The Assessment of The Effect of Plasmodiasis On Some Haematological Parameters of Patients in Rivers State University Teaching Hospital (RSUTH) Port Harcourt

Isomah Chiladi J, Mbata C. A., Confidence Idaye

Rivers State University, Nider Delta University Wlberforce Island Bayelsa State

All Corresponding to:chiladijeffisomah@yahoo.com08037602806

ABSTRACT

Mapproximately 229 million people worldwide with 409,000 deaths most of which occurred in Africa, followed by South East Asia. These haematological changes caused by plasmodium involves the major cell types such as the Red Blood Cells, White Blood Cells and Platelets. The aim of this study was to assess the effect of plasmodiasis on some haematological parameters of patients attending Rivers State University Teaching Hospital (RSUTH), Port-Harcourt. This was a cross sectional study involving 200 subjects within the age range of 10-90 years of which 125 (62.5%) were males and 75 (37.5%) were females. The presence of plasmodium falciparum malaria was determined by staining a thick and thin blood film with Giemsa stain and viewing under a microscope. Haematological parameters of the patients was analyzed by auto analyzer method using Sysmex XN-550 haematology analyzer. It was shown from the result gotten that male (65.5%) are more exposed to malaria in Port Harcourt, Rivers State than female (35.5%). The study also showed a statistical significance in the Haemoglobin of Male (8.81±3.61) as compared to that of the female (11.62±3.77) (p=0.0097) while other parameters showed no statistical significance at p<0.05. The result showed a lower mean value for RBC, PCV, HB, MCV, MCH and MCHC of plasmodium parasitized patients when compared with the non- parasitized patients. Higher mean value for WBC, Lymphocytes, Monocytes, and Eosinophils where statistically significant when compared with the control subjects. The result gotten emphasised the need for proper management of P. falciparum malaria. It is also recommended that full blood count should be carried out on a malaria parasitized patients in order to guide treatment.

INTRODUCTION

Plasmodiasis is a disease transmitted by a bite of Pinfected mosquito. It occurs in Humans and other animals. Severe disease is largely caused by Plasmodium falciparum, while the disease caused by Plasmodium Vivax, Plasmodium ovale and Plasmodium Malariae are generally milder and rarely fatal. Plasmodium knowlesi a zoonotic Malaria parasite that causes Malaria in macaques but can also infect Humans, these species of Plasmodium differ in morphology, immunology, geographical distribution, relapsed pattern, incubation time and in drug response (American Mosquito Control Association, 2016). The World Health Organization (WHO) estimates that there were 229 million cases of malaria in worldwide 2019, with 409,000 deaths, most of which occurred in Africa, followed by South East Asia. 67% of all malaria deaths were in children under 5 year of age. (World Health Organization, 2015) Thus, malaria continues to be viewed as a highly significant disease of global public health importance (World Health Organization, 2020).

There are six major Plasmodium species infecting humans: Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, Plasmodium ovale curtisi, Plasmodium ovale wallikeri and Plasmodium knowlesi (Sutherland et al., 2010). Plasmodium falciparum and P. vivax are the two main causes of human malaria infections. Falciparum malaria poses a risk of severe complications and contributes to the majority of deaths (White et al., 2013). However, evidence have shown that Nigeria has the highest population at risk of Malaria in Africa and therefore most vulnerable to the risk of missing millennium development goal target (World Health Organization, 2020).

Changes in Haematological parameters are likely to be influenced by any disease condition including endemic diseases, such as Malaria, that can affect health of mankind with various clinical presentations. Malaria is a major cause of deaths in the tropical area of the world. Two hundred and nineteen million cases were reported worldwide in 2010. Haematological alterations that are thought to characterize malaria are related to the overt biochemical changes that occur during the asexual stage of the life cycle of the malaria parasite (Alexandra et al., 2017).

