% are due to thalassemia
61
World Health Organization. Thalassaemia and other haemoglobinopathies.2006
 Burden of
Hemoglobinopathies in India

• Hemoglobinopathies in India: - 1.2/ 1000 live births /

year

• β thalassemia:1
– Number of children with Thalassemia major - 1 to 1.5
in 100,000
– Carriers of β thalassemia trait – 35-45 million (3-4%)

India has the largest number of children

with Thalassemia major (TM) in the world

1.Madan N, Sharma S. Sood SK, Colah R, Bhatia HM. Frequency of β -thalassemia trait and other hemoglobinopathies in northern and western India. Indian J Hum Genet. 2010
Jan;16(1):16-25;
1. Mohanty D, Colah RB, Gorakshakar AC, Patel RZ, Master DC, Mahanta J, Sharma SK, Chaudhari U, Ghosh M, Das S, Britt RP, Singh S, Ross C, Jagannnathan L, Kaul R, Shukla DK,
Muthuswamy V. Prevalence of β -thalassemia and other hemoglobinopathies in six cities in India: a multicentre study. J Community Genet 2013;4:33-42 6
2
 Burden of
Hemoglobinopathies in India

Β- thalassemia

Hb S

Hb E

MoHFW. Prevention and Control of Hemoglobinopathies. Thalassemia, Sickle cell disease and other variant hemoglobinopathies.
6 2016
3
 Burden of
Hemoglobinopathies in India

• HbS (Sickle cell disease):1

– Number of children with sickle cell disease – 1.5
in 100,000
– Carriers 5 to 35%
– Highly prevalent in the tribal populations of
Southern, Central and Western states
• HbE - common in the North Eastern states
• HbD - 2% of people in Punjab
Reference:
1.Madan N, Sharma S. Sood SK, Colah R, Bhatia HM. Frequency of β -thalassemia trait and other hemoglobinopathies in northern and
western India. Indian J Hum Genet. 2010 Jan;16(1):16-25;
1. Mohanty D, Colah RB, Gorakshakar AC, Patel RZ, Master DC, Mahanta J, Sharma SK, Chaudhari U, Ghosh M, Das S, Britt RP, Singh S,
Ross C, Jagannnathan L, Kaul R, Shukla DK, Muthuswamy V. Prevalence of β -thalassemia and other hemoglobinopathies in six6 cities
in India: a multicentre study. J Community Genet 2013;4:33-42 4
 Economic Burden of
Hemoglobinopathies

• Thalassemia Major (TM) children born every year in India – 10,000- 15,000
• Treatment options: Bone marrow transplant (not available for all) or blood
transfusion
• Annual cost of transfusing & chelating a 30 kg body weight child (2008) - INR.
200,000
• Cost for 10,000 children with Thalassemia Major / year with excepted 50
years of survival is Rs. 100 billion

Hemoglobinopathies lead to significant economic

burden to the health system and also the family

Reference: Chandy M. Developing a National Programme for India. In: Control and management of Thalassemia and other Hemoglobinopathies in the Indian 65
Subcontinent_ Synoptic Views. Editor: Ghosh K, Colah R. Published by National institute of Immunohaematology, 2008.
Inheritance
of Hemoglobinopathies

Both β thalassemia and Sickle cell disease are

autosomal recessive disorder
66
 Prevention
of Hemoglobinopathies
Screening pregnant
Extended family
women
Pre-marital and and
screening
their of cases
husbandsand carriersGenetic
Pre-conceptional counselling
carrier screening
Carrier screening Diagnostic facilities
programmes at at district level
schools
Community
education and Prenatal diagnostic
awareness facilities at State
programmes level
Prevention
of
Hemoglobi
nopathies

6
7
 Prevention
of Hemoglobinopathies

• Comprehensive prevention, screening & management at

the existing service delivery platforms
• Pre-marital and pre-conception screening and counselling
services
• Screening during the first trimester of pregnancy to be
integrated with ANC services
• Discussions and dialogue on non-nutritional causes of
anemia using existing platforms 68
 Platform for Counselling

S Target Population Platform for counselling

No.
1 Adolescents Schools, Adolescent Health Day- Rashtriya
Kishore Swasthya Karyakram (RKSK)

