1. Conducting the Anaemia Test
Food and Nutrition Security Survey

2. Introduction and General Preparations

3. Introduction to Anaemia Testing
Anaemia is a reduction in the volume of blood cells and a decrease in the concentration of haemoglobin in the blood
Malaria and micronutrient deficiency are significant causes of anaemia, with iron deficiency being the single, largest contributor. Genetic causes also contribute to anaemia.
Severe anaemia is life threatening. Non-severe anaemia has negative effects that can decrease learning ability and productivity
Haemoglobin measurement is the primary tool for anaemia screening
Children age 6 months to 5 years and women 15 to 49 years will have haemoglobin measured

4. Introduction to Hemocue System
Capillary blood samples are taken from the finger of adults and either the heel or finger of children
Blood samples are taken using the Hemocue System, which contains a microcuvette and a photometer
A lancet is used to make a puncture and the microcuvette draws up the blood

5. Introduction to Hemocue System
The microcuvette is placed in the photometer to measure haemoglobin
Microcuvettes are sensitive to humidity and require proper handling and storage
The photometer self-calibrates when turned on, but must be cleaned every day to work properly
To ensure that the HemoCue® Hb 301 system operates properly, allow the photometer to come to the
ambient temperature and protect it from direct sunlight. The device can be operated between 10 and 40 degrees C. The photometer has an internal electronic “SELF TEST”; every time the device is turned on, it automatically verifies the performance of its optronic unit.
To turn the photometer on, pull the cuvette holder out to the loading position (see figure) and press and hold the left button until the display is activated (all symbols appear on the display). Each time it is turned on, the analyzer automatically verifies the performance of the unit. After ten seconds, the display will show three flashing dashes in the center of the display and the HemoCue® symbol. This indicates that the unit is ready to use. If the cuvette holder is in the measuring position the most recent result will be displayed (see figure).
To turn the unit off, press and hold the button until the display reads OFF and then goes blank. When operating on battery power, the analyzer will automatically turn off after approximately 5 minutes.
The photometer’s black microcuvette holder has three operating positions:
1. Pushed in, for measuring
2. Pulled out until “clicked,” for placing the microcuvette
3. Completely withdrawn for cleaning.

6. Microcuvette Handling and Storage
• Record on the container the date on which it is first opened
• Remove from the container only those microcuvettes required for immediate testing
• Do not get alcohol on the microcuvettes
• Always keep the microcuvette container lid snapped on
• Keep the microcuvette container at room temperature and avoid exposing it to heat or strong sunlight. Microcuvettes can be stored at degrees C.
Under these conditions, a microcuvette container can be stored for up to 3 months (90 days) after
opening. In field conditions, it is advisable not to store the microcuvettes in the opened container for more than one month. Microcuvettes from unopened containers can be used up to the expiration date on the container.

7. Cleaning the Hemocue
Clean the microcuvette holder at the end of each day’s fieldwork
Clean with an alcohol swab or cotton wool (can use cotton- tipped swabs) moistened with 70% alcohol
Blood can get inside on optronic unit if microcuvettes are mishandled
The optronic unit will show an error code when it needs cleaned

8. Cleaning the Hemocue – Steps for Cuvette Holder
Check that the analyzer is turned off and the display window is blank.
• Pull the cuvette holder out to its loading position. Carefully press the small catch positioned in the upper right corner of the cuvette holder using a pointed object.
• While pressing the catch, carefully pull the cuvette holder away from the analyzer.
• Clean the cuvette holder with HemoCue® Cleaner or with an alcohol swab or cotton wool moistened with 70% alcohol (ethanol or isopropyl alcohol).

