Methods and analyzers for hemoglobin measurement in clinical laboratories and field settings

Evaluation of HemoCue 201 Performance for Hemoglobin Measurement and Anemia Detection in EDTA, Heparinized, and Capillary Blood Samples

INTRODUCTION

This study aimed to evaluate the analytical and diagnostic performance of the HemoCue 201 device by comparing venous EDTA, venous heparinized, and capillary blood samples.

METHODS

The HemoCue 201 device was compared with an automated analyzer. Hemoglobin levels were measured from EDTA, heparinized, and capillary blood samples. Analytical performance was assessed using mean ± SD, paired t-test, intraclass correlation coefficient (ICC), and Bland-Altman plots. The CLIA 2025 criteria for acceptable error were applied to determine agreement. Diagnostic performance was determined via sensitivity, specificity, diagnostic effectiveness, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios.

RESULTS

The results showed excellent reliability with ICC values of 1.00 for both EDTA and heparinized, and 0.97 for capillary blood. Bland-Altman plots indicated small biases for EDTA (0.08 [-0.27 to 0.42]) and heparin (0.09 [-0.40 to 0.57]), but larger negative biases for capillary blood (-0.12 [-1.21 to 0.97]). According to CLIA 2025 criteria, 98% of EDTA and 95% of heparin samples were within the ±4% cut-off, whereas only 68% of capillary samples met this criterion. Diagnostic performance demonstrated strong potential as a rapid and reliable anemia screening tool due to its high sensitivity (100%) and NPV (100%).

CONCLUSION

The HemoCue 201 device reliably measured hemoglobin and detected anemia in all sample types. Heparinized blood, commonly used in point-of-care blood gas tests, can effectively support hemoglobin testing, reducing the need for additional blood draws. However, capillary samples exhibited greater bias, with variability influenced by pre-analytical factors. Standardized protocol and manufacturer guidelines helped minimize analytical variation.

Development and evaluation of an electrical impedance tomography (EIT) sensor for real-time monitoring of hemolysis dynamics

BACKGROUND

Real-time monitoring of hemolysis dynamics is essential for clinical diagnosis, ensuring transfusion safety, and supporting medical device development. Traditional methods such as spectrophotometry have limitations in real-time monitoring capabilities, often posing higher operational costs and restricted temporal resolution.

RESULTS

This study presents an Electrical Impedance Tomography (EIT) sensor designed for real-time monitoring of hemolysis dynamics. The EIT sensor comprises 16 circular electrodes within a cylindrical test chamber, connected to computer-controlled hardware and software for comprehensive data acquisition and analysis. Experimental validation shows that the EIT sensor can effectively monitor and visually display the dynamic process of hemolysis, irrespective of its underlying cause. Results from EIT measurements align closely with those obtained by the conventional spectrophotometric method. Furthermore, the EIT sensor accurately detects and monitors hemolysis in real-time, even when hemolysis is induced by ultrasound, chemical reagents, or a copper-simulated blood-contacting material with a super glue surface coating, within just 20 min of contact with blood.

SIGNIFICANCE

This EIT sensor represents a novel approach to hemolysis monitoring, providing valuable insights into hemolytic mechanisms, especially those related to biomaterials application. With its high temporal resolution, low cost, non-invasiveness, and portability, the EIT sensor offers a promising alternative tool for detecting and characterizing hemolysis, with potential applications in fundamental research and clinical practice, such as blood sample collection and long-term preservation.

Etorphine induces pathophysiology in immobilized white rhinoceros through sympathomimesis that is attenuated by butorphanol

White rhinoceros are a sentinel species for important ecosystems in southern Africa. Their conservation requires active management of their population, which, in turn, requires immobilization of individuals with an ultra-potent opioid such as etorphine. Unfortunately, when immobilized with etorphine, they develop severe hypoxaemia that may contribute to morbidity and mortality. We hypothesized that (i) etorphine causes sympathetic upregulation that is responsible for physiological complications that produce hypoxaemia and (ii) butorphanol, a partial μ opioid agonist, mitigates sympathetic upregulation, thereby improving arterial oxygen content (CaO2) and delivery (DO2). Six subadult male white rhinoceros were administered two treatments in random order: etorphine-saline (ES) and etorphine-butorphanol (EB). After intramuscular etorphine (~2.6 μg kg-1), rhinoceros became recumbent (time 0 min [t0]) and were instrumented. Baseline data were collected at t30, butorphanol (0.026 mg/kg) or 0.9% saline was administered intravenously at t37, and data were collected again at t40 and t50. At baseline, plasma noradrenaline concentration was >40 ng ml-1, approximately twice that of non-immobilized rhinoceros (t test, P < 0.05); cardiac output (Qt, by thermodilution) and metabolic rate (VO2, by spirometry/indirect calorimetry) were greater than predicted allometrically (t test, P < 0.05), and pulmonary hypertension was present. After butorphanol, noradrenaline concentration remained greater than in non-immobilized rhinoceros; in EB, CaO2 was greater, while Qt, DO2, VO2, and pulmonary pressures were less than in ES (linear mixed effect model, all P < 0.05). Increased noradrenaline concentration with increased Qt and hypermetabolism supports etorphine-induced sympathetic upregulation. Butorphanol partly attenuated these effects, increasing CaO2 but reducing Qt and, thus, DO2. Since plasma noradrenaline concentration remained increased after butorphanol administration while Qt, DO2, and VO2 decreased, a pathway independent of plasma noradrenaline concentration might contribute to the cardiopulmonary and hypermetabolic effects of etorphine. Developing treatments to combat this sympathomimesis could reduce capture-related morbidity in white rhinoceros.

What works for anemia reduction among women of reproductive age? Synthesized findings from the exemplars in anemia project

BACKGROUND

Few countries have succeeded to decrease the prevalence of anemia in women of reproductive age (WRA), and where improvements have been observed, contributing factors are not well understood.

OBJECTIVES

To synthesize cross-cutting findings from specific exemplar studies in Uganda, Senegal, the Philippines, and Pakistan by reviewing anemia trends, policies, and programs, comparing drivers of change, and proposing strategies to achieve further reductions in WRA anemia.

METHODS

A mixed-methods approach was used for exemplar case studies: 1) descriptive analyses of Demographic and Health Surveys and national survey data; 2) review of relevant policies/programs; 3) stakeholder in-depth interviews and focus group discussions with WRA and community members; and 4) Oaxaca-Blinder decomposition to identify determinants of hemoglobin change over time. This cross-country analysis performs triangulation of qualitative and quantitative analyses.

RESULTS

Compound annual change rates for anemia from the ∼2005-2018 period were -0.7% in Senegal, -2.4% in Uganda, -3.4% in Pakistan, and -6.2% in the Philippines. Despite these reductions, WRA anemia burden in Senegal and Pakistan continues to be a severe public health problem. Direct and indirect health sector strategies, such as iron-folic acid supplementation in pregnancy, vitamin A supplementation during lactation, malaria control (Uganda and Senegal), investments in family planning, and better access to health services through community-based approaches, contributed to a median of 36.5% (range: 30%-66%) change in hemoglobin. Nonhealth sector strategies, including social protection and poverty alleviation schemes, empowering of girls and women, and improving household conditions, contributed to a 21% (18%-58%) change in hemoglobin. Large-scale food fortification (for example, wheat flour with iron) could have also contributed to improved micronutrient intakes and reduction in iron deficiency anemia.

CONCLUSIONS

A context-specific, multisectoral approach is needed to decrease WRA anemia, incorporating direct nutritional interventions and indirect strategies within the health and nonhealth sectors. Lessons from the successes and challenges from exemplar countries could help accelerate global anemia reduction.

Project Gender NutriScope: Methods of a Mixed Methods, Community-Engaged Study Design to Explore the Nutritional Needs of Transgender and Gender-Diverse Youth and Young Adults

OBJECTIVE

Despite growing evidence of distinct nutrition-related experiences and disparities, transgender and gender-diverse (TGD) youth and young adults are an underrepresented population in nutrition research. This paper describes the methods and study design from Project Gender NutriScope, a study that will explore the nutritional needs of TGD youth and young adults.

DESIGN

Parallel convergent cross-sectional mixed methods; community-engaged.

SETTING

A purposive sample will be recruited in a Midwest city through clinics, youth organizations, and a large state university.

PARTICIPANTS

Transgender and gender-diverse youth and young adults aged 13-24 years.

INTERVENTION

Findings from this formative study will be used to inform future intervention development.

MAIN OUTCOME MEASURES

Dietary intake, eating patterns, disordered eating patterns, food security status, perceptions of relationship with food, and nutrition-related concerns.

ANALYSIS

Quantitative data will be analyzed using descriptive summary statistics. Qualitative data will be analyzed by reflexive thematic analysis. The 2 databases will be integrated iteratively.

Evaluation of the Performance of Portable Hemoglobinometers at Measuring Hemoglobin and Detecting Anemia in a Periurban Pediatric Population in Lima, Peru

As many as one in three people worldwide have anemia, with young children at increased risk of both disease and complications. In settings without clinical laboratories, portable hemoglobinometers serve important roles in diagnosing anemia and estimating prevalence. Here, we assess the validity of two such point-of-care devices-the HemoCue Hb201 and the HemoCue Hb301-relative to the international reference standard, the cyanmethemoglobin method. In total, 428 children ages 6-60 months were recruited at health posts in Lima, Peru, and venous and capillary blood samples were collected from each participant. Venous blood was assessed with the cyanmethemoglobin method, whereas capillary blood was assessed using the Hb201 and the Hb301; 16.1% of participants were found to have anemia using the cyanmethemoglobin method. Both the Hb201 (43.7%) and the Hb301 (20.6%) overestimated this prevalence, with the former reaching statistical significance (P <0.0001 and P = 0.11, respectively). Both devices also tended to underestimate hemoglobin concentration, with the Hb201 (mean difference = -0.99 g/dL; percentage error = -8.1%) being appreciably less accurate than the Hb301 (mean difference = -0.35 g/dL; percentage error = -2.7%). Areas under the curve for the Hb201 (0.92) and the Hb301 (0.93) were statistically similar (P = 0.28); however, the Hb201 incorrectly classified 29.4% of participants compared with 11.0% for the Hb301. Both devices had more false positives than false negatives. In conclusion, the Hb301 was found to be significantly more accurate than the Hb201 at measuring hemoglobin, diagnosing anemia, and estimating anemia prevalence.

Comparative effectiveness of daily therapeutic supplementation with multiple micronutrients and iron-folic acid versus iron-folic acid alone in children with mild-to-moderate anaemia in rural India: an open-label, randomised controlled trial

BACKGROUND

Anaemia is a major public health problem among children younger than 5 years and supplementation with iron-folic acid alone has not been found to result in desired improvements in haemoglobin concentrations. We aimed to compare the effect of supplementation with iron-folic acid plus multiple micronutrients versus iron-folic acid supplementation alone on haemoglobin concentration and cure rates in children with mild-to-moderate anaemia.

METHODS

In this individually randomised controlled trial conducted in rural Haryana, India, children (aged 6-59 months) with mild-to-moderate anaemia (haemoglobin ≥7 to <11 g/dL) were randomly assigned (1:1) to receive either daily iron-folic acid plus multiple micronutrients or iron-folic acid alone for 90 days. The primary outcomes were mean haemoglobin concentration and the proportion of children cured of anaemia (haemoglobin ≥11 g/dL) at 90 days, assessed in the intention-to-treat population, which included all randomly assigned participants for whom primary outcome assessments were done. Safety was assessed in all randomly assigned participants. The trial was registered with the Clinical Trial Registry-India, CTRI/2020/10/028298.

