#1INTEGRATED ANEMIA PREVENTION AND CONTROL NATIONAL ANEMIA WORKING GROUP MEETING February 4, 2016#2OUTLINE What is anemia and why is it a problem? What are the causes of anemia? What are effective interventions to address these causes? What is the anemia situation in Sierra Leone? e#3WHAT IS ANEMIA? • Red blood cells . transport oxygen from the lungs to cells • RBCs contain a protein Red blood cell called hemoglobin that Hemoglobin carries the oxygen • Anemia - Greek word anaimía "want of blood" molecules Oxygen from lungs Oxygen bonded Oxygen released to tissue cells. with hemoglobin molecules e#4CONSEQUENCES OF ANEMIA ◆ risk of disease & disability ↓ economic productivity, and cost to society birth weight, ◆ preterm delivery maternal mortality ✓ Quality of life for adolescent academic performance WHO 2001 Black 2013 Christian 2009 Kassebaum, 2014 Stoltzfus 2003 development of domains - physical, cognitive & socio- emotional child mortality#5Deficient intake: iron, vit. A, zinc, folate, vit. B12 Inflammation Hepcidin Redistribution of iron and Vit. A CAUSES OF ANEMIA Malaria: Destruction and impaired production RBC Helminths: Internal bleeding (loss of iron) Thalassemias, HbAS, HbSS, Hb-E, G6PD: ◆ Destruction & ↓ RBC production & ↓ lifespan Cook, et al. 1994; Scott et al. 2007; Selhub et al. 2009; Ganz et al. 2011; George, et al. 2012; Pasricha et al. 2010; Suchdev et al. 2012 MA#6GENETIC DISORDERS AND ANEMIA CAMBODIA-women (n=420) Genetic hemoglobin disorder 54% Anemia 30% With genetic disorder 45% Without genetic disorder 11% Low iron stores 2% Karakochuk et al. 2015#760.0 Kenya 2010, Foote 2013 50.0 40.0 Prevalence Fraction for Anemia (%) 30.0 20.0 16.8 10.0 0.0 60.0 52.1 50.0 Prevalence Fraction for Severe Anemia (%) Malaria Age <24 mo. Iron Deficiency Non-Malarial Inflammation 8.4 8.3 6.1 5.7 5.0 3.5 2.3 0.8 Male Sex (-a/aa) a-Thalassemia Stunting (-a/-a) a-Thalassemia Wasting 40.0 31.2 30.0 20.0 16.1 10.0 0.0 Malaria Non-Malarial Inflammation Stunting#8Interventions for Anemia - strong evidence - • SUPPLEMENTATION • FORTIFICATION ⚫ DEWORMING · MALARIA - IPTP, LLIN, FORTIFI ADDED VALUE F FOOD INDOOR RESIDUAL SPRAYING; PROMPT DIAGNOSIS AND TREATMENT e Iron Folic Acid TABLETS & CAPSULES 100 TABLETS ALBENDAZOLE TABLETS 400 mg A. 400 De T-8064 SEP 08 te AUG.11#9Interventions for Anemia - indirect evidence WATER, SANITATION & HYGIENE • DIETARY INTERVENTIONS • INFANT & YOUNG CHILD FEEDING . FAMILY PLANNING FEMALE EDUCATION * Nuts Leafy Green Eggs Red Meat Cereals Legumes Citrus Fruits Broccoli & Mustard Dry Fruits Fish ©HarvestPlus: A woman harvests high iron beans in Northern Province, Rwanda. Photo: HarvestPlus/Angoor Studios - See more at: http://bit.ly/1JV03WO#10Variable INTEGRATION: COMBINED EFFECT OF IFA AND IPTP ON NEONTAL MORTALITY n Hazards ratio (HR) HR (95% CI) P FeFol and malaria prophylaxis No FeFol+no malaria prophylaxis (ref) 24803 Any FeFol + no malaria prophylaxis 18225 No FeFol+SP-IPT 3990 Any FeFol+SP-IPT 16076 No FeFol+ other malaria prophylaxis 4481 