Haematological changes are some of the most common complications in Malaria and they play a major role in Malaria pathogenesis. These changes involve the major cell types such as RBCs, leucocytes, and thrombocytes. Malaria infected patients tend to have significantly lower platelets, WBCs, lymphocytes, eosinophils, RBCs and Hb level, while monocyte and neutrophil counts were significantly higher in comparison to non-Malaria infected patients (Facer 214). One study showed patients with higher WBCs count compared with community controls. The most common complication during Malaria Infection is thrombocy -topenia. Persons with platelet counts < 150,000/µL were 12-15 times more likely to have Malaria Infection than persons with platelet counts > 150,000/µL. (Deng et al., 2016) A previous study found that the ratio of monocytes to lymphocytes correlated with risk of clinical Malaria during follow-up (Kotepui et al., 2014)

MATERIALS AND METHODS

2.1 Study Design This was a cross sectional study where the subjects were randomly selected. The study was carried out among

patients attending Rivers State University Teaching Hospital in PortHarcourt, Rivers State. Two hundred (200) subjects were recruited for this study and their blood samples were collected to screen for malaria and analyzed for haematological parameters.

2.2 Study Area

This study was carried out in RSUTH, Port Harcourt, River state, Nigeria. Rivers State is situated in the SouthSouth region of Nigeria with a population of 5,198,716 according to 2006 Census report and is located at o o coordinates, 4 55' N, 6 50'E. Rivers State is bound at the south by Atlantic Ocean, the North by Imo, Abia, and Anambra States, to the the East by Akwa-Ibom State and to the West by Bayelsa and Delta States. Two hundred (200) subjects were recruited for this study.

2.3 Eligibility Criteria

2.3.1 Inclusive criteria

The subjects included in the study include those within the age range of 10-90years who had malaria parasitaemia with no history of other underlying illness and were not on any anti-malarial drug. Controls group were apparently healthy individuals who were not infected by malaria parasite and other underlying illness

The subjects included in the study include those within the age range of 10-90years who had malaria parasitaemia with no history of other underlying illness and were not on any anti-malarial drug. Controls group were apparently healthy individuals who were not infected by malaria parasite and other underlying illness

2.3.2 Exclusive criteria

Those who were excluded from this study include all malaria infected subjects on anti-malaria medication or other medications prior to commencement of this study, Smokers, and alcoholics

2.4 Ethical Approval and Informed Consent

The Ethics Committee of the Rivers State University, Port Harcourt, Nigeria approved the protocol for this study. A written Informed consent was obtained from the subjects and the institutional authorities.

2.5 Subject Selection

Subjects were selected randomly from the RSUTH having ensured that they met the criteria that made them suitable for inclusion and exclusion.

2.6 Sample Collection and Preparation

5ml of venous blood was antiseptically collected from each individual involved in this study both for the test and control. Each sample was collected and dispensed into ethylenediamine tetra-acetic acid (EDTA) contained bottles and mixed properly for malaria malarasite test and assessment of haematological parameters.

2.7 Laboratory Analysis

2.7.1: Blood film preparation (World Health Organization, 1999; Cheesbrough, 2006)

2.7.1.1: Thin and thick film preparation

blood was placed at the centre of a clean grease free glass slide and another drop of blood at the right side of the same slide with the aid of a Pasteur pipette. Using a smooth edged slide spreader, the drop of blood was spread to make a thin film. The end of a Pasteur pipette was used to spread the drop of blood to make an even thick smear. This was allowed to air dry before staining.

2.7.2: Staining Thin and Thick films using Giemsa's stain

The dried thin film was fixed in methanol. This was then stained with the thick film using Giemsa's stain. 3% solution of Giemsa stain was made and the films were stained for 30 minutes. The back of each slide was blotted with cotton wool and place in the draining rack for drying. The films were examined using x100 Objective lens, (Oil immersion). The presence of malaria parasite was done using the thick blood films while the identification of the species was done using thin blood films. Aslide was scored as no parasite seen when 100 per high power fields had been examined without seeing any malaria parasite.

2.9 Statistical Analysis

The data obtained from the study were analysed using the GraphPad Prism Version 8.0.2.263. The data were expressed as mean and standard deviation. Comparison of the means was done using the one-way analysis of variance (ANOVA). The Tukey comparison test was used to verify significant differences between the groups at P<0.05.

RESULTS

3.1 The Total Number of Malaria Parasitized and Non Parasitized Subjects in relation to gender.

A total of 200 samples were collected for this study of which 145(72.5%) were confirmed to be parasitized by Malaria while 55 (27.5%) samples were non parasitized. Out of this 200 samples 125(62.5%) were from male and 75 (37.5%) were from female. Of the 145 parasitized samples, 95 (65.5%) were from male and 50 (34.5%) were from female. And for the 55 non parasitized samples 30 (54.5%) were from male and 25 (45.5%) were from female.