FINDINGS

Between March 1, 2021, and March 7, 2022, 1300 children were randomly assigned to the iron-folic acid plus multiple micronutrients group (n=648) or the iron-folic acid alone group (n=652). At baseline, 93 (20%) of 472 children had vitamin B12 deficiency (≤203 pg/mL), 16 (3%) of 475 children had serum folate deficiency (<4 ng/mL), and 44 (9%) of 468 children had zinc deficiency (<66 μg/dL). 611 children in the iron-folic acid plus micronutrients group and 626 children in the iron-folic acid alone group had a blood sample collected at the end of the 90-day supplementation period and were included in the primary outcome assessment. At 90 days, no differences in mean haemoglobin concentration were identified between the treatment groups (mean difference 0·06 [95% CI -0·05 to 0·16]). 489 (80%) of 611 children in the iron-folic acid plus micronutrients group and 492 (79%) of 626 children in the iron-folic acid alone group were cured of anaemia (risk ratio 1·02 [95% CI 0·90 to 1·16]). Compliance rates in both groups exceeded 75%. Black stools were the most common side-effect observed in both groups (640 [99%] of 648 children in iron-folic acid plus micronutrients group and 643 [99%] of 652 children in the iron-folic acid alone group).

INTERPRETATION

In children with mild-to-moderate anaemia, supplementation with multiple micronutrients and iron-folic acid did not result in significant benefits compared with iron-folic acid alone. Efforts that focus on ensuring high compliance with iron-folic acid supplementation alone might achieve satisfactory rates of anaemia recovery.

FUNDING

Indian Council of Medical Research and the Government of India.

Postmortem point-of care hemoglobin testing is feasible and potentially accurate among children in South Africa

Anemia is an important cause of child morbidity and mortality. Postmortem point-of-care hemoglobin testing is a potential method for assessing anemia at death, but its reliability has not been extensively studied. We aimed to assess the feasibility and validity of postmortem point-of-care hemoglobin assessment using HemoCue in the setting of a child mortality surveillance program in South Africa.In a pilot cohort study, 44 children under five years of age who died in an academic hospital in South Africa were enrolled. Hemoglobin levels were measured from venous blood antemortem using standard hematology analyzers and postmortem using the HemoCue 201 from blood collected within 72 hours of death (either by needle aspiration or from whole blood collected in an EDTA tube). Updated World Health Organization hemoglobin cutoffs to define anemia were used. Wilcoxon signed-rank tests, equivalence tests, and regression models assessed the concordance between antemortem and postmortem hemoglobin concentrations. Postmortem testing showed a significant decrease in hemoglobin concentrations compared to antemortem levels. However, no significant differences were found between hemoglobin measurements from needle aspiration and those from EDTA tubes postmortem. The prevalence of anemia increased from 52% antemortem to 73-77% postmortem, with the most notable rises in moderate and severe anemia. Bland-Altman analysis confirmed a systematic, not random, decrease in postmortem hemoglobin measurements. Upon applying a fixed adjustment of 2.5 g/dL, the sensitivity and specificity of postmortem hemoglobin testing to diagnose anemia were 69.6% and 61.9%, respectively. Postmortem point-of-care hemoglobin testing using HemoCue is feasible and offers a potentially valid reflection of antemortem anemia status in deceased children, despite consistently lower measured values postmortem. These findings support the utility of postmortem hemoglobin assessments in determining the presence and severity of anemia at the time of death.

Evaluation of point-of-care haemoglobin measurement accuracy in surgery (PREMISE) and implications for transfusion practice: a prospective cohort study

BACKGROUND

Point-of-care testing devices to measure haemoglobin (Hgb) frequently inform transfusion decision-making in surgery. This study aimed to examine their accuracy in surgery, focusing on Hgb concentrations of 60-100 g L-1, a range with higher potential for transfusion.

METHODS

This was a prospective diagnostic cohort study focused on method comparison, conducted at two academic hospitals. Consecutive patients undergoing noncardiac surgery and requiring point-of-care Hgb measurements were eligible. Hgb concentrations from arterial and central venous blood samples were measured concurrently using three devices and compared with laboratory Hgb. The primary outcome was individual pairwise comparisons between point-of-care and laboratory Hgb values; agreement was determined based on a threshold of within 4 g L-1. The primary analysis consisted of computing limits of agreement.

RESULTS

A total of 1735 intraoperative blood samples were collected (1139 participants); 680 samples had a laboratory Hgb <100 g L-1. The limits of agreement among those with Hgb <100 g L-1 were -9.5 to 8.0 g L-1 for HemoCue®, -16.2 to 11.5 g L-1 for i-STAT®, and -14.7 to 40.5 g L-1 for Rad-67®. HemoCue was associated with a 5.8% incidence of potentially clinically significant transfusion error, whereas i-STAT and Rad-67 were associated with 25.3% and 28.2%, respectively. HemoCue yielded Hgb measurements within 10 g L-1 in 98% of intraoperative blood samples.

CONCLUSIONS

No point-of-care Hgb device demonstrated limits of agreement that were smaller than the agreement difference of 4 g L-1. Despite this, HemoCue can be safely used to inform transfusion decisions in surgery, given its error probability of <4% in transfusion scenarios.

Development of a photoacoustic acquisition system and their proof-of-concept for hemoglobin detection

Recently, Organ-on-a-Chip (OoC) platforms have arisen as an increasingly relevant experimental tool for successfully replicating human physiology and disease. However, there is a lack of a standard technology to monitor the OoC parameters, especially in a non-invasive and label-free way. Photoacoustic (PA) systems can be considered an alternative and accurate assessment method for OoC platforms. PA systems combine an illumination source to excite the sample molecules, with an ultrasound sensor to measure the generated ultrasonic waves, combining the advantages of optics and acoustic methodologies to safely acquire tridimensional signals and images at various depths. This work is focused on the design, implementation and test of an acquisition electronics circuit, based on the PA principle, for hemoglobin (Hb) detection, aiming towards a future integration within an OoC platform. Based on the measured frequency response of commercial piezoelectric transducers, an electronics design comprising a differential charge amplifier and a band-pass filter was developed. Experimentally it was verified Hb detection for concentrations of Hb between 2.5 and 10 mg/mL in aqueous solutions, roughly 48 times lower than the typical in vivo blood concentrations. This creates the possibility of developing this technique to monitor Hb at low concentrations in small volumes, which is highly appropriate for OoC devices.

Comparison of a non-invasive point-of-care measurement of anemia to conventionally used HemoCue devices in Gambella refugee camp, Ethiopia, 2022

Annual surveys of refugees in Gambella, Ethiopia suggest that anemia is a persistent public health problem among non-pregnant women of reproductive age (NP-WRA, 15-49 years). Measurement of anemia in most refugee camp settings is conducted using an invasive HemoCue 301. We assessed the accuracy and precision of a non-invasive, pulse CO-oximeter in measuring anemia among NP-WRA in four Gambella refugee camps. We conducted a population-representative household survey between November 7 and December 4, 2022. Hemoglobin (Hb) concentration was measured by HemoCue 301, using capillary blood, and Rad-67, a novel non-invasive device. We collected four measurements per participant: two per device. We calculated Rad-67 bias and precision of Hb measurements and sensitivity and specificity of detecting anemia. Of the 812 NP-WRAs selected, 807 (99%) participated in the study. Anemia was detected in 39% of NP-WRA as classified by the Rad-67 compared with 47% of NP-WRA as classified by the HemoCue 301. Average bias of Rad-67 measurements was 1.1 ± 1.0 SD g/dL, using HemoCue 301 as a comparator. Absolute mean difference between the first and second measurements was 0.9 g/dL (95% CI 0.8, 0.9) using the Rad-67, compared with 0.6 g/dL (95% CI 0.5, 0.6) using the HemoCue 301. The Rad-67 had 49% sensitivity and 70% specificity for detecting anemia, compared with the HemoCue 301. The Rad-67 can be a useful tool for anemia screening; however, lower accuracy and precision, and poor sensitivity suggest it cannot immediately replace the HemoCue 301 in the study area.

An Analysis of Monitoring Solutions for CAR T Cell Production

The chimeric antigen receptor T cell (CAR T) therapy has shown remarkable results in treating certain cancers. It involves genetically modifying a patient's T cells to recognize and attack cancer cells. Despite its potential, CAR T cell therapy is complex and costly and requires the integration of multiple technologies and specialized equipment. Further research is needed to achieve the maximum potential of CAR T cell therapies and to develop effective and efficient methods for their production. This paper presents an overview of current measurement methods used in the key steps of the production of CAR T cells. The study aims to assess the state of the art in monitoring solutions and identify their potential for online monitoring. The results of this paper contribute to the understanding of measurement methods in CAR T cell manufacturing and identify areas where on-line monitoring can be improved. Thus, this research facilitates progress toward the development of effective monitoring of CAR T cell therapies.

Comparison of haemoglobin concentration measurements using HemoCue-301 and Sysmex XN-Series 1500: A survey among anaemic Gambian infants aged 6-12 months

BACKGROUND

In low-income countries, point-of-care photometers are used in the screening and management of anaemia in individuals, but also in the assessment of population iron status when evaluating efficacy of intervention studies or public health interventions.

AIMS

We aimed to evaluate the accuracy of a commonly used photometer, HemoCue-301, in determining haemoglobin concentration among anaemic children aged 6-12 months in a field setting in rural Africa.

METHODS

This report concerns a secondary analysis of data from Gambian infants being screened for an ongoing randomized controlled trial. In those found to be anaemic by HemoCue-301, haemoglobin concentration was measured by Sysmex XN-1500, an automated haematology analyser that was used as a reference. Passing-Bablok regression analysis was used to estimate the regression constant (systematic deviation between two measurement methods that remain consistent across the range of measurements) and proportional bias (systematic deviation between two measurement methods that change in magnitude relative to the value being measured).

RESULTS

Analysis was based on 227 participants. There was strong evidence of absolute bias among moderately anaemic participants (haemoglobin concentration at 8.0g/dL) (absolute bias: 1.12g/dL; 95% CI: 0.91 to 1.37g/dL; proportional bias: 14.0%; 95% CI: 11.4% to 17.1%) in haemoglobin concentrations measured by HemoCue-301 compared to those measured by Sysmex XN-Series1500. Bias was marginal at haemoglobin concentration of 11.0g/dL (absolute bias: -0.08g/dL; 95% CI: -0.18 to 0.07g/dL; proportional bias: -7.3%; 95% CI: -6.5% to 0.6%).

CONCLUSION

Haemoglobin measurements by HemoCue-301 seem substantially biased in participants with haemoglobin less than 8.0g/dL.

Maternal Anemia during Pregnancy and Infant Birth Outcomes: A Prospective Cohort Study in Eastern Maharashtra, India

Background

Anemia during pregnancy may be associated with poor infant outcomes, although its consequences may vary based on etiology and timing.

Objectives

We examined the associations between anemia and anemia-related biomarkers during pregnancy and infant outcomes [birthweight, gestational age at birth, birthweight-for-gestational age percentile, and infant hemoglobin (Hb) at 6 wk of age] in Nagpur, Eastern Maharashtra, India.

