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Anaemia in African children
Anaemia is a serious and common problem among young children in sub-Saharan Africa. As a first step towards developing guidelines for its recognition and treatment, we conducted a study to evaluate the ability of health workers to use clinical findings to identify children with anaemia. Health care workers examined a total of 1104 children under 5 years of age at two hospital-based outpatient clinics in rural Malawi. Blood samples were taken to determine haemoglobin concentrations. Pallor of the conjunctiva, tongue, palm or nail beds was 66% sensitive and 68% specific in distinguishing children with moderate a anaemia (haemoglobin concentration, 5-8 g/dl) and 93% sensitive and 57% specific in distinguishing those with severe anaemia (haemoglobin concentration, < 5 g/dl). Even without laboratory support, which is often unavailable in rural Africa, clinical findings can identify the majority of children with anaemia.
Luby SP. Kazembe PN. Redd SC. Ziba C. Nwanyanwu OC. Hightower AW. Franco C. Chitsulo L. Wirima JJ. Olivar MA.
Using clinical signs to diagnose anaemia in African children.
Bulletin of the World Health Organization. , 1995.
Anaemia and Plasmodium falciparum infections
Although the aetiology of anaemia in tropical areas is multifactorial,
Plasmodium falciparum malaria is commonly associated with anaemia in
children living in holoendemic malaria areas. Such an association was
examined in a population based study of 338 children 6 to 40 months of age
living in the Bagamoyo area of Tanzania. Stepwise regression analysis
showed that fever and parasitaemia were effective in predicting anaemia
and that the anaemic condition was age dependent. The majority of the
children were iron deficient, followed by normochromic macrocytic
anaemias. There was strong evidence in this age group that the anaemia was
associated with malaria and not geohelminth infection. The importance of
malaria and anaemia as a cause of childhood morbidity in Africa is
discussed. This condition has taken on new significance with the
realization that blood transfusions commonly used to treat severe anaemia
are a major vehicle for Human Immunodeficiency Virus (HIV) transmission.
Premji Z. Hamisi Y. Shiff C. Minjas J. Lubega P. Makwaya C.
Anaemia and Plasmodium falciparum infections among young children in an
holoendemic area, Bagamoyo, Tanzania.
Acta Tropica. 59(1):55-64, 1995 Mar.
The haematological profile of urban black Africans
A stratified probability sample (n = 986) with quotas was drawn from black
residential areas in the Cape Peninsula, South Africa. Subjects (n = 819)
aged 15-64 years, participated in a coronary heart disease (CHD) risk
factor survey, the BRISK Study. Nutritional status and prevalence of CHD
was determined in this population undergoing rapid urbanization. Full
blood and differential white blood cell counts provided data to calculate
population reference values based on the 95% reference limits of the
haematological parameter. Mean haemoglobin concentrations (Hb) in men
(14.0 g/dl) and women (12.4 g/dl) were +/- 1.5 g/dl lower than previous
South African reports. Mean BRISK Hb values were very similar to the World
Health Organization's Hb cutoff criteria (< 13 g/dl men; < 12 g/dl women),
indicating a possible high prevalence of anaemia. Significantly higher (P
< 0.05) mean values for red cell indices were confirmed in men, which also
reflected equally higher red blood cell counts (RBC), haematocrit (HCT)
and mean corpuscular haemoglobin (MCH) values. Mean Hb values were
significantly lower in the younger (15-24 years) and older (55-64 years)
men compared with 25-54 year-olds (P < 0.05). Hypochromic microcytic
anaemia was more prevalent in women, possibly due to iron deficiency (ID),
while macrocytic anaemia was more prevalent in men. No significant
differences were noted in mean total and differential white blood cell
counts (WBC) between men and women.(ABSTRACT TRUNCATED AT 250 WORDS)
[References: 32]
Badenhorst CJ. Fourie J. Steyn K. Jooste PL. Lombard CJ. Bourne L. Slazus W.
The haematological profile of urban black Africans aged 15-64 years in the Cape Peninsula. [Review]
East African Medical Journal. 72(1):19-24, 1995 Jan.
Haematological condition of the San
A cross-sectional study was undertaken to assess the haematological
condition of the San (Bushmen) relocated from Namibia to South Africa. We
studied 238 subjects--145 men and 93 women; none of the women was
pregnant. We performed full blood counts and estimations of serum vitamin
B12, folate, ferritin and erythrocyte folate concentrations. The mean
haemoglobin concentration among the men was 14.7 g/dl and 19 (13%) were
anaemic; among the women it was 13.8 g/dl and 18 (19%) were anaemic.
Thirteen (9%) of the men and 22 (24%) of the women had low concentrations
of serum ferritin, and 38 (26%) of the men and 22 (24%) of the women had
erythrocyte folate concentrations of less than 270 nmol/l. Three (2%) men and 4 (4%) women had serum vitamin B12 concentrations of less than 120
pmol/l. Eighty-one (56%) of the men and 76 (82%) of the women had
eosinophilia, probably because of parasitic infections. It would appear
from this and previous studies that prolonged exposure of these
hunter-gatherers to a Western lifestyle has resulted in a high prevalence
of anaemia, caused by low iron and folate intakes, complicated by alcohol
consumption.
Registry Numbers
59-30-3 (Folic Acid). 68-19-9 (Vitamin B 12). 9007-73-2 (Ferritin).
Coetzee MJ. Badenhorst PN. de Wet JI. Joubert G.
Haematological condition of the San (Bushmen) relocated from Namibia to
South Africa.
South African Medical Journal. 84(7):416-20, 1994 Jul.
Megaloblastic anaemia
In a study of the pathogenesis and clinical features of megaloblastic anaemia in southern Africa, we evaluated 144 consecutive Zimbabwean patients with megaloblastic haemopoiesis. Vitamin B12 deficiency was diagnosed in 86.1% of patients and was usually due to pernicious anaemia; isolated folate deficiency accounted for only 5.5% of cases. Anaemia was present in 95.8% of patients; the haemoglobin (Hb) was < or = 6 g/dl in 63.9%. Neurological dysfunction was noted in 70.2% of vitamin B12-deficient patients and was most striking in those with Hb values > 6 g/dl. Serum levels of methylmalonic acid, homocysteine, or both, were
increased in 98.5% of patients. Vitamin B12 deficiency is the primary cause of megaloblastic anaemia in Zimbabwe and, contrary to textbook statements, is often due to pernicious anaemia. Isolated folate deficiency
is less common. As reported in industrialized countries 75 years ago, anaemia is almost always present and often severe. Neurological dysfunction due to vitamin B12 deficiency is most prominent in patients
with mild to moderate anaemia.
Registry Numbers
0 (Gastrins). 0 (Hemoglobins). 454-28-4 (Homocysteine). 516-05-2
(Methylmalonic Acid). 59-30-3 (Folic Acid).
Savage D. Gangaidzo I. Lindenbaum J. Kiire C. Mukiibi JM. Moyo A.
Gwanzura C. Mudenge B. Bennie A. Sitima J. et al.
Vitamin B12 deficiency is the primary cause of megaloblastic anaemia in Zimbabwe [see comments] British Journal of Haematology. 86(4):844-50, 1994 Apr.
Sickle cell anaemia
The hospital records of 62 Zambian children with sickle cell anaemia (SCA) who died during a 3 year period (January 1987 to December 1989) at the Paediatric Wing of the University Teaching Hospital, Lusaka, Zambia, were reviewed retrospectively. The SCA patients accounted for 2.92 percent of the total admissions and the average case fatality was 6.61 percent of the total SCA admissions. The case fatality rate has reduced considerably as compared to the one observed in 1970 in Zambia, although the major causes of death remain the same. The maximum mortality was noted in the age group of one to five years (54.84%). The common causes of death were infections (29.54%), vasoocclusive crises (22.72%) and splenic sequestration crises
(20.45%). The problems of sub-Saharan Africa, like malaria, malnutrition and now the HIV infection also adde to the mortality (15.90%).
Athale UH. Chintu C.
Clinical analysis of mortality in hospitalized Zambian children with sickle cell anaemia.
East African Medical Journal. 71(6):388-91, 1994 Jun.
