Bolivia Anemia

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					The Micronutrient Initiative                                             Activity in 2005                                                            SCN 2006

The work of the Micronutrient Initiative in Latin America & the
Summary of activity

The work of the Micronutrient Initiative in Latin America & the Caribbean ............................................... 1
  Bolivia ....................................................................................................................................................... 2
  Guatemala ................................................................................................................................................. 4
  Haiti .......................................................................................................................................................... 6
  Nicaragua .................................................................................................................................................. 8

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The Micronutrient Initiative                     Activity in 2005                                   SCN 2006

1.    Bolivia, commonly acknowledged to be the poorest country in non-Caribbean Latin America, has an
      under-five mortality rate of 661. Chronic malnutrition among Bolivian children under the age of five
      years has been estimated at 25.6%. Bolivia is also a country with great regional disparities. In terms
      of health indicators, Bolivia‟s disparities are particularly marked such that children living in the rural
      highland areas are generally much worse off than their urban and lowland counterparts2. In terms of
      micronutrient nutrition, vitamin A, iron, and zinc deficiencies are of primary concern. Among
      children under the age of five, the national prevalence of subclinical vitamin A deficiency is
      estimated at 23%3. For the same age group, estimated prevalence of anemia is approximately 52%,
      with 70% of the 6-24 month olds being anemic4. Iron deficiency anemia also affects approximately
      30% of women of child-bearing age. IDA affects approximately 23% of children under 5 years and
      approximately 50% of all cases of anemia are caused by iron deficiency (ECIN 2003). Although
      direct measures of zinc deficiency are not available, 37% of childhood deaths have been attributed to
      diarrhoeal diseases5. On a positive note, the prevalence of iodine deficiency disorders has been
      greatly reduced in the last few decades, and approximately 85% of households consume iodized salt 3.

2.    This year, MI adopted a comprehensive strategy and supported national efforts to reduce
      micronutrient deficiency on multiple fronts. Specifically, MI focused on the three micronutrients
      whose deficiencies are most acute: vitamin A, iron, and zinc.

Reducing VAD in Bolivia

VAS delivery support

3.    MI supported a project to improve the coverage of vitamin A supplements received by children under
      five via routine health services and immunisation campaigns through the National Nutrition
      Programme (PRONAN) of the Bolivian Ministry of Health, with support from UNICEF/La Paz. The
      focus was on strengthening the human capacity of PRONAN, improving partnership between
      PRONAN and other MOH departments, improving education of primary health workers,
      implementing communication strategies, and monitoring/reporting capsule distribution.

4.    The project was successful in achieving many of these. PRONAN was restructured for improved
      performance, and strengthened by the addition of a coordinator and an epidemiologist, who links
      micronutrient program indicators directly with the National Health Information System (SNIS). VAS
      coverage indicators were modified to reflect first and second dose performance
      ( PRONAN undertook a comprehensive
      situation assessment of the supply chain and management of vitamin A supplements throughout the
      country. Primary health care workers were educated about micronutrient malnutrition and Vitamin A
      Deficiency control guidelines as part of the resulting Information, Communication and Mobilization

5.    But, given the significant progress made in the above areas, trends in Vitamin A coverage that
      occurred over this time period were disappointing. The first year of the project (2003) saw an
      increase in coverage, from 55% of children under 5 years receiving 2 doses in 2002 to 60% receiving

  UNICEF: State of the World‟s Children 2005
  UNICEF. Regional Disparities in LAC: Rapid Nutritional Assessment 2003.
  MICRONUTRIENT INITIATIVE: VMD global progress report 2004.
  PAHO, unpublished National Food Intake and Iron Status Survey, 2003.
  PAHO: Country Health profile Bolivia 2001

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The Micronutrient Initiative                         Activity in 2005                                 SCN 2006

         2 doses in 2003. However, coverage during the second year of the project (2004) fell to only 38%
         receiving both doses. This apparent decrease in coverage was attributed to incomplete/ incorrect
         registration of the second dose and to disagreements regarding census data used as a target population
         denominator. Coverage data for January-November 2005 were 100% for children 6-11 months, and
         for children 12-59 months of age: 51% for the first dose and 33% for the second dose.