Methods

We conducted a prospective cohort study of 200 pregnant women. In the first trimester, venous blood was collected to assess Hb via cyanmethemoglobin analysis, micronutrient status (ferritin, vitamin B12, and folate), and inflammation (C-reactive protein). Hb was also assessed in capillary samples using a hemoglobinometer in the first and third trimesters for mothers and at 6 wk for infants. Associations were assessed using generalized linear models controlling for background characteristics.

Results

In the first trimester, high (compared with normal) venous Hb was significantly associated with lower gestational age at birth [β: -1.0 wk, 95% confidence interval (CI): -1.9, -0.2] and higher birthweight-for-gestational age percentile (β: 20.1, 95% CI: 9.0, 31.2). Mild anemia, moderate anemia, and high (compared with normal) capillary Hb were significantly associated with lower birthweight (β: -147.7 g, 95% CI: -243.4, -51.7; β: -77.7 g, 95% CI: -123.9, -31.4; and β: -236.0 g, 95% CI: -478.0, -48.1) and birthweight-for-gestational age percentile (β: -7.3, 95% CI: -13.7, -0.9; β: -8.4, 95% CI: -14.1, -2.8; and β: -8.9, 95% CI: -15.9, -1.9). Higher serum ferritin was significantly associated with higher birthweight (β: 2.0 g, 95% CI: 0.1, 3.9) and gestational age at birth (β: 0.01 wk, 95% CI: 0.00, 0.01). In the third trimester, mild anemia was significantly associated with lower gestational age at birth (β: -0.5 wk, 95% CI: -0.7, -0.3).

Conclusions

Associations between maternal anemia during pregnancy and infant outcomes were mixed indicating further studies are needed to better understand these relationships.

Evaluating the Feasibility and Cost-Effectiveness of EzeCheck for Hemoglobin Screening Across India

Background Anemia, particularly due to low hemoglobin levels, is a significant public health concern in India. Traditional invasive screening methods can be burdensome and may limit access to diagnosis. This study evaluated the feasibility and cost-effectiveness of a noninvasive hemoglobin screening device called EzeCheck for determining hemoglobin levels across diverse populations in India. We aimed to assess the user feasibility of the EzeCheck device and to conduct a comparative analysis of its cost-effectiveness against other available invasive and noninvasive methods to determine hemoglobin levels. Methods This study adopted a mixed-methods approach, incorporating both quantitative and qualitative data for analysis. User feedback was collected through surveys and interviews with healthcare professionals and workers across various regions. A cost-effectiveness analysis compared the EzeCheck device with other available noninvasive devices and standard invasive methods, accounting for factors such as equipment costs, consumables requirements, time efficiency, and overall testing costs. Results Preliminary findings suggest that the EzeCheck device was well-received by users, with 198 (86%) healthcare professionals reporting improved workflow and patient satisfaction. The comparative analysis revealed that the EzeCheck device was the most affordable option in terms of overall screening costs, while also increasing screening efficiency to a great extent. Moreover, it provided a safer and more comfortable experience for patients and users. Conclusions The noninvasive EzeCheck hemoglobin screening device demonstrates superior feasibility and cost-effectiveness over traditional methods. This study highlights its potential for enhancing anemia detection in India, particularly in underserved areas. By improving accessibility and reducing costs, this device could significantly impact public health outcomes and inform future health policy initiatives.

Trends and predictors of severe and moderate anaemia among children aged 6-59 months in India: an analysis of three rounds of National Family Health Survey (NFHS) data

BACKGROUND

Childhood anaemia remains a significant public health problem in India, as it adversely affects child development and overall health outcomes. This study aimed to analyse the prevalence of severe and moderate anaemia among children aged 6-59 months and identify consistent predictors of this condition over the past 15 years.

METHODS

Data from the three most recent rounds of the NFHS were used for this analysis. The final weighted sample included 40,331 children from the NFHS-3 (2005-2006), 200,093 from the NFHS-4 (2015-2016), and 178,909 from the NFHS-5 (2019-2021). Descriptive and bivariate analyses were conducted, followed by binary logistic regression to identify factors associated with severe and moderate anaemia in children aged 6-59 months. All statistical analyses were performed using Stata version 14.

RESULTS

Over the past 15 years, the prevalence of severe and moderate anaemia among children in India has shown a slight decline. However, the influence of various predictors has changed over time. Young children (aged 6-23 months), those from Scheduled Caste (SC) and Scheduled Tribe (ST) communities, and children born to mothers with high parity and low educational attainment remain particularly vulnerable to anaemia. Additionally, short-term illness significantly increases the risk of anaemia. Furthermore, women's autonomy, indicated by higher education and lower fertility rates, along with maternal nutrition education, have emerged as key factors in reducing anaemia burden in the future. Notably, children whose mothers had no education were 1.4 times more likely to suffer from severe or moderate anaemia. Similarly, children born to mothers with four to five children (OR 1.1, p < 0.05) and those with six or more children (OR 1.2, p < 0.05) had an elevated risk of anaemia.

CONCLUSION

The findings highlight three key areas for programmatic focus to accelerate anaemia reduction in India: [1] targeting young children (aged 6-23 months); [2] ensuring the inclusion of SC and ST communities in all relevant interventions; and [3] promoting women's autonomy. These strategies are essential for reducing the burden of anaemia across the country.

The prevalence of anemia during pregnancy and its correlates vary by trimester and hemoglobin assessment method in Eastern Maharashtra, India

Approximately half of pregnant women in India are anemic, representing over 7.5 million women. Few studies have assessed the relationship between multiple micronutrient deficiencies and anemia during pregnancy or the trajectory of hemoglobin (Hb) during pregnancy in low-resource settings. We enrolled 200 pregnant women from the Maternal and Newborn Health (MNH) registry, a population-based pregnancy and birth registry in Eastern Maharashtra, India to address these gaps. The women provided capillary (finger-prick) and venous blood specimens at enrollment (<15 weeks), and a second capillary specimen in the 3rd trimester (>27 weeks). Capillary specimens were analyzed at the time of collection with a HemoCue Hb 201+; venous specimens were shipped on dry ice to a laboratory for cyanmethemoglobin assessment. In the 1st trimester, mean Hb concentration and anemia (Hb<11.0 g/dL) prevalence using capillary specimens were 10.9 ± 1.5 g/dL and 51.1%; mean Hb concentration using venous blood specimens was estimated to be 11.3 ± 1.3 g/dL and anemia prevalence was 37.5%. The prevalence of iron, vitamin B12 and folate deficiencies were 40%, 30% and 0%, respectively. Among women with anemia in the 1st trimester (venous blood), 56% had concurrent iron deficiency (inflammation-adjusted serum ferritin <15 µg/L) indicating that their anemia may be amenable to iron supplementation. In total, 21% of women had ID and anemia, 19% ID in the absence of anemia, 16.5% anemia in the absence of ID and 43.5% had neither. By the 3rd trimester, mean Hb from capillary specimens had declined to 10.1 ± 1.35 g/dL and anemia prevalence increased to 70.7%, despite 99.4% mothers reporting receipt of iron-folic acid (IFA) supplements during her current pregnancy, and 83.9% reporting IFA consumption the previous day. Significant predictors of anemia in the 1st trimester (both venous and capillary) included the number of weeks gestation at the time of Hb assessment and inflammation-adjusted serum ferritin. For 3rd trimester anemia, significant predictors included 1st trimester height, BMI and IFA consumption during the 3rd trimester (but not 1st trimester micronutrient biomarkers), indicating that IFA supplementation over the course of pregnancy may have influenced micronutrient status and anemia risk. Our findings highlight the severity of the burden of anemia and micronutrient deficiencies in Eastern Maharashtra, but also highlight that in many cases, ID and anemia affect different individuals. Preventing and managing anemia in pregnancy in India will require strengthening both clinical and community-based strategies targeting iron deficiency, as well as other causes of anemia.

Numerical and in vitro experimental studies for assessing the blood hematocrit and oxygenation with the dual-wavelength photoacoustics

Assessing the blood hematocrit (Hct) and oxygenation (SO2 ) levels are essential for diagnosing numerous blood-related diseases. This study examines the ability of the photoacoustic (PA) technique for quantitative evaluation of these parameters. We conducted the Monte Carlo and k-Wave simulations to compute PA signals at four different optical wavelengths from test blood samples followed by rigorous in vitro experiments. This method can estimate the Hct and SO2 levels faithfully with ≥ 95% and ≥ 93% accuracies, respectively in the physiologically relevant hematocrits utilizing PA signals generated at 700 and 1000 nm optical wavelengths. A 2% decrease in the scattering anisotropy factor demotes SO2 estimation by ≈ 27%. This study provides sufficient insight into how the opto-chemical parameters of blood impact PA emission and may help to develop a PA setup for in vitro characterization of human blood.

Emerging Evidence and Critical Issues with the Use of Single-Drop Capillary Blood for the Measurement of Hemoglobin Concentration in Population-Level Anemia Surveys

Accurate and precise measurement of hemoglobin concentration is critical for reliable estimations of anemia prevalence at the population level. When systematic and/or random error are introduced in hemoglobin measurement, estimates of anemia prevalence might be significantly erroneous and, hence, limit their usefulness. For decades, single-drop capillary blood has been the most common blood source used for the measurement of hemoglobin concentration in surveys, especially in low-income and middle-income countries. In this study, we highlight historical and emerging evidence that single-drop capillary blood introduces a high degree of random error (variability) to hemoglobin estimates, leading to less reliable estimates of anemia prevalence at the population level. At present, the best practice is to collect and use venous blood for measurement of hemoglobin with an automated hematology analyzer, following standard operating procedures and quality assurance measures. Where use of an automated analyzer is not possible, the analysis of venous blood in a point-of-care hemoglobinometer by trained phlebotomists or specimen collectors should be considered. A forthcoming systematic review will provide additional evidence on the accuracy and precision of single-drop capillary blood for hemoglobin assessment. In the meantime, we raise caution when using single-drop capillary blood for hemoglobin measurement as it can result in inaccurate hemoglobin estimates and less reliable anemia prevalence estimates.

Hematological and neurological impact studies on the exposure to naturally occurring radioactive materials

Naturally Occurring Radioactive Materials (NORM) contribute to everyone's natural background radiation dose. The technologically advanced activities of the gas and oil sectors produce considerable amounts of radioactive materials as industrial by-products or waste products. The goal of the current study is to estimate the danger of long-term liability to Technologically Enhanced Naturally Occurring Radioactive Materials (TE-NORM) on blood indices, neurotransmitters, oxidative stress markers, and β-amyloid in the cerebral cortex of rats' brains. Twenty adult male albino rats were divided into two equal groups (n = 10): control and irradiated. Irradiated rats were exposed to a total dose of 0.016 Gy of TE-NORM as a whole-body chronic exposure over a period of two months. It should be ''The results showed no significant changes in RBC count, Hb concentration, hematocrit percentage (HCT%), and Mean Corpuscular Hemoglobin Concentration (MCHC). However, there was a significant increase in the Mean Corpuscular Volume of RBCs (MCV) and a significant decrease in cell distribution width (RDW%) compared to the control. Alteration in neurotransmitters is noticeable by a significant increase in glutamic acid and significant decreases in serotonin and dopamine. Increased lipid peroxidation, decreased glutathione content, superoxide dismutase, catalase, and glutathione peroxidase activities indicating oxidative stress were accompanied by increased β-amyloid in the cerebral cortex of rats' brains. The findings of the present study showed that chronic radiation liability has some harmful effects, that may predict the risks of future health problems in occupational radiation exposure in the oil industries. Therefore, the control of exposure and application of sample dosimetry is recommended for health and safety.

