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Anaemia in a Rural
Community
Ian Couper
Professor of Rural Health
Objective
Discuss intervention strategies for
addressing anaemia in rural
communities
Aim
To explore multiple
causative factors of
anaemia in a rural
context and
possible
intervention
strategies to
address these.
Ms Dorah Mahlangu



24 years old
Lives in rural Kosi
Bay area
Presents to you
with tiredness
Tiredness

Many causes
• Physiological
• Physical (organic)
• Psychological

Acute vs. Chronic
Ms Dorah Mahlangu



24 years old
Lives in rural Kosi Bay area
Presents to you with tiredness.
• Also shortness of breath on exertion,
palpitations, headache.

On examination, her mucous membranes
are very pale
Anaemia

Definition:
• “abnormally low levels of haemoglobin
in the blood”

What is abnormal?
• <14g% in men; <12g% in women

Need to confirm: how?
• FBC
• Haemoglobinometer ( “finger prick Hb”)
• Copper sulphate solution
Ms Dorah Mahlangu




24 years old
Lives in rural Kosi Bay area
Presents to you with tiredness (etc)
On exam, mucous membranes very pale
• Also, pitting oedema of legs, soft ejection
systolic murmur

Hb = 4.3g%
Is this a diagnosis?

No!
• Anaemia is a sign of disease, like fever

Acute versus chronic
• Implications of such a low Hb (severe anaemia)
• Both dangerous in different ways:
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Acute: Shock
Chronic: Decompensation
• Compatible with ongoing life?

Adaptation dependent on
•
•
•
•
Severity
rapidity of onset
age
pre-existing disease (especially cardiovascular)
Types of anaemia

What are causes?
• What kind of anaemia is it?
• Classification:

Pathophysiological
• Impaired Hb production
 Nutritional deficiencies
 Disturbances of bone marrow function
 Secondary to other conditions (e.g. infections,
malignancies, etc)
• Increased Hb loss (haemorrhage)
• Increased Hb destruction (haemolysis)

Morphological (red cell size)
• Microcytic
• Macrocytic
• Normocytic
Ms Dorah Mahlangu






24 years old
Lives in rural Kosi Bay area
Presents to you with tiredness (etc)
O/E mucous membranes very pale, etc
HB = 4.3g%
Microcytic anaemia
Microcytic anaemia

Caused by iron deficiency anaemia
• Can confirm by measuring serum iron,
other iron studies, serum ferritin, etc.


Not normally done in a rural hospital
Need to exclude anaemia of chronic
disorders and thalassaemia syndromes
• Is this a diagnosis?

What are the causes of her iron deficiency?
Causes of iron deficiency anaemia

Inadequate iron intake
• Dietary deficiency
• Impaired iron absorption (gastric lesions and
malabsorption syndromes)

Iron use exceeds intake
• Loss due to bleeding


Acute vs. chronic
Sites of chronic blood loss
• genital tract e.g. excessive menstrual loss
• urinary tract e.g. haematuria
• GI tract e.g. piles, parasites
• Excessive requirements


Infancy
pregnancy
Ms Dorah Mahlangu

History: Menorrhagia
• We have found a cause: are we now ready to
treat?
• What is causing the menorrhagia?

Examination: Bleeding piles
(haemorrhoids)
• We have found 2 causes: are we now ready
to treat?
• What is causing the piles?

Urine dipsticks
• Haematuria
• What is causing the haematuria?

Stool microscopy
• Hookworm
Ms Dorah Mahlangu

So …
• Tiredness anaemia  iron deficiency
blood loss

menorrhagia (hormonal imbalance)
piles (since last child born)
haematuria (due to urinary bilharzia
= Schistosoma haematobium infection)
hookworm infestation
(Ancylostoma duodenale and Necator
americanus)

Treatment?
Treatment

Treat symptoms
• Analgesic, e.g. paracetamol, for headache, etc

Treat superficial cause
• Dietary advice

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Animal foods (eggs, fish, meat, etc)
Green vegetables (beans, peas, spinach, etc)
• Iron supplementation

E.g. ferrous sulphate 200mg 3X daily
• Transfusion?
Treatment

Treat underlying causes
• Hormonal regulation

E.g. oral contraceptive pill
• Piles
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E.g. dietary advice, local preparations
• Hookworm
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E.g. albendazole 2 tablets
• Bilharzia

