Introducing Sprinkles in Kyrgyzstan
From people’s mandate to national policy
Von Tobias Schüth / Schweizerisches Rotes Kreuz SRK
Starting in 2001, participatory assessments of people’s health priorities, within the context of a community capacity building program, revealed anemia as one of the top health concerns of people. Dietary iron deficiency was the likely cause as other possible causes were ruled out. However, a previous program that had provided iron supplementation with tablets and syrup in one region had shown no effect. In this context, in 2003, Swiss Red Cross came to know about Sprinkles as an alternative form of iron supplementation.
In 2001, we started a program for community capacity building around health issues in one rayon (district) of Kyrgyzstan. It was called Community Action for Health and would evolve over the years to become a countrywide partnership between Village Health Committees and the governmental health system. In each region to which the program was extended, an extensive, qualitative, participatory assessment of people’s health priorities was conducted in order to develop interventions for health issues identified as priorities by the people. While extending the program throughout the country, we found that people identified anemia everywhere as one of their most important health issues. This led us down the path of searching for an intervention to fight anemia. This essay describes the evolution from this mandate by the people to find a strategy against anemia to choosing micronutrient home fortification as a key strategy for the prevention and control of anemia in Kyrgyz children.
Anemia in Kyrgyzstan
Studying the available epidemiological data confirmed that anemia and other micronutrient deficiencies are highly prevalent among young children in Kyrgyzstan. In the 1997 Demographic and Health Survey, the prevalence of anemia was 50% in children 6–36 months of age. (Research Institute of Obstetrics and Pediatrics 1998) Non-nationally representative surveys undertaken since 1997 suggest that the prevalence of anemia has not declined. (Schueth et al 2007, Lundeen et al, Serdula et al 2009) Studies measuring ferritin had not yet been conducted, but it was assumed that dietary iron deficiency was the cause of the high prevalence of anemia among young children. As the prevalence of anemia among children under 3 years of age was higher than 40%, it could be inferred that all children in that age group have some degree of iron deficiency. (UNICEF/UNU/WHO 2001)
There was evidence of other micronutrient deficiencies as well. In 2003, a serological study of 504 children <5 years of age detected vitamin A deficiency (< 20µg/dl or 0.7 µmol/l) in 33% of children. (Evaluation/assessment of Vitamin A deficiency 2003) Growth stunting in children under 5 years is also a serious public health problem in Kyrgyzstan, with a national prevalence of 13.7%, while wasting, on the other hand, is almost at normal levels at 3.5%. (MICS, UNICEF. 2006) High levels of stunting, in the absence of wasting, was also suggestive of micronutrient deficiencies.
Previous experience and preliminary investigations
The World Health Organization recommends universal iron supplementation for children 6-36 months of age when the prevalence of anemia is greater than 40%. (UNICEF/UNU/WHO 2001) The Ministry of Health (MoH) with support from UNICEF, therefore, implemented an iron supplementation program from 1998 to 2000, in one region of the country. They distributed iron tablets for pregnant women and iron syrup for children. Unfortunately, instead of showing a reduction in anemia, the prevalence of anaemia actually worsened over the course of the program period of two years. (Haemoglobin level research 2001) Reasons for the disappointing outcome were thought to be poor distribution, communication and training, and to a lesser extent, side effects of tablets, which resulted in low compliance. (Anaemia prevention and control assessment 2001)
But this failure led some in the health system to suspect that iron deficiency was not the chief cause of the high prevalence of anemia. As mentioned, no studies had been conducted measuring ferritin, and at the time, ferritin measurement was not possible in Kyrgyzstan. Years later studies including ferritin measurements did confirm iron deficiency (Assessment of Nutritional Status 2008), but at the time, we could only indirectly establish dietary iron deficiency as the cause of the anemia. Malaria could be excluded as a cause because it exists only in defined pockets of the country and the incidence is very low. Existing studies on intestinal parasites, as well as a study we initiated, did not find any existence of hookworm infection. (Ministry of Health and DFID, 2004/ Prevalence of Helminth Infection 2006) We also investigated a small number of women and men in the same communities and found that while women had a high level (44-62% prevalence) of anemia, 90% of the men were not anemic, which made causes other than iron deficiency very unlikely. (Small Cross-Sectional Sample 2007) Lastly, several investigations of nutrition patterns had shown that a large part of the population consumes food low in micronutrients and especially iron. (Nutrition patterns in Jumgal rayon, 2003 / Nutritional patterns in Talas and Naryn oblasts, 2004) Furthermore tea, which is high in tannin content (a known inhibitor of dietary iron), is widely consumed in large quantities, especially at meals. Mothers start to give their babies tea at a very early age, and by the age of 1 year virtually all children drink tea.
