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| Year : 2009 | Volume
: 52
| Issue : 3 | Page : 360-362 |
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| Hemoglobin color scale a diagnostic dilemma |
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Hema Anand, Rashid Mir, Renu Saxena
Department of Haematology, All India Institute of Medical Sciences, New Delhi - 110 029, India
Click here for correspondence address and email
| Date of Web Publication | 12-Aug-2009 |
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 Abstract | | |
Hemoglobin color scale (HCS) is a commercially available test to screen anaemia in the absence of laboratory based hemoglobinometry. The present study was aimed at to compare the efficacy of HCS with Sahli's method (SM) for haemoglobin estimation and to estimate its sensitivity and specificity with respect to auto analyzer as the gold standard. The study was conducted from November 2006 to April 2007 at the department of hematology, All India Institute of Medical Sciences, New Delhi as a project of World Health Organization. The haemoglobin level was measured by all the three methods in 401 patients attending Haematology out patient department. Consent was taken from all the patients. Sensitivity of Sahli's method was 98.2% and specificity was 66.2%, whereas the sensitivity of HCS was 30% and specificity was 100%. Sahli's method was found to be in good agreement with autoanalyzer (gold standard). It was thus concluded that HCS is not as efficacious, as sahil's method for hemoglobin estimations in field. Keywords: Anemia, field study, hemoglobin color scale
How to cite this article:
Anand H, Mir R, Saxena R. Hemoglobin color scale a diagnostic dilemma. Indian J Pathol Microbiol 2009;52:360-2 |
| Introduction | |  |
Several methods are available for estimation of hemoglobin in field setting, like copper sulphate specific gravity method, the Lovibond comparator and portable hemoglobin meters. [1] The less sophisticated is the device, it is easier for the primary health care worker to perform the test. [2]
Until now, Sahli's hemoglobinometer method of hemoglobin (Hb) estimation is the one which has been recommended by the Government of India for use by the health workers at both the field and at the laboratory facility levels . The Hemoglobin color scale has been proven at the global level to be a very sensitive and specific method for estimating hemoglobin levels and diagnosing anaemia. Recently, the World Health Organization (WHO) developed the hemoglobin color scale (HCS) to screen for anaemia in the absence of laboratory based hemoglobinometry. [3] HCS is a simple and inexpensive device for providing a reliable, indicator of the presence and severity of anaemia. [4]
Since currently in the field, the Sahli's method is being used for the estimation of Hb, it would be interesting to see relative efficiency of HCS with respect to Sahli's method and auto-analyzer for Hb estimation.
The present study was aimed to compare the efficacy of HCS with Sahli's method and auto-analyzer for hemoglobin estimation.
| Materials and Methods | | |
The study was conducted by using samples from patients referred from different out patient departments for hemogram, registered in our institute. Ethical clearance was taken from the institutional ethical committee.
The voluntary participants included were doctors and trained laboratory technicians. For HCS commercial kit was used (COPAC, Germany). After cleaning with 70% alcohol, blood drops were taken after puncturing the ring finger with a sterile lancet. First two drops were discarded and the third drop had been used for hemoglobin estimation. HCS comprises of a small card with six shades of red that represents hemoglobin levels of 4, 6, 8, 10, 12 and 14gm/dl respectively. The test strips were kept dry, clean and protected from direct sunlight at all times. A 5cm length of test-strip was torn off for the use.
A single drop of the blood was taken at one end of the test-strip, so that it formed a stain large enough to spread beyond the area of an aperture in the color scale (about 1cm in diameter) and after 30 seconds the blood spot is put against one of the hues on the scale for colour matching as shown in [Figure 1]. Auto-analyzer using 13 parameters including 3 histrogram was used (Sysmex K-4500,Transasia, India). Venous blood was collected in 1.6% ethylene diamine tetra acetic acid (EDTA) vial. Auto-analyzer was calibrated by references of National accreditation board of laboratory (NABL). The results of autoanalyzer, HCS, Sahli's were entered on the reporting forms and then reviewed by the investigator.
It was suggested to analyze the results giving the number of patients showing variability of >±1gm/dl as well as ±>2gm/dl, since HCS is a scale which gives reading in a multiple of 2. The results of HCS, Sahli's and autoanalyzer were analyzed statistically.