9. Cleaning the Hemocue – Steps for Optronic Unit
Push a HemoCue Cleaner swab into the opening of the cuvette
Move from sided to side 5-10 times
If the swab is stained repeat with a new swab
Clean the black details of the cuvette holder
Wait 15 minutes before replacing the cuvette holder. Make sure the cuvette holder is locked into place by the small catch

10. General Precautions and Rules for Capillary Blood Sample
Follow general precautions to avoid exposure to bloodborne pathogens such as hepatitis b and HIV
Follow general rules to avoid injury and to make sure haemoglobin measurement is correct

11. General Precautions and Rules
• Wear gloves. Gloves help to prevent exposure of skin and mucous membranes to blood. A new pair of gloves should be used with each respondent. Gloves must never be reused! • Good position in relation to the respondent. Position yourself well before you make a puncture on the respondent’s finger. • Do not prick the fingers if the hand is cold! Warm the child’s hand by rubbing them between your palms vigorously, or ask the parent/adult responsible for the child to rub the child’s hands. • Never “milk” the finger. Excessive massaging or squeezing of the finger or foot will cause tissue juice to mix with and dilute the blood. This will result in erroneous test results.

12. General Precautions and Rules (continued)
• Never mix alcohol with the blood. Alcohol, which is used to clean the puncture site, can mix with the blood leading to errors in the testing results. The finger or heel must be air dried completely before being punctured.
• Avoid obstructing blood flow. It is important to hold the finger properly to allow for the accumulation of blood in the puncture-site area. Holding the finger too tightly can obstruct the blood flow to the finger.
• Avoid shallow puncture. A deep puncture should be made to ensure the blood flows better and to have a representative concentration of red blood cells. To ensure a deep puncture, place the lancet firmly against the skin before pressing the lancet’s trigger. 
• Avoid penetrating injuries. Although gloves can prevent blood contamination of intact and nonintact skin surfaces, they cannot prevent penetrating injuries caused by the instruments used for finger or heel pricks. Safety lancet devices reduce the risk of penetrating injuries.

13. General Precautions and Rules (continued)
• Lancets should not be used for purposes other than a single finger or heel prick to collect blood for the biomarker testing. Immediately after the testing is completed, the device should be placed in a puncture- resistant sharps container. • If an accident occurs, any skin surfaces or mucous membranes that become contaminated with blood should be washed immediately and thoroughly with running water or copious amounts of standing water. Use soap if available. • Never eat or drink during the testing. Since eating, drinking, and applying cosmetics may distract from the procedure, they are not permitted during haemoglobin measurement. • Properly dispose of all biohazardous materials. All materials being exposed to blood must be placed in a biohazardous waste container after use and disposed according to the survey’s policy on infectious waste disposal. • Clearly label biohazardous waste containers. The biohazardous waste containers should be labeled “biohazard.” Take precaution when storing and transporting the waste containers during the fieldwork

14. Detailed Procedures for Conducting the Anaemia Test

15. Overview of Major Steps for Anaemia Testing
Complete the general preparations for the testing
Prick the woman’s finger or the child’s finger or heel
Wipe away the first 2-3 drops of blood
Collect the third or fourth drop of blood to perform haemoglobin testing with the HemoCue®
Record the final outcome of the anaemia testing process for the woman and child
Inform the woman and parent/adult responsible for the child the haemoglobin level and provide written results and information on anaemia.

16. General Preparations for Anaemia Testing
1. If possible, find an indoor site to encourage privacy and protection from factors like heat, rain or dust that may threaten the integrity of the tests. If you find you must do the test outdoors, find a site in the full shade and away from environmental elements that might affect the sample. 2. Make sure that you have all of the documents you will need for the testing including the Household Questionnaire and Anaemia Information and Results Form. 3. Confirm the identity of all women and children listed as eligible for the testing in the questionnaire and obtain permission. If there is more than one eligible child and woman, test in the order in which they are listed. 4. After you have established the number of people you will test, take out the appropriate equipment and supplies

17. General Preparations (continued)
5. In all cases, confirm identities before proceeding with the testing. For children, determine if a finger or heel prick will be used. 6. When and where possible, wash and dry your hands. Put on gloves before handling microcuvettes and before beginning the collection of the blood sample from the first person. New gloves are to be used for every person being tested. 7. Open the microcuvette container and take out a microcuvette. Make sure that you close the container tightly after removing the microcuvette. 8. Turn on the HemoCue® photometer and check that it shows the three flashing dashes and the HemoCue® symbol, indicating the unit is working correctly. 9. Describe to the parent/or adult responsible for the child exactly what will be done during the collection of the blood sample and how he/she can assist, e.g., holding the child on his/her lap andholding the child’s hand during the collection of the sample.
Children that are greater than 10 kg or those that are already walking get a finger prick; this will be the majority of children. All adults get a finger prick. Children that are less than 10 kg and not yet walking get a heel prick.