In 2001, UNICEF and Asian Development Bank began to promote flour fortification with iron in Kyrgyzstan. We therefore investigated the consumption of flour by people in villages (where roughly two-thirds of the population live) and found that the majority grow their own wheat and have it milled in small local mills. (Use of wheat and flour in Naryn oblast, 2004) A study by UNICEF found an average of 1.5 flour mills per village and a low consumption of fortified flour. (UNICEF, 2004) As fortification in small mills is not feasible and convincing people to buy fortified flour would involve major changes in food consumption patterns for a majority of households, we concluded that for the short- and medium-term, supplementation was the only feasible strategy to provide children and pregnant women with the necessary iron. However, due to the failure of the previous program, supplementation with iron tablets and syrup was discredited in Kyrgyzstan. Also, a review of literature found that iron supplementation in large prorgrams has proven to be ineffective and difficult to implement. (Zlotkin, 2005)
Studies with Sprinkles
It was in this context, in 2003, that we first learned about Sprinkles as an alternative method of iron supplementation, and began to explore this option. Meanwhile, we also initiated other interventions that aimed at improving nutrition. Village Health Committees were trained to help people grow vegetables and to promote a balanced diet, exclusive breastfeeding in the first 6 months, and proper complementary feeding.
Iron supplementation with Sprinkles has been developed by the Sprinkles Global Health Initiative at the Hospital for Sick Children in Toronto, Canada. Sprinkles are a mixture of iron and various other micronutrients in powder form. The micronutrients are packaged in single dose sachets and contain microencapsulated iron, zinc, vitamins A and C, and folic acid. This powder is sprinkled over semi-solid food right before it is consumed. Sprinkles have considerable advantages over traditional iron-containing drops and tablets in terms of compliance, convenience, acceptability, cost, incorporation of other micronutrients, and reduced side effects. (Zlotkin et al, 2001/Tondeur et al, 2004/Zlotkin et al, 2004) Lipid encapsulation of the iron prevents it from interacting with food, and thus there are minimal changes to the color, taste, and texture of the food to which Sprinkles are added. The use of Sprinkles does not require mothers to alter their feeding practices, as they can easily be mixed with any home-made food.
The efficacy, safety, and acceptability of Sprinkles for infants and young children has been tested through several community-based studies in developing countries in Asia, Africa, and Latin America. (Zlotkin, 2005) Sprinkles have proven to be as effective as the standard iron drops in treating and preventing anemia in young children, with cure rates ranging from 55-90%. (Zlotkin, 2005)
We initiated a partnership with the Sprinkles Global Health Initiative, and in 2005, we conducted a study on the effectiveness of Sprinkles given to children 6-36 months of age and pregnant women in one region of the counry. As the efficacy of Sprinkles had been proven through studies in several other countries, we opted for an effectiveness study with cross-sectional samples taken pre- and post-intervention. A recent efficacy study in Bangladesh had shown that 2 months of weekly administration of Sprinkles in children was almost as effective as daily administration for 2 months. (Ziauddin, 2007) These results encouraged us to try a weekly regimen in the hope that, if proven effective, it would lower the costs of a national program and therefore increase the likelihood that Kyrgyzstan would adopt this strategy. To compensate for the lower compliance that could be expected in an intervention study, as compared to the efficacy study in Bangladesh, we prolonged the duration of the intervention to six months. The Sprinkles sachets for children contained 30 mg of iron as ferrous fumarate, and for women they contained 60 mg. Unfortunately, the results of this study were disappointing for both children and pregnant women. There were differences in the results between intervention and control groups, but the effect was by far not sufficient to justify a strategy based on this dosing regimen. (Schueth et al, 2007) There was a dose-response effect among the children, based on compliance, but even in the highest compliance group, the effect was markedly lower than what had been reported in Bangladesh among the weekly administration group. This was true despite the fact that the high compliance group in Kyrgyzstan received a cumulative dose of iron almost four times higher than the weekly group in the Bangladesh study. On the positive side, we learned that Sprinkles were accepted by mothers, compliance was generally good, and there were few side effects.