Antibacterial Activity and Proposed Mode of Action of Extracts from Selected Zimbabwean Medicinal Plants against Acinetobacter baumannii

Acinetobacter baumannii was identified by the WHO as a priority pathogen in which the research and development of new antibiotics is urgently needed. Plant phytochemicals have potential as sources of new antimicrobials. The objective of the study was to determine the antibacterial activity of extracts of selected Zimbabwean medicinal plants against A. baumannii and determine their possible mode of action. Extracts were prepared from the leaves of the eight plants including the bark of Erythrina abyssinica using solvents of different polarities. Antibacterial activity was evaluated using the microbroth dilution method coupled with the in vitro iodonitrotetrazolium colorimetric assay. The effect of the extracts on membrane integrity was determined by quantifying the amount of protein and nucleic acid leaked from the cells after exposure to the extracts. The effects of the extracts on biofilms were investigated. Toxicity studies were carried out using sheep erythrocytes and murine peritoneal cells. Seven out of eight evaluated plant extracts were found to have antibacterial activity. The Combretum apiculatum acetonie (CAA) extract showed the highest inhibitory activity against A. baumannii with a minimal inhibitory concentration of 125 µg/mL. The minimum inhibitory concentration (MIC) of the CAA extract caused a protein leakage of 32 µg/mL from A. baumannii. The Combretum apiculatum acetonie (CAA), C. apiculatum methanolic (CAM), Combretum zeyheri methanolic (CZM), and Erythrina abyssinica methanolic (EAM) extracts inhibited A. baumannii biofilm formation. The EAM extract was shown to disrupt mature biofilms. The potent extracts were nontoxic to sheep erythrocytes and mouse peritoneal cells. The activities shown by the extracts indicate that the plants have potential as sources of effective antibacterial and antibiofilm formation agents against A. baumannii.

Daily oral iron supplementation during pregnancy

BACKGROUND

Iron and folic acid supplementation have been recommended in pregnancy for anaemia prevention, and may improve other maternal, pregnancy, and infant outcomes.

OBJECTIVES

To examine the effects of daily oral iron supplementation during pregnancy, either alone or in combination with folic acid or with other vitamins and minerals, as an intervention in antenatal care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Registry on 18 January 2024 (including CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO's International Clinical Trials Registry Platform, conference proceedings), and searched reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials that evaluated the effects of oral supplementation with daily iron, iron + folic acid, or iron + other vitamins and minerals during pregnancy were included.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed trial eligibility, ascertained trustworthiness based on pre-defined criteria, assessed risk of bias, extracted data, and conducted checks for accuracy. We used the GRADE approach to assess the certainty of the evidence for primary outcomes. We anticipated high heterogeneity amongst trials; we pooled trial results using a random-effects model (average treatment effect).

MAIN RESULTS

We included 57 trials involving 48,971 women. A total of 40 trials compared the effects of daily oral supplements with iron to placebo or no iron; eight trials evaluated the effects of iron + folic acid compared to placebo or no iron + folic acid. Iron supplementation compared to placebo or no iron Maternal outcomes: Iron supplementation during pregnancy may reduce maternal anaemia (4.0% versus 7.4%; risk ratio (RR) 0.30, 95% confidence interval (CI) 0.20 to 0.47; 14 trials, 13,543 women; low-certainty evidence) and iron deficiency at term (44.0% versus 66.0%; RR 0.51, 95% CI 0.38 to 0.68; 8 trials, 2873 women; low-certainty evidence), and probably reduces maternal iron-deficiency anaemia at term (5.0% versus 18.4%; RR 0.41, 95% CI 0.26 to 0.63; 7 trials, 2704 women; moderate-certainty evidence), compared to placebo or no iron supplementation. There is probably little to no difference in maternal death (2 versus 4 events, RR 0.57, 95% CI 0.12 to 2.69; 3 trials, 14,060 women; moderate-certainty evidence). The evidence is very uncertain for adverse effects (21.6% versus 18.0%; RR 1.29, 95% CI 0.83 to 2.02; 12 trials, 2423 women; very low-certainty evidence) and severe anaemia (Hb < 70 g/L) in the second/third trimester (< 1% versus 3.6%; RR 0.22, 95% CI 0.01 to 3.20; 8 trials, 1398 women; very low-certainty evidence). No trials reported clinical malaria or infection during pregnancy. Infant outcomes: Women taking iron supplements are probably less likely to have infants with low birthweight (5.2% versus 6.1%; RR 0.84, 95% CI 0.72 to 0.99; 12 trials, 18,290 infants; moderate-certainty evidence), compared to placebo or no iron supplementation. However, the evidence is very uncertain for infant birthweight (MD 24.9 g, 95% CI -125.81 to 175.60; 16 trials, 18,554 infants; very low-certainty evidence). There is probably little to no difference in preterm birth (7.6% versus 8.2%; RR 0.93, 95% CI 0.84 to 1.02; 11 trials, 18,827 infants; moderate-certainty evidence) and there may be little to no difference in neonatal death (1.4% versus 1.5%, RR 0.98, 95% CI 0.77 to 1.24; 4 trials, 17,243 infants; low-certainty evidence) or congenital anomalies, including neural tube defects (41 versus 48 events; RR 0.88, 95% CI 0.58 to 1.33; 4 trials, 14,377 infants; low-certainty evidence). Iron + folic supplementation compared to placebo or no iron + folic acid Maternal outcomes: Daily oral supplementation with iron + folic acid probably reduces maternal anaemia at term (12.1% versus 25.5%; RR 0.44, 95% CI 0.30 to 0.64; 4 trials, 1962 women; moderate-certainty evidence), and may reduce maternal iron deficiency at term (3.6% versus 15%; RR 0.24, 95% CI 0.06 to 0.99; 1 trial, 131 women; low-certainty evidence), compared to placebo or no iron + folic acid. The evidence is very uncertain about the effects of iron + folic acid on maternal iron-deficiency anaemia (10.8% versus 25%; RR 0.43, 95% CI 0.17 to 1.09; 1 trial, 131 women; very low-certainty evidence), or maternal deaths (no events; 1 trial; very low-certainty evidence). The evidence is uncertain for adverse effects (21.0% versus 0.0%; RR 44.32, 95% CI 2.77 to 709.09; 1 trial, 456 women; low-certainty evidence), and the evidence is very uncertain for severe anaemia in the second or third trimester (< 1% versus 5.6%; RR 0.12, 95% CI 0.02 to 0.63; 4 trials, 506 women; very low-certainty evidence), compared to placebo or no iron + folic acid. Infant outcomes: There may be little to no difference in infant low birthweight (33.4% versus 40.2%; RR 1.07, 95% CI 0.31 to 3.74; 2 trials, 1311 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. Infants born to women who received iron + folic acid during pregnancy probably had higher birthweight (MD 57.73 g, 95% CI 7.66 to 107.79; 2 trials, 1365 infants; moderate-certainty evidence), compared to placebo or no iron + folic acid. There may be little to no difference in other infant outcomes, including preterm birth (19.4% versus 19.2%; RR 1.55, 95% CI 0.40 to 6.00; 3 trials, 1497 infants; low-certainty evidence), neonatal death (3.4% versus 4.2%; RR 0.81, 95% CI 0.51 to 1.30; 1 trial, 1793 infants; low-certainty evidence), or congenital anomalies (1.7% versus 2.4; RR 0.70, 95% CI 0.35 to 1.40; 1 trial, 1652 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. A total of 19 trials were conducted in malaria-endemic countries, or in settings with some malaria risk. No studies reported maternal clinical malaria; one study reported data on placental malaria.

AUTHORS' CONCLUSIONS

Daily oral iron supplementation during pregnancy may reduce maternal anaemia and iron deficiency at term. For other maternal and infant outcomes, there was little to no difference between groups or the evidence was uncertain. Future research is needed to examine the effects of iron supplementation on other maternal and infant health outcomes, including infant iron status, growth, and development.

Assessing Accuracy and Precision of Hemoglobin Determination in Venous, Capillary Pool, and Single-Drop Capillary Blood Specimens Using three Different HemoCue® Hb Models: The Multicountry Hemoglobin Measurement (HEME) Study

BACKGROUND

Anemia prevalence estimates reported in population surveys can vary based on the blood specimen source (capillary or venous) and analytic device (hematology autoanalyzers or portable hemoglobinometers) used for hemoglobin (Hb) determination.

OBJECTIVES

This study aimed to compare accuracy and precision of Hb measurement in three blood specimen types on three models of hemoglobinometers against the results from venous blood from the same individuals measured on automated analyzers (AAs).

METHODS

This multisite (Cambodia, Ethiopia, Guatemala, Lebanon, Nigeria, and Tanzania) study assessed Hb measurements in paired venous and capillary blood specimens from apparently healthy women (aged 15-49 y) and children (aged 12-59 mo) using three HemoCue® Hb models (201+, 301, and 801). Measurements were compared against reference values: venous blood in hematology AA and adjusted via regression calibration or mean difference in HemoCue® Hb. Venous, capillary pool, and single-drop capillary blood specimens were assessed for accuracy and precision.

RESULTS

Venous blood measured using HemoCue® Hb 301 exhibited a positive mean error, whereas responses in HemoCue® Hb 201+ and 801 were nondirectional compared with the reference. Adjustment with the reference harmonized mean errors for all devices across study sites to <1.0 g/L using venous blood. Precision was highest for venous blood (±5-16 g/L) in all sites, lowest for single-drop capillary (±9-37 g/L), and intermediate (±9-28 g/L) for capillary pool blood specimen. Imprecision differed across sites, especially with both capillary blood specimens, suggesting different levels of personnel skills.

CONCLUSIONS

Findings suggest that venous blood is needed for accurate and precise Hb determination. Single-drop capillary blood use should be discouraged owing to high measurement variability. Further research should evaluate the viability and reliability of capillary pool blood for this purpose. Accuracy of HemoCue® Hb devices can be improved via standardization against results from venous blood assessed using AA.

Comparison of venous and pooled capillary hemoglobin levels for the detection of anemia among adolescent girls

Introduction

Blood source is a known preanalytical factor affecting hemoglobin (Hb) concentrations, and there is evidence that capillary and venous blood may yield disparate Hb levels and anemia prevalence. However, data from adolescents are scarce.

Objective

To compare Hb and anemia prevalence measured by venous and individual pooled capillary blood among a sample of girls aged 10-19 years from 232 schools in four regions of Ghana in 2022.

Methods

Among girls who had venous blood draws, a random subsample was selected for capillary blood. Hb was measured using HemoCue® Hb-301. We used Lin's concordance correlation coefficient (CCC) to quantify the strength of the bivariate relationship between venous and capillary Hb and a paired t-test for difference in means. We used McNemar's test for discordance in anemia cases by blood source and weighted Kappa to quantify agreement by anemia severity. A multivariate generalized estimating equation was used to quantify adjusted population anemia prevalence and assess the association between blood source and predicted anemia risk.

Results

We found strong concordance between Hb measures (CCC = 0.86). The difference between mean venous Hb (12.8 g/dL, ± 1.1) and capillary Hb (12.9 g/dL, ± 1.2) was not significant (p = 0.26). Crude anemia prevalence by venous and capillary blood was 20.6% and 19.5%, respectively. Adjusted population anemia prevalence was 23.5% for venous blood and 22.5% for capillary (p = 0.45). Blood source was not associated with predicted anemia risk (risk ratio: 0.99, 95% CI: 0.96, 1.02). Discordance in anemia cases by blood source was not significant (McNemar p = 0.46). Weighted Kappa demonstrated moderate agreement by severity (ĸ = 0.67). Among those with anemia by either blood source (n = 111), 59% were identified by both sources.