3.2 Comparative Analysis of Haematological Parameters of Malaria Parasitized Subjects Against Non-parasitized subjects

Comparing the haematological parameters of the parasitized and non parasitized sample it was shown that the White Blood Cell had a statistical significance with mean + STD of 5.95 + 3.38 and 4.93±1.17 respectively with a Pvalue of 0.0457, the Red blood cell had a significance value with mean + STD of 3.07±1.42 and 4.63±0.62 respectively with a P-value of 0.0001, the Haemoglobin was statistically significant with mean + STD of 10.16±3.92 and 13.47±1.11 respectively with P-value of 0.0001, the Haematocrit was statistically significant with mean + STD of 28.64±4.73 and 39.72±3.58 respectively and p-value of 0.0001, Mean Corpuscular Volume was significant with mean + STD of 69.52±10.8 and 83.81±8.08 respectively with p-value of 0.0001, Mean Corpuscular Haemoglobin was significant with mean + STD of 23.98±4.90 and 33.63±1.58 respectively with p-value of 0.0001, Mean Corpuscular Haemoglobin Concentration was also significant with mean + STD of 28.37±2.99 and 33.63±1.58 respectively with pvalue of 0.0001, Lymphocyte was significant with mean + STD of 49.09±29.68 and 33.68±5.31 respectively with pvalue of 0.0005, monocyte was also significant with mean + STD of 10.11±4.04 and 5.20±2.33 respectively with p-value of 0.0001 and Eosinophils was also significant with mean + STD of 5.16±0.69 and 3.02±1.36 respectively with p-value of 0.0001. Other parameters like the platelet, Neutrophil and Basophils were statistically non-significant all set at a significant level of p<0.05 as shown in table 4.2 below

Table 3.2: Comparative Analysis of Haematological Parameters of Malaria Parasitized sujects Against Nonparasitized Subjects

3.3 Comparative Analysis of Haematological Parameters of Malaria parasitized Subjects Based on Gender

Comparing the haematological parameters of male and female malaria parasitized subjects, it was shown that only the haemoglobin value was statistically significant with mean + STD of 8.81±3.61 and 11.62±3.77 respectively with p-value of 0.0097 while other parameters were statistically non-significant at a significant level of p<0.05

D I S C U S S I O N , C O N C L U S I O N A N D RECOMMENDATIONS

4.1 Discussion

This study was carried out to investigate the haematological parameters of malaria parasitized individuals in Rivers State University Teaching Hospital (RSUTH), Nigeria

A total of 200 samples were collected for this study of which 145(72.5%) were confirmed to be parasitized by Malaria while 55 (27.5%) samples were non parasitized. Out of this 200 samples 125(62.5%) were from male and 75 (37.5%) were from female. Of the 145 parasitized samples, 95 (65.5%) were from male and 50 (34.5%) were from female. And for the 55 non parasitized samples 30 (54.5%) were from male and 25 (45.5%) were from female.

Our findings showed that male (65.5%) are more exposed to malaria in Port Harcourt, Rivers State than female (35.5%). Which is in agreement with a study carried out by Mana et al., (2020) which indicated in their study that male are more exposed to malaria than female in Portharcourt, Nigeria. This might be because male do more menial jobs than females and these jobs exposes them to a non-hygienic environment exposing them to mosquito bites and consequently malria infestation. The study also showed a statistical significance in the Haemoglobin of Male (8.81±3.61) as compared to that of the female (11.62±3.77) (p=0.0097) while other parameters showed no statistical significance. This is in agreement with a study carried out by Menendez et al., (2000) but in discord with another study carried out by Prce et al., (2001), they stated in their study that there is no statistical significance in the Haemoglobin of male and female. This disparity might be due to the difference in sample size for both male and female. In their study they had more male female participants than male, rather in this study we had more male participants

