TOR/SOW to hire lab agency for

Comprehensive National Nutrition

Survey (CNNS)
Section

Content

Definition
of
requiremen
t

The selected lab agency will require collecting blood, urine and
stool samples to provide comprehensive nutritional profiling of
preschoolers (0-5 years), school-age children (6-14 years) and
adolescents (15-19 years) in 30 states of India. List of the
required indicators are given in annexure 1. The
anthropometry and behavioural related data will be collected
by other survey agencies. The selected lab agency will
coordinate with the survey agencies during household data
collection for collecting the blood, urine and stool samples
from selected subjects across the 30 states of India and
around 2500 locations (refer annexure 2) and provide the
results.

Objective

To estimate a nationally representative and comprehensive

nutritional profiling of preschoolers (0-5 years), school-age
children (6-14 years) and adolescents (15-19 years) in a robust
manner to provide the true nutrition burden at national and
states level among three age groups.

Background India has one of the worlds highest child undernutrition rates.
The 2006 National Family Health Survey shows that 48% of
Indian children under five are stunted and 70% are anaemic.
Importantly, micronutrient deficiencies are highly prevalent in
India due to the poor quality of diet. A number of small-scale
surveys have indicated a high prevalence of deficiencies of
iron, vitamin A, folic acid, and other B-vitamins, which serves
as the main underlying cause of anaemia. Even mild to
moderate deficiencies of micronutrients lead to impaired
cognitive development, poor physical growth, increased
morbidity, and decreased work productivity in adulthood.
Increasing evidence shows that deficiencies of other
micronutrients such as vitamin D and zinc are also very
common in Indian children. Vitamin D status is strongly linked
to the risk of developing osteoporosis and cancers of the
breast, colon, prostate, and ovary later in life. Zinc deficiency
leads to deficits in cognitive and motor function and

contributes to an increased incidence and severity of diarrhea

and pneumonia. Moreover, a large proportion of Indian
children are affected by worm infestation, aggravating the
incidence and prevalence of underweight and anaemia.
Importantly, however, no nationally representative data on the
micronutrient status and worm infestation of preschool
children exist in India. The most relevant information comes
from the 2012 National Nutrition Monitoring Bureau (NNMB)
Survey conducted in 10 states which assessed the population
intake of micronutrients from food consumption data and
clinical
signs
of
micronutrient
deficiencies.
Clearly,
micronutrient status and worm infestation measured by
biochemical indicators have not been examined in any of the
existing and planned national surveys.
Recently, nutrition in school-age children and adolescents has
been receiving growing attention in India. Available evidence
indicates that more than one third of Indian school-age
children and adolescents are thin and more than half the
adolescent girls aged 15-19 years are anaemic. Micronutrient
deficiencies and worm infestation are likely to be ubiquitous.
Widespread undernutrition in these age groups poses a
significant threat to their ability to fulfil their potential,
impedes progress towards Education for All, and slows down
economic and national development.
Notably, India has been increasingly confronted with the
double burden of malnutrition, characteristically defined by
the coexistence of under- and over-nutrition. An increased
prevalence of overweight and obesity is observed in children
and adolescents, which has life-long consequences for noncommunicable diseases (NCD) in adulthood. In addition, poor
eating habits, lack of physical exercise, high glucose
concentrations, and harmful lipid profiles during adolescence,
which are all linked to NCDs in adulthood, are likely to be
increasing.
Despite these devastating nutritional challenges, there is a
dearth of information on the current nutritional status of
school-age children and adolescents in India. School-age
children and adolescents have often been excluded from
health and nutrition surveys and surveillance. Although
anthropometry and hemoglobin data will be collected in some