Conclusion

In Ghanaian adolescent girls, there was no difference in mean Hb, anemia prevalence, or predicted anemia risk by blood source. However, only 59% of girls with anemia by either blood source were identified as having anemia by both sources. These findings suggest that pooled capillary blood may be useful for estimating Hb and anemia at the population level, but that caution is needed when interpreting individual-level data.

Burden of Submicroscopic Plasmodium Infections and Detection of kelch13 Mutant Parasites in Military and Civilian Populations in Papua New Guinea

Malaria remains a major public health problem in Papua New Guinea (PNG) and an important force health protection issue for both PNG and Australian Defence Forces. To investigate the malaria burden in the military and civilians residing on military bases, a cross-sectional survey was conducted in April 2019 at three military bases in Wewak, Manus Island, and Vanimo, PNG. A total of 1,041 participants were enrolled; 235 military personnel from three bases and 806 civilians from Wewak and Vanimo. Polymerase chain reaction (PCR) revealed an overall high prevalence of Plasmodium infection in both the military and civilians. Among the military, the infection prevalence was significantly higher in Wewak (35.5%) and Vanimo (33.3%) bases than on Manus Island (11.8%). Among civilians, children (<16 years old) had significantly higher odds of being PCR positive than adults (≥16 years old). At Wewak and Vanimo, Plasmodium vivax accounted for 85.4%, 78.2%, and 66.2% of infections in military, children, and adult populations. Overall, 87.3%, 41.3%, and 61.3% of Plasmodium infections in the military, children, and adults, respectively, were detected only by PCR, not by microscopy (submicroscopic [SM] infections). Children had a significantly lower proportion of SM infections than adults and Papua New Guinea Defence Force personnel. Infection status was not associated with hemoglobin levels in these populations at the time of the survey. Mutant kelch13 (C580Y) parasites were identified in 5/68 Plasmodium falciparum-infected individuals. The survey results indicate extensive malaria transmission on these bases, especially in Wewak and Vanimo. More intensified interventions are required to reduce malaria transmission on PNG military bases.

Hemoglobin measurement in venous blood compared with pooled and single-drop capillary blood: a method-comparison study in a controlled and survey setting in Uganda among children and women

BACKGROUND

Standard practice for estimating anemia in population-based surveys is to use a point-of-care device to measure hemoglobin (Hb) in a single drop of capillary blood. Emerging evidence points to larger than expected differences in Hb concentration depending on the blood source.

OBJECTIVE

We evaluated use of different blood sources to measure Hb with a HemoCue 201+ analyzer compared with the reference method of venous blood tested with a Sysmex XN-450 hematology analyzer.

METHODS

Hb concentration in venous, pooled capillary, and single-drop capillary blood were collected in controlled (laboratory) and survey (Demographic Health Survey-8 pilot) settings in Uganda among children 6-59 mo and nonpregnant women 15-49 y. Venous and capillary blood collected from the same individual was tested using a HemoCue 201+ analyzer and the venous blood was also measured with a Sysmex XN-450 hematology analyzer. Agreement between measures was estimated using Lin's concordance correlation coefficient, Bland-Altman plots, and Deming regression. Means and prevalences were compared using paired t-tests and McNemar's tests, respectively.

RESULTS

The limits of agreement between Hb measured using a HemoCue 201+ analyzer and the reference method were lowest for venous (1.1-1.96 g/dL), followed by pooled capillary (1.45-2.27 g/dL), and single-drop capillary blood (2.23-3.41 g/dL). Mean differences were <0.5 g/dL across comparators. There were statistically significant differences in Hb concentration from both types of capillary blood. Anemia prevalence was lower in pooled capillary blood compared with the reference method.

CONCLUSIONS

The variability of Hb measured by capillary blood using the HemoCue 201+ analyzer is higher than venous blood but the extent to which this impacts the validity of Hb and anemia estimates requires further exploration. Future research is also needed to evaluate the implications of using venous compared with capillary blood in population-based surveys. This trial was registered at clinicaltrials.gov (NCT05059457).

Overview of Trends in Anemia and Iron Deficiency in the Mexican Population From 1999 to 2018-19

BACKGROUND

Despite the emergence of diverse programs in Mexico to address anemia and micronutrient deficiencies in disadvantaged groups, progress on reducing their prevalence has stagnated. In Mexico, anemia surveillance at the population level is conducted through the National Health and Nutrition Survey ENSANUT (for its acronym in Spanish).

OBJECTIVE

To overview the trends in anemia and iron deficiency (ID) from 1999 to 2018-19 in the Mexican population before COVID-19 pandemic.

METHODS

Data from five nationwide surveys in Mexico were used. Where available, data on anemia, ID, and ID anemia (IDA) were extracted from ENSANUTs 1999, 2006, 2012, 2016, and 2018-19 in participants from 1 to 99 years old. Blood sample collection methods were similar across surveys (1999-2018) where capillary drop blood was used to estimate Hb using a HemoCue and serum blood samples to measure ferritin and C-reactive protein concentration.

RESULTS

The trend in anemia prevalence shows a U-shape from 1999 to 2018-19 in <60 years old. In older adults (≥60 years), an increasing trend was observed. Anemia declined progressively from 1999 to 2012 but increased from 2016 to 2018-19 in comparison with 2012. In contrast, ID declined from 2006 to 2018-19, mainly in children, while IDA did not change over this period. In older adults, ID prevalence remained constant over time.

CONCLUSIONS

The shifting trend in anemia prevalence across ENSANUTs 1999 through 2018-19 did not mimic the decreasing trend of ID over the same period of time. Other noncausal factors seem to play an important role in the variability of hemoglobin measurements.

Ten2Twenty-Ghana: a randomised controlled trial on the efficacy of multiple micronutrient-fortified biscuits on the micronutrient status of adolescent girls

Adolescent girls are an important target group for micronutrient interventions particularly in Sub-Saharan Africa where adolescent pregnancy and micronutrient deficiencies are common. When consumed in sufficient amounts and at levels appropriate for the population, fortified foods may be a useful strategy for this group, but little is known about their effectiveness and timing (regarding menarche), particularly in resource-poor environments. We evaluated the effect of consuming multiple micronutrient-fortified biscuits (MMB), sold in the Ghanaian market, 5 d/week for 26 weeks compared with unfortified biscuits (UB) on the micronutrient status of female adolescents. We also explored to what extent the intervention effect varied before or after menarche. Ten2Twenty-Ghana was a 26-week double-blind, randomised controlled trial among adolescent girls aged 10-17 years (n 621) in the Mion District, Ghana. Biomarkers of micronutrient status included concentrations of Hb, plasma ferritin (PF), soluble transferrin receptor (TfR) and retinol-binding protein (RBP), including body-iron stores. Intention-to-treat analysis was supplemented by protocol-specific analysis. We found no effect of the intervention on PF, TfR and RBP. MMB consumption did not affect anaemia and micronutrient deficiencies at the population level. MMB consumption increased the prevalence of vitamin A deficiency by 6·2 % (95 % CI (0·7, 11·6)) among pre-menarche girls when adjusted for baseline micronutrient status, age and height-for-age Z-score, but it decreased the prevalence of deficient/low vitamin A status by -9·6 % (95 % CI (-18·9, -0·3)) among post-menarche girls. Consuming MMB available in the market did not increase iron status in our study, but reduced the prevalence of deficient/low vitamin A status in post-menarcheal girls.

Determinants of iron deficiency and anemia among Nunavimmiut: results from the Qanuilirpitaa? 2017 Nunavik Health Survey

OBJECTIVE

To estimate the prevalence of iron deficiency (ID) and anemia and study their main distal and proximal protective and risk factors among Nunavimmiut 16 years and older in 2017.

METHODS

In a cross-sectional participatory survey of 831 women and 436 men from the Qanuilirpitaa? 2017 Nunavik Inuit Health Survey, venous blood samples were collected to measure various indicators of iron status and anemia as well as biomarkers of nutritional and inflammatory status and contaminant exposures. Sociodemographic, food security status, anthropometric, lifestyle, dietary, and health data were collected using questionnaires, clinical sessions, and a medical chart review. ID and anemia diagnoses were based on serum ferritin (SF) and hemoglobin (Hb), respectively. Multiple regressions were used to assess correlates of anemia and iron status.

RESULTS

Prevalence of ID was highest among women of childbearing age (16-49 years old, 33%) and anemia among adults aged 50 years and older (31%). These estimates are prone to biases due to the relatively low participation rate (37%). Serum vitamin D, omega-3 polyunsaturated fatty acid content of erythrocyte membranes, blood selenium, inflammation, higher socioeconomic status (SES), obesity, and alcohol consumption were all positively associated with SF, while Helicobacter pylori infection and a recent pregnancy were negatively associated with Hb among women of childbearing age. Among older adults, food insecurity was associated with lower SF.

CONCLUSION

While data reported here provide some indication of an improvement since the previous survey conducted in 2004, additional efforts should be devoted to further increasing the SES and access to country foods and nutritious market foods in this population, the two main protective factors against ID and anemia identified in the present study.

Comparing Non-Invasive Spectrophotometry to Hematology Analysis for Hemoglobin Measurements in Sickle Cell Disease Patients

Patients with sickle cell disease (SCD) require repeated blood sampling for hemoglobin (Hb) concentration measurements. The primary aim of this study was to compare non-invasive spectrophotometric hemoglobin (SpHb, g/dL) measurements to those taken via an automated hematology analyzer (Hb, g/dL) in patients with SCD visiting outpatient clinics and to investigate the correlations and agreements between both measurement techniques. Secondarily, we aimed to identify the SpHb cut-off concentration for the diagnosis of anemia and to monitor the effects of the pleth variability index (PVI, %) and perfusion index (PI) on SpHb measurements. The results gained from the examination of one hundred and fifty-eight patients indicated that the SpHb measurements overestimated the lab Hb concentrations, with a mean (SpHb-Hb) bias of 0.82 g/dL (SD 1.29). The SpHb measurements were positively correlated with the Hb measurements (Kendall's tau correlation (τ), n = 158, τ = 0.68, p < 0.001), with an intra-class correlation (ICC) of 0.67 and a 95% CI from 0.57 to 0.74 (p = 0.000). The SpHb cut-off concentration to diagnose anemia was 11.4 and 11.7 g/dL for males and females, respectively. SpHb sensitivity was low for males and females at 64.4% and 57.1%; however, the specificity was higher at 90.9% and 75%, with positive predictive values (PPVs) of 95.6 and 85.7, respectively. No correlation existed between SpHb measurements and the PVI (%) in contrast with a moderate correlation with the PI (r = 0.049, p = 0.54, and r = 0.36, p < 0.001, respectively). The mean PI was low at 2.52 ± 1.7. In conclusion, the SpHb measurements were consistently higher than the lab Hb concentrations, with a positive correlation. The sensitivity and precision of the SpHb measurements were lower than expected. However, the SpHb specificity and its positive predictive values (PPVs) indicated that it is less likely for a patient with a positive SpHb test result for anemia to be non-anemic. These results will allow SpHb measurement to play a role in excluding the presence of anemia. In light of the low PI values determined, the SpHb measurements were challenging to take and, thus, require further technological improvements.