18. Detailed Steps for Testing – Step 1: Prepare Puncture Site
1. Use the third or fourth finger for collecting the blood. The fingers should be relaxed, but not bent to allow for maximum blood flow. 2. If the hand is cold, warm the hand by rubbing it. This will increase blood flow to the fingertip 3. With an alcohol swab, clean the skin of the finger thoroughly. If the skin is very dirty, use a second swab. Allow the alcohol to air dry. Do not blow on the area to dry the alcohol.
The finger puncture is used to go through all steps. There are also directions on the heel puncture after the last step.
It is usually easier if you sit on the side of the child opposite to the hand from which you will collect blood. For example, if you want to collect the specimen from the left hand, place yourself to the right side of the child. The cuvette holder should be in its loading position before starting.

19. Detailed Steps for Testing – Step 1: Prepare Puncture Site
4. Ensure that the lancet and microcuvette are easily accessible. For women and children you will use children’s lancets, which pierce the skin to a depth of 2.0 mm. 5. Remove the blade slot cover a. For the child lancet, remove the blade slot cover by first twisting it 360 degrees and then pulling it out. b. Do not remove the blade slot cover from the lancets other than instructed above, as this may cause the blade not to pierce the skin.

20. Detailed Steps for Testing – Step 2: Prick
1. Make sure that the finger is below the level of the child’s heart level to increase the flow of blood to the finger. Using a rolling movement of your thumb, lightly press the finger from the top knuckle toward the tip. That action will stimulate a flow of blood to the sample area. 2. It may be helpful if the parent/responsible adult assists you by having the child in his/her lap and holding the child’s hand

21. Detailed Steps for Testing – Step 2: Prick
3. When your thumb passes the last knuckle, maintain gentle pressure on the finger. Place the lancet on the end portion of the finger so that the wide body of the lancet is facing upwards, slightly off center at the side of the fingertip. Avoid the very tip of the finger or the sides beyond the ’pad’ of the finger, because of the risk of piercing the underlying bone.
4. Puncture the skin by placing the blade-slot surface of the lancet against the finger and pressing the trigger. The tip of the blade ejects through the blade slot, producing a micro-incision in the skin, and immediately retracts into the device. Do not release the pressure on the finger! After puncturing the skin, turn the finger up slightly to prevent blood from running into the grooves of the fingerprints. When the blood appears, use a sterile gauze pad to wipe away the first drops of blood.

22. Detailed Steps for Testing – Step 2: Prick

23. Detailed Steps for Testing – Step 3: Collect Blood
1. The first 2-3 blood drops are wiped away. 2. Re-apply gentle pressure towards the puncture site to form another medium-sized drop of blood—the third or fourth drop of blood. 3. Place the tip of the HemoCue® microcuvette in the middle of the blood drop. The microcuvette will fill itself automatically by capillary action. The tip of the microcuvette needs to be filled completely. Never “top off” the microcuvette after the first filling.
If the blood stops flowing before a sufficient amount has been collected, the skin puncture procedure may be repeated with the consent of the parent or adult responsible for the child on one of the other fingers recommended for finger sticks. Do not reuse any of the supplies used for the first puncture.
In the unusual event that the microcuvette is not completely filled, use a fresh microcuvette and attempt to fill it with the next blood drop that forms.