Any FeFol+other malaria prophylaxis 32089 0.25 0.5 1 2 Favors treatment Christiana R Titaley et al. Am J Clin Nutr 2010;92:235-243 ©2010 by American Society for Nutrition e 1.00 0.90 (0.73, 1.12) 0.34 1.08 (0.74, 1.57) 0.69 0.76 (0.58, 0.99) 0.04 0.84 (0.60, 1.17) 0.29 0.86 (0.70, 1.06) 0.16#11WHA - ANEMIA TARGETS • REDUCE ANEMIA GLOBALLY BY 50% AMONG WOMEN OR PRODUCTIVE AGE BY 2025 • REQUIRES A 15% REDUCTION • 1995 – 2011 (4% REDUCTION WRA, 5 % REDUCTION PREGNANT WOMEN) Global Nutrition Targets 2025 Anaemia Policy Brief 2 WHO/NMH/NHD/14.4#12ANEMIA IS WHERE COUNTRIES ARE FINDING IT MOST DIFFICULT TO MAKE PROGRESS ONLY 5 OUT OF 185 COUNTRIES WITH ANEMIA DATA ARE ON COURSE TO REDUCE ANEMIA. e#13KEY LESSONS LEARNED FROM UGANDA ⚫ INCREASE DISTRICT INVOLVEMENT • STREAMLINE WITH OTHER COORDINATING BODIES INCREASED INTEGRATION ACROSS INTERVENTIONS "we need move away from these conference rooms to the field where the people are" e#14ANEMIA IN WEST AFRICA CHILDREN MOROCCO ALDANIA TURKEY TURKMENISTAN AZERBAIJAN JORDAN TUNISIA EGYPT DOMINICAN REPUBLIC CAPE VERDE Legend SENEGAL TRINIDAD AND TOBAGO GUYANA Up to 60.3 EQ > 1 + Legend 60.4 to 70.1 70.2 to 76.6 76.7 and higher BRAZIL DOMINICAN REPUBLIC WRA Up to 42.4 TRINIDAD AND TOBAGO GUYANA 42.5 to 49.1 EQ 49.2 to 54.3 54.4 and higher BRAZIL MAURITANIA MALI BURKINA NIGER SUDAN CHAD GUINEA FASO GHANA NIGERIA SIERRA LEONE LIBERIA BENIN COTE D'IVOIRE GABON TOGO SAO TOME MOROCCO AND PRINCIPE CAMEROON CONGO CENTRAL AFRICAN REPUBLIC GANDA ETHIOPIA YEMEN DEMOCRATIC REPUBLIC OF KENYA THE CONGO TANZANIA RWANDA BURUNDI COMOROS ANGO AFGHANISTAN PAKISTA MALDIVES POWERED BY esri ALDANIA TURKEY TURKMENISTAN AZERBAIJAN TUNISIA JORDAN EGYPT MAURITANIA CAPE VERDE SENEGAL MALI BURKINA NIGER SUDAN YEMEN CHAD GUINEA FASO NIGERIA GHANA SIERRA LEONE LIBERIA BENIN COTE D'IVOIRE GABON TOGO SAO TOME CAMEROON CONGO ETHIOPIA CENTRAL AFRICAN REPUBLIC GANDA KENYA AND PRINCIPE ANG DEMOCRATIC REPUBLIC OF THE CONGO TANZANIA RWANDA BURUNDI COMOROS Data compiled using DHS STATCompiler at http://www.statcompiler.com/ AFGHANISTAN PAKISTA MALDIVES POWERED BY⚫ esri#15Sierra Leone Micro Nutrient rvey Team Ministry of Health and Sanitation (Sierra Leone), UNICEF, Helen Keller International, and WHO. 2013 Sierra Leone Micronutrient Survey. Freetown, Sierra Leone; 2015.#1680 70 60 50 430 40 30 20 10 PREVALENCE OF ANEMIA AND KEY RISK FACTORS IN SIERRA LEONE, NATIONALLY 0 Anemia Malaria Inflammation SLMS 2013 e Children Women#17OPREVALENCE OF ANEMIA, ID AND IDA IN SIERRA LEONE CHILDREN, NATIONALLY Anemia 76% IDA ID 4% 5% SLMS 2013#18CONTEXT SPECIFIC CAUSES OF ANEMIA SHOULD DRIVE INTERVENTIONS Causes Malaria related- Anemia Interventions MALARIA PREVENTION & TREATMENT Micronutrient deficiencies, stunting Tropical enteropathy, nutrient malabsorption diarrhea Blood loss NUTRITION PROGRAMS WATER TREATMENT & HYGIENE DEWORMING#19O 100 90 COVERAGE ANEMIA-RELATED INTERVENTIONS IN SIERRA LEONE, NATIONALLY 80 70 60 58 50 45 46 40 40 30 30 27 30 36 32 20 17 10 10 0 Latrines Contraception