From the result it is shown that the White Blood Cell had a statistical significance with values of 5.95 + 3.38 and 4.93±1.17 respectively with a P-value of 0.0457, the Red blood cell had a significance value of 3.07±1.42 and 4.63±0.62 respectively with a P-value of 0.0001, the Haemoglobin was statistically significant with values of 10.16±3.92 and 13.47±1.11 respectively with P-value of 0.0001, the Haematocrit was statistically significant with values of 28.64±4.73 and 39.72±3.58 respectively and pvalue of 0.0001, Mean Corpuscular Volume was significant with values of 69.52±10.8 and 83.81±8.08 respectively with p-value of 0.0001, Mean Corpuscular Haemoglobin was significant with values of 23.98±4.90 and 33.63±1.58 respectively with p-value of 0.0001, Mean Corpuscular Haemoglobin Concentration was also significant with values of 28.37±2.99 and 33.63±1.58 respectively with pvalue of 0.0001, Lymphocyte was significant with values of 49.09±29.68 and 33.68±5.31 respectively with p-value of 0.0005, monocyte was also significant with values of 10.11±4.04 and 5.20±2.33 respectively with p-value of 0.0001 and Eosinophils was also significant with values of 5.16±0.69 and 3.02±1.36 respectively with p-value of 0.0001. Other parameters like the platelet, Neutrophil and Basophils were statistically non-significant all set at a significant level of p<0.05 as shown in table 4.3. this result is in agreement with previous studies carried out by Ktra et al., (2017) and Abdala, (2019).

Comparing the haematological parameters of male and female malaria parasitized subjects it was shown that only the haemoglobin value was statistically significant with values of 8.81±3.61 and 11.62±3.77 respectively with pvalue of 0.0097 while other parameters were statistically non-significant at a significant level of p<0.05 which agrees with previous studies carried out by Mana et al., (2010) and Abdala (2019).

The result from this study as seen in Table 4.3 shows a lower mean value for RBC, PCV, Hb, MCV, MCH and The Effect of Plasmodiasis On Some Haematological Parameters of Patients

MCHC of malaria parasitized subjects when compared to the non-parasitized subjects. Higher mean value for WBC, Lymphocytes, Monocytes, and Eosinophils where statistically significant when compared with the nonparasitized subjects which is in agreement with studies carried out by Prce et al., (2001) and Mana et al.,(2020). This can be attributed to increased consistent hemolysis caused by malaria paritaemia.

This study confirms that haematological abnormalities in malaria infection are common. Leukocytosis was frequently seen in the malaria-infected patients which was confirmed by another study by Mana et al., (2010) that have demonstrated leukocytosis and contrast with other studies that had demonstrated leucopenia such as those done by Menendez et al., (2018) and Prce et al., (2001). Neutrophil and lymphocyte counts were the most important leukocytic changes associated with malaria infection. The increase in neutrophil count associated with malaria infection is in agreement with previous studies by Mana et al., (2020) which suggested that this increase might be due to activated neutrophil production or release from the marrow or suppressed peripheral removal (Mana et al., 2020).

The observation of increased monocytes counts in this Study is also in agreement with previous studies by Abdala, (2019) and that carried out by Mana et al., (2020). Mononuclear cells, which are activated by Plasmodium during malarial infection, produce inflammatory cytokines, such as tumor necrosis factor (TNF),interleukin-1 (IL1) and interleukin-6 (IL6). These cytokines stimulate the hepatic synthesis of acute phase inflammatory proteins, including CRP, which increase during malaria infection ( Abdala, 2019).

Anaemia is one of the most common complications in malaria infection especially in younger children and pregnant women in high transmission areas (Menendez et al., 2018). The pathogenesis of anaemia during malaria infection is not clearly understood. However, It is thought to result from the parasite's primary target in the red blood cell resulting in RBCs destruction, accelerated removal of both parasitized and non-parasitized (Prce et al., 2001), bone marrow dysfunction (Abdala, 2019) and the level of parasitemia (Ktua et al., 2017). This study, reported a significant reduction of Hb level, RBC count, MCV, MCH, and MCHC levels in Patients infected with malaria as compared To non-malaria infected group.

Platelet abnormalities in malaria are both qualitative and quantitative change. In this study, platelet counts was not statistically significant

4.2 Conclusions

In conclusion, the association of haematological parameters of plasmodium parasitized individuals attending Rivers State University Teaching Hospital was determined. The most commonly changed parameters were Hb, RBC, MCV, MCH, MCHC, WBC, neutrophil, and lymphocyte counts. Presence of anaemia in people from endemic areas may be useful as supportive diagnostic criteria for malaria in case with low level of parasite number. Therefore, when used with other clinical and microscopy parameters, it can significantly improve malaria diagnosis and timely further treat for malaria infection.

