Severe Anemia in Malawian Children: Risk Factors, Mortality and Malaria Chemoprevention

Abstract

Children aged less than five years who are hospitalized with severe anemia have nine times higher risk of mortality compared to children in the community. The risk of dying and re-hospitalization remains high up to 6 months after discharge from the hospital. Causes of severe anaemia are multifactorial and vary in different settings. These include genetic factors and malignancies, nutritional deficiencies and infectious diseases such as malaria. Malaria remains a major contributor to slow hematological recovery, morbidity and mortality. New or recrudescent malaria infections after discharge negate the initial rise in hemoglobin due to on-going red cell destruction and red blood cell production failure. Studies have found that in addition to the protective effect of insecticide treated nets (ITNs), provision of post- discharge malaria chemoprevention (PMC) using monthly doses of antimalarial medication to children with severe anaemia prevented as much as 31% of deaths or hospital readmissions.

Using data from a prospective study that was investigating severe anaemia in children aged less than 5 years old in Malawi, we did a cohort analysis to compare the risk of death between severely anaemic children who had moderate to severe malnutrition and those who had severe anaemia alone (Paper I). A total of 382 severely anaemic children were screened and 331 enrolled of which a total of 53 children had moderate to severe malnutrition (exposed) and 275 did not (unexposed). During the 18-month follow period, 28.3% of children with moderate to severe malnutrition died, compared to 13.1% among children with severe anaemia alone, (IRR 2.1, CI 0.9-4.2, p=0.03). However, the number of hospitalizations and recurrence of severe anaemia was similar between the two groups [IRR 0.8 (0.4-1.4), p=0.6 and IRR 1.1 (0.3-2.8), p=0.8] respectively.

We conducted a 5-arm, cluster-randomized trial among 375 hospitalized to determine the optimum PMC delivery mechanism by comparing community- versus health facility-based strategies in order to inform policy. Children, aged <5 years with severe anemia received 3-day monthly treatment courses of dihydroartemisinin-piperaquine (DP) either through community-based methods compared to health facility-based methods. We found that adherence was 24% higher among children when PMC was delivered in the community compared to when delivered at the health facilities. In addition, we found that when compared to the facility-based, non-SMS arm (control arm); community-based delivery utilizing community health workers (CHWs) resulted in higher adherence [39/76 (51·3%) vs. 54/79 (68·4%); IRR=1·32, 1·14-1·54, p<0·001].

With the objective of assessing the feasibility of involving community health workers (CHWs) in the scaling up of PMC into the Malawian health system, we conducted focus group discussions and in-depth interviews to explore perceptions, experiences and motivation of the CHWs who were involved in the PMC trial in Malawi. We found that CHWs were motivated to remind caregivers to administer PMC medication to their children mainly by altruism. However, professional, structural and community factors were barriers that prevented them from carrying out the assigned tasks. In conclusion, it is crucial to investigate and manage acute malnutrition among severely anaemic children, as this might be another treatable factor associated with high mortality. If PMC is scaled up and made into policy of treatment for children with severe anemia, community delivery is effective for high adherence and access. However, community delivery anchored in CHWs may not be feasible.