The Burden of Anemia and Operational Challenges in Conducting Clinical Research at a Medical Ward in Lilongwe, Malawi
Authors: Strand Eric D , Broadhurst Richard , Hoffman Irving , Yohannie Mlombe , Hosseinipour Mina 
Published: October 2019

Abstract
Background: Anemia in sub-Saharan Africa is a significant problem, but has not been well studied in the general adult population. Factors contributing to anemia include: HIV, malaria, tuberculosis, hematological malignancy and nutritional deficiencies. Often, hematological malignancy presents as an anemia or cytopenia. Understanding the prevalence and types of anemia in this part of the world will help to fully understand the impact of these causes and may help to further identify the prevalence of hematological malignancy in this setting.
Methods: We tracked all patients who were admitted to the medical service of Kamuzu Central Hospital (KCH) in Lilongwe, Malawi for a one-month period from 8 June until 9 July 2014. Data collected upon admission included: age, gender, admitting diagnosis, HIV status (if known), Antiretroviral (ARV) status, organomegaly, lymphadenopathy and any known comorbid illnesses. Complete blood counts (CBCs) were ordered on all patients during this period
Results: The medical ward admitted372 patients during the study period. Anemia was the admitting diagnosis for 10.75% of patients. Other common admitting diagnoses were: Sepsis (11.83%), Pneumonia or TB (11.02%), and Malaria (7.53%). CBCs were ordered on all patients, but only 38.17% received a result. Of the patients who received a CBC result (n=142), mean Hgb was 9.40 gm/dL and mean WBC was 7.76 gm/dL. Anemia (Hgb<13 gm/dL in men and Hgb<12 gm/dL in women) was present in 73.33% of men and 71.64% of women with a CBC result. Of the patients with anemia, 74.80% had normocytic anemia, 9.76% had macrocytic anemia, and 15.44% had microcytic anemia. Anemia requiring transfusion per ASH guidelines (Hgb≤7 gm/dL) was present in 26.67% of men and 38.80% of women. Overall mortality of patients admitted during the study period was 11.04%. Of patients with a completed CBC, 21.4% of deaths were patients with Hgb<7 gm/dL. For the patients who did not receive a CBC, 68.93% of samples were not drawn or transported to the lab, 26.70% of patients were admitted during a time where there was no reagent for the hematology analyzer, 2.42% of samples arrived clotted, and 1.94% of orders arrived with no sample.
Conclusions: Conducting clinical research in the developing world is challenging, but it presents opportunities for quality improvement and capacity building. This was the first time that the medical ward attempted to take blood draws on all patients. There was no department policy regarding responsibility for lab draws on the medical service at KCH, which resulted in many blood draws not being done. Supply of lab reagents ran out during the last week of the study period due to the order not arriving on time. This highlights the importance of all parts of a healthcare system in delivering quality patient care. Anemia was one of the top three admitting diagnoses at the KCH medical ward. This shows that anemia is a significant problem. The majority of patients at KCH had hemoglobin values below the WHO threshold for anemia, regardless of overall health. This, and the low mean hemoglobin, shows that western measurements of anemia may not be appropriate for Malawi. This is especially true given the shortage of blood in Malawi, and the risks of transfusion. The causes of anemia at KCH are still fully not known, which warrants further investigation. Study in hematological malignancy, aplastic anemia, and anemia of chronic disease is ongoing at KCH in order to pursue these underlying causes.

Disclosures
No relevant conflicts of interest to declare.