Anemia in pregnancy in rural Tanzania: associations with micronutrients status and infections

OBJECTIVE

We studied the association between anemia in pregnancy and characteristics related to nutrition and infections.

DESIGN

Cross-sectional study.

SETTING

Four antenatal clinics in rural northern Tanzania.

SUBJECTS/METHODS

A total of 2547 women were screened for hemoglobin (Hb) and malaria plasmodia in capillary blood and for infections in urine. According to their Hb, they were assigned to one of five groups and selected accordingly, Hb<70 g/l (n=10), Hb=70-89 g/l (n=61), Hb=90-109 g/l (n=86), Hb=110-149 g/l (n=105) and Hb> or =150 g/l (n=50). The 312 selected subjects had venous blood drawn, were interviewed, and their arm circumference was measured. The sera were analyzed for ferritin, iron, total iron binding capacity (TIBC), cobalamin, folate, vitamin A, C-reactive protein (CRP), and lactate dehydrogenase (LD). Transferrin saturation (TFsat) was calculated. Urine was examined by dipsticks for nitrite.

MAIN OUTCOME MEASURES

Unadjusted and adjusted odds ratio (OR and AOR) of anemia with Hb<90 g/l.

RESULTS

Anemia (Hb<90 g/l) was associated with iron deficiency (low s-ferritin; AOR 3.4). The association with vitamin deficiencies were significant in unadjusted analysis (low s-folate; OR 3.1, low s-vitamin A; OR 2.6). Anemia was also associated with markers of infections (elevated s-CRP; AOR 3.5, urine nitrite positive; AOR 2.4) and hemolysis (elevated s-LD; AOR 10.1). A malaria positive blood slide was associated with anemia in unadjusted analysis (OR 2.7). An arm circumference less than 25 cm was associated with anemia (AOR 4.0). The associations with less severe anemia (Hb 90-109 g/l) were similar, but weaker.

CONCLUSIONS

Anemia in pregnancy was associated with markers of infections and nutritional deficiencies. This should be taken into account in the management of anemia at antenatal clinics.

SPONSORSHIP

The study was supported by the Norwegian Research Council (NFR) and the Centre for International Health, University of Bergen.

Anemia in pregnancy in the highlands of Tanzania

BACKGROUND

Anemia in pregnancy is common in Tanzania, but many areas have not been investigated. This study describes prevalence and determinants of anemia among rural pregnant women living at 1300-2200 meters above sea level in Northern Tanzania.

METHODS

Three thousand eight hundred and thirty-six pregnant women from two rural divisions of Mbulu and Hanang districts attending antenatal clinic between January 1995 and March 1996 were assessed in a cross-sectional study. Blood samples were examined for hemoglobin concentration (Hb) and thick blood slide (BS) for malaria. Information on date of examination, village, age, ethnic and religious affiliation, gestational age, and parity was recorded. Altitude was derived from official maps. Main outcome measures were mean Hb level and risk of anemia defined as a Hb of less than 9.0 g/dl.

RESULTS

Hb levels ranged from 4.5 to 18.1 g/dl, and mean was 12.1 g/dl. Twenty-three per cent had a Hb of less than 11 g/dl, 4.6% less than 9 g/dl and 0.5% less than 7 g/dl; standardized to sea level 36.1%, 8.8%, and 1.1%, respectively. The mean Hb increased by 0.3 g/dl per 200 m increased altitude, and the risk of anemia decreased with a factor of 0.6 per 200 m increased altitude. We found higher risk of anemia at higher maternal age (1.2 times increased risk per 5 years). Furthermore, the Datoga tribe had twice the risk of anemia compared with the Iraqw. The risk of anemia was only half at 3-4 months of gestation compared to at 7-8 months. The risk increased six-fold in the rainy season of 1995, and the risk was almost double among those with malaria parasitemia.

CONCLUSIONS

Anemia in pregnancy was common in this area of high altitude in rural Tanzania, but less prevalent than indicated by studies from most other parts of the country. The study confirms that preventing anemia is a challenge in preventive antenatal care in the highlands of Tanzania. Studies focussing on the specific etiologic agents are needed.

Estimates of maternal mortality by the sisterhood method in rural nothern Tanzania: a household sample and an antenatal clinic sample

OBJECTIVE

To estimate maternal mortality in two samples of a population in northern Tanzania.

SETTING

Rural communities and antenatal clinics, Mbulu and Hanang districts, Arusha region, Tanzania.

POPULATION

From a household survey 2,043 men and women aged 15-60, and from an antenatal clinic survey 4,172 women aged 15-59.

METHOD

The indirect sisterhood method.

MAIN OUTCOME MEASURES

The risk of maternal deaths per 100,000 live births (maternal mortality ratio), and the lifetime risk of a maternal death.

RESULTS

The risk of a maternal death per 100,000 live births was 362 (95% CI 269-456) and 444 (95% CI 371-517) for the household and antenatal clinic surveys, respectively. The lifetime risk of maternal death was 1 in 38 and 1 in 31, respectively, for the two surveys. A significantly lower risk of maternal death was observed for the respondents attending antenatal clinics closer to the hospital than for those attending clinics further away: 325 (95% CI 237-413) compared with 561 (95% CI 446-677) per 100,000 live births. Lifetime risk of maternal death was 1 in 42 and 1 in 25, respectively.

