ANEMIA AWARENESS

Quality Health Services Ltd. 2010. All Rights Reserved.

ANEMIA AWARENESS TABLE OF CONTENTS SECTION 1 INTRODUCTION WELCOME TO QUALITY HEALTH SERVICES LTD 4 OUR VISION, MISSION AND GOALS.. 5 HOW TO GET STARTED 6 SECTION 2 ANEMIA OVERVIEW WHAT IS ANEMIA. 7 WHAT CAUSES ANEMIA. 8 TYPES AND CAUSES. 8 SECTION 3 HEMOGLOBIN OVERVIEW WHAT IS HEMOGLOBIN. 13 ROLE OF HEMOGLOBIN IN DISEASE .14 WHAT DO HEMOGLOBIN TEST RESULTS INDICATE ..15 SECTION 4 SCREENING HEMOGLOBIN ANALYSIS Hemocue Hb 201+ .16 How Does it Work?... 16 Performing an Analysis. 17 SECTION 5 CLINIC BEFORE THE CLINIC Receive Confirmation From Clinic Coordinator... 18 Contact Clinic Purchaser/Contact Person.. 18 Receive Equipment 18 Quality Assurance Check... 19

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ANEMIA AWARENESS THE DAY OF THE CLINIC Arrival 20 Things to Do at the Beginning of Each Client Appointment. 20 Anemia Handout/Brochure 21 At the End of the Client Appointment... 22 AFTER THE CLINIC Clean Up 22 Clinic Evaluation... 22 What to Return or Ship.. 22 SECTION 6 REVIEW & REFERENCES Review Questions... 23 References... 23 Review Answers... 24

Quality Health Services Ltd. 2010. All Rights Reserved.

ANEMIA AWARENESS

SECTION 1 INTRODUCTION WELCOME TO QUALITY HEALTH SERVICES LTD. We would like to take this opportunity to welcome you aboard as part of our Quality health team. It is our intention to help you experience our vision and set fourth personal goals in order to help you grow within our organization. As an integral part of our team, you will work with us to promote health awareness and health education to the public.

Who We Are Quality Health Services Ltd. (QHS) is a subsidiary of Quality Underwriting Services Ltd. (QUS), a wholly Canadian owned company that has been the industry leader since 1976 in providing paramedical and medical examinations, inspection reports and attending physician services collection services for the Canadian Life Insurance and Financial Industries. With 23 locations from coast to coast and affiliated offices in the United States and South East Asia, QHS has access to the most extensive network of health care professionals in North America and around the world!

What We Do QHS provides people with the opportunity to take a proactive approach to their health by promoting health awareness through education clinics and state of the art screening services. We have been in the business of health promotion for ten years and know we are making a difference on a local level, however we would like you to help us make a difference on a national level. By joining our team, you are making a difference!

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ANEMIA AWARENESS

SECTION 1 - INTRODUCTION OUR VISION, MISSION AND GOALS Our Vision Our vision is to promote health awareness to all people by providing them with the opportunity to obtain the information they need in a safe, familiar environment.

Our Mission We are in the business of health education and disease prevention. Our mission is to raise the publics level of health awareness thus enabling them to make informed decisions regarding their healthcare and improving their quality of life.

Our Goals To deliver innovative, interactive and educational programs with our primary focus on prevention. To continually research and develop results oriented programs within the community. To help improve the publics general quality of life.

To help create Life in Balance on a global basis.

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ANEMIA AWARENESS

SECTION 1 INTRODUCTION HOW TO GET STARTED 1) Review the Healthcare Professionals Orientation Manual Please review your healthcare professionals orientation manual as it contains much of the general information that you need to know on running a successful clinic. For example, good sections to review are the uniform and dress code, confidentiality, breaks and overtime, etc. 2) Read this Anemia Self-Training Manual! It seems silly to state this when obviously if you have reached this section you are reading this manual. However, please, do not just skim through the manual or only read the sections in which you are interested. Read through the complete manual at least once. 3) Attend a Clinic or Receive Training If you find that reading the manual and viewing the video are not enough, or if it was not available to you, you can attend a clinic or receive training. Call your QHS Branch clinic coordinator to see if another healthcare professional will be running a clinic near you and take the opportunity to see a live demonstration. If there are no clinics in your area ask about our training options.

