Introduction

Parasite infestations such as malaria are common in the tropical and sub-tropical regions. They lead to severe consequences such as Anemia with high morbidity and mortality rates, especially in children [1]. WHO report on Anemia (2020), estimate that the global prevalence of anemia was 39.8% in children aged 6 to 59 months and 29.9% in women of childbearing age (% of women aged 15 to 49). This equates to 269 million anemic children and over half a billion women aged 15 to 49 respectively [2].

In Côte d’Ivoire, Anemia is endemic like Malaria and rages with varying prevalence from one region to another, depending on age and sex. The recent WHO report of year 2020 on anemia indicated that in Côte d`Ivoire a prevalence of 72.2% in children aged 6 to 59 months and 51% in women of childbearing age (women aged 15 to 49) [2,3]. Hence, it seems appropriate, even essential, to conduct research to highlight these morbidities, which represent some public health problems for a better prevention and cure. This community-based research study aims to characterize the type of anemia observed in anemic children in the Tonpki Region (Man), in the Western part of Côte d`Ivoire, in order to recommend better strategy of care.

Methods

Study area and participants

This observational clinical research study was carried out from March 2020 to May 2021 in twenty two (22) villages in Man, the “TONKPI Region” (Figure 1). The sample size of 451 was obtained from Schwartz’s formula:

Where: P is the expected prevalence of anemia in the target population estimated at 73.4% [4]; E an accuracy of 5%; C a corrective coefficient for the cluster effect of 1.5 and Z a confidence level of 95% (Z = 1.96).

Figure 1: Map of the TONKPI Region indicating the study sites in orange color.

Children aged 3 months to < 7 years were enrolled and provided blood samples for the diagnosis of anemia and malaria. All study participants belong to a variety of ethnical groups (Akan, Gour, Mande, Krou and others from neighboring countries such as Burkina Faso, Mali and Guinea) and reside in rural area with similar life style patterns and their parents earn their living either mostly as farmers or commercial traders.

Socio-demographic

Socio-demographic data including age, sex, height (to the nearest centimeter), weight (to the nearest 0.5 kg) and parent’s profession were also collected through a questionnaire administered to each enrolled participant who provided a signed written informed consent or give a fingerprint (illiterates).

Blood collection

2 mL of venous blood were drawn in the morning in EDTAtreated evacuated tubes from each of the 451 consented study participants. Blood samples were kept on ice until transported to the central laboratory at the Centre Hospitalier Regional (CHR) Man for the hematology testing (FBC).

Hemoglobin determination and classification of Anemia

The full blood count (FBC) was performed using URIT 3000 PLUS analyzer, Urit Medical Electronics, China and the result printed and further analyzed and characterized on the basis of the mean corpuscular hemoglobin (MCH) (normal value = 27 to 31 picograms (pg) and mean corpuscular hemoglobin concentration (MCHC) (normal value = 33 - 36 grams per deciliter (g/dL) as Normochromic or Hypochromic and the mean cell volume (MCV) (normal value = 80 - 100 fl) as Normocytic, Microcytic or Macrocytic.

Anemia was assessed and classified according to the age, sex of the participants and the concentration value of the hemoglobin (Hb) as per WHO guidelines (http://www. Who.int/vmnis/ indicators/haemoglobin.pdf). Thus, children from 3 months to 6 years with an Hb level of less than 11 g/dL were considered as anemic while those with an Hb level ≥11 g/dL were considered as normal (non-anemic). Anemia was also categorized as mild if the Hb level was less than 10 g/dL, moderate between 7 and 10 g/dL and severe below 7 g/dL and further characterized on the basis of the MCH and MCHC as Normochromic or Hypochromic and on the basis of the MCV as Normocytic, Microcytic or Macrocytic.

Data management and analysis

Data were entered into a database using the double-entry system in Epi-data version 3.1 (EpiData, Odense Denmark, 2004). Inconsistencies were cleaned and, after validation, the data were exported for the analysis to SPSS version 20 (IBM Corp; 2011) and STATA 16 software (STATA Corporation, College Station, Texas, USA). Univariate analysis (Chi-2 test (x2) and P: (Probability) were used for comparison between groups. Significant test was considered at a threshold of 0.05.

Ethical consideration

This study was conducted after obtaining an ethical clearance from the “Comité National d’Ethique des Sciences de la Vie et de la Santé (CNESVS) de la Côte d’Ivoire” (N/Ref: 024- 21/MSHP/CNESVS-km). Further permission to conduct the study was obtained from each visited village chief`s. In essence, the full study details i.e., the aims, the procedures, the potential risks and the benefits were explained to the physicians, nurses, and assistant nurses of each involved Health Center and the villagers before the start of the study.

Since all the participants were minors, consent from one of the parent was sought and obtained before any study procedure was completed. Only voluntary consented participants were included in the study. Treatment was made available free of charge to all sick participants. Those who required further assistance were referred to the local health center for assistance.