2 Young adults ASHA’s under Mission Parivar Vikas

(unmarried/ activities, Village Health Sanitation and
married) Nutrition Day (VHSND) platforms (pre-
marital and pre-conceptional)
3 Pregnant mothers ANC contact points, VHSND
4 Community Social and Behaviour Change
Communication and Information Education
and Communication by frontline workers at
community based events

69
 Challenges of Hemoglobinopathies
Prevention and Control Program

1. Lack of awareness
2. Social and cultural believes associated with
prenatal diagnostics
3. Lack of appropriate infrastructure
4. High cost of equipment
5. High cost of treatment
6. Requirement for trained manpower
70
Integrated Approach for Management
of Hemoglobinopathies

Screening Diagnosis Treatment

Individuals with hemoglobinopathies may

have normal or low level of hemoglobin
7
1
Screening of Hemoglobinopathies – Target
population

NESTROFT Test DCIP test Solubility Hb test

(Naked Eye (Di- Test by Digital
Single Chlorophenol- Hemoglobinometer
Tube Red cell Indo-
Osmotic Phenol)
Fragility Test)

For Beta For HbS For HbE Mild, moderate and

thalassemia trait severe anemia

Test for diagnosis of hemoglobinopathies: HPLC

7
Test for confirmation: DNA Analysis 2
 Integrated Approach for Management of
Hemoglobinopathies Screening
Premarital &
Class VIII Pregnant
preconception
New born students women
screening

Screening 1. Solubility test

2. Nestroff test 5.
4. CBC
3. DCIP test Hemoglobin
estimation*
Any one Any
Severe
positive abnormali
anemia
ties

Diagnosis HPLC at district level (CBC, Peripheral smear)

Positive *if all hemoglobinopathy screening test
are –ve and patient & if having
Confirmation DNA mild/moderate anemia, treat with IFA.
No improvement after 2 months –Refer
analysis to district level for HPLC 7
3
 Iron Supplementation for
Management of Hemoglobinopathies

• No anemia – Prophylactic iron and folic acid

(IFA) dose

• Mild or moderate anemia - should be

referred to PHC or CHC or should be
provided therapeutic IFA

• Severe anemia - to be referred to District

Hospital / District Early Intervention Centre
and subjected to CBC and HPLC 74
 Integrated Approach for
Management of Hemoglobinopathies

• Management of Thalassemia Major

a) Bone marrow transplantation (BMT)/
Hematopoietic stem cell transplant (HSCT)
b) Blood transfusion therapy with packed red blood
cells (pRBCs)
c) Iron chelation for iron overload
d) Monitoring of complications
e) Management of complications
f) Psychological support

75
 Integrated Approach for Management
of Hemoglobinopathies

• Management of Non Transfusion Dependant

Thalassemia (NTDT):
a) Monitoring of iron overload- which can occur even
if transfusions are not given.
b) Monitoring of growth and endocrine and bone
problems, including extra- medullary
hematopoiesis.
c) Surveillance for gall stones, liver, cardiac disease.
d) Treatment with Hydroxyurea

76
Integrated Approach for Management
of Hemoglobinopathies

Management of Sickle cell disease:

a) Prevention of infections:
 Pneumococcal immunization
 Penicillin prophylaxis

b) Prevention and management of other

complications:
Treatment with Hydroxyurea
Judicious use of blood transfusions
77
 Countries Endemic for
Malaria in 2016

Estimated total
number of cases
worldwide = 219
million

Total Malaria deaths

worldwide = 435,000

Endemic or high malaria transmission area: Annual

Parasite Incidence > 1/1000 population

World Malaria Report 2016 78

 Estimated country
share of malaria, 2017

(a) Total malaria cases

and (b) vivax malaria
cases, 2017

India

World Malaria Report 2018 79

 Burden of Malaria in India

1. India’s share in global malaria case burden (2017) = 4%

2. India’s share in global malaria mortality (2017) = 4%
3. Total number of malaria cases (2016) = 1.09 million
4. Reported death due to malaria (2016) = 331
5. High risk / endemic states (API >1) : Andaman & Nicobar
Islands, Arunachal Pradesh, Chhattisgarh, Jharkhand,
Madhya Pradesh, Meghalaya, Mizoram, Odisha and Tripura
Almost 80% of all malaria cases globally were in 15 African countries and in
India
1,2: World Malaria Report 2018
3, 4: http://www.nvbdcp.gov.in/index4.php?lang=1&level=0&linkid=420&lid=3699&theme=Brown&Background=Dark&font=Increase
5: National Framework For Malaria Elimination In India (2016–2030) 8
0
 Burden of Malaria in India
Geographic distribution of malaria incidence (API) in India (2014)

