An evaluation of hemoglobin measurement tools and their accuracy and reliability when screening for child anemia in Rwanda: A randomized study

PLoS One. 2018 Jan 4;13(1):e0187663. doi: 10.1371/journal.pone.0187663. eCollection 2018.


Blood hemoglobin (Hb) is a common indicator for diagnosing anemia and is often determined through laboratory analysis of venous samples. One alternative to laboratory-based methods is the handheld HemoCue® Hb 201+ device, which requires a finger prick and wicking of blood into a pretreated cuvette for analysis. An alternative HemoCue® gravity method is being investigated for improved accuracy. Further, recent developments in noninvasive technologies could provide an accurate, rapid, safe, point-of-care option for hemoglobin estimation while addressing some limitations of current tools, but device performance must be assessed in low-resource settings. This study evaluated the performance of two HemoCue® Hb 201+ blood sampling methods and a noninvasive device (Pronto® with DCI-mini™ sensors) in a Rwandan pediatric clinic. Reference hemoglobin values were determined in 132 children 6 to 59 months of age by using a standard hematology analyzer (Sysmex KN21TM). Half were tested using the HemoCue® wicking method; half were tested using the HemoCue® gravity method; and 112 had successful hemoglobin readings with Pronto® DCI-mini™. Statistical analysis was used to assess the level of bias generated by each method and the key drivers of bias. The HemoCue® gravity method was the least biased. The HemoCue® wicking and Pronto® methods biases were inversely related to the Sysmex KN21TM results. Both HemoCue® sampling methods correctly classified patients' anemic status in 80% or more of instances, whereas the Pronto® device had a correct classification rate of only 69%. The HemoCue® gravity method was more accurate than the traditional HemoCue® wicking method in this study, but its accuracy and operational feasibility should be confirmed by future studies. The Pronto® DCI-mini™ devices showed considerable promise but require further improvements in sensitivity and specificity before wider adoption.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anemia / diagnosis*
  • Child, Preschool
  • Cross-Sectional Studies
  • Female
  • Hemoglobins / analysis*
  • Humans
  • Infant
  • Male
  • Rwanda
  • Sensitivity and Specificity


  • Hemoglobins

Grants and funding

Support for this project was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the HealthTech Cooperative Agreement # AID-OAA-A-11-00051. Additional support for this project was provided through funding from private foundations and individual donors to the Health Innovation Portfolio at PATH (Program for Appropriate Technology in Health, The contents are the responsibility of PATH and do not necessarily reflect the views of USAID or the US Government. PATH developed the study design, subcontracted the data collection, lead the analysis and decision to publish, and PATH staff prepared the original content of the manuscript.