Health Care Seeking Behavior among Caregivers of Sick Children Who Had Severe Malarial Anaemia

Aims: The western region in Kenya is holoendemic to malaria and experience stable P. falciparum malaria transmission. The use of health care options has a direct influence on the outcome of severe malaria. As such, the current study will assess the health care seeking behavior among caregivers of sick children who had severe malarial anaemia (SMA) inwestern Kenya.Study Design:Cross section study.Place and Duration of Study:The study was conducted at Jaramogi Odinga Oginga Teaching and Referral Hospital (JOOTRH) between September 2014 to July 2015. Methodology: It was open to all children ≤10 years (n=271) admitted and diagnosed with SMA (hemoglobin <5.0 g/dl and any density of P. falciparum. Caregivers were interviewed on the health care options before seeking care at a heath facility, when the childstarted to get sick, if they took child to another health centre/dispensary/private hospital before coming to JOOTRH Results: Majority of the caregivers interviewed, 80.07% (217) had attained Primary education. Majority of the caregivers were in the age category of19-24 75(27.67%) years and 25-29 years 75 Original ResearchArticle (27.67%). 74.90% (203) of their children were below five years and 25.09% (68) were above 5 years. 61.62% (167. Majority of the caregivers gave some remainder drugs before presenting to a heath facility 32.5% (88). A good number bought drugs at drug stores/pharmacies 27.7% (75). None visited a traditional healer. A minority used herbs 10% (27). There were no statistically significant differences between most of the pre-hospitalization measures taken s with regard to patient’s gender and age, and caretaker’s level of education. Caregivers who chose to give herbs to their sick children took longer in deciding to take their children to hospital. This was however statistically significant between those who used herbs and those who bought drugs only (median 4 days vs. 3 days, respectively, p = 0.0063). There was no significant difference in the delay of child admission at JOOTRH between caregivers who had had primary education only and those with a minimum of secondary education (p = 0.9842). Conclusion:Self-medication is a common practice before seeking care at a heath facility. There is need for community awareness for correct and comprehensive information about drawbacks associated with self-medication practices. Since safety continues to be a major issue with the use of herbal remedies, it becomes imperative, therefore, that relevant regulatory authorities put in place to ensure that all herbal medicines are safe and of suitable quality.

Increased Complement Deposition on Red Blood Cells in Children with Sickle Cell Trait.

Aims: Immune-mediated mechanism, such as deposition of complement (C3b) on erythrocytes leading to enhanced receptor-mediated uptake by macrophages has been proposed to contribute partly to the destruction of non-infected cells leading to anaemia. The extent of complement deposition on RBC (red blood cells) may therefore influence an individual's resistance or susceptibility to severe malarial anaemia. Our objective was to see if RBC of sickle cell trait individuals have increased susceptibility to deposition of complement in vivo. Under oxygenated and deoxygenated conditions, cytofluorometry was used to determine susceptibility of RBC from individuals with normal haemoglobin and those with heterozygous sickle cell trait to complement deposition. Methods: Children aged 0-192 months (n=116) were enrolled in the nested case controlled study and were stratified into HbAS (n=47) and HbAA (n=69). The 47 HbAS individuals were matched to the 69 HbAA individuals of similar age (± 2 months or ± 24 months for those below or more than 192 months, respectively) at a ratio of 1:1 or 1:2. We measured the red cell C3b by flow cytometry under normal and reduced oxygen saturation. Individuals who were positive for malaria were treated and blood was collected when they were free of parasitemia. Analysis of variance was used to identify independent variables associated with the complement C3b positive red cells and Hb level. Results: The mean complement C3b-positive cells for the HbAS was significantly higher than HbAA (P=0.0191). This was also true when this was repeated under deoxygenated conditions (P=0.00065). When the study volunteers were grouped by age cohorts into 0-12, 13-48 and 49-192 months, it was noted that generally; the mean complement C3b positive red cells was higher in the HbAS compared to HbAA but was not statistically significant. Under deoxygenated conditions, the trend was the same. However, between the ages of 49-192 months, the difference was statistically significant. Conclusion: Increased complement C3b deposition on red cells of HbAS cells may predispose the HbAS individuals to increased RBC destruction and therefore protection from severe manifestations of malaria.

