Assessment of Anemia as a Public Health Problem in Rural Cameron Natalie Beaty 1, Danielle Fine 1, Cecilia Sorensen 1, Carine Tagni 1, Dennis Richardson 2, George Bwelle 3 1 Bush Medicine Partnership, Connecticut, USA. 2 Bawa Health Initiative, Connecticut, USA 3 Association des Competences pour Une Vie Meilleure, Cameroon, West Africa
Introduction In Sub-Saharan Africa, poverty and poor health are inextricably linked and have multifactorial etiologies. This region has the highest rates of people living in extreme poverty in the world, with an astounding 48% of the population living in extreme poverty 1. Government expenditures on health care accounts for a meager 5.6% of the GDP, forcing 94.4% of the costs of care to come out-of-pocket from people who cannot afford it. One major consequence of this inaccessibility of health care is poor health. For instance, the main causes of death for children under five are preventable diseases: malaria, diarrhea and pneumonia 2. Such neglected tropical diseases are a cause of morbidity and disability and continue the cycle of poverty in low-income and marginalized populations living in rural areas 3,4. Cameroon, a country in West Africa, holds true to most of the health statistics for Sub- Saharan Africa. Malaria, pneumonia and diarrhea are the top causes of mortality in children under five. In rural communities, less than 50% have access to improved drinking-water sources and less than 35% have access to improved sanitation facilities. Less than 45% of births are attended by skilled health personnel, and the rural underfive mortality is 169/100 live births 5. Clinical experience and recent research show that tropical diseases are an enormous burden in rural Cameroon. For instance, the most common diseases in Cameroon are the same neglected tropical diseases which affect about 1.4 billion people globally each year, including ascaris lumbricoides, giardia lamblia, schistosoma hematobium, hookworm and whipworm infection 6. A clinical outcome of malaria, helminth, protozoan, and other diarrheal infections that is responsible for over ½ of malaria deaths in young children is anemia 7. Anemia is clinically defined as a reduction in the oxygen carrying capacity of an individual due to a reduced number of red blood cells and/or hemoglobin molecules. Measurements of hemoglobin in patients serve to assess the level of anemia in an individual, and, taken together, that of a population. Major clinical complications of anemia include decreases in cognitive and neurological development, depression, and cardiac problems. Combined with the direct negative clinical consequences of malaria and NTD infection, anemia and its complications contribute to poverty by increasing disability and decreasing quality of life 8. In sub-saharan Africa, anemia is a clinical sign with a multifactorial etiology. Malnutrition, malaria, and helminth and protozoan infections are the most common causes of anemia in populations in Cameroon. The research community regards anemia as an appropriate marker for an assessment of general health in this area, and acknowledges that, while non-specific, anemia measurements afford a reflection of helminth and malarial infections and malnutrition 9. Thus, anemia status may be used as a general marker of health and can be used to track progress by organizations working in rural villages.