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ANEMIA AWARENESS SECTION 2 ANEMIA OVERVIEW WHAT IS ANEMIA? Anemia is a condition where there is a reduction in the number or volume of circulating red blood cells (erythrocytes) or an alteration in hemoglobin. Anemia is not a disease; it is a symptom of any number of disorders. Red blood cells are the most common type of blood cell and are the primary method of delivering oxygen to the bodys tissues. Hemoglobin is an iron-binding transport protein inside the red blood cell. Its purpose is to bind to oxygen, which is then transported throughout the body in the red blood cell, and it releases this oxygen in the various tissues of the body. Generally speaking, a hemoglobin level below 13.5 g/dL in men and 11.5g/dL in females is considered to be anemia. Anemia is often the first detectable sign of conditions such as: Arthritis Infection Major illnesses such as cancer Drug use Hormonal disorders Chronic inflammation of the body Surgery Bleeding disorders Diverticular diseases Liver damage Bone marrow disease Dietary deficiencies

There are also hereditary disorders that can cause anemia, most commonly sickle cell disease and thalassemias.

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ANEMIA AWARENESS

WHAT CAUSES ANEMIA? Anemia is classified as being either nutritional or non-nutritional. Anemia caused by nutritional deficiencies is most commonly caused by a deficiency in iron, vitamin B12, or folic acid. Less common causes of nutritional anemia include deficiencies of vitamins B2, B6, C, A, D, E, and K. Deficiencies of zinc, copper, calcium, and protein are also less common causes of nutritional deficiencies. Non-nutritional causes are those that result in the decreased development of the red blood cell precursors, decreased red blood cell production, or in an increase in red blood cell destruction.

TYPES OF ANEMIA There are three general categories of anemia, they are: 1. Microcytic 2. Normocytic 3. Macrocytic MICROCYTIC ANEMIA: Microcytic anemia is characterized by abnormally small erythrocytes and a reduced concentration of hemoglobin. The diagnosis of microcytic anemia is made by checking the value of the mean corpuscular volume (MCV), which will be less than 76fl. The most common cause of microcytic anemia is a deficiency of iron. In children, thalassemias are also a cause of microcytic anemia. In adults, the causes of microcytic anemia are as follows: Iron deficiency anemia Sideroblastic anemia Anemia of chronic disease Pyridoxine deficiency Lead poisoning Other causes of normocytic and macrocytic anemia should also be considered in the diagnosis of microcytic anemia.

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ANEMIA AWARENESS The most common signs and symptoms of microcytic anemia include: Weakness Fatigue Lightheadedness Dizziness Pallor (pale skin) Headache Rapid heartbeat

The following picture compares a normal red blood cell (TOP) and a microcytic red blood cell (BOTTOM):

Normal

Microcytic

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ANEMIA AWARENESS NORMOCYTIC ANEMIA: Normocytic anemia is caused by a destruction or depletion of normal or mature erythrocytes. In normocytic anemia, the erythrocytes are relatively normal in size and normal in hemoglobin content, but are insufficient in number. Normocytic anemia shares no common cause, pathologic mechanism, or morphologic characteristics with the microcytic and macrocytic anemias. There are five common conditions associated with normocytic anemia, they include: 1. Increased red blood cell loss or destruction Acute blood loss Hypersplenism Hemolytic disorders Congenital disorders (sickle cell disease) 2. Disorders of red blood cell membranes Hereditary spherocytosis Hereditary elliptocytosis 3. Red blood cell enzyme deficiencies Glucose-6-phosphate dehydrogenase deficiency Pyruvate kinase deficiency 4. Acquired conditions Mechanical hemolysis Autoimmune hemolysis Paroxysmal nocturnal hemoglobinuria 5. Decreased red blood cell production Primary causes: Marrow hypoplasia, myelopathies, myeloproliferative diseases, and pure red blood cell aplasia. Secondary causes: Chronic kidney failure, liver disease, endocrine deficiencies, anemia of chronic disease, sideroblastic anemias 6. Increased plasma volume Pregnancy Over-hydration