Oil fortification

6.       In partnership with WFP, PSI and the Nutrition Programme of the Bolivian Ministry of Health, MI
         invested in fortifying locally produced edible vegetable oils with Vitamin A through donation of
         vitamin A premix and the provision of technical assistance in the areas of food science and social
         marketing and communication. One major initial achievement of the project was to have successfully
         negotiated with one of four national edible oil producers to initiate oil fortification voluntarily.
         Through the PRONAN director and WFP, the MI also engaged the higher levels of government in
         policy advocacy. A third focus of the project has been enhancing consumer and retailer demand for
         the fortified product (a national vitamin A logo has been registered and will visibly brand all fortified

7.       Since November 2004, the third largest oil producer (with 25% of market share) has been voluntarily
         fortifying all of its products with Vitamin A. The remaining oil producers are now set to follow suit,
         in wake of a Ministerial Decree for Mandatory Fortification of staple foods and condiments that was
         promulgated in October 2005. Thus we can expect that in the near future, all oil sold legitimately in
         the Bolivian market (barring illegal imports) will be fortified.

8.       Given the successful promulgation of the Ministerial Decree, MI is now supporting the accreditation
         of a network of Bolivian laboratories. The ability of each laboratory to successfully perform Vitamin
         A content analyses is being tested in a series of four rounds in partnership with Craft Laboratories of
         North Carolina. Ultimately, the country will count on this national laboratory network to ensure that
         marketed oil conforms to the fortification levels specified in the Decree.

Home Fortificants to reduce iron deficiency

9.       Under an agreement with the PanAmerican Health Organization (PAHO) and the Bolivian MOH, MI
         undertook to support the supply of sachets of multiple micronutrients (“Chispitas6”) to all Bolivian
         children between 6 and 24 months of age. The sachets contain vitamin A, vitamin C, folic acid, iron
         and zinc. For children in this age group, the Chispitas will replace ferrous sulphate syrup in the
         package of health services supplied through SUMI (the national universal health plan targeting
         mothers and children). This is the first instance of a national government scaling up the free
         distribution of home fortificants to a national level.

10.      This year, the MI and partners engaged in officially registering the product in Bolivia, in procuring
         and shipping Chispitas with local resources, in laying the necessary logistic and organizational
         foundations for the distribution of the sachets, and in initiating a communication and education
         campaign. Distribution of Chispitas is scheduled to begin in early 2006. Once implemented at the
         national level, Chispitas will reach approximately 400,000 toddlers. It is furthermore anticipated that
         the program will be expanded to all children 6-59 months of age by approximately 2007 (at which
         point it will reach approximately 750,000 young children).

For further information please contact Zoë Boutilier:

    A SprinklesTM product developed for the Bolivian context

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The Micronutrient Initiative                      Activity in 2005                                    SCN 2006

11.   Guatemala has an U5MR of 457. It is estimated that 21% of Guatemalan children under the age of
      five are deficient in Vitamin A8. The prevalence of iron deficiency anemia in this age group is 39.7%
      with 65% of children 6-11 months and 20% of women of child bearing age having anemia9.

12.   In Guatemala, MI‟s highest priorities this year were to consolidate the institutional achievements in
      VAS coverage and reporting, and to motivate the initiation of a home fortification program targeting
      iron deficient children under two. The table below summarizes our projections and best estimates of
      what has been achieved in VAS as a result of contributions from MI.

Reducing VAD in Guatemala

13.   Our work on strengthening Vitamin A supplementation in Guatemala in conjunction with World
      Vision Guatemala and the Guatemalan Food Security and Nutrition section (PROSAN) has been
      ongoing since 2003. It built on progress achieved in 2004: policy change for expansion of the target
      age group for VAS to all children 6-59 months; expansion of technical assistance and supervision of
      VAS to 15 provinces, and improvements to supply chain logistics and health card design and
      utilization. In 2005, inter-agency cooperation between various governmental departments focused on
      improving VAS coverage for children over the age of one (coverage of the under-ones was already
      very high). PROSAN was successful in incorporating VAS coverage goals into the government‟s
      official plans up to 2007 as well as into University nutrition program curricula, and worked with the
      Social Security Health Services agency to ensure that VAS were provided to the 10% of Guatemalan
      children under five who are direct beneficiaries of this private component of the health system.
      PROSAN also coordinated with the bodies administering daycare, and INGOs distributing local food
      aid, to ensure that these populations also received two high dose VA capsules per year.

14.   In terms of monitoring and evaluation, PROSAN focused on sending out official reminders for and
      reminding service providers within the public health sector to collect and report VAS data, by
      working with the Epidemiological Division of the MOH and with local grassroots NGOs to
      strengthen local-level coverage monitoring. Although official figures have not been released,
      available figures confirm that the goal of reaching 70% of children under 1 with VA supplementation
      was exceeded, and 40% of children 12-59 months were covered with at least 2 doses per year.

