Intervention 2: Iron/Folate Supplements and Deworming

Iron and Folate Supplements

Iron deficiency is the most common micronutrient deficiency and it predominantly affects women. Women who have iron-deficiency anaemia are more likely to have poor birth outcomes. The best way to prevent iron-deficiency anaemia is to ensure that all women are iron replete, through adequate diets, throughout their reproductive years. Where this is not happening, pregnant women should be targeted first for iron deficiency because this deficiency severely affects infants.

Folate helps to produce and maintain new cells in the body and is also important in preventing anaemia. It is recommended that all pregnant women take daily iron/folate supplements as soon as they find out they are pregnant to protect against the effects of iron-deficiency anaemia.Supplementation should continue for at least six months, though it is best to continue supplementation throughout the pregnancy. This additional iron should be complemented with increased iron intake through iron-rich, or fortified, foods. The best iron-rich foods are animal-source foods, but iron can also be found in dark green leafy vegetables.

7-11 programming ensures that pregnant women are aware of the importance of iron/folate supplementation and iron-rich foods. It will also encourage these women to seek appropriate ANC where these services are provided.

Definitions:

Supplemental intake and increased iron and folate food intake; promotion of locally available foods such as animal foods, vitamin A and C-rich foods, access to iron and folate supplements

Target Behaviours/Results:

Pregnant woman takes iron/folate supplements for 6 months (according to national government policy)
Pregnant women eats local foods rich in iron and folate

Deworming

7-11 programming includes education about intestinal worms, the connections between worm infestations and maternal anaemia, and the importance of de-worming. Pregnant women are encouraged to seek appropriate ANC (Antenatal Care) where de-worming tablets will be administered according to national policy and guidelines. WHO and UNICEF recommend that albendazole or mebendazole be given to pregnant women after the first trimester of pregnancy.

DEFINITIONS:

Soil-transmitted (STHs) and Schistosomiasis are caused by parasitic worms, and are diseases of poverty. They can be effectively treated with medicines, but require combined water, sanitation and hygiene interventions to control spread and re-infection.
STH affects the health and livelihoods of over one billion people worldwide, and undermines global development efforts. Treating women of childbreaing age and young children for STHs and Schistosomiasis can play a major role in strenghtening maternal, newborn and child health.
The World Health Organization(WHO) recomends pregnant women recieve treatment for hookworm(a type of STH) after the first trimester, and if at risk of Schistosomiasis, they should receive treamtne for this also.

TARGET BEHAVIOURS/RESULTS:

Pregnant women receive de-worming medication during pregnancy per national government protocols
Pregnant women practice good sanitation and hygiene
Pregnant women do not walk barefoot

Questions: Iron-Folate Supplements:

Why is iron important?

A lack of iron causes anaemia – a deficiency in the number of red blood cells. Red blood cells are important because they carry oxygen from the lungs to all tissues. Cells depend on oxygen to survive and replicate. So, anaemia = lack of red blood cells = lack of oxygen to cells.

Some community members may refer to this as “weak blood”. That is fine if it helps to understand the seriousness.

What are the consequences of anaemia?

When a woman has anaemia she feels tired and has less energy than usual, and her ability to think clearly and learn is reduced.

Women with severe anaemia in pregnancy are at greater risk of complications during pregnancy and delivery, and possible death during childbirth

If a pregnant woman does not have sufficient iron in her body, the risk of anaemia is passed to her baby, and this can result in learning difficulties and slower growth and development

Anaemia in a pregnant woman may also result in the baby being born early or with low birth weight Her child may never catch up in terms of growth and, as an adult, will run an increased risk of chronic illness such as heart disease and diabetes.

Is sufficient iron the only thing that causes anaemia?

About half of all anaemia in women worldwide is due to iron deficiency, but there are other causes of anaemia, to include: hookworm infections, other deficiences in nutrition, especially folate and vitamins A, B12, and C, conditions inherited at birth, such as an inherited blood disease known as ‘sickle cell disease.

Malaria is a very common cause of anaemia, and anaemia is a particularly important complication of malaria in pregnant women. In places where malaria is common, pregnant women, especially women who are pregnant for the first time, are more at risk of severe anaemia.

Can a pregnant woman get iron from the foods that she eats?

Yes, but it's difficult for a pregnant woman to get all of the iron she needs through food alone. That is why pregnant women are given iron/folic acid supplements.

Which foods contain iron?

Some examples include meats, fish insects and dark green leafy vegetables.

It is best to eat food containing iron together with a food containing Vitamin C. This will help the body to absorb the iron better. Some examples of Vitamin C-enriched foods are citrus fruits and tomatoes.

What if our staple foods are fortified with iron? Should the pregnant woman still take the supplements?

Pregnant women should still take iron tablets because the level of iron in fortified foods is very low and a pregnant woman needs more than what fortified foods alone will provide.

The levels of iron in fortified foods are set at a lower level because everyone in the population needs to consume them.

What is folate and what is folic acid?

Folate is a naturally occuring vitamin. Folic acid is the synthetic form used as a supplement or available in fortified food. The folic acid supplement is usually combined with the iron supplement.

Why is folate important?

It plays a big role in the production of new cells in the body, and is particularly important during periods of rapid cell formation such as pregnancy and infancy.

Folate, like iron, is also very important in preventing anaemia.

Folic acid protects against neural tube defects. These defects can lead to malformations of the spine (spina bifida – where the spinal cord does not become enclosed by a spinal column), or of the brain (anencephaly – an infant’s brain does not develop).

What foods contain folate?

Some examples include leafy vegetables, lettuce, legumes (nut and beans), sunflower seeds

How often should a pregnant woman take iron/folic acid supplements?

