The work of the Micronutrient Initiative in Latin America & the Caribbean. 1
1. Bolivia, commonly acknowledged to be the poorest country in non-Caribbean Latin America, has an under-five mortality rate of 66[1]. 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 counterparts[2]. 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 anemic[4]. 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 diseases[5]. 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 salt3.
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
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 (http://www.sns.gov.bo/bolsns/mon_indica/genera.asp). 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 strategy.
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 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.
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 products).
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 (“Chispitas[6]”) 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: zboutilier@micronutrient.org
11. Guatemala has an U5MR of 45[7]. It is estimated that 21% of Guatemalan children under the age of five are deficient in Vitamin A[8]. 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 anemia[9].
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 Verapaz).
For further information please contact Zoë Boutilier: zboutilier@micronutrient.org
16. Haiti has an U5MR of 117[10], 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 A[11]. 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 [12]. 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
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.
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: zboutilier@micronutrient.org
26. Nicaragua is at a relatively advanced stage in terms of ongoing national level control of micronutrient malnutrition.
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 place.
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: zboutilier@micronutrient.org
[2] UNICEF. Regional Disparities in LAC: Rapid Nutritional Assessment 2003.
[3] MICRONUTRIENT INITIATIVE: VMD global progress report 2004.
[4] PAHO, unpublished National Food Intake and Iron Status Survey, 2003.
[6] A SprinklesTM product developed for the Bolivian context
[7] UNICEF SOWC 2005.
[8] MICRONUTRIENT INITIATIVE: VMD global progress report 2004
[9] Encuesta Nacional de Salud Materno Infantil 2002 (ENSMI2002). Ministerio de Salud Publica y Asistencia Social de Guatemala (MSPAS). Guatemala, October 2003.
[10] UNICEF SOWC 2005
[11] Survey of the Prevalence of Vitamin A and Iodine Deficiency in Haiti, July 2005, Institut Haitien de l’Enfance
[12] Survey of the Prevalence of Vitamin A and Iodine Deficiency in Haiti, July 2005, Institut Haitien de l’Enfance