THE PREVALENCE OF ANEMIA IN RIO GRANDE DO

SUL, BRAZIL.

Lucia Mariano da Rocha SillaHead of the Hematology and Bone Marrow

Transplantation – HCPAProfessor of Hematology at the Federal University of

Rio Grande do SulPresident of NGO: HEMOAMIGOS-HCPA

10.582.84010.582.840 inhabitantsinhabitants

~ 1.800.000 ~ 1.800.000 children < 6 YoAchildren < 6 YoA

child. mortality child. mortality rate: 15.4/thousandrate: 15.4/thousand

GOP R$ 144.344 MGOP R$ 144.344 M

Public Health System

(SUS)

Federal University of Rio Grande do Sul

HCPAHCPA

● ● 750 beds (90% SUS)● ● ICU for adults, children and neonates● ● ICU for Coronary Disease● ● Solid Organ Transplant Program● ● Bone Marrow Transplant Program autologous, autologous,

relate and non-related alogeneic relate and non-related alogeneic ● ● Day Care and Out Patient Clinic● ● CT scan and MIR● ● Basic health UnitBasic health Unit

HCPAHCPA

0

10

20

30

40

50

60

70

93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 8

TRIAGEM NEONATAL : Cobertura Rio Grande do Sul - 1997 / 2002

14%

20% 19%

27%

55%

65%

0

20.000

40.000

60.000

80.000

100.000

120.000

140.000

160.000

180.000

200.000

97 98 99 00 01 02

Fonte: Faculdade de Farmácia / UFRGS

Nº

0%

10%

20%

30%

40%

50%

60%

70%

No. Nasc vivos N. Testes Cobertura %

Até abril

5

912

2

MGSS 1:1,400

AS 1:23

RJRJSS 1:1,200SS 1:1,200

AS 1:21AS 1:21

RSRSSS 1:11,000SS 1:11,000

AS 1:65AS 1:65

SPSS 1:4,000

AS 1:35

GO SS 1:1,800

AS 1:28

MASS 1:1,400

AS 1:23

ESSS 1:1,800

AS 1:28

SCSS 1:13,000

PESS 1:1,400

AS 1:23

neonatalscreening

SCSS 1:13,000

BABASS 1:650SS 1:650AS 1:17AS 1:17

2008 sickle cell disease in Brazil2008 sickle cell disease in Brazil

Hematology and Bone Marrow Transplantation

• 29 beds (12 for BMT)

• 850 pts/month

• Clinical Research (Industry)

• Basic Research (Lab cell culture and molecular characterization of stem cells)

• Graduation

• Post-Graduation Program

Childhood Acute Leukemia

Germany cure rate 80%HCPA cure rate 65%

47% advanced diseasedelay in referral

40% IDA blocking the agenda

Iron Deficiency AnemiaIron Deficiency Anemia

• only happens after total iron storage depletion

HEMOAMIGOSHEMOAMIGOS

Pastoral da CriançaPastoral da Criança

Gabinete da Primeira DamaGabinete da Primeira Dama

Secretaria da SaúdeSecretaria da Saúde

Secretaria da EducaçãoSecretaria da EducaçãoCAIXA RSCAIXA RS

SESC RSSESC RS

SESISESI

UNESCOUNESCO

FAMEDFAMED

UFRGSUFRGSHCPAHCPA

SIMERSSIMERS

AJERTAJERTUNESCOUNESCO

OAB RSOAB RS

AMRIGSAMRIGSJob-Herve Job-Herve comunicaçcomunicaç

õesões

ARIARI

TeachingTeaching

Civil Society

Basic health facilities

Pre- and Elementary

Schools

MD, nurses, pharmacists, health agents

Nutricionists and Biologists

Medical and Nurse Schools

Nutrition and Biology Schools

State Health and Education departments

information

Prevalence DeterminationPrevalence Determination

Sample: for 30% of prevalence = 500 children and 500 women

– children < 6 years of age – women from 14 to 30 years of age: non-pregnant,

non-puerperal, non-post-abortion and not related to the tested children

– demografic data– informed consent – socioecomic form– capillary hemoglobin concentration

Socioeconomic classificationSocioeconomic classification

• Brazilian Association of Market Research Agencies

utilized by the government to classify the Brazilian population along 5 levels:

A to E – being A the highest and E the lowest socioeconomic level

http://www.abep.org/codigosguias/ABEP_CCEB.pdf

The Socioeconomic level distribution urban The Socioeconomic level distribution urban areas in Brazilareas in Brazil

Target PopulationTarget Population

“Healthy” population at their homes Pastoral da Criança

http://www.pastoraldacrianca.org.br/

SESC-RS workershttp://www.sesc-rs.com.br/site/home.htm

Medical Students10 Schools of Medicine in RS

ResultsResults

• Over 800 people involved all over the state• 76 lectures for health care personal (6.584)• Printed material distribution• A foam doll called “Fera” (slang for “the best”)• A theater named “Fera does not have anemia”

