Dropout rate during prolonged physical stress training in the military may be determined by haematological changes

A public health research paper on sustained physical training in the military leading to high drop-out rates amongst new recruits in the Zimbabwe National Army.Sustained physical training has profound effects on haematological adaptive changes and these may influence physical performance, the dropout rates and casualties in a military setting. Prompted by reports of increases in the number of dropouts during military training, the impact of haematological changes on dropout rates and physical performance was studied in 60 male Zimbabwe National Army (ZNA) recruits during 60 days of military training at the Nyanga training camp. The training programme included, among other things, bush exercises in the rugged terrain of the Nyangani range of mountains. Blood for full blood count (FBC) were collected by venepuncture in a forearm vein in a seated position two weeks pre-training (day zero). Subsequent samples were collected at seven, 30 and 60 days. FBC analyses was carried out by Sysmex K800 (Kobe, Japan) and urine samples were analyzed for urobilinogen. The results showed significant decreases in the red blood cells (RBC) and haemoglobin (Hb) (P<0.05) and (P<0.04) on day seven and day 30 respectively when compared to day zero. The persistent increase in haematocrit throughout the 60 days suggested haemoconcentration and a fall in plasma volume (PV). When compared to pre-training, granulocytes were significantly higher on day 60 than on day 30 (P<0.004). Lymphocytes and eosinophils were lower on day seven (P<0.001) when compared to day zero and (P<0.04) and (P<0.013) when compared to day 30 and 60 respectively, suggesting that the subjects had a decreased protection against infection. However, lymphocytes were higher on day 60 than on day seven (P<0.01). This observed recovery in lymphocytes on day 60 when compared to day seven and 30, suggested that acclimatization and adaptation had occurred. Of the 60 subjects, 18 percent were hospitalized [four with pulmonary TB and a hypochromasia blood picture while three had bronchopneumonia and a raised neutrophil count]. The number of dropouts was 16 (27 percent) of the 60 subjects under study. Laboratory observations showed proteinuria, a shift to the left in the myeloid series, nucleated red blood cells, platelet clumps, macrocytosis and red cell fragments. These were associated with casualties, dropouts and poor physical performance. These results suggested that severe haematological changes might be associated with poor performance, high rates of casualties and dropouts. Therefore, monitoring the trends of haematological changes at regular intervals during stress training can minimize casualties and the rates of dropouts

Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial.

BACKGROUND: Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. METHODS: We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. FINDINGS: Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. INTERPRETATION: Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. FUNDING: Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.The SHINE trial is funded by the Bill & Melinda Gates Foundation (OPP1021542 and OPP113707); UK Department for International Development; Wellcome Trust, UK (093768/Z/10/Z, 108065/Z/15/Z and 203905/Z/16/Z); Swiss Agency for Development and Cooperation; US National Institutes of Health (2R01HD060338-06); and UNICEF (PCA-2017-0002)