Some studies have suggested that helminth infections increase the risk of malaria infection and are associated with increased number of malaria attacks and anaemia. Thus interventions to control helminth infections may have an impact on incidence of clinical malaria and anaemia. The current study assessed the impact of two anthelmintic treatment approaches on malaria infection and on anaemia in school and pre-school children in Magu district, Tanzania.A total of 765 children were enrolled into a prospective randomized anthelmintic intervention trial following a baseline study of 1546 children. Enrolled children were randomized to receive either repeated treatment with praziquantel and albendazole four times a year  or single dose treatment with praziquantel and albendazole once a year . Follow up examinations were conducted at 12 and 24 months after baseline to assess the impact of the intervention. Stool and urine samples were collected and examined for schistosome and soil transmitted helminth infections. Blood samples were also collected and examined for malaria parasites and haemoglobin concentrations. Monitoring of clinical malaria attacks was performed at each school during the two years of the intervention.Out of 1546 children screened for P. falciparum, S. mansoni, S. haematobium, hookworm and T. Trichiura at baseline, 1079 (69.8%) were infected with at least one of the four parasites. There was no significant difference in malaria infection  and in the prevalence of anaemia between the repeated and single dose anthelmintic treatment groups at 12 and 24 months follow up (p > 0.05). However, overall, there was significant improvement in mean haemoglobin concentrations (p < 0.001) from baseline levels of 122.0g/L and 123.0g/L to 136.0g/L and 136.8g/L for the repeated and single dose treatment groups, respectively, at 24 months follow-up which resulted in significant reduction in prevalence of anaemia.These results suggest that repeated anthelmintic treatment did not have an impact on malaria infection compared to single dose treatment. However, both treatment approaches had overall impact in terms of improvements of haemoglobin levels and hence reductions in prevalence of anaemia. Malaria, schistosomiasis and soil transmitted helminth infections (STH) are considered the most important parasitic infections in Sub-Saharan Africa, contributing to a major part of disease burden ,2. The dGlobally, major control interventions are currently being undertaken to control malaria and helminth infections. These include use of insecticide impregnated bed nets, indoor residual spraying (IRS) and early and effective detection and management of cases using artemisinin based combination therapy for malaria -14. For P. falciparum [P. vivax malaria and hookworm co-infections in pregnant women were associated with more frequent malaria attacks and severe anaemia than seen in women who harbour only one parasite infection. In the Philippines, it was demonstrated that even at low infection intensities, multiple parasite infections enhance the risk of anaemia [Some previous studies have demonstrated that helminth infections may increase the risk of infections with lciparum -20 and olciparum ,22. Howelciparum . Anotherlciparum . A studylciparum  observed anaemia ,26. Thus anaemia . However anaemia -30. MostP. falciparum infection in an infection intensity dependent manner and thus increase susceptibility to malaria infection and related morbidity. Thus control of helminth infections would enhance immune response against P. falciparum malaria and reduce incidence of clinical malaria attacks and anaemia.The objective of this study was therefore to assess the impact of an anthelmintic intervention delivered through two different approaches on malaria infection and on anaemia. The study was designed to test the hypothesis that helminth infections modulate immune responses against The study was implemented in Magu district, Mwanza region, North-western Tanzania, and involved six primary schools namely Mwamayombo, Nyashimo, Bulima, Milambi, Ihale and Ijitu. From each school, school children aged 6–13 years (grades I-V) were randomly selected and included in the study. The aim was to get at least 100 children per school. Where the required number of 100 school children was not reached, pre-school children aged 3–5 years were also enrolled into the study. Selection of pre-school children was made conveniently whereby parents and guardians living in the community surrounding each school were requested to bring their children to the examination centre.P. falciparum, S. mansoni, S. haematobium, hookworm and T. trichiura was determined using standard methods as described in Kinung’hi et al. [The study was a longitudinal open label intervention trial which was preceded by cross-sectional baseline study that enrolled 1546 children in the catchment areas of the 6 primary schools. During the baseline study, the prevalence and infection intensity of S. mansoni or S. haematobium or both. Exclusion criteria were: Children who had stayed in the village for less than one year, children whose parents or legal guardians did not provide informed consent and children with severe malaria and anaemia. Severe malaria was defined as a seriously sick child presenting with fever (axillary temperature ≥ 37.5) plus one or more signs of seizures, respiratory distress, prostration, impaired consciousness or coma combined with the presence of P. falciparum parasitemia but in the absence of other causes of febrile illness [Following the baseline study, 765 children were selected and included in the longitudinal study. The inclusion criteria were: Being pre-school children (age 3 to 5 years) or school children (age 6 to 13 years) living in the selected villages for at least one year. In addition, selected children were those infected with either  illness ,32. SeveHaemoglobin concentrations were taken as the reference variable for calculation of sample size. A minimum sample size of 620 children (310 children for the repeated anthelmintic treatment group and 310 children for the single dose treatment group) was considered sufficient to give a power of 90% to be able to detect a significant difference of at least 5g/L between the two groups at 95% confidence interval and 5% level of precision. However, after baseline survey and assessment for inclusion criteria, 765 children were selected and randomized into either the repeated anthelmintic treatment group  or the single dose anthelmintic treatment group . Generation of random allocation sequence and assignment of participating children to intervention and control groups was performed by an experienced statistician.Children in the intervention group were treated with repeated doses of praziquantel 40mg/kg and albendazole 400mg four times a year at three months interval while children in the control group were treated with a single dose of praziquantel 40mg/kg and albendazole 400mg once a year. The two treatment approaches for the intervention and control groups were based on the assumption that the intensive repeated treatment (four times a year) of the intervention group will make this group helminth free while for the control group, the standard single dose treatment (once per year) will allow for re-infection to take place in 50% or more of children in this group -35. BothP. falciparum, S. mansoni, S. haematobium and hookworm as well as haemoglobin concentrations were assessed. The 12 months follow up assessment took place between October and November 2007 and included 655 children. The 24 months follow up assessment took place between October and November 2008 and involved 592 children. Of the 592 children who completed both the 12 months and the 24 months surveys, 297 were from the intervention group while 292 were from the control group. This amounted to a compliance rate of 75.4% and 78.8%, respectively. This study is registered on ClinicalTrials.gov, registration number NCT00347113; registered June 30, 2006 and reported according to CONSORT guidelines for randomized trials [The cohort of 765 children was followed up at 12 and 24 months after baseline. During these two follow up time points, the prevalence and infection intensity of d trials ,37. The Major reasons for loss to follow-up included migration from the study area, missing a second stool or urine sample, withdrawal of consent, sickness during follow-up survey days and death.During the 24 months follow-up period, the incidence of clinical malaria attacks was monitored at each primary school assisted by trained school teachers. Monitoring of incidence of clinical malaria attacks was done for all children included in the longitudinal study by passive case detection whereby children were asked to report to teachers when they had febrile illness. The parents and guardians of all children enrolled in this study were also informed about the study and requested to report to teachers when their children had febrile illness. The teachers were trained on how to make presumptive diagnosis and treatment of malaria cases. They were also trained to collect finger prick blood, prepare and stain thick blood smears using the Giemsa stain method and keep records. A register of malaria cases was established at each primary school. A laboratory technician visited each school on a weekly basis to collect the Giemsa stained blood smears and all information recorded. Blood smear examination was undertaken at the parasitology laboratory of the National Institute for Medical Research (NIMR), Mwanza Centre. School children found with febrile illness were treated with Artemether-Lumefantrine which was the first line antimalarial drug at the time of the study or were referred to nearby health facilities according to national guidelines on malaria treatment. A malaria episode (case) was defined as a child presenting with febrile illness with axillary body temperature ≥37.5°C plus a positive thick blood smear for malaria parasites in the absence of signs for other infectious diseases.Prevalence of malaria parasitaemia defined as the proportion of children with a positive blood smear for malaria parasites by the Giemsa stain method.Malaria parasite density defined as the number of malaria parasites per microlitre (μL) of blood calculated assuming 8000 white blood cells/μL of blood and estimated by counting the number of parasites per 200 leucocytes in Giemsa stained thick films at 100× magnification. Malaria parasite density was classified as low (<5000 parasites/μL of blood) and high (≥5000 parasites/μL of blood).Incidence of clinical malaria attacks defined as number of new cases of children presenting with febrile illness with axillary body temperature ≥37.5°C plus a positive thick blood smear for malaria parasites by Giemsa stain method in the absence of signs for other infectious diseases. The incidence of clinical malaria attacks was observed for the entire duration of the intervention (two years).Prevalence of anaemia and severe anaemia defined as the proportion of children with haemoglobin (Hb) concentrations less that 120 g/L and 80 g/L, respectively, measured by the Haemocue method.The following study outcome measures for malaria infection and anaemia were assessed during the study:S. mansoni, S. haematobium, soil-transmitted helminthiasis and P. falciparum and those found with ailments not targeted by the project were treated free of charge according to national guidelines. Study identification numbers were used instead of children names and information collected was kept confidential. Feedback to the study population in the form of dissemination workshops was conducted during the course of the study.The study was approved by the Medical Research Coordination Committee (MRCC) of the National Institute for Medical Research (NIMR), Tanzania (Reference No. NIMR/HQ/R.8a/Vol. IX/355). Before commencement of the study, the research team conducted meetings with village leaders, teachers and community members of all selected villages. During these meetings, the objectives and procedures of the study were explained including study benefits and potential risks and discomforts. Written informed consent for children who participated in the study was sought from parents or legal guardians after they had been informed about the study. Children were also requested to give written assent and were informed of their right to refuse to participate in the study and to withdraw at any time during the study without jeopardizing their right of access to other health services. Invasive procedures such as collection of blood samples were explained to parents and children and were carried out using sterile disposable materials. All children found infected with any of the parasites P. falciparum and geometric mean of eggs per gram of faeces for S. mansoni and hookworms. For S. haematobium, infection intensity was calculated as geometric mean of eggs per 10ml of urine. For each survey point , the Chi-square test was used to compare proportions  of malaria infection and prevalence of anaemia between the intervention and control groups. Likewise, for each survey point, the student’s t-test was used to compare geometric mean parasite counts and mean haemoglobin concentrations between the intervention and control groups where two groups were compared. The repeated measures analysis of variance (rmANOVA) was used to compare geometric mean parasite counts and mean haemoglobin concentrations where repeated measurements for all three survey points  were compared longitudinally. Comparison of the incidence (or risk) of clinical malaria attack among children in the intervention group and those in the control group was performed by calculating the relative risk (risk ratio) using 2×2 contingency tables. Tests were considered statistically significant at p < 0.05.Data were double entered into Dbase V software  and analyzed using STATA Version 10 . Infection intensities (of positive samples only) were calculated as geometric mean of parasites per microlitre of blood for Table P. falciparum, S. mansoni, S. haematobium, Hookworm and T. trichiura. Children who were infected with P. falciparum were 144 (24.5%), out of whom 55 (38.2%) had helminth co-infections. Only 3 children (0.5%) had T. Trichiura infection and hence T. Trichiura infection was excluded from further analysis.Out of the 765 children included in the longitudinal study, 589 (77.0%) completed the two year follow up period and were included in the analysis of whom 291 (49.4%) were boys. Mean age was 9 years. Out of the 589 children who completed the 24 months follow up, 302 (51.4%) were infected with at least one of the parasites There was no significant difference in malaria infection  and in the prevalence of anaemia between the intervention and control groups at 12 and 24 months follow up period (p > 0.05)  was 2.1% and 2.2% for the intervention and control group, respectively and was reduced to 0% at the end of the intervention. This represented a significant reduction over the two years follow up period but without significant differences between groups . Likewise, there was an overall significant reduction in malaria parasite density  from baseline levels of 530 (95% CI 414–678) and 510 (95% CI 403–645), for the intervention and control groups, respectively, to 326 (95% CI 279–382) and 343 (95% CI 294–400) for the intervention and control groups, respectively, at the 24 months follow-up period but without significant differences between groups   children completed the two year follow up period for malaria attacks (297 were in the intervention group while 292 were in the control group). A total of 221 children presented with febrile illness suggestive of malaria of whom 114 were from the intervention group and 107 were from the control group. However only 85 children (38.5%) met the criteria of confirmed malaria cases . Forty confirmed malaria cases were reported from the intervention group while 45 confirmed malaria cases were reported from the control group. Eighteen children (21.2%) reported more than one episode of clinical malaria attacks (2–4) per year during the first year of the intervention. However, this occurred less frequently during the second year of the intervention whereby only 7 children (8.2%) reported more than one episode of clinical malaria attacks with the highest frequency of 2 attacks per child per year. There was clustering of overall clinical malaria attacks by school which corresponded with baseline malaria prevalence at respective schools (data not shown).Overall, there was no significant differences in the incidence of clinical malaria attacks  or malaria parasite density  between children in the intervention group and those in the control group Table .Table 3et al. [S. mansoni particularly those carrying the highest egg loads as compared to uninfected children. Fenton [et al. [S. mansoni infection reduced the incidence of cerebral malaria in P. bergheii infected mice but the effect was dependent on S. mansoni parasite load. As most of the helminth infections in this study were light, their impact on malaraia infections might have been weak. The results are however in agreement with findings of Beasley et al. [S. haematobium and STHs are co-endemic. He observed that 15 to 16 weeks following anthelmintic treatment using praziquantel and albendazole, children in the treatment group had significant reductions in prevalence and infection intensity of S. haematobium and STHs and in the prevalence of anaemia compared to children in the control (placebo) group but did not differ in terms of prevalence and infection intensity of P. falciparum malaria. Another important observation was the relatively few confirmed malaria attacks relative to the number of cases who reported with febrile illness. Out of the 221 reported cases of febrile illness, only 85 (38.5%) were confirmed to be due to P. falciparum infection. This observation suggests that there are other causes of febrile illness in this study area. Similar observations have been made in other parts of Tanzania [Results of the current study suggest that repeated anthelmintic treatment  did not have any impact on malaria infection  compared to the single dose annual treatment as no differences were observed between children in the repeated anthelmintic treatment (intervention) group compared to children in single dose annual treatment (control) group. This is contrary to what was expected. Previous studies had observed that helminth infections increases the risk of malaria infection -19,38,39et al.  observed. Fenton  observed [et al.  demonstry et al.  who workTanzania -47 and hAs observed by previous studies investigating the association between malaria and helminth infections ,48, one et al. [A. lumbricoides) resulted into an increase of malaria cases. Two further studies with similar design were conducted in Madagascar [A. lumbricoides) had a significant increase in malaria parasite densities compared to untreated controls suggesting a negative interaction between A. lumbricoides infection and malaria parasite density. It might be difficult to compare findings of the current study with the studies of Murray and Brutus. While the study of Murray et al. [P. falciparum and A. lumbricoides infections which involved a different helminth specie (A. lumbricoides) from the helminth species investigated in the current study . Further, the studies of Murray and Brutus were conducted in a different epidemiological setting (and hence different disease transmission patterns) and used different treatment regimen against helminth infections. While Murray et al. [et al. [Earlier studies to investigate the association between malaria and helminth infections using a randomized design include the study of Murray et al.  which sudagascar ,51 and sy et al.  includedy et al. -51 invesy et al.  used pip [et al. ,51 used S. mansoni, S. haematobium and hookworms) and the prevalence and infection intensity of P. falciparum infection in line with reports by other investigators [P. falciparum and S. haematobium infections were the most important predictors of anaemia in the studied population. Other studies which have provided evidence on the importance of malaria infections on anaemia include studies on interventions directed against malaria such as Insecticide Treated Nets (ITNs) and chemoprophylaxis. Results of these studies demonstrated increases in haemoglobin levels and a strong impact on anaemia [Likewise, there were no significant differences in prevalence of anaemia or in haemoglobin levels between children in the intervention group compared to children in the control group over the two years assessment periods. However, for both groups, there was significant improvement in mean haemoglobin levels and hence a reduction in prevalence of anaemia. The observed changes in haemoglobin levels and the prevalence of anaemia followed a similar trend as changes in the prevalence and infection intensity of malaria suggesting that malaria infection was the most important contributor to anaemia in the studied population in line with findings of other studies ,53. Furttigators ,44,54,55 anaemia ,57. The In conclusion, findings of the current study show that repeated anthelmintic treatment did not have a direct impact on malaria infection  as compared to single dose annual treatment. However, both treatments had an overall impact in terms of improvements of haemoglobin levels and hence reductions in prevalence of anaemia.


The use of proportional weight gain as a discharge criterion for MUAC admissions to programs treating severe acute malnutrition (SAM) is no longer recommended by WHO. The critical limitation with the proportional weight gain criterion was that children who are most severely malnourished tended to receive shorter treatment compared to less severely malnourished children. Studies have shown that using a discharge criterion of MUAC ≥ 125 mm eliminates this problem but concerns remain over the duration of treatment required to reach this criterion and whether this discharge criterion is safe. This study assessed the safety and practicability of using MUAC ≥ 125 mm as a discharge criterion for community based management of SAM in children aged 6 to 59 months.A standards-based trial was undertaken in health facilities for the outpatient treatment of SAM in Lilongwe District, Malawi. 258 children aged 6 to 51 months were enrolled with uncomplicated SAM as defined by a MUAC equal or less than 115 mm without serious medical complications. Children were discharged from treatment as ‘cured’ when they achieved a MUAC of 125 mm or greater for two consecutive visits. After discharge, children were followed-up at home every two weeks for three months.p = 0.0013) established for the study. All children with negative outcomes had achieved weight-for-height z-score (WHZ) above −1 z-scores at discharge. Children admitted with lower MUAC had higher proportional weight gains (p < 0.001) and longer lengths of stay (p < 0.0001). MUAC at admission and attendance were both independently associated with cure (p < 0.0001). There was no association with negative outcomes at three months post discharge for children with heights at admission below 65 cm than for taller children (p = 0.5798).This study confirms that a MUAC discharge criterion of 125 mm or greater is a safe discharge criterion and is associated with low levels of relapse to SAM (1.9 %) and mortality (1.3 %) with long durations of treatment seen only in the most severe SAM cases. The proportion of children experiencing a negative outcome was 3.2 % and significantly below the 10 % standard (These results are consistent with MUAC ≥ 125 mm for two consecutive visits being a safe and practicable discharge criterion. Use of a MUAC threshold of 125 mm for discharge achieves reasonable lengths of stay and was also found to be appropriate for children aged six months or older who are less than 65 cm in height at admission. Early detection and recruitment of SAM cases using MUAC in the community and compliance with the CMAM treatment protocols should reduce lengths of stay and associated treatment costs. MUAC isThe use of proportional weight gain as a discharge criterion for MUAC admissions is no longer recommended by WHO , as it hA consultation between academics and non-governmental organisations (NGOs) in December 2012  concludeThe aims of this study were to evaluate the safety and practicability of using MUAC as a discharge criterion for children aged 6 to 59 months admitted to outpatient treatment for SAM using MUAC.Written consent was obtained from a parent (or primary caregiver) of the child to be enrolled in the study. Each parent/caregiver signed an individual consent form detailing the proposed treatment, the right to refuse enrolment into the study, the right to confidentiality and anonymity and that no payment would be received for participation.This study complied with World Medical Association Declaration of Helsinki  and was approved by the National Health Sciences Research Committee of Malawi .The study design was a standards-based trial. There are no internationally agreed standards for post-discharge relapse and mortality in CMAM programs. The standard adopted for the study was informed by a review by Ashworth , 7, whicThe study was conducted in five outpatient health facilities run by the Government of Malawi Ministry of Health (MoH) and located in Lilongwe District, Malawi, with care delivered by MoH staff. A research team from Valid International  trained MoH staff in study protocols and assisted directly in the measurement and treatment of all study subjects. The Malawi National Guidelines for Community-based Therapeutic Care  formed tThe study enrolled children aged between 6 and 59 months with uncomplicated severe acute malnutrition (SAM) as defined by MUAC ≤ 115 mm and without medical complications. Children with a MUAC ≤ 115 mm with concurrent bilateral pitting oedema or medical complications were referred to inpatient care according to Malawi National Guidelines and enrolled into the study on their return from inpatient care.Subjects were recruited between February 2011 and March 2012. Age was verified by reference to the child’s ‘health passport’. Children whose caregivers were resident outside of Lilongwe District were excluded from the study but were admitted to the CMAM program and provided with standard care according to the Malawi National Guidelines. MUAC, weight and height were measured on admission. An appetite test was conducted to confirm the appropriate consumption of Ready to Use Therapeutic Food (RUTF) which is required in order to receive treatment as an outpatient.Routine medications given on admission followed the Malawi National Guidelines and included a broad spectrum antibiotic (amoxicillin or co-trimoxazole) and vitamin A. Each child was assessed for malaria using a rapid diagnostic test, (Paracheck Pf®), and if positive, was treated with antimalarials (lumefantrine and artemether). If the Paracheck Pf®, rapid test was unavailable, the patient was treated empirically for malaria if they presented with a fever of unknown origin. Each caregiver and child was routinely offered serial testing for Human Immunodeficiency Virus (HIV) using the Determine HIV-1/2 Assay™ and, if tested positive, Uni-Gold Recombigen HIV assay™. HIV positive cases were included in the study and referred for appropriate treatment. It was not monitored whether the child went on to receive treatment for HIV. At each visit the child was given a ration of RUTF according to their weight  and at the second visit anthelminthic treatment  was given. The dosage for all medicines was age or weight related and given according to the Malawi National Guidelines.Study subjects were requested to attend outpatient treatment for SAM on a weekly basis. At each clinic visit the child was measured for weight and MUAC and their appetite for RUTF was assessed. Due to the rotation of MoH clinical staff in attendance at the health centres, a single observer from the research team conducted each of the measurements of weight, height, and MUAC in order to minimise inter-observer variation. The standardisation of the measurements was assessed using the method of Habicht , using tIf the status of the child had not improved or had deteriorated since the previous visit then the child was referred to the MoH clinician for further assessment according to Malawi National Guidelines. Any child absent from treatment was followed up at home by a Health Surveillance Assistant (HSA) or community-based volunteer and encouraged to return for treatment.Each study subject was discharged ‘cured’ from outpatient treatment when they achieved a MUAC of 125 mm or greater on two consecutive clinic visits. On discharge the caregiver was given a fourteen-day supply of RUTF calculated according to the weight of the child. The child was referred to a Supplementary Feeding Program (SFP) if such a program were operating in the health area of residence. A study subject was also discharged from the study if the child died, ‘defaulted’ (i.e. was absent for three consecutive visits) or was ‘non-cured’ (i.e. had not reached the discharge criteria) after sixteen weeks (112 days). All admissions and discharges from the study were approved and verified by a member of the Valid International research team. Any study subject discharged from the study as ‘non-cured’ was also assessed according to Malawi National Guidelines and referred back to the standard Ministry of Health programme for further treatment if the child had not reached the discharge criteria as ‘cured’ according to national guidelines.Previous studies had indicated that most mortality following treatment for SAM occurs within three months of discharge . Each chNo preferential treatment was given to study subjects compared with non-study subjects.On admission and at each subsequent visit, the child’s weight was measured (naked or wearing light undergarments and without shoes) to the nearest 100 g using Salter™ scales , the model used by the health centre for the clinical management of SAM cases. MUAC was measured to the nearest millimetre using a standard non-elastic MUAC tape . On admission and discharge the child’s height was measured to the nearest millimetre using a standard paediatric height board (supine length was measured for children less than 24 months of age).After discharge as ‘cured’, the child was followed up at home every two weeks for a three-month period by a HSA trained in the study protocols. At each follow-up visit the child was assessed for illness  and their MUAC was measured by the HSA.R Language for Data Analysis and Graphics [null hypothesis for the Kruskal-Wallis test is that the data in each group have the same distribution of the variable of interest. The strength of association between cure and MUAC at admission and attendance rate was investigated using logistic regression.Data were collected on paper forms designed for the purpose and were entered into an EpiData Version 3.1  database using both interactive checking for range and legal values and double-entry validation. Statistical analysis was performed using the Graphics . Height-Graphics . The KruTable Figure Table Figure p < 0.0001). Each millimetre increase in admission MUAC resulted in a 2.2 %  increase in the odds of cure. Each percentage point increase in the attendance rate was associated with a 1.13 %  increase in the odds of cure. These increases appear small but they are for small increases in variables with wide ranges. A ten millimetre increase in admission MUAC (e.g. from 102 mm to 112 mm) was associated with a 23.8 %  increase in the odds of cure. A twenty-percentage point increase in attendance (e.g. from 60 % to 80 %) was associated with a 25.2 %  increase in the odds of cure.The median attendance rate for ‘cured’ patients  was 87.0 %. Figure The 19 children identified as being HIV positive showed similar treatment outcomes to other children: ‘Cured’ 52.6 %, ‘Died’ 5.3 %, ‘Default’ 21.1 %, and ‘Non-cured’ 15.8 %.p < 0.0001) with a median duration of treatment in the lowest MUAC group of 98 days (IQR = 60 days – 105 days) and in the highest MUAC group of 42 days (IQR = 35 days—63 days).Figure p < 0.0001) with median proportional weight gain of 42 % in the lowest MUAC group (IQR = 40 % − 47 %) and 18 % in the highest MUAC group (IQR = 14 % − 22 %).The median proportional weight gain of all children in the study was 21 % (IQR = 16 % − 27 %). Children with lower MUACs experienced higher proportional weight gains  and a longer median length of stay under treatment than taller children . These children were no more likely to be discharged as ‘non-cured’ than taller children (relative risk (RR) = 0.93, 95 % CI = 0.77 − 1.13, chi-square = 0.33, p = 0.5667). There was no association with negative outcomes at three months post discharge for children with heights at admission below 65 cm than for taller children , p = 0.5798).Figures p = 0.0645).The median height at admission of ‘cured’ cases was 67.5 cm (IQR = 63.5–72.6) and the median height at admission of ‘non-cured’ cases was 66.5 cm (IQR = 60.8–70.1). Lower height at admission was not significantly associated with being’non-cured’ . This analysis should be interpreted with caution as defaulter follow-up was limited and deaths in defaulters may have not been detected and recorded.The median height at admission for those known to have died was 62.2 cm (IQR = 60.1–65.9) and the median height at admission for those not known to have died was 67.5 cm (IQR = 63.0–72.3). Lower height at admission was significantly associated with mortality . None of the children identified as HIV positive and discharged ‘cured’ either ‘relapsed’ or ‘died’ within the three-month follow-up period.The proportion of patients discharged as ‘cured’ and experiencing relapse to SAM  or non-violent/non-accidental death  was 3.2 %  receivedSFP rations. There were no negative outcomes amongst these 45 children after three months of follow-up . Of the 45 children receiving SFP, 20 % (n = 9) became moderately acutely malnourished (MAM) with a MUAC between 11.5 and 12.4 cm during the follow-up period. 44 % (n = 4) of those who became MAM during follow-up remained MAM at the last follow-up visit.Of the 155 children followed up after being discharged as ‘cured’, 29 %  of the cohort of ‘cured’ patients and non-accidental and non-violent deaths formed 1.3 % (95 % CI = 0.2 %–4.6 %) of the cohort of ‘cured’ patients over the three-month follow-up period. Negative outcomes occurred in 3.2 % (95 % CI = 1.1 %–7.4 %) of the cohort of ‘cured’ patients over the three-month follow-up period. None of the negative outcomes observed during the 3-month follow-up were in children identified as HIV positive at admission. Post-discharge deaths were not associated with relapse to SAM and were not associated with having a discharge WHZ below −2 z-scores. While there are no internationally agreed standards for relapse and mortality following cure from CMAM programmes, all cases with a negative outcome following discharge had a discharge WHZ above −1 z-scores. This suggests that MUAC ≥ 125 mm for two consecutive visits is as at least safe as discharge using WHZ > − 1 z-scores. The rate of relapse and mortality following discharge as ‘cured’ reported in this study are also similar or lower to those reported by Ashworth in other studies using weight for height (e.g. WHZ > −1 or weight-for-height percentage of median > 85 %) as the discharge criterion from CMAM programmes [Children with lower MUAC at admission had longer durations of treatment and higher proportional weight gains than the children admitted with a higher MUAC. This shows that the MUAC discharge criterion ensures children who are the most malnourished remain under treatment longer and are discharged with a higher proportional weight gain. This eliminates the problems previously identified with the proportional weight gain criterion  and its Children with height less than 65 cm at admission also showed greater proportional weight gain and had longer lengths of stay than taller children and showed no association with negative outcomes three months after discharge. These findings may be partly explained due to younger children typically having higher weight gains even when well nourished and that, on average, younger children are shorter. However, these children respond and benefit the most from treatment, and the evidence of this study should allay concerns that using MUAC is not appropriate as an admission or discharge criterion for stunted children aged 6 months or older with a height below 65 cm.A high proportion of children (92.2 %) received antimicrobials during treatment although the compliance with protocol was lower for Vitamin A and anthelminthics. A low proportion of children (65.1 %) received the full CMAM protocol of medicines. This was due to shortages of supply at the clinics. Whilst this may represent a limitation to this study, the outcomes of the study reflect the context of an MoH programme with supply shortages.Reasons for defaulting included waiting times for treatment at the clinic site and prioritisation of household labour (e.g. harvesting). Some defaulters had reportedly migrated away from their temporary home in the treatment catchment area.It was expected that enrolment into SFP after cure would have a large positive effect on negative outcomes following discharge, however, negative outcomes were rare and any analysis will lack statistical power to detect all but very large effects. The data suggest a small positive effect of SFP enrolment may be present.Study findings included a high non-cure rate (18.9 %) for all children combined (15.8 % for children identified as HIV positive at admission). MUAC at admission and attendance rate were positively associated with cure.In the absence of the incentivised follow-up of absentees and defaulters; reducing waiting and transit times for clinic visits, frequent counselling to refrain from sharing RUTF, and case review by physicians did little to improve attendance and reduce the non-cure rate over time.These results provide strong evidence that the proportion ‘cured’ can be influenced by program design and activities that improve the detection, early recruitment and retention of SAM cases as well as compliance to the SAM treatment protocol.Care should be taken in extrapolating these results to other populations, however data from CMAM programmes using the same discharge criterion in other contexts report similar findings in terms of median duration of treatment (approximately 8 weeks or 56 days). , 4.Additional studies may be needed to assess whether a discharge criterion of MUAC ≥ 125 mm is safe in other CMAM programs with low levels of supervision and in other settings. There are currently no internationally agreed standards by which to assess the safety of MUAC or other discharge criteria, however this study indicates that low rates of relapse and mortality following cure are achievable in low resource, non-emergency settings.This study confirms that a discharge criterion of MUAC ≥ 125 mm is safe and practical leading to low mortality and relapse at three months post discharge in the context of Malawian Ministry of Health outpatient care facilities. Negative outcomes were not associated with failing to meet the WHZ > −2 z-scores criterion. This MUAC discharge criterion was also found to be appropriate for children aged six months or older who are less than 65 cm in height at admission. Compliance, as measured by attendance rate, and MUAC at admission were both positively associated with cure.Children admitted with lower MUAC remain under treatment longer and achieve higher proportional weight gains when MUAC discharge criteria are used. The introduction of MUAC discharge may lead to longer average length of stay initially where there is limited case finding and admission MUAC may be expected to be low. Early detection and recruitment of severe acute malnutrition cases using MUAC in the community and compliance with the CMAM treatment protocols should, however, reduce lengths of stay and associated treatment costs.


Plasmodium falciparum is responsible for most of the morbidity and mortality. There are differences in both the epidemiology of imported malaria and in the facilities available to treat travellers with severe malaria between different parts of the world. There are limited data to guide clinicians caring for adults with imported malaria in an intensive care unit (ICU). Available data from the English-speaking literature concerning such patients was reviewed.Malaria is the most important imported tropical disease. Infection with PubMed was searched for studies on adults with imported malaria treated in an ICU. Data were extracted on the epidemiology, management, rates of concomitant community-acquired bacterial infection and outcomes.Thirteen studies were identified, which between them included 1,001 patients over more than 40 years. Forty-one per cent were born and often still resident in an endemic country and were assumed to have at least partial immunity to the disease. Acute kidney injury (AKI) (36%), acute respiratory distress syndrome (ARDS) (31%) and impaired consciousness (25%) were common. Hyperparasitaemia (more than 2%) was seen in 57%. Thirty-four per cent required mechanical ventilation and 22% required renal replacement therapy. Community-acquired bacterial co-infection was seen in 8%; 2% had gram-negative bacteraemia at admission. Overall the case fatality rate was 9%.Many patients who require admission to ICU were originally from malaria-endemic countries and many did not have hyperparasitaemia. Gram-negative bacteraemia was uncommon among adults with severe malaria. The case fatality rate remains high; however, improvements in ICU care and increasing use of artemisinins may reduce this in the future. Plasmodium falciparum is responsible for virtually all cases of imported malaria that require admission to an intensive care unit (ICU), including those that die, which may be as many as 29%   10] repoTen studies  reported the presence of impaired consciousness, used as a proxy for cerebral malaria, which was seen in 238 patients overall .Five studies (n = 624) reported the total number of complications that occurred per patient. The mean number of complications seen was 2.86% (95% CI 2.81-2.91%). Individual patient data was not available to assess if particular combinations of complications occurred with an increased frequency.WHO defines severe malaria using a range of other criteria that include: acidosis, coagulopathy, hypoglycaemia, jaundice, and anaemia. The rates of these complications, where available, are shown in Table Case fatality rates were reported in all 13 studies. The overall case fatality rate was 9% (95% CI 8-11%) but a case fatality rate of over 15% was reported in four studies.This is the first review of imported falciparum malaria among adults who were sufficiently unwell to require admission to ICU. The review supports four important conclusions. First, hyperparasitaemia, however this is defined, is not a feature in almost 50% of patients; second, up to 40% of these patients were originally from or still resident in a malaria-endemic region and may therefore be assumed to have at least partial immunity to the disease; third, co-infection with community-acquired gram-negative bacteraemia is uncommon among adults; and, finally, the case fatality rate for severe imported malaria in ICU is in the region of 10%.AKI, ARDS and cerebral malaria were all common. Invasive ventilation was required in 22% and renal replacement therapy was required in approximately 22%. Hyperparasitaemia, which is often used as a proxy for severe falciparum, was seen in only 57% of subjects when a cut-off of ≥2% was used. When using a definition of ≥5% parasitaemia, which the WHO recommends as the criterion for severe disease in endemic areas, this proportion fell to 44%. Clinicians would be well advised not to rely on parasite count as the only indicator of severe disease.Salmonellae, is a well recognized complication of malaria in children [Gram-negative bacteraemia, classically with non-typhoidal children , occurrichildren . While 8The overall case-fatality rate was 9% although one study  reportedThis review has several weaknesses. A number of studies that were not published in English were excluded and it is possible that this may have had an effect. Most of the included studies were from Europe and the conclusions may not be relevant to other settings where imported malaria is seen. In particular, indications for ICU admission are likely to have varied both between the study sites and over the period that the studies were conducted, which may partially explain the spectrum of disease severity and outcomes seen. Individual patient data were often unavailable, which meant paediatric cases could not reliably be excluded, although there were only 15 of these. For the same reasons, it was not possible to analyse temporal trends in case fatality rates or perform a detailed meta-analysis of risk factors associated with mortality. However, the review includes all series of more than ten patients published in English over more than 40 years and provides important insights into the management of this relatively uncommon disease.It is noteworthy that no case series from North America were included in the current paper. In 2011 the United States reported 1,925 cases of America of which 183 were reported to have severe disease . Given tThe overall case fatality rate of 9% may not reflect modern practice. Management of ARDS has improved considerably in recent years and newer strategies for fluid resuscitation, in particular, may reduce the incidence of both multi-organ failure and long-term disability . SimilarThe authors declare that they have no competing interests.MM undertook the literature search, performed the data collection and analysis and wrote the first draft of the paper. MA contributed to data interpretation, figures and writing of subsequent drafts. DW contributed to data interpretation and writing of subsequent drafts. TD initiated the project, contributed to data interpretation and the writing of subsequent drafts. All authors read and approved the final manuscript.Definitions of Immunity. The data provided outline the definitions of ‘immunity’ used in the studies included in this paper.Click here for fileDefinitions of Complications. The data provided outline the definitions of complications of malaria used in the studies included in this paper.Click here for file


We earlier established that nitric oxide (NO) is protective against severe malaria and that arginine and NO levels are reduced in malaria patients. We now show that an M2-like blood monocyte phenotype is significantly associated with hypoargininemia, NO insufficiency, and disease severity in Tanzanian children with falciparum malaria. Compared to control children (n = 106), children with moderately severe (n = 77) and severe falciparum malaria (n = 129) had significantly higher mononuclear cell arginase 1 mRNA, protein, and enzyme activity; lower NOS2 mRNA; lower plasma arginine; and higher plasma IL-10, IL-13, and IL-4. In addition, monocyte CD206 and CD163 and plasma soluble CD163 were elevated. Multivariate logistic regression analysis revealed a significant correlation of risk of severe malaria with both plasma IL-10 and soluble CD163 levels. Monocyte M2 skewing likely contributes to NO bioinsufficiency in falciparum malaria in children. Treatments that reverse the M2 polarization may have potential as adjunctive treatment for malaria. Falciparum malaria remains an important worldwide problem with over 200 million cases and an estimated 584,000 deaths each year234567in vivo or in vitro in response to infection with microbes or cytokines to display different phenotypes. Infection with Listeria monocytogenes or bacillus Calmette Guerin, or in vitro in treatment with cytokines such as IFN-γ and TNF causes “classical” (M1) activation with cells displaying enzymatic mechanisms of microbicidal activities including high NOS2-produced NO and NADPH oxidase-produced superoxide91011in vivo or in vitro by treatment with factors such as IL-4, IL-13, IL-10, and TGF-ß13141516171815161718Investigators have noted that monocytes and macrophages can be activated We enrolled 312 subjects—106 HC, 77 MSM, 78 SM without cerebral malaria, and 51 with SM with CM  . In the Malaria patients had significantly elevated monocyte and neutrophil counts, as well as decreased lymphocyte counts, and monocyte/lymphocyte ratios . PlateleAs we have reported before, plasma arginine levels were significantly lower in all malaria groups compared to HC subjects at the time of presentation (day 0), but the levels were comparable in MSM, SM, and CM . Plasma Mononuclear phagocytes (monocytes and macrophages) can produce either arginase 1 or 23in vivo, or after in vitro treatment with factors such as IL-4, IL-13, IL-10, and TGF-ß131415161718Arginase 1 is typically elevated in alternatively activated (M2) monocytes and macrophages We measured plasma levels of selected cytokines and chemokines to assess potential soluble factors associated with M2 activation of the monocytes. Levels of the cytokines/chemokines characteristic of M1 monocytes   were ele10 sCD163 was associated with a 4.68-fold  increase in odds of severe malaria  increase in odds of severe malaria  monocytes. Based on these findings, we conclude that these plasma cytokine/chemokine and PBMC/monocyte alterations characterize a unique malaria monocyte activation phenotype that likely contributes to the NO bioinsufficiency that is significantly associated with the development of severe malaria. 14in vivo during infection with intracellular organisms such as Listeria monocytogenes or bacillus Calmette Guerin91011101112Macrophage activation was initially characterized in mouse peritoneal macrophages based on “activation” in vitro studies with human monocytes have established numerous conditions for activating these cells to several different phenotypes1516171819111414Later a second pathway of “alternative” (M2) activated mononuclear phagocytes was characterized15161718RBC contain arginase 1, and RBC lysis releases arginase 1 into plasma. We have noted high levels of erythrocyte-free hemoglobin in plasma of Indonesian adults with falciparum malariaThe increased polarization towards the M2 phenotype and the increased arginase activity may also affect the immune response in malaria by altering the metabolism substrates available to lymphocytes34CD163 is a receptor for hemoglobin-haptoglobin complexes. Mononuclear phagocyte expression of CD163 can be stimulated by free hemoglobin, heme, hemozoin, IL-10, IL-4, and glucocortioids2337IL-10 and lactic acid levels are of particular interest. Both IL-10474849Plasmodium yoellii have reduced ability to resist infection with non-typhoid Salmonella typhimurium. This is associated with high levels of IL-10 and presence of macrophages with certain characteristics of alternative activationS. typhimurium infection in the mice. In other work, Antonelli and others using a different classification for monocytes showed that patients with P. vivax infection have “activated monocytes” in the blood defined as CD14+CD16+ , CD14+CD16+ (inflammatory), and CD14loCD16+ (patrolling) cellsP. vivax-infected reticulocytes, which induced them to produce high levels of TNF-α and reactive oxygen species. Teirlinck and co-workers studied antigen presenting blood cells in normal volunteers intradermally infected with P. falciparum sporozoitesIn studies of a malaria co-infection model in mice, Lokken and co-workers noted that animals infected with et al.Martinez and GordonIn this report, we have studied healthy children, children with moderately severe malaria, and children with severe malaria. Future studies of children with asymptomatic parasitemia and children with malaria not requiring hospitalization  will likely provide additional important information relevant to work that we report here. Also, it is possible that helminth infestation may have affected our findings. We did not test for helminth infestation in any of the children. The influence of helminth infestation on malaria severity is controversial—depending on the helminth and the publication, some have reported that helminthiasis may either reduce or enhance malaria severity5556In summary, the M2-like activation of monocytes in malaria leads to hypoargininemia and NO insufficiency. It is important to note that there are a variety of agents that can prevent activation to M2, or reverse M2 activation to unactivated cells or M1 cells. These include IFN-γ1010In addition to reducing malaria severity, studies in mice have shown that it is possible that some of these agents  could, through pro-inflammatory effects, make the malaria worseWe obtained written informed consent for participation from parents or guardians of all subjects. In Dar es Salaam, Tanzania, children between ages 4 and 8 years were enrolled from Amana or Mwananyamala District Hospitals, or the Hubert Kairuki Memorial University Memorial University (HKMU). The study was approved by the Ethics Committees/IRBs of HKMU, the Tanzanian National Institute for Medical Research, Duke University Medical Center, University of Utah, Menzies School of Health Research, and the Salt Lake City and Durham V.A. Medical Centers. Methods were carried out in accordance with the approved guidelines. Subjects were enrolled from 2008 through 2014.Healthy controls (HC) were defined as unrelated children who were subjectively well with no history of fever in the preceding 48 hours, no parasitemia by microscopy, and no concurrent illness or medication. Moderately severe malaria (MSM) children were defined as those with fever or a history of fever in the past 48 hours; with >2,500 asexual falciparum parasites/μL ; no other etiology identified, and requiring inpatient parenteral therapy because of inability to tolerate oral therapy, but exhibiting no WHO warning signs or criteria for severe malaria20Heparinized blood was collected and processed rapidly, and counted on an automated blood counting machine . Hemoglobin, biochemistry, acid base parameters, and lactate were measured with a bedside analyzer (i-STAT Corp). WBC differentials were determined manually by visual examination of stained blood films. Plasma levels of arginine were quantitated by HPLC as previously describedhttp://universalprobelibrary.com). The quantitative PCR reactions were done using an ABI7300 machine. Samples were run in triplicate, or in duplicate if sample amount was limiting. We selected GAPDH and HPRT1 genes as endogenous control genes. The average crossing threshold (Ct) of the endogenous controls for each sample was used in the dCt calculation. We used each sample dCt and the averaged healthy control dCt or individual ddCt values. For group ddCt values, we used the average dCt for each group to calculate ddCt for the group. The data are expressed as 2-ddCt, which is the fold change as compared to the average of the healthy controls. Surface antigens on blood cells were detected with a Becton-Dickinson LSR-II cytometer using the following antibodies: CD14 , CD163 , and CD206 . We determined cell viability with Aqua Vital Dye , and we gated Vital Dye negative and CD14 positive cells as monocytes. We quantified PBMC arginase 1 protein by immunoblot with densitometry using an affinity purified polyclonal, goat anti-human arginase 1 antibody .We isolated PBMC using standard methods with density gradient sedimentation with ficoll/Hypaque. Cellular RNA and protein were extracted using the “All Prep” kit . We subjected RNA to real-time reverse transcriptase-polymerase chain reaction (RT-PCR) analysis as we have described beforeStatistical analyses were performed using STATA software . Results are presented as mean with standard deviation for normally distributed continuous variables or median with interquartile range for variables with non-parametric distribution. For continuous variables with normal distributions, differences across groups were compared by ANOVA with Bonferroni adjustment for multiple comparisons, and differences between groups were compared using Student’s t-test. For continuous variables with a nonparametric distribution, we compared differences across groups with the Kruskal-Wallis test and differences between groups with the Wilcoxon rank-sum test. Correlation between variables with non-parametric distributions was assessed using Spearman correlation coefficients. Differences in proportions between groups were assessed with Chi-square test. We did multivariate linear regression analyses to control for age, weight and sex when comparing concentrations of chemokines and cytokines among the various clinical groups.Among patients with malaria, backward stepwise multivariate logistic regression was performed to determine whether plasma soluble CD163, plasma IL-10, or plasma arginase activity were independently associated with disease severity. Bivariate logistic regression was used for analysis of soluble CD163, IL-10, and arginase activity along with other cytokines/chemokines. Additional variables included in the multivariate model based on biological plausibility included hemoglobin and absolute monocyte count ; lactate ; age, weight and sex . Other established biomarkers of disease severity, such as HRP-2 or angiopoietin-2, were not included in the final multivariate logistic regression model due to the limited number of observations . Similarly, a combined summary multivariate logistic regression including sCD163, IL-10, arginase activity, and other biologically plausible variables was not feasible because of the limited number of observations that included all variables. Continuous variables with non-parametric distributions were log-transformed to meet normality assumptions for use in the logistic regression models. We assessed goodness-of-fit with the Hosmer-Lemeshow test. A two-sided p-value < 0.05 was employed as the cut-off for statistical significance throughout.How to cite this article: Weinberg, J. B. et al. Monocyte polarization in children with falciparum malaria: relationship to nitric oxide insufficiency and disease severity. Sci. Rep.6, 29151; doi: 10.1038/srep29151 (2016).


