HIV and blood transfusion in sub-Saharan Africa

Malaria prevalence in HIV-positive children, pregnant women, and adults: a systematic review and meta-analysis

Background

Malaria in human immunodeficiency virus (HIV)-positive patients is an ever-increasing global burden for human health. The present meta-analysis summarizes published literature on the prevalence of malaria infection in HIV-positive children, pregnant women and adults.

Methods

This study followed the PRISMA guideline. The PubMed, Science Direct, Google Scholar, Scopus and Cochrane databases were searched for relevant entries published between 1 January 1983 and 1 March 2020. All peer-reviewed original papers evaluating the prevalence of malaria among HIV-positive patients were included. Incoherence and heterogeneity between studies were quantified by the I2 index and Cochran’s Q test. Publication and population biases were assessed with funnel plots, and Egger’s regression asymmetry test.

Results

A total of 106 studies were included in this systematic review. The average prevalence of malaria among HIV-positive children, HIV-positive pregnant women and HIV-positive adults was 39.4% (95% confidence interval [CI]: 26.6–52.9), 32.3% (95% CI = 26.3–38.6) and 27.3% (95% CI = 20.1–35.1), respectively. In adult patients with HIV, CD4+ (cluster of differentiation 4) < 200 cells/µl and age < 40 years were associated with a significant increase in the odds of malaria infection (odds ratio [OR] = 1.5, 95% CI = 1.2–1.7 and OR = 1.1, 95% CI = 1–1.3, respectively). Antiretroviral therapy (ART) and being male were associated with a significant decrease in the chance of malaria infection in HIV-positive adults (OR = 0.8, 95% CI = 0.7–0.9 and OR = 0.2, 95% CI = 0.2–0.3, respectively). In pregnant women with HIV, CD4+ count < 200 cells/µl was related to a higher risk for malaria infection (OR = 1.5, 95% CI = 1.1–1.9).

Conclusions

This systematic review demonstrates that malaria infection is concerningly common among HIV-positive children, pregnant women and adults. Among HIV-positive adults, ART medication and being male were associated with a substantial decrease in infection with malaria. For pregnant women, CD4+ count of < 200 cells/µl was a considerable risk factor for malaria infection.

Graphical Abstract

Seroprevalence and associated risk factors for HIV, Hepatitis B and C among blood Donors in South Gondar District blood Bank, Northwest Ethiopia

Background

Despite the undeniable significance of blood transfusion in saving a millions life in emergencies and medical treatment, the quality of blood faced challenges from transfusion-transmitted infections (TTIs) such as HIV (human immunodeficiency virus), HBV (hepatitis B virus) and HCV (hepatitis C virus). This cross-sectional study was undertaken with the aim of determining the seroprevalence and risk factors of HIV, HBV, and HCV among blood donors.

Methods

An institutional based cross-sectional study was conducted at Debre Tabor district hospital from January 2017 to February 2018. Blood samples from volunteer donors collected; serum separated and screened with ELISA tests for detection of anti-HIV, hepatitis-B surface antigen (HBsAg) and anti-HCV. Fishers’ exact test was employed to see the association between variables as well logistic regression tests were applied to identify potential risk factors. P-value of less than 0.05 was considered as statistically significant.

Result

A total of 310 volunteer donors were included in the study. The proportion of blood donors having at least one viral-TTI was 12.6% while the magnitudes of HIV, HBV, and HCV were 2.6, 5.8 and 4.2%, respectively. Educational status and multiple sexual behaviors are significantly associated with HIV acquisition whilst marital status was significantly associated with HBsAg seropositivity.

Conclusion

Seroprevalence of transfusion-transmissible infections was high and alarming therefore proper screening of donated blood with test methods having better diagnostic performance should be employed. Also encouragement of blood donation from voluntary donors and creating awareness on the general public regarding HIV, HBsAg and HCV transmission and prevention should be strengthen.