Recommendations may vary based on government policy in your country. The pregnant woman will be instructed when she goes to the clinic for ante-natal care.

Questions: De-worming:

What are the main worms that we are concerned about?

Soil Transmitted Helminth (STHs) is the scientific name for the worms that we are concerned about. There are three main species that affect humans: Roundworm, Whipworm, and Hookworms.

While STHs are the most common worms we are concerned about, another type of parasite is known as Schistosomiasis.

How do we get infected with STHs?

These worms live inside the infected person, and they produce thousands of eggs each day. These eggs pass out through the faeces. If a person defecates outside, or if faeces are used as a fertiliser, eggs are deposited on the soil. The eggs can then become infective after about 3 weeks.

Infections in humans are caused by: Ingestion (eating) of infective eggs from soil contaminated with human faeces, eating infected eggs in contaminated food, such as vegetables that are not carefully cooked, washed or peeled, or worms penetrating the skin when walking barefoot on contaminated soil.

One person cannot pass worms to another person through their faeces because eggs in faeces need about 3 weeks in the soil before they become infective.

What are the symptoms of worms in adults?

Symptoms may include stomach problems such as diarrhoea and pain or discomfort and general tiredness and weakness.

What are some of the results of being infected with worms?

Some results may inlcude blood loss in the intestine that can result in anaemia, lowered immunity, malnutrition, and blockages in the intestine which may require surgery.

Why do we need to treat worms in pregnant women and women of childbearing age?

Hookworm infections cause anaemia in women, and when a woman becomes pregnant, this anaemia can cause: Illness or death of the mother, the baby's growth to be slowed, early delivery of the baby, and/or low birth weight of the baby.

Low birth weight is a risk factor for the baby which can lead to increased illness or death. The baby may never catch up in terms of growth and, as an adult, will run an increased risk of chronic illness such as heart disease and diabetes.

If worm infections exist with other more severe infections such as HIV, malaria or TB, the effects will be even more serious, leading to very poor nutrition, poor ability to fight illness, and possibly damage to the internal organs of the body.

In many cases, untreated worm infections are undoing all the positive work being done to improve the mother and child’s health and nutrition. If the mother and child are eating well but have worm infections, it is as if they are not eating well.

How can we avoid becoming infected with worms?

The main risks for worm infections are related to unclean water and poor sanitation. Proper disposal of human waste is especially important, since a small amount of faeces can contain up to 100 eggs.

To control worm infections in areas where they are common, there should be treatment with medicines of all at-risk populations living in these endemic regions.

To reduce the spread of worms, these actions are important:

More people using latrines instead of defecating outdoors
Appropriate hand washing and preparation of food
Using footwear, not walking barefoot
Clean water for personal hygiene
Not using uncomposted human faeces as fertilizer

Who is most at risk for worm infections?

Populations at risk in endemic areas for STH are: preschool-aged children, school-aged children, women of childbearing age, and pregnant women in the second and third trimesters

What is the main objective of a de-worming program?

While the main objective is to reduce worm infections in humans, it is also to keep the levels of infection low. Death and illness is directly related to how heavy the worm infection is in the person's body: the greater the number of worms in the infected person, the worse the problem will be.

Through the de-worming program, even if you are infected with worms, the quantity of worms won't be as heavy as it would have been without the de-worming.

Do I need to be dianosed with worms to get the medicine?

No. De-worming medicines are given without an individual diagnosis. Your Ministry of Health will determine how frequent your de-worming program should occur- usually once or twice or year, depending on how much worm infections there is in your country.

What medicines are used in de-worming programs?

The World Health Organization (WHO) has recommended medicines for STH de-worming called Albendazole and Mebendazole.. These medicines are effective, inexpensive and easy to administer, even by non-medical people. For example, teachers can give de-worming medicine. These medicines have been through many safety tests and have been used in millions of people with very few and very minor side-effects.

Besides STH, what other worms are we concerned about?

Known as blood flukes or tremadode worms, these worms are found in the water and are responsible for a disease called Schistosomiasis or Bilharzia.

Bilharzia is most commonly found in Africa, as well as parts of Asia and South America.

How do people get infected with Bilharzia?

When people suffering from Bilharzi contaminate freshwater with their faeces, the eggs in the faeces hatch in the water. Snails then eat the eggs and release larvae into the water, which can enter the skin of people who are in contact with the infested water. This means you should not swim in lakes or ponds that are known or suspected to be contaminated.

What are the symptoms of Bilharzia?

There are two types of Bilharzia, with different symptoms: Bilharzia of the intestine and Urogenital Bilharzia.

Bilharzia of the intestine can result in stomach pain, diarrhoea and blood in the faeces. Liver enlargement is also common in advanced cases. Urogenital Bilharzia can cause blood in the urine. In women you may find lesions on the genitals and bleeding from the vagina. In men, urogenital bilharzia can cause problems with seminal vesicles, prostate and other organs. Kidney failure and bladder cancer are possible complications in the later stages. This disease may also have other long-term irreversible consequences, including infertility.

What is the recommended medicine for Bilharzia?

Praziquantel is the name of the de-worming medicine recommended to treat all forms of Bilharzia. It is effective, inexpensive and easy to administer, even by non-medical personnel such as teachers. Praziquantel been through many safety tests and have been used in millions of people with very few and very minor side-effects when used in accordance with Ministry of Health screening protocols.

How can I know if a pond of lake is infected with Bilharzia?

There is no way of knowing if a pond or lake is infected with Bilharzia just by looking at it. However, there are some things to keep in mind when trying to detect whether or not the water holds a risk for Bilharzia: if the water is fresh water(not sea water), if there are snails in the water, if the water is shallow, and if there are reeds or grass growing in the water.