Building Support for Home Fortificants – Acceptability and Efficacy Studies

15.   MI‟s advocacy resulted in high-level (Vice-Minister of Public Health) interest in introducing home
      fortification of complementary food targeting iron deficient children under two. MI, the MOH and
      UNICEF undertook an acceptability study among mothers of children under 2 in 4 different ethnic
      groups living in poor rural areas. The promising results (100% acceptability) helped to catalyze
      USAID support for a follow-up efficacy study to be carried out in 2006. Finally, as part of the
      process of building evidence to support the integration of a home fortification program into the
      national nutrition program, MI has proposed a pilot implementation trial to provide preventive home
      fortificants and therapeutic zinc supplements to 25,000 children in a northern province (Alta

  MICRONUTRIENT INITIATIVE: VMD global progress report 2004
  Encuesta Nacional de Salud Materno Infantil 2002 (ENSMI2002). Ministerio de Salud Publica y Asistencia Social de
Guatemala (MSPAS). Guatemala, October 2003.

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The Micronutrient Initiative                  Activity in 2005                       SCN 2006

For further information please contact Zoë Boutilier:

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The Micronutrient Initiative                        Activity in 2005                                      SCN 2006

16.     Haiti has an U5MR of 11710, the highest rate in the Americas and one of the highest in the Western
        hemisphere, and 32% of children under five are deficient in Vitamin A11. Iodine deficiency is a mild
        to moderate public health problem as evidenced by a 2005 survey of 6-12 year olds in which 60% of
        urinary samples had an iodine concentration below 100 ug/l and 25% of samples were below 50ug/l
           . The estimated prevalence of anaemia is 66% in children under 5 years of age and 54% in women
        of child bearing age.

17.     This year, our work in Haiti took the form of research, dialogue, planning, and advocacy. MI‟s
        highest priorities in this reporting period were to: complete a national survey on the prevalence of
        vitamin A and iodine deficiency in Haiti; pilot efforts to combat iron deficiency through commercial
        distribution of home fortificants; to lay the foundations for a universal salt iodization program to
        combat iodine deficiency; and to provide technical assistance to government efforts to start small-
        scale fortification of bouillon cubes and cassava bread.

Reducing VAD in Haiti

Vitamin A Supplementation

18.     This project started in 2004 was originally designed to strengthen the delivery of high-dose Vitamin
        A capsules through routine health services. However the Haitian routine health care delivery system
        proved not to have the minimum capacity necessary to achieve meaningful and sustainable
        improvements in coverage. The MI and partners (MOH, UNICEF & USAID/MOST) agreed to
        move towards Vitamin A supplementation during semi-annual „National Child Health Weeks‟
        (NCHW) as a one-week intensification of routine services at health facilities and rally posts.

19.     The MI is contributing a coordinator to ensure successful incorporation of VAS in NCHW activities,
        support for monitoring, VA-related data collection, and evaluation of the NCHWs, advocacy and
        planning activities, social mobilization and advocacy. A NCHW took place in June 2005, reaching
        58% of children 6-11 months and 27% of children 12-59 months with one dose. MOH statistics
        suggested that 56% of children 6-11 months and 39% of children 12-59 months received at least one
        dose via the routine health system.

20.     There are plans for two NCHWs in 2006; aimed at reaching 40% of children 6-59 months with two
        annual doses. Assuming the routine system continues to deliver comparable results, this will assire
        both doses for another 20% of children.

National Survey on the Prevalence of Vitamin A and Iodine in Haiti

21.     MI support to the Institut Haiten de l‟Enfance and UNICEF helped accomplish a nationally
        representative survey of the prevalence of vitamin A and iodine deficiency, a crucial step because of
        the lack of reliable national data. The survey report was completed and disseminated in July and
        indicated that Vitamin A and iodine deficiency are of public health significance. The survey also
        noted that the prevalence of these deficiencies was greater in rural than urban areas.

   Survey of the Prevalence of Vitamin A and Iodine Deficiency in Haiti, July 2005, Institut Haitien de l‟Enfance
   Survey of the Prevalence of Vitamin A and Iodine Deficiency in Haiti, July 2005, Institut Haitien de l‟Enfance

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Reducing IDA in Haiti

Home Fortificants (“BabyFer”)

22.   MI was instrumental in conceptualizing, initiating and implementing a program to make multi-
      micronutrient home fortificants available for anemia control (“Babyfer” a variant of SprinklesTM)
      through commercial channels to Haitian children under the age of two. The product was placed in
      retail outlets after mini commercial launches in 5 of the 9 provinces in October 2005, which targeted
      mothers, caretakers, and retail outlet owners in the more remote and under-served areas.