24. Detailed Steps for Testing – Step 3: Collect Blood
4. Wipe any surplus blood off both sides of the microcuvette, using the clean end of a sterile gauze pad. Ensure that no blood is sucked out of the microcuvette when wiping it. Do not touch the open end of the microcuvette.
5. After filling, the microcuvette needs to be visually inspected for air bubbles. Since air bubbles may influence the haemoglobin measurement, any microcuvette containing air bubbles must be discarded. Small bubbles around the edge can be ignored.
6. Place the filled microcuvette in the cuvette holder within 40 seconds after filling. 
7. Gently touch the cuvette holder. It will automatically slide to the measuring position. During the measurement an hourglass symbol will be shown. 
8. After approximately 10 seconds, the haemoglobin value is displayed. The result will remain on the display as long as the cuvette holder is in the measuring position. Do not remeasure the cuvette.
In the case that a microcuvette needs to be discarded, with the permission of the parent or responsible adult, repeat the blood drop collection using one of the other recommended fingers (middle or “ring” fingers) or the other heel. Again, you must use new disposable supplies and follow all of the steps described previously in obtaining the new sample.

25. Detailed Steps for Testing – Steps 4&5: Bandaging and Recording
After testing, wipe the child’s finger a final time and then bandage it to ensure the puncture site is protected until the bleeding stops. Change gloves before testing another person
Recording:
1. First check the HemoCue® device and record the haemoglobin level in AA14 in the Household Questionnaire. If the haemoglobin level is less than 10 g/dl, be sure that a zero (“0”) is recorded in the first box.
2. Record the outcome of the anaemia and malaria tests for the child in the Anaemia Information and Results Form.
3. Before leaving the household, you will verbally report the test results of the measurement for each child and woman for whom anaemia testing was completed.
4. When reporting the anaemia test results, briefly explain what the haemoglobin reading means and discuss what can be done to prevent or treat anaemia.
5. Since severe anaemia is a life threatening condition, you must advise any person found to be severely anemic during the testing to go to a health facility for follow-up medical attention. For each respondent with severe anaemia, you will fill out an Anaemia Referral Slip, including the measured haemoglobin level.

26. Summary of Key Steps for Testing
• Lay out all supplies • Turn on HemoCue® machine, take out a microcuvette. • Clean the child’s middle or ring finger with alcohol. • Prick the finger using sterile lancet. • Wipe away the first 2-3 blood drops. • Take sample with microcuvette of 3rd or 4th drop • Dispose of all materials used for testing • Record haemoglobin result in Household Questionnaire. • Record the test result in the Anaemia Information and Results Form. • Inform of the test result. • Refer severe anaemia to a health facility

27. Tables from Information and Results Form
Referral Slip

28. Detailed Steps for Testing – Step 2: Prick (when heel is required)
1. The puncture should be made at the heel, either outside of a line drawn from the middle of the big toe and parallel to the lateral aspect of the heel, or outside a line drawn from the area between the fourth and fifth toes and parallel to the medial aspect of the heel. Do not prick the central area of the foot within the area demarcated by the two parallel lines to avoid injury to the nerves and tendons, or the center of the heel (to avoid piercing the heel bone).

29. Detailed Steps for Testing – Step 2: Prick (when heel is required)
2. Hold the heel firmly. Apply moderate pressure near the puncture site. This can be done by wrapping the heel using your thumb and second finger. The child’s caretaker can help by holding the child.
3. Clean the site with an alcohol swab. Make sure the site is dry before puncturing the skin with the lancet.
4. Wipe away 2-3 drops of blood and perform the anaemia tests with the third or fourth drop.

30. Disposal of Biohazardous Waste
Any material coming in contact with blood or serum (lancets, alcohol swabs, gauze, microcuvettes, and gloves) is considered biohazardous
Safe disposal of such materials is very important to prevent the transmission and spread of various blood-borne diseases, such as hepatitis B and HIV
During biomarker collection and testing, used lancets should be placed in a “Sharps” container, generally a red puncture-resistant container. Once the Sharps container is full, the lid should be locked to allow for safe transport and disposal. Other waste, such as bandages, gloves, etc., should be placed in a bag clearly labeled “Biohazard”
Biohazardous waste will be transported to and disposed of in the nearest health facility incinerator.

31. Additional Resources
Video on Hemocue System
Video on Capillary Sampling
Common Problems and Solutions in Anaemia Testing (in manual)
HemoCue Hb301 Troubleshooting Guide for error codes (in manual)

32. This presentation goes along with a manual prepared for the FNSS
This presentation goes along with a manual prepared for the FNSS. Questions can be sent to Joel Conkle: