Blood transfusion and mortality in children with severe anaemia in a malaria-endemic region

ABSTRACT

Background

In children in sub-Saharan Africa, severe anaemia (SA) is an important cause of mortality, and malaria is a primary cause. The World Health Organization (WHO) recommends blood transfusion for all children with haemoglobin (Hb) <4 g/dL and for those with Hb 4–6 g/dL with signs of instability. In sub-Saharan Africa, evidence of the effect on mortality of transfusion in children with SA with and without malaria is mixed.

Aim

To determine in children with and without malaria whether receipt of transfusion was associated with lower mortality at WHO transfusion thresholds.

Methods

This was a retrospective cohort study of 1761 children with SA (Hb ≤6 g/dL) admitted to Kamuzu Central Hospital in Malawi. In those whose Hb was 4–6 g/dL, mortality was compared by transfusion, stratified by haemoglobin, malaria status and signs of instability.

Results

Children with profound anaemia (Hb <4 g/dL) and malaria were the only subgroup who had a significant decrease in the odds of in-hospital death if they received a transfusion (OR 0.43, p = 0.01). Although children with Hb 4–6 g/dL and at least one sign of instability had higher mortality than children with none, there was no difference in the odds of mortality between those who received a transfusion and those who did not (OR 1.16, p = 0.62).

Conclusions

This study suggests that transfusion of children with profound anaemia and malaria may confer increased in-hospital survival. An understanding of the factors associated with mortality from SA will allow for interventions to prioritise the provision of limited blood.

KEYWORDS:

• Severe anaemia
• profound anaemia
• blood transfusion
• malaria
• sub-Saharan Africa
• mortality

Abbreviations

BCS: Blantyre coma scale; Hb: haemoglobin; KCH: Kamuzu Central Hospital; LMIC: low- and middle-income countries; MRDT: malaria rapid diagnostic test; SA: severe anaemia; SMA: severe malaria with anaemia; SSA: sub-Saharan Africa; WHO: World Health Organization.

Data Availability Statement

The data for the findings of this study are available from Kamuzu Central Hospital at [email protected] on reasonable request.

Acknowledgments

The authors wish to thank the data clerks who collected all relevant patient data, the KCH paediatric staff for their diligent care of the patients, and all the patients and caregivers for their involvement in the study.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The statistical analysis in this investigation was supported by the University of Utah Population Health Research (PHR) Foundation, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 5UL1TR001067-05 (formerly 8UL1TR000105 and UL1RR025764). In addition, the database described was supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, through Grant Award Number UL1TR001111. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Notes on contributors

Elizabeth M. Keating

Elizabeth M. Keating is a fellow in Pediatric Emergency Medicine and Global Health at University of Utah, USA.

Msandeni Chiume

Msandeni Chiume is head of the Department of Paediatrics, Kamuzu Central Hospital, Malawi.

Elizabeth Fitzgerald

Elizabeth Fitzgerald is an Assistant Professor of Pediatric Emergency Medicine, University of North Carolina Chapel Hill School of Medicine, USA, and Director of UNC Pediatric Global Health.

Yamikani Mgusha

Yamikani Mgusha is the Deputy Head of the Department of Paediatrics, Kamuzu Central Hospital, Malawi.

Tisungane Mvalo

Tisungane Mvalo is a Senior Clinical Research Investigator and Pediatrician at the University of North Carolina Project Malawi and Research Assistant Professor at the Department of Pediatrics at the University of North Carolina at Chapel Hill, North Carolina, USA.

Nora Fino

Nora Fino is a biostatistician in the Division of Epidemiology at the University of Utah, USA.

Heather L. Crouse

Heather L. Crouse is an Associate Professor of Pediatrics in Pediatric Emergency Medicine, Baylor College of Medicine, USA.

Michelle Eckerle

Michelle Eckerle is an Assistant Professor of Pediatrics in Pediatric Emergency Medicine, Cincinnati Children’s Hospital, USA.

Kathleen Gorman

Kathleen Gorman is a student of public health at the London School of Hygiene and Tropical Medicine, UK.

Emily J. Ciccone

Emily J. Ciccone is an Infectious Diseases fellow, University of North Carolina Chapel Hill School of Medicine, USA.

Gladstone Airewele

Gladstone Airewele is is an Associate Professor of Pediatrics in Pediatric Hematology and Oncology, Baylor College of Medicine, USA.

Jeff A. Robison

Jeff A. Robison is an Associate Professor of Pediatrics in Pediatric Emergency Medicine, University of Utah, USA.