Accuracy of a portable hemoglobinometer (HemoCue) to measure fetal hemoglobin values during in utero transfusion

OBJECTIVES

The current recommended treatment for severe fetal anemia is in utero transfusion (IUT). During this procedure, the evaluation of the necessary volume of transfused blood is based on regular measurement of fetal hemoglobin (FHb) concentration. The gold standard measurement is performed in the biology laboratory. A rapid medical test such as HemoCue® is an effective way to predict FHb concentration. It would reduce the time to obtain results and therefore the procedure duration. To evaluate the accuracy of HemoCue® to measure FHb during IUT, we compared Hb levels obtained by HemoCue® and by our biology laboratory.

METHODS

This retrospective study involved all pregnant women who had undergone an IUT in the university hospital of Clermont-Ferrand, France, during the period from 1 January 2010 to 6 June 2021. The FHb level was evaluated by two methods, a rapid medical test, HemoCue®, and a standard method in the biology laboratory.

RESULTS

We obtained 244 pairs of results from HemoCue® and our laboratory, of 90 IUT procedures. The correlation between the two sets of results was excellent, with Lin's concordance correlation coefficient of 0.979. However, we established that the measurements were not significantly modified by IUT number, puncture time, cause of fetal anemia, estimated fetal weight, gestational age, and delay between two IUT or middle cerebral artery peak systolic velocity values.

CONCLUSION

Our results allowed to extend the relevance of FHb measurements by HemoCue® during IUT.

Improving Anemia Assessment in Clinical and Public Health Settings

We aim to provide a practical approach to assess anemia and its primary causes, both in clinical settings and in the context of public health programs. Anemia remains a global challenge; thus, to achieve goals for anemia reduction and assess progress, standardized approaches are required for the assessment of anemia and its causes. We first provide a brief review of how to assess anemia, based on hemoglobin concentrations and cutoffs that correspond to age, sex, and physiologic status. Next, we discuss how to assess the likely causes of anemia in different settings. The causes of anemia are classified as non-nutritional (for example, because of infection, inflammation, blood loss, or genetic disorders) or nutrition-specific (for example, because of deficiencies of iron, vitamin A, riboflavin, vitamin B12, or folate). There is an important overlap between these 2 categories, such as the increased likelihood of iron deficiency in the context of inflammation. Given the multifaceted nature of anemia etiology, we introduce a framework for anemia assessment based on the "ecology of anemia," which recognizes its many overlapping causes. This conceptual framework is meant to inform what data on anemia causes may need to be collected in population surveys. The framework has a supporting table with information on the diagnostic tests, biomarkers and proposed cutoffs, characteristics, and feasibility of collecting the myriad information that can help elucidate the anemia etiology. We also provide examples of how this framework can be applied to interpret the anemia risk factor data from population-based surveys that can inform decisions about context-specific interventions. Finally, we present research gaps and priorities related to anemia assessment.

Characteristics of hemoglobin distributions in preschool children and non-pregnant women of reproductive age and their implications for establishing quality control criteria for hemoglobin data in field surveys: evidence from 483 surveys conducted in refugee settings worldwide

BACKGROUND

Currently, there is a lack of clear guidance on hemoglobin (Hb) data quality parameters and plausible flagging ranges for population-representative surveys. There is a need to determine which properties of Hb data indicate lower data quality and increased measurement error and which represent intrinsic statistical properties of Hb distributions rather than quality problems.

METHODS

We explored statistical characteristics of Hb distributions and plausible exclusion ranges in population-representative surveys of non-pregnant women of reproductive age (WRA) (15-49 years, n = 401 surveys) and children (6-59 months, n = 461 surveys) conducted in refugee settings by the United Nations High Commissioner for Refugees (UNHCR). Hb distribution characteristics [standard deviation (SD), skewness and kurtosis] were compared to those from Demographic and Health Surveys (DHS).

RESULTS

Overall, 0.08% of child and 0.14% of WRA Hb values were outside of the previously proposed 4.0-18.0 g/dL plausible range. Surveys conducted in Uganda tended to have unusually high SD compared with surveys from other settings, possibly an indication of problematic measurement quality. We therefore used summary results on SD, skewness and kurtosis excluding surveys from Uganda when comparing with DHS results or proposing plausible ranges. Both WRA and child Hb distributions tended to be left-skewed and had excess positive kurtosis. Mean survey-level SD was greater, mean skewness more negative, and mean kurtosis more positive in WRA surveys compared to child surveys. All these findings were broadly similar to those from DHS surveys. Mean SD in DHS surveys was higher than that in our data for both children (1.48 vs. 1.34) and WRA (1.58 vs. 1.43).

CONCLUSIONS

We observed several statistical characteristics of Hb distributions that may not necessarily be indicative of data quality problems and bear strong similarities with the characteristics found in DHS surveys. Hb distributions tended to be negatively skewed and positively kurtotic, and SD in many surveys exceeded 1.5 (previously proposed upper plausible range). Based on our empirical evidence, surveys with skewness above + 0.2 and kurtosis below -0.5 or Hb SD outside the range of 1.1-1.55 g/dL for children (6-59 mo) or 1.1-1.65 g/dL for non-pregnant WRA (15-49 y) may require further quality investigation.

Clinical and Analytic Accuracy of Simultaneously Acquired Hemoglobin Measurements: A Multi-Institution Cohort Study to Minimize Redundant Laboratory Usage

OBJECTIVES

Frequent diagnostic blood sampling contributes to anemia among critically ill children. Reducing duplicative hemoglobin testing while maintaining clinical accuracy can improve patient care efficacy. The objective of this study was to determine the analytical and clinical accuracy of simultaneously acquired hemoglobin measurements with different methods.

DESIGN

Retrospective cohort study.

SETTING

Two U.S. children's hospitals.

PATIENTS

Children (< 18 yr old) admitted to the PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified hemoglobin results from complete blood count (CBC) panels paired with blood gas (BG) panels and point-of-care (POC) devices. We estimated analytic accuracy by comparing hemoglobin distributions, correlation coefficients, and Bland-Altman bias. We measured clinical accuracy with error grid analysis and defined mismatch zones as low, medium, or high risk-based on deviance from unity and risk of therapeutic error. We calculated pairwise agreement to a binary decision to transfuse based on a hemoglobin value. Our cohort includes 49,004 ICU admissions from 29,926 patients, resulting in 85,757 CBC-BG hemoglobin pairs. BG hemoglobin was significantly higher (mean bias, 0.43-0.58 g/dL) than CBC hemoglobin with similar Pearson correlation ( R2 ) (0.90-0.91). POC hemoglobin was also significantly higher, but of lower magnitude (mean bias, 0.14 g/dL). Error grid analysis revealed only 78 (< 0.1%) CBC-BG hemoglobin pairs in the high-risk zone. For CBC-BG hemoglobin pairs, at a BG hemoglobin cutoff of greater than 8.0 g/dL, the "number needed to miss" a CBC hemoglobin less than 7 g/dL was 275 and 474 at each institution, respectively.

CONCLUSIONS

In this pragmatic two-institution cohort of greater than 29,000 patients, we show similar clinical and analytic accuracy of CBC and BG hemoglobin. Although BG hemoglobin values are higher than CBC hemoglobin values, the small magnitude is unlikely to be clinically significant. Application of these findings may reduce duplicative testing and decrease anemia among critically ill children.

The relationship between hemoglobin and V ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x : A systematic review and meta-analysis

OBJECTIVE

There is widespread agreement about the key role of hemoglobin for oxygen transport. Both observational and interventional studies have examined the relationship between hemoglobin levels and maximal oxygen uptake (V ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x ) in humans. However, there exists considerable variability in the scientific literature regarding the potential relationship between hemoglobin andV ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x . Thus, we aimed to provide a comprehensive analysis of the diverse literature and examine the relationship between hemoglobin levels (hemoglobin concentration and mass) andV ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x (absolute and relativeV ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x ) among both observational and interventional studies.

METHODS

A systematic search was performed on December 6th, 2021. The study procedures and reporting of findings followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Article selection and data abstraction were performed in duplicate by two independent reviewers. Primary outcomes were hemoglobin levels andV ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x values (absolute and relative). For observational studies, meta-regression models were performed to examine the relationship between hemoglobin levels andV ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x values. For interventional studies, meta-analysis models were performed to determine the change inV ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x values (standard paired difference) associated with interventions designed to modify hemoglobin levels orV ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x . Meta-regression models were then performed to determine the relationship between a change in hemoglobin levels and the change inV ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x values.

RESULTS

Data from 384 studies (226 observational studies and 158 interventional studies) were examined. For observational data, there was a positive association between absoluteV ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x and hemoglobin levels (hemoglobin concentration, hemoglobin mass, and hematocrit (P<0.001 for all)). Prespecified subgroup analyses demonstrated no apparent sex-related differences among these relationships. For interventional data, there was a positive association between the change of absoluteV ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x (standard paired difference) and the change in hemoglobin levels (hemoglobin concentration (P<0.0001) and hemoglobin mass (P = 0.006)).

CONCLUSION

These findings suggest thatV ˙ ⁢ O 2 ⁢ m ⁢ a ⁢ x values are closely associated with hemoglobin levels among both observational and interventional studies. Although our findings suggest a lack of sex differences in these relationships, there were limited studies incorporating females or stratifying results by biological sex.

Exploring the Involvement of Cytokines in Pediatric Patients Afflicted by Simple Febrile Seizures: A Case-Control Study

AIM

Most children under six with seizures experience febrile seizures (FS), which occur with a temperature of 38°C or higher and no apparent infectious or metabolic causes. FS has a multifaceted etiology, involving genetic and environmental factors. This study aimed to explore the connection between the cytokine system (part of the immune system related to inflammation) and FS to uncover potential relationships.

METHOD

This research was carried out on 50 patients experiencing FS and 25 patients experiencing only fever served as cases and controls, respectively. The patient's blood was obtained under sterile circumstances from the antecubital/femoral vein as soon as feasible following the commencement of seizures. The complete hemogram analysis was done using the Mindray BC-5800 auto hematology analyzer (Mindray Medical International Limited, Shenzhen, China).

RESULT

The cases group had significantly higher interleukin-4 (IL-4) concentrations (292.85 pg/mL) than controls (81.04 pg/mL), indicating a statistically significant difference (p<0.05), respectively. In the current research, case participants had a significantly lower mean level of interleukin-6 (IL-6) than control participants. The average IL-6 concentration in cases was 28.00 pg/mL, whereas in controls was 93.09pg/mL. Patients with FS have an important function for the cytokine network to perform.

CONCLUSION

The findings showed a significant difference in cytokine concentrations between patients with FS and control subjects, highlighting a potential link between the cytokine system and FS. Additionally, lower levels of IL-6 in case participants suggest a complex role of cytokines in FS, emphasizing the importance of the cytokine network in this condition.

Association between maternal haemoglobin concentrations and maternal and neonatal outcomes: the prospective, observational, multinational, INTERBIO-21st fetal study

BACKGROUND

Anaemia in pregnancy is a global health problem with associated maternal and neonatal morbidity and mortality. We aimed to investigate the association between maternal haemoglobin concentrations during pregnancy and the risk of adverse maternal and neonatal outcomes.