Association des Competences pour Une Vie Meilleure (ASCOVIME), is a nongovernmental organization that works to reduce poverty and improve health and education in rural areas in Cameroon. ASCOVIME, which uses mobile medical and educational campaigns, was founded in 2001 by Cameroonian surgeon and faculty member at The Central Hospital of Yaounde, Dr. Georges Bwelle. In 2011, ASCOVIME serviced over 15 villages with its mobile clinic, distributing both medical and educational supplies and services. Bush Medicine Partnership, a non-profit, non-governmental Connecticut organization founded by Drexel University College of Medicine student Cecilia Sorensen in 2010, has been supporting the mission of ASCOVIME through the provision of medicines and medical supplies. Bush Medicine Partnership is now poised to assist ASCOVIME in addressing specific health problems that affect the communities and trap them in the cycle of poverty. The purpose of this study is to assess the overall health in the rural villages of Cameroon that are serviced by ASCOVIME. First, the methods of the study are described. Second, anemia status is used as a marker to analyze the burden of disease in the villages of Minkang II, Lomie, and N ditam. Finally, recommendations are made based on the prevalence and severity of anemia in these communities. These can be used to guide the work of ASCOVIME as they continue to provide health care to these communities each year. Methods In June 2011, ASCOVIME took anthropometric measurements of patients in three villages, Lomie, Minkang II and N ditam. The anthropometric data, including age, height, weight and hemoglobin concentration, is used to gauge the general health of a population of these villages. This data will serve as a point of reference for baseline or early intervention by ASCOVIME. Collection of this data will be conducted in conjunction with the routine public health interventions on a yearly basis. These measurements will be repeated over time to gauge any changes in general health in these populations. Before collecting data, each subject was informed of the nature of this project and gave oral consent to being involved in the study. In the future, written informed consent was obtained and recorded (see Sample Informed Consent Form). ASCOVIME members secured all data collection. Around fifty patients were selected at random from the clinic line. After proper consent was obtained, the name, age, birth date and gender of each subject was recorded. The height and weight were measured using a tape measurer and a scale. Hemoglobin concentration was measured by placing a single drop of blood (obtained by dermal puncture administered by a properly trained individual) on an electronic Stanbio STAT-Site M Hemoglobin Photometer. Hemoglobin concentration was used as an indicator of anemia, which was then used as a marker of the overall health status based on malnutrition, malaria, and/or helminthic infection. All three of the communities showed considerable prevalence of anemia indicating that it is a severe public health problem.
Microsoft Excel was used to analyze the data based on WHO standards. The World Health Organization has provided a set of clinical values of hemoglobin measurements, which correlate to the degree of anemia in individuals sampled. Figure 1 shows the standard clinical values for anemia severity classification based on these WHO recommendations. WHO has also provided clinical thresholds for absolute anemia in different populations, reflecting age, gender, and pregnancy status, as shown in Figure 2. Figure 1: Classification of anemia by hemoglobin level Category of anemia Hemoglobin value (g/dl) No anemia 12.0 Mild anemia 10.0 11.9 Moderate anemia 8.0 9.9 Severe anemia 8.0 Figure 2: Classification of anemia by hemoglobin level Age or gender group Children (0.5 4.9 years) 11.0 Children (5.0 11.9 years) 11.5 Children (12.0 14.9 years) 12.0 Non-pregnant women ( 15.0 12.0 years) Pregnant women 11.0 Men ( 15.0 years) 13.0 Hemoglobin Threshold (g/dl) The WHO has also provided standards for classification of anemia in a population with regards to its significance as a public health problem. The anemia prevalence values, as shown in Figure 3, serve to identify populations in which anemia poses a public health problem. Figure 3: Classification of anemia as a public health problem Category of public health Prevalence of anemia (%) significance No public health problem 4.9 Mild public health 5.0-19.9 problem Moderate public health 20.0-39.9 problem Severe public health 40.0 problem