Conflicting Views in Narratives on HIV Transmission via Medical Care

Molecular studies suggest that HIV arose in Africa between 1880 and 1940. During this period, there were campaigns by European colonial governments that involved unsterile injections of large numbers of Africans. That, along with other unsafe therapeutic interventions, may have propelled the evolution of HIV from SIV. Since subtype B in Africa may have been concentrated in white African homosexuals, it is possible that Westerners rather than Haitians introduced the virus to the New World. Amplification of HIV subtype B took place in Haiti, where transmission was facilitated by hazardous medical procedures including plasmapheresis. Representations in the media, however, largely ignore Western contributions to the spread of AIDS. This article focuses on the value of alternative narratives in fostering a balanced view that is less stigmatizing on developing nations.

Observation of Blood Donor-Recipient Malaria Parasitaemia Patterns in a Malaria Endemic Region

Background

Asymptomatic malaria parasitaemia has been documented in donor blood in West Africa. However, donated blood is not routinely screened for malaria parasites (MPs). The present study therefore aimed to document the frequency of blood transfusion-induced donor-recipient malaria parasitaemia patterns, in children receiving blood transfusion in a tertiary health-centre.

Methodology

A cross-sectional, observational study involving 140 children receiving blood transfusion was carried out. Blood donor units and patients' blood samples were obtained, for the determination of malaria parasites (MPs). Giemsa staining technique was used to determine the presence of malaria parasitaemia.

Results

Malaria parasites were detected in 7% of donor blood and in 8.3% of the recipients' pretransfusion blood. The incidence of posttransfusion MPs was 3%, but none of these were consistent with blood transfusion-induced malaria, as no child with posttransfusion parasitaemia was transfused with parasitized donor blood. Majority of the blood transfusions (89.4%) had no MPs in either donors or recipients, while 6.8% had MPs in both donors and recipients, with the remaining 3.8% showing MPs in recipients alone.

Conclusion

In conclusion, the incidence of posttransfusion malaria parasitaemia appears low under the prevailing circumstances.

HIV-Sero-prevalence trend among blood donors in North East Ethiopia

BACKGROUND

Although blood transfusion is one of the known therapeutic interventions that cuts across a number of clinical disciplines. It is necessary to test all intending blood donors for HIV infection before donation. The aim of this study was to determine the prevalence of HIV among blood donors at Dessie Blood Bank, Northeast Ethiopia.

METHODS

A retrospective study was conducted in Dessie Blood Bank through the year 2008-2012. Sera from blood donors were tested for the detection of Anti HIV by using 4th generation ELISA. Data were abstracted from records and analyzed using Microsoft Excel sheet.

RESULTS

From the total of 9384 screened blood samples collected, the prevalence of HIV in blood donors in the blood bank was 5.1% in the five consecutive years but the trend of HIV infection has decreased from 2008(5.2%) to 2012 (2.3%). The age groups 15-24 and 35-44 were the highest prevalence and the age group 45-54 was the lowest prevalence of HIV infection. The prevalence of HIV among female (7.9%) was higher than in male donors (4.4%). The trend of HIV infection was decreasing for both male and female blood donors.

CONCLUSION

The prevalence of HIV infections among blood donors is still high in this study setting, and needs constant monitoring to evaluate prevention and control strategies to reduce the burden of transfusion-transmissible HIV infections.

The contribution of unsafe blood transfusion to human immunodeficiency virus incidence in sub-Saharan Africa: reexamination of the 5% to 10% convention

BACKGROUND

Historical estimates have attributed 5% to 10% of new human immunodeficiency virus (HIV) infections in sub-Saharan Africa (SSA) to unsafe blood transfusions. Although frequently cited, the validity of this statistic is uncertain or outdated. Recent estimates suggest blood transfusion's contribution to new HIV infections in the region may be much lower.

STUDY DESIGN AND METHODS

We searched the peer-reviewed and gray literature for quantitative estimates of the specific contribution of unsafe blood transfusion to the proportion of new HIV infections occurring in SSA. The sources and methods used to generate attribution estimates were evaluated against published country-specific HIV prevalence data.

RESULTS

Despite multiple secondary citations, a primary published source attributing 5% to 10% of new HIV infections to blood transfusions in SSA could not be established for the current era. The United Nations Programme on HIV and AIDS (UNAIDS) modes of transmission (MOT) reports representing 15 countries suggest that between 0 and 1.1% of new HIV infections per year (median, 0.2% or approx. two out of 1000 new infections each year) may be attributable to blood transfusions.