Participants were further informed that their information will be anonymized (confidential) using a coding system instead of their names.

Results

Characteristics of the study populations

A total of 451 children from 22 villages were enrolled in the study. Among them, 230 (51.0%) children were boys and 221 (49.0%) children were girls (Table 1).

We also noted in this study that the prevalence of anemia among children aged less than 5 years, was higher (45.3%) than the global prevalence (42.0%) [9]. Furthermore, 66.0 % of the younger children aged 3 months to 2 years in our study were anemic with the highest prevalence in term of intensity i.e., 5.7% severe and 74.3% moderate compare to the other stratified age groups. This alarming status can be explained by the fact that iron is a major factor of anemia in the first 46 months; the interval from conception of the fetus to 2 years of life is a critical window when the needs of nutrition must be ensured. If not, the child morbidity or mortality may occur [10]. In the children of 6 to < 7 years old group, we noted the highest prevalence of the mild anemia (55.5%) and the lowest prevalence of moderate (44.4%) and severe anemia (0.0%) in comparison to the others stratified age groups. This may be explained by the fact that at this age the children are most of time erranding or playing outside in various environmental settings where there is an additional food supplements such as legumes, nuts and seeds, and fruits and vegetables to be grabbed in addition to their normal shared family food. These extra micronutrients will provide them a healthy iron balance necessary to reduce their absolute deficiency in iron. In fact, as per Gupta et al., [11] Iron deficiency anemia is usually preventable and highly treatable with fortified diet or whole grains, legumes, nuts and seeds, and fruits and vegetables [11]. Similar results were reported by Righetti et al., [12] in 2012 in Côte d`Ivoire where 78.1% infants and 46.8% children were anemic with 61% mild, 32% moderate and 7% severe among the infants population versus 94.6% mild, 5.4% moderate and 0% severe in children population [12].

The consequences of anemia are well established in general and, it has several times been reported that anemia due to iron deficiency affects the intelligence of infants and children irreversibly, the rapid brain development, physical growth, and early learning capacity with a lifelong consequences on the cognition that translates to the equivalent of a 5 - 10-point deficit in intelligence quotient [10,13-18].

When the observed anemia was further characterized on the basis the mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC) and the mean corpuscular volume (MCV) the highest prevalence was the hypochromic microcytic anemia (78.6%) followed by the normochromic microcytic anemia (11.69%). Indeed, iron deficiency is the most common cause of microcytic and hypochromic anemia [19]. Iron deficiency anemia (IDA) is classically described as a microcytic anemia and appears when iron demand by the body is not met by iron absorption from the diet. In the majority of cases, microcytosis is the result of impaired hemoglobin synthesis. Disorders of iron metabolism and protoporphyrin and heme synthesis, as well as impaired globin synthesis, lead to defective haemoglobin production and to the generation of microcytosis and microcytic anemia [16,20]. These IDAs have previously been reported in Côte d’Ivoire by Franziska et al., in 2001 with an estimated 50% prevalence [21] as well as elsewhere in other studies [5,6,22-24].

Our study has some limitations; firstly, we did not measure serum ferritin levels to assess iron status or the reticulocyte count for confirming if the anemia is regenerative or not and secondly, the small sample size and thirdly, we did not assess the presence of other parasites that may have co-infected the same participant causing the observed anemia.

Conclusion

Based on our results, the prevalence of anemia among children aged less than 7 years is still high with the moderate hypochromic microcytic anemia being more prevalent in children under 7 years in the Western region of Côte d`Ivoire. Therefore, continued and effective efforts are needed to improve the general health of the high-risk population.

Acknowledgments

We are grateful to Dr Mamadou Ouattara, Dr. Diakité Nana Rose - N`goran and Dr. Fidele Bassa for helpful assistance in the collection of some data and to Dr. Gaoussou COULIBALY for some data analysis. We thank the Bantegouin, Biakale, Blapleu, Bogouiné I, Botongouiné, Bloleu, Douele-Dimba, Gbangbe

Zélé, Gouimpleu II, Guezon, Guianle, Guiapleu, Kabacouma, Kiélé, Kpanzaopleu, Kpata, Koutongouiné II, Lamapleu, Plouba, Tiakeupleu, Tiapleu and Zoba community for their willing participation in field study and for all the study participants for their commitment and willingness to collaborate. We are grateful to Dr. Tra Bi Joel, the head of Laboratory at CHR of Man and the laboratory technician for the processing of the clinical samples. Many thanks go to Dr. Bah Die Anicette, Dr. Aka Assande Ronald and Dr. Mougoh Ella for helpful clinical assistance in the management of the transferred children at CHR of Man.

Financial support and sponsorship

Nil.

References

1. Snow RW (2015) Global malaria eradication and the importance of Plasmodium falciparum epidemiology in Africa. BMC Med 13: 23.
2. WHOa (2020) Prevalence of anaemia in children under 5 years (%). Geneva, World Health Organization, 2020. (Accessed le 10 July 2022).
3. The WORLD BANK (2020) Prevalence of anemia among children (% of children ages 6-59 months) - Cote d’Ivoire. (Accessed 10 July 2022).
4. Stevens GA, Finucane MM, De-Regi LM, Pacioreket CJ, Flaxman SR, et al., (2013) Global, regional, and national trends in hemoglobin concentration and prevalence of total and severe anemia in children and pregnant and non-pregnant women for 1995-2011: A systematic analysis of population-representative data. Lancet Glob Health 1:16
5. Knoblauch AM, Winkler MS, Archer C, Divall MJ, Owuor M, et al., (2014)The epidemiology of malaria and anaemia in the Bonikro mining area, central Côte d’Ivoire. Malaria Journal 13:194.
6. Prieto-Patron A, Hutton ZV, Fattore G, Sabatier M, Detze P (2020) Reducing the burden of iron deficiency anemia in Cote D’Ivoire through J Health Popul Nutr 39:1.
7. WHO (2017) Discussion paper The extension of the 2025 Maternal, Infant and Young Child nutrition targets to 2030.
8. Magalhães RJS, Clements ACA (2011) Spatial heterogeneity of haemoglobin concentration in preschool-age children in sub-Saharan Bull WHO: 89:459–468.
9. WHO (2016) Health Topic, Anemia. Geneva: World HealthOrganization.
10. Sun J, Wu H, Zhao M, Magnussen CG, Xia B (2021) Prevalence and changes of anemia among young children and women in 47 low- and middle-income countries, 2000-2018. EClinicalMedicine 41:101136.
11. Gupta PM, Perrine CG, Mei Z, Scanlon KS, et al. (2016) Iron, Anemia, and Iron Deficiency Anemia among Young Children in the United Nutrients 8:330.
12. Righetti AA, Koua AG, Adiossan LG, Glinz D, Hurrell RF, et al., (2012) Etiology of Anemia Among Infants, School-Aged Children, and Young Non-Pregnant Women in Different Settings of South-Central Côte d’Ivoire. Am J Trop Med Hyg 87:425-434.
13. Pasricha SR, Drakesmith H, Black J, Hipgrave D, Biggs BA (2013) Control of iron deficiency anemia in low-and middle-income countries. Blood 121:2607-2617.
14. Osorio MM, Lira PI, Batista-Filho M, Ashworth A (2001) Prevalence of anemia in children 6-59 months old in the state of Pernambuco, Brazil. Rev Panam Salud Pública 10:101-107.
15. Christian P, Mullany LC, Hurley KM, Katz J, Black RE (2015) Nutrition and maternal, neonatal, and child health. Semin Perinatol 39:361-372.
16. Grantham-McGregor S, Ani C (2001) Review of Studies on the Effect of Iron Deficiency on Cognitive Development in Children. J Nutr 131:649S-666S.
17. Starck T, Bulstra CA, Tinto H, Rouamba T, Sie A, et al., (2021) The effect of malaria on haemoglobin concentrations: a nationally representative household fixed-effects study of 17,599 children under 5 years of age in Burkina Faso. Malar J 20:416.
18. Sundararajan S, Rabe H (2021) Prevention of iron deficiency anemia in infants and toddlers. Pediatric Research 89:63-73.
19. Christian P, Mullany LC, Hurley KM, Katz J, Black RE (2015) Nutrition and maternal, neonatal, and child health. Semin Perinatol 39:361-372.
20. Chang KH, Stevenson MM (2004) Malarial anaemia: mechanisms and implications of insufficient erythropoiesis during blood-stage malaria. Int J Parasitol 34:1501-1516.
21. Asobayire FS, Adou P, Davidsson L, Cook JD, Hurrell RF (2001) Prevalence of iron deficiency with and without concurrent anemia in population groups with high prevalences of malaria and other infections: a study in Côte d‘Ivoire. Am J Clin Nutr 74:776-782.
22. Rohner F, Zimmermann MB, Amon RJ, Vounatsou P, Tschannen AB, et al., (2010) In a randomized controlled trial of iron fortification, anthelmintic treatment, and intermittent preventive treatment of malaria for anemia control in Ivorian children, only anthelmintic treatment shows modest benefit. J Nutr 140:635-641.
23. Righetti AA, Adiossan LG, Ouattara M, Glinz D, Hurrell RF, et al., (2013) Dynamics of anemia in relation to parasitic infections, micronutrient status, and increasing age in south-central Côte d’Ivoire. J Infect Dis 207:1604-1615.
24. Muriuki JM, Mentzer AJ, Mitchell R, Webb EL, Etyang AO, et al., (2021) Malaria is a cause of iron deficiency in African children. Nat Med 27:653-658.