Epidemiology of Anemia at the Internal Medicine Department in Borgou Departmental Hospital Center (DHC) in Parakou (Benin) ()
1. Introduction
Anemia is a public health problem according to World Health Organisation. Anemia is defined as a condition in which there is less than the normal hemoglobin (Hb) level in the body, which decreases oxygen-carrying capacity of red bloodcells to tissues. World Health Organization (WHO) definitions for anemia differ by age, sex and pregnancystatus as follows: children 6 months to 5 year anemia is defined as a Hb level < 11 g/dl, children 5 - 11 years Hb < 11.5 g/dl, adult males Hb < 13 g/dl; nonpregnant women Hb < 12 g/dl and pregnant women Hb < 11g/dl. Anemia could be classified as mild, moderate and severe. The Hb level for each class of anemia in pregnancy are 10.0 - 10.9 g/d1 (mild), 7 - 9.9 g/dl (moderate) and <7 g/dl (severe) [1] [2] [3] . In fact, Anemia is associated with a high rate of morbidity and mortality [4] [5] . More than two milliard people are affected in the world with a high share in developing countries [6] [7] [8] . Thirty three percent (32.9%) of the world population were anemic in 2010 [1] . In hospitalized patients, this prevalence varies between 40% and 50% [9] . Anemia has many effects on individual health like a reduction in the productivity and the physical capacity [10] [11] . It is also linked to the elevation of morbidity in hospital. Anemia may be due to a single factor such as a nutritional deficiency or its cause may be multifactorial. Anemia results from one or more of the following events: loss of red blood cells, reduction in the production of red blood cells, increased destruction of red blood cells, and shorter life span of red blood cells. Multiple factors may contribute to the development of complex anemia in hospitalized patients, including nutritional deficiencies, suppression of RBC production bymedications, inflammatory cytokines (inflammatory anemia or anemia of chronic disease), and chronic or acute bleeding [12] . In northern Benin, the problem extent is unknown. The goal of this study was to describe anemia clinical and biological characteristics in the Internal Medicine Department of Borgou Departmental Hospital Center.
2. Patients and Methods
This transversal and descriptive study is aimed at analyzing with a prospective data collectioncovering the period between the 1 st January 2017 and 31st March 2017. The inclusion criteria were: to be over 15 years of age, to be hospitalized in the Internal Medicine Department, having performed a hemogram and to have provided their informed consent to participate in the study. The data collection was conducted via a questionnaire and a medical examination record elaborated for this purpose. The questionnaire contained sociodemographic characteristics, clinical and biological characteristics of the patients.
Anemia has been defined as a hemoglobin level under 12 g/dL in men and under 11.5 g/dL in women. The severity of the anemia has been assessed according to the following degrees: mild when hemoglobin level is at 10 g/dL or higher, moderate when the hemoglobin level is less than 10 g/dL and superior or equal to 7g/dL, severe when the haemoglobin level is less than 7 g/dL anddecompensated when the haemoglobin level is inferior to 7 g/dL and the patient has at least one sign of intolerance. The anemia is normocytic if the mean corpuscular volume (MCV) is between 80 and 90 fL, microcyticif MCV is inferior to 80 fL and macrocyticif MCV is higher than 90 fL. The anemia is normochromicifthe mean corpuscular hemoglobin concentration (MCHC) is between 30 and 36 g/dL and/or the Mean corpuscular hemoglobin (MCH) is between 25 and 32 pg, hypochromicifthe MCHC is lower than 30 g/dL and/or MCH is inferiorto 25 pg. According to the Body Mass Index (BMI) the three following classes have been retained: normal if BMI is between 18.5 and 25 kg/m2, over weight if BMI is superiorto 25 kg/m2 and thin orcachectic if BMI is under18.5 kg/m2. The softwares EPI INFO version 3.5.3. and Epi-7 have been used for the processing and analysis of the data. The statistical tests Chi-square and z-score transformation have been used to investigate the significance level of the suspected associations between the study factors.
3. Results
3.1. Sociodemographic Characteristics
The average age of the anemic patients was 40.62 ± 16.91 years with the extremes 16 years and 92 years. The median age was 39 years. Whereas the average age of the non-anemic patients was 49.19 ± 18.81 with the extremes 21 and 85 years and the median age was 45 years. Out of 123 patients included in this study, 68 were male. Ninety three were married, a prevalence of 75.60%; 76 patients came from Parakou, 18 lived more than 10 km from Parakou and 29 came from others departments of Benin or from the neighbouring countries.
3.2. Clinical and Biological Characteristics
Seventy eight patients had a normal nutritional status, 26 were under nourished and 19 were overweight out of 123 patients included in the study; 76 suffered from anemia, or a prevalence at 61.8%.
According to the anemia severity, 19 patients (25%) had mild anemia, 36 (47.4%) suffered from moderate anemia, 21 (27.6%) from severe anemia and 8 (10.5%) from decompensated anemia.
According to the type of anemia, using the MGV for the classification: microcytic anemia represented 36.8%, normocytic anemia 46.1% and macrocytic anemia accounted for 17.1%. On the basis of the MCHC: The normochromic anemia represented 81.6% and hypochromic anemia 18.4%.
The pathologies most encountered in anemic patients are digestives pathologies (17%), the nephropathies (17%), cardiac pathologies (13%), malaria (12%) and pulmonary pathologies (9%).
3.3. Risk Factors Associated with Anemia
Sex was not associated with anemia.
The younger age was associated with anemia (p = 0.043) (Table 1).
