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1 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 2 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 3 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 33 38 41 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: 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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Paper presented at the Ninth Meeting of the International Nutritional Anemia Consultative Group. Geneva: WHO (cited by Li, 1995). Zhang ZW, et al, 1997. Nutritional evaluation of women in urban areas in continental China. Tohoku J Exp Med 182:41-59. 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 ChengjingVice 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 jinlunOfficer of County Office Li yuqinVice Director of Health Bureau in Dafang County Wushuhua: Director of Education Bureau in Dafang County Zhujianming: Officer of Health Bureau in Dafang County GaoKeHuoOfficer 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 CaowenxueCounty 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 L:\china\finalaugust1wjanetscomments2.doc 010-84045748 010-84045752 010-84045740 010-84045753 010-68792369 August 13, 2001 12:45 PM