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VITAMIN A DEFICIENCY AND IRON DEFICIENCY IN CHINA:
PROBLEMS, PROGRAMS, AND POLICIES
Report on a consultancy for the World Bank, including field trips to Henan and Guizhou
By
Ted Greiner, PhD, Department of Women's and Children's Health, Uppsala University, Sweden
Liu Yunguo, MD, Deputy Director General, Foreign Loan Office, Ministry of Health, China
Jiang Jing-Xiong, MD, Director, Dept of Nutrition, Capital Institute of Paediatrics, China
Yan Di Ying, MD, Prof, Head of Chronic Disease Branch, Chinese Academy of Preventive
Medicine
August 7, 2001
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ABBREVIATIONS
BFHI:
CIP:
Hb:
IDA:
IDD:
IFA:
RDI:
RDA:
UNICEF:
VA:
VAC:
VAD:
WHO:
Baby Friendly Hospital Initiative
Capital Institute of Pediatrics
hemoglobin
iron deficiency anemia
iodine deficiency disorders
iron-folic acid
recommended dietary intakes
recommended dietary allowances
United Nations Children’s Fund
vitamin A
vitamin A capsules
vitamin A deficiency
World Health Organization
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TABLE OF CONTENTS
Page No.
SUMMARY
1
BACKGROUND
3
METHODS
4
FINDINGS
Vitamin A
Prevalence
Causes of Vitamin A Deficiency
Policies
Programs
Critique of Current Approaches
5
5
5
6
9
10
11
Iron
Prevalence
Causes of Iron Deficiency
Policies
Programs
Critique of Current Approaches
13
13
17
19
19
22
CONCLUSIONS
24
RECOMMENDATIONS
25
ACKNOWLEDGMENTS
29
REFERENCES
30
ANNEX 1: Persons Met With in July 2000
ANNEX 2: Persons Met With in January 2001
ANNEX 3: China’s Policy Statement Regarding Micronutrient Malnutrition
ANNEX 4: Chinese Recommended Daily Intakes Vitamin A and Iron, 2000
ANNEX 5: Vitamin A Capsule Schedules
ANNEX 6: Guidelines for Intervention Programs for Childhood
ANNEX 7: Tanzania Example of Disease-Targeted Vitamin A Capsules
ANNEX 8: Workshop Held January, 2000
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38
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42
44
45
46
47
SUMMARY
The health and nutritional status of the population of China has improved greatly over the last
several decades. Under-five mortality declined from 65 deaths/1,000 live births in 1980 to 39 in
1997 and while infant mortality stayed relatively constant over the same period (estimated at 4247 deaths/1,000 live births), these overall rates are lower than in other East Asian countries (e.g.,
Cambodia, Lao PDR, Myanmar). Rates of undernutrition and stunting also declined to 16% and
31%, respectively—similar to rates in Malaysia and Thailand. Progress has also been made in
reducing iodine deficiency disorders by improving the coverage of iodized salt from 39% of all
salt iodized in 1995 to 89% in 1999.
While much of the improvement in the health and nutritional status of the population of China
may be attributed to economic growth and concomitant improvements in the standard of living,
an important contribution has been made by targeted interventions to improve child health and
nutritional status. The success of these targeted interventions serves as a reminder and example
that some of the remaining nutritional deficiencies and health problems can similarly be
ameliorated in China and other countries in the region.
The World Bank has a special interest in the application of cost effective interventions to reduce
micronutrient deficiencies whether through supplementation or fortification. Following China’s
great progress in reduction of iodine deficiency disorders, with assistance of the Bank and other
agencies, it was decided to support an assessment of the situation with respect to vitamin A and
iron deficiencies. A team of experts reviewed current policies and available data on these
deficiencies, conducted field trips in Henan and Guizhou provinces, including observation and
interviews with a range of interested groups from province to village level, and carried out a
social assessment in two townships of each province.
The findings of the team suggest that sub-clinical vitamin A deficiency remains a problem of
public health significance in some provinces, largely in the west. It is most severe in younger age
groups, particularly among infants under six months of age. Iron deficiency anemia is likely to be
a public health problem among pregnant women and children of 6-24 months of age everywhere,
but anemia is also more severe in the western provinces. Both deficiencies are likely to be worse
among the poor.
Government policy statements indicate an intention to eliminate these public health problems.
However, clear strategies and detailed modern protocols for prevention and treatment have not
yet been developed, and the effectiveness and efficacy of the various approaches currently used
to manage both deficiencies in the provinces visited were questionable. The effectiveness of
traditional medicine in treating nutritional deficiencies needs to be discussed in China. It appears
to be used to treat anemia at unnecessarily high cost to the patient. While vitamin A capsules
(VAC) are currently being distributed to all children 6-36 months old in 40 counties under a
special initiative, there is no clear policy to give vitamin A to children of this age in China.
Food fortification with both nutrients has been initiated on pilot basis and plans are to expand it.
However, the main approach currently in use to prevent both deficiencies is dietary advice given
by health professionals. The impact of that advice is not known, but may not be effective because
the foods recommended may not have high vitamin A content (e.g., eat green leaves) or may be
unavailable to those most at risk of deficiency (e.g., eat more meat) because of the high cost.
To reduce vitamin A and iron deficiencies, both short term and longer term preventive and
curative approaches could be identified for wide and consistent use throughout China. In the
short-medium term, intensified efforts in supplementation are recommended. Preventive
supplementation with vitamin A should continue in the 40 counties where it is currently being
distributed and lessons learned from this activity should be shared throughout the country. For
the entire country, clear strategies and protocols based on current international recommendations
should be developed for presumptive treatment of vitamin A deficiency, targeting two groups,
children with serious illness and women after delivery. Preventive and curative protocols are also
needed for iron deficiency anemia, focusing on children aged 6-24 months and pregnant women.
In addition, guidelines are needed to ensure that dietary counseling is tailored to the needs and
life style of the target groups.
With a view to a greater contribution from food fortification in the longer term, pilot fortification
efforts should continue, and if successful be expanded. Counseling clients to consume any
available fortified foods should be part of the overall strategy to reduce micronutrient
malnutrition. Health workers should be retrained accordingly to use the new protocols and
counseling messages and a supportive supervision and monitoring system should be used to
reinforce implementation of the protocols and track the increase in coverage of these
interventions. Pilot testing may be required for strategy and protocol development and to
examine how these interventions should best be implemented in the Chinese context.
BACKGROUND
Several countries in the East Asia region, including China, have made significant progress in
improving health and nutrition indicators over the last several decades. In China, under-five
mortality declined from 65 deaths/1,000 live births in 1980 to 39 in 1997 and while infant
mortality stayed relatively constant over the same period (42-47 deaths/1,000 live births), the
rates are lower than in other East Asian countries (e.g., Cambodia, Lao PDR, Myanmar). Rates of
undernutrition and stunting also declined to 16% and 31%, respectively—similar to Malaysia and
Thailand. Some of the improvement in the health and nutritional status of the population of
China is due to economic growth and concomitant improvements in the standard of living.
However, much of the improvement has been the result of targeted interventions to improve
child health and nutritional status.
Three micronutrient deficiencies, iron, iodine and vitamin A, have received international
attention for their widespread prevalence, the substantial harm they do to public health and
economic development, their ease of identification, and the availability of cost effective means of
preventing them. China has, in recent years, made significant progress in solving its iodine
deficiency problem, with support from the World Bank and other agencies, by increasing national
coverage for iodized salt from 39.9% in 1995 to 89% in 1999. The increased consumption of
iodized salt resulted in reduced rates of goiter with only 9% of school-age children (ages 8-10
years) affected in 1999 compared with 20% in 1995. However, in China less attention has been
given to date to the other two micronutrients, and this has important implications for health in
China, particularly in poor areas of the country where these deficiencies are more severe.
International experience has shown that vitamin A deficiency in young children is associated
with increased risk of morbidity and mortality from childhood diseases. Giving vitamin A to
even mildly deficient children or to postpartum women to ensure their infants receive breastmilk
with adequate vitamin A can reduce mortality in children 0-5 years by at least 23% (Beaton et al,
1993). Iron deficiency anemia is associated with increased risk of morbidity and mortality,
decreased capacity to learn, and increased susceptibility to disease in young children. Anemic
women are at greater risk of dying during delivery and the postpartum period with smaller
amounts of blood loss. It is estimated that as many as 20% of maternal deaths are associated with
anemia. In all adults, anemia is associated with decreased work capacity. There is a 10% decrease
in productivity with each 1 g/dL decrease in hemoglobin, causing millions of dollars in lost
productivity annually where anemia prevalence is high. A recent analysis estimated that $4.2
billion are lost annually in India, Bangladesh and Pakistan due to iron deficiency anemia (Horton
& Ross, 2000).
There are Cost effective interventions recognized internationally to address vitamin A and iron
deficiencies that include:



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
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semi-annual doses of vitamin A for children 6-59 months;
a dose of vitamin A for all postpartum women, given within 60 days after delivery
doses of vitamin A targeted to children with undernutrition and serious illnesses;
daily iron-folate supplementation for pregnant and postpartum women;
daily iron-folate supplements for children 6-24 months of age;
vitamin A and iron fortification of foods consumed by vulnerable groups;
deworming of children over 5 years of age and pregnant women (second and third


trimesters) where hookworm infection and/or schistosomiasis are prevalent;
exclusive breastfeeding from immediately after birth continuing for 6 months;
adequate introduction of complementary foods (with good sources of vitamin A and iron,
if possible) starting at about six months with continued breastfeeding through two years.
The World Bank has a special interest in the application of cost effective interventions to reduce
micronutrient deficiencies whether through supplementation or fortification. Following China’s
great progress in reduction of iodine deficiency disorders, it was decided to support an
assessment of the situation with respect to vitamin A and iron deficiencies. A team of experts
reviewed current policies and available data on these deficiencies, conducted field trips in Henan
and Guizhou provinces, including observation and interviews with a range of interested groups
from province to village level, and carried out a social assessment in two townships of each
province. Specifically, the team, with support from Danish and Swedish Trust Funds,
summarized:




the extent to which deficiencies of iron and vitamin A are public health problems at
national and provincial levels,
what policies are already in place to address these deficiencies,
what programs are in place to prevent and treat them (focusing on areas in Henan and
Guizhou Provinces where field visits were taken), and
a process of discussion regarding possible new approaches, in part through holding
seminars on the Team’s findings with some of the key actors from national and provincial
levels (see Annex 7 for a list of recommendations and participant list from the national
seminar).
Recommendations on how to improve interventions to address these deficiencies are made based
on the team’s findings. This is a comprehensive report, building on an earlier one from the first
mission in July and from the social assessment and fulfills the provisions of various Terms of
Reference. This report also covers the following topics:





the significance/prevalence of vitamin A and iron deficiencies both nationally and
regionally;
the causes of vitamin A and iron deficiencies: known causes internationally and evidence
for the causes in China;
policies and programs addressing vitamin A and iron deficiencies;
a critique of the effectiveness of current approaches in China to address vitamin A and
iron deficiencies (this is based on international recommendations to address these
deficiencies); and
recommendations to improve current approaches to address vitamin A and iron
deficiencies.
METHODS
The Chinese and English-language scientific literature was reviewed. During two periods in July
2000 and January 2001, the Team conducted a series of interviews and discussions with national,
provincial, county and township level officials, experts, health workers, and villagers. Field trips
were made first to Xichuang County, Henan Province and later to Da Fang County, Guizhou
Province (See Annex 1 and 2 for a list of persons met). Two rural townships were visited in each
county. A social assessment was conducted in two townships in Guizhou Province and two
townships of Henan Province. This included conducting a participatory rural assessment with
structured and key-informant interviews and a focus group discussion with farmers. Finally,
provincial and national workshops were held near the end of the exercise, a summary of which is
included (Annex 8).