Results In the three villages sampled, anemia was calculated using Microsoft Excel and analyzed using the cut-points provided by the WHO seen in Figure 2. The total prevalence of anemia in each community was calculated by adding all cases of mild, moderate or severe anemia. It was then analyzed with an adjusted 95% confidence interval program provided by, and with thanks to, Dr. Ed Gracely of Drexel University College of Medicine School of Public Health. This total prevalence of anemia in each community is shown in Figure 4. Figure 4a:Classification of anemia by hemoglobin level Minkang 2 Lomie N ditam Age or gender Prevalence n Prevalence n Prevalence n group Children (0.5 100.0 (70.4 14 60.0 (23.1 5 100.0 (38.0 3 4.9 years) 95.3) 88.0) 104.9) Children (5.0 89.5 (67.2 19 50 (19.1 6 85.7 (67.7 28 14.9 years) 98.1) 81.0) 94.8) Non-pregnant women ( 15.0 years) 93.8 (69.4 100.6) 16 71.4 (49.7 86.3) 2 1 57.1 (36.5 75.5) 21 Men ( 15.0 years) 95.5 (76.2 100.7) 22 64.5 (46.8 78.9) 3 1 55.2 (37.6 71.5) 29 The public health significance of these results was analyzed by calculating the prevalence of anemia in each community and comparing it to the WHO standards for anemia and public health (Figure 3). The public health burden of anemia in each village based on experimental results is shown in Figure 5. Figure 5: Anemia prevalence as percent of population with 95% confidence interval Minkang 2 Lomie N ditam Age or gender Prevalence n Prevalence n Prevalence n group Children (0.5 100.0 (70.4 14 60.0 (23.1 5 100.0 (38.0 3 4.9 years) 95.3) 88.0) 104.9) Children (5.0 89.5 (67.2 19 50 (19.1 6 85.7 (67.7 28 14.9 years) 98.1) 81.0) 94.8) Non-pregnant women ( 15.0 years) 93.8 (69.4 100.6) 16 71.4 (49.7 86.3) 2 1 57.1 (36.5 75.5) 21 Men ( 15.0 years) 95.5 (76.2 100.7) 22 64.5 (46.8 78.9) 3 1 55.2 (37.6 71.5) 29
.Figures 5 and 6 show the value of anemia severity in each population. Figures 6a and 6b display the percentage of mild, moderate and severe anemia by village and age group. Figure 6a: Childrens (1-15 years old) anemia rankings by percentage of population Minkang 2 Lomie Nditam 51.5 40.0 33.3 42.4 33.3 27.3 6.1 15.2 15.213.3 13.3 9.1 OK MILD MODERATE SEVERE. Figure 6b: Adults (16-65 years old) anemia rankings by percentage of population Minkang 2 Lomie Nditam 50.0 52.2 37.5 36.7 31.3 26.1 17.4 15.6 15.6 10.0 4.3 3.3 OK MILD MODERATE SEVERE.
Discussion Overall All combined gender populations studies showed that anemia is at least a moderate public health concern in the children and adults in each village surveyed. The data is also evaluated by stratifying samples by gender, which demonstrates that anemia is at best a mild public health concern in the populations. However, the sample size of many of these groups becomes too low to be held reliable. Anemia is a severe public health concern in child populations in Minkang 2 and N ditam and in adult populations in Minkang 2 and Lomie. In each village, children under 16 suffer equally or more from anemia than adults; however, the levels of adult anemia are also very high. These results suggest that the multifactorial etiology of anemia should be investigated in these populations. ASCOVIME notes that each of these communities suffers extensively from malaria, helminth infections, and malnutrition. The combination of these illnesses undoubtedly contributes to the widespread anemia and alarmingly high level of severe anemia in children. The elderly and pregnant were not individually studied at this time and should be included to gauge the level of health in those populations. Error One possible source of error to consider in this study is volunteer selection bias. People who come to ASCOVIME s clinic may be more sick or more in need of medical care than the average population. Conversely, ASCOVIME may not draw in a representative sample of the community because some may not be able to leave their farming jobs to wait in line for the clinic. Another possible source of experimental error is interference of the sickle-cell trait with the hemoglobin monitor. The sickle cell trait also presents as an analytical problem, because these people naturally have lowered hemoglobin. In the future, people could be screened for the sickle cell trait before hemoglobin sampling to be sure we rank their anemia status appropriately. Both of these areas need more investigation. Recommendations Anemia is shown to be a severe public health problem in the villages of Minkang 2, Lomie, and N ditam. Knowledge about anemia and clinical experience in these areas indicate that malnutrition, malaria, and helminth infections may be the main contributors to this problem. Targeted public health interventions such as anti-helminth administration, installation of water filters, bed netting, and hygiene/sanitation education have proven to help stop the spread of malaria, helminth and diarrheal infections. Clinically, malarial, helminth, protozoan and other diarrheal infections often cause anemia. Anemia is by clinical definition either a reduction in the effective number of red blood cells or in the oxygen-carrying molecule called hemoglobin in an individual. Measurements of hemoglobin in patients serve to assess the level of anemia in an individual, and, taken together, that of a population. In sub-saharan Africa, anemia is a