Reference: National Framework For Malaria Elimination In India (2016–2030) 81

Pathogenesis of Anemia in Malaria

• Rupture of infected red

blood cells

• Immune mediated RBC

destruction

• Dysfunction of the bone

marrow

• Unavailability of iron for

synthesis of haemoglobin

A major part of the life cycle of malarial parasite

is spent in the erythrocytes (RBC)
82
 Strategies for Control
of Malaria and Anemia
1. Active and passive case detection and management
of malaria
2. Introduction of Artemisinin-based combination
therapy
3. In malaria endemic regions:
1. Integrated testing for malaria and anemia
2. Patients tested for malaria will be tested for
anemia
3. Distribution of long-lasting insecticidal nets by
pregnant mothers and under-five children

83
Iron Supplementation in
Malaria Endemic Region

Iron treatment does not increase the risk of clinical malaria when
regular malaria prevention or management services are provided.

84
 Diseases
(Infection and Inflammation)

The following diseases increase the risk of

anemia in low- and middle-income countries:

Soil Transmitted Helminth

Parasite infections
infestation

Tuberculosis (TB) HIV/ AIDS

85
 Environmental
Enteric Dysfunction
• Environmental enteropathy defined as a state of
chronic intestinal inflammation, without obvious
diarrhea

• Occurs in individuals exposed to long-term poor water,

sanitation and hygiene and repeated exposure to
environmental pathogens especially populations
belonging to low income settings.

Environmental enteropathy may be important contributor

in the etiology of anemia in India
86
 Environmental
Enteric Dysfunction

Gut damage due to chronic intestinal inflammation

reduces nutrient absorption and utilization

http://duncanmarasanitation.blogspot.com/2009/09/tropical-enteropathy-
3.html
87
 Outline

1. Introduction
2. Burden of anemia
3. Causes of Anemia
4. Anemia Mukt Bharat
5. National Centre of Excellence and
Advanced Research on Anemia Control
(NCEAR–A)
6. Diagnosis of Anemia
7. Approaches to address Anemia
8. Partnership for Anemia Control
88
 NCEAR-A

‘National Centre of Excellence and Advanced

Research on Anemia Control (NCEAR-A)’ has been
established at Centre of Community Medicine, All
India Institute of Medical Sciences (AIIMS), New
Delhi.

8
 Vision of NCEAR-A

• To develop and provide technical support to the

Ministry of Health and Family Welfare,
Government of India, for incorporating scientific,
policy and community perspective in policy and
programmatic decisions for control of anemia.

90
 Mandate of NCEAR-A:
Capacity Building in three domains

Resea
rch

Progra Polic
m y
91
 Outline

1. Introduction
2. Burden of anemia
3. Causes of Anemia
4. Anemia Mukt Bharat
5. National Centre of Excellence and Advanced Research
on Anemia Control (NCEAR–A)
6. Diagnosis of Anemia
7. Approaches to address Anemia
8. Partnership for Anemia Control

92
 Diagnostic Tests for Anemia

• Hemoglobin level
- Direct (Venous Blood)
- Indirect Method (Capillary Blood)

• Complete Blood count

- Packed cell volume
- Red cell indices
• Peripheral Blood smear

• Bone Marrow Examination

93
Diagnostic Tests for Anemia

94
 Hemoglobin levels to
Diagnose Anemia
Anemia is defined as hemoglobin less than normal range specified for age
and sex

Population No Mild Moderate Severe

Anemia Anemia Anemia Anemia
(g/dl) (g/dl) (g/dl) (g/dl)
Children 6-59 10-10.9 7-9.9 <7
months of age ≥11
The hemoglobin cut
Children 5-11 ≥11.5 11-11.4 8-10.9 <8
years of age offs for diagnosis of
Children 12-14 ≥12 11-11.9 8-10.9 <8 anemia amongst
years of age children between (0-5
Non-pregnant ≥12 11-11.9 8-10.9 <8
women (15 years months) and lactating
of age and above) women not known
Pregnant women ≥11 10-10.9 7-9.9 <7
Men (15 years of ≥13 11-12.9 8-10.9 <8
age and above)

WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information
System. Geneva, World Health Organization, 2011. 95
 Hemoglobin level
adjustments for Smokers

WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information
System. Geneva, World Health Organization, 2011. 96
 Hemoglobin level adjustments (g/dl)
for Altitude

WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information
System. Geneva, World Health Organization, 2011. 97
 Adjustment of Hemoglobin

• WHO hemoglobin cutoffs for anemia refer to sea-level values

• Add the correction value to the Hb cut off values or subtract

the adjustment from the measured hemoglobin concentration
at the relevant altitude.