For purposes of simplification, in this report, vitamin A deficiency (VAD) is defined as a serum
retinol concentration below 20 mcg/dL (equivalent to 7mmol/dl). VAD is considered to be a
moderate public health problem where 10-20% of children 6-71 months of age are below this
level and severe at >20%. Iron deficiency anemia (IDA) is more difficult to define because the
indicator usually used is anemia, measured by low hemoglobin in the blood, and anemia can be
caused by other factors than iron deficiency. There are other indicators more specific for iron
deficiency but they are amenable for use in only research settings because of their cost and the
difficulty in interpreting their meaning. However, because in most controlled settings
hemoglobin levels improve when iron supplements are given to anemic individuals, it is assumed
that the majority of low values are due to iron deficiency and a hemoglobin test is still
recommended as a good predictor of iron deficiency. Low hemoglobin values are defined
according to age, physiological status and altitude, and INACG/UNICEF/WHO (1998)
recommend the following cutoffs for children and women of reproductive age living at sea level:
Children 6 mos-5 years
Non-pregnant women
Pregnant women
anemia
<11 g/dL
<12 g/dL
<11 g/dL
mild-moderate anemia
7.0-10.9 g/dL
8.0-11.9 g/dL
7.0-10.9 g/dL
severe anemia
<7 g/dL
<8 g/dL
<7 g/dL
FINDINGS
Findings are presented where available for the national, provincial, county and township levels.
Vitamin A
Prevalence
National and regional levels
In the late 1980s, Chen et al. (1992) cited studies in various provinces that found biochemical
evidence of low serum retinal levels. Between 20-40% of preschool children had vitamin A
deficiency (VAD).
A study of plasma retinol, retinol-binding protein, and beta-carotene concentrations among adults
35-64 years old in 24 provinces found low vitamin A status only in a few counties. In general
adults had adequate vitamin A status or were marginally deficient (Wang et al, 1996). Similarly,
Root et al (1999) found that only 3% of middle-aged women had VAD.
UNICEF sponsored a Ministry of Health (MOH, MCH Department) survey of about 600
preschool age children in each of 17 provinces starting in December 1999. Serum retinol was
analyzed at the Capital Institute of Pediatrics (CIP) using a fluorometric method. Table 1
summarizes the preliminary results with rural and urban combined. It can be assumed that the
rural prevalence is slightly higher than this combined one. For example, for Qinghai, 11.2% of
urban children had VAD compared to 20.6% of rural children and the average was 17.5%.
Table 1. Proportion of preschool children with VAD (serum retinol concentrations <20
mcg/dL), by province, in 1999-2000 (preliminary, unpublished data)
Province
Percent < 20 mcg/dL serum retinol
Quinghai
18
Beijing
5
Xinjiang
18
Nei Mongol
18
Jilin
7
Gansu
39
Yunnan
16
Guizhou
18
Shaanxi
4
Sichuan
6
The survey found that VAD was most common in infants below six months of age, something
not seen in many other countries. VAD declined steadily in prevalence with increased age. It
should be noted from the prevalence rates in Table 1 that around 4-5% of a well-nourished
population can be expected to have a serum retinol concentrations below 20 mcg/dL in a crosssectional study, and that in this survey, the possible retinol-lowering effect of infection was not
controlled for.
Henan Province
In Henan, a province-wide survey was conducted in 1993, including 500 children 6-59 months of
age in 8 rural counties and 189 children in Zhenzhou City. The prevalence of mild VAD (serum
retinol <20 mcg/dL) in rural areas was 33% and prevalence of severe VAD was 3% (<10
mcg/dL). The respective urban values were 13% for mild VAD and 1% severe VAD.
During the Team’s field visit, most health workers in the county said they did not see any
patients with clinical signs of VAD or complaining of night blindness. The only ophthalmologist
interviewed was in one of the townships and she saw about five cases of night blindness and one
case with clinical eye signs per year. These were all children from poor families and were usually
malnourished. This is of course not enough evidence to judge whether VAD is a public health
problem in this area.
Guizhou Province
According to the preliminary findings of the 1999 MOH survey, 18 % of preschool children were
VAD based on the two counties that were sampled (N=600). In field visits, the Team found that
on rare occasion night blindness was seen in young children and women, but usually only in
special cases, for example, in children from families with social problems.
Causes of vitamin A deficiency
Known causes worldwide
Many factors, particularly acute infection, influence vitamin A status, but the major cause is poor
dietary intake of vitamin A. Animal sources are more bioavailable but rarely available to people
living in rural areas. The bioavailability of vitamin A in plant sources is influenced by how they
are prepared and cooked. High heat and exposure to the sun destroy vitamin A so it is
recommended that vegetables be cooked minimally and immediately before serving and that
foods should be dried in shade rather than in direct sunlight. In addition, a source of fat
consumed with plant sources of vitamin A can improve absorption. Fats are rarely used by the
poor, but addition of a small amount would help, so there is room for communication for
behavior change. The absorption of vitamin A from green leaves and orange fruits and vegetables
may be reduced among young children with ascaris (roundworm) infestation, and this is said to
be common in many rural areas.
Contributing to poor intakes of vitamin A are poor feeding practices in children (delayed
initiation and non-exclusive breastfeeding, use of unhygienic complementary foods with low
nutritional value, and discontinuation of breastfeeding before 2 years of age). When other foods
are given in addition to breastmilk during the first half-year, the breastfed infant sucks less at the
breast and breastmilk production declines. Indeed, foods and fluids, even water, replace
breastmilk and can damage the lining of the gut, increasing the ability of pathogens to enter the
body or resulting in malabsorption of micronutrients.
Also contributing to poor dietary intake of vitamin A are cultural taboos and food preferences
that prevent people from consuming rich sources of vitamin A, and lack of awareness about the
importance of consuming vitamin A.
Evidence for poor dietary intakes of vitamin A
In surveys of children under five in 101 relatively poor counties throughout the country
(N=81,000), Zai et al 1995 found that the mean daily intake of retinol increased from 169 mcg in
1990 to 180 mcg in 1993 and to 228 mcg in 1995. Despite this trend of increasing intakes of
retinol, intakes were still less than what is recommended for children-- 300-400 mcg of retinol
per day.
The third national nutrition survey, conducted in China in 1992 (Ge, et. al.), found that the retinol
equivalent intake of children 6-12 years of age was 75% of the Recommended Dietary
Allowances (RDA) among boys and 67% among girls in the urban areas and only 55% and 47%
respectively in the rural areas. Intake was similar among adolescents 13-17 years of age. The
mean retinol intake of the ‘reference man’ was 157 mcg but the retinol equivalent intake (taking
into account consumption of plant sources of vitamin A) was 476 mcg, 62% of the Chinese
RDA. A national study in 1990 found that only 20% of the vitamin A in the diet in four
provinces came from animal sources (Chen and Gao, 1993).
Middle-aged women from five areas of China were found to have low intakes of vitamin A
(county averages 13-78% of RDA). However, diet was not well correlated with plasma levels of
retinol or beta carotene so ‘intrinsic factors’ such as menopause and inflammation were thought
to be more important than diet in explaining micronutrient status (Root, et al, 1999a).
The Social Assessment conducted by Team members used a qualitative food frequency
questionnaire to determine the consumption of vitamin-A rich foods in households annually and
found that vitamin A intake was highly seasonal, which is corroborated from studies elsewhere in
the world. In the spring season there were several good sources consumed frequently but good
sources of vitamin A were not consistently available the rest of the year.
Evidence for poor infant feeding practices
According to national statistics, vitamin A status is markedly lower in infants under 6 months
than in other areas of the world. Research to date has been inadequate to know the extent to
which maternal deficiency may contribute to this. It would seem likely that inadequate
breastfeeding practices are involved. The foods and fluids commonly given to young infants in
China contain too little vitamin A. Health workers recommend starting solid foods already at four
months though WHO now recommends exclusive breastfeeding for six months. But foods and
fluids are usually added in the early weeks of life and are likely to reduce infant intakes and
stores of vitamin A and other nutrients.
Zai et al (1995) found that 14% of the infants studied were not breast fed at all and another 30%
were mixed breast and bottle-fed. Immediate and exclusive breastfeeding was not common, with
only 30% of mothers initiating breastfeeding on the first day of life and about 95% giving
sweetened water during the first week of life. For 39% of children, breastfeeding ended in the
first year of life. Interviews conducted by the Team suggested that solid foods were introduced
too late by many mothers in the previous generation. While many health professionals appear to
believe that this is still the case, on average the premature introduction of foods is now a bigger
problem. The average age for starting supplemental feeding was 2.0 months for breast milk
substitutes, 4.8 for cereals, 4.9 for eggs, 4.8 for fruit, 5.2 for vegetables, 4.2 for legumes, and 4.4
for meat. Thus the age of complementation is rather close to the one recommended by Chinese
policy. However, a 1998 study in Henan Province found that only 60% of infants 4-6 months of
age received solid foods. The biggest problem in most of the country appears to be the
widespread use of non-human milk and other fluids from an early age.
In a study of 13 poor counties in 6 provinces, Ma et al (1995) found that the most common
potentially micronutrient-rich food eaten by infants was vegetables and yet 59% at 7-9 months of
age and 47% at 10-13 months ate them less than once per month or never, suggesting that dietary
intakes are far below those needed to avoid vitamin A deficiency. The results of this study are
presented in Table 2.
Policies
There is no nutrition unit or nutrition focal point in the Ministry of Health, although the Division
for the Control of Non-Communicable Diseases is increasingly involved in efforts to prevent
micronutrient malnutrition, as described below. The Team found reference to micronutrients in
the National Plan of Action for Nutrition for China, excerpted in Annex 3. It gives the health
sector responsibility for developing “proposals, recommendations and recommendations” to
prevent micronutrient deficiencies. The food industry is asked to develop priority nutrient
fortification and universal salt iodization is advocated for. Pilot studies are called for as the basis
for promoting vitamin A supplementation among children less than three.
There is a China Nutrition Association, which has recommended a Dietary Guideline for
Children. A book with new Chinese Recommended Dietary Intakes has just been published. The
RDIs for vitamin A and iron are presented in Annex 4. In 1994, a standard similar to those used
internationally for defining VAD was established by the Chinese Pediatric Society. Subclinical
vitamin A deficiency was defined as serum retinol<0.7mumol/L (<20 mcg/dL). Clinical VAD
was
Table 2. Frequency of feeding of potentially micronutrient rich foods among infants in 13
poor counties
Age (months)
N
Type of food
% consuming it less
than once per month
7-9
306
vegetable
59
ground meat
81
fish
92
liver
97
milk powder
70
fruit
69
10-12
223
vegetable
47
ground meat
79
fish
91
liver
96
milk power
76
fruit
53
defined as serum retinol<0.35mumol/L (<10 mcg/dL) and suspected subclinical VAD was
defined as serum retinol<1.05mumol/L (<30 mcg/dL). However, otherwise there are no detailed
guidelines on how to prevent or treat VAD.
Nearly all the health professionals interviewed, including staff at the Ministry of Health, said
they thought VAD was a public health problem in China--some adding, “at least in the poor rural
areas”. UNICEF has been working to raise such awareness. Nevertheless, nutrition policies are
not developed completely, and awareness of them often is vague, particularly below national
level. There also seemed to be little awareness at national level of how unevenly the existing
policies are implemented at provincial level.
Programs
Program options used internationally for prevention and treatment of VAD include:
 food fortification;
 universal vitamin A capsule (VAC) supplementation to young children 6-59 months in
areas with a high infant mortality rate and postpartum women;
 targeted supplementation (particularly to children with certain diseases); and
 dietary improvement, often consisting of both social marketing (or some other form of
nutrition education) and support for increased household-level production of vitamin Arich foods.
(See Annex 4 for recommended intakes of vitamin A and Annex 5 for schedules and doses
for vitamin A distribution. Table 1 of Annex 5 is for so-called “universal” distribution and
Table 2 for “disease-targeted” distribution.)
Awareness
A lack of current knowledge and awareness of the availability and cost-effectiveness of vitamin
A program approaches was widespread at all levels. According to the MOH, flour in the North
and soy sauce in the South are being fortified with vitamin A, calcium and iron. The
government’s new Western Development Program includes some attention to food fortification,
nutrition education and home gardening.
Supplementation
The MOH, with support of UNICEF, began in April 2000 to provide VAC (200,000 IU twice a
year) to all children six months to three years of age in 40 poor counties (13 of which are
participating in the World Bank-supported Health VIII project). Counties decide how to conduct
the distribution, but in most cases have used the immunization infrastructure. Coverage data are
not yet available, but it is estimated to be around 80%, the kind of high coverage rate that is
necessary to reduce risk of vitamin A deficiency-related mortality. This approach is in line in line
with international praxis. Consideration is being given in these 40 counties to providing women
with VAC postpartum when their infant is given a BCG vaccination. China is now producing its
own vitamin A capsules, avoiding difficulties with importing it.
Treatment
Disease-targeted use of vitamin A does not seem to be practiced but openness and interest in
exploring it as an option was widespread among those interviewed. The most dangerous disease
in this context, measles, seems to have been conquered in most areas through vaccination,
including in the areas the Team visited. However, several other conditions can be targeted using
this approach, and it would then provide vitamin A to a large proportion of seriously ill children
brought to health centers. (See Annex 5, Table 2.)
The cases of VAD found in the areas the Team visited were given capsules containing 4500 IU
of vitamin A (combined with vitamin D) daily for about one week and another week's treatment
was given if there was no improvement.
When asked how vitamin A deficiency was treated with traditional Chinese medicine, the
response was that it was not, and cases were referred to health providers.
Deworming
Many individual families obtain deworming medicines from health workers, and effective
preparations are widely available at reasonable cost. Routine mass deworming of school-age
children is practiced in some areas.
Dietary Advice
In theory, dietary advice is given through the health services to prevent vitamin A deficiency.
Eggs were thought to be particularly valuable to promote for this purpose, as production has been
increasing and prices going down.
In the interviews conducted, there appeared to be little knowledge of fortification as an option for
improving vitamin A intake and little interest in fortification was expressed. It was not thought to
be a useful way to reach the poor and there was concern that any small changes it made in food
quality or appearance would make the food unacceptable to consumers. However, beliefs about
food fortification may be different in areas where food already is reportedly being fortified with
vitamin A.
Infant feeding
The Baby Friendly Hospital Initiative (BFHI) was introduced in China in the early 1990s,
providing health workers with better training on breastfeeding and improving hospital routines.
This is generally thought to have improved early feeding practices somewhat in recent years.
However, in other countries, substantial additional community-based efforts have proven to be
required to increase levels of exclusive breastfeeding beyond the first couple weeks of life and
mother support groups or community counseling did not appear to be active where the Team
visited. There is also evidence that BFHI is declining in China and many hospitals are reverting
to industry-supported practices such as giving free samples of infant formula to all mothers.
Decreasing rates of undernutrition must mean that infant feeding has improved in the past several
decades; however, based on the food frequency information collected, infant feeding of vitamin
A-rich foods is not widely promoted.
Critique of current approaches
Awareness
Although there was a lack of knowledge about the extent of VAD and cost-effective programs to
address it, widespread and apparently growing awareness of the problem of VAD has created a
climate in which it may be possible to discuss current policies and programs and if necessary test
and implement modified approaches.
During interviews, it was often emphasized that attention to VAD might have to wait, however,
as government was concentrating first on efforts to reduce mortality. Thus awareness of research
showing that elimination of mild-moderate VAD will reduce young child mortality by 23%
(Beaton, 1993) may not be widespread (nor of the preliminary findings from Nepal [West, et al,
1999] of a 44% reduction in maternal mortality by supplementing women before and during
pregnancy with VA).
Vitamin A supplementation
While the level of coverage in the first round of VAC distribution in the UNICEF supported
MOH project may have reached the high level needed to have a public health impact (80% of
children receiving 2 doses of vitamin A/year), doubt was expressed to us that such a high level
can be maintained for many years. However, in order to further reduce infant and child mortality,
vitamin A supplementation is needed in young children where vitamin A deficiency is prevalent.
As is commonly done, infants less than six months are excluded from the UNICEF program and
other interventions are needed to reach this group. The major interventions for this age group
would be to supplement postpartum women with vitamin A and ensure that infants are
exclusively breastfeed to six months.
Treatment
In China 5,000 IU vitamin A capsules (VAC) and 25,000 IU capsules are available for cases of
VAD. However, they may not be widely available at present in the rural areas. The Team only
found it available in lower dosages, together with vitamin D. This limits the amount of vitamin A
that can be given for treatment of VAD, since in large doses vitamin D is the more toxic of the
two. The approach of treating VAD by giving a small daily dose for a week and then repeating
this if there is no improvement (It is difficult to imagine how the health worker knows this, since
blood testing is not done.) is not consistent with the internationally recommended approach
(200,000 IU immediately, repeated the next day and again one-two weeks later). It will not build
up the child's liver stores and risks a rapid relapse, with possible risk of permanent blindness or
mortality linked to VAD. It is not recommended that high dose vitamin A be made available on
the open market, as it is potentially toxic when used incorrectly, but it could be added to the
essential drugs available to primary health care workers.
Deworming
As a public health measure, the low-cost, safe and effective procedure of deworming is now
being implemented in school-age children under some projects in China. This is perhaps
logistically simpler for this age group than for preschool children. However, the preschool age
group tends to have more severe levels of infection with ascaris, toddlers tend to contribute
toward spreading it before they are able to defecate in sanitary places, and younger children are
also the ones in whom the combination of severe illness and mild VAD is most common and can
lead to death. Thus routine deworming of preschool children in areas where ascaris is prevalent,
though logistically more difficult, would probably be cost-effective, along with continued efforts
to improve sanitation and hygiene. However, since there is little experience with it, pilot testing
might be needed. Most helminth control programs are associated with controlling hookworm and
schistosomes which cause anemia, but these helminths are not prevalent in preschool children.
Dietary advice
Infant feeding
Nearly all the health professionals interviewed named the late addition of solid foods as the
major problem with infant feeding. However, as can be seen from the section above on infant
feeding, the age of introduction of solid foods, though it may have been a problem in earlier
years, was at most a problem for a small minority of children by 1995. Little awareness or
concern was expressed about the nearly total lack of exclusive breastfeeding that the figures
above (and those of other studies) reveal except in Guizhou. (More recent official statistics may
be misleading, as pressure to achieve baby-friendliness in hospitals may lead to over-optimistic
reporting. And in rural areas few babies are born in hospitals anyway: in the areas visited, project
efforts tend to have increased the proportion of women delivering in hospitals from about 1520% at baseline to about 25-35%.) Again there seemed to be lack of awareness of findings from
other countries on this matter.
There was also little awareness of international research on the age of introduction of solid foods
that almost unanimously shows no advantage of adding solid foods before six months of age. Zai
et al (1995) found no consistent trend in age of initiation of milk and solid foods from 1990-95 in
community-based surveys in poorer counties.
While most children are receiving foods other than breast milk by six months there still may be
problems with adequate quality, including vitamin A content, and the amounts of foods
introduced. As shown in Table 2, the majority of children 7-12 months were not regularly
consuming animal foods, fruits and vegetables. While it might not be possible for families to
increase the consumption of animal products, health workers should be given training and
messages to deliver to mothers that can help them optimize the resources they do have and to
feed their children with adequate amounts of food and micronutrients. Proper cooking and
processing techniques such as mitigating exposure of fruits and vegetables to high heat and
sunlight, giving small amounts of oils and fats to young children at each meal, consuming
vitamin A-fortified foods, if they are available, etc. could improve the vitamin A status of young
children if mothers are made more aware. Pregnant and lactating women should also be
counseled to improve their diet and consume good sources of vitamin A. Other family members
should be counseled to support better intakes of vitamin A in both young children and women.
Iron
Prevalence
Findings are presented where available for the national provincial, county and township levels.
National and regional levels
In 1980, in 8 provinces, 40% of children under 7 had Hb<11, peaking at over 80% from 6-12
months of age. Thirty-six per cent of pregnant women were anemic (Van, 1991). Other studies in
1980-82 of children under seven years old found that 40-50% were anemic (Zhang, 1985). Liao
et al (1983) found that anemia levels were higher among infants under 12 months than among
children 1-3 years of age.
Zai, et al 1995 found the anemia levels reported below in Table 3. Henan Province is included for
comparison.
Table 3. Mean hemoglobin and percent with anemia in children under five in 101 poor
counties.
Mean Hb
%< Hb 11g/dL
Area
(g/dL)
1990
1993
1995
1990
1993
1995
Henan
11.3
12.0
12.0
39
21
19
Province
Total 101
11.4
12.0
12.1
38
21
19
Counties
The results from the national nutrition survey (Ge et al, 1992) are presented in Table 4. Again,
Henan is included for comparison. Nationally, anemia levels were similar between rural and
urban areas.
Table 4. Percent of children, men and women with anemia according to WHO criteria in
the National Nutrition Survey, 1992
Area
Children 0-6 yrs Children 6-14
Adult men
Adult women
yrs
Henan Province
20.3
16.1
20.3
19.9
China (national)
14.5
17.2
14.6
22.7
A study conducted in 1991-3 among 7374 children 3-72 months old in 8 provinces (Wang et al,
undated) found an average rate of anemia of 39% in the South and 16% in the North. The highest
levels (51%) were found among those 6-12 months of age.
A subsample of the nutrition surveillance data (which started in 1997) was analyzed for Hb in
2416 preschool children from 6 sites. Overall the anemia rate was 17%, but it was 31% among
children 6-12 months old (Jia and Fu, 2000).
The fourth national school physical examination and fitness survey was conducted in 1995.
Results for anemia (Hb<12) are presented in Table 5, combined rural and urban (Department of
Health and Fitness of Chinese Students, 1995). These reflect a reduction since 1991 when the
prevalence varied from 24-42%.
Table 5. Proportion of school children with Hb<12 by age and sex from the national school
physical examination and fitness survey, 1995
Age (years)
Boys
Girls
% Hb < 12
% Hb < 12
7
31
32
9
27
28
12
20
21
14
28
21
17
16
21
Among school children 13-15 years old in Shanghai, anemia rates were 16% for boys and 35%
for girls. Prevalence was 49% in those identified as “picky eaters” compared to 22% for the
others (Wen, 1997).
An anemia survey was conducted in early 2000 in a city and two counties in each of 15
provinces. Hemocue tests were used to measure the Hb, but may have given misleading results in
the northern provinces, as it is too cold to use this technology, even indoors, at that time of year
in poorer areas. (The timing for when the read-out is shown cannot compensate for the slowness
at which the necessary chemical reactions take place.) Preliminary results available so far are
presented in Table 6.
Table 6. Preliminary data on proportion of women and young children with Hb<11, by
province, 2000
Province
Children < 3 years of age
Mothers
Gansu
Ningxia
Qinghai
Xinjiang
Guizhou
18
12
22
38
32
15
7
20
24
44
Provincial level
According to a survey reported in 1985 (but perhaps conducted in 1979) on 1200 children under
seven years old in two counties in Henan Province, 51% in the city and 69% in the rural area had
anemia. The mountainous area was more severely affected than the lowland area. Table 7
presents the results of a 1989 survey in two other counties in the province.
Table 7. Proportions with anemia and iron deficiency anemia (IDA) in two counties in Henan Province, 1989
Group
infant 3-12 mon
children 1-3 yrs
children 3-5 yrs
school children
non-preg women
preg 1st trimester
preg 2nd trimester
preg 3rd trimester
lactating women
post-mena.
women
men
N
83
47
44
109
205
44
95
71
74
78
Mean Hb
11.6
11.9
12.6
12.7
13.1
12.8
12.5
12.1
12.8
13.3
% with anemia
72
51
35
42
34
48
37
66
55
27
% with IDA
30
19
16
20
17
14
18
20
16
20
80
15.7
23
10
With the help of Dr. Ma Baojing, the Team noted the results from a random series of recent
records of pregnant women who attended antenatal care at two township hospitals visited. In the
first one, the first attendance occurred relatively early in pregnancy: in 17 of 22 cases by the 12th
week of pregnancy, and in some as early as the 8th or 9th week. In the second one, women
tended to make the first visit to the family planning center, and 16 of 30 cases made the first
hospital visit at the 15th week or later, many at the 26-28th week. In the first hospital, the
average Hb for the 17 for whom results were recorded was 11.3. Many are recorded as 11, so
only 3 were below that. None received iron, including one with an Hb of 9 at 14 weeks; nor did
she receive iron at 35 weeks when she was found to have an Hb of 7.5. The other hospital had a
mean Hb of 11.4 for 28 measurements. The two women who had Hb<10 had received iron but
none of the other three cases with Hb below 11 had received iron.