of the planned national survey (NFHS-4), micronutrient status,

worm infestation, and the nutritional risk factors for NCDs such
as physical fitness, blood pressure, glucose concentration and
lipid profiles have never been assessed among school-age
children and adolescents in India.
Rationale
It is evident that contemporary and nationally representative
data is virtually non-existent on several important facets to
determine the true malnutrition burden, reorient policy
according to needs of nutrition transition and serve as a
baseline to evaluate progress of recently launched important
initiatives such as the Rashtriya Kishor Swasthya Karyakram
(RKSK), Rashtriya Bal Swasthya Karyakram (RBSK), and
National Iron Plus Initiative (NIPI). There is an urgent need to
dissect out the settings, burden and potential functional
consequences of both undernutrition and overnutrition so that
interventions initiated to remedy the former may not worsen
the latter (for example, food supplementation). The
noteworthy evidence gaps include anthropometric assessment
of school children, biomarkers of important micronutrient
deficiencies and cardio-metabolic risk, body composition,
physical activity patterns, muscular strength, fitness, diet
diversity and non-nutrient factors (sub-clinical inflammation,
STH infection, education, and WASH practices). The proposed
comprehensive nutritional survey is being designed to
generate robust evidence on these aspects.
Intended
user/s

The survey will provide the first-ever national data on the

micronutrient status and worm infestation of children and
adolescents in India. The information will help elucidate the
major determinants of anaemia in children and adolescents,
and
evaluate
the
impact
of
the
national
micronutrient/deworming programmes. It will also be the first
national efforts to document the extent and severity of over
nutrition and nutritional risk factors for NCD among school-age
children and adolescents at a national scale. These findings
will serve as useful baseline data for important new initiatives
such as the RKSK, RBSK, and NIPI and provide an
unquestionable
evidence
base
for
advocacy,
policy
development, and programme design with the Government of
India and State Governments.

Location/

Sample collection from all 30 Indian states

duty
Station of
work
Total
Total 15 months from start date
duration of
the
assignment
Travel
Around 2500 villages/wards in 30 states - refer annexure 2
requiremen
t
Scope
Work

of Roles and Responsibilities:

Identify/recruit team (for e.g. team leader, medical
coordinators cum master trainers, quality assurance
supervisors, health investigator for sample collection)
Sending master trainers to attend centralized TOT
organized by lead agency to understand operation
Organize states level trainings for lab team by master
trainers on standard operating procedure (SOP) and ethical
issues under the supervision of quality control (QC) lab
Collections of blood, urine and stool samples of
preschoolers (0-5 years), school-age children (6-14 years)
and adolescents (15-19 years) in the 30 states (around
60,000 subjects) under the monitoring and supervision of
QC lab, lead agency and UNICEF
Transportation of blood, urine and stool samples to
designated laboratory centre within stipulated time
Use best standard methods/technics to measure required
indicators listed in annexure 1.
Ensure quality of sample collection and coordinate with QC
lab/lead agency
Submit results of ongoing samples by unique ID in
electronic medium to lead agency and QC lab

Methodolog As stated before, there is a need to conduct blood, urine and

stool tests using internationally recognised standard to provide
y
comprehensive nutritional profiling of pre-schoolers, schoolage children and adolescents to measure required indicators
listed
in
annexure
1
through
best
standard
methods/procedures. The anthropometry and behavioural data
will be collected by other survey agencies and randomly
selected subjects will be assigned to lab agency to collect the
blood, urine and stool samples. The lab agency will coordinate
with the survey agencies to get the subject name and address
to collect the sample next day as soon as possible. There will
be around 24 subjects in one location (village in rural area and
ward in urban area) to collect the sample equally (eight) from
the three age groups. The survey will cover around 2500

locations across the 30 sates (refer annexure 2).

Supervisor Praween K. Agrawal
Reporting Weekly updates on sample collection by states
frequencies Monthly progress report of whole lab agency work
Performanc Yes, as stated above and listed in deliverables
e/ Progress
Reporting
Requireme
nts
References No significant difference in the lab agency results from the QC
to
lab (maximum 5 %)
standards
Deliverable Deliverables:
1. An inception report on operational plan detailing
s
recruitment and training of lab team, test type (for e.g.
type of biomarkers), detailed analysis procedure,
monitoring and supervision of sample collection,
coordination mechanism with survey team, quality
assurance plan and SOP with timeline within two
months of contract signed
2. A report on training attended by their medical coordinators
cum master trainers with day wise attendance list within
a week of TOT
3. State-wise report on training organized for lab team (quality
supervisors, sample collectors) by medical coordinators
cum master trainers with day wise attendance list within
a week of state training by survey agency
4. State-wise field movement plan as per household survey
team (list and phone number of quality supervisors and
sample collectors) one week before movement
5. Fortnightly progress report on sample collection and quality
assurance report along with photographs from field
6. Results of collected samples by unique ID (by village/ward)
in electronic medium - within a week of collection
7. State-wise fieldwork completion report- within a week of
completion
Payment
schedule