Disposal of used lancets and cotton was done according to the WHO guidelines.
| Results | | |
A total of 401 samples were analyzed by HCS, Sahli's hemoglobinometer method and by autoanalyzer. The results of hemoglobin were recorded in g/dl and analyzed by calculating the difference between the hemoglobin determined by HCS, Sahli's and autoanalyzer. The number of samples where this difference was greater than + 1gm /dl or + 2gm/dl is given in [Table 1]. Anemia was graded as mild, moderate (Hb 6-12g/dl) and severe (Hb <6g/dl). It was considered normal where Hb was more than 12g/dl as shown in [Table 2]. It was observed that the results of HCS with respect to Sahli's method and autoanalyzer, were systematically higher. It was found that there is no difference in hemoglobin level with respect to sex. Hence sex is not a confounding factor. [Table 3] showed agreement analysis of HCS and Sahli's. If three parameters meet the criteria, then the method in question is in agreement [Table 3]. Sahli's method is in agreement with the autoanalyzer. The cut point was taken as 2 standard deviation and the values that lie between ± 2 standard deviation were taken as positive and the others as negative. HCS had moderate, good significant agreement. So sensitivity of HCS was 30% and specificity was 100%. Agreement (Kappa) was 42.6%. Sensitivity of Sahli's was 98.2% i.e. high sensitivity and moderately high specificity i.e.66.2%. Agreement (Kappa) is 97.37%. So Sahli's is in high agreement with the autoanalyzer The Scatter diagram [Figure 2] and [Figure 3] shows the interval for autoanalyzer and Sahli's is very concise and with high correlation coefficient where as correlation with HCS and autoanalyzer had more width and thus showed poor correlation.
| Discussion | | |
The hemoglobin color scale was developed as a clinical tool to detect anemia by WHO. Anemic patients also detected by Sahli's method and by the autoanalyzer. But there inherent practical problems for both the Sahli's method and the autoanalyzer, So, HCS was evaluated since it was simple and has been proven at global level to be a very sensitive and specific method for estimating hemoglobin and diagnosing anemia. Sahli's method showed a higher sensitivity compared to HCS. This study showed that Sahli's method is more accurate when compared to autoanalyzer.
In this study, the results on specificity of the HCS were not as satisfactory as in similar field studies conducted in other countries, though HCS proves to be the test easy to perform. [5],[6],[7],[8],[9],[10],[11],[12],[13]
| Conclusion | | |
It is concluded that current hemoglobin color scale is not efficacious, as erroneous results were obtained in this study and should not be used for hemoglobin estimation. However there is a need to develop a new hemoglobnin color scale.
| Acknowledgement | | |
Mr Katoch, Mr Keshav, Mr Sukhbir, Mr Rajender, Miss Pooja.[Table 4]
| References | | |
| 1. | Stone JE, Simmons WK, Jutsunn PJ, Gurney JM. An evaluation of methods of screening for anaemia. Bull World Health Organ 1984;82:115-20.  |
| 2. | Haemoglobin colour scale practical answer to a vital need. Department of blood safety and Clinical Technology, World Health Organization, Geneva: WHO; 2001. |
| 3. | Stott GJ, Lewis SM. A simple and reliable method for estimating haemoglobin Bull World Health Organ 1995;73:369-73. |
| 4. | Ingram CF, Lewis SM. Clinical use of WHO haemoglobin colour scale: Validation and critique. J Clin Pathol 2000;53:933-7. [PUBMED] [FULLTEXT] |
| 5. | Montresor A, Albonica M, Khalpan N. Field trial of Haemoglobin colour scale: An effective tool to detect, anaemia in preschool children. Trop Med Int Health 2000;5:129-33. |
| 6. | Critchley J, Bates I. Haemoglobin colour scale for anaemia diagnosis where there is no laboratory: A systematic review. Int J Epidermol 2005;34:1425-34. |
| 7. | Lewis SM, Stott GJ, Wynn KL. An inexpensive and reliable new haemoglobin colour scale for assessing anaemia. J Clin Pathol 1998;51:21-4. |
| 8. | Munster M, Lewis SM, Erasmus LK, Mendelow BV. Field evaluation of a novel haemoglobin measuring device designed for use in a rural setting. S Afr Med J 1997;87:1522-6. |
| 9. | Gosling R, Walraven G, Manneh F. Problems in training health workers to use the WHO haemoglobin colour scale. Trop Med Int Health 2000;5:214-21. |
| 10. | Stott GJ. Lewis SM. A simple and reliable method for estimating haemoglobin Bull World Health O rgan 1995;73:369-73. |
| 11. | Lewis SM, Stott GJ, Wynn KL. An inexpensive and reliable new haemoglobin colour scale for assessing anaemia. J Clin Pathol 1998;51:21-4. |
| 12. | Munster M, Lewis SM, Erasmus LK, Mendelow BV. Field evaluation of a novel haemoglobin measuring device designed for use in a rural setting. S Afr Med J 1997;8:1522-6. |
| 13. | Gosling R, Walraven G, Manneh F, Bailey R, Lewis SM. Problems in training health workers to use the WHO haemoglobin colour scale. Trop Med Int Health 2000;5:214-21. [PUBMED] [FULLTEXT] |
Correspondence Address:
Renu Saxena
Department of Haematology, All India Institute of Medical Sciences, New Delhi - 110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0377-4929.54994
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4] |
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