County
Xichuan County began a new approach this year to combat anemia among children. Annually all
children <7 years of age are to be surveyed by taking a sample of capillary blood. The first such
survey had been started in June. (The method used is not considered completely reliable and may
slightly underestimate the extent of anemia.) However, so far the counties do not appear to have
the capacity to implement this approach. The Team estimated that at the rate they were going it
would take ten years to cover all the villages.
Township
In Siwan Township, 1098 children had been tested and anemia (Hb<11) was found in 35.6%. In
Xianghua, 31.3% of the 138 tested were anemic. Most of the anemia was mild and the age range
with the greatest prevalence was 6-24 months.
It was not possible to identify local studies on IDA in Guizhou Province. However, levels of
anemia revealed in records of the hospitals visited made it appear to be somewhat worse than
Henan Province.
Causes of anemia and iron deficiency
Known causes worldwide
Anemia is caused by two major factors worldwide. Iron deficiency is the main cause and is due
to poor dietary intake and blood loss due to helminth infections (e.g., hookworm, schistosomes),
heavy blood loss during menstruation and delivery. In endemic areas, anemia also is caused by
malaria (usually that caused by falciparum) in young children and women in their first
pregnancies. In some areas genetically-linked anemia is a cause but the significance of this is not
high.
Dietary intake of iron is usually low in developing countries because sources of bioavailable iron
from animal products is not affordable by most people. While many plants have adequate
amounts of iron, this iron is generally not readily absorbable because of the presence of
substances that inhibit the absorption of this iron. Tea and coffee consumption can also inhibit
the absorption of iron. Contributing to poor dietary intakes of iron are poor feeding practices in
children. Many children are born with low stores of iron because their mothers are iron deficient
before and during pregnancy due to their own high requirements for iron and poor dietary intake.
Infants during their first six months of life depend on the iron from their own stores and that in
breastmilk to supply them with enough iron during that period. Non-exclusive breastfeeding
decreases an important source of iron during the first six months. Late introduction of
complementary foods and inadequate quantities of iron in foods when they are introduced also
are important reasons for iron deficiency and the anemia associated with it.
Iron deficiency and other nutritional deficiencies
Ma et al (1983) found that about half of anemia in infants under 6 months in Shanghai and
virtually all that seen from 6-24 months was due to iron deficiency. Wang et al (1986) found that
Hb levels among anemic children < 3 years of age in Beijing increased when they were given
iron-fortified drinks, suggesting that iron deficiency was responsible. In the 1985 Henan Province
survey, nearly 80% of the anemia was due to iron deficiency (based on two indicators of IDA).
As can be seen from Table 7, a much smaller proportion of the anemia in the 1989 survey
seemed to be due to iron deficiency. In the latter half of the 1980s, levels of iron deficiency
anemia were reported to be about 35% among children under 7 years of age, 43% among school
children, and 35% among pregnant women (Chen et al, 1992). In one of the studies cited, bone
marrow biopsy confirmed 36% iron deficiency anemia in pregnant women. Wang et al (undated)
found that 83% of young child anemia was due to iron deficiency. Wang et al (1999) found that
the majority of anemia among women 14-49 years old was the “iron deficiency type”. Du et al
(2000) estimate that 85%-95% of anemia in China is due to iron deficiency. Li et al (1993) also
found that most of the anemia in Beijing female cotton mill workers was due to iron deficiency.
However, Ronnenberg et al (2000) found that, although 80% of a group of women textile
workers in Anqing were anemic (60% with Hb 10-12, and 20% with Hb<10), only 17% had
depleted iron stores based on serum ferritin concentrations < 12 μg/dl and only 11% based on
elevated serum transferritin receptor concentrations. (However, others may have used a higher
cut-off point to define iron deficiency. For example, Wang et al (undated) used 16μg/dl.)
Other types of nutritional anemias do occur in China. Among female textile workers in Anqing
(Ronnenberg et al, 2000) 23% had biochemical evidence of folic acid deficiency, 26% were
deficient in vitamin B6 and 10% had low vitamin B12; 44% had at least one of these deficiencies.
However, these types of anemia are not likely to be detected or prevented at most levels of the
health care system. One hospital the Team visited looked for macrocytic anemia in cases that
failed to respond to iron and saw perhaps 20 cases a year. In one hospital they said they do not
give folic acid unless the anemia is severe and in one town ship hospital they said they did not
really know really what macrocytic anemia was and did not know how to examine blood for
macrocytes.
Dietary intake
The Chinese RDA for iron is 10 mg for children under 7 years of age, 12mg for adult men and
women over 45, and 18mg for women 18-45 years of age (Chinese Nutrition Society, 1990).
However, the US National Institute of Health states that iron intakes need to be twice as high for
vegetarians, which poor Chinese people are for most of the year.
Wang et al (1986) found a mean iron intake among preschool children of 8.3mg per day,
compared to the Chinese RDA of 10mg for children under 7 years of age. Zai et al (1995) found
that iron intakes remained at about 9-10mg from 1990-95 in preschool children in poorer
counties, about equal to the RDA. According to the National Nutrition Survey of 1992, on a
representative sample of the population, the mean rural iron intake of adults 18-60 years was
25.2mg/day compared to the urban intake of 22.8mg. On aggregate, this represented 177% of the
RDA. Intake of vitamin C was similarly 180%. Neither varied significantly by income level.
Animal food provided 19% of total dietary energy. About 45% of males and 29% of females had
intakes below the Chinese RDA. Only about 3% of the iron was heme iron, much higher in urban
(1.3mg) than rural (0.5mg) areas. However, only about one-third of the people consumed no
heme iron during the three-day period studied (Ge et al, 1992; Du et al, 2000).
These findings for children correlate with the food frequency results of the study by Ma et al
(1995) in Table 2 which shows that the majority of children 7-12 months are not consuming an
iron-rich food daily.
Intakes of iron in urban areas seemed adequate: 22 mg/day in Jinan, 25 mg/d in Zangaui (Qu et
al, 1997) and 24mg/d in Beijing (Zhang et al, 1997). A recent survey of middle-aged women
found that intakes were 15-29 mg/day in five counties, but heme iron intake was negligible in
two of them (Root et al, 1999b).
Food intake is measured by the National Food and Nutrition Surveillance System started in 1997
at 40 sites in 26 provinces. Animal food consumption had gone up to 75.9kg/capita/year
compared with 63.4 in the Nationwide Nutritional Survey five years earlier. The average iron
consumption was 18.5 mg in the urban area and 24.0 mg. in the rural area and increased with
higher income only in the rural area (Chen, 2000).
Not only consumption of meat and fish, but also fruits and vegetables were found to enhance iron
absorption beyond the effect of their vitamin C content. However, tea, rice and bean consumption
was associated with a decline in absorption of iron from foods consumed at the same time (Du et
al, 2000).
Knowledge about IDA and the type of diet that would prevent this deficiency is poor. In one
study, less than one-third of students knew how to prevent IDA and similarly only 29% of their
parents knew which foods had high iron availability (Guan, 1995).
Infant feeding
For infants, the suboptimal feeding practices undoubtedly contribute to their high levels of
anemia. Any substance given to infants during the first half year of life is almost certain to reduce
absorption of the iron in breast milk (in part by altering the gut microflora from the lactobacilli
which, in the exclusively breast-fed infant, keeps the pH low and thus favorable to iron
absorption). In addition, the average age of introduction of non-human milk is two months, and
only a minority of mothers is likely to exclusively use iron-fortified infant formula. Cow milk has
five times the concentration of calcium as human milk does, and this can compete with iron for
absorption, reducing the absorption of iron from breast milk or any other food consumed with it.
Finally, if fluid milk rather than powered milk is given to infants, especially during the first halfyear, it can cause occult intestinal bleeding.
Parasites
In general in China nowadays it can perhaps be assumed that the majority of anemia is due to
iron deficiency, because malaria and schistosomiasis are coming under control and genetic causes
of anemia (e.g., thalassemia) are rare. Many people in the rural areas still lack clean water and
sanitary facilities, and hookworm can still be a partial cause of anemia in some areas, though
school deworming may be reducing the loads. On the whole, Du et al (2000) believe that
infectious and parasitic diseases are not likely causes of IDA in China.
Contraception
The use of contraceptive pills can reduce overall menstrual blood loss in women of childbearing
age, and the use of an IUD can increase blood loss if they improperly inserted. In Beijing cotton
mill workers, IUD use was not found to increase the incidence of anemia, but increased severity
in those who had it (Li et al, 1993).
Policies
In 1986, the Ministry of Health issued guidelines for the treatment of four childhood diseases. A
translated version of the protocol for iron deficiency anemia is included as Annex 6. There is no
similar policy for adults.
In 1992, the MOH, National Education Committee and the National Patriotic Health Campaign
announced a multiple intervention for anemia in school children. In 1997, an Action Plan on
Improvement and Intervention was announced. One goal was to reduce IDA by 1/3 of 1990
levels.
The ministries of health and education have asked the provinces to address five public health
problems in school children, one of which is anemia and one, helminthiasis. Regarding anemia,
the school nurse is supposed to look for clinical signs and refer suspected cases.
Programs
Special flour fortified with iron is available in Beijing. Fortification of soy sauce with iron EDTA
is being tested. Earlier, fortified infant cereal (Li et al, 1988) and rusks (Liu et al, 1993) have
been found to be efficacious, as was a soft drink powder with iron and vitamin C (Chen et al,
1992) but these are available only in urban areas.
In recent years, treatment methods for anemia, in Beijing at least, have changed, as
experimentation at CIP showed that lower doses were equally effective and gave fewer side
effects. Currently, pregnant women receive ferrous sulfate at the level of 2mg elemental
iron/kg/wk (100-120 mg/week) for 12 weeks along with 100mg vitamin C and 250-400g folic
acid. For children, 1mg/kg/day may be given, or 2mg/kg/wk, in either case for 12 weeks. Hb is
tested at 2, 4 and 8 weeks to ensure response. For prevention, 1mg/kg/wk may be given for 9-12
weeks per year.
Deworming seems to be routine (usually once or twice a year for younger children and once
every two or three years for older children) in many schools using a single 400mg dose of
mebendazole.
Henan and Guizhou
In Henan, the apparent decline in anemia between the two surveys in 1985 (1979?) and 1989 was
thought to be due to the provincial health service's response in strongly promoting health
education in response to the results of the first one.
An anemia project is being conducted in four counties in Guizhou, one of the worst affected
provinces, funded by the World Food Programme. All children below five are screened and iron
is provided to all with Hb<11 and deworming for all children.
Similar approaches were being used in both areas visited in both provinces. Health workers gave
dietary advice to patients with Hb 9-11 to eat more green leaves, eggs and meat. However, no
one mentioned the concept of retesting a person one month after giving the dietary advice in
order to give them iron if they had not improved.
Cases with obvious pallor or relevant symptoms are referred for Hb testing where possible.
Where this is not possible, anemia is assumed and treatment is given. It is usually the village
doctor who decides whether to use modern or traditional treatment. Their initial training is
apparently the main factor influencing this decision. For those who use a more balanced
approach, acute health problems are usually treated with modern medicine and chronic ones with
traditional treatments. Sometimes patients are asked which type of treatment they prefer. Poor
ones are more likely guided toward iron, since it is cheaper. There do not appear to be clear
protocols to treat or prevent iron deficiency, and since anemia is usually chronic in nature, it is
likely that most receive traditional treatment.
When iron treatment is chosen, it usually lasts only a few days and is rarely followed up on. One
village doctor said she gave tablets for only 1-3 days for pallor, weakness and dizziness. If
severe, she may give vitamin B12 as well, sometimes even by injection, but although trained
about it, she had forgotten about folic acid. Treatment for those with Hb<9 utilized versions of
the treatment regime prescribed in the MOH policy of 1986 (Annex 6) and described in more
detail in an old medical text book which now apparently has been superseded. Adults received
300mg ferrous sulfate/kg/day in one hospital and three 300mg tablets per day in others and also
from the village doctors when they treat anemia with iron. (See the discussion of traditional
medical treatment for anemia below.) Children with Hb<9 were treated with 6mg/kg/day with
crumbled tablets. In theory, all were provided with a 5-7 day supply. In practice, the village
doctors said they gave 3-5 days' worth. Patients are asked to return to receive tablets for a second
week at which time compliance and side effects are to be checked and evidence of improvement
sought (but not via a blood test). All stated that a large proportion of patients do not return (in
one case, 75% did not to return). Hospitals said they tested adults again after two weeks and
continued treatment at this dosage for a month or two or until the Hb level rose above 9, at which
time dietary advice was given on the assumption that it would lead to further improvement.
However, there was never mention that follow up was provided to check on whether this actually
occurs. Health workers say that parents usually refuse to allow children to be retested.
Although the Team did not come across any research on this issue, it is claimed by health
workers that there is widespread resistance among pregnant women to taking iron tablets.
Perhaps half of them are thought to believe it may hurt the fetus. After getting a week's tablets,
perhaps only about half come back for more. Others may feel better, live too far away or are not
able to afford transport or even the tablets themselves (see costs below). Many children do not
like the taste of the iron, and it causes vomiting in some. Those who have continued trouble with
side effects or the taste of the iron tablets may be sent to the county hospital to obtain a more
expensive formulation.
Opinions vary on the importance of side effects in both groups. No doubt side effects are fairly
widespread, given the large doses used and combination with large doses of vitamin C. (Giving
vitamin C together with iron is not recommended internationally due to its effect of increasing
side effects without having much impact on iron absorption.) When people return and complain
about gastric side effects, temporary dosage reduction does not seem to be recommended. Rather
some drug for stomach pain is given. Taking iron with meals is recommended from the outset.
The 300 mg iron tablets are brown in color and sugar-coated. There did not appear to be any
awareness of the danger of young children finding and eating these tablets (although ingestion of
medications is a fairly common cause of childhood poisoning in China), and warnings about
where to store issued tablets were not given. (Admittedly the amounts given at any one time--a
maximum of about 20--are smaller than in many other countries.)
Patients themselves have to pay for iron (like virtually all aspects of health care, even most
preventive measures), but it is very cheap, compared to most other modern and traditional
treatments. The hospital pays 13 Yuan (currently 8.2 Yuan=US$1) for a 1000-tablet tin, 2 Yuan
for 100 tablets of folic acid (5mg) and 10 Yuan for 1000 tablets of vitamin C (100 mg). The
hospitals say they have a very small profit margin, which should mean that patients do not pay
much more than 1 Yuan per week for the standard treatment. The Team was informed that the
treatment cost “less than 10 Yuan” to the patients.
However, many patients receive traditional Chinese medicine instead, which is more expensive.
One treatment consisted of four different herbs and roots plus dried donkey skin, cost 5 Yuan per
day, depending on how the ingredients changed over time, and would cost over 100 Yuan for an
entire treatment. The village doctor who used it said he treated perhaps 3-4 patients with
traditional medicines per month and virtually none with iron. Indeed, of 5 village doctors visited,
three had no iron in stock and the other two (one not trained in traditional medicine), said they
used about one tin (1000 tablets) a year.
Hospital usage of iron was also small, about 300-500 tablets per month, even for one hospital
that had 1000 in-patients and 40,000 outpatients per year.
Critique of the current approaches
Similar to the case of VAD, lack of attention to anemia was often explained as a result of the
need to focus on interventions that can reduce mortality. In the case of maternal mortality, it was
stated that anemia is rarely a cause--the most important one is hemorrhage. Thus the connection
between the two seems not to have occurred to policy-makers or health workers (i.e., that a
woman with a low Hb may die from even small blood loss at delivery).
Treatment of anemia
It would appear likely that most anemia perceived by health workers with training in traditional
medicine will be treated with traditional cures. Traditional practitioners do not perceive the
symptoms as being due to nutrient deficiencies, and thus the traditional medicines are not chosen
to be rich in vitamin A or iron respectively. Thus, if the treatment used--which may vary--has any
curative effect, it will be somewhat by chance.
Even when modern medical approaches are used, there seemed to be no consensus at the various
levels of the health care system as to how anemia should be treated, and the only clinical protocol
for this was for children. (See Annex 6.) Most health workers did not treat patients with a Hb of
9 g/dL, but only gave dietary advice, though some said a Hb of <10 g/dL was the cut-off point. In
one hospital we found different departments in the same hospital using different approaches for
treatment of anemia. In another hospital, none of the patient records we went through indicated
that almost none of the women who made antenatal visits had received iron; 7 of 37 had Hb<9,
but none had received iron, even those with Hb 6 or 7.
The dose of iron given in treating anemia is at the high end of what is recommended
internationally (60 mg elemental iron three times a day), and likely to cause side effects. The
model of anemia treatment used may be in part based on the largely incorrect assumption that
iron is a dangerous and/or expensive drug that should be used restrictively. (Small numbers of
individuals may have genetic susceptibility to iron overload. Parenteral iron should not be given
in highly malarious areas or where the blood supply is unsafe such as in areas with high
prevalence of HIV/AIDS, but this is not relevant for most of China. See Gillespie, 1997.)
It was commonly assumed from respondents interviewed that compliance in taking iron tablets
will be very poor over any longer period of treatment and that this explains why large doses are
given for relatively short periods of time. Perhaps a course of iron similar to a course of oral
antibiotics (three times a day for several days) is expected to lead to better compliance. Such
assumptions may be incorrect. For example, apparently compliance with taking calcium is high,
which is attributed partly to its better taste and partly to the heavy promotion it has received.
Thus the issue of compliance must be researched, including the importance of the taste and
appearance of the tablets and the importance of side effects with and without patient education
about them. Even if the educational effort required to achieve compliance with more modern
treatment and prophylactic regimes is large, it is likely to be well worth the effort. In the
meantime, it would seem unlikely that such short periods of treatment, even with large doses, are
providing the iron pregnant women need.
This model is also based on the questionable assumption that everyone in the high-risk groups
(children under seven years old and pregnant women) can be regularly blood-tested by hospitallevel personnel using cheap but reliable test methods. (School children are to be reached through
a school-based approach but the Team did not examine how well that is working.) As in many
other countries, other adults are reached only if they present with symptoms severe enough for
the health worker to decide to test them. Besides begin difficult to implement and sustain with
high coverage levels, this is an expensive approach, particularly if hospital personnel and
reagents are in short supply.
Where pregnant mothers book early, it would seem to be particularly inappropriate not to treat
those who already have Hb 9-11. The hemo-dilution of pregnancy and the growing iron
requirements of the fetus mean that these women's Hb levels will surely decline by the time they
deliver, no matter how effective any dietary advice might be.
It also is questionable, given the current trend toward considering nutrition to be a human right,
to allow large numbers of people to actually develop anemia before there is any chance of their
receiving medical attention. Even if this approach worked optimally, many people would suffer
from anemia for months at least before being discovered and effectively treated. Also this
method of treatment is very likely to result in relapses in most cases. Finally it is subject to
increased risks of unhygienic blood taking techniques and inaccuracy in Hb measurement, the
latter apparently common in some rural facilities.
In a population of 40,000 where some 20-30% of women and children are likely to be anemic,
this means that at least 5000-8000 people require treatment. About 2-3% are likely to be severely
anemic, that is 500-800 people. Since 300-500 tablets were used monthly in the hospital where
the Team obtained data (and assuming that 40 were given per patient on average), only about 100
patients in this population received treatment per month and perhaps another 100-200 received
some kind of treatment from a village doctor. Besides the question of why so few of those who
need it receive treatment is the question of how effective such treatment is--particularly the much
more expensive traditional medicine.
Dietary advice
Anemia levels appear to be improving in China, but this is probably due more to the improved
economic situation than the health sector's efforts to control the problem. In particular, as
incomes increase, the people are eating more meat (Wang et al, 2000). However, meeting the
iron needs of vulnerable groups through diet is probably unrealistic in China. It would seem
unlikely that women who have gone even below that level have access to an iron-rich diet, but
even if they do, the deficit is simply too large to overcome through diet, especially during
pregnancy, when needs are so high. Few pregnant women in the rural areas in China are likely to
have iron stores, which is preferable for those about to suffer substantial blood loss at delivery.
The quality of dietary advice given is not specific and little attempt was made to make it specific
for a given patient's needs or financial situation. Of the few parents interviewed whose children
had tested positive for anemia and they stated that they had not been able to comply with the
dietary advice they had been given. One woman had even been too busy to obtain the iron tablets
for her child; she gave the child some vegetables every day or two but had too little income to
buy animal foods. It is not known if people are encouraged to increase intakes of vitamin C at
meals to improve absorption of plant sources of iron or asked to restrict tea consumption to
between meal times. Little effort appears to have been made in China at any level to determine
the efficacy of dietary approaches, let alone effectiveness of this approach.
(Even in Western countries, middle ear infections and certain other diseases are less common in
exclusively breast-fed babies.) Currently it appears that little is being done to promote exclusive
breastfeeding in China in the first six months, which will and thus deliver optimal amounts of
iron to infants;. Women should be encourage to exclusively breastfeed until about 6 months,
which will deliver optimum amounts of iron, ensure the proper absorption of iron and other
micronutrients and decrease the absorption of pathogens, as part of the integrated strategy to
control anemia. Improving counseling to optimize the introduction of complementary foods at six
months is essential. Giving messages to encourage giving animal products to children when they
are available and discouraging giving tea to young children, if this is a practice, are also
important.
China should seriously consider reviewing the expensive and probably ineffective approaches
being used at least in the rural areas, in addition to continuing ongoing explorations of possible
partial solutions that might emerge from food fortification. While fortified soy sauce may prove
capable of making an important contribution, it cannot solve the problem for young children, as
they do not consume enough of it at the level at which it is being fortified in current testing
(Chen, 2000). Counseling and/or social marketing will be needed to ensure the use of fortified
foods as they become available is needed.
Deworming
Mebendazole is used for routine deworming, and while somewhat it is less effective against
hookworm than albendazole, it is widely available still effective and much less expensive,
therefore more cost effective in the local situation. Other groups may need to be dewormed
periodically, such as women in their second or third trimesters, to eliminate this cause of anemia.
CONCLUSIONS
The Chinese health care system has proven its remarkable capacity to solve many health
problems once the decision is made to tackle them seriously. Infant and child mortality and
morbidity rates have declined in the last several decades and are apparently continuing to decline,
as is undernutrition. While these improvements may in part be due to economic expansion and
concomitant improvement in the standard of living, the eradication or substantial reduction of
many diseases, including measles and iodine deficiency diseases, is certainly the result of direct
and targeted intervention. China can serve as example for reducing vitamin A deficiency and
particularly iron deficiency which, of the three micronutrient deficiencies (iron, iodine and
vitamin A), few countries have made progress in reducing. However, it should also be noted that
improvements have been more rapid in some areas than others and the capacity of the health
system to reach those living in poor and remote areas, particularly in Western provinces, needs
improving. Finding ways to give special attention to these areas in the next five years will be of
special challenge to the health system.
Vitamin A and iron deficiencies are public health problems in China, particularly in poor rural
areas. The major causes of vitamin A deficiency are poor dietary intakes of vitamin A and
possibly problems with malabsorption due to non-exclusive breastfeeding and certain types of
helminthes (ascaris). The major causes of iron deficiency are poor dietary intakes and loss of
blood due to helminth infections. Currently there are no consistent or monitored policies and
programs to address these deficiencies because policy makers, program implementers and civil
society lack awareness about their prevalence, causes and consequences. However, there are
currently ongoing programs and policy statements that are conducive to developing accelerated
interventions in the short and medium term to address vitamin A and iron deficiencies.
RECOMMENDATIONS
1. Because lack of awareness that vitamin A and iron deficiencies are prevalent in some areas of
the country and contribute significantly to morbidity and mortality in these areas, a major effort is
required in the area of advocacy and awareness raising in health workers, politicians, and civil
society about the causes and consequences of vitamin A and iron deficiencies. Health workers
need to trained on delivering programs to address both these deficiencies.
1.1 As part of this advocacy, disseminate widely the following three documents which have
already been translated into Chinese: 1) “Preventing Iron Deficiency in Women and Children,
Technical Consensus on Key Issues” (A UNICEF/UNU/WHO/MI Technical Workshop, 1998);
2) “Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia” by
RJ Stoltzfus and ML Dreyfuss (INACG, WHO and UNICEF, 1998); and 3) “Vitamin A
Supplements, A Guide to Their Use in the Treatment and Prevention of Vitamin A Deficiency
and Xerophthalmia” (WHO/UNICEF/IVACG Task Force, Second Edition, 1997).
1.2 Hold a national meeting on vitamin A and iron deficiencies with the mandate to recommend
changes in government policy and to produce new strategies and protocols for treating and
preventing VAD and IDA. Copies of these three documents and the present report translated into
Chinese should be provided to participants well in advance. The kind of attention that has
successfully resulted in such great progress in eliminating iodine deficiency can lead to similar
progress for IDA and VAD. Government and party leaders should be invited to the meeting, as
they can play a key role in social mobilization. Because VAD and IDA activities should be
integrated into existing program work, representatives from related programs should be invited
(e.g., immunization, parasitic diseases control, family planning, the women's federation, etc.).
1.3 Key policy makers at provincial as well as national level could be sent to international
workshops such as IVACG and INACG.
Specifically:
2. There needs to be advocacy by raising awareness about:
2.1 the strong evidence for the link between vitamin A deficiency and young child mortality and
its possible link to maternal mortality, and between iron deficiency and young child morbidity,
mortality and capacity to learn (with emphasis on the 6-24 month age group) and adult mortality
(pregnant women) and capacity to work, emphasizing evidence from a study in China that work
out of cotton mill workers decreased due to iron deficiency (Li, et al., 1994).
2.2 that cost effective approaches for preventing VAD and IDA could further reducing mortality
and improve educability and productivity in the poorer counties in the country, particularly in the
West.
3.1 A three-tiered model might be acceptable and cost-effective for preventing VAD and IDA in
China:
First tier: continue and expand with distribution of the UNICEF-sponsored VAC distribution in
the poorest counties, and assess costs and benefits after some years. This information would
guide policy development for VAD prevention on a larger scale and help target activities first to
areas where VAD is highest. However, eventually decisions will need to be made regarding the
criteria for inclusion in that component, how it will be financed, and criteria for “graduation” to
the second tier (for example, once IMR rates decline below about 60/1000 live births in all
provinces or counties).
Anemia control should focus on the two most vulnerable groups for IDA, pregnant women and
children 6-24 months by providing daily presumptive treat for anemia with iron-folate
supplements. Screening for anemia is not cost-effective or necessary and Iron-folate tablets
should be given routinely to pregnant women in China. Supplements should consist of 60 mg of
ferrous sulfate and 400 mcg. of folic acid. Even though a few studies have found an intermittent
schedule to be effective at reducing anemia (Liu, et al., 1995; Liu & Liu, 1996), a daily schedule
is still recommended for pregnant women (Beaton, et al., 1998). Supplementation should be
introduced at the first antenatal visit and should continue for at least six months in pregnancy
(Stoltzfus & Dreyfuss, 1998). In areas where antenatal visits are later in pregnancy, iron-folate
supplementation may need to continue into the postpartum period. A pilot test may be needed to
determine if compliance is a problem or not. Research from 7 developing countries found that the
main reason women did not take iron tablets was because they were not available and that when
in ample supply compliance could be ensured by giving messages about why, when, and how to
take the tablets and how to manage side effects if they should occur (Galloway, et al.,
forthcoming). Any pilot test should include indicators on logistics, record keeping, consumer and
health worker knowledge (including traditional medical workers), and compliance with the
counseling given. Some qualitative research should be included on behaviors of consumers and
health workers (taking tablets, willingness to pay, willingness/feasibility of eating vitamin C-rich
foods, demand/preference for traditional medicine, etc.).
Iron-folate tablets are not given routinely to children 6-24 months in China or for that matter,
most areas of the world—even though iron requirements are highest during this time of life and
international recommendations are to give children of this age either iron-folate
supplement/drops or foods fortified with enough iron to supply their needs. Recognition that
reaching young children with iron is essential, international recommendations advise that these
children should receive 12.5 mg iron and 50 mcg of folic acid per day. In order to refine the
recommendations for supplementing children, a pilot study may be needed. As suggested above,
any pilot test should include indicators on logistics, record keeping, consumer and health worker
knowledge (including traditional medical workers), and compliance with the counseling given.
Some qualitative research should be included on behaviors of consumers and health workers
(taking supplements, willingness to pay, willingness/feasibility of eating vitamin C-rich foods,
demand/preference for traditional medicine, etc.). Designing complementary counseling and
campaigns will be essential to sensitize families about the importance of preventing iron
deficiency to protect the mental function of young children and improve their ability to learn.
That parents want their only child to do as well in school as possible may be a big selling point.
Consideration might should also be given to providing routine deworming for preschool or
school-age children in areas where intestinal parasite infestation is expected or shown to be
ascaris (or hookworm) is common. Deworming is very inexpensive, so that may be popular
enough that even relatively poor parents would be willing to pay for it. Other groups who might
benefit from also may need deworming and iron tablets includes such as adolescent girls and
newly married women, if they can easily be reached.
3.2 Second tier: --initiate disease-targeted distribution of VAC. Like the universal VAC
distribution under UNICEF sponsorship, this could be easily pilot-tested in one or a few of the
poorest counties, examining logistical issues through the use of process indicators. International
data on the impact of vitamin A on mortality is already adequately convincing, and thus any
study of impact would be unnecessary and simply delay implementation. However, reduction in
child mortality rates can be calculated using accepted impact data from these studies: 23%
reducing in mortality when at least 80% of children 6-59 months received a semi-annual dose of
vitamin A. An awareness-raising component about the importance of vitamin A is needed, both
for health workers and civil society.
--initiate disease-targeted distribution of iron-folate tablets to those suspected of having severe
anemia. While screening for anemia in individuals is not cost effective where anemia prevalence
is high and routine supplementation is recommended for vulnerable groups, it is still prudent to
identify cases of severe anemia and this can be done by using clinical signs and treating those
suspected severe anemia accordingly (about 50-75% of severe anemia can be detected using
clinical signs). Providing additional iron and giving special follow up to these individuals is
important to avert the morbidity and mortality associated with severe anemia.
3.2.1 Hold a “review and consensus” workshop on policy development and a follow-up national
workshop to achieve consensus among relevant national and provincial experts on the doses to
provide to the various age groups for various diseases, how supplies of vitamin A and iron would
be obtained and provided to the various levels of the health care system, and on how health
workers would be trained. (Efforts are already being made to establish domestic production of
vitamin A in oil.)
3.2.2. Once agreed to, large-dose VAC and appropriate doses of iron-folate would need to be
added to the essential drug list and be made available at all levels down to the village doctor. A
large-scale training program would be necessary to train health workers on the importance of
each micronutrient, and to present the new protocol to them, including the agreed-upon criteria
for giving VAC and iron-folate, the dosages to be used, and the need for careful record-keeping
to avoid risks of excess usage and to track compliance with iron-folate supplementation. The
near universal availability of child health cards should make this relatively simple. (An example
of how disease-targeted VAC distribution was started in Tanzania is presented in Annex 7.)
Under the universal VAC procedure, VAC is always under the control of health workers and is
provided free. For disease-based distribution, it can be sold (since parents will pay for medicine
for severely ill children), but the health sector must maintain control of it so it is not sold without
prescription and misused or given in excess doses, causing toxicity. Iron-folate tablets are often
provide free of charge but there is no reason why they cannot be purchase; however, research
may be needed to determine the willingness of health clients to buy iron-folate tablets and how
much they can afford to pay.
3.2.3. Deworming should be provided, as part of disease-targeting, for all individuals with
hookworm or other anemia causing intestinal helminths.
3.3. Third tier: an improved nutrition education approach. The successful IDD educational
campaign in China used a three-pronged approach: mass media, face-to-face messages from
health workers, and school health education. IDA and VAD should receive the same kind of
attention using the same approaches. Messages need to be made more appropriate for poorer
communities, since both deficiencies are likely to be common in the vulnerable groups. Foods
could be added to the list of those recommended for preventing VAD, particularly locally
available yellow and orange fruits and vegetables. (They appear to have about twice as much
vitamin A effectiveness as green leaves.) Those that deserve more attention in the northern areas
include carrots, orange and red varieties of sweet potatoes and dark orange varieties of pumpkin.
There may be others in various parts of the country, particularly where papaya and mango are
available in the south. Papaya, carrot, pumpkin and red sweet potatoes have the additional
advantage that they can be available during much of the wintertime when green leaves are not
available. In areas were very small fish are available and acceptable as food for young children,
they might be advised as well. (The liver, which is the part of fish and meat that contains vitamin
A, is likely to be removed along with other entrails from all but the very small fish.) Green leaves
certainly deserve mention, as they often do not enjoy the status their nutritional value justifies.
Using a small amount of oil in preparing them can lead to an increase in the bioavailability of
vitamin A.
Increasing the intakes of the more bio-available forms of iron is more difficult problematic
because these foods are usually less affordable by poor families. However, when animal foods,
the richest sources of iron, are available, families should be encouraged to include them in the
diet of their young children. Even small amounts of iron at meals can significantly improve the
absorption of iron from plant sources as can including a vitamin C source with meals and advice
should be given to caregivers to give these foods to their children. Health workers could provide
a list of vitamin C rich foods that are commonly available for the season. Avoiding tea at meals
should be encouraged and cooking in iron pots, where it is practiced, should be encouraged—
albeit as small amount of iron is provided through iron cooking pots.
Because the group with the highest levels of deficiency in China is infants under six months of
age, dietary advice must emphasize the importance of immediate and exclusive breastfeeding.
Women should be encouraged to eat adequate amounts of foods rich in vitamin A and iron
during pregnancy and while lactating to make sure their infants have adequate stores and intakes
of iron and vitamin A during their first six months of life. The tendency to isolate breastfeeding
from other dietary advice (for example, only giving attention to it within the BFHI) needs to be
resisted. Breastfeeding advice also should be integrated into advice on introducing and feeding
complementary foods. Starting at about six months of age children should be introduced to
different orange, yellow and red fruits and vegetables and green leafy vegetables and animal
foods, when available, and should become an essential part of their everyday meals and/or
snacks.
Health worker training will then need to take place, followed by central production and
dissemination to all relevant health workers of materials that could assist them in this work,
including brochures and flip charts. Supporting messages through mass media and schools will
also be required. Designing an overall plan for both VAD and IDA prevention using social
marketing techniques might be the most effective approach. Some kind of capacity for
monitoring and evaluation should also be built up.
The recommendations that emerged from the workshop on January 17 are listed in Annex 8 .
ACKNOWLEDGEMENTS
We were met with the utmost hospitality and offered maximum assistance by all the officials
listed in Annex 1 and 2 at every level from national to household, and others whom we regret
may have been omitted. We particularly want to thank Madam Liu Keling, MD, Deputy Director
General, and Madam Song Lanqing, MD, Chief of the Child Health Division of the Primary
Health Care and MCH Department of the Ministry of Health. Everyone's kindness and
enthusiasm for our work made this consultancy a pleasure to conduct.
In addition, we would like to acknowledge the important technical contributions made by Ma
Baojing and Qui Huahao, both professors at Henan Medical University. Drs. Ma Guansheng and
Zhai Fengying of the Institute of Nutrition and Food Hygiene kindly shared with us their personal
expertise and various publications and Dr. Ray Yip of UNICEF gave us valuable information and
assistance, including access to preliminary findings from recent and ongoing research. There are
a number of experts on these deficiencies we were unable to meet with due to shortage of time or
their not being available during the periods when this work was done. We hope to consult with
them during follow up work.
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Annex 1. Persons met in July 2000
Beijing
Liu Keling, MD, Deputy Director General, Department of Primary Health Care and Maternal and
Child Health
Song Langin, MD, Director, Children's Unit, Department of Primary Health Care and Maternal
and Child Health
Ray Yip, MD, Senior Advisor, Health and Nutrition, UNICEF
Zhai Fengying, MD, Deputy Director, Institute of Nutrition and Food Hygiene, Chinese Academy
of Preventive Medicine
Ma Guansheng, MD, Chief, Department of Students' Nutrition, Chinese Academy of Preventive
Medicine
Yang Yan, Assoc Prof, Division of Epidemiology, Chinese Academy of Preventive Medicine
Jin Chunhua, MD, Director, Department of Child Health Care, Capital Institute of Paediatrics
II. Welcome Meeting
21 July 2000
Topics: 1. Welcome
2. Introduction to the general condition of Henan Province, Nan Yang city and Xichuan County
3. Introduce the development of Health VIII Program in Xichuang.
Participants in Xichuang County Welcome Meeting, 21 July 2000
Name
Position
Institution
Ted Greiner
Advisor of WB
Uppsala University, Sweden
Liu Yunguo
Vice Director
FLO, MOH
Yan Diying
Professor
CAPM
Jiang Jingxiang
Associate Prof.