Table 2 and Table 3 show respectively anemia prevalence according to the nutritional status and the diagnosis on leaving. The nutritional statuts was not associated with anemia (Table 2). According to the diagnosis on leaving, neurological pathologies were associated with anemia (Table 3).
4. Discussion
The lack of technical capacity means didn’t allow to determine the reticulocyte rate in order to identify a regenerative or a non-regenerative anemia and the small sample of echantillon. This study allowed the description of anemia epidemiology according to the conditions for exercisingin the developing countries like Benin.
![]()
Table 1. Patients distribution by age.
![]()
Table 2. Patients distribution by the nutritional condition.
![]()
Table 3. Anemia prevalencebythe retained diagnostic on leaving.
Among the main causes of hospitalization in Benin, Anemia was in second position (12.3%) aftermalaria (32.2%) [13] . Adingni reported a hospital frequency at 25.4% in Cotonou [14] . The anemia frequency in the internal department of Borgou DHC was 61.8%. That very high frequency was due to our study method. Over 3 months period, we realized a complete blood count in all the patients hospitalized in the service without prejudice of the reason for hospitalization. That method allowed us to diagnosis a larger number of anemic patients even the subclinical cases. That frequency is superior to 25.4% reported by Adingni [14] in Cotonou during a retrospective study on the records of the patients registered as the ones suffering from anemia in CNHU-HKM internal medicine department in Cotonou from 2006 to 2010. The high frequency of anemia in internal medicine department of Borgou DHC could be also justified by the fact that hospitalized patients come from several specialities: Nephrology, Cardiology and Infectiology. Shill [3] and Terrier [15] have reported a similar prevalence at respectively 53.3% and 65%. In people living with HIV, 44% of them are anemic in Tanzania. In Bangladesh, 32% of patients suffering from pulmonary diseases are anemic [16] . In United States, the prevalence of anemia in hospitalized patients is low at 22.8% [12] . That variance is due to socio-economic difference between developed countries and the developing ones [1] .
The number of the patients suffering from a mild anemia was 19 (25%). The ones who had a moderate anemia were 36 (47.4%) and 21 (27.6%) had a severe anemia. Adingni [14] reported a higher number of severe anemia (40.4%), followed by mild anemia (31.4%) and moderate anemia (28.2%). In Maroc, El Hioui et al. [17] rather noted in their series that almost half of the investigated patients (45%) had a hemoglobin level inferior to 6.5 g/dL.
Classifying anemia according to MGV, microcytic anemia represented 36.8%, normocytic anemia at 46.1% and macrocytic anemia represented 17.1%. According to Adingni [14] , microcytic anemia represented 30.4%, normocytic anemia 40.8% and macrocytic anemia 28.8%. According to El Hioui et al. [17] microcytic anemia represented 39% followed by macrocytic anemia 37.8% andnormocytic anemia 23.2%.
On the basis of the MCHC, normochromic anemia represented 81.6% and hypochromic anemia 18.4%. Adingni [14] found the same generaltrend: 54.6% of normochromic anemiaand 45.4% of hypochromic anemia. According to Sellam et al. [10] , hypochromic anemia was the more frequent (88.6%) than normochromic anemia (11.4%).
In our series, the pathologies found in anemic patients were digestive pathologies (22.4%), nephropathies (22.4%), cardiac pathologies (17%) and malaria (15.8%). The high rate of nephropathies found in ours sample could be explained by the fact that in Borgou DHC, nephrology is attached to internal medicine department. According to Diallo et al. [18] in Mali, the pathologies most often encountered were tuberculosis (21.8%), livercirrhosis (14.3%) anddiabetes (7.5%). But his study was on people living with HIV. In Cotonou and Parakou, hepato-digestive pathologies and HIV infection are encountered in anemic patients. The factors associated with anemia were young age neurological pathologies. Sellam and et al., Leite et al. and Makubi et al. have reached the same association [8] [10] [19] . This association between anemia and youngest patients could be explained by the lower average of the anemic patients. In this study, the average age of the anemic patients was 40.62 ± 16.91 years where as the one of the non-anemic was 49.19 ± 18.81 years. Adingni, El Hioui et al. have reported a similar average age with respectively 42.8 years and 41 ± 18.33 years [14] [17] . Anani and al [20] confirmin their studies at the Blood Diseases Department that most of the anemic patients (74.6%) were under 40 years old. Whereas according to Bach et al. and Pilgrim et al. studies, anemia prevalence is higher in the old patients [4] [21] .
Patients suffering from neurological problems are more anemic. The loss of autonomy and the alteration of consciousness could explain that association.
5. Conclusion
The frequency of anemia is high in the internal medicine department at Borgou DHC. Normocytic, normochromic and moderate anemia are the most encountered. The pathologies encountered the most in anemic patients were digestive, renal, cardiac, pulmonary and infectious and especially malaria. Awareness of populations and practitioners for early health care of the pathologies that create anemia could improve this presentation in order to avoid its harmful effects.
Appendix
Data Collection Sheet
Name
Age (years)
Sex
Ethnicity
Religion
Profession
Marital status
Education
Residence
Weight (kg)
Height (m)
Body Mass Index
Diabetes mellitus Yes No
Hypertension Yes No
Sickle cell disease Yes No
HIV Yes No
Chronic kidney failure Yes No
Tobacco use Yes No
Alcohol intake Yes No
Reason for consultation
Functional signs
Condition
State of consciousness
Respiratory rate
Pulse
Blood pressure
Diagnosis retained:
Hemogram data:Hemoglobin level
- MCV
- MCHC