Sickle Cell Trait (HbAS) is Associated with Increased Expression of Erythrocyte Complement Regulatory Proteins CR1 and CD55 Levels in Children.

Aims: Erythrocyte complement regulatory proteins, complement receptor 1 (CR1) and decay accelerating factor (CD55) protect red blood cells (RBCs) from complement mediated damage by controlling complement activation cascade and potentially protect RBCs from complement mediated damage that may occur when immune complexes are formed following malaria infection. Given the important role of RBCs in regulation of complement activation, we considered the competence of sickle cell trait RBCs in these functions. Methods: Children (age 0-192 months; n=116) were enrolled in a nested case controlled study conducted in Kombewa Division, Kisumu west District between October and December 2004. Based on hemoglobin (Hb) type, children were stratified into those with HbAS (n=47) and HbAA (n=69). The 47 HbAS individuals were matched to the 69 HbAA individuals of similar age (± 2 months or ± 24 months for those below or more than 192 months, respectively) at a ratio of 1:1 or 1:2. Circulating CR1 levels and CD levels were quantified using a FACScan cytometer under normal and reduced oxygen saturation. Results: The mean CR1 copy numbers per RBC was comparable in the two groups. However, between the ages of 49-192 months, the mean CR1 copy numbers per erythrocyte was significantly higher in children who had HbAS compared to those with HbAA (P=0.0332). The mean CD55 levels were comparable between the two groups but after deoxygenation, the mean CD levels in RBCs of individuals with HbAS was significantly higher than in the HbAA (P=0.011). Conclusion: The mean CR1 and CD55 copy numbers per RBC were comparable between the two groups under normal and reduced oxygen saturation. Beyond the age of 49 months, the CR1 copy numbers was higher in the HbAS compared to HbAA and this was also true for CD55 levels under deoxygenated conditions. Taken together, these results demonstrate that in the younger age groups, the protection afforded by HbAS against severe manifestations of malaria may be due to other factors other than complement regulatory proteins but beyond the age of 49 months, this protection may be partly due to the high CR1 copy numbers in the HbAS individuals.

Association between Sickle Cell Trait and Low Density Parasitaemia in a P. falciparum Malaria Holoendemic Region of Western Kenya.

Aims: The frequency of the mutant gene for sickle cell is widely distributed in the sub-Saharan Africa, the Middle East, and the Indian subcontinent. There is epidemiologic evidence that sickle cell trait confers a survival advantage against malaria and that the selection pressure due to malaria has resulted in high frequencies of the mutant gene in areas of high malaria transmission. We carried out a study to look at the relationship between sickle cell trait, age, haemoglobin level, and malaria parasite density. Methods: We carried out a cross-sectional study between the months of October and December, 2004 in Kombewa Division of Kisumu West District, a P. falciparum malaria holoendemic area with entomological inoculation rates estimated at 31.1 infective bites per person per year. We screened and quantified malaria parasitaemia in participants (age 0 to 45 years n = 342). Haemoglobin electrophoresis was performed on blood from all the participants. Results: In total, 402 participants were screened of which 342 were enrolled. Of these, 280(81.4%) had haemoglobin AA, 60(17.4%) had haemoglobin AS and 2(0.6%) had haemoglobin SS. Those with HbAA and HbAS were included for the analysis bringing the total number to 340 participants. For asymptomatic individuals in the community who displayed no signs of an acute or chronic illness and who were P. falciparum malaria parasite positive; the mean parasite density/µL for HbAS of 4064.0 (95% CI 1858.0 – 6270.0) was significantly lower than that of HbAA 11,067.9 (95% CI 7616.0 – 14520.0) (P = 0.001). Conclusion: The sickle cell carrier status is high (17.4%) in this population and is protective against high density parasitaemia. It is suggested that any malaria intervention strategies should factor in the possibility of sickle cell trait as a confounder to the protective effect of the intervention.