Capital Institution of Pediatrics
Liu Xeizhou
Vice director
Health Bureau in Henan Province
Zhu Hongbiao
Director
Finance Department in Health Bureau
of Henan Province
Wu Jian
Office
Finance Department in Health Bureau of
Henan Province
Ma baojing
Professor
MCH Institute in Henan Province
Qiu Huahao
Professor
MCH Institute in Henan Province
Wei Suijun
Vice Director
Nanyang City Health Bureau
Liz Hengsheng
Vice director
Nanyang City Health Bureau
Li Yunzhen
Vice director
Nanyang City Health Bureau
Guo Changwei
Office
Nanyang City Health Bureau
Yan Diandong
Office
Nanyang City Health Bureau
Hu Jingxu
Li Guizhi
Liu Hengen
Vice Governor
Director
Office
Xichuang County
MCH Institute in Xichuang County
Xichuang County Health Bureau
III. Ciwang Township Meeting
22 July, 2000 in Ciwang Township Xichuang County
Topics: 1. Anemia and Vit A situation in the township
2. Health VIII implementation in the township
Participants in Ciwang Township Meeting, 22 July, 2000
Name
Position
Institutions
Ted Greiner
Advisor of WB
Uppsala University, Sweden
Liu Yunguo
Vice Director
FLO, MOH
Yan Diying
Professor
CAPM
Jiang Jingxiang
Associate Prof.
Capital Institution of Pediatrics
Liu Xuzhou
Vice director
Health Bureau in Henan Province
Zhu Hongbiao
Director
Finance Department in Health Bureau
of Henan Province
Wu Jian
Officer
Finance Department in Health Bureau of
Henan Province
Ma Baojing
Professor
MCH Institute in Henan Province
Qiu Huahao
Professor
MCH Institute in Henan Province
Wang Baoyun
Director
Nanyang City Health Bureau
Wei Xiuyun
Vice director
Nanyang City Health Bureau
Li Yunzhen
Vice director
Nanyang City Health Bureau
Guo Xhangwei
Officer
Nanyang City Health Bureau
Yan Diandong
Officer
Nanyang City Health Bureau
Cao Mingjie
Director
Xichuang CountyHealth Bureau
Hu Jingxu
Vice governor
Xichuang County
Li Zhengsheng
Vice director
Xichuang County Health Bureau
Liu Hengen
Officer
Xichuang county health Bureau
Li Jingxian
Officer
Xichuang county health Bureau
Li Guizhi
Director
MCH Institute in Xichuang County
Zhang Yaming
Governor
Ciwang Township
Nie Zhiguo
Vice governor
Ciwang Township
Zhao Ziyu
Director
Ciwang Township Hospital
IV. XianHua Township Meeting
23 July, 2000 in Xianhua Township Xichuang county
Topics: Introduction of Health Program implementation in the township.
Participants in Ciwang Township Meeting, 23rd July, 2000
Name
Ted Greiner
Liu Yunguo
Yan Diying
Jiang Jingxiang
Liu Xuzhou
Zhu Hongbiao
Position
Advisor of WB
Vice Director
Professor
Associate Prof.
Vice director
Director
Wu Jian
Office
Ma Baojing
Qiu Huahao
Wang Baoyun
Wei Xiuyun
Li Yunzhen
Guo Xhangwe
Yan Diandong
Hu Jingxu
Cao Mingjie
Li Zhengsheng
Li Guizhi
Li Zhenghai
Zhou Haijun
Professor
Professor
Director
Vice director
Vice director
Office
Office
Vice governor
Director
Vice director
Director
Governor
Director
Institutions
Uppsala University, Sweden
FLO, MOH
CAPM
Capital Institution of Pediatrics
Health Bureau in Henan Province
Finance Department in Health Bureau
Of Henan Province
Finance department in Health Bureau of
Henan Province
MCH Institute in Henan Province
MCH Institute in Henan Province
Nanyang City Health Bureau
Nanyang City Health Bureau
Nanyang City Health Bureau
Nanyang City Health Bureau
Nanyang City Health Bureau
Xichuang County
Xichuang CountyHealth Bureau
Xichuang County Health Bureau
MCH Institute in Xichuang County
Xianhua Township
Xianhua Township hospital
V. MCH Institute Meeting in Xichuang County
24 July, 2000 in Xichuang County
Topics: To learn about MCH condition in Xichuang
Participants in MCH Institute Meeting 24 July, 2000
Name
Position
Institutions
Ted Greiner
Advisor of WB
Uppsala University, Sweden
Liu Yunguo
Vice Director
FLO, MOH
Yan Diying
Professor
CAPM
Jiang Jingxiang
Associate Prof.
Capital Institution of Pediatrics
Zhu Hongbiao
Director
Finance Department in Health Bureau
of Henan Province
Wu Jian
Officer
Finance Department in Health Bureau of
Henan Province
Ma Baojing
Professor
MCH Institute in Henan Province
Qiu Huahao
Professor
MCH Institute in Henan Province
Wang Baoyun
Director
Nanyang City Health Bureau
Li Yunzhen
Vice director
Nanyang City Health Bureau
Guo Xhangwe
Officer
Nanyang City Health Bureau
Yan Diandong
Officer
Nanyang City Health Bureau
Li Zhengsheng
Li Guizhi
Li Guizhi
Li Guizhi
Liang Zhunzhi
Vice director
Director
Director
Director
Vice director
Xichuang County Health Bureau
MCH Institute in Xichuang County
MCH Institute in Xichuang County
MCH Institute in Xichuang County
MCH Institute in Xichuang County
VI. Feedback in Xichuang County
24 July, 2000 in Xichuang county
Topics: Feedback
Participants in Feedback Meeting in Xichuang 24th July, 2000
Name
Position
Institutions
Ted Greiner
Advisor of WB
Uppsala University, Sweden
Liu Yunguo
Vice Director
FLO, MOH
Yan Diying
Professor
CAPM
Jiang Jingxiang
Associate Prof.
Capital Institution of Pediatrics
Zhu Hongbiao
Director
Finance Department in Health Bureau
of Henan Province
Wu Jian
Officer
Finance Department in Health Bureau of
Henan Province
Ma Baojing
Professor
MCH Institute in Henan Province
Qiu Huahao
Professor
MCH Institute in Henan Province
Wang Baoyun
Director
Nanyang City Health Bureau
Li Yunzhen
Vice director
Nanyang City Health Bureau
Guo Xhangwe
Officer
Nanyang City Health Bureau
Yan Diandong
Officer
Nanyang City Health Bureau
Hu Jingxu
Vice governor
Xichunag County
Cao Mingjei
Director
Xichuang County Health Bureau
Li Zhengsheng
Vice director
Xichuang County Health Bureau
Liu Henggen
Officer
Xichuang County Health Bureau
Li Jingxan
Officer
Xichuang County Health Bureau
Su Yuqong
Officer
Xichuang County Health Bureau
Li Guizhi
Director
MCH Institute in Xichuang County
Li Guizhi
Director
MCH Institute in Xichuang County
VII. Henan Health Bureau Meeting
25 July, 2000 in Zhengzhou
Topics: Discussion on strategies of Anemia and Vit A deficient
Participants in Province Health Bureau Meeting in Zhengzhou 25th July, 2000
Name
Position
Institution
Ted Greiner
Advisor of WB
Uppsala University, Sweden
Liu Yunguo
Vice Director
FLO, MOH
Yan Diying
Jiang Jingxiang
Liu Xuezhou
Zhang Zhimin
Zhu Hongbiao
Professor
Associate Prof.
Vice Director
Director
Director
Li Hongxing
Vice director
Wu Jian
Officer
Ma Baojing
Qiu Huahao
Professor
Professor
CAPM
Capital Institution of Pediatrics
Health Bureau of Henan Province
MCH & Basic Health Department of Henan Health Bureau
Finance Department in Health Bureau
of Henan Province
Finance Department in Health Bureau of
Henan Province
Finance Department in Health Bureau of
Henan Province
MCH Institute in Henan Province
MCH Institute in Henan Province
Annex 2. Persons met in January, 2001
8 Jan, Guiyang
Dr. Ted Advisor
Liu yungo: director of FLO
Yan Di Ying: Professor from CAPM
Jangjingxiong: Associate Professor form Pediatric Institution of Beijing
Xujingju: Director of FLO in GuiZhou Province
Lijiahu: Director of Health Bureau in Guizhou Province
Luo Zhi Xiong: Director of PHC in Guizhou Province
Jiang Xi: Officer of FLO in GuiZhou Provinc
10 Jan, Shuan san Township Hospital Meeting
Dr. Ted Advisor
Liu yungo: Director of FLO
Yan Di Ying: Professor from CAPM
Jangjingxiong: Associate Professor form Pediatric Institution of Beijing
Xujingju: Director of FLO in GuiZhou Province
Lijiahu: Director of Health Bureau in Guizhou Province
Luo Zhi Xiong: Director of PHC in Guizhou Province
Xujingju: Director of FLO in GuiZhou Province
Jiang Xi: Officer of FLO in GuiZhou Provinc
Yan JiaSheng: Director of MCH of Guizhou
Zhangjipei: Vice Governor of Dafang County
Liyuqin: Vice Director of health Bureau of Dafang County
Shanyanli : Director of MCH of Dafang County
Mao Keyong: Officer of Health Bureau of Dafang County
Zhujinglun: Officer of Health Bureau of Dafang County, health VIII Program
Zhang Jirong: Accountant of Health Bureau in Dafang County
Lisong: Director of pediatric in County Hospital
ChengjingVice Governor in Shang San Township
Zaoxinjin: Director of Shang San Township Hospital
Wang Wanli: Director of Ru long Township Hospital
Huang Yulong: Traditional Doctor
Gao Xiangxu: Officer of County Health Bureau , Health VIII Program
Ming Sichang: Accountant, Shang San Township Hospital
10 Jan, County Meeting
Dr. Ted Advisor
Liu Yungo: Director of FLO
Yan Di Ying: Professor from CAPM
Jangjingxiong: Associate Professor form Pediatric Institution of Beijing
Xujingju: Director of FLO in GuiZhou Province
JiangXi :Offcer of Health VIII Program Office in Guizhou Province
Yanjiasheng: Director of MCH in Guizhou Province
Zhen ji pei: Vice governor
Zhu jinlunOfficer of County Office
Li yuqinVice Director of Health Bureau in Dafang County
Wushuhua: Director of Education Bureau in Dafang County
Zhujianming: Officer of Health Bureau in Dafang County
GaoKeHuoOfficer of Health VIII Program Office in Dafang County
Maokeyong: Officer of Health Bureau in Dafang County
Liujiazhi: Director Of MCH in Dafang County
Hu kelan:Director of County Hospital in Dafang County
Wumingzhu: Vice Director of County Hospital in Dafang County
Yangyongsong: Vice Director of County Hospital in Dafang County
FuGuanghau: Officer of County Hospital in Dafang County
Lisong: Director of Pediatric of County Hospital in Dafang County
Deng zhengmin: Director of MCH of County Hospital in Dafang County
Yangcaiping: Nurse head of County Hospital in Dafang County
Chen de xin: Director of EPS in Dafang County
Chenzhiyu: Vice Director of Tradition Medicine Hospital in Dafang Count
Lu guoli: Officer of Tradition Medicine Hospital in Dafang County
Jiangzhongyun: Manager of pharmacy company , traditional medicine
Xiemingdong: Offer of pharmacy company, traditional medicine
CaowenxueCounty pharmacy company
GaoXiangxu Director of Shuan san Township hospital
Jiangshouzhong: Director of Jichang Hospital
Yangfajun: Director of Ma Chang Hospital
Zhang Zaixun: Guowa Hospital
Chen Hongzhao: Guowa Hospital
Zhao Liejun :Director of Jichang Hospital
11 Jan Liulong Township
He zhilin: Leader in Liulong Township
Luo Yubi: Governor in Liulong Township
Xu Ning: Education station in Liulong Townshi
Wang Wanlin: Director of Liulong Township Hospital
Huang Yulong: Doctor in Liulong Township Hospital
Li Qin: Head of prevention Department in Liulong Township
Chen Yongde: Doctor in Liulong Township Hospital
Xiong Denghu: Accountant in Liulong Township Hospital
San Yanli: Director of MCH in Dafang County
Huang Caifu: Doctor in MCH in Dafang County
Zhu Youngli: Doctor in MCH in Dafang County
Zhang Jirong: Economic worker in Dafang County
Maokeyong: Officer in Health Bureau in Dafang County
Li yuqin: Vice director of Health Bureau in Dafang County
Dr. Ted Advisor
Liu yungo: director of FLO
Yan Di Ying: Professor from CAPM
Jangjingxiong: Associate Professor form Pediatric Institution of Beijing
Xujingju: Director of FLO in GuiZhou Province
JiangXi :Offcer of Health VIII Program Office in Guizhou Province
Yanjiasheng: Director of MCH in Guizhou Province
11 Jan Chang Bu Village of Liu long Township
He mingxiu: Village doctor
Wang shi: Villager
Li shi: Villager
Annex 3. China’s policy statement regarding Micronutrient Malnutrition
"The National Plan of Action for Nutrition for China", a Document of the General Office of the
State Council, GBF(1997)45 , December5, 1997, was formulated by the following agencies:
Ministry of Health, State Planning Commission, State Science and Technology Commission,
State Education Commission, Ministry of Civil Administration, Ministry of Finance, Ministry of
Agriculture, Ministry of Internal Trade, Office of the Leading Group on Poverty Alleviation and
Development of the State Council, China Council of Light Industry, and the All China Women's
Federation.