Anaemia and blood transfusion
Severe anaemia among women in sub-Saharan Africa is frequently treated with blood transfusions. The risk of transmission of human immunodeficiency virus (HIV) through blood products has led to a
re-evaluation of the indications for transfusions. Prospective surveillance of women admitted to a district hospital in western Kenya was conducted from 1 December 1990 to 31 July 1991, for haemoglobin (Hb)
transfusion status, and outcome. Of the 2986 enrolled women (mean Hb 10.4 g/dL, SD +/- 2.6, median age 24.4 years), 6% were severely anaemic (Hb <6.0 g/dL). Severe anaemia was associated with a higher mortality rate (10.7% vs. 1.4%, odds ratio (OR) = 8.2, 95% confidence interval (CI) 2.6, 34.2) compared with women with Hb > or = 6.0 g/dL. Decreased mortality rates in hospital were observed with increasing Hb values (OR = 0.43, 95% CI 0.19, 0.98), but blood transfusions did not improve survival in hospital (OR = 1.56, 95% CI 0.22, 11.03). The attributable mortality due to HIV infection and severe anaemia was 75% and 31%, respectively. Maternal/child health care services must include prevention strategies for HIV transmission and the prevention, recognition, and treatment of severe anaemia.
Registry Numbers 0 (Hemoglobins).
Zucker JR. Lackritz EM. Ruebush TK. Hightower AW. Adungosi JE. Were
JB. Campbell CC.
Anaemia, blood transfusion practices, HIV and mortality among women of reproductive age in western Kenya.
Transactions of the Royal Society of Tropical Medicine & Hygiene.
88(2):173-6, 1994 Mar-Apr.
Anaemia and plasmodium
Although the aetiology of anaemia in tropical areas is multifactorial, Plasmodium falciparum malaria is commonly associated with anaemia in children living in holoendemic malaria areas. Such an association was
examined in a population based study of 338 children 6 to 40 months of age living in the Bagamoyo area of Tanzania. Stepwise regression analysis showed that fever and parasitaemia were effective in predicting anaemia and that the anaemic condition was age dependent. The majority of the children were iron deficient, followed by normochromic macrocytic anaemias. There was strong evidence in this age group that the anaemia was associated with malaria and not geohelminth infection. The importance of malaria and anaemia as a cause of childhood morbidity in Africa is discussed. This condition has taken on new significance with the
realization that blood transfusions commonly used to treat severe anaemia are a major vehicle for Human Immunodeficiency Virus (HIV) transmission.
Premji Z. Hamisi Y. Shiff C. Minjas J. Lubega P. Makwaya C.
Anaemia and Plasmodium falciparum infections among young children in an
holoendemic area, Bagamoyo, Tanzania.
Acta Tropica. 59(1):55-64, 1995 Mar.
Surgical management of severe anaemia
Twenty one consecutive patients who had an average packed cell volume (PCV) of 16.2% (range 13-25) due to acute blood loss were treated surgically without perioperative blood transfusion. All the surgical
procedures were carried out under intravenous ketamine hydrochloride. The surgical wound in each patient healed by primary intention. The packed cell volume rose to 35% and above in an average of six weeks by use of oral haematinics. The only morbidity observed was dizziness which lasted for an average of six days in ten patients. There were no deaths and all the patients remained well at an average follow-up period of 42 weeks. The study shows that perioperative blood transfusion can be avoided in surgical care of most patients who have severe anaemia due to acute blood loss without mortality and without significant morbidity.
Elechi EN. Elechi GN.
Surgical management of patients with severe anaemia due to acute blood
loss: a case for withholding perioperative blood transfusion.
East African Medical Journal. 72(6):343-4, 1995 Jun.
Chicken anaemia virus
The coding information for three putative chicken anaemia virus proteins (VP1, VP2, VP3) was inserted into a baculovirus vector and expressed in insect cells. The immunogenic properties of the chicken anaemia virus
(CAV) proteins produced separately or together in insect-cell cultures were analysed by inoculating them into chickens. Only lysates of insect cells which have synthesised equivalent amounts of all three recombinant
CAV proteins or cells which synthesised mainly VP1 plus VP2 induced neutralising antibodies directed against CAV in inoculated chickens. Progeny of those chickens were protected against clinical disease after
CAV challenge. Inoculation of a mixture of lysates of cells that were separately infected with VP1-, VP2- and VP3-recombinant baculovirus did not induce significant levels of neutralising antibody directed against
CAV and their progeny were not protected against CAV challenge. Our results indicate that expression in the same cell of at least two CAV proteins, VP1 plus VP2, is required to obtain sufficient protection in
chickens. Therefore, recombinant CAV proteins produced by baculovirus vectors can be used as a sub-unit vaccine against CAV infections.
Koch G. van Roozelaar DJ. Verschueren CA. van der Eb AJ. Noteborn MH.
Immunogenic and protective properties of chicken anaemia virus proteins
expressed by baculovirus.
Vaccine. 13(8):763-70, 1995.
Anaemia in pregnancy
This study was performed to assess the pregnant women's knowledge and attitudes towards anaemia, its causes, prophylaxis, and treatment and to describe existing problems with interventions for anaemia in antenatal clinics. A total of 310 women were interviewed from three MCH-clinics in suburban Dar-es-Salaam. Anaemia was considered a major problem by 88% and 75%, respectively in the two peripheral MCH clinics, but by only 44% of attenders in the hospital MCH clinic. Over 85% of interviewees were aware of the causes of and ways of preventing anaemia. The most frequently mentioned cause of anaemia were related to nutrition while intestinal parasites was mentioned by a few women. Only 5% believed that anaemia might not be dangerous for the mother. In all three clinics more than 90% were aware of the advantages of early booking for antenatal care. None of the mothers had received any ferrous supplements during the current pregnancy, and only a minority (38%) in the previous pregnancy though 40% of them said they were informed they had anaemia in the previous pregnancy. Side effects were not reported as a reason for non-compliance. Thus, mothers were aware that anaemia is a health problem in pregnancy. They would accept effective intervention if they were offered them. The irregular and inadequate supply of haematinics to antenatal clinics is a
far more important obstacle to the implementation of the anaemia prevention programme than the knowledge and attitudes of the mothers.
Massawe S. Urassa E. Lindmark G. Nystrom L. Anaemia in pregnancy: perceptions of patients in Dar-es-Salaam. East African Medical Journal. 1995 Aug.
Anaemia and renal failure
Epoetin alfa is a recombinant form of erythropoietin, a glycoprotein hormone which stimulates red blood cell production by stimulating the activity of erythroid progenitor cells. This review discusses the use of
the drug in the management of anaemia in diseases often associated with advancing age [renal failure, cancer, rheumatoid arthritis (RA) and other chronic diseases, and the myelodysplastic syndromes (MDS)] and in surgical patients. Intravenous and subcutaneous therapy with epoetin alfa raises haematocrit and haemoglobin levels, and reduces transfusion requirements, in anaemic patients with end-stage renal failure undergoing haemodialysis or peritoneal dialysis. The drug is also effective in the correction of anaemia in patients with chronic renal failure not yet requiring dialysis and does not appear to affect renal haemodynamics adversely or to precipitate the onset of end-stage renal failure. Response rates of 32 to 82% with epoetin alfa therapy have been reported in patients with anaemia associated with cancer or cytotoxic chemotherapy. Limited data in patients with anaemia associated with RA show correction of anaemia after epoetin
alfa treatment. Response rates to the drug of 0 to 56% have been noted in patients with MDS. Epoetin alfa also reduces anaemia, increases the capacity for autologous blood donation and reduces the need for allogeneic blood transfusion in patients scheduled to undergo surgery. Hypertension occurs in 30 to 35% of patients with end-stage renal failure who receive epoetin alfa, but this can be managed successfully with correction of fluid status and antihypertensive medication where necessary, and is minimised by avoiding rapid increases in haematocrit. Although vascular access thrombosis has not been conclusively linked to therapy with the drug, increased heparinisation may be required when it is administered to patients on haemodialysis. Epoetin alfa does not appear to exert any direct cerebrovascular adverse effects. Thus, epoetin alfa is a well established and effective therapy for the management of anaemia associated
with renal failure. It also improves haematocrit and quality of life in patients with anaemia associated with cancer or chemotherapy. Epoetin alfa increases the capacity for blood donation and reduces the decrease in
haematocrit seen in patients donating autologous blood prior to surgery. It also reduces, but may not eliminate, the need for allogeneic blood transfusion.(ABSTRACT TRUNCATED AT 400 WORDS)
Dunn CJ. Wagstaff AJ.
Epoetin alfa. A review of its clinical efficacy in the management of anaemia associated with renal failure and chronic disease and its use in surgical patients. [Review]
Drugs & Aging. 1995 Aug.