CONCLUSION

Recent modeled estimates suggest that blood transfusions account for a very low proportion of new HIV infections in SSA, likely an order of magnitude lower than 5% to 10%. Direct quantification of risk is challenging given the paucity of data on the variables that impact transfusion-associated HIV. Specifically, data on HIV incidence in blood donors, blood bank laboratory test performance, and posttransfusion surveillance are lacking. Findings suggest an urgent need for improved surveillance and modeling of transfusion-associated HIV transmission in the region.

Transfusion-Transmissible Infections among Voluntary Blood Donors at Wolaita Sodo University Teaching Referral Hospital, South Ethiopia

Background. Transfusion-transmissible infections, human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and syphilis are among the greatest threats to blood safety and pose a serious public health problem. Objective. To determine the magnitude of blood borne infections among blood donors at Wolaita Sodo University Teaching Referral Hospital. Methods and Materials. A cross-sectional study was conducted from 10/11/2015 up to 10/12/2015. 390 donors were consecutively included and data on donor's age, sex, blood type, and serum screening results were obtained by structured questionnaire and laboratory investigation. The collected data were entered into Epi Data version 1.4 and then exported to SPSS version 20.0 for analysis. Result. The seroprevalence of blood borne pathogens is 29.5% of which HCV, HBV, HIV, and syphilis account for 8.5%, 9.5%, 6.4%, and 7.5%, respectively. Multiple infections were observed among 2.8% of the infected individuals. In addition, age ≥ 30 has a significant association with HCV. Conclusion. Significantly higher prevalence of transfusion-transmissible infections was identified from blood donors and they remain to be the greatest threat to blood safety, so comprehensive screening of donors' blood for HIV, HBV, HCV, and syphilis using standard methods is highly recommended to ensure the safety of blood recipient.

Pregnancy complicated by haemorrhagic ascites in a woman with newly diagnosed HIV

A young pregnant Zambian woman was referred from a district hospital in South Zambia to the university teaching hospital, Lusaka with severe anaemia and ascites. The ascites had developed over a month and the woman was currently 15 weeks pregnant. Further workup revealed that the patient was HIV-positive and the ascitic tap showed haemorrhagic fluid. After being reviewed by multiple doctors, the cause of the haemorrhagic ascites remained unclear; therefore, the decision was made to do a laparotomy. The laparotomy revealed haemoperitoneum and a large cyst attached to the liver containing 5 L of bloodstained fluid. The histopathology report revealed features consistent with a giant haemangioma. There were many barriers to accessing optimum healthcare in this case. These included limited access to blood, poor communication resulting in the patient being unaware of her HIV status and lack of patient education about HIV.

HIV P24 antigen among HIV antibody seronegative blood donors in Osogbo Osun State, South Western Nigeria

BACKGROUND

Efforts to curb the spread of HIV transmission through transfusion of blood and its products is still a problem because of challenge in countries using antibody-based rapid methods to detect infection during window period. Transmission of HIV through infected blood and its products accounts for approximately 10% in African region.

METHODS

This study analyzed true negativity of HIV infection in blood donors screened by ELISA test based on p24 core antigen detection. Four hundred and eighty (480) blood donors initially negative for HIV antibody by rapid screening kit, Determine™ HIV-1/2 (Abbott Laboratory, IL, USA) and re-screened with Immuno Comb® II HIV 1 and 2 (Bispot kit PBS Organics and Israel 2005). The samples were further tested for the presence of HIV antibody and p24 HIV core antigen using ELISA kits (Genscreen TM ULTRA HIV Ag-Ab) following manufacturer's instructions. All donors initially tested negative for Hepatitis B virus, Hepatitis C virus.

RESULT

Two (0.42%) of 480 blood donors tested positive for the p24 HIV core antigen. The two positive donors for the p24 antigen had multiple sexual partners and recent sexually transmitted infections.

CONCLUSION

The association of the HIV p24 antigen with blood donation was highly significant (p = 0.000) and pose a great risk to recipients if screening of blood donor is only carried out by HIV antibody detection.

Fluid Management of Severefalciparum Malaria in African Children

Most African children with severe malaria who die do so on the day of admission as a result of the complications of falciparum malaria. We highlight the value of a rapid structured triage assessment to look for emergency signs that will prioritize initial management and implementation of basic life support. This can be delivered with few resources and by non-specialist medical personnel. Reduction in case fatality can only come through the wider appreciation of the need for and application of supportive therapies to treat the life-threatening complications. Hypovolaemia has emerged as a common feature of children presenting with severe malaria complicated by acidosis. Early recognition and prompt treatment may lead to improvements in outcome. We discuss the new evidence supporting the role of hypovolaemia in severe malaria and potential treatment options whilst awaiting the results of clinical trials.

Evaluation of Blood Transfusions in Anemic Children in Effia Nkwanta Regional Hospital, Sekondi-Takoradi, Ghana

Blood transfusion is a common practice in sub-Saharan Africa as a way of correcting anemia in children with mild and severe sicknesses. This study evaluated this practice in a secondary health-care institution in Ghana. A retrospective study was done over a 3-year period from January 2010 to December 2012. Medical records of children admitted, successfully treated, and discharged from the hospital were collected and analyzed. Data were analyzed using Epi Info version 7. Transfusions were more among male children (89, 63.1%) than female children (52, 36.9%). The highest number of blood transfusions were carried out on children in the age range 0-1 year (66, 46.8%). The majority of the blood transfusions were done on children with hemoglobin concentration level of 5 g/dL and below. Children with malaria parasitemia (83, 58.9%) had more transfusions than children without malaria parasitemia (58, 41.1%). Fever alone (43, 30.5%) and fever with gastrointestinal symptoms (33, 23.4%) were the predominant symptoms among children who had blood transfusions. In conclusion, younger children received more transfusions than older children. Also, male children received more blood transfusions than female children. Malaria was observed as a major contributory factor to the requirement for blood transfusions among the children.

Estimation of the prevalence and rate of acute transfusion reactions occurring in Windhoek, Namibia

BACKGROUND

Acute transfusion reactions are probably common in sub-Saharan Africa, but transfusion reaction surveillance systems have not been widely established. In 2008, the Blood Transfusion Service of Namibia implemented a national acute transfusion reaction surveillance system, but substantial under-reporting was suspected. We estimated the actual prevalence and rate of acute transfusion reactions occurring in Windhoek, Namibia.

METHODS

The percentage of transfusion events resulting in a reported acute transfusion reaction was calculated. Actual percentage and rates of acute transfusion reactions per 1,000 transfused units were estimated by reviewing patients' records from six hospitals, which transfuse >99% of all blood in Windhoek. Patients' records for 1,162 transfusion events occurring between 1(st) January - 31(st) December 2011 were randomly selected. Clinical and demographic information were abstracted and Centers for Disease Control and Prevention National Healthcare Safety Network criteria were applied to categorize acute transfusion reactions.

RESULTS

From January 1 - December 31, 2011, there were 3,697 transfusion events (involving 10,338 blood units) in the selected hospitals. Eight (0.2%) acute transfusion reactions were reported to the surveillance system. Of the 1,162 transfusion events selected, medical records for 785 transfusion events were analysed, and 28 acute transfusion reactions were detected, of which only one had also been reported to the surveillance system. An estimated 3.4% (95% confidence interval [CI]: 2.3-4.4) of transfusion events in Windhoek resulted in an acute transfusion reaction, with an estimated rate of 11.5 (95% CI: 7.6-14.5) acute transfusion reactions per 1,000 transfused units.

CONCLUSION

The estimated actual rate of acute transfusion reactions is higher than the rate reported to the national haemovigilance system. Improved surveillance and interventions to reduce transfusion-related morbidity and mortality are required in Namibia.

Blood supply safety in Afghanistan: a national assessment of high-volume facilities

BACKGROUND

Little information is available regarding blood supply safety in Afghanistan. The purpose of this study was to assess blood safety through serologic and observational measures in Afghanistan.

STUDY DESIGN AND METHODS

This cross-sectional assessment included the 40 highest-volume facilities collecting and transfusing blood nationally identified in a previous survey. At each facility, study representatives completed a standardized instrument assessing staff performance of transfusion-related activities and performed rapid testing for human immunodeficiency virus, syphilis, and hepatitis B and C with rapid diagnostic tests on clinically discarded specimens. Reactive samples received confirmatory testing. Descriptive statistics were generated, with differences analyzed using chi-square or Fisher's exact tests.