4.3 Contribution to Knowledge

1. It has been established from the result of this study that male are more exposed to malaria than female.
2. It has also shown from the result of this study that the most commonly affected parameters by plasmodiasis were Hb, RBC, MCV, MCH, MCHC, WBC, neutrophil, and lymphocyte counts.

4.3 Recommendation

It is therefore recommended that proper management of P. falciparum malaria should be carried out in order to know when to administer treatment. It is also recommended that full blood count should be carried out on a malaria parasitized patients in order to guide treatment. Further study should be carried out for determine the effect of malaria on the haematological parameters of individuals.

REFERENCES

1. Abdala, S. H (2019). Hematopoiesis in human malaria. Blood Cells Journal, 16:401-416
2. Alexandra J., Rowe, Ian, G., Handel, W., Mahamadou, A. & Thera, A. (2017). Blood group O protects against severe Plasmodium falciparum malaria through the mechanism of reduced rosetting. American Journal of Diseases. 104(44):17471-17476.
3. Deng, T., Yang, P., Zhao, D., Feng, P., Pine, D., Chmelka, B. F. & Stucky, G. D. (2019). “Hierarchically ordered oxides,” Science, 282(5397), 2244-2246.
4. Dua, V.K., Kar, P.K.& Sharma, V.P. (2016). Chloroquine resistant Plasmodium vivax malaria in India. Tropical Medicine International Health.4, 816- 819.
5. Facer, C.A. (2014). Hematological aspects of malaria, In:Infection and Hematology.Oxford:Butterworth Heinmann Ltd., 259-94.
6. Ian, A., Clark, C., Alison, C., Budd, F., Lisa, M., Alleva, R., William, B., Cowden. T. (2006). Human malarial disease: a consequence of inflammatory cytokine release. Malaria Journal, 5:85.
7. Ktra, A.Y., Smith, T.A., Aonso, P.L., Urassa, H., Masanja, H.K., Mario,J. & Tanner, M. (2017). The role of oweve Plasmodium falciparum parasitaemia in anaemia among infants ivinginan area of intense and perennial transmission. Journal of Tropical Medical and Health, 2:325–333
8. Kotepui, M., Bhukdee, P., Nuoil, P, Chaowanee, C & Suwit, D. (2014). “Effect of Malarial Infection on Haematological Parameters in Population near Thailand-Myanmar Border M,” Journal of Malaria, 13:218.
9. Mana, R. N., Wash, D., Gaddy, C., Hongo, G., Waitumb, J., Otieno, L., Jones, D., & Ogutu, B. R. (2020). Impact of Plasmodium falciparum infection on haematoogical parameters in children living in Western Kenya. Malaria Journal. 9, 3:4.
10. Menendez, C., Feming, A.F., Aonso, P. L. (2018). Malaria-treated anaemia. Parasitology Today 6:469- 476.
11. Price, R.N., Simpson, J.A., Nosten, F., Luxemburger, C., Hkirjaroen, L. & Kuile, F. (2001). Factors contributing to anemia after uncomplicated falciparum malaria. American Journal of Tropical Medicine and Hygiene, 65(5):614-622.
12. Sutherland, C.J., Tanomsing, N., Nolder, D., Oguike, M., Jennison, C. & Pukrittayakamee, S. (2020). Two nonrecombining sympatric forms of the human malaria parasite Plasmodium ovale occur globally. Journal of Infectious Disease, 201:15, 44–50.
13. Tjitra, E., Anstey, N.M., Sugiarto, P., Warikar, N., Kenangalem. (2008). Multidrug-Resistant Plasmodium vivax Associated with Severe and Fatal Malaria: AProspective Study in Papua, Indonesia. Plos Medicine 5(6):128.
14. Taylor-Robinson, A.W. (2018). Immunoregulation of malarial infection: balancing the vices and virtues. International Journal of Parasitology, 28(1):135-148.
15. World Health Organization. (2015). World malaria report 2015. Geneva: World Health Organization. (2020) World malaria report, Geneva: World Health Organization; 2020. https ://www.who.int/docs/White, N.J., Pukrittayakarnee, S., Hien, T.T., Faiz, M.A., Makuolu, O.A., Dondorp, A.M. (2013). Malaria Lancet. 383:723–35.

Download the PDF version of this edition here