Anaemia in African children
Anaemia is a serious and common problem among young children in sub-Saharan Africa. As a first step towards developing guidelines for its recognition and treatment, we conducted a study to evaluate the ability of
health workers to use clinical findings to identify children with anaemia. Health care workers examined a total of 1104 children under 5 years of age at two hospital-based outpatient clinics in rural Malawi. Blood samples
were taken to determine haemoglobin concentrations. Pallor of the conjunctiva, tongue, palm or nail beds was 66% sensitive and 68% specific in distinguishing children with moderate a anaemia (haemoglobin
concentration, 5-8 g/dl) and 93% sensitive and 57% specific in distinguishing those with severe anaemia (haemoglobin concentration, < 5 g/dl). Even without laboratory support, which is often unavailable in
rural Africa, clinical findings can identify the majority of children with anaemia.
Luby SP. Kazembe PN. Redd SC. Ziba C. Nwanyanwu OC. Hightower AW. Franco C. Chitsulo L. Wirima JJ. Olivar A. Using clinical signs to diagnose anaemia in African children.
Bulletin of the World Health Organization. 1995.
Anaemia of prematurity
Twenty-four premature infants, < 32 weeks gestational age, were randomly assigned in a double-blind, placebo-controlled trial to 6 weeks of treatment with either recombinant human erythropoietin (rHuEpo) 150 U/kg three times per week given sc (n = 12) or placebo (n = 12). The infants were fed a diet rich in protein (3.2 g/kg/day) and energy (130 kcal/kg/day) based on their own mother's milk fortified with bovine protein together with moderate iron supplementation (4 mg/kg/day). During the treatment (rHuEpo versus placebo) significant differences in mean (+/- SD) reticulocyte count (4.8 +/- 1.2 versus 2.7 +/- 1.4%; p < 0.01), mean
packed red cell volume (PCV) (0.38 +/- 0.03 versus 0.34 +/- 0.04, p <0.05) and mean haemoglobin concentration (12.6 +/- 1.1 versus 11.5 +/- 1.2 g/100 ml; p < 0.05) were found. Within the rHuEpo group, PCV and haemoglobin concentration remained unaltered from entry to 1 week after cessation of treatment whereas a significant decline was observed in the placebo group. No indications of iron deficiency were seen. We conclude that moderate doses of rHuEpo given to infants fed a diet rich in protein and energy are effective in ameliorating anaemia of prematurity. High iron supplementation does not seem to be essential for a significant
erythropoietic response. No adverse effect attributable to rHuEpo was observed.
Ronnestad A. Moe PJ. Breivik N.
Enhancement of erythropoiesis by erythropoietin, bovine protein and energy
fortified mother's milk during anaemia of prematurity.
Acta Paediatrica. 84(7):809-11, 1995 Jul.
[ZHID Table of Contents]
Table 5.8.2. Common causes of childhood anaemia in the tropics
Low birth weight
Nutritional deficiencies of iron, folate, cyanoccobalamin
Infections that interfere with foo intake and intestinal absorption - diarrhoea, espiratory infections, measles
Parasities - hookworm, Trichuris (whipworm), malaria,
leishmaniasis, schisstosomiasis
Genetic anaemias - haemoglobinooopathiies (HbS, HbE).
thalassaemais
Loss of intact red blood cells
In many children, more than one of the listed causes contributes
to the anaemia
Symptoms and signs:
General symptoms of anaemia include lethargy, fatigue, sleepessness, impaired memory, poor concentration, palpitations, throbbing headache, anorexia, and shortness of breath on slight exertion. Other sysmptoms relate to the coue of anaemia,for example chills and fever in malaria. Atrophic changes in the stomach may lead to dysphagia and the Plummer0Vinson syndrome.
The signs of anaemia include pallor, tachycardia, a collapsing pulse in severe anaemia, pedal oedema, and atrophic glossistis (see also p. 780). Other signs relate to the specific cause of anaemia, for example jaundice and splenomedaly in haemolytic disorders. In iron-deficiency anaemia the nails break and splinter haemorrhages may seen; the concave appearance of the nails is referred to as koilonychia. Craking of and soreness of the mouth as well as corners of the mouth (angular stomatitits) are often associated, although these changes may also occur in other deficiencies such as of vitamin B12 and other B group vitamins.
Investigation:
The nutritional history, episodes of bleeing and chronic ill health have a mjor bearing on the choice of investigative procedures (see p. 982). The history, coupled with physical examination will lead one to the most appropriate laboraotry tests,listed in Fig 5.8.1 (see also p. 975). To these may be added a thick film for malaria parasites, stool microbiology and a serum bilirubin. Anaemia can be objectively diagnosed by measuring the haemoglobin concentration and haematcrit. The haematocrit is roughly three times the haemoglobin concentration. These two indice may provide value of mean corpuscular haemoglobin concentration (MCHC). The relationship is shown in the following equation (Hb = haemoglobin; PCV = packed cell volume).
The normal MCHC value = 31 - 35 g/dl. This range cannot be exceeded, as the red blood cells are normally filled with haemoglobin. However, low values (below this range) are found in iron deficiency, thalassaemia, and other microcytic anaemias.
The peripheral blood examination will enable abnormalities of the shape size and haemoglobinization of the red blood cells to be identified (table 5.8.3). Examination of the periphery smear will reveal the morphology of the white cells and give an indication of the numbers. Very immature ceels indicative of laeukemia will be evident on aperiphery smear. In the tropics, eosinophilia would be indicative of parasitic infestation. Platelets count would reveal thrombocytopenia which sometimes may accompany immune thrombocytopenic purpura, aplstic anaemia or leukenmia. A peripheral smear may sometimes be used to estimate the adquacy of platelets in the peripheral blood if other methods of platelets count are not available.
The serum ferritin and serum iron are both low in iron-defieciency anaemia. Although the former is more sensitive , ferritin is an acute-phase protein and is high during acute infections, even when iron deficiency is present. the sensitivity of serum ferritin is therefore decreased in the tropics where infections are common. Absence of sustainable bone marrow iron may indicate depletion of iron stores , but not necessarily anaemia. total iron binding capacity is quite high in iron deficiency and like serum ferritin or serum iron is useful in following therapy.
Serum or red folate are low in macrocytic anaemia due to folic acid deficiency. Since vitamin B12 may produce the same periphery blood and bone marrow smear, it is prudent to measure both folate and vitamin B12 deficiency, particularly in severe protein -energy malnutrition and chronic haemolytic anaemias.
Reticulocyte counts are low in untreated iron deficiency, in leukemia, and in hypoplastic or aplasitc anaemia due to any cause. The white blood cell count is low in hypoplastic anaemia, although in the early stages the count may be at the lower limit of normal. In the black African there is relative leucopenia. Where doubts exist, a bone marrow aspiration may resolve the issue. In a few cases, the bone marrow asoiration may be normal initially because of patchy hypoplastic or aplastic sites in various areas of the bone marrow.
Bone marrow aspiration (see p.10110) may yield information leading to the diagnosis of infiltrative lesions, such as leukemia, neuroblastoma, myelofibrosis, and lipid storage diseases such as Gaucher's disease. In may also reveal featuresof hypoplasia. Special stains may show ringed sideroblasts and absence of stainable iron. Evidence of parasites (e.g. malaria and trypanosomes) may also be seen.
Laboratory Investigation:
The haemoglobin will be less than 10 g/dl. the MCV is also decreased to less than 24 pg, the MCH to less than 78 fl, and the MCHC to less than 30 g/dl. The peripheral blood smears show microcytosis and hypochromia. The reticulocyte count is low, although after haemorrhage it may be as high as 306 per cent. Thrombocytopenia may be present; the white count is normal. Stool examination should be done to exclude hookworm or Trichuris trichuria or gastre-intestinal bleeding. Urinalysis is imoportant to exclude Schistosoma haematobium as cause of loss of blood in the urine. The platelet counts may be low in immune throm-bocytopenica purpura, aplastic and hypoplastic anaemia; they are also low in hypersplenism. The bone marrow may sahow abasence of stainable iron. The serum iron is reduced and transferrin saturation is laso low, below 120. In the absence of this test, a low haemoglobin alone should be an indication for iron therapy.
Iron Deficiency Anaemia:
Iron deficiency is the most common cause of anaemia in children in the subtropics and tropics, and indeed in the whole world. A committee on nutrition of the American Academy of Paediatrics recommended that all infants recieve iron-fortified formula until at least 12 months of age.
The growing fetus is an efficient parasite and draws it's iron requrement from it's mother against a concentration gradient. The fetus may thus become iron replete at the expense of the mother. In the newborn, most of the iron is in the circulating red blood cell, followed by the liver, tissue and bone marrow. The haemoglobin concentration is reduced during the first few weeks of an infant's life, being lowest at about two to three months of age. This is because of the reduced life span of fetal the red blood cell and decreased erythropoiesis due to an initial polycythemic state. The released iron is stored in the bone marrow for future use.