METHODS

In this prospective, observational, multinational, INTERBIO-21st fetal study conducted at maternity units in Brazil, Kenya, Pakistan, South Africa, and the UK, we enrolled pregnant women (aged ≥18 years, BMI <35 kg/m2, natural conception, and singleton pregnancy) who initiated antenatal care before 14 weeks' gestation. At each 5±1 weekly visit until delivery, information was collected about the pregnancy, as well as the results of blood tests taken as part of routine antenatal care, including haemoglobin values. The outcome measures were maternal (gestational diabetes, pregnancy-induced hypertension, and preterm premature rupture of membranes) and neonatal outcomes (small for gestational age, preterm birth, and acute respiratory distress syndrome).

FINDINGS

Between Feb 8, 2012, and Nov 30, 2019, 2069 women (mean age 30·7 years [SD 5·0]) had at least one routinely haemoglobin concentration measured at 14-40 weeks' gestation, contributing 4690 haemoglobin measurements for the analysis. Compared with a haemoglobin cutoff of 110 g/L, the risk was increased more than two-fold for pregnancy-induced hypertension at haemoglobin concentrations of 170 g/L (risk ratio [RR] 2·29 [95% CI 1·19-4·39]) and higher, for preterm birth at haemoglobin concentrations of 70 g/L (RR 2·04 [95% CI 1·20-3·48]) and 165 g/L (RR 2·06 [95% CI 1·41-3·02]), and for acute respiratory distress syndrome at haemoglobin concentrations of 165 g/L (RR 2·84 [95% CI 1·51-5·35]). Trimester-specific results are also presented.

INTERPRETATION

Our data suggests that the current WHO haemoglobin cutoffs are associated with reduced risk of adverse maternal and neonatal outcomes. The current haemoglobin concentration cutoffs during pregnancy should not only consider thresholds for low haemoglobin concentrations that are associated with adverse outcomes but also define a threshold for high haemoglobin concentrations given the U-shaped relationship between haemoglobin concentration and adverse neonatal and maternal outcomes.

FUNDING

Bill & Melinda Gates Foundation.

Silk Fibroin Particles as Carriers in the Development of Hemoglobin-Based Oxygen Carriers

Oxygen therapeutics have a range of applications in transfusion medicine and disease treatment. Synthetic molecules and all-natural or semi-synthetic hemoglobin-based oxygen carriers (HBOCs) have seen success as potential circulating oxygen carriers. However, many early HBOC products stalled in development due to side effects from excess hemoglobin in the blood stream and hemoglobin entering the tissue. To overcome these issues, research has focused on increasing the molecular diameter of hemoglobin by polymerizing hemoglobin molecules or encapsulating hemoglobin in liposomal carriers. This work leverages the properties of silk fibroin, a cytocompatible and non-thrombogenic biopolymer, known to entrap protein-based cargo, to engineer a fully protein-based oxygen carrier. Herein, an all-aqueous solvent evaporation technique was used to form silk particles via phase separation from a bulk polyvinyl alcohol phase (PVA). Particles size was tuned, and particles were formed with and without hemoglobin. The encapsulation efficiency and ferrous state of hemoglobin were analyzed, resulting in 60% encapsulation efficiency and a maximum of 20% ferric hemoglobin, yielding 100 µg/mL active hemoglobin in certain sfHBOC formulations. The system did not elicit a strong inflammation response in vitro, demonstrating the potential for this particle system to serve as an injectable HBOC.

Prevalence of and factors associated with childhood anaemia in remote villages of the Peruvian Amazon: a cross-sectional study and geospatial analysis

BACKGROUND

Anaemia is a public health problem in Peru. In the Loreto region of the Amazon, ≥50% of children may be anaemic, although insufficient information exists for rural villages.

METHODS

To generate more data about childhood anaemia in the Peruvian Amazon, haemoglobin was measured as part of a trachoma survey in 21 randomly selected villages. All children 1-9 y of age from 30 randomly selected households per village were recruited. Anaemia was classified according to the World Health Organization guidelines and a socio-economic status (SES) index was created for each household using principal component analysis. Spatial autocorrelation was determined using Moran's I and Ripley's K function.

RESULTS

Of 678 children with complete haemoglobin data, 25.4% (95% confidence interval [CI] 21.2 to 30.1) had mild-or-worse anaemia and 22.1% (95% CI 15.6 to 30.3) had moderate-or-worse anaemia. Mild-or-worse anaemia was more common among children whose primary source of drinking water was surface water (prevalence ratio [PR] 1.26 [95% CI 1.14 to 1.40], p<0.001) and who were in the lowest SES tercile (PR 1.16 [95% CI 1.02 to 1.32], p=0.021). Moderate-or-worse anaemia was more common among boys (PR 1.32 [95% CI 1.09 to 1.60], p=0.005). No evidence of geospatial clustering was found.

CONCLUSIONS

Remote villages of the Amazon would benefit from interventions for childhood anaemia and the poorest households would have the most to gain. Integrating anaemia screening into neglected tropical diseases surveys is an opportunity to use public health resources more efficiently.

Diagnosing anemia: Challenges selecting methods, addressing underlying causes, and implementing actions at the public health level

Accurate and affordable tools for diagnosing anemia and its main determinants are essential for understanding the magnitude and distribution of the problem and the appropriate interventions needed for its timely prevention and treatment. The objective of this review is to address methods, equipment, and sample-related and quality control aspects of hemoglobin measurement for anemia diagnosis. Also, other iron-, infectious-, and genetic-related causes of anemia are addressed in individuals and populations. The best practice for hemoglobin determination is the use of venous blood, analyzed on automated hematology analyzers, with high-quality control measures in place. The importance of a correct anemia diagnosis is highlighted by the cost of a misdiagnosis. A false-negative diagnosis may result in missing out and not treating anemia, its causes, and its adverse effects. On the other hand, a false-positive diagnosis may result in the provision of unneeded treatment or referral for expensive laboratory tests to determine a cause of anemia, wasting valuable resources and risking causing harm. At the individual level, clinicians must understand the causes of absolute and functional anemia to diagnose and treat anemia at the clinical level. Actions toward anemia diagnosis and control at public health levels require global, regional, and country actions that should cover general and context-specific characteristics.

Factors associated with anaemia in pregnancy: A retrospective cross-sectional study in the Bolgatanga Municipality, northern Ghana

BACKGROUND

Anaemia in pregnancy (AIP) remains a severe public health problem associated with adverse outcomes. This study assessed haemoglobin levels and the prevalence of anaemia during antenatal care (ANC) registration, at 28 weeks and 36 weeks of gestation as well as the factors associated with AIP at the different stages of pregnancy.

METHODS

A retrospective cross-sectional design was implemented. Using ANC registers as the sampling frame, 372 pregnant women, within 36 and 40 weeks of gestation were randomly sampled from 28 health facilities for the study. The participants were all receiving ANC in the Bolgatanga Municipality. Data were collected via clinical records review and a questionnaire-based survey between October and November, 2020. Using the Statistical Package for the Social Sciences (SPSS), descriptive analysis of haemoglobin levels and the prevalence of anaemia were performed. In addition, binary logistic regression was used to identify the factors associated with anaemia in pregnancy. AIP was determined using the national practice of 11.0g/dl haemoglobin cut-off point and the World Health Organisation's recommended adjustment for the 2nd trimester of pregnancy was made using the cut-off of 10.5g/dl to account for the effect of haemodilution.

RESULTS

At booking, AIP prevalence was 35.8% (95%CI:30.9, 40.9) using a cut-off of 11.0g/dl and 25.3% (95%CI:20.9, 30.0) using a cut-off of 10.5g/dl for those in the 2nd trimester. At 28 weeks, AIP prevalence was 53.1% (95%CI:45.8, 60.3) and 37.5 (95%CI:30.6, 44.8) using a cut-off of 11.0g/dl and 10.5g/dl for those in the 2nd trimester, respectively. At 36 weeks, AIP prevalence was 44.8% (95%CI:39.2, 50.4) using a cut-off of 11.0g/dl. At p<0.05, registering after the first trimester (AOR = 1.87, 95%CI: 1.17, 2.98, P = 0.009) and at a regional hospital (AOR = 2.25, 95%CI: 1.02, 4.98, P = 0.044) were associated with increased odds of AIP but registering at a private hospital (AOR = 0.32, 95%CI: 0.11, 0.92, P = 0.035) was associated with decreased odds of AIP at booking. At 28 weeks, age group 26-35 years (AOR = 0.46, 95%CI: 0.21, 0.98, P = 0.044), Christianity (AOR = 0.32, 95%CI: 0.31, 0.89, P = 0.028.), high wealth (AOR = 0.27, 95%CI: 0.09, 0.83, P = 0.022) and tertiary education (AOR = 0.09, 95%CI:0.02, 0.54, P = 0.009) were associated with decreased odds of AIP. At 36 weeks, booking after first trimester of pregnancy was associated with increased odds (AOR = 1.72, 95%CI: 1.05, 2.84, P = 0.033) whilst high wealth (AOR = 0.44, 95%CI: 0.20, 0.99, P = 0.049), higher age groups-26-35 (AOR = 0.38, 95%CI: 0.21, 0.68, P = 0.001) and 36-49 years (AOR = 0.35, 95%CI: 0.13, 0.90, P = 0.024) and secondary education of spouse were associated with reduced odds (AOR = 0.35, 95%CI: 0.14, 0.88, P = 0.026) of AIP.

CONCLUSION

AIP consistently increased from registration to 36 weeks of gestation. Given the observed correlates of AIP, we recommend that interventions geared towards early ANC registration, improved household wealth, and improved maternal education are required to reduce AIP.

The Prevalence of Anemia in Children Aged 6-23 Months and its Correlates Differ by District in Kapilvastu and Achham Districts in Nepal

Background

Analyses of predictors of anemia or malnutrition often pool national or regional data, which may hide variability at subnational levels.

Objectives

We sought to identify the risk factors for anemia in young Nepali children aged 6-23 mo in 2 districts: Kapilvastu and Achham.

Methods

This is an analysis of two cross-sectional surveys that were conducted as part of a program evaluation of an infant and young child feeding and micronutrient powder intervention that included anemia as a primary outcome. Baseline and endline surveys in each district (in 2013 and 2016) included hemoglobin assessments in n = 4709 children who were representative of children 6-23 mo in each district. Log-binomial regression models accounting for the survey design were used to estimate univariable and multivariable prevalence ratios for risk factors at multiple levels-underlying, direct, and biological causes. Average attributable fractions (AFs) for the population were calculated for significant predictor biomarkers of anemia in multivariable models.

Results

In Accham, the prevalence of anemia was 31.4%; significant predictors included child's age, household asset ownership, length-for-age z-score, inflammation (CRP concentration > 0.5 mg/L; α-1 acid glycoprotein concentration > 1 mg/mL), and iron deficiency (serum ferritin concentration < 12 μg/L with BRINDA-inflammation adjustment). In Kapilvastu, the prevalence of anemia was 48.1%; significant predictors included child's sex and ethnicity, wasting and weight-for-length z-score, any morbidity in the previous 2 wk, consumption of fortified foods, receipt of multiple micronutrient powder distributions, iron deficiency, zinc deficiency (nonfasting serum zinc concentration of <65 μg/dL in the morning and that of <57 μg/dL in the afternoon), and inflammation. In Achham, average AFs were 28.2% and 19.8% for iron deficiency and inflammation, respectively. Average AFs for anemia in Kapilvastu were 32.1%, 4.2%, and 4.9% for iron deficiency, zinc deficiency, and inflammation, respectively.