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ANEMIA AWARENESS Symptoms of normocytic anemia are vague and similar to those of microcytic anemia, they include: Loss of appetite Pallor Weakness Fatigue Light-headedness Headache Shortness of breath Dizziness Chest pain Cold skin MACROCYTIC ANEMIA: Macrocytic anemia is also known as megaloblastic anemia, and is named as such because the red blood cells are unusually large compared to those of microcytic and normocytic anemia. Macrocytic anemia is characterized by the presence of hypersegmented neutrophils on peripheral smear. It is an anemia caused by vitamin deficiencies that result in the inhibition of DNA synthesis in red blood cell production. Macrocytic anemia can be cause by: 1. Vitamin B12 deficiency 2. Folic acid deficiency Vitamin B12 deficiency can be caused by: Alcoholism Dietary deficiency Malabsorbtion due to intestinal disease Lack of intrinsic factor (responsible for B12 absorption in the intestine) Chronic pancreatitis Biological competition for vitamin B12 (tapeworm infection, diverticulosis)

The symptoms of B12 deficiency anemia are similar to regular anemic symptoms (weakness, fatigue, light-headedness, pallor, shortness of breath); in addition it presents itself with neurological impairments such as: Numbness and tingling in the hands and feet Lack of balance Walking difficulties Confusion 11

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ANEMIA AWARENESS Depression Memory loss Dementia Burning in the tongue

Folic Acid deficiency causes: Alcoholism Dietary deficiency (classically the tea and toast diet) Increased needs (pregnancy, infancy) Malabsorbtion diseases Intestinal resections Deficiency of thiamine and enzymes responsible for its metabolism Toxins Drugs (methotrexate, 6-mercaptopurine, phenytoin) Signs and Symptoms of folic acid deficiency: Common symptoms of anemia (weakness, fatigue, pallor, light-headedness) Bleeding easily Intestinal symptoms Malabsorbtion The following picture compares a normal red blood cell (Top Picture) and a macrocytic red blood cell with hypersegmented neutrophils (Bottom Picture):

Normal RBC

Macrocytic Anemia (with hypersegmented neutrophils)

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ANEMIA AWARENESS SECTION 3 HEMOGLOBIN OVERVIEW

WHAT IS HEMOGLOBIN? Hemoglobin is an iron-containing protein that transports oxygen in the red blood cells. Hemoglobin in the blood is responsible for transporting oxygen from the lungs to the rest of the body, where it gets released for use by the cell. In mammals, hemoglobin makes up approximately 35% of the total content of the red blood cell. Hemoglobin has the capacity to bind 1.36-1.37ml of oxygen per gram of hemoglobin. Hemoglobin levels are ordered as part of the complete blood count, which may be ordered for many different reasons. Measuring hemoglobin is an integral part of the health evaluation, as it is important in evaluating: Severity of anemia or polycythemia (too many red blood cells) To monitor the response to treatment of anemia or polycythemia Decisions about blood transfusions if anemia is severe.

Hemoglobin is composed of four globin chains, which are made of proteins, as well as four heme groups. Iron is bound to the heme molecules, which in turn provide a binding site for oxygen. The adult type of hemoglobin is called hemoglobin A. The protein component of hemoglobin is made up of four subunits, which consist of 2 alpha chains and 2 beta chains. The gene for the beta globin is located on chromosome 11, and is involved in oxygen transport. The alpha globin gene is also a member of this family. Proteins are made from sequences of amino acids, and the sequence of amino acids is critical for proper functioning of the hemoglobin. Should the amino acid sequence be disrupted, the hemoglobin will not function properly, leading to what is known as a hemoglobinopathy. The best-known hemoglobinopathy is sickle cell disease, which is caused by a mutation in the hemoglobin B gene.