At about four months of age erythropoirsis becomes active and the stores are mobilised in the formation of haemoglobin,myoglobin, and other tissue enzymes such as the cytochrome group of enzymes. If no exogenous supply of iron is given to the infant the iron stores will be depleted. It is estimated that among 12-18 month old infants of economically deprived families in America the incident of iron deficiency is aproximately 40 per cent. The incidence is higher in African countries where the peak of protein-energy malnutrition is between 12 and 18 months.
Iron deficiency is not synonymous with iron-deficiency anaemia; one can be iron deficient without being anaemic. About 10 per cent of the naturally occurring iron in cereals, in green and yellow vegetables, starined meat, fortified milk formulars and fruits is absorbed by a full-term infant. Cow's milk is a poor source of iron and breast milk has 0.3mg of iron per litre (half of this is absorbed by the intestine). Iron absorption from vegtables may be enhanced by the addition of meat, fish or foods containing vitamin c, such as fruits. Preterm infants do not absorb iron as efficiently as full-term newborns.
The total body iron of an adult is about 5 g , whereas that of infant is about 0.5 g. to make up the deficit which goes to production of haemoglobin, myogolib and other enzymes, the infant should take in approximately 0.8 mg of iron per day. Additional iron is required to replace to the ongoing losses in the gastro-intestinal tract and sweat, so that daily requirements to 0.8-1.5 mg are required during infancy, child and early adolensence. Since only 10 per cent of iron is absorded, a daily intake of 10-15 mg iron must be ingested, for growth, protein and haemoglobin synthesis.
Causes of Iron Deficiency:
The cause of iron deficiency are many and there is often interaction between causative agents or factors. The causes are as follows:
Inadequate supply of iron
. Prematurity, twins an low-birth-weight babies
. Fetal blood loss at or before delivery in conditions such as abruptio placenta, placenta pravia, twin-t-twin transfusion, bleeding from an unclamped cord.
Inadequate intake of iron
. Lack of adequate iron in diet.
. Prologed milk feeding withour supplementary cereals or semi-dolids.
Impaired absorption
. Chronic diarrhoea in protein-energy maluntrion.
. Malbsorption.
. Gastro-intestinal abnormality.
. Milk allergy.
Blood loss
. Accute haemorrhage - concealed or external.
. Parasitic infection - hookworm, amoebiasis, schistosomiassis.
Treatment:
A definite diagnosisshould be made wherever possible before giving iron. the most common preparation and cheapest form of iron is ferrous suplhate which contains 20 per cent elemetal iron by weight, whereas ferrous gluconate contains 10-12 per cent weight. A total 6 mg/kg of elemental iron in three divided doese for three or four weeks is recommended and provides adequate treatment. The iron must be givene between meals, as some fodd interfere with its absorption.
In rare cases where oral iron cannot be taken, parenteral iron may be used; the indications include:
. intolerance of oral iron;
. poor absorptiop in small bowel malabsorption syndromes;
. frequent blood loss;
. when the patient is unreliable taking oral iron, e.g mentally distrubed patients.
The dose required to raise the Hb above 10 g/dl (normally to 12.5 g/dl) can be calculated from the following formula:
The blood voulume of children is approximnatley 70-80 ml/kg body weight.
Iron dextran complex and iron sorbital citric acid complex are available; however, these may cause anaphyllyactic reactions, urticaria, oedema, arthralgia and fever. Infants in tropical counties such as Papua New Guinea who received intramuscular injections of iron dextran have been found to suffer increased attacks of P. falciparum malaria and respiratory infections. In the newborn and increase in Gram-negative bacterial meningitis has been reported.
The response to parenteral therapy is no different from oral therapy and a reticulocytosis is expected within three to four days. Blood transfusion is reserved for those who are:
. acutely bleeing;
. in cardiac failure
. severaly anaemic in association wiith infecction particularly respiratory
If there are no facilities for testing donor blood for HIV infection, transfusion should only be done as a last resort. Transfusion in the presence of severe cardiac failure musst be approached with great caution. Very often the symptoms and signs of cardiac failure due to severe anaemia will abate when the child is propped up in bed rest. if blood transfusion is decided upon, it should be given as packed cells, slowly and combined with a diuretic. The venous pressure in neck veins and liver and signs of pulmonary congestion must be oabserved. Sometimes a modified exchange transfusion will save a child ain extremis.
Iron dextran complex ad iron sorbital citric acid complex are available; however, these may cause anaphylactic reactions, urticaria, oedema, arthralgia and fever . Infants in tropical countires such as Papua New Guinea who received intramuscular injections of iron dextran have been found to suffer increased attacks of P. falciparum malaria and respiratory infections. In the newborn an increase in Gran-negative bacterial meninigitis ahs been reported.
The response to parental therapy is no different from oral therapy and a reticulocytosis is expected within three to four days. Blood transfusion is reserved for theose who are:
. acutely bleeding;
. in cardiac failure
. severely anaemic in association with infection, particulary respiratory.
If there are no facilities for testing donor blood for HIV infection, transfusion should be done as a last resort. Transfusion in the presence of severe cardiac failure must be approached with great caution. Very often the symptoms and signs of cardiac failure due to severe anaemia will abate when the child is propped up in bed at rest. If blod transfusion in decided upon, it should be given as packed cells, slowly and combinded with a diuretic. the venous pressure in neck veins and liver and signs of pulmonary congestion must be observed. Sometimes a modified exchange transfusion will save a child in extremis.
The total body iron of an adult is about 5g, whereas that of infant is about 0.5g. To make up the deficit which goes to production of haemoglobin, myoglobin and other enzymes, the infant should take in approximately 0.8 mg of iron per day. Additional iron is required to replace the ongoing losses in the gastro-intestinal tract and sweat, so that daily requirements of 0.8-1.5 mg are required during infancy, childhood and early adolescene. Since only 10 per cent of iron is absorded, a daily intake of 10-15 mg iron must be ingested, for growth, protein and haemoglobin synthesis.
Causes of Iron Deficiency:
The cause of iron deficicency are many and there is often interaction between causative agents or factors. The causes are as follows:
Inadequate supply of iron
. Prematurity, twins and low-birth-weight babies.
. Fetal blood at or before sdelivery in conditions such as abruption placenta, praevia, twin-to-twin transfusion, bleeding from an unclamped cord.
Indequate intake of iron
. Lack of adequate iron in diet.
. Prolonged milk feeding without supplementary cereals or semi solids.
Impaired absorption
. Chronic diarrhoea in protein-energy malnutrition.
. Malabsorption.
. Gastro-intesstinal abnormality.
. Milk allergy.
Blood loss
. Acccccute haemorrhage - concealed or ecternal.
. Parasitic infection - hookworm, amoebiasis, schistosomiasis.
[ZHID Table of Contents]
Background:
Globally, about 1000 million people are anaemic, and anaemia is the commonest manifestation there is of disease. Prevalences are greatest in the developing worl, especially among preschool children (about 51%), school-age chidlren (46%) and pregnant women (59%). The not frequent causes are iron deficiency which contributes to about 70% of all anaemias, folate deficiency, malaria especially Plasmodium falaciparum, and the haemoglobinopathies, of which sickle-cell disease in Africa and the thalassaemias in Asia are the most important. Anaemia of chronic disorders is a defined entity, but one which is largely ignored and poorly undetstood by many health-professionals: it accounts for the majority of anaemias seen amongest adults requiring dospital admission, is among the six most common causes of anaemia, and is showing a rapidly growing incidence as a result of the pandemics of HIV and tuberculosis.
Anaemia has three stages of severity;
Compensated Anaemia:
Decompensated Anaemia:
Anaemic heart failure:
Further readingAnaemia
Alan F Fleming, Director of Laboratory Services, UTH & Honorary Professor of Haematology, UNZA
(i) Compensated
(ii) decompensated
(iii) congestive cardiac failure
The severity of anaemia does not depend only on the concentration of haemoglobin (Hb). Anaemia is more likely to reach the stages of decompensation and heart failure,
(i) when it is rapidly progressive, so not allowing time for the compensatory mechanisms to function,
(ii) in patients who are hypervolaemic as a result of pregnancy, especially multiple pregnancy, or of hypersplenism,
(iii) in patients with high rates of metabolism, for example due to hyperthyroidism or to exertion which can include obstetric delivery,
(iv) in the elderly, and
(v) in patients with underlying cardic, vascular or respiratory disease.