Deliverables:
1. On receipt of inception report 15%
2. On approval of inception report for TAC 15%
3. A report on training with day wise attendance list 10%
4. Completion report of 10 states 15%
5. Completion report of other 10 states 15%
6. Completion report of rest 10 states 15%
7. Completion report from lead agency about all states data
merged with household survey data 15%

Qualificatio n
requiremen ts
-

Team leader Mater in Pathology (preferably PhD) AND

must have experience in handling blood products
Medical coordinators cum master trainers - Mater in
pathology AND must have experience in handling blood
products
Health investigators - Graduate in Medical lab
technology/ B Pharma/ BUMS/BHMS/BAMS/ Degree in
Nursing or Diploma in Medical lab technology AND must
have experience in blood collecting/handling blood products

Technical
evaluation
criteria and
weight
allocated
between
technical
and price
proposal
(please
consult
supply
specialist
before
arriving at
this
section)

Weight assigned- (50% Technical and 50% Price)

Scope of
work need
to be
completed
by -

Tick appropriate
With one and only one agency
With one and more agencies
With one individual

Annex for
preparation
of
proposals

Annexure 1. List of indicator to measure by lab in the three

age groups
Annexure 2: Approx. number of village/ward to cover for
required sample size by states

Annex for
reporting
mechanism

Technical Proposal (50%)

Agency background and experience of conducting similar
work [25%]
Proposing best standard methods/procedures to measure
indicators listed in annexure 1 [25%]
Quality assurance mechanism [25%]
Team composition for viability of survey, implementation
plan along with risk assessment and mitigation plan [25%]

NA

This section is for internal use and must be part of all TOR/ MOU
Suggestive format for assumptions to be identified with each task/ deliverables S. Objectives
No.

Activities

To estimate a
nationally
representative
and
comprehensiv
e nutritional
profiling of
preschoolers
(0-5 years),
school-age
children (6-14
years) and
adolescents
(15-19 years)
in a robust
manner to
provide the
true nutrition
burden at
national and
states level

Resources Deliverables
/
with
Assumptio milestones
ns

Use best standard Available

methods/technics
to measure
required indicators
Identify/recruit lab
team
Centralized TOT
/States level
trainings for lab
team on operation
and SOP
Collections of
blood, urine and
stool samples
(around 60,000
subjects)
Transportation of
samples to
designated
laboratory centre
within stipulated
time
Ensure quality of

Operational
plan SOP
submitted by
8th week of
contract

Risks Risk mitigation plan Effect of

identified
Risk on
project
Delay in
Regular TAC
TAC/MHFW meeting at every
approval
development
Make Government
office take
responsibility to
own the whole
project
Team work

Field work
completed
High cost
and lab results
shared to lead
agency to
merge with
unique ID of
household
survey in one
year time

Negotiation with all

possible labs

Projected
time may
increase
Cost
implication

among three

age groups

sample collection
Submit results of
ongoing samples
by unique ID in
electronic medium

Examples of reporting clear deliverable linking with activities

#

Activities/ Tasks

Duration

Deliverables

Mileston
e

Preparatory phase:
Develop operational plan (team
composition, quality assurance,
coordination mechanism to shared
results with lead agency etc.) and
SOP for the proposed assignment
Hold discussions/meetings with
UNICEF/TAC/lead agency
Finalize the operational plan SOP
and

8 weeks
4 weeks

Inception report
Will lay out the detailed operational
plan and readiness to launch the
survey providing details about team
composition, quality assurance,
coordination mechanism to shared
results with lead agency and SOP

Operation
al plan
and SOP
submitted
by 8th
week of
contract

Field work:
Undertake training of lab teams
Collect sample and provide the test
results