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ANEMIA AWARENESS This illustration demonstrates the structure of hemoglobin, which consists of the four globin chains (2 alpha, 2 beta), and the heme-iron (Fe2+) group, which is the site of oxygen binding.

ROLE OF HEMOGLOBIN IN DISEASE Hemoglobin plays an important role in disease. Hemoglobin deficiency can be caused either by decreased amount of hemoglobin molecules as in anemia, or decreased ability of each molecule to bind oxygen at the same partial pressure of oxygen. Hemoglobinopathies (structural defects in the hemoglobin molecules) may cause both. In either case, hemoglobin deficiency decreases blood oxygen-carrying capacity. Other common causes of low hemoglobin include blood loss, nutritional deficiencies, bone marrow problems, chemotherapy, kidney failure, and structural defects. Some globin chain mutations are associated with hemoglobinopathies such as sickle cell disease and thalassemias, while others are benign. There are a group of conditions known as porphyrias, which result as a result of a defect in the pathway of hemoglobin synthesis. Hemoglobin plays a role in diabetes testing as well, by way of the hemoglobin A1C test. This test measures the amount of glycosylated hemoglobin, which is the amount of hemoglobin attached to glucose. This allows for measurement of the blood-glucose control over a 90-day period, and can determine how well diabetes is being controlled.

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ANEMIA AWARENESS Elevations of hemoglobin are associated with conditions such as: Congestive heart disease Cor pulmonale (right-sided heart failure) Pulmonary fibrosis Polycythemia vera WHAT DO HEMOGLOBIN TEST RESULTS INDICATE? Normal values of hemoglobin in men range from 14-18g/dL (140-180 g/L) and from 12-16g/dL (120-160 g/L) in women. Levels in children are generally lower, in the range of 11-13g/dL (110130 g/L). Elevated levels of hemoglobin may indicate the following: Dehydration (most common) Excess production of red blood cells in the bone marrow Severe lung disease

Below normal levels of hemoglobin may indicate the following: Iron deficiency or other deficiencies Inherited hemoglobin defects Cirrhosis of the liver Excessive bleeding Excessive erythrocyte destruction Kidney disease Chronic illness Bone marrow failure Cancers of the bone marrow

In the event that a test result is outside of the normal range, please direct the patient to consult their doctor for further analysis.

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ANEMIA AWARENESS

SECTION 4 - SCREENING HEMOGLOBIN ANALYSIS The Hemocue Hb 201+ is a system used for the determination of the total amount of hemoglobin in whole blood. The system consists of a specially designed analyzer with specially designed microcuvettes containing dried reagents. The microcuvette serves as pipette, reaction vessel and as a measuring microcuvette. No dilution is required. The hemoglobin measurement takes place in the analyzer, which follows the progress of the reaction until the steady state has been reached. The analyzer is factory calibrated against the hemoglobincyanide (HbCN) method, the international reference method for the determination of the hemoglobin concentration in blood, and needs no further calibration. The reaction in the microcuvette is a modified azidemethemoglobin reaction. The erythrocyte membranes are disintegrated by sodium deoxycholate, releasing the hemoglobin. Sodium nitrate converts the hemoglobin iron from the ferrous to the ferric state to form metheglobin, which then combines with azide to form azidemethemoglobin.

The microcuvettes are to be stored at room temperature (15-30 C), and are not to be refrigerated. The expiration date of the micvrocuvettes is printed on the sealed vial. Once the seal is broken, the microcuvettes are stable for 3 months. Always keep the container properly closed.

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ANEMIA AWARENESS PERFORMING AN ANALYSIS

Step 1 Puncture the skin using the safety lancet. Wipe away the first drop of blood with clean gauze, this is important since the first drop may contain traces of alcohol. After wiping away the first initial drop of blood gently squeeze the finger to produce a fair-sized drop of blood. Apply the microcuvette to the specimen. The correct volume is drawn into the cuvette by capillary action. (Capillary, venous or arterial blood can be used).