Anti-malarials IFA (90+) *first visit of the second trimester Iron-rich foods Iron syrup Malaria diagnosis IPTP VitamA-rich foods Deworming (women) * Water 72 73 67 00 60 IFA (any) Deworming (child) Own ITN DHS 2013, Sesay 2012) VAS 92#20WHO RECOMMENDATIONS FOR MNP World Health Organization WHERE? ANEMIA >20% WHO? CHILDREN 6-23 MO Guideline: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6-23 months of age WHY? REDUCE IRON DEFICIENCY AND ANEMIA O De-Regil et al. 2011#21Review: Oral iron supplements for children in malaria-endemic areas Comparison: Iron versus placebo or no treatment Outcome | Clinical malaria (by anaemia at baseline) Study or subgroup I Angeria log [Risk Ratio] (SE) Risk Ratio MVFixed,95% CI Weight Risk Ratio IMFixed,95% C Adam 1997 (C 0.401106 (0.19702878) 5.9% 1.49 [1.02, 2.20] Ayoya 2009 0.732368 (0.58467408) 0.7% 2.08 [066, 6.54] Desai 2003 -0.52742 (0.19357679) 6.1% 0.59 [040, 0.86] Fahmida 2007 0313161 (0.7553618) 0.4% 1.37 [031, 601] Gebreselassie 1996 0465092 (0.27861906) 2.9% 1.59 [0.92, 2.75] Massaga 2003 -Q1705 (0.14303878) 11.2% 084 [064, 1.12] Massaga 2003 0.054615 (0.23254496) 42% 1.06 [067, 1.67] Smith 1989 (C) 0473541 (0.48487584) 1.0% 1.61 [062, 4.15] Verhoef 2002 0.356675 (031150403) 24% 1.43 [078, 263] Verhoef 2002 0.04256 (0.24648012) 38% 1.04 [064, 1.69] Subtotal (95% CI) 38.5 % 1.02 [0.88, 1.19] Heterogeneity: Chi² = 19.77, df = 9 (P=0.02); 1² =54% Test for overall effect: Z-031 (P = 0.76) 2 No anaemia Harvey 1989 -0.08004 (0.16178459) 8.7% 092 [067, 1.27] Lawless 1994 -0.04652 (0.14975946) 10.2% 095 [071, 1.28] Leenstra 2009 0.625938 (0.7978724) 0.4% 1.87 [0.39,893] Menendez 1997 -0.06236 (0.12627568) 14.3% 094 [073, 1.20] Menendez 1997 -01779 (0.20514197) 5.4% 0.84 [0.56, 1.25] Richard 2006 0044784 (0.10073627) 22.5% 1.05 [0.86, 1.27] Subtotal (95% CI) 61.5 % 0.97 [0.86, 1.09] Heterogeneity: Chi² = 1.92, df = 5 (P=0.86); 1² =0.0% Test for overall effect: Z = 0.48 (P = 0.63) Heterogeneity: Chi² = 21.98, df = 15 (P=0.11); 1²=32% Total (95% CI) Test for overall effect: Z=018 (P = 0.85) Test for subgroup differences: Chi² = 0.29, df = 1 (P=0.59), 1² =0.0% 100.0 % 0.99 [0.90, 1.09] 02 05 2 5#22MNP SAFETY CONSIDERATIONS Safety of iron: Pemba trial Tanzania Trial halted because of increased hospitalizations and death in the groups supplemented with iron and zinc Ghana No increased risk of malaria with bednet distribution and prompt diagnosis and treatment of a malaria Kenya Cote d'Ivoire Increased pathogenic gut microbiota profile Increased pathogenic gut microbiota profile South Africa No difference in gut microbiota profile Sazawal S et al. 2006, Zlotkin et al. 2013, Jaegg et al. 2014; Dostal et al. 2014; Zimmermann et al. 2010, Soofi et al. 2013 Pakistan Increase risk for diarrhea Context matters#23CAUSES OF ANEMIA – FUTURE DIRECTIONS - HIGH IRON GROUND WATER →.51 (MASONFONYIA) TO 1.2 (GBANGIENE) GENETICS →UNDERWAY e#24THANK YOU e#25REFERENCES... • • • • • • • • • HOTEZ, P. 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