Patients are breathless on exertion only. The major compensatory mechanism is an increase of intraerythrocytic 2-3 disposhoglycerate (2-3DPG) which acts through lowering the oxygen affinity of Hb, so allowing for oxygen release ot tissues to be increased by up to 40%. The major impact of compensated anaemia is to decrease work capacity, which has serious consequences on the economy of both the individual and the family, and on that of the whole community where there is a high prevalence. In pregnancy, this level of anaemia results in fetal hypoxia, compensatory placental hypertrophy, intrauterine growth retardation and low birthweight. Childhood anaemia, especially iron-deficieny anaemia, is causatively associated with slow growth, delayed development and poor cognitive function, which in infancy, appear to be irreversible despite treatment.
It develops when the Hb falls belwo about 7.0g/dl. Patients are breathless even at rest; in developing countries, may patients present for th first time at this stage, as they are no longer able ot perform any manual labour effectively. the major mechanisms for increasing oxygen delivery are through increasing cardiac ouput, both by increased stroke volume and by tachycardia, and vasodilation to enhance blood flow to vital organs, including the myocardium, skeletal muscle and brain. As patients are unable to work, the economy and management of the household, and the care of children all decline drastically. Untreated decompensated anaemia in pregnancy results in serious intrauterine growth retardation, high rates of low birthweight (up to 80%, with 50% very low birthweight [less than 2000g] in some series) and of perinatal mortality (up to 35%). About half of maternal deaths in developing countries occur in women with Hb ,7.0g/dl, who are not able to withstand the stress of haemorrahage and other obstetrics complications, although anaemia itself is not a directo cause of death.
When the Hb falls further, below about 3.0g/dl, the oxygen supply is insufficiwent to meeet the now high requirements of themyocardium, and high-output cardica failure develops. Patients are severely breathless. the heart is enlargeed; there is engorgement of the jugular veins and other signs of both right an dleft sided failure. Death may follow if there is no appropriate treatment. About 20% of maternal deaths in aFrica and India used to be due ot anaemic heart failure, and where there is no adequate blood transfusion service with the appropriate use of blood, it is probable that there is stll this high rate of mortality.
There is a clear understanding of the interventions at community, primary health care, district and national levels, which are needed to prevent and treat anaemia cost-effectively. Regrettably, these have not been implemented in many developing countries.
Fleming AF. Anaemia as a world health proble.
In, Weatherall DJ, Ledingham JGG, Warrel DA (editors).
Oxford Textbook of Medicine, 3rd edtion. Oxford, Oxford University Press, 1966. pp 3462-3470.
Fleming AF. Haematological disease in the tropics.
In, Cook GC (editor). Manson's Tropical Diseases, 20th edition. London, WB Saunders,
1966. pp 101-173.
[ZHID Table of Contents]
| Hospital-Specific Data | QED | KCH | Ekwendeni | MDH | Overall Mean | Overall Median |
|---|---|---|---|---|---|---|
| # of Months Data Reviewed | 2 | 3 | 30 | 14 | NA | NA |
| Mean # of Complete Abortions Per Month | 384 | 330 | 303 | 308 | NA | NA |
| Mean # of Incomplete Abortions Per Month | 192 | 110 | 10 | 22 | 83.5 | 66 |
| Number of Incomplete Abortions Per Year* | 2304 | 1320 | 120 | 264 | 1002 | 792 |
| % of Incomplete Abortions<12 weeks** | 66% | 63% | 58% | 63% | 62.5% | 63.5% |
| % of Incomplete Abortions>13 weeks** | 32% | 29% | 27% | 29% | 29.3% | 29% |
| Mean Patient Age | 25 | 25 | 26 | 26 | 25.5 | 25.5 |
| Mean Patient Parity | 2 | 2 | 2 | 3 | 2.3 | 2 |
| Mean Uterine Size | 12 | 13 | 12 | 12 | 12.3 | 5 |
| % Facility Abortion Case Fatality Rate | 0% | 2.0% | NR | 2.0% | 1.3% | 2.0% |
NA=Not Applicable
NR=Not Recorded
**Estimate calculated from mean number of incomplete abortions per month multiplied by 12 months
**Percentages do not add up to 100% due to missing data
Ward Observation:
In two hospitals (QEH and KCH), abortion patients were admitted into the gynaecology ward; in the other two hospitals they were admitted into the female ward. The mean daily number of abortion patients recorded during the 5-day observation period in the gynaecology ward was 10 (KCH) and 25 (QEH). Foe each of the two hospitals, the mean daily bed occupancy (DBO) rate for the gynaecology ward abortion patients (in the two hospitals taken together) was 26%. For the two female wards, the overall mean DBO rate for abortion patients was 3%.
Interview with the Head of the Maternal Mortality Review Committee (MMRC):
The head of the MMRC in each facility ( usually a physician) was interviewed and asked to provide estimate of a number of abortion-related statistics. Estimates of the number of incomplete abortion patients treated in their hospitals each year range from a low 120 (Ekwendeni) to a high of 1940 (QEH). These are close to the number calculated from monthly logbook averages for these hospitals which suggests that the administrators are aware of the magnitude of the problem as experienced in their facilities.
In the three of the four hospitals, a MMRC exists which regularly reviews cases of maternal death; such a committee does not exist in MDH and, therefore, a senior physician provided the responses for this section. Non of the MMRCs had written guidelines to assist them in the review precess.
The estimated number of hospital deaths due to complications of abortion each year ranged from 1(Ekwendeni) to 12 (QEH) (mean=8,3;median=10). Two of the three administrators who responded to this question noted that the patients who die of abortion complications in their facilities are usually in their early 20s and single.
Responses about who the MMRC heads thought performed the abortion procedure varied, including traditional healers and paramedics. In terms of the types of presenting complications typically seen, two respondents cited localised infection, all four indicated septicaemia and three mentioned haemorrhage.
The respondents for one hospital, MDH,, cited uterine perforation and two respondents (from QEH and Ekwendeni) noted cervical injury.
Cost:
Despite the fact the cost data were very difficult to obtain, the researchers (using guidelines provided as part of the study) estimated that, in all hospitals except Ekwendeni- for which the estimate was US$2.00-it cost approximately US$3.00 per day to treat an abortion patient with no serious complications (TABLE 2). The longest ALOS estimate for KCH (74,3 hours or 3,1 days), followed by Ekwendeni (48,2 hours or 2,0 days), MDH (47 hours or 2,0 days) and QEH (44,4 hours or 1.9 days). This, the researchers noted, is higher than the amount allocated per capita in 1994 by the parliament of Malawi for the annual health care budget.
Table 2
| Post-Related Data | QEH | KCH | Ekwendeni | MDH |
|---|---|---|---|---|
| # of Gynaecology Cases/Year* | 4660 | 3500 | 404 | 420 |
| # of Incomplete Abortion Cases/Year* | 1942 | 1800 | 181 | 300 |
| % of Incomplete Abortion Cases (of Gynaecology Patients) |
.42 | .51 | .45 | .71 |
| Mean Cost of Daily Patient Stay (US$) | $3 | $3 | $2 | $3 |
| Total Estimated Cost of Treating Incomplete Abortion Patients/Year-A (US$) |
$10,778 | $16,686 | $728 | $1,764 |
| Total Estimated Cost of Treating Incomplete Abortion Patients/Year-B (US$) |
$12,787 | $12,236 | $482 | $1,552 |
A) Based on estimate* provided by hospital adminstrators of the number of incomplete abortions
B) Based on estimate** of all the numbers of incomplete abortions
*Verbal estimate
**Calculate estimate
Provider Profile -- Provider Perspectives:
Table 3 shows the number of providers interviewed for the studt in each Malawian hospital. There were slightly more female than male provider respondents (57,6% and 42,4% respectively) and over two thirds(66,7%) were married. Of the 33 providers interviewed, 17 (51,5%) were nurses and nine (27,3) were clinical officers. According to the country research team, this sample reflects the general distribution of human resources working in health services in the country (for example, specialists in Obs/Gynaes work only at tertiary hospitals such as QEH). Approximately half (45,5%) of the respondents said that the medical officer is the most likely professional to provide postabortion services in their hospital; the other half (48,5%) cited the clinical officer.