Step 2 After wiping off any excess of the specimen from the sides of the cuvette, place it in the cuvette holder and insert it into the instrument.

Step 3 The lab quality result is displayed automatically in 15-60 seconds. Additional manuals and videos have been made available to each QHS branch. Please contact your branch coordinator for access to these materials. Quality Health Services Ltd. 2010. All Rights Reserved. 17

ANEMIA AWARENESS

SECTION 5 CLINIC BEFORE THE CLINIC Receive Confirmation from Clinic Coordinator Once you have agreed to perform the clinic at the appointed date, time, and pay you will receive in the mail or over the web a Health Professionals Confirmation Sheet. Also, on this sheet will be the amount of time you will have for a break, the amount of time allotted for each client appointment, and contact information for the clinic purchaser/contact person. Indicate that you accept the terms and return your acceptance to the clinic coordinator in the manner that you have agreed upon. Contact Clinic Purchaser/Contact Person About 7 days before the clinic date, contact this person to reaffirm the clinic date, time, and subject (Anemia Awareness in this case). Also, restate the time for each client appointment. In this case, each client is allotted 15 minutes for screening. This allows time to review the risk factors with the client, perform a hemoglobin analysis, give specific preventative tips and clean the equipment before the next clients use. Remind this person that s/he needs to allot time for your break and not to schedule appointments during that time. This is also a good time to request that a table and chairs should also be provided for setup. Receive Equipment Clarify with the clinic coordinator when you will be receiving the equipment. If you have not received the equipment by this date then call to inquire what has happened. ALWAYS contact your clinic coordinator if you have not received the equipment 3 days before the clinic, as she/he needs time to track it down and ship it out to you. When you have received your shipment open it as soon as possible and make sure that you have received everything. There will be list of the supplies and equipment you should have received included with your shipment, make sure you have everything on that list. The sooner you find out if something is missing the easier it is for the clinic coordinator to ship it out to you. If it becomes necessary for you to purchase something, like batteries, clarify it with your clinic

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ANEMIA AWARENESS

SECTION 5 CLINIC coordinator beforehand and retain the receipt. At the end of the clinic mail the receipt with rest of the things returned to your clinic coordinator and you will be reimbursed. In general for an Anemia clinic you will need: Clinic Registries Handouts/Brochures Hemocue Hb 201+ Microcuvettes Alcohol Swabs Band-aids Users Manual Gloves Hand Sanitizer Clinic Evaluation Sometimes not all equipment/supplies will be needed and sometimes more will be included, always refer to the list included in your shipment.

Quality Assurance Check Once you have confirmed that you received your entire shipment of supplies and equipment, test it to make sure that it works. In this case, calculate your own body fat percentage with the Omron. Again, it is important that you do this as soon as possible for if the equipment does not work then you need time to contact the clinic coordinator for help or other equipment.

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ANEMIA AWARENESS

SECTION 5 CLINIC DURING THE CLINIC Arrival Arrive at the clinic destination about 15-20 minutes early in order to give you time to setup. This gives you time to assess your surroundings, layout the equipment to your liking, find where the washrooms are, etc. This also gives you time to introduce yourself to the clinic purchaser/contact person that you have talked to over the phone and obtain a list of people that have pre-booked for the clinic. Then you are ready for your first client.

Things To Do At The Beginning of Each Client Appointment At the start of each appointment you will: Introduce Yourself Describe the Clinic Be sure to inform the client that it will take 15 minutes, she/he will have one-on-one time with a healthcare professional (you!), she/he will be learning more about Anemia. As well she/he will receive a hemoglobin analysis. Show the Disclaimer Have the client read the disclaimer on the registry or on the bottom of the What Can I Expect? foam board. In any screening there is a possibility that the results were inaccurate. Client Registry Sheet Have the client sign in on the client registry sheet. This is documentation required by the government/professionals college and QHS does not use it for any purpose.