• Example:

A woman living at 4200 m and smoking half a pack of cigarettes/

bidi (1 pack= 20-22 cigarettes/20 bidis) a day would be:

=12 (non- pregnant) + 3.4 (altitude) + 0.3 (smoking) = 15.7g/dl.

Reference: WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition
Information System. Geneva, World Health Organization, 2011. 98
 Diagnosis of Anemia
by Morphology of RBCs

99
 Evaluation of
Microcytic anemia

100
 Evaluation of
Macrocytic anemia

101
 Evaluation of
Normocytic anemia

102
 Biomarkers of Anemia
Cause Biomarkers
Iron deficiency Serum Ferritin, soluble transferrin
receptors, serum iron, bone marrow
examination, red cell morphology
Other nutritional deficiencies Red cell morphology, dietary intake
(such as Folate, Vitamin B12) data
Malaria Parasite antigen, thick and thin blood
smear
Helminthic infections Stool and/or egg counts,
Immunological tests
Chronic infections Specific clinical tests for pathogens
Inflammation Acute phase proteins
Haemoglobinopathies Genetic screening, electrophoresis
Gastric and intestinal diseases Feacal blood

103
 Anemia Status Indicators
Iron status indicator Change

Hemoglobin Decreased

Serum Ferritin Decreased

Serum Iron Decreased

Transferrin Saturation Decreased

Total Iron Binding Capacity (TIBC) Increased

Soluble Transferrin receptor Increased

Hepcidin Decreased 10
105
 Interpretation of Biomarkers
of Iron Deficiency

Assessing the iron status of populations. Second edition including literature reviews. Report of a Joint World Health
Organization/Centers for Disease Control and Prevention technical consultation on the assessment of iron status at
the population level, Geneva, Switzerland, 6–8 April 2004. Geneva: World Health Organization; 2007 106
 Outline

1. Introduction
2. Burden of anemia
3. Causes of Anemia
4. Anemia Mukt Bharat
5. National Centre of Excellence and Advanced Research
on Anemia Control (NCEAR–A)
6. Diagnosis of Anemia
7. Approaches to address Anemia
8. Partnership for Anemia Control

107
POCT for Hemoglobin Estimation
• Invasive methods:
– Indirect cyanmethemoglobin method
– Sahli’s method
– Hb color scale method
– Copper sulphate method
– Vanzetti’s method and modifications
(HemoCue 201, HemoControl, TrueHb)

• Invasive methods with reagent free cuvettes:

– HemoCue 301
– DiaSpect

• Non-invasive methods:
– Occlusion spectroscopy (NBM 200)
– Pulse co-oximetry
– Trancutaneous Reflection Spectroscopy (HemoSpect)
 Point of care testing
Can be used in
for Hemoglobin
community
Rapid turnover setting
No loss to follow
up
Ease of obtaining
time, more the sample
beneficiaries (capillary Vs
covered venous)
Laboratory,
Small volume of
technicians &
blood sample
phlebotomists
required
not required

Advanta
ges of
POCT

Faster Rapid Rapid

treatment Improve
access to clinical and d health
test decision intervention
outcome 109
 Outline

1. Introduction
2. Burden of anemia
3. Causes of Anemia
4. Anemia Mukt Bharat
5. National Centre of Excellence and Advanced Research
on Anemia Control (NCEAR–A)
6. Diagnosis of Anemia
7. Approaches to address Anemia
8. Partnership for Anemia Control

