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Anemia Mukt Bharat

Introduction
Objectives
Beneficiaries and Targets
Strategy for implementation
Interventions

Prophylactic Iron and Folic Acid (IFA) supplementation
Deworming
Therapeutic Management of Anemia

The Anemia Mukt Bharat- intensified Iron-plus Initiative aims to strengthen the existing mechanisms and foster newer strategies for tackling anemia.

It focusses on six target beneficiary groups, through six interventions and six institutional mechanisms to achieve the envisaged target under the POSHAN Abhiyan.

Introduction

Anemia is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet the body’s physiological requirements, which vary by age, sex, altitude, smoking habits, and during pregnancy.

The manifestations of anemia vary by its severity and range from fatigue, weakness, dizziness and drowsiness to impaired cognitive development of children and increased morbidity.

Anemia in pregnancy is associated with post-partum haemorrhage, neural tube defects, low birth weight, premature births, stillbirths and maternal deaths. In malaria endemic regions, anemia is one of the most common preventable causes of maternal and child deaths. In its most severe form, anemia can also lead to death.

There are many causes of anemia, out of which iron deficiency accounts for about 50 percent of anemia in school children and among women of reproductive age-group, and 80 percent in children 2–5 years of age. Other nutritional deficiencies besides iron, such as vitamin B12, folate and vitamin A, can cause anemia although the magnitude of their contribution is unclear. Infectious diseases - in particular malaria, helminth infections, tuberculosis and haemoglobinopathies - are other important contributory causes to the high prevalence of anemia.

Anemia is defined as haemoglobin concentration below established cut-off levels in the blood. The haemoglobin cut-offs which are used for diagnosing anemia across ages are described below.

Haemoglobin levels to diagnose anemia (g/dl)

Population	Anemia
Population	Mild	Moderate	Severe
Children 6–59 months of age	10–10.9	7–9.9	<7
Children 5–11 years of age	11–11.4	8–10.9	<8
Children 12–14 years of age	11–11.9	8–10.9	<8
Non-pregnant women (15 years of age and above)	11–11.9	8–10.9	<8
Pregnant women	10–10.9	7–9.9	<7
Men (15 years of age and above)	11–12.9	8–10.9	<8

According to the National Family Health Survey 4 (NFHS-4), 2015/16, anemia prevalence across all ages is extremely high in India; varying from 30 percent to 69 percent. It is also to be noted that in the last 10 years (NFHS-3, 2005/06 to NFHS-4, 2015/16), the percentage point reduction of anemia prevalence has been extremely low in most age groups.

Prevalence of anemia in India

Age group	2006 (NFHS-3)	2016 (NFHS-4)	NFHS-5 (2019-21)
Children 6–59 months (Haemoglobin<11 g/dl), %	69	58	67
Adolescent girls 15–19 years (Haemoglobin<12 g/dl), %	56	54	59
Adolescent boys 15–19 years (Haemoglobin<13 g/dl), %	30	29	31
Women of reproductive age (Haemoglobin<12 g/dl), %	55	53	57
Pregnant women (Haemoglobin<11 g/dl), %	58	50	52
Lactating women (Haemoglobin<12 g/dl), %	63	58	57

Objectives

The reduction of anemia is one of the important objectives of the POSHAN Abhiyaan launched in March 2018. Complying with the targets of POSHAN Abhiyaan and National Nutrition Strategy set by NITI Aayog, the Anemia Mukt Bharat strategy has been designed to reduce prevalence of anemia by 3 percentage points per year among children, adolescents and women in the reproductive age group (15–49 years), between the year 2018 and 2022.

Beneficiaries and Targets

The strategy is estimated to reach out to 450 million beneficiaries with specific anemia prevalence targets for year 2022 to be achieved among various population groups

Anemia Mukt Bharat beneficiaries and anemia reduction targets for different age groups for 2022

Age Group	Estimated beneficiaries (in millions)
Children (6–59 months)	124
Children (5–9 years)	134
Adolescent boys (10–19 years)	47
Adolescent girls (10–19 years)	68
Women of reproductive age (20–24 years)	17
Pregnant women	30
Lactating women	27
Total beneficiaries	~450 million

Beneficiary estimations are as per Census 2011 estimations for 2017.

Estimated number of beneficiaries will be annually revised and updated. While all women of reproductive age should ideally be covered, the estimated number of beneficiaries are those women aged 20–24 years from Mission Parivar Vikas Yojana who will be initially covered in Anemia Mukt Bharat.

The Anemia Mukt Bharat strategy will be implemented in all villages, blocks, and districts of all the States/UTs of India through existing delivery platforms as envisaged in the National Iron Plus Initiative (NIPI) and Weekly Iron Folic Acid Supplementation (WIFS) programme.

Anemia Mukt Bharat - Anemia reduction Targets for 2022

Age Group	Anemia prevalence (%)
Age Group	Baseline (NFHS 4)	National target 2022 (at 3 percentage points per annum from baseline)
Children (6–59 months)	58	40
Adolescent girls (15–19 years)	54	36
Adolescent boys (15–19 years)	29	11
Women of reproductive age	53	35
Pregnant women	50	32
Lactating Women	58	40

Strategy for implementation

A snapshot of the Anemia Mukt Bharat 6X6X6 strategy is depicted below.

Interventions

The Anemia Mukt Bharat strategy is a universal strategy and will focus on the following interventions:

Prophylactic Iron and Folic Acid supplementation
Deworming
Intensified year-round Behaviour Change Communication Campaign (Solid Body, Smart Mind) focusing on four key behaviours

Improving compliance to Iron Folic Acid supplementation and deworming
Appropriate infant and young child feeding practices,
Increase in intake of iron-rich food through diet diversity/quantity/frequency and/or fortified foods with focus on harnessing locally available resources and
Ensuring delayed cord clamping after delivery (by 3 minutes) in health facilities

Testing and treatment of anemia, using digital methods and point of care treatment, with special focus on pregnant women and school-going adolescents
Mandatory provision of Iron and Folic Acid fortified foods in government-funded public health programmes
Intensifying awareness, screening and treatment of non-nutritional causes of anemia in endemic pockets, with special focus on malaria, haemoglobinopathies

Prophylactic Iron and Folic Acid (IFA) supplementation

Prophylactic Iron Folic Acid supplementation given to children, adolescents, women of reproductive age and pregnant women, irrespective of anemia is a key continued intervention under Anemia Mukt Bharat.

Prophylactic dose and regime for Iron Folic Acid supplementation

Age Group	Dose and regime
Children 6–59 months of age	Biweekly, 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 (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	Weekly, 1 Iron and Folic Acid tablet. Each tablet containing 60 mg elemental Iron + 500 mcg Folic Acid, sugar-coated, 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, 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.

Deworming

Dose and regime for deworming

Age Group	Dose and regime
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 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	One dose of 400 mg albendazole (1 tablet), after the first trimester, preferably during the second trimester

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.

Therapeutic Management of Anemia

Anemia management protocol for children:

Traget 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)	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 officer/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 officer 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 officer/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 officer at the First Referral Unit/District Hospital based on investigation

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 officer 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 first 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 first 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 officer 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 first 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 is contraindicated for patients with thalassemia major and sickle cell disease. Treatment of anemia through folic acid is recommended in thalassemia major cases.

For the complete Operational Guidelines, click here.

Source: Anemia Mukt Bharat portal

Last Modified : 3/27/2024

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