CONCLUSIONS

The risk of maternal death per 100,000 live births in this area were comparatively high, but in our survey substantially lower than in previous surveys in Tanzania. Increasing distance from the antenatal clinics to the hospital was associated with higher maternal mortality. There was no significant difference between results based on household and antenatal clinic data, suggesting that accessible health facility data using the sisterhood method may provide a basis for local assessment of maternal mortality in developing countries.

The diagnosis of urinary tract infections among pregnant women in rural Tanzania; prevalences and correspondence between different diagnostic methods

BACKGROUND

To assess the prevalence of dysuria, dipsticks positive on nitrite and leukocyte esterase and positive Uricult dip slides among pregnant women in rural Tanzania.

METHODS

3,715 pregnant women were examined for dysuria and had their urine tested with nitrite and leukocyte esterase dipsticks and Uricult dipslides, at their first antenatal visit in 1995-96.

RESULTS

The prevalences of positive symptoms and tests were as follows: dysuria 32%, nitrite 40.3%, leukocyte esterase 65.6%, and Uricult dip slides 16.4%. A general log-linear model where all four variables were analyzed simultaneously showed poor correspondence between the diagnostic methods. Odds ratio with 95% confidence intervals were as follows: dysuria vs. nitrite [1.6 (1.4 1.8)]. dysuria vs. leukocyte esterase [1.2 (1.0-1.4)], nitrite vs. leukocyte esterase [4.2 (3.6-4.9)], and leukocyte esterase vs. Uricult [1.4 (1.1-1.7)]. Dysuria and nitrite were not associated with Uricult dipslide.

CONCLUSION

A high prevalence of positive tests, but a poor correspondence between the methods was found, emphasizing the need for more attention to the problem of urinary tract infections among pregnant women in developing countries, and the need for better screening tests for urinary tract infections in these countries.

Hyaluronan in human deciduous tooth germs in the bell stage. Histochemistry and immunohistochemistry

The primary aim of the present study was a localization of hyaluronan (HA) in human deciduous tooth germs in the bell stage. HA was compared to the content of chondroitin sulfates (CSs). HA was detected with a biotin-labeled HA-binding protein (HABP) and CS with a monoclonal antibody. As controls, enzyme digestions were carried out. Furthermore, the glycosaminoglycans were investigated histochemically with enzyme digestions followed by alcian blue staining. The investigation showed a considerable content of HA in the stellate reticulum, although CS was also found, primarily when treatment with protease was omitted. The dental papilla contained both HA and CS, while the predentin and the dentin contained only CS. The enamel did not contain any CS, but some staining with HABP was observed along the borderline between the ameloblasts and the enamel. The significance of HA in the stellate reticulum is discussed. The importance of carrying out investigations with and without protease digestions is stressed.

Immunocytochemical localisation of tumor necrosis factor alpha in thyroid tissues from patients with neoplastic or autoimmune thyroid disorders

It is disputed to what extent tumor necrosis factor-alpha is present in the thyroid follicular epithelial cells and/or in the interstitial cells in different disorders of the thyroid gland. We describe the immunohistochemical detection of tumor necrosis factor-alpha using formaldehyde fixed and paraffin embedded tissue and a polyclonal anti-serum with high tumor necrosis factor-alpha neutralising activity. We examined the distribution of tumor necrosis factor-alpha in interstitial cells and follicular epithelial cells in thyroid carcinomas, adenomas, non-toxic multinodular goiters and autoimmune thyroid diseases. Tumor necrosis factor-alpha was demonstrated in thyroid follicular epithelial cells, most frequently in non-toxic multinodular goiters (six of seven patients) and less frequently in adenomas (three of nine patients), papillary carcinomas (two of five patients), follicular carcinomas (one of five patients), Hashimoto's disease (one of six patients) and Grave's disease (one of seven patients). Tumor necrosis factor-alpha producing interstitial cells were found in two thirds of patients with all six thyroid diseases.

Immunocytochemical localisation of interleukin-1 alpha and interleukin-6 in thyroid tissues from patients with neoplastic or autoimmune thyroid disorders

