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) WHO Hemoglobin cut offs (2024) Population Anemia Non anemic Mild Moderate Severe Children 6–23 months of age 10.5 or higher 9.5-10.4 7.0-9.4 <7 Children 24 to 59 months 11.0 or higher 10.0-10.9 7.0-9.9 <7 Children 5–11 years of age 11.5 or higher 11–11.4 8–10.9 <8 Children 12–14 years of age 12.0 or higher 11–11.9 8–10.9 <8 Non-pregnant women (15 - 65 years) 12.0 or higher 11–11.9 8–10.9 <8 Pregnant women - First & Third trimester 11.0 or higher 10.0-10.9 7–9.9 <7 Pregnant women -Second trimester 10.5 or higher 9.5-10.4 7.0-9.4 <7 Adult males - 15-65 years 13.0 or higher 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). Anemia Mukt Bharat beneficiaries Low Birth Weight Babies (0–6 months) Children 6-59 months Children 5-9 years Adolescents 10-19 years Pregnant women Lactating mothers Women in reproductive age (20-49 years) The Anemia Mukt Bharat strategy will be implemented in all villages, blocks, and districts of all the States/UTs of India. Strategy for implementation 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 Eating Right – promotion of locally available iron-rich food and diet diversification 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 contains 20 mg elemental Iron + 100 mcg) IFA bottle (50 ml) with dropper Children 5–9 years of age Weekly, one Pink WIFS-IFA tablet (Each sugar coated tablet contains 45mg elemental Iron + 400 mcg Folic Acid) Adolescents 10–19 years Weekly, one Blue WIFS-IFA tablet (Each sugar coated tablet contains 60 mg elemental Iron + 500 mcg Folic Acid ) Women of reproductive age (non-pregnant, non-lactating) 20–49 years Weekly, one Red-IFA tablet (Each sugar coated tablet contains 60 mg elemental Iron + 500 mcg Folic Acid ) Pregnant women Daily one Red-IFA tablet for 180 days starting from the second trimester of pregnancy. (Each sugar coated tablet contains 60 mg elemental Iron + 500 mcg Folic Acid ) Lactating mother Daily one Red-IFA tablet for 180 days starting from delivery upto 6 months post partum (Each sugar coated tablet contains 60 mg elemental Iron + 500 mcg Folic Acid ) Low Birth Weight Babies (0–6 months) As prescribed by the attending Pediatrician/ Specialist at the Health facility 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. Note 2: Prophylaxis with IFA tablets/syrup will be gradually tapered with more emphasis being placed on testing followed by treatment till resolution along with inclusion of iron rich foods in the daily diet. 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: At VHSND/ T4 camps/AAM/ Immunization session sites (during MR1, MR-2 vaccination; Vitamin A supplementation) RBSK MHT: at Anganwadi Centre SN/ MO/ CHO: Opportunistic screening of children visiting the OPD at health facility Periodicity Annual If Mild and Moderate anemia First level of treatment (at all levels of care) Therapeutic doses (IFA) Syrup for 3 months: 6 - 12 months (6-10.9Kg) – 1 mL IFA syrup daily 1 - 3 years (11-14.9 Kg) – 1.5 mL IFA syrup daily 3 – 5 years (15-19.9 Kg) – 2 mL IFA syrup daily Counselling for IFA compliance and Eating right Follow-up ASHA will follow up through home visits HBNCC visits ASHA will mobilise all anemic cases for follow up testing after 3 months of treatment Counselling of mothers/caretakers by ASHA and ANM on reassurance of common side effects of the Iron supplementation ANM to report compliance on AMB Abhiyaan portal If no improvement after first level of treatment Refer the child to higher facility - FRU/DH for further investigation and management of anemia . Follow up as per advise of treating Paediatrician. If 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 RBSK MHT : In school and Out of school in AWC CHO /ANM: Opportunistic screening and referrals from schools/ community/AWC Periodicity Annual If mild and moderate anemia First level of treatment (at all levels of care) Therapeutic doses-1 IFA Pink tablet once daily for 3 months Counselling for IFA compliance and Eating right Follow-up Class teacher/ Nodal teacher at school to orient parents during Parent Teacher Meeting (PTM) for compliance of treatment Parents to follow-up of child after 90 days at nearest AAM/health facility RBSK MHT to follow up child with coordination with nodal teachers/ HWAs If no improvement after first level of treatment Refer the child to higher facility - FRU/DH for further investigation and management of anemia . Follow up as per advise of treating specialist/Paediatrician. If 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 (10 - 19 years) Target group All adolescents 10–19 years Who will screen and place of screening RBSK MHT: In school and Out of school in AWC CHO /ANM: Opportunistic screening and referrals from schools/ community/AWC Periodicity Annually Mild and Moderate Anemia First level of treatment (at all levels of care) Therapeutic doses-1 IFA Blue tablet once daily for 3 months Counselling for IFA compliance and Eating right Follow-up Class teacher/ Nodal teacher at school to orient parents during Parent Teacher Meeting (PTM) for compliance of treatment Parents to follow-up for retest after 90 days of therapeutic treatment at nearest AAM/health facility RBSK MHT to follow up child in coordination with nodal teachers/HWAs during next visit If no improvement after first level of treatment Refer the adolescent to higher facility - First Referral Unit (FRU)/District Hospital (DH) for further investigation and management of anemia If 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 Women of Reproductive Age (20 - 49 years) Target group Women of Reproductive Age 20–49 years Who will screen and place of screening CHO: at AAM- opportunistic screening and referrals MO: opportunistic screening and referrals T4 Camps/Health camps Periodicity Annually Mild and Moderate Anemia First level of treatment (at all levels of care) Therapeutic doses- 1 IFA Red tablet once daily, for 3 months Counselling for IFA compliance and eating right Follow-up ASHA will monitor every month for compliance Further, ASHA is given incentive for mobilizing WRA for testing, compliance and follow up under Anemia Mukt Bharat Abhiyaan. If no improvement after first level of treatment Refer the women to higher facility - First Referral Unit (FRU)/District Hospital (DH) for further further investigation and management of anemia. Follow up as per advice of treating specialist/gynaecologist If severe anemia First dose of treatment Refer the women to higher facility - First Referral Unit (FRU)/District Hospital (DH) for further further investigation and management of anemia. Follow up as per advice of treating specialist/gynaecologist Anemia management protocol for pregnant women Target group Pregnant women registered for antenatal care Who will screen and place of screening ANM: VHSND/UHSND/ANC clinic SN/MO : Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) Periodicity At every ANC contact (at least 4 times): 1st- within 12 weeks 2nd- 14-26 weeks 3rd- 28-34 weeks 4th- 36-40 weeks 8 times for all HRPs If mild and moderate anemia First level of treatment (at all levels of care) IFA tablet – 2 tablets daily for 1 month after Hb testing If there is improvement, but target Hb not reached; continue the treatment with 2 tablets daily for 1 months If there is improvement, and target Hb reached; switch to prophylaxis dose (once daily) If no improvement, refer the Pregnant women to higher facility - FRU/DH for further investigation and management of anemia Intravenous Iron treatment - For moderate anemia as advised by treating physician based on gestation period and clinical evaluation: IV Iron Sucrose – 5 doses; IV FCM – 2 doses (Please refer to Operational guidelines - Intravenous Iron treatment for Pregnant women and lactating mothers)) Follow-up Monthly home visits by ASHA for treatment compliance VHSND If no improvement after first level of treatment If no improvement, Refer the Pregnant women to higher facility - First Referral Unit (FRU)/District Hospital (DH) for further investigation and management of anemia (IV iron /Blood transfusion). Follow up as per advice of treating specialist/gynaecologist. If severe anemia First level of treatment Refer the Pregnant women to higher facility - First Referral Unit (FRU)/District Hospital (DH) for further investigation and management of anemia (IV iron /Blood transfusion). Follow up as per advice of treating specialist/gynaecologist. 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 7 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