E.g. praziquantel
Prevention
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Dietary advice (as above)
Ongoing supplementation (FeSO4 at lower
dose)
Educate re bowel habits
Avoiding contaminated water sources
Knowing the signs – getting treatment
early
Hygiene
What about the community?
Ms Mahlangu’s community

Poor rural community
• Few people have cattle

Sandy soil:
• Parasites common (intestinal worms and S. hamatobium)
• Difficult to grow vegetables
• VIP latrines difficult to build

No reticulated water:
• Streams used for washing clothes, bathing, water for
consumption, etc
• Impact on sanitation

Sub-tropical
• Malaria common

High fertility rate
• Early age of first pregnancy

High infant mortality
• Increased number of pregnancies
Treating the community
An example of one project:
Manguzi School Health Programme
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Nutritional intervention
Iron supplementation
Treatment of worms
Treatment of bilharzia
Education of students and families
Dilemmas:
dealing with conflicting knowledge
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Example 1: Bilharzia
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Correct advice: avoid contaminated water
Problem:
• All water in the community is contaminated
• Climate very hot

A solution: offer regular treatment
Dilemmas:
dealing with conflicting knowledge
Example 2: Anaemia in antenatal patients in
Kosi Bay
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Very common
Causes
•
•
•
•
Physiological
Diet
Parasites (intestinal and urinary)
Malaria
Dilemmas:
dealing with conflicting knowledge
Example 2: Anaemia in antenatal patients in Kosi
Bay (cont)

Problems:
• Patients not responding
• Dangerous (haemorrhage and maternal death)
• Patients more at risk of complicated malaria (due to
pregnancy and anaemia)
• albendazole (for worms) and praziquantel (for
bilharzia) not advised in pregnancy

Action:
• Iron (and folate) supplementation
• Treatment of all patients for parasites after 1st
trimester
Causality
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One cause-one disease model is too simple
Illness in an individual results from a multitude of
prior circumstances
Causal factors differ among individuals with the
same illness
Criteria for evaluating causality:
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•
•
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Temporality of association (time factor)
Strength of association
Specificity of association
Consistency of association
Biological plausibility
Epidemiological understanding of
causality
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Cause = stimulus that produces an effect or
outcome
Statistically significant association between 2
factors. Relationship may be causal or noncausal (e.g. living in Kosi Bay area and anaemia)
Casual relationships may be:
• direct e.g. menorrhagia anaemia
• indirect e.g. pregnancy increased requirements for iron
anaemia (in absence of increased intake)
• sometimes they are both e.g. pica (i.e. eating sand) 
Fe deficiency anaemia, in 2 ways: directly, by decreasing
availability of Fe and indirectly via parasitic infection
Multiple causation

Concept of multiple causes
• Multiple causes of symptoms/illness

E.g. anaemia
• Multiple causes of single diseases
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E.g. chronic diseases
Multiple causes: meanings
• Multiple factors involved in inducing the mechanism that
causes the disease
• Each factor in disease causation has its own set of
determinants
• Identical diseases may be caused
by different sets of factors

Concept of a web of causation
Web of causation:
Anaemia in a Rural Community
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Nutritional
• Diet poor in iron

Environmental
• Worms common in soil
• Bilharzia common in water
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Infectious diseases
• Malaria
• HIV

Fertility rate
• Many pregnancies with poor recovery between
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Other illnesses common
• Chronic disease
Why is it a problem?
(Is there a need to intervene?)
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Increased incidence of infection
• The malnutrition-infection cycle.
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Increased mortality from malaria
Increased risk of maternal and
neonatal death
Poor school performance
• Impact on future nutrition
• Impact on health seeking behaviour
• etc
Intervention
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Must be multifactorial
Dealing with individuals only does not
solve the problem
Community wide approaches e.g.
•
•
•
•
•
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Water programmes
Sanitation programmes
Spraying for mosquitoes
Education
Fortification of foods
Community wide supplementation
Principles
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Always determine the cause of anaemia
(any illness) before treating it
Clinical reasoning: Always ask “why?”
Illness often has multiple causes:
causation is not simple and linear
We cannot always know all the causes.
Treatment and prevention cannot be
separated
Management of individuals is often
insufficient:
• Systematic approaches (cf. antenatal clinic example)
• Community level action (cf. school health example)