The Plan of Action was formulated based on the commitment of the Government to the "World
Declaration on Nutrition" and the "Plan of Action of Nutrition" that were adopted at the
International Conference on Nutrition (ICN), a conference with ministerial level participation in
1992. Section 23, Prevent Micronutrient Deficiencies. states: “23.1 Taking micronutrient
deficiency situation in the community into account, the health sector is to develop proposals,
measures and recommendations. 23.2 Formulate a program for control of micronutrient
deficiencies. 23.3 Implement the program for universal salt iodization 23.4 To meet the demand
of the consumer, food industry shall develop priority nutrient fortified food and cereal products.
To advocate growing micronutrient-rich vegetables in home gardens. 23.5 Based on the
experiences of pilot sites, the health sector is to promote the supplementation of vitamin A
among children aged under three. 23.6 The prevention of rickets among children is to be
strengthened.”
Annex 4. Chinese Recommended Daily “Adequate” Intakes of Vitamin A and Iron,
published in 2000
Vitamin A
Age (years)
Quantity (IU)
0-1
400
1-4
500
4-7
600
7-14
700
>14
800
pregnant,
2-3 trimester
900
lactating
1200
Iron
Age (years)
Quantity (mg)
0-.5
0.3
5.-1
10
1-11
12
11-14
male
female
16
18
14-18
male
female
20
25
18-50
male
female
15
20
>50
15
pregnancy
2nd trimester
3rd trimester
25
35
lactation
25
Annex 5. Vitamin A Capsule Schedules
Table 1. High-dose universal distribution schedule for prevention of vitamin A deficiency
Target group
Infants <6 months
Dose of oral vitamin A
50,000 IU
Infants 6-12 months
100,000 IU every 4-6 months
Children > 12 months
200,000 IU every 4-6 months
Motheres
200,000 IU within 8 weeks of delivery
Table 2. High-dose prevention schedule for children at high risk* of vitamin A deficiency
Target group
Infants <6 months
Infants 6-12 months
Children >12 months
Dose of oral vitamin A**
50 000 IU
100 000 IU
200 000 IU
*High-risk children are those with measles, diarrhea, respiratory disease, chickenpox, other
severe infections, or severe protein-energy malnutrition, or who live in the vicinity of children
with clinical vitamin A deficiency (further refinement of these categories should be made,
according to local conditions)
**Those known to have received a high-dose vitamin A supplement within the last 30 days
should not receive an additional dose unless they have clinical signs of vitamin A deficiency.
Clinical signs of VAD should be treated with three doses of vitamin A: one immediately, one
the next day, and a third dose one-two weeks later.
Annex 6. Guidelines for Intervention Programs for Childhood, Iron Deficiency Anemia
May 25, 1986 Ministry of Health
1. Prevention
1) Health education about breastfeeding and the knowledge of anemia to target population.
2) Dietary advance to pregnant and lactating mothers.
3) Breastfeeding for the young infants under 4 months.
4) After 4 months old, the infants should be given solid foods rich in iron and iron-fortified
infant foods.
5) Total iron intake of children should be 1mg/kg/day and should be less than 15mg/day.
2. Diagnosis
1) Hb<11g/dl (in all hospitals).
2) Counting the RBC number and observing the RBC shape (in township hospitals).
3) If possible, testing serum iron, FEP and SF (in county hospitals).
4) Degree of anemia
Mild: Hb 9-11g/dl, moderate: Hb 6-9g/dl, severe: Hb 3-6g/dl, very severe: Hb < 3g/dl.
5) History of iron deficiency.
6) Clinical symptoms.
7) Monitoring: For every infant, Hb should be tested during 7-12 months and 18-24 months.
3. Treatment
1) Treatment in different level
Mild: Being treated in village clinical. Middle: Being treated in township hospital.
Severe and very severe: Being treated in county hospital or referral hospital.
2) Therapy
Hb9g/dl: Giving dietary advance first. Testing Hb a month later, if no improved, giving iron.
Hb<9g/dl: Treatment with iron.
3) Dosage of iron
For children under 4 years olds:
Liquid: iron element 5mg/kg/day, divided into three doses
Tablet: iron element 30mg/day, divided into two doses
For children above 4 years olds:
Tablet: elemental iron 60mg/day, divided into two doses
4) Others
Vitamin C 300mg/day, taking with iron.
Treatment for respiratory infection, diarrhea and worms.
5) Follow up
Hb be tested every 4 weeks up to 11g/dl, then continue to give iron for another 8 weeks. If Hb
has not improved after treatment for 4 weeks, the patient should be taken to superior hospital to
identify the cause.
Annex 7. Example of how disease-targeted vitamin A capsule distribution was implemented
in Tanzania
An anemia and vitamin A project was implemented under a World Bank project in Tanzania.
They chose to have 50,000 IU VAC available through the essential drug kits. Infants were to
receive 100,000 IU, and other children 200,000 IU whenever they were suffering from chronic
diarrhea (longer than one week), severe respiratory tract infections, or protein-energy
malnutrition. In addition, a three megadose course of treatment was to be given to children with
measles or clinical signs of vitamin A deficiency. Record-keeping was to take place on the
existing growth charts.
A training program was held in every district in the country and included one staff member from
every health center. It was three days long, as it also took the opportunity of training them about
all three of the micronutrients. Other topics such as improved approaches toward giving dietary
advice and the importance of exclusive breastfeeding and good complementation practices could
be added.
Annex 8. Agenda, Recommendations and participant list for workshop on VAD and IDA
control in China, January 17, 2001
Agenda for Workshop on vitamin A deficiency and iron deficiency anemia control in China.
Foreign Loan Office, Ministry of Health, People's Republic of China, January 17, 2001
9:00
Welcome and introduction
Liu Yunguo, Deputy Director, FLO
9:30
Importance of VAD and IDA
and international trends
Ted Greiner, World Bank consultant,
Sweden
10:00 International recommendation for
Jiang Jing-Xiong, Director, Nutr Dept
treatment and prevention of IDA and VAD CIP
11:00 Results of social assessment conducted in
Guizhou Province
Yan Di Ying, Head, Chron Dis Branch,
CAPM
12:00 Additional findings on how VAD and IDA Ted Greiner
are dealt with in Henan and Guizhou
13:00 Lunch
14:00 Discussion of morning presentations. What are current policies and programs in China?
15:00 Brainstorming on what else needs to be done
16:00 Recommendations regarding health sector practices and other interventions
16:30 What next? Setting out steps toward a strategy.
Recommendations
To raise enough funds from various sources for the VAD and IDA prevention and
treatment over the country. To explore possible financial support from WHO, UNICEF
and other agencies or donors.
VAD is related to IDA as found in the Chongqing study. They are health problems in the
city. Health education is most important strategy to promote their prevention. Calcium
is less problematic but due to excessive market promotion it has been over-stressed in
China. For VAD and IDA we need to initiate public education to raise public awareness
their importance.
To develop an acceptable type of iron remedy for children is a practical issue, as
most of the current presentations are not well accepted by young children. This is
important in China. In poor areas people also are concerned about the cost of the
remedy. Efforts should be made to reduce its costs as well. MOH should cooperate with
drug industry for the development, selection and promotion of an appropriate remedy.
How to deliver iron safely and effectively and who really needs it is to be explored.
To have an operational organization working on VAD and IDA prevention needs to
be led by MOH, including training of health workers at grassroots levels in rural
counties.
A campaign on both issues like a wide administration of pills containing Vitamin A
and iron to the groups at risk.
Monitoring the implementation of an agreed strategy for VAD and IDA prevention is
equally important. The central level experts should develop a sort of guideline for
effective monitoring.
To set up surveillance points by the national level in three locations for better
understanding of the trends and effectiveness of interventions is needed.
A baseline survey on VAD and IDA in rural areas is necessary. In Guizhou there could
be many other counties that have worse situation than Dafang County where the
mission visited.
It is strongly recommended that a pilot intervention (preventive use of iron and
disease-based targeting VAC) should be conducted in some selected counties on the
basis of current policy and technical recommendations. The pilot should explore proper
way of drug delivery, management, compliance of clients, effective methods of
education and even appropriate dosage and remedy of iron and vitamin A.
To incorporate VAD and IDA into national health care framework.
Clearer guidelines for treatment of VAD and IDA developed and provided by national
level.
Next steps:
A special workshop to be organized by MOH to discuss what to do next, including pilot
location selection (focus on rural areas and with various economic situations, having
functional health services system and adequate governmental commitment on the
work).
To develop a standardized handbook describing the importance, strategies and
interventions for wide public health education by mass media and health sector. It
should provide correct and standard messages.
Workshop of Vitamin A Deficiency and Iron Deficiency Project—Participant list
Jan 17, 2001, Beijing
Name
Ted Greiner
Zhu Baoduo
Liu Yunguo
Wang Jie
Sex
M
M
M
F
Units
Title
Consultant
Director General
Deputy Director
Deputy Division
Chief
Project Officer
Professor Assistant
Tel
Liu Maowei
Yan Jun
M
F
Yan Diying
M
Wang
Wenguang
Ma
Guansheng
Jiang
Jingxiong
Lu
Guangkun
Tan
Zangwen
Song
Xiaofang
Li Haiqi
Ma Baojing
M
F
Foreign Loan Office, MOH
Department of Disease
Control, MOH
Chinese Academy of
Preventive Medicine
Chinese Academy of
Preventive Medicine
Chinese Academy of
Preventive Medicine
Capital Institute of Paediatrics
Professor
010-63045571
Professor
010-63403615
Professor
010-63189844
Division Chief
010-65127766-5579
M
Capital Institute of Paediatrics
Professor
010-65127766-5579
F
Capital Institute of Paediatrics
Association Professor
010-65127766-5579
F
Capital Institute of Paediatrics
Professor Assistant
010-65127766-5579
F
F
Chongqing Medical University
Maternal and Child Health
Center of Henan Province
Maternal and Child Health
Center of Henan Province
Maternal and Child Health
Center of Xichuan County,
Henan Province
Health Bureau of Guizhou
Province
Maternal and Child Health
Center of Guizhou Province
Health Bureau of Dafang
County, Guizhou Province
Maternal and Child Health
Center of Dafang County,
Guizhou Province
Professor
Professor
023-63622764
0371-6978387
Zou Liping
F
Association Professor
0371-6977753
Li Guizhi
F
Division Chief
0377-4213038
Jiang Xi
M
Division Chief
0851-6888015
Yan
Jiasheng
Zhang
Jirong
Liu Jiazhi
M
Association Professor
0851-6850683
Doctor
0857-5221630
Association Professor
0857-5221189
M
M
M
Foreign Loan Office, MOH
Foreign Loan Office, MOH
Foreign Loan Office, MOH
WB14109
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010-84045748
010-84045752
010-84045740
010-84045753
010-68792369
August 13, 2001 12:45 PM