Table 3
| Providers Interviewed | QEH | KCH | Ekwendeni | MDH | Total |
|---|---|---|---|---|---|
| # of Providers Interviewed (% of Total) | 11 (33%) | 9 ( (27.3%) | 9 (27.3%) | 4 (12.1%) | 33 (100%) |
Provider Role:
Almost everyone (94%) interviewed indicated that their role in caring for abortion patients is to provide medical/clinical treatment; overall, 63,6% noted that they also have a role counselling the patient about the treatment. At QEH, the proportion noting that they also have a role counselling the patient about treatment was only 27% compared to between 75% and 88% for the other three facilities. This probably reflects the fact that specialists provide different aspects of postabortion care at QEH and a number of Obs/Gynaes were interviewed at that facility as part of the study. Almost half (45,5%) of everyone surveyed cited FP counselling as one of their job functions. This proportion was highest for KCH (77,8%) and lowest for QEH (81,2%). Again, because specialists involved in different aspects of postabortion care were interviewed at QEH, it is not surprising that on an individual basis, many responded that they are not involved in an array of job functions. Mostly clinical officers were interviewed in KCH which suggests that in that particular facility, emergency treatment and FP services could be fairly easily integrated, with the clinical officer playing a key role.
Client Profile:
The providers described a "typical" incomplete abortion patient as young , aged 15 to 25 years (mean=19 years). Of those interviewed, 27,3% were of the opinion that abortions are performed in the community mostly by the traditional healer. Forty percent suspected someone other than a health professional or traditional healer (e.g., self-induced or a friend). Only one respondent said that abortions are most likely performed by doctors.
Complications/ALOS:
The providers interviewed identified haemorrhage and localised infection as the most frequently occurring presenting complications among abortion patients. Table 4 lists the presenting complications occurring the most frequently, as cited by those interviewed. Estimates of the amount of time that incomplete abortion patients remain hospitalised ranged from 6 to 72 hours (mean=40; median =48). The lowest mean estimate (34 hours) was for QEH and the highest (46 hours) was for KCH. Provider estimates of the mean number of hours patients wait before treated ranged from 0 to 26 hours (overall mean/median=12 hours). Overall facility means for this response were highest for KH(17 hours) and lowest for Ekwendeni (8 hours). The majority (69,7%) of respondents felt that most women suffering from abortion complications in the hospital's "catchment" area go to that facility fro treatment. Despite these percentages, 76% still agreed that death from abortion complications is a major problem in their community (91% agreed in QEH; 50% in MDH).
Table 4
| Complication | Localized Infection | Haemorrhage | Septicaemia | Uterine Profusion | Cervical Injury |
|---|---|---|---|---|---|
| Complication: % of Providers Citing (n=33) | 81.8% | 69.7% | 57.6% | 15.2% | 27.3 % |
Contraception Use Among Patients:
There was a general consensus among all providers that incomplete abortion patients are not FP users. They cited lack of knowledge (67,7%) spouse/partner disapproval (39,4%) and poor access (27,3%), among others, as reasons why women do not use contraception.
Provision of FP Information/Services:
Ninety-seven percent of providers surveyed felt that FP information should be offered to incomplete abortion patients post-procedure. Fewer, 66,7%, thought that patients are interested in getting this type of information while hospitalised. (This response was given by only 44% of the providers interviewed at Ekwendeni compared to around 75% in the other three facilities.) A substantial percentage (e.g., 44% in Ekwendeni), however, said that this depends on the woman's situation. In three of the four hospitals (not in MDH), some respondents said that FP information is currently already being provided. These proportions ranged from 18% (QEH) to 40-50% (KCH and Ekwendeni).
The majority, 81%, expressed that FP services should be provided to the patients in the hospital post-procedure. Overall, however, 79% noted that such FP services are not currently available. In KCH and Ekwendeni, these services appear to be available to some degree as evidenced by the fact that 30-40% of the providers interviewed form those facilities responded yes to this question. Oral contraceptive, condoms, injectable, IUDs, Norplant(r) implants and both male and female sterilisation were all noted as available FP methods, albeit by only a few respondents in the two centres. In addition to the lack of FP services offered to patients post-procedure in the hospitals surveyed, 45,5% noted about where in the community they could obtain a contraceptive method. For these women in particular, the possibility of a repeat unplanned pregnancy and induced abortion is a real concern. Of the four facilities, fewer respondents (25%) in MDH and more (78%) in Ekwendeni said that such information was provided. In terms of access to services, 75,7% of the providers felt that FP services are easily accessible to women in the local community.
Abortion Laws:
In general, the providers lacked awareness of the provisions under which induced abortionn is legally allowed in Malawi. According to World Abortion policies 1994, (Annex 16) abortion is legally permitted in Malawi to save the woman's life and to preserve physical health. Table 5 shows the conditions under which the providers believedabortionn is legal in their country. Approximately half (45,5%) of the providers felt that the current laws in Malawi on this reproductive health issue are too restrictive; 36,4% stated that the laws are appropriate. Despite these figures, almost everyone (91%) felt that women make their decision regarding pregnancy termination and that providers perform the procedure without regard for the law.
Table 5
| Condition | Save a Woman's Life | Woman's Mental Health | Foetal Deformity | Rape | On Demand | Social Reasons | |
|---|---|---|---|---|---|---|---|
| Condition: % of Providers Citing (n=33) | 45.5% | 24.2% | 9.1% | 9.1% | 6.1% | 3.0% |
ReasonsWomen Seek an Abortion:
The overwhelming majority (87,9%) of providers believed that the reason why women decide to terminate their pregnancy is because they are unmarried. The next most ccommon reason cited was poor timing of the pregnancy. Other reasons why the providers surveyed thought women seek an abortion are listed in Table 6.
Table 6
| Reasons for Abortion | Unmarried | Timing | Children Too Close in Age | Financial Reasons | Rape | Woman's Health | Foetal Deformity | Mental Health |
|---|---|---|---|---|---|---|---|---|
| Reason % of Providers Citing (n=33) | 87.9% | 45.5% | 39.4% | 33.3% | 30.3% | 12.1% | 6.1% | 3.0%3.0% |
Access to Abortion Services:
A majority (58%) of the providers responded that access to abortion for Malawian women is relatively easy. Seventy-nine percent also thought that treatment for complication of an induced abortion is easy to obtain. The proportion stating that access is difficult was much higher (50%) in the district facility, MDH, than in any other centre. At QEH, the main tertiary referral hospital in Blantyre, 64% said the access is very easy.
Patient Perspectives --Patient Profile:
Fifty abortion patients from the four facilities surveyed in this country were interviewed for the study (Table 7). The age of these abortion patients ranged from 17 to 43 years (mean=25,9; median=24,5). Twenty-eight percent of the patients interviewed were aged 20 years or younger (defined here as adolescents). The mean age of the adolescents was approximately 18 years. Parity levels among all of the women interviewed ranged from nulliparous to eight children (overall mean=1,5). The overwhelming majority (82%) started that they were married. Personal information given during the interviews, which suggests that the values are accurate as provided.
Table 7
| Patient Interviewed | QEH | KCH | Ekwendeni | MDH | Total |
|---|---|---|---|---|---|
| Number of Patient Interviewed (% of Total) | 20 (40%) | 20 (40%) | 3 (6%) | 7 (14%) | 50 (100%) |
Contraceptive Use among Patients:
Consistent with the opinions of the providers, only 12% (6) of the patients interviewed had ever used a modern method of FP prior to their most recent pregnancy (no one from MDH). Of these six, 33,3% had used OCs and 16,7% had used injectable. Two (33,3%) of these six women (both from KCH) said they had become pregnant sometime in the past while using a FP method. Overall, only two (4%) out of the 50 women interviewed were using a contraceptive method at the time of the pregnancy (both from KCH, possibly the same two as for the previous question).
Reasons Patients Sought Treatment:
The two main reasons why the women interviewed said they went to the hospital were vaginal bleeding (82%) and abdominal pain (66%) (Table 8). Forty-two percent said their symptoms(s) had persisted for one day or less before they sought treatment at the hospital; 20% indicated 2 days; and 36% noticed their symptom(s) 3 or more days before seeking treatment.
Table 8
| Treatment Reasons | Vaginal Bleeding | Abdominal Pain | Fever |
|---|---|---|---|
| Reasons: % of Patients Citing (n=50) | 82.0% | 66.6% | 2.0% |
Transportation:
The interval between onset of symptoms and arrival at the hospital was 3 or more days for 66,7% of the women interviewed at Ekwendeni compared to 25-45% for the other three centres. This suggests that =women in the northern region are wither travelling to Ekwendeni from farther away, transportation is poorer or they are waiting longer making the decision to seek treatment. Twenty-four percent of the women interviewed (i.e., all of those who were surveyed from Ekwendeni), said that they walked to the facility. In the other centres, the women used both private (36%) and public (30%) transport to get to the hospital. Eighty percent overall expressed that it was easy for them to get to the facility. It took less than 2 hours for 61,2% of those interviewed to get to the hospital; for 26,5% , it took 2 to 4 hours. Interestingly, 100% of the women interviewed from Ekwendeni-all of whom walked-said that it took them between 0 to 2 hours to reach the hospital.
