1. THE PREVALENCE OF ANEMIA IN RIO GRANDE DO SUL, BRAZIL. Lucia Mariano da Rocha Silla Head of the Hematology and Bone Marrow Transplantation – HCPA Professor of Hematology at the Federal University of Rio Grande do Sul President of NGO: HEMOAMIGOS-HCPA

3. 10.582.840 inhabitants ~ 1.800.000 children < 6 YoA child. mortality rate: 15.4/thousand GOP R$ 144.344 M

5. Public Health System (SUS) Federal University of Rio Grande do Sul HCPA

6. ● ● 750 beds (90% SUS) ● ● ICU for adults, children and neonates ● ● ICU for Coronary Disease ● ● Solid Organ Transplant Program ● autologous, relate and non-related alogeneic ● Bone Marrow Transplant Program autologous, relate and non-related alogeneic ● ● Day Care and Out Patient Clinic ● ● CT scan and MIR ● Basic health Unit HCPA

7. 5 9 12 2

8. MG SS 1:1,400 AS 1:23 RJ SS 1:1,200 AS 1:21 RS SS 1:11,000 AS 1:65 SP SS 1:4,000 AS 1:35 GO SS 1:1,800 AS 1:28 MA SS 1:1,400 AS 1:23 ES SS 1:1,800 AS 1:28 SC SS 1:13,000 PE SS 1:1,400 AS 1:23 neonatal screening SC SS 1:13,000 BA SS 1:650 AS 1:17 2008 sickle cell disease in Brazil

9. 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

10. Childhood Acute Leukemia Germany cure rate 80% HCPA cure rate 65% 47% advanced disease delay in referral 40% IDA blocking the agenda

12. Iron Deficiency Anemia only happens after total iron storage depletion

14. HEMOAMIGOS Pastoral da Criança Gabinete da Primeira Dama Secretaria da Saúde Secretaria da Educação CAIXA RS SESC RS SESI UNESCO FAMEDUFRGS HCPA SIMERS AJERT UNESCO OAB RS AMRIGS Job-Herve comunicações ARI

15. Teaching 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

16. Prevalence 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

17. Socioeconomic 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

18. The Socioeconomic level distribution urban areas in Brazil

19. Target Population “Healthy” population at their homes Pastoral da Criança http://www.pastoraldacrianca.org.br/ SESC-RS workers http://www.sesc-rs.com.br/site/home.htm Medical Students 10 Schools of Medicine in RS

20. Results 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

21. 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 68,7% Hg inferior a 11 em crianças 68,7% 65,9% Hg inferior a 12 em mulheres 65,9% Região Nordeste 29,1% Hg inferior a 11 em crianças 29,1% 19,3% Hg inferior a 12 em mulheres 19,3% Região Leste Hg inferior a 11 em crianças 42,2% Hg inferior a 12 em mulheres 35,4%

22. Bagé Rio Grande do Sul 44,2% Hg inferior a 11 em crianças 44,2% 36,3% Hg inferior a 12 em mulheres 36,3% F. Westphalen Crianças 2375 Mulheres 1999

23. Prevalence of anemia in children by socioeconomic class level p < 0,001

24. Prevalence of anemia in women by socioeconomic class level p = 0,006

25. age distribution of anemia in children p < 0,001

26. Prevalence of anemia in children by socioeconomic class level p < 0,001

27. Prevalence of anemia in women by socioeconomic class level p = 0,006

28. Diagnosis √ √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 is not readily available for practitioners

37. depressed or low IQ mother low stimulus low socioecomic level high risk

39. Strategies 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

40. Startegies for Solutions In all documents about human development, MUST BEFORE health and development MUST be listed BEFORE education Otherwise, we are enforcing another form of power TO KNOW BETTER

41. Our Startegy p < 0,001 age distribution of anemia in children

43. before being a mother avoid anemia

44. “before being a mother avoid anemia” 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 enfasis in midle class individuals)

45. before being a mother avoid anemia 12 semanas 246 children SESC-RS beforeafter > 11g/dl< 11g/dl> 11g/dl< 11g/dl drop in anemia % intervention Aelca33/6330/63 (48% )51/6312/63 (19%)60% NSap28/5527/55 (49%)36/5519/55 (35%)29% Perp. Soc57/6609/66 (14%)60/6606/66 (9%)36% TOTAL118/18466/184 (36%)147/18437/184 (20%)44% control Ciranda14/2208/22 (36%)15/2207/22 (32%)11% São José47/5811/58 (19%)49/5809/58 (16%)16% TOTAL61/8019/80 (24%)64/8016/80 (20%)16%

46. “before being a mother avoid anemia” 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

47. “before being a mother avoid anemia” 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)

48. 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

49. Thank you