23.   In the first two months, 135,302 sachets of Babyfer were sold, mainly due to delays in the national
      commercial launch. Registration of the product proved to be an extremely lengthy process and the
      launch did not occur until October 2005. Much time was also invested in the research underpinning
      product packaging, branding, and communication messaging. Future commercial expansion into
      other countries will benefit from this research. In 2006, we anticipate an increase in commercial sales
      to at least 1.2 million sachets over the year. Expansion of the market to include food aid programs for
      children under 5 will be explored as well.

24.   The MI worked with FANTA, the International Food Policy Research Institute (IFPRI ) and World
      Vision to perform assessments within the currently established food aid distribution to children in
      World Vision Programs in Île de La Gonâve and Plateau Centrale. The study concluded that 2
      months (60 sachets) of micronutrient BabyFer Sprinkles were effective in improving Hemoglobin
      levels and reducing anaemia in populations with a high prevalence of anemia, such as rural Haiti.
      Within a well-established MCHN program, it also proved feasible to distribute Sprinkles and to
      promote their appropriate use through group education sessions. Vitamin A supplementation should
      also contribute significantly to iron status in a country with such a high prevalence of VAD.

Exploration of the Feasibility of Fortifying Haitian Bouillon Cubes

25.   Given high rates of iron deficiency anaemia, the low coverage with iron supplementation, and the
      lack of a suitable vehicle for universal or targeted fortification with iron, in August 2005, the MI
      supported the collaboration of a fortification expert with Haitian bouillon cube producer Sunia Cubes
      to conduct iron fortification feasibility trials during the manufacturing process. This answered
      preliminary questions but raised others, with regards to the stability of a fortified bouillon cube
      product and the commitment and preparedness of the local industry to go ahead with fortification.
      Consequently, the MI is now supporting laboratory development of a stable fortified bouillon cube,
      estimation of costs of fortification, and exploration of the interest of other bouillon cube
      manufacturers in the Latin American and Caribbean region that handle part of the Haitian bouillon
      cube market to bring the technology to industrial scale.

For further information please contact Zoë Boutilier:

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The Micronutrient Initiative                    Activity in 2005                                  SCN 2006

26.   Nicaragua is at a relatively advanced stage in terms of ongoing national level control of micronutrient

27.   MI‟s work with other partners in Nicaragua has focused on institutionalising the Integrated Nutrition
      Interventions Surveillance System (SIVIN) fully within the Ministry of Health, as a model approach.
      SIVIN is a centralised, modular, integrated information system developed jointly by CDC/ MI/
      MOST/ UNICEF/PAHO and the Ministry of Health of Nicaragua to monitor and periodically
      evaluate impact and process indicators for the country‟s principal nutrition interventions. SIVIN
      gathers, integrates and analyses relevant information from the following nutrition programs:
            Micronutrient supplementation;
            Food fortification with micronutrients;
            Promotion and protection of breastfeeding; and
            Community Health and Nutrition Program (PROCOSAN).

28.   MI‟s support to SIVIN has targeted specifically the first two: monitoring of VAS and iron/folate
      supplementation programs as well as the sugar, wheat flour, and salt fortification programs already in

29.   In its first 2 years of operation (2003-04), SIVIN produced annual national reports that were widely
      disseminated within government and civil society. In 2005, SIVIN carried out the 3rd annual round of
      information gathering, thus completing the sample size necessary for representative results for each of
      the 3 subnational regions requested by the GoN. The 2003-2005 results will be used as input by the
      decentralized health systems and for SIVIN‟s own assessment during 2006.

National IDD control program

30.   In 2005, the MI facilitated the collaboration of the national salt producers association of Nicaragua
      with a Peruvian salt processing engineer to establish the specifications for construction and furbishing
      of a salt processing plant. This plant will centralize salt processing and confer to the Nicaraguan salt
      industry the capability to produce >90% of the iodine and fluorine forrtified salt required for the
      entire population. The plant specifications have been submitted and the plant will be built with public
      and private funds during the first quarter of 2006.

Sharing the Nicaraguan Success Story

31.   SIVIN is a unique example of a locally-developed system of surveillance and management of
      deficiencies which may be applied elsewhere in the world. For this reason, the MI is currently
      preparing a publishable report describing the Nicaraguan experience with (SIVIN) with special
      emphasis on the transferability of the SIVIN model. The MI is also supporting the preparation of a
      paper that re-examines the observation of anemia reduction among children and women of child
      bearing age in Nicaragua. This paper will provide a description of relevant activities, an account of
      good implementation practices, a description of program costs, and a diagnosis of lessons learned.
      The MI aims to publish this report in 2006.

For further information please contact Zoë Boutilier:

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