Waiting Period:
Once at the hospital, 60% said they had waited 2 hours or less before seeing a doctor. Twenty-eight percent, however, had waited from 6 to more than 10 hours to be treated. This proportion was highest for QEH, the tertiary referral hospital. Despite these figure, the majority (74%) indicated that they felt the amount of time they had waited was "acceptable."
Procedure Experience:
Overall, only 20% responded that they felt pain during the procedure. Thirty percent of these patients, however, indicated that the pain was severe. In only 8% of the cases (no patients from MDH) did the patient remember someone explaining to her what the treatment would entail; and, alarmingly, 86% noted that they had received no information about how to care for themselves once they had been discharged and returned home.
Provision of FP Information/Services:
In contrast to the providers' responses, 92-100% of the patients said that no one had either talked to them about FP nor made any F\P method available to them yet. In only 4% of the cases (no one from QEH or Ekwendeni) could the woman remember anyone telling her where in the community she could got to obtain a FP method. Overall, only 52% of the respondents were in favour of having a FP method offered to them in the hospital post-procedure. The proportion of women in MDH who responded yes to this question was particularly low at 14%. Only approximately 40% felt that any woman seeking treatment for complications of an incomplete abortion would like to have FP services made available to her while still in the hospital. A fair number, 48%, however, said they "didn"t know" as the response to this question.
Personal Treatment at the Hospital:
All of the patients said that staff at the hospital treated them considerately. Almost everyone (92%) expressed that they were satisfied of very satisfied with the services they had received. The patients responded unanimously that they would encourage any friend or relative who had the same problem to be treated at the facility. As with the other countries, a little over one third (34%) said that they knew a friend or relative who had either died or become seriously ill from an incomplete abortion.
[ZHID Table of Contents]
1.0 Introduction
Each year, each District Health Management Board (DHMB) is compelled to include a budget for Emergencgy preparedness.
The proviso is meant to cater for any possible disaster that may befall in any part of the district requiring Swift action.
1.1 Disaster
Is unpredictable happening that can strike suddenly at any material time and anywhere. The conseqences are usually catastrophic causing disruptions, loss or damage to life and property respectively. The causative agents vary greatly ranging from natural causes to "man-made". The former include earthquakes, flood and droughts while the latter due to the following:
- epidemics due to disease outbreaks
- conflicts and wars - displacement of people (refugees)
- fatal accidents especially passager carriers (land, air, water-automobile), industrial and mining mishaps.
1.2. Current Situation on Disasters
The profile in Zambia, and at districts in particular is latently viewed as a new phenomenon (drought). The picture of epidemiology on the other hand is obliterated with specific disease outbreaks. One feature, however, however, is the high endemicity of some diseases reaching to "threshold" (during tramission periods) of epidemicity. Worse still is the fact that seemingly old diseases are resurfacing including the emergence of new but deadly contagious diseases:
- anthrax
- meningitis
- polio mylitis
- tuberculosis / Aids
- cholera
- dysentry
- malaria
Cases of plague, yellow fever, ebola have been reported elsewhere in the subregion including intensity of refugees.
2.0 Emergency Alertness
With the above mentioned scenerio of diseases development, a call for awekening to the challenges is appropriate. The District Health Management Boards (D.H.M.B.) have so far prevented and controlled disease outbreaks with fairly degree successes: There is no doubt that scores of achievement came about due to the effective utilisation of emergency preparedness, including quick responses to the reports received. The catch is not to be taken by surprise (critical). There could hardly be any progress made without the use of District Surveillance Committees (D.S.C.)
2.1 Characteristics of District Surveillance Committee
The objective is predominantly ro review trends of diseases in the population of a given district including raising appropriate signals of threatening or worsening conditions attributable to disease outbreak. To fulfill its intended purpose, the surveillance committee should adhere to the following licence to the following:
i) Composition - membership to be integrated and multisectoral in the nature but essentially including the core-service units (surveillance sub-committees)
-clinical or medical
-public health or environmental
-health management information system (H.M.I.S.)
-information education communication (I.E.C.)
-quality assurance (QA)
-management or administrative support.
ii) Agenda- issues to emanate from the above sub-committees (partly to keep relevance and partly sustain activated quorum).
iii) Frequency of meetings - quarterly, but can be summoned at short notice upon receipt of authenticated adverse epidemiology reports.
iv) Health indicators-good measurements used extensively in epidemiology.
2.2 Surveillance Sub-committees Scope or Work
Ideally each chairman of the sub committee is a contact person for district surveillance and should be conversant and alert (24 hours).
2.2.1 Clinical
a) early detection and notifications of disease outbreaks
b) barrier case management (isolation)
c) physicians to link up case histories of patients with adverse environmental health
conditions and appreciate.
2.2.2 Environmental
a) prompt inspection to spot hazards ( source of infection and transmission)
b) ideally risk factors and contaminants and pollutants to water, food and air (hazard analysis critical control point)
c) concurrent and terminal disinfection
e) demographic risk groups
-immunisation status
-refugees
-boarding or lodging institutions
-tourists and transit centres
-festivals and shows (gatherings)
-rapid and adverse seasonal changes
2.2.3 Health Management Information System, Education, Communication
a) data collection, analysis, utilisation and storage
.
b) use illustrations to show trends and disease patterns
c) advocacy and solicit for popular support (partnership)
2.2.4 Administrative / Management Support
a) logistic and resource mobilisation
-personnel
-drugs, equipment, material and supplies
-transport
-funds
b) identification and maintenance of treatment centres
2.2.5 Quality Assurance
a) performance audit according to designated standards.
b) monitor the development indicators including rates used in epidemiology
c) regulatory and code of practices compliance
3.0 Summary
The role of emergency preparedness can only be meaningful and useful to any District Health Management Board if a viable District Surveillance Committee (D.S.C.) is perceived as a tool that will assist monitor the health of the whole district community. This is a virtue which every district should strive to achieve by turning emergency aletness into disease intelligence system which not only provide information for action but also provide brigade skills that will prevent and control epidemics.
3.1 Conclusion and the Way Forward
The high edemicity, the re-emergence of old and the comming up of new diseases including the stubborness and virility of tuberculosis and AIDS respectively should be viewed as some of the medical challenges which existed for centuries and will be there for centuries to come.
What is needed now is to measure up to the present challenges and boldly look into the future by taking initiatives. There is the skill, the experience and the "will" driving forward with the new epidmiological developments.
TO BE OR NOT TO BE ALERT!!! WHICH WAY FORWARD
References:
Ministry of Health, Health Reforms Implementation Team (HRIT 1995) Health Care Quality Assurance Manual, Some Basic Concepts in Quality Assurance (Prepared by Limbambala M. E., Tembo J.N.)
Ministry of Health, Health Reforms Implementation Team (HRIT Secretariat November 1995) District Guidelines Functions and Responsiblities of the District Board, District Health Management Team.
Ministry of Health, Health Information Unit. (HIV 1987 - 1998) Bulletin of Health Statistics Major Health Trends 1978 - 1988
[ZHID Table of Contents]
Dr S. Banda: Medical Education & Research
Dr E. Chomba: Medical Council
Dr C. Kunda: Health & Environment
Dr P. Matondo: Publications
ENDING HABITUAL ZMA REVIVALS:
So the Zambia Medical Association(ZMA) main body has been revived again! We commend the gallant men and women behind the revival. But lest it be forgotten; this is yet another revival in the turbulent history of ZMA. Hence, while a wave of euphoria is justifiable, this should not obscure the need to search for a permanent solution.
For the record the last revival was in 1990/91. This was, to be precise, a revival of the central division but it ultimately led to a call for a national ZMA meeting which resulted in the Kawimbe administration. The rest of the story needs no further retelling: that we needed a revival in 1996 says it all. Therefore what is needed now is a permanent remedy to the habitual fatiguability. Why do successive ZMA revivals ultimately run out of steam? Ladies and gentlemen, that is the crucial question!
The interim executive identified the need for a ZMA secretariat. That vision has to be applauded and fully supported, for it is the only key to a perennial ZMA. Since the interim executive was retained at the recent election, it is hoped that the vision will be transformed into a physical reality.