clinical sign with a multifactorial etiology. Malnutrition, helminth, protozoan, and malaria infections are the most common causes of anemia in populations in Cameroon(Impact of malaria control on childhood anaemia in Africa a). The research community regards anemia as an appropriate marker for an assessment of general health in this area, and acknowledges that, while non-diagnostic, anemia measurements afford a reflection of helminth and malarial infections and malnutrition(bates I, 2007). Thus, anemia status is used as a general marker of health and progress by organizations working in rural villages, such as ASCOVIME. This marker may also be used to follow trends in health patterns in the villages ASCOVIME serves over time. Many organizations in the developing world have acted to help improve health in the communities they serve. The Bawa Health Initiative serves as a model for intervention programs in rural Cameroon. Since its establishment in 2005, it has conducted thorough needs assessments and public health interventions in two villages in rural Cameroon. They have utilized the recommendations of WHO to establish a preventative chemotherapy program with epidemiological surveillance that helps decrease the negative effects of helminth infections in their community. Their research links the prevalence of amebiasis, giardiasis and helminth infections in rural villages in Cameroon to contaminated drinking water and lack of proper sanitation systems 10, 11. In addition, they recommend the use of long lasting insecticidal bed nets across the population against malaria infection. These studies are performed in demographically and socioeconomically similar areas to the villages that ASCOVIME serves, and thus can provide a model for health-improving interventions for ASCOVIME. ASCOVIME visits over 15 villages a year which could benefit from measures which help alleviate the burden of chronic helminth and malaria infections. At this time, ASCOVIME could expand their interventional program to follow the procedures adopted by the Bawa Health Initiative. Measurement of anemia as a general marker of health will help ASCOVIME assess the epidemiological situations in individual villages,. Measurement of anemia will also allow ASCOVIME to track health progress in these villages over time and determine whether these models should be transplanted to other villages. A helminth surveillance program will allow ASCOVIME to properly implement a preventative chemotherapy program as outlines by WHO, and will allow assessment of the success of this program. In addition to the anti-helminth program, ASCOVIME could attempt to reduce malaria infections in the villages that it visits. Malaria can be reduced by installing bed nets into every sleeping area in the communities, or at the very least by giving bed nets to pregnant women and children under five. Long-lasting insecticidal bed nets can help reduce the transmission of malaria and decrease child mortality. The implementation of a strong education program for community health workers to discuss the importance of clean water and hygiene to stop the spread of preventable disease would further the mission of ASCOVIME and can help improve health throughout the year. To achieve this, ASCOVIME could have one permanent volunteer who provides afternoon-long education programs for village community health workers during their clinic. Lastly, water quality can be monitored and imporved if funding sources become available. All of these projects can be carried out cheaply and would only require bi-yearly measurements.
Acknowledgements Dr. Bwelle, Natalie Beaty, Danielle Fine and Dr. Richardson devised the plan for anemia measurements during the spring of 2011. Dr. Dennis and Kristen Richardson of Bawa Health Initiative assisted in providing invaluable information and experience about this type of work based on their non-profit work in Bawa, Cameroon. Materials were purchased in the US and transported to Cameroon. ASCOVIME s laboratory technician Teneng Neba Susan collected blood samples for rapid anemia testing and these values were made available to consulting physicians and me for clinical and research purposes, respectively. 56 samples were taken in Minkang 2, 47 in Lomie and 63 in N ditam. Samples were stratified by age into kids, ages 1-15, and adults, aged 16-65. The elderly population was not studied due to lack of resources and lack of sample availability.
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