3rd month
4th to 15th
months

1. A report on training attended by

their medical coordinators cum
master trainers with day wise
attendance list within a week of
TOT
2. State-wise
report
on
training
organized for lab team (quality
supervisors, sample collectors) by
medical coordinators cum master
trainers with day wise attendance
list within a week of state
training by survey agency
3. State-wise field movement plan as
per household survey team (list and

Field work
complete
d and lab
results
shared to
lead
agency to
merge
with
unique ID
of
household
survey in
one year

2 weeks
2 weeks

phone
number
of
quality
supervisors and sample collectors)
one week before movement
4. Weekly sample collection progress
report and data quality assurance
report along with photographs from
field - within a week
5. Results of collected samples by
unique ID (by village/ward) in
electronic medium - within a week
of collection
6. State-wise fieldwork completion
report- within a week of
completion

Annexure 1. List of indicator to measure by lab in the three age groups

Nutritional
Indicator Group
Body
Composition
Physical fitness
Anemia and
hemoglobinopat
hies
Inflammatory
biomarkers
Protein
Micronutrients

Preschool Children
(0 - 5 years)
Bioimpedance

School-age Children
(6 - 14 years)
Bioimpedance

Adolescents
(15-19 years)
Bioimpedance

Hemoglobin
Variant Hemoglobins

Hand Grip Strength

Hemoglobin
Variant Hemoglobins

Hand Grip Strength

Hemoglobin
Variant Hemoglobins

C-reactive protein

C-reactive protein

C-reactive protein

Serum protein and albumin

Iron: Ferritin, Serum transferrin
receptor
Vitamin A: Serum retinol
Iodine : Urinary Iodine
concentration, TSH
Zinc : Serum zinc
B-vitamins: erythrocyte folate,
Serum B12, Methyl-malonic acid
Vitamin D: Serum 25 (OH) D

Serum protein and albumin

Iron: Ferritin, Serum transferrin
receptor
Vitamin A: Serum retinol
Iodine : Urinary Iodine
concentration, TSH
Zinc : Serum zinc
B-vitamins: erythrocyte folate,
serum B-12, Methyl-malonic
acid Vitamin D: Serum 25
(OH) D
Blood Pressure
Blood Glucose, HbA1C
Lipid profile: Serum
cholesterol, HDL/LDL,
Triglycerides
Renal function: Serum
creatinine, urinary protein
creatinine ratio
Stool samples

Serum protein and albumin

Iron: Ferritin, Serum transferrin
receptor
Vitamin A: Serum retinol
Iodine : Urinary Iodine
concentration, TSH
Zinc : Serum zinc
B-vitamins: erythrocyte folate,
serum B-12, Methyl-malonic
acid Vitamin D: Serum 25
(OH) D
Blood Pressure
Blood Glucose, HbA1C
Lipid profile: Serum cholesterol,
HDL/LDL, Triglycerides
Renal function: Serum
creatinine, urinary protein
creatinine ratio

Non
communicable
Diseases

Soil transmitted

Stool samples

Stool samples

Nutritional
Indicator Group
heminthiasis

Preschool Children
(0 - 5 years)

School-age Children
(6 - 14 years)

Adolescents
(15-19 years)

Annexure 2: Approx. number of village/ward to cover for required

sample size by states and urban rural area
States
Urban
Rural
Total
Arunachal Pradesh
25
48
73
Assam
25
53
78
Bihar
25
80
105
Chhattisgarh
25
48
73
Goa
38
25
63
Gujarat
28
60
88
Haryana
25
40
65
Himachal Pradesh
25
55
80
Jammu & Kashmir
25
70
95
Jharkhand
25
48
73
Karnataka
25
38
63
Kerala
30
33
63
Madhya Pradesh
25
70
95
Maharashtra
78
60
138
Manipur
25
43
68
Meghalaya
25
50
75
Mizoram
33
30
63
Nagaland
25
45
70
NCT of Delhi
60
25
85
Odisha
25
50
75
Punjab
25
38
63
Rajasthan
25
70
95
Sikkim
25
45
70
Simandhra
25
40
65
Tamil Nadu
80
33
113
Telangana
75
40
115
Tripura
25
45
70
Uttarakhand
25
98
123
Uttar Pradesh
25
43
68
West Bengal
75
68
143
INDIA
1020
1485
2505