12 presentations• TV spot (cartoon) and radio talks• 14 public shows involving about 20.000 low

income people (SESC shows) all over the state

Bagé

Região Norte

Hg inferior a 11 em crianças 40,7%

Hg inferior a 12 em mulheres 28,8%

Região Oeste

Hg inferior a 11 em crianças 42,0%

Hg inferior a 12 em mulheres 40,5%

Região Sul

Hg inferior a 11 em crianças 68,7%68,7%

Hg inferior a 12 em mulheres 65,9%65,9%

Região Nordeste

Hg inferior a 11 em crianças 29,1%29,1%

Hg inferior a 12 em mulheres 19,3%19,3%

Região Leste

Hg inferior a 11 em crianças 42,2%

Hg inferior a 12 em mulheres 35,4%

Bagé

Rio Grande do Sul

Hg inferior a 11 em crianças 44,2%44,2%

Hg inferior a 12 em mulheres 36,3%36,3%

F. Westphalen

Crianças

2375

Mulheres

1999

Prevalence of anemia in children by

socioeconomic class level

25

33.340.4

46.6

57.9

0

10

20

30

40

50

60

70

A B C D E

socioeconomic level

Per

cen

tag

e

p < 0,001

Prevalence of anemia in women by socioeconomic class level

p = 0,006

14.3

26.2

35.7 37.8

45.9

05

1015

202530

3540

4550

A B C D E

socioeconomic level

Per

cent

age

age distribution of anemia in children

p < 0,001

77

58

44 4035

28

0

10

20

30

40

50

60

70

80

90

18 a 23meses

24 a 35meses

36 a 47meses

48 a 59meses

60 a 71meses

72 mesesou mais

per

cen

tag

e

Prevalence of anemia in children by

socioeconomic class level

25

33.340.4

46.6

57.9

0

10

20

30

40

50

60

70

A B C D E

socioeconomic level

Per

cen

tag

e

p < 0,001

Prevalence of anemia in women by socioeconomic class level

p = 0,006

14.3

26.2

35.7 37.8

45.9

05

1015

202530

3540

4550

A B C D E

socioeconomic level

Per

cent

age

DiagnosisDiagnosis

√√ Uncertainties about the definition of anemia√√ Anemia Anemia is asymptomatic, as a consequence,

physicians don’t see the hidden burden√√ Physicians don’t know about micronutrients

deficiencies (physicians are the key health professionals in developing countries)

√√ Regular Nutritionists lack the knowledge about iron-rich food and its absorption

√ √ WHO literature as well as UN’s WHO literature as well as UN’s is notis not readily readily available for practitioners available for practitioners

depressed or low IQ motherdepressed or low IQ motherlow stimuluslow stimuluslow socioecomic levellow socioecomic level

high riskhigh risk

Strategies for solutionsStrategies for solutions

• push health international professionals and scholars to settle the issue about anemia definition

• push health authorities in the developing world to better inform basic health physician/professionals about the most prevalent issues

• gather similar information from other studies/countries/professionals

• implement multidisciplinary iniciatives

Startegies for SolutionsStartegies for Solutions

In all documents about human development,

health and development MUSTMUST be listed BEFOREBEFORE education

Otherwise, we are enforcing another form of power

TO KNOW BETTERTO KNOW BETTER

Our StartegyOur Startegy

p < 0,001

77

58

44 4035

28

0

10

20

30

40

50

60

70

80

90

18 a 23meses

24 a 35meses

36 a 47meses

48 a 59meses

60 a 71meses

72 mesesou mais

per

cen

tag

e

age distribution of anemia in children

before being a mother avoid anemiabefore being a mother avoid anemia

““before being a mother avoid before being a mother avoid anemia” Strategyanemia” Strategy

• submitt a paper to a high impact medical journal (and let the brazilians know about that)

• be here and anywhere else where the public health problems are being discussed by authorities in the field (and let everyone know that)

• collect finantial resourses from industries• apply marketing strategies for health professionals

similar to the pharmaceutical companies: personal letters, e-mail marketing, cultural events, published material, etc

• spread the news to the society (with enfasisin midle class individuals)

before being a mother avoid anemia before being a mother avoid anemia 12 semanas 24612 semanas 246 children children SESC-RSSESC-RS

before after

> 11g/dl < 11g/dl > 11g/dl < 11g/dldrop in anemia

%

intervention

Aelca 33/63 30/63 (48% ) 51/63 12/63 (19%) 60%

NSap 28/55 27/55 (49%) 36/55 19/55 (35%) 29%

Perp. Soc 57/66 09/66 (14%) 60/66 06/66 (9%) 36%

TOTAL 118/184 66/184 (36%) 147/184 37/184 (20%) 44%44%

control

Ciranda 14/22 08/22 (36%) 15/22 07/22 (32%) 11%

São José 47/58 11/58 (19%) 49/58 09/58 (16%) 16%

TOTAL 61/80 19/80 (24%) 64/80 16/80 (20%) 16%16%

““before being a mother avoid before being a mother avoid anemia” Strategyanemia” Strategy

• empower Pastoral da Criança • MESA BRASIL SESC• civil society pushing a law for school meals• push local Pediatric and Gynecology/Obstetrics

Societies to implement obligatory blood tests in women at childbearing age and children

• hopefully to be able to show changes in three years, at least in attitude

““before being a mother avoid before being a mother avoid anemia” Strategyanemia” Strategy

• push the necessary changes in Public Health Schools and Social Work Schools (with your help)

• push Federal Health authorities to stablish a minimal training for future public health professionals (public guarantee job)

• push Public Schools of Medicine to teach the basic health problems (with your advice)

Direct Collaborators

Alice Zelmanowicz, Larissa Brouwers, Ingrid Mitto, Ana Maria Moreira, Mariana Michalowski, Liane Daudt, Marta Alves, Denise Leugeur, João Fridrisch, Christina Bittar, Tania Hewlig, Marco Shiling, Gustavo Fischer, Rosane Bittencourt, Laura Fogliatto, Carlos do Bem, Alessandra Paz, Zilda Arns

Thank youThank you