RESULTS

Between November 2010 and May 2011, a total of 332 blood donor collection procedures were observed. Only 52.4% of observed encounters correctly screened and deferred donors by international criteria. Public and private facilities demonstrated glove use, proper sharps disposal, and patient counseling and relayed screening test results in less than 75% of observed events, significantly less likely than military facilities (p < 0.01). Of 1612 specimens assessed, confirmed cases of hepatitis B (n = 6), hepatitis C (n = 1), and syphilis (n = 3) were detected among units already prescreened and accepted for transfusion.

CONCLUSION

Lapses in proper donor screening contributed to the presence of confirmed-positive units available for transfusion, as detected in this study. Steps must be taken to ensure standardization of testing kits requirements, documentation, and mandatory training and continuing education for blood bank staff with regard to counseling, drawing, processing, and transfusion of blood products.

High Rates of Hepatitis B and C and HIV Infections among Blood Donors in Cameroon: A Proposed Blood Screening Algorithm for Blood Donors in Resource-Limited Settings

Background. Infections with human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C virus (HCV) are currently major public health problems. Methods. A retrospective study was conducted from January to June 2008 at the Blood Bank of the Central Hospital, Yaoundé (Cameroon). The objective was to study the prevalence of HIV, HBV, and HCV and their coinfections among blood donors. Results. A total of 4650 donors were identified, and the sex ratio (male/female) was 14/1. The median age of donors was 28 years (range: 16 to 69 years). Among blood donors, HBV, HIV, and HCV infection prevalences were 12.14%  (n = 565) , 4.44%  (n = 206), and 1.44%  (n = 67), respectively. Coinfection with HIV and HBV was observed among 0.77% donors, followed by hepatitis B and C co-infection (0.21%) and HIV and HCV coinfection (0.06%). Co-infection with HIV-HBV-HCV was encountered in 2 donors. The HIV, HBV, and HCV infections lead to a destruction of one out of six sets of blood collected. Conclusion. There is a need to review policies for blood collection from donors, by modifying the algorithm of blood donors testing. Pretesting potential donors using rapid tests could help to avoid collection and destruction of (infected) blood.

Blood transfusion safety in Africa: a literature review of infectious disease and organizational challenges

Blood safety remains an important public health concern in Africa where lack of availability or provision of unsafe blood adversely impacts morbidity and mortality in the region. In recognition of this shortfall, the World Health Organization (WHO) established a goal of regional blood safety by 2012 through improved "organization and management, blood donor recruitment and collection, testing of donor blood as well as appropriate clinical use of blood" (Tagny et al: Transfusion. 2008;48:1256-1261; Tapko et al: Status of Blood Safety in the WHO African Region: Report of the 2006 Survey http://www.afro.who.int/en/divisions-a-programmes/dsd/health-technologies-a-laboratories.html. Brazzaville, Republic of Congo: WHO Regional Office for Africa; 2006). Although there has been substantial progress toward meeting these objectives, there are continued obstacles to both development and sustainability. In a setting where transfusion oversight is still being improved, transfusion-transmitted infections are of real concern. The high prevalence of some transfusion-transmissible agents such as hepatitis B virus and HIV in the general population means that some infected blood units escape detection by even well-performed laboratory testing, resulting in potential downstream transmission to patients. The spectrum of transfusion-transmitted infection include conventional as well as exotic pathogens, many of which are endemic to the region, thereby imparting ongoing challenges to recruitment and testing strategies.

Nonvertical, nonsexual transmission of human immunodeficiency virus in children

In a cohort of 450 human immunodeficiency virus (HIV)-infected children followed up in Maputo, Mozambique, 22 were born to HIV-uninfected mothers and had no history of sexual abuse. A case record review of these nonvertically, nonsexually infected children as well as a case-control study strongly suggests health care as possible source of infection for many of these children. This facet of the pediatric HIV epidemic should not be overlooked.

Adequacy and pattern of blood donations in north-eastern Nigeria: the implications for blood safety

In a retrospective analysis, the quantities, patterns and adequacy of blood donations made, between 1984 and 2006, at the University of Maiduguri Teaching Hospital in north-eastern Nigeria were explored and related to blood safety in the study area. The types of blood donor were reviewed and the annual increments in the number of donations made were estimated and compared with the annual increments in the numbers of in-patients managed at the study hospital. The mean annual increment in the number of blood donations (4%) fell well below the mean annual increment in in-patient numbers (11%). The blood donations received at the hospital fell into four types: voluntary, family-replacement, commercial and pre-deposit autologous donations. Over the study period, the percentage of donations falling into the voluntary and family-replacement categories fell from 31% to 5% and from 49% to 23%, respectively. These falls were matched by increases in the percentages of donations categorised as commercial and autologous, which rose from 20% to 63%, and from 1% to 9%, respectively. By the end of the study period, the quantity of blood being donated at the hospital was grossly inadequate and predominantly derived from family and commercial donors, who were found to be generally inferior, in terms of blood safety, to voluntary donors. There is an urgent need to rectify this situation by setting up a functional and national blood-transfusion service in Nigeria.

Reducing replacement donors in Sub-Saharan Africa: challenges and affordability

In 1975, the World Health Assembly recommended that blood for transfusion should come from voluntary, non-remunerated donors; yet, in Africa, 75-80% of blood for transfusion still comes from hospital-based replacement donors. Although comprehensive economic data are scarce, evidence indicates that blood from voluntary donors recruited and screened at centralized transfusion centres, costs four to eight times as much as blood from a hospital-based, replacement donor system. Donor recruitment, quality assurance systems and distribution mechanisms in the centralized system are major reasons for the cost difference. There are concerns about the sustainability of centralized voluntary donor systems and their compatibility with the levels of health care that exist in many poor countries yet burdening patients' families with the responsibility of finding replacement blood donors will exacerbate poverty and reduce the safety of the blood supply. There are measures that can be introduced into hospital-based systems to improve safe blood supply in Africa but their effectiveness in different contexts needs to be evaluated.

Malarial anemia: of mice and men

Severe malaria is manifest by a variety of clinical syndromes dependent on properties of both the host and the parasite. In young infants, severe malarial anemia (SMA) is the most common syndrome of severe disease and contributes substantially to the considerable mortality and morbidity from malaria. There is now growing evidence, from both human and mouse studies of malaria, to show that anemia is due not only to increased hemolysis of infected and clearance of uninfected red blood cells (RBCs) but also to an inability of the infected host to produce an adequate erythroid response. In this review, we will summarize the recent clinical and experimental studies of malaria to highlight similarities and differences in human and mouse pathology that result in anemia and so inform the use of mouse models in the study of severe malarial anemia in humans.

Sickle cell disease in Africa: burden and research priorities

Sickle cell disease (SCD) has recently been recognised as a problem of major public-health significance by the World Health Organization. Despite the fact that >70% of sufferers live in Africa, expenditure on the related care and research in the continent is negligible, and most advances in the understanding and management of this condition have been based on research conducted in the North. In order to target limited resources, African countries need to focus research and interventions on areas that will lead to the maximum impact. This review details the epidemiological and clinical background of SCD, with an emphasis on Africa, before identifying the research priorities that will provide the necessary evidence base for improving the management of African patients. Malaria, bacterial and viral infections and cerebrovascular accidents are areas in which further research may lead to a significant improvement in SCD-related morbidity and mortality. As patients with high concentrations of foetal haemoglobin (HbF) appear to be protected from all but mild SCD, the various factors and pharmacological agents that might increase HbF levels need to be assessed in Africa, as options for interventions that would improve quality of life and reduce mortality.

Research priorities in the management of severe Plasmodium falciparum malaria in children

Severe malaria is a common reason for admission to paediatric wards in hospitals across sub-Saharan Africa. Despite over 100 years of research, mortality remains high. Deaths are associated with severe metabolic acidosis, shock, severe anaemia, hypoglycaemia, impaired consciousness, raised intracranial pressure, and status epilepticus. Most inpatient deaths occur within 24 h of admission to hospital, before the beneficial effects of treatment with antimalarial drugs are achieved. This review covers the priority areas for research in the care of children with severe malaria, addressing each of the main risk factors associated with death, in a bid to reduce the inpatient mortality.