Blood transfusions can reduce mortality among children with severe malarial anaemia, but there is limited evidence quantifying the relationship between paediatric malaria and blood transfusions. This study explores the extent to which the use of paediatric blood transfusions is affected by the number of paediatric malaria visits and admissions. It assesses whether the scale-up of malaria control interventions in a facility catchment area explains the use of paediatric blood transfusions.The study was conducted at a referral hospital for 13 rural health centres in rural Zambia. Data were used from facility and patient records covering all paediatric malaria admissions from 2000 to 2008. An interrupted time series analysis using an autoregression-moving-average model was conducted to assess the relationship between paediatric malaria outpatient visits and admissions and the use of paediatric blood transfusions. Further investigation explored whether the use of paediatric blood transfusions over time was consistent with the roll out of malaria control interventions in the hospital catchment area.p < 0.05). For each additional paediatric admission for severe malarial anaemia, there were 1.09 additional paediatric blood transfusions . There were 19.1 fewer paediatric blood transfusions per month during the 2004–2006 malaria control period , a 50% reduction compared to the preceding period when malaria control was relatively limited. During the 2007–2008 malaria control period, there were 27.5 fewer paediatric blood transfusions per month , representing a 72% decline compared to the period with limited malaria control.For each additional paediatric malaria outpatient visit, there were 0.07 additional paediatric blood transfusions (95% CI 0.01-0.13; Paediatric admissions for severe malarial anaemia largely explain total use of paediatric blood transfusions. The reduction in paediatric blood transfusions is consistent with the timing of the malaria control interventions. Malaria control seems to influence the use of paediatric blood transfusions by reducing the number of paediatric admissions for severe malarial anaemia. Reduced use of blood transfusions could benefit other areas of the health system through greater blood availability, particularly where supply is limited. Plasmodium falciparum[Malaria is one of the leading causes of child mortality in sub-Saharan Africa (SSA). According to the most recent estimates from the World Health Organization World Malaria Report 2013, malaria accounted for approximately 627,000 deaths world-wide in 2012, of which almost 77% were among children under five years of age . Severe Evidence demonstrates that blood transfusions can save the lives of children with severe malarial anaemia , 9, and Other frequent uses of blood transfusions, particularly in low- and middle-income countries, include severe obstetrical haemorrhage, trauma, and severe childhood anaemia, which is often but not always due to malaria , 16. DesGiven the extensive use of blood transfusions to treat severe malarial anaemia, particularly among children, reducing the incidence of malaria through improved malaria control could substantially reduce the need for paediatric blood transfusions. In turn, reductions in the use of paediatric blood transfusions could benefit non-malaria patients, such as trauma patients or patients with post-partum haemorrhage, particularly in areas with blood supply shortages. There is limited research assessing the effect of malaria control on the use of paediatric blood transfusions. Two studies focused on the effects of improved malaria treatment. In Zanzibar, the number of blood transfusions for children under five years of age fell by 67% with the introduction of artemisinin-based combination therapy (ACT) . In ZambUsing retrospective time-series data from 2000 to 2008 from one hospital in Zambia, this study quantifies the extent to which the use of paediatric blood transfusions is associated with the number of paediatric malaria outpatient visits, paediatric malaria admissions, and paediatric admissions for severe malarial anaemia. Paediatric admissions for severe malarial anaemia are a sub-category of all paediatric malaria admissions; other malaria admissions include complications such as malarial anaemia, cerebral malaria, and the combination of these. This study tests the underlying assumption that a reduction in malaria outpatient visits is associated with a reduction in malaria admissions, which in turn may influence blood transfusion use. The rate at which malaria outpatient visits decrease over time relative to inpatient malaria admissions may depend on factors such as hospitals continuing to admit the most serious malaria cases. This study seeks to test these various relationships to better understand their associations with each other and, ultimately, their relationship with paediatric blood transfusion use.The study then investigates whether the use of paediatric blood transfusions is associated with the scale-up of malaria control efforts in the hospital’s catchment area over time. Specifically, it assesses whether there is a difference in the rate of monthly use of paediatric blood transfusions before and after malaria control scale-up, as well as a difference in the average monthly use before and after scale-up. Not only does this study complement the evidence from Ghana on the effect of malaria control scale-up on paediatric blood use, it also quantifies the extent to which the use of paediatric blood transfusions varies with paediatric malaria visits and admissions.This study also explores the seasonality of paediatric blood use, for which there is limited evidence. Countries with high seasonality of malaria incidence are those where 60% of the annual rainfall occurs within three months; these countries mostly include SSA countries located in the Sahel and sub-Sahel . In ZambFinally, this study conducts exploratory analyses to identify whether total blood use at the hospital is influenced by blood use in the paediatric ward. It also tests whether use of blood transfusions in the paediatric ward affects use of blood transfusions in other patient wards, to identify potential spillover effects (or indirect benefits) for other patients. There are no known studies assessing the potential benefits of malaria control scale-up for non-malaria patients, by freeing up blood supply for other conditions.This study was conducted in Zambia, a country in southern Africa with historically high prevalence of malaria that has made significant progress in reducing malaria morbidity and mortality over the past decade . Zambia Plasmodium falciparum[Anopheles arabiensis are the main vector responsible for malaria transmission in the Macha area [et al. 2003); this EIR is similar to other countries in sub-Saharan Africa and lower than many countries in West Africa [Malaria transmission in MMH’s catchment area, covering approximately 160,000 people, has traditionally been hyperendemic transmission of lciparum. Anophelcha area . A 2002 t Africa .In Southern Province, there is one rainy season from November to April, followed by a cool dry season (April-August) and a hot dry season (August-November) . Data shIn 2003, the Zambian government introduced a revised malaria treatment policy by including ACT, specifically artemether-lumefantrine (AL), making Zambia the first country in Africa to adopt ACT as the national first-line therapy for the treatment of uncomplicated malaria. MMH introduced ACT as its first line of treatment soon after the policy shift Figure . Kalomo In 2005, the three districts in MMH’s catchment area received RDTs in line with the National Malaria Control Programme’s new policy to strengthen malaria diagnosis with RDTs . In addiThe study uses retrospective monthly time-series data, drawn from facility and patient records from 2000 to 2008. Inpatient malaria admission data, available from 2003 to 2008, were extracted from an electronic database that included all malaria admissions for patients five years and under. These data include patient age, sex, length of stay, malaria microscopy results, primary and secondary discharge diagnosis, treatment for malaria (including blood transfusions), and co-morbidities. Data on monthly under-five outpatient visits for malaria were extracted from the hospital-affiliated health centre disease aggregation forms and were available for the period 2000–2008.Monthly blood transfusion data for the paediatric (five and under), maternity, women’s, men’s, and tuberculosis wards were collected from an electronic database tracking all blood transfusions given at MMH from 2000 through 2008. The database was periodically consolidated by Macha Research Trust using the hospital-based laboratory blood bank transfusion log books; the senior author on this study coordinated and supervised the quality of these data throughout the reference period of the study to ensure quality and consistency. The data represent total monthly blood transfusions given by ward. Transfusions are measured as the number of transfusions completed per patient, and not as a measure of the units of blood transfused. Blood transfusion data specifically for paediatric malaria admissions were obtained from an electronic database of all paediatric malaria admissions from 2003–2008. The analyses used the data on total paediatric blood transfusions rather than paediatric blood transfusions for severe malarial anaemia from these patient records. These latter data were only available for 2003–2008, limiting the number of time points prior to malaria control scale-up. The statistical correlation between total paediatric blood transfusions and those used for severe malarial anaemia is high (0.94), justifying the use of total paediatric blood transfusion as a proxy for those used for severe malarial anaemia.Given differing data sources and data management approaches among sources, the data on total hospital admissions and outpatient visits use different age thresholds than the malaria admission and blood transfusion data. The HMIS data report data for children under five years of age, while the electronic database on paediatric inpatient malaria admissions and blood transfusion reports data on children five years and under. Although there is a discrepancy in the age categorization across sources, this does not affect the main analysis between malaria admissions and paediatric blood transfusions since the same age threshold is used. Hereafter, for simplicity, all patient data will be referred to as paediatric cases.For this study, paediatric admissions with severe malarial anaemia and cerebral malaria with severe anaemia were classified based on the first and second discharge diagnosis in the patient records. Severe malarial anaemia was diagnosed if haemoglobin (Hb) <5 g/100 ml. At MMH, the criteria for transfusion is haemoglobin less than or equal to 5 g/100 ml, consistent with the WHO guidelines for treating severe anaemia. In reality, blood transfusions may have been given to patients with Hb >5 at the discretion of the physician if the patient was thought to be unstable, had very high parasitaemia, experienced cardiac failure, or had co-existing malnutrition. Because the blood transfusion data for the paediatric malaria admissions were drawn directly from patient records, these transfusions are reflected in the data. Cerebral malaria with severe anaemia was diagnosed if a child has a positive malaria smear with coma (Blantrye Coma Score ≤2) with no other cause found for the coma, and also had Hb <5 g/dl.The aim of this study was to assess the extent to which the use of blood transfusions in the paediatric ward is associated with the number of paediatric outpatient malaria visits, paediatric inpatient malaria admissions, and paediatric inpatient admissions for severe malarial anaemia. It then explores whether this association can be attributed to the scale-up of malaria control interventions in MMH’s catchment area, based on the timing of these interventions. The following presents the hypothesized logic model relating malaria control scale-up with use of paediatric blood transfusions: First, effective malaria control should reduce the incidence of malaria in the hospital’s catchment area. A decrease in malaria incidence across the population should reduce the number of paediatric outpatient malaria visits. More effective malaria control, through prevention, should decrease the number of malaria cases. In addition, more effective first-line treatment should decrease the number of severe malaria cases, including severe malarial anaemia. Together, the number of admissions for malaria should fall. Since a large portion of paediatric blood transfusions are used for malaria, a reduction in these admissions should reduce the use of paediatric blood transfusions overall.Malaria control scale-up may also indirectly affect the use of blood transfusions in other patient wards. If the blood supply is limited at a health facility and there are competing uses for blood resources, a decline in blood transfusion use in one ward may result in greater blood availability for other wards. If blood transfusion use in the paediatric ward declines with malaria control scale-up, then more blood may be available for use in other wards. These potential spillover effects (or indirect benefits) are most likely to occur if the total blood supply is fixed or limited, and if it is rationed between wards; otherwise, such spillover effects may not exist, or may be relatively small.All analyses used an autoregressive-moving-average (ARMA) model to account for potential autocorrelation of time-series data. By accounting for the potential correlation over time in the outcome variable, this model prevents the observed effects from being confounded by secular trends over time, which also affect the outcome. The model also accounts for potential correlation of the residual (unobserved) term over time. Based on the autocorrelation function for the monthly paediatric blood transfusion data, the best-suited model for the main analyses included two lag variables for both the autoregressive model and the moving-average model (defined as a AR(2)MA(2) model which means that there exist correlations across the two most recent time periods). The ARMA model uses a maximum likelihood estimator. To account for potential unequal variance in the error term by year (heteroskedasticity), the model used robust standard errors. All analyses were conducted using Stata SE .The main outcome of interest was the number of monthly paediatric blood transfusions. The first analyses quantified the relationship between the use of paediatric blood transfusions and the number of paediatric malaria outpatient visits. In this model, the regression included an interaction term that identifies the 2004–2008 period which represents the time period of malaria control scale-up in MMH’s catchment area. The interaction term shows whether the relationship between paediatric malaria visits and paediatric blood transfusions changes when malaria control is scaled-up. Similar analyses were conducted using paediatric malaria admissions and paediatric admissions for severe malarial anaemia, respectively, as the independent variables.The next set of analyses used an interrupted time series model to investigate whether the rate of use of paediatric blood transfusions is different when malaria control is scale-up and whether the average number of paediatric blood transfusions used differs as well. In these models, the independent variables included: 1) a monthly trend variable for the 2000–2003 period, 2) a variable capturing the average difference in quantity of paediatric blood transfusions used per month during the 2004–2008 period relative to the 2000–2003 period, and 3) a monthly trend variable for the 2004–2008 period. The 2000–2003 monthly trend variable represents the rate of paediatric blood transfusion use prior to malaria control scale-up in the hospital’s catchment area. The 2004–2008 monthly trend variable identifies the rate of paediatric blood transfusion use from 2004–2008, representing the malaria control scale-up period. A comparison of these two variables shows whether the rate of use is different before and after malaria control scale-up. The difference in monthly use variable identifies whether average number of monthly paediatric blood transfusions used during the 2004–2008 period is different than the monthly average used in the 2000–2003 period. A similar model was run separating the malaria control scale-up period into two periods: 2004–2006 and 2007–2008. This specification allows the monthly trend (change in use over time) and average difference in monthly use during both post scale-up periods to be different from each other, since different malaria control activities were taking place in these two periods. In addition, 2006 was a year when malaria control was limited because of the ACT shortage. By separating these years, this allows the magnitude of the effects to differ.The model assumed that all years prior to 2004 were considered years when malaria control was not scaled up in MMH’s catchment area. The next set of analyses used the same model but included, as the dependent variable in separate regressions, the number of paediatric malaria outpatient visits, paediatric malaria admissions, and paediatric admissions for severe malarial anaemia, respectively. These analyses served to confirm whether the changes in the use of paediatric blood transfusions as a function of malaria control scale-up could be explained by the changes in malaria outpatient visits and malaria inpatient admissions related to malaria control scale-up.Exploratory analyses were conducted to identify the relationship between paediatric blood transfusion use and total use of blood transfusions at the hospital. Similar analyses were also done using, as dependent variables, blood transfusion use in different patient wards, including the maternity, women’s, men’s, and tuberculosis ward. These analyses include an interaction term, to assess whether the relationship between blood use in the paediatric ward and blood use in other wards is different during the 2004–2008 malaria control scale-up period.Summary statistics for both paediatric outpatient malaria visits and paediatric malaria admissions at MMH show substantial declines over time Table . During Over the same period, yearly paediatric blood transfusions followed similar trends as paediatric malaria admissions and outpatient visits. In 2000, there were 588 blood transfusions in the paediatric ward , and for each additional paediatric admission for malaria, there were 0.19 additional paediatric blood transfusions . Lastly, for each additional paediatric admission for severe malarial anaemia, there were 1.09 additional paediatric blood transