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advancing Knowledge | 13
The hidden costs
of anaemia
Even when treated successfully,
severe anaemia increases the risk of death.
3 4
KEMRI–Wellcome Trust Research
Programme at Kilifi and its 240 000-
strong local community. A malaria
vaccine trial (see page 38) provided an
opportunity to assess internationally
recommended ‘best practice’ for
informed consent – such as community
as well as individual consent and formal
tests of participants’ understanding.
Qualitative studies confirmed the value of
such practices.
However, a quiz designed to test
understanding appeared to fuel
misconceptions, and unearthed concerns
about blood sampling and vaccine
side-effects. This encouraged additional
discussions between the research team
and potential participants. Overall, the
relationships between the two groups
were identified as central to community
members’ perceptions of trials.
Informed consent is thus not simply a
matter of providing factual information and
testing participants’ understanding, which
may underplay the significance of
pre-existing and evolving relationships
and attitudes.
Pro-active community engagement is at
the heart of the Wellcome Trust’s new
international public engagement initiative,
which made 15 awards in 2007/08,
including several in East Africa.
References for this article can be found at
www.wellcome.ac.uk/annualreview.
Severe anaemia is a major problem in
Africa. It is responsible for 12–29 per
cent of childhood admissions to
hospital, and between 4 and 10 per
cent of these children are likely to die
in hospital. And as Kamija Phiri, Job
Calis, Michaël Boele van Hensbroek
and Malcolm Molyneux in the
Malawi–Liverpool–Wellcome Trust
Programme for Research in Tropical
Medicine in Blantyre, Malawi, have
discovered, an alarming number of
those that survive die after discharge
from hospital.
Nearly 20 years ago, a group in Kenya
reported that children who had been
treated for anaemia in hospital continued
to die in unexpectedly high numbers
after being discharged. As this finding
had never been followed up, Dr Boele
van Hensbroek and Professor Molyneux
set out to see if it was also true of
Malawian children.
They compared three groups – children
admitted to hospital with anaemia,
children admitted for other reasons and
a community sample – following them for
18 months after enrolment.
They found the same disturbing pattern
– children who had had severe anaemia
were far more likely to die (all-cause
mortality of 12.6 per cent, compared with
2.9 per cent of the hospital controls and
1.4 per cent of the community controls).
The biggest single factor associated with
death after discharge was HIV status.
As anaemia is so common, these figures
point to an alarmingly large number of
deaths among young African children
who have left hospital.
What might be causing anaemia in the
first place? The investigators found that
admission to hospital with severe
anaemia was strongly associated with
bacterial infections, malaria, hookworm
infections, HIV and vitamin deficiencies,
but not iron or folate deficiencies.
Severe anaemia in children in sub-
Saharan Africa has generally been
thought to be mainly a result of malaria,
but these findings suggest that other
infections or dietary deficiencies may
also be of importance. Understanding
the causes of severe anaemia is an
important step towards designing
effective treatment and preventative
strategies for it, to ensure that the health
of vulnerable young children is protected
both in hospital and back in the
community.
Phiri KS et al. Long term outcome of severe anaemia
in Malawian children. PLoS ONE 2008;3(8):e2903.
Calis JC et al. Severe anemia in Malawian children.
N Engl J Med 2008;358(9):888–99.