110
 Approaches to
Address Anemia
•Food •Parasitic
based
strategies
•Dietary
Nu infections
: malaria Nu
and soil-
diversifica
tion
•Micronut
triti transmitt
ed
helminth
triti
rient
suppleme on- infestatio
n
•Water,
on-
ntation:
iron (and
folic acid)
•Social
Sp sanitation
and
hygiene
Se
and
behaviour
-change
ecif •Reproduct
ive health
practices
nsit
communi
cation
strategies
ic •Intersecto
ral
actions
ive
111
 Approaches to
Address Anemia
Approaches •Improving
Supplementa sanitation and
tion hygiene
- Tablets /
Food Based Capsules Public health •Health
measures
- Syrup education
- Parenteral
Diet iron •Communicati
ary Food
Forti on for
diver behavioural
sifica ficati
on change
tion •Potential vehicles
- Adding foods with high  Flour •Prevention
micronutrient density to  Milk and prompt
staple diets  Salt treatment of
- Promotion of iron rich  Sugar hookworm and
food  Condiments malaria
- Methods like germination,  Bread
fermentation etc.  Biscuits
112
Guidelines for Prophylaxis of Anemia

Children 6-59 months of age:

Bi-weekly, 1 ml iron and folic acid syrup. Each ml of iron and folic acid syrup
containing 20 mg elemental iron + 100 mcg of folic acid
Bottle (50mg) 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 and Out-of-school adolescent girls and boys, 10-19 years of

age

Weekly, 1 iron and folic acid tablet. Each tablet containing 60 mg elemental
iron + 500 mcg folic acid, preferably sugar-coated, blue-colour 113
Guidelines for Prophylaxis of Anemia

Women of reproductive age (non-pregnant, non- lactating) 20-49 years:

Weekly, 1 iron and folic acid tablet. Each tablet containing 60 mg elemental iron + 500
mcg folic acid, preferably sugar-coated, red-colour

Pregnant and Lactating women:

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).
Each tablet containing 60 mg elemental iron + 500 mcg folic acid, sugar-coated,
red-colour

Lactating mothers (0-6 months child):

Daily, 1 iron and folic acid tablet to be continued for 180 days, post-partum.

Each tablet containing 60 mg elemental iron + 500 mcg folic acid, sugar-coated, red-colour.
114
 Deworming

Children 12-59 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 and Out-of-school adolescent girls and boys, 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:

One dose of 400 mg albendazole (1 tablet), after the first trimester, preferably during the second
trimester 115
Treatment of Anemia amongst
children (6-59 months)
Anemic (Hb <11g/dl)

Mild and moderate anemia Severe anemia (<7 g/dl )

(7–10.9 g/dl)
Children 6–
12 months
Children 1–
3 years (11–
Children 3–
5 years (15–
Refer urgently to
(6–10.9 kg) 14.9 kg) 19.9 kg) FRU/DH
Provide 1 ml Provide 1.5 Provide 2 ml
IFA syrup, ml IFA syrup, IFA syrup,
Daily for 2 Daily for 2 Daily for 2
months months months

No improvement of Hb after 2 months Improvement of Hb to >10.9g/dl

Refer to FRU/DH Provide Prophylactic IFA dose and

counselling
 Treatment of Anemia amongst
children (5–9 years)
Hb <11.5 g/dl

Mild and moderate anemia (8–11.4

g/dl) Severe anemia (<8 g/dl)

3 mg of iron/kg/day for 2
Refer urgently to FRU/DH
months

No
Improvement
improvement
of Hb to
of Hb after 2
>11.4g/dl
months
Provide
Prophylact
Refer to ic IFA dose
FRU/DH and
counsellin
g
 Treatment of Anemia amongst
adolescents (10–19 years)
Adolescents with anemia

Mild anemia*, moderate anemia (8–

Severe anemia (<8 g/dl)
10.9 g/dl)

Two IFA tablets (each with 60

mg elemental iron and 500
Refer urgently to FRU/DH
mcg folic acid), Daily, for 3
months, orally after meals
No Improveme
improvemen
t of Hb after nt of Hb to
3 months normal Hb

Provide
Refer to Prophylactic
FRU/DH IFA dose and
counselling
 Treatment of Anemia amongst
Pregnant woman
Hb <11 g/dl

Mild anemia (10–10.9 g/dl), Moderate

Severe anemia (<7 g/dl)
Anemia (9.9-7 g/dl)
Detected in Early
pregnancy: Detected in late
Two tablets of Iron pregnancy:
and Folic Acid Parental
No iron (IV Hb value 5.0–6.9
Hb value <5 g/dl
tablet (60 mg Iron
improv Sucrose or g/dl
elemental Iron and Ferric Carboxy
ement Refer urgently
500 mcg Folic Acid) Maltose
of Hb (FCM) to FRU/DH for
daily Improv Immediate
(<1 g/dl The treatment
No improvement of ement hospitalization
Hb (<1 g/dl increase) increas will be done
of Hb to irrespective of
after one month of e) after using IV Iron
treatment >10.9
Provi period of
one Sucrose/Ferric
g/dl
de gestation
month Carboxy
of Proph Maltose (FCM)
Refer
Refer to treatme ylacti
to
nt c IFA
FRU/DH FRU/
dose
DH
and
couns Immediate
elling hospitalization
in the third
trimester of
pregnancy
Forms of Iron Supplementation

• Tablets

• Capsules

• Syrup

• Intra venous Iron Sucrose/

Ferric Carboxy Maltose
 Parenteral Treatment
of Iron
Parental treatment may be the first line of management in:
1. Severe anemia
2. Moderate anemia in second or third trimester of pregnancy
3. Postpartum if oral iron is not suitable or effective
4. Requirement for rapid iron repletion
5. Contraindications to oral iron, or compliance or tolerance (side
effect) issues
6. Comorbidities which may impact iron absorption (eg. intestinal
mucosal disorders), or bone marrow response
7. Chronic renal impairment receiving erythropoiesis-stimulating
agent
8. Ongoing iron losses that exceed absorptive capacity
 Parenteral Treatment
of Iron

• Types of Dextran free iron supplement Parenteral

Iron Formulations:
– Iron Sucrose
– Ferric Carboxy Maltose (FCM)

• Advantages of Parenteral Iron overcomes the

challenges of oral supplementation such as:
– Adherence
– Behaviour change
– Poor absorption
– Restores the body iron store in a short period 122
 Ferric Carboxy Maltose

• Ferric carboxy maltose (FCM) is very stable

and releases iron directly inside cells of
reticuloendothelial system and not into the
bloodstream (unlike other iron formulations

• The compound has near neutral pH and

physiological osmolarity
 Administration of FCM

• A single maximum dose of 1000 mg can be

administered with a total cumulative dose
and can be repeated after one week

• FCM can be administrated as slow

intravenous infusion over a short period of
15 minutes

124
 Advantages of FCM

• Multiple administrations are not required

• Economic, manpower and material loss is avoided

to the health system

• After administration, FCM allows controlled

delivery of iron to bone marrow (primarily), liver
and spleen. Thus, the chance of toxicity is very
minimal even after administration of large dose in
a short period of time
 Food based strategies

Dietary diversification Infant and young child

and enhancing the feeding: promotion of
bioavailability of breastfeeding and
micronutrients complementary feeding

Food
fortification

126
 Food Fortification

• Mandatory provision of iron

and folic acid fortified
products in government
health programs:
– Iron Fortified Whole Wheat
Flour/Refined Flour/ Rice
(Sodium Federate NaFeEDTA
@ 20mg per Kg)
– Iron fortified Salt/Double
Fortified Salt (Fe @ 850-1100
ppm) 127
 Outline

1. Introduction
2. Burden of anemia
3. Causes of Anemia
4. Anemia Mukt Bharat
5. National Centre of Excellence and Advanced Research
on Anemia Control (NCEAR–A)
6. Diagnosis of Anemia
7. Approaches to address Anemia
8. Partnership for Anemia Control

128
 Partnerships

– Government Agencies
– Academic Institutions and Professional Associations
• National Institute of Nutrition (NIN)
• Indian Council of Medical Research (ICMR)
• IAP, FOGSI, IPHA
– Bilateral and Development Agencies
• WHO, UNICEF, WFP, GAIN, MI, PATH, BMGF
– Food Industry
• Processed food industry, wheat flour, rice
– Civil Society

129
Intersectoral Partnerships MoHFW: Food
MoHFW: Ministry of Safety and MoHFW:
Drinking WaterStandards Behaviour
National Vector
and Sanitation
Borne Disease Authority of Change
Control India (FSSAI)
Communication
Programme (BCC)MoHFW:
MoHFW: (NVBDCP) National
programmes
National Programme for
Deworming Day Prevention and
(NDD) Control of
Fluorosis
Government
Department
s
THANK YOU

131