Conclusions

The prevalence of anemia and its risk factors varied between districts, with inflammation contributing to a greater share of anemia in Achham than in Kapilvastu. The estimated AF for iron deficiency was around 30% in both districts; iron-delivering interventions and multisectoral approaches to anemia are warranted.

Accelerating action to reduce anemia: Review of causes and risk factors and related data needs

Anemia is a major public health concern. Young children, menstruating adolescent girls and women, and pregnant women are among the most vulnerable. Anemia is the consequence of a wide range of causes, including biological, socioeconomic, and ecological risk factors. Primary causes include: iron deficiency; inherited red blood cell disorders; infections, such as soil-transmitted helminthiasis, schistosomiasis, and malaria; gynecological and obstetric conditions; and other chronic diseases that lead to blood loss, decreased erythropoiesis, or destruction of erythrocytes. The most vulnerable population groups in low- and middle-income countries are often at the greatest risk to suffer from several of these causes simultaneously as low socioeconomic status is linked with an increased risk of anemia through multiple pathways. Targeted and effective action is needed to prevent anemia. Understanding the causes and risk factors of anemia for different population subgroups within a country guides the design and implementation of effective strategies to prevent and treat anemia. A coordinated approach across various expert groups and programs could make the best use of existing data or could help to determine when newer and more relevant data may need to be collected, especially in countries with a high anemia burden and limited information on the etiology of anemia.

Prevalence of anemia and associated factors among adults in a select population in Lagos, Southwest Nigeria

Background

Anemia is a public health problem affecting people in both the developed and developing world and has serious consequences on health.

Objective

This study determines the prevalence of anemia amongst people of different socioeconomic levels, associated factors, and the prevalence of anemia in populations other than children or pregnant women.

Methods

This is a descriptive cross-sectional study using a pretested interviewer-administered questionnaire to collect data from 387 residents. A multi-stage random sampling technique was used. Analysis of blood samples using the HemoCue301 system and data analysis using SPSS 20. Chi-square test and binary logistic regression were used to test association and determine predictors of anemia respectively, with P<0.05 considered statistically significant.

Results

The mean age of respondents was 35±11.8 years, with 28.9% of respondents being anemic. Female respondents (52.7%) were more than male respondents (47.3%). Female respondents (39.2%) had a higher prevalence of anemia than male respondents (17.5%). There was a significant association between sex, level of education, and anemia status. Being female, having no formal education, or only having a primary school level of education were significant predictors of anemia [odds ratio (OR)=2.55; 95% confidence interval (CI)=1.54, 4.23; P=0.00; OR=12.57; 95%CI=2.39, 66.27; P=0.00; and OR=2.54; 95%CI=1.16, 5.58; P=0.02 respectively].

Conclusion

There was a higher prevalence of anemia among women, younger people, and those with no or only primary levels of formal education. Awareness programs targeted at women and people with lower levels of education are necessary to reduce the overall prevalence of anemia in this region.

Association between hemoglobin and elevation among school-aged children: a verification of proposed adjustments

BACKGROUND

Anemia is defined by a hemoglobin (Hb) concentration lower than normal based on cutoffs specific to age, sex, and pregnancy status. Hemoglobin increases with elevation as an adaptive response to lower blood oxygen saturation, thus, adjusting Hb concentration for elevation is necessary before applying cutoffs.

OBJECTIVE

Recent evidence among preschool-aged children (PSC) and non-pregnant reproductive-aged women (WRA) suggests that current World Health Organization (WHO) recommended Hb adjustments for elevation need updating. To confirm these findings, we examined the cross-sectional association between Hb and elevation among non-pregnant school-age children (SAC).

METHODS

Using data from 9 population-based surveys, we examined 26,518 SAC 5-14 years (54.5% female) with data on Hb and elevation (-6 to 3,834 meters, m). We used generalized linear models to assess the association between Hb and elevation under varying conditions, including controlling for inflammation-corrected iron and vitamin A deficiency. Hemoglobin adjustments for each 500 m increase in elevation were estimated for SAC and compared to existing adjustments and those estimated for PSC and WRA. We evaluated the impact of adjustments on anemia prevalence.

RESULTS

Hemoglobin concentration (g/L) was positively associated with elevation (m). The SAC elevation adjustments were consistent with those reported among PSC and WRA and suggest current recommendations may under-adjust Hb for those residing at lower elevations (<3000 m) and over-adjust Hb for those residing at higher elevations (>3000 m). Among the surveys included, proposed elevation adjustments increased anemia prevalence among SAC by 0 (Ghana, United Kingdom) to 15 (Malawi) percentage points relative to current elevation adjustments.

CONCLUSION

Results confirm that current recommended Hb adjustments for elevation may need updating, and anemia prevalence in SAC may be higher than currently estimated. Findings will inform the WHO reexamination of global guidelines on the use of Hb adjustments for anemia assessment and may result in improved identification and treatment of anemia.

The efficacy of Bloso fish (Glossogobius giuris sp.) in improving hemoglobin, hematocrit, platelet, and albumin levels of Wistar rats with hypoalbuminemia

Tuberculosis (TB) is an infectious disease worldwide that causes death. Common clinical manifestations of patients with TB include anemia, hypoalbuminemia, and malnutrition. Most patients with TB are infected with coccus bacteria, such as Staphylococcus aureus, that commonly attack the respiratory tract. However, the consumption of heme protein sources could improve the nutritional status of patients with TB. Fish comprise one of the most widely consumed sources of heme. The bloso fish (Glossogobius giuris sp.), considered a fish without economic value is a new alternative source of heme protein. This study aimed to develop supplements using bloso fish (Glossogobius giuris sp.). This study used an experimental pretest-post-test control group design. Seven male Wistar rats were used as the negative control group. Twenty- eight male Wistar rats were administered S. aureus, fed a protein-deficient diet, and divided into the positive control group, the K1 group, which received up to 675 mg/200 g of bloso fish flour, the K2 group, which received up to 67.5 mg/200 g of bloso fish oil, and the K3 group, which received up to 675 mg/200 g of bloso fish fluor from oil extraction dregs. Treatment was administered for 28 days. The hemoglobin (Hb), hematocrit (Ht), platelet, and albumin levels in blood serum from the retroorbital vein were measured. Data were processed using a paired t-test and one-way analysis of variance. The results showed differences in Hb, Ht, platelet, and albumin levels were observed before and after treatment. Additionally, differences in Hb, Ht, platelet, and albumin levels were observed in the groups that received bloso fish flour and bloso fish oil. Bloso fish flour and bloso fish oil increased the Hb, Ht, platelet, and albumin levels of rats with hypoalbuminemia.

Smartphone-based point-of-care anemia screening in rural Bihar in India

BACKGROUND

The high prevalence of anemia in resource-constrained settings calls for easy-to-use, inexpensive screening tools. The Sanguina Smartphone App, an innovative tool for non-invasive hemoglobin estimation via color-sensitive, algorithm-based analysis of fingernail bed images, was validated in the United States. This study evaluates the performance of the App in a population with different socio-economic, ethnic, demographic and cultural composition in rural Bihar, India.

METHODS

For 272 mainly adult patients of a private health centre, hemoglobin measurement with the App is compared with the gold standard laboratory blood analysis. For a second sample of 179 children attending pre-schools, hemoglobin measurement with the App is compared to the results of the HemoCue Hb 301, a point-of-care device using a small blood sample, serving as the reference standard for field-based settings.

RESULTS

The App reaches ±4.43 g/dl accuracy and 0.38 g/dl bias of comparator values in the clinic-based sample, and ±3.54 g/dl and 1.30 g/dl, respectively in the pre-school sample. After retraining the algorithm with the collected data, the validity of the upgraded version is retested showing an improved performance (accuracy of ±2.25 g/dl, bias of 0.25 g/dl), corresponding to the results of the original validation study from the United States.

CONCLUSIONS

The initial version of the App does not achieve the accuracy needed for diagnosis or screening. After retraining the algorithm, it achieves an accuracy sufficient for screening. The improved version with the potential for further adaptions is a promising easy-to-use, inexpensive screening tool for anemia in resource-constrained point-of-care settings.

Silk Fibroin Particles as Carriers in the Development of All-Natural Hemoglobin-Based Oxygen Carriers (HBOCs)

Oxygen therapeutics have a range of applications in transfusion medicine and disease treatment. Synthetic molecules and all-natural or semi-synthetic hemoglobin-based oxygen carriers (HBOCs) have seen success as potential circulating oxygen carriers. However, many early HBOC products were removed from the market due to side effects from excess hemoglobin in the blood stream and hemoglobin entering the tissue. To overcome these issues, research has focused on increasing the molecular diameter of hemoglobin by polymerizing hemoglobin molecules or encapsulating hemoglobin in liposomal carriers, where immune responses and circulation times remain a challenge. This work looks to leverage the properties of silk fibroin, a cytocompatible and non-thrombogenic biopolymer, known to entrap protein-based cargo, to engineer a silk fibroin-hemoglobin-based oxygen carrier (sfHBOC). Herein, an all-aqueous solvent evaporation technique was used to form silk fibroin particles with and without hemoglobin to tailor the formulation for specific particle sizes. The encapsulation efficiency and ferrous state of hemoglobin were analyzed, resulting in 60% encapsulation efficiency and a maximum of 20% ferric hemoglobin, yielding 100 µg/mL active hemoglobin in certain sfHBOC formulations. The system did not elicit a strong inflammation response in vitro, demonstrating the potential for this particle system to serve as an injectable HBOC.

Causes of Moderate and Severe Anaemia in a High-HIV and TB-Prevalent Adult Population in the Eastern Cape Province, South Africa

BACKGROUND

Anaemia affects one in four adults in South Africa, with a higher prevalence in persons with HIV and tuberculosis. The aim of this study is to characterise the causes of anaemia in primary care and a district hospital setting.

METHODS

A cross-sectional study design investigated a purposive sample of adult males and non-pregnant females at two community health centres and a hospital casualty and outpatients. Fingerpick blood haemoglobin was measured with HemoCueHb201+. Those with moderate and severe anaemia underwent clinical examination and laboratory tests.

RESULTS

Of 1327 patients screened, median age was 48 years, and 63.5% were female. Of 471 (35.5%) with moderate and severe anaemia on HemoCue, 55.2% had HIV, 16.6% tuberculosis, 5.9% chronic kidney disease, 2.6% cancer, and 1.3% heart failure. Laboratory testing confirmed 227 (48.2%) with moderate and 111 (23.6%) with severe anaemia, of whom 72.3% had anaemia of inflammation, 26.5% iron-deficiency anaemia, 6.1% folate deficiency, and 2.5% vitamin B12 deficiency. Overall, 57.5% had two or more causes of anaemia. Multivariate modelling showed that patients with severe anaemia were three times more likely to have tuberculosis (OR = 3.1, 95% CI = 1.5-6.5; p-value = 0.002). Microcytosis was present in 40.5% with iron deficiency, macrocytosis in 22.2% with folate deficiency, and 33.3% with vitamin B12 deficiency. The sensitivities of the reticulocyte haemoglobin content and % hypochromic red blood cells in diagnosing iron deficiency were 34.7% and 29.7%, respectively.

CONCLUSIONS

HIV, iron deficiency, and tuberculosis were the most prevalent causes of moderate and severe anaemia. The majority had multiple causes. Iron, folate, and vitamin B12 deficiencies should be identified by biochemical testing rather than by red cell volume.