The clinical and pathophysiological features of malarial anaemia

This review will focus on the principal clinical and pathophysiological features of the anaemia of falciparum malaria, including the problems of treating malarial anaemia, and also will suggest how recent advances in genomics may help our understanding of cellular and molecular mechanisms underlying this syndrome.

Pre-transfusion management of children with severe malarial anaemia: a randomised controlled trial of intravascular volume expansion

Symptomatic severe malarial anaemia (SMA) has a high fatality rate of 30-40%; most deaths occur in children awaiting blood transfusion. Blood transfusion services in most of Africa are not capable of delivering adequate supplies of safe blood in a timely manner to critically ill children with SMA. Contrary to widely held belief, hypovolaemia, rather than heart failure, has emerged as a common complication in such children. We examined the safety of pre-transfusion management (PTM) by volume expansion, aimed at stabilizing children and obviating the urgency for blood transfusion. Kenyan children with severe falciparum anaemia (haemoglobin <5 g/dl) and respiratory distress were randomly assigned to 20 ml/kg of 4.5% albumin or 0.9% saline or maintenance only (control) while awaiting blood transfusion. PTM was apparently safe since it did not lead to the development of pulmonary oedema or other adverse events. There was no significant difference in the primary outcome [mean percentage reduction in base excess between admission and 8 h (95% confidence interval)] between the control group 42% (19-66%) albumin group 44% (32-57%) and saline group 36% (16-57%); adjusted analysis of variance F=0.31, P=0.7. However, the number of children requiring emergency interventions was significantly greater in the control group, four of 18 (22%) than the saline group 0 of 20 (P=0.03). We have established the safety of this PTM in children with SMA whilst awaiting blood transfusion at a hospital with an adequate blood-banking program. The impact on mortality should be assessed where blood transfusion services are unable to supply emergency transfusions.

Pathophysiology of severe malaria in children

Over the past decade there has been a growing recognition that the rationalization of severe malaria in children into the two major syndromes of cerebral malaria and severe malaria anaemia is much too simplistic. Indeed, it has become apparent that death from severe malaria may arise from a wider spectrum of pathophysiological disorders with many features in common with the derangements seen in sepsis syndromes. Amongst these derangements acidosis has emerged as a central feature of severe malaria and the major predictor of a fatal outcome. We review the improved understanding of the pathophysiology of severe malaria through a series of clinical scenarios that reflect more accurately the clinical diversity of severe malaria in African children. Current therapeutic challenges are discussed and research priorities are highlighted.

Clinical presentation of severe anemia in pediatric patients with sickle cell anemia seen in Enugu, Nigeria

Anemia is a major cause of morbidity and mortality among patients with sickle cell anemia. In this study, 108 episodes of severe anemia were prospectively evaluated in 108 patients with hemoglobin SS disease attending the pediatric sickle cell clinic of the University of Nigeria Teaching Hospital, Enugu, Nigeria. Young children between the ages of 2 and 4 years were found to be at the greatest risk of developing anemic crises (severe anemia). There was a gradual but progressive decline in the incidence of severe anemia in the age range 8-16 years old. Upper respiratory tract infections are the most commonly associated infections in patients with severe anemia. Others included malaria, septicemia, urinary tract infection, acute chest syndrome, and osteomyelitis. Their role in precipitating episodes of severe anemia among the patients studied could not be fully evaluated. Pallor, jaundice, and fever were the most commonly encountered symptoms in patients with severe anemia on admission. About half of the parents/guardians failed to notice severe anemia among the patients studied, perhaps due to the dark color of the African skin. Caregivers need to be educated on how to recognize anemia among patients with sickle cell anemia when they develop febrile episodes.

Malaria-related anaemia

Malaria infection in humans by Plasmodium species is associated with a reduction in haemoglobin levels, frequently leading to anaemia. Plasmodium falciparum causes the most severe and profound anaemia, with a significant risk of death. This cannot be explained simply by the direct destruction of parasitized red blood cells at the time of release of merozoites, a process shared by all these species. In this review, Clara Menendez, Alan Fleming and Pedro Alonso focus on recent advances in our knowledge of the pathophysiology, epidemiology, management and prevention of anaemia from falciparum malaria.