In reviewing these results, we noted that Sprinkles had never before been tested in a context where black tea consumption was ubiquitous in small children and suspected that this may explain our results. We therefore decided to conduct an efficacy study that would answer the question of whether Sprinkles could in principle be effective under the prevailing nutritional patterns in Kyrgyzstan. This second Sprinkles study was conducted in 2007, among children 6-36 months of age and pregnant women. It was a cluster-ransomized trail among 2193 children and 228 pregnant women. The intervention consisted of two months of daily Sprinkles administration (12.5 mg iron as ferrous fumerate for children, 60 mg iron as ferrous fumerate for pregnant women). In this study, Sprinkles were found to be effective in preventing and treating anemia in children, with a 28% relative reduction in the prevalence of anemia among children in the intervention group (from 71.9% to 52.0%) vs. an increase in anemia among the control group. Among pregnant women the Sprinkles intervention did not reduce the prevalence of anemia, nor increase the mean hemoglobin. However, when we compared the pre- and post-intervention results between the intervention and control groups, it was clear that Sprinkles did have some impact on hemoglobin, anemia prevalence, and iron stores. This effect, however, was not large not enough to counter the physiological effects of pregnancy that lead to anemia. (Lundeen et al)
We concluded that, despite tea consumption, daily administration of Sprinkles could be an effective tool in the fight against anemia in Kyrgyz children. A number of influential people in the health system had been involved in planning the study and became advocates of Sprinkles when the second study showed their effectiveness. Together with them we began to lobby for the inclusion of the Sprinkles intervention becoming a part of the strategy to prevent and control anemia in Kyrgyzstan. For pregnant women, we recommended that the government wait for additional evidence on Sprinkles and multiple micronutrient tablets before determining which one to choose for supplementation. The skeptics that remained, despite our positive study results among children, were gradually convinced using lobbying measures that included a trip to a successful Sprinkles program in Mongolia (World Vision Mongolia, 2005), a national conference on international evidence for Sprinkles with experts from CDC Atlanta, their inclusion in the working group on development of an anemia prevention and control strategy, and countless individual talks.
By 2009, these efforts over time led to the MoH itself becoming the main driving force behind Sprinkles becoming a key intervention against anemia in Kyrgyzstan. Meanwhile, a coalition of partners (MoH, UNICEF, Swiss Red Cross, Centers for Disease Control and Prevention) initiated in mid-2009 a pilot Sprinkles program for children 6-24 months in one region, while an extension to another region is in preparation for 2010. Sprinkles were locally branded for Kyrgyzstan as “Gulazyk” (a Kyrgyz word refering to an old tradition of drying meat for long journeys). Village Health Committees are involved in education efforts for Sprinkles and in promoting compliance. Thus, the initial prioritization of anemia by communities has come full circle, as Village Health Committees are now participating in promoting an effective intervention against it. Proposals to a variety of donors are in preparation for financing the nationwide extension.
*Dr. Tobias Schueth from Germany is a public health physician who has worked for the last 15 years for community development and health in rural areas of South Asia and Central Asia. Since 2001 he is the country representative of the Swiss Red Cross in Kyrgyzstan and has developed there the countrywide Community Action for Health program that has become a part of the national health reform.
Research Institute of Obstetrics and Pediatrics (Kyrgyz Republic) and Macro International Inc. (1998). Kyrgyz Republic Demographic and Health Survey, 1997. Calverton, Maryland. Pgs. 128 and 132.
- Schueth, T. Hyder Z, Tondeur M. Report on a Study with Weekly Dosage of Sprinkles for 6 Months in Kyrgyzstan. Technical Report. Kyrgyz-Swiss-Swedish Health Project. 2007.
- Lundeen, E, Schueth T, Toktobaev N, Hyder Z, Houser R, Zlotkin S. Daily Home Fortification for 2 Months with Micronutrient Sprinkles Reduces Anemia among 6-36 Months old Children in the Kyrgyz Republic: A Cluster-Rendomized Trial. In preparation for publication.