We describe the distribution of interleukin-6 and interleukin-1 alpha in thyroid tissues obtained from patients with autoimmune diseases or neoplastic thyroid disorders employing immunohistochemistry in sections from paraffin embedded tissue blocks. Interleukin-6 was found in thyroid follicular epithelial cells (TFEC) from papillary carcinomas (four of five patients) but not in follicular carcinomas (five patients). Interleukin-6 was also detected in non-toxic multinodular goiters (four of seven patients), in patients with Graves' disease who did not have an early recurrence of hyperthyroidism after surgery (three of four patients), in follicular adenomas (five of nine patients), in Hashimoto's thyroiditis (two out of six patients, both belonging to a group of three with an early stage of the disease), and in paraadenomatous tissues (in three of nine patients). Interleukin-1 alpha positive TFEC were found less frequently than interleukin-6, and only in tissues with interleukin-6 positive TFEC. Only few interleukin-6 and interleukin-1 alpha positive interstitial cells were found, even in the lymphocyte infiltrates (in both the autoimmune, benign or malignant disorders). In conclusion, both interleukin-6 and interleukin-1 alpha could be demonstrated in TFEC from patients with autoimmune diseases, benign neoplasms or papillary carcinoma, whereas follicular cancer tissues were without interleukin-6 and interleukin-1 alpha. In contrast with previous studies, interleukin-6 and interleukin-1 alpha were demonstrated in TFEC from patients with both Graves' disease and Hashimoto's thyroiditis, and the presence of these cytokines was related to the stage of the autoimmune process.

Immunohistochemistry of the intercellular matrix components and the epithelio-mesenchymal junction of the human tooth germ

The immunohistochemical localization of heparan sulphate, collagen type I, III and IV, laminin, tenascin, plasma- and cellular fibronectin was studied in tooth germs from human fetuses. The lamina basalis ameloblastica or membrana preformativa, which separates the pre-ameloblasts from the pre-dentin and dentin, contained heparan sulphate, collagen type IV, laminin and fibronectin. Enamel reacted with antifibronectin, but the reaction varied depending on the type of fibronectin and the source of antibody. In early pre-dentin, collagen type I, laminin, tenascin and fibronectin were present. In late pre-dentin and dentin collagen type I was found in intertubular dentin and in the zone between enamel and dentin. The close relationship between collagen type I in dentin and fibronectin in immature enamel is interesting, as it may contribute to the stabilization of the amelodentinal interface. In dental pulp, collagen type IV and laminin were found in the endothelial basement membranes. Collagen type I and III, tenascin and fibronectin were localized to the mesenchymal intercellular matrix. The results of this study have supported the assumption that the lamina basalis ameloblastica is a basement membrane, and have lead to the suggestion that ameloblasts are producers of fibronectin or a fibronectin-like substance.

Quantitative cytochemical demonstration of intracellular thyroglobulin in cultured human thyrocytes. Effects of fixatives, TSH and interleukin-1 beta

A quantitative immunocytochemical method is described for measuring intracellular thyroglobulin in human thyrocytes grown in monolayer, based on the imidazole-enhanced 3,3'-diaminobenzidine/peroxidase reaction. The influence of ten different fixatives on the content of thyroglobulin immobilized on nitrocellulose filters and in single cells and the influence of thyrotropin and interleukin-1 beta (IL-1 beta) on the amount of intracellular thyroglobulin were evaluated. The most suitable fixatives for single cells were 2% carbodiimide, Lison's 'Gendre fluid' and 2 or 4% paraformaldehyde, whereas Bouin, Carnoy A and B, formalin-calcium and Lillie's formaldehyde-acetic acid-alcohol fixative all resulted in reduction of intracellular thyroglobulin. Two per cent glutaraldehyde caused a considerable reduction (p less than 0.0001). Nitrocellulose filters were not suitable for evaluation of the fixatives, since the results did not correspond to those obtained with single cells. Thyrotropin (1 U/l) increased intracellular thyroglobulin, whereas addition of interleukin-1 beta to the culture medium for three days caused a dose-dependent reduction with a plateau level at 2 x 10(-6) gl-1 (10(4) U/l) of interleukin-1 beta. It is concluded that changes in intracellular thyroglobulin concentration caused by either thyrotropin or IL-1 beta can be quantified under experimental circumstances where samples for measurements of thyroglobulin-mRNA or extracellular thyroglobulin are difficult or impossible to obtain.

Evidence for compartmentation of synaptosomal phosphate-activated glutaminase

Phosphate-activated glutaminase (EC 3.5.1.2) in synaptosomal preparations is inhibited 40-60% by the sulphydryl group reagent N-ethylmaleimide (NEM), forming the basis for distinction between NEM-sensitive and NEM-insensitive glutaminases. The NEM effect cannot be explained by differential effects on distinct glutaminases because other glutaminases have not been detected, and the synaptosomal glutaminase activity can be fully accounted for by the activity of phosphate-activated glutaminase. By fractionation of mitochondria isolated from synaptosomal preparations, which are preincubated with and without NEM, both NEM-sensitive and NEM-insensitive glutaminases are found to be localized to the inner mitochondrial membrane. Variations in pH (7.0-7.6) and the phosphate concentration (5-10 mM) affect chiefly NEM-sensitive glutaminase, demonstrating that this glutaminase may be subject to regulation by compounds in the cytosol having restricted permeability to the inner mitochondrial membrane. Since p-hydroxymercuribenzoate, which is known to be impermeable to the inner mitochondrial membrane, inhibits glutaminase similarly to NEM, phosphate-activated glutaminase is assumed to be compartmentalized within the inner mitochondrial membrane. Thus, NEM-sensitive glutaminase is localized to the outer face and NEM-insensitive glutaminase to the inner region of this membrane and probably also to the matrix region.