The other factor, pointed out by Dr Hilda Mutayabarwa, who spoke on behalf of family/ private practitioners at the AGM, is the need to make ZMA attractive. She cited the need for "benefits" for members of ZMA. For example discounts for ZMA members on various services and goods.
That would be a useful start. ZMA executive take note! Ride on the goodwill while it lasts! It is also worth finding ways of financing the association by contributions from employers. In this regard since ZMA intends to run Continuing Medical Education(CME) seminars, and to circulate the Zambian Medical Journal to all paid up members, employers must be seen to encourage their doctors to remain abreast with developments and changes in medical practice. The way to pursue this would be to liaise with the medical council so that ZMA gets.
APRIL/MAY 1996:
An official mandate to run CME courses, the attendance of which will be a requirement for doctors to receive practice licences. There are undoubtedly many other ways to make ZMA an organisations doctors will desire to join. We would welcome any suggestions that would help create an all-weather ZMA.
AGM REPORT:
The ZMA interim national executive convened an annual general meeting on 5th April at the Pamodzi hotel in Lusaka. The aims of the meeting were twofold. Firstly to elect an executive committee to soldier-on with the noble tasks initiated by the interim executive. In short to revive the fledging ZMA. Secondly, to provide an opportunity for a meeting of colleagues in the profession on an academic and scientific level.
Both objectives were achieved and, it has to be said, achieved very well. The meeting was opened by deputy minister of health, Dr Katele Kalumba. He delivered a watershed speech, in which he explained the health reforms to members of ZMA and pointed out that the health reforms are, among other things looking for an accountable medical profession. He ended his speech by imploring members of the profession to use science to educate and to serve the Zambian people, adding that " the Zambian Medical Association has the obligation to defend the legal and scientific status of the practice of healing".
The deputy minister's speech was followed by presentations from doctors representing factions of the medical profession in the employ of various organisations. The recurring theme to many of the presentations was the need to have a strong and effective ZMA.
The general assembly was a success as well. However, it did reveal some areas where work still needs to be done to generate harmony within the various "ranks" in the profession. The issue of payment of membership fees was a sore point. There was a feeling that members of other subordinate organisations such as the Resident doctors Association(RDA) should pay by way of affiliation fees. However, this was not accepted and it did in fact lead to members of RDA who are not paid up with ZMA to lose the right to vote.
The ZMA constitution in its current form also proved a moot point. This was not helped by the fact that most of those present at the general assembly were not familiar with it. There was a palpable feeling that there needs to be a review of the constitution as well as a need to harmonise the issue of payment of ZMA membership. The membership fees are still pegged at K20,000; paid directly to ZMA.
Owing to administrative difficulties encountered by the treasurer in the preparation of the financial report, it was resolved that the financial year of ZMA should, with effect from 1997, end on 31 March of each year. This would give chance to the treasurer to prepare a financial report for that financial year, unlike was the case previously when the books would still be open at the time of the AGM to cater for expenditures incurred. In future all expenditure incurred at the AGM would be reflected in the books of the new executive. Also, the financial books of ZMA would at future AGMs be required to be audited by external auditors to promote transparency and accountability.
SCIENTIFIC SESSION:
The scientific session was a resounding success. there was a collection of good quality papers presented either as posters or oral. One poster in particular was of such outstanding quality that it was felt necessary to present the author, Dr V. Mudenda with a prize. For all the good organisation of the scientific session, the tireless efforts of Dr Banda and his organising team(comprising: Drs G. Muyinda, V. Mudenda, and J Mwansa) were singled out and applauded.
ELECTION RESULTS:
Following the general assembly, elections of the substantive ZMA national executive were held. The following individuals were declared duly elected to serve in the respective posts:
President: Dr C. Lwenje
V/President: Dr G. Muyinda
Secretary: Dr K. Katebe
Treasurer: Dr M. Mumba
Chairpersons for functional Boards:
Dr S. Banda: Medical Education & Research
Dr E. Chomba: Medical Council
Dr C. Kunda: Health & Environment
Dr P. Matondo: Publications
A WORD FROM THE PRESIDENT!
The ZMA national president, his excellency Dr C. Lwenje would like to thank all the participants who contributed to the deliberations at the last AGM. He extends special thanks to the following colleagues who stayed on despite other equally important commitments: Professor C. Chintu, Dr T.K Lambert, Dr I. Yikona, and Dr E Chomba. He also acknowledges and applauds the role played by RDAZ in the recent revival of ZMA. He hopes the medical profession will accord the executive full support as we move into the next phase and begin to look for lasting solutions to the ZMA malaise. The presidential plea is: doctors of all ranks, status and employment affiliation, please let us all work together. In the meantime, the executive has been on a one month recess, meant to revitalise the energy that was expended during the run-up to the recent AGM and scientific meeting. We shall soon spring back, with a refined vision and renewed commitment.
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MEDICAL JOURNAL REVIVED:
The ZMA National executive committee has set in motion a proceeds that will revive the latent Zambian Medical Journal. It is intended that the Journal will not only provide a medium for reporting research findings relevant to medical practice in Zambia, but also provide a vehicle for delivering Continuing Medical Education (CME) for doctors and other health workers within and without Zambia. The Editor of the revived Journal wishes to send a call for papers in the form of original research articles, clinical case reports, review articles, letters to the Editor, as well as commentaries of a Medico-political nature. Full details of the editorial board will be announced in the next Newsletter. In the meantime get writing! Send your articles to :
The Editor,
Zambian Journal of Medicine and Health Science
PO BOX 50903, LUSAKA.
MEDICAL EDUCATION & RESEARCH:
The Chairman of the Medical Education and Research Board, Dr S. Banda is constituting a panel of representatives from UTH, UNZA, City Councils, Ministry of Health and the provinces. the aim of this board is to co-ordinate and conduct seminars and workshops for continuing medical education for doctors in Zambia. It is also concerned with matters pertaining to medical research and training in general. The chairman of MERB intends to hold a residential seminar later this year to appraise members of the board on its roles and functions; and draft a calender of activities. To the chosen few our word of encouragement: when you get the call, get busy!
EDITOR FOR ZMA NEWSLETTER:
The chairman of the publications board wishes to invite members to apply for the posts of editor of the ZMA newsletter and membership of the editorial board of the same. Members of ZMA with some writing ability and editorial skills plus lots of commitment and enthusiasm are encouraged to apply to: Dr P. Matondo, chairman of the Publications board, ZMA PO BOX 50903, LUSAKA..
NIGERIAN CONFERENCE:
The Nigerian Medical Association has requested the Zambian Medical Association to participate in a conference on Sexual health for the youth. ZMA wishes to request individuals who wish to present a paper on STDs in the youth, contraception, abortions and related aspects of sexual health for the youth to get in touch with Dr S. Banda, chairman of MERB for further details.
ZIMBABWEAN INVITATION!
The Zimbabwean Medical Association has invited ZMA to send a team of representatives to their annual congress. The congress will particularly focus on the issue of health sector reforms vis-a-vis the structural adjustment programs(SAP). The indications are that ZMA has accepted the challenge and in fact requested to field a team of doctors to present papers on the Zambian experience so far. The congress is due to be held on 22-25 August 1996. For a full report, keep an eye on ZMA Newsletter.
ZMA ACQUIRES A POSTAL BOX:
The ZMA national executive has finally secured a postal box at Ridgeway Post Office. Henceforth, all official correspondence to ZMA should now use the official box: PO BOX 50903, LUSAKA.
A RADIOTHERAPIST/ONCOLOGIST AT LAST!
Special welcome to Dr Mushikita Nkandu who has recently completed his postgraduate studies in Radiotherapy and Oncology in Zimbabwe under a WHO training Fellowship. Those of you with an ear to the ground will have heard that plans are underway to set up a radiotherapy center at UTH. In the meantime, Dr Nkandu is offering his services at the Zambian-Italian Othorpaedic hospital in Longacres, Lusaka. He runs an oncology clinic there. The hospital has a radiotherapy machine which can be used for treating a range of benign and malignant conditions such as keloids, superficial skin cancers ; and curative and palliative treatment for a range of cancers. The hospital also offers a wide range of other supportive services for cancer patients; and plans to increase its bed capacity in the near future. We have waited, and our cancer patients have ssuffered long enough, long enough: welcome back to hard work!
The editor of ZMA Newsletter welcomes contributions from members. To make your point, or report news write to: The Editor, ZMA NEWSLETTER PO BOX 50903, LUSAKA.
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Last updated February 27, 1997