Whole Blood Transfusion for Severe Malarial Anemia in a High Plasmodium falciparum Transmission Setting

Abstract

Background Severe malaria due to Plasmodium falciparum is the leading parasitic cause of death in children worldwide, and severe malarial anemia (SMA) is the most common clinical presentation. The evidence in support of current transfusion guidelines for patients with SMA is limited. Methods We conducted a retrospective cohort study of 911 hospitalized children with SMA in a holoendemic region of Zambia to examine the association of whole blood transfusion with in-hospital survival. Data were analyzed in adjusted logistic regression models using multiple imputation for missing data. Findings The median age of patients was 24 months (interquartile range 16-30) and overall case fatality was 16%. Blood transfusion was associated with 35% reduced odds of death in children with SMA (odds ratio 0.65, 95% CI 0.52-0.81, p = 0.0002) corresponding to a number-needed-to-treat (NNT) of 14 patients. Children with SMA complicated by thrombocytopenia were more likely to benefit from transfusion than those without thrombocytopenia (NNT = 5). Longer storage time of whole blood was negatively associated with survival and with the post-transfusion rise in the platelet count but was not associated with the post-transfusion change in hemoglobin concentration. Interpretation Whole blood given to pediatric patients with SMA was associated with improved survival, mainly among those with thrombocytopenia who received whole blood stored for <4 weeks. These findings point to a potential use for incorporating thrombocytopenia into clinical-decision making and management of severe malaria, which can be further assessed in prospective studies, and underline the importance of maintaining reliable blood donation networks in areas of high malaria transmission.

Supplementing routine hospital surveillance of malaria to capture excess mortality and epidemiological trends: a five-year observational study

“…The impact of blood stockouts on malaria mortality was not detectable in the aggregated HMIS data, which does not distinguish cases of severe malarial anemia from other clinical presentations of malaria. In the patient-level data, however, blood stockouts of matching blood types were shown to be associated with nearly double the risk of mortality in children with severe malarial anemia, a similar finding to our previously published results of a retrospective study of blood transfusion for severe malarial anemia at the same site (Ippolito et al, 2022b). In practical terms, the effort required to account for blood group type of the units of blood in the blood bank and the individual patients presenting with severe malarial anemia is outside the range of minimum essential data for current surveillance, which still relies largely on paper records.…”

“…Malaria accounts for the plurality of pediatric admissions and deaths (Ippolito et al, 2018). Diagnosis is almost exclusively made by antigen-based rapid diagnostic test; microscopy is scarcely done (Ippolito et al, 2022b). Artesunate has been first-line treatment for patients meeting criteria for severe malaria since 2012, and antibiotics are often given empirically.…”

Scientific Findings of the Southern and Central Africa International Center of Excellence for Malaria Research: Ten Years of Malaria Control Impact Assessments in Hypo-, Meso-, and Holoendemic Transmission Zones in Zambia and Zimbabwe

“… 53 – 55 In hospitalized children with malaria, blood stockouts and referral from a village or health center further from the hospital were associated with higher inpatient mortality. 56 Whole blood transfusion was associated with improved survival in children with severe malarial anemia, and transfusion using whole blood stored > 28 days was no better than no transfusion. 57 …”

Leveraging deep learning for detecting red blood cell morphological changes in blood films from children with severe malaria anaemia

“…SMA is a life-threatening condition requiring immediate blood transfusion followed by the administration of antimalarial treatment. [3][4][5] The point-of-care diagnosis is based on clinical presentation at admission, assessment of Hb concentration or haematocrit and the analysis of a peripheral thick blood film to detect the presence of malaria parasites (MPs).…”