- Serdula, M. Assessment of Nutritional Status of Children 6-24 Months, Their Mothers, and the Role of Village Health Committees in Health Education. Bishkek, Kyrgyzstan. UNICEF, Kyrgyz Ministry of Health, Center for Disease Control and Prevention. 2009. Pg. 39.
- UNICEF/UNU/WHO. Iron Deficiency Anaemia Assessment, Prevention and Control: A Guide for Program Managers (publication No. WHO/NHD/01.3). Geneva, Switzerland. 2001. Pg. 28. Retrieved April 5, 2009 from www.who.int/reproductive-health/docs/anaemia.pdf
- Evaluation/assessment of Vitamin A deficiency prevalence in the Kyrgyz Republic. UNICEF office in CARK, Kazakh Academy of Nutrition, Kyrgyz Research Institute of Obstetrics and Pediatrics. 2003
- Multiple Indicator Cluster Survey (MICS), UNICEF. 2006.
- Haemoglobin level research in women of reproductive age and children under three years of age in Naryn oblast. Centre of Public Opinion Studies and Forecast on behalf of UNICEF. 2001
- Anaemia prevention and control assessment. UNICEF. 2001
- Assessment of Nutritional Status of 6-24 Months of Age Children, Their Mothers and the Role of Village Health Committees in Health Education. Talas Oblast, Kyrgyz Republic. Ministry of Health of the Kyrgyz Republic, UNICEF, Centers for Disease Control and Prevention (CDC)/USA. 2008.
- Personal communication from Rural Sanitation and Hygiene Project based on around 1000 stool examinations of children in 2003. Ministry of Health and DFID. 2004.
- Prevalence of Helminth Infection among 2-12 year old children in At-bashy Rayon, Naryn Oblast. Report of an investigation by the Sanitary Epidemiological Service (SES) of the Ministry of Health of the Kyrgyz Republic. 2006.
- Small Cross-Sectional Sample of Men in Naryn and Talas Oblasts to Determine the Prevalence of Anemia. Kyrgyz-Swiss-Swedish Health Project. 2007.
- Nutrition patterns in Jumgal rayon. Qualitative study with Participatory Reflection and Action (PRA) instruments. Kyrgyz-Swiss Health Reform Support Project. 2003.
- Nutritional patterns in Talas and Naryn oblasts. Action Research by Village Health Committees. Kyrgyz-Swiss Health Reform Support Project. 2004.
- Use of wheat and flour in Naryn oblast. Kyrgyz-Swiss Health Reform Support Project. 2004
- Assessment of use of wheat and flour in Kyrgyzstan. UNICEF. 2004
- Zlotkin, S. Micronutrient Sprinkles to Control Childhood Anemia. PLoS Medicine. January 2005. Vol. 2 Issue 1 pg. 0025.
- Zlotkin, S. Arthur P., Antwi K.Y. and Yeung G. Treatment of anaemia with microencapsulated
ferrous fumarate plus ascorbic acid supplied as sprinkles to complementary (weaning) foods. Am J Clin Nutr 2001:74(6): 791-5.
- Tondeur MC, Schauer CS, Christofides AL, Asante KP, Newton S, Serfass RE, Zlotkin SH.
Determination of iron absorption from intrinsically labeled microencapsulated ferrous fumarate
(sprinkles) in infants with different iron and hematologic status by using a dual-stable-isotope method.
Am J Clin Nutr 2004;80:1436-44.
- Zlotkin S, Christofides A, Schauer C, Asante KP, Owusu-Agyei S. Home fortification using
sprinkles containing 12.5 mg of iron successfully treats anaemia in Ghanaian infants and young
children. Abstract, International Nutritional Anaemia Consultative Group (2004) INACG Symposium.
- Hyder SM Ziauddin, Haseen F, Rahman M, Tondeur MC, and Zlotkin S. Effect of daily versus once-weekly home fortification with micronutrient Sprinkles on hemoglobin and iron status among young children in rural Bangladesh. Food Nutr Bull 2007; 28/2: 156-64.
- Effectiveness of Home-Based Fortification of Complementary Foods with Sprinkles in an Integrated Nutrition Program to Address Rickets and Anemia. World Vision Mongolia. 2005.