After this you will start to review the Anemia Handout/Brochure with the client. Going through this Handout/Brochure provides a step-by-step on how to proceed throughout the rest of the appointment.

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ANEMIA AWARENESS

Anemia Handout/Brochure Become familiar with the handout/brochure before the clinic. It is a condensed form of all the information that you have received earlier in this manual. 1) Outside-First Panel - Anemia Awareness clinic provided by Quality Health Services Ltd. 2) Inside Second Panel a) Learning about Anemia awareness and testing b) Managing Anemia Explaining various health conditions and causes. 3) Inside Third Panel a) Is Anemia permanent? Acute and Chronic conditions. b) Diet and Anemia managing your diet to counter Anemia 4) Outside Back Panel a) Dietary Sources of Iron includes mg per serving b) Iron absorption Gives importance and role of Vitamin C. c) B12 Deficiency effects on red blood cells and Crohn`s Disease

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ANEMIA AWARENESS At the End of The Client Appointment After you have completed the last panel of the brochure with the client, review the pertinent details. Ask if the client has any questions. Hopefully the information provided will give you a basis to answer these questions, but do try to pursue the additional resources. Over time you will get used to fielding questions. Do not attempt to answer questions that you are unsure about, simply refer them to their doctor. Remember do NOT diagnose. Reiterate that with any screening there is a chance that the results could be false, but that if the client has a high complete risk assessment she/he should really see a doctor. Fill out the part of the clinic registry with the clients results and that handout information was given. If the equipment was not cleaned, do so now before the next client. Proceed onto the next client following the same format until the end of the clinic.

AFTER THE CLINIC Clean-Up Give the equipment a thorough cleaning and pack everything away. Also, clean your surrounding environment and leave the area the way that you found it. Clinic Evaluation Talk to the clinic purchaser/contact person and ask how s/he thinks the clinic went. Ask if they have any suggestions, concerns, etc. Request that s/he fills out the clinic evaluation form and faxes it to your clinic coordinator at Quality Health Services. What to Return or Ship If you are to return the equipment to your clinic coordinator, include all the left over supplies as well as all of your paperwork (clinic registries, list of supplies, etc.). Affix the included waybill/bill of lading to the package. Return it however was arranged with your clinic coordinator. If you are to send the equipment to another healthcare professional, do not ship your paperwork. Keep the paperwork and send it to your clinic coordinator. Once you have returned all the equipment, supplies and paperwork, your clinic day is done!

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ANEMIA AWARENESS SECTION 6 REVIEW & REFERENCES REVIEW QUESTIONS: 1. What is the MCV value at which point anemia is considered to be microcytic? 2. How many heme molecules are included within each hemoglobin molecule? 3. Name three common symptoms of all anemias. 4. What is the most common cause of anemia in Canada and the U.S. ? 5. Deficiency of what vitamin causes anemia plus neurologic findings? 6. Name the three categories of anemia. 7. What is the finding of the peripheral blood smear that suggest macrocytic anemia?

REFERENCES: http://www.umss.edu.bo/epubs/earts/downloads/85.e.pdf http://www.bio.miami.edu/~cmallery/150/chemistry/hemoglobin.jpg http://www.nlm.nih.gov/medlineplus/ency/article/003645.htm http://sickle.bwh.harvard.edu/hemoglobinopathy.html http://www.healthsystem.virginia.edu/UVAHealth/adult_blood/anemias.cfm

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ANEMIA AWARENESS

REVIEW QUESTION ANSWERS: 1. Less than 76fl 2. There are 4 heme molecules per molecule of hemoglobin 3. Pallor, light-headedness, fatigue, weakness, headache, shortness of breath. 4. Iron deficiency anemia 5. Vitamin B12 deficiency causes neurological symptoms on top of anemia 6. Microcytic, normocytic, and macrocytic. 7. The common finding of macrocytic anemia is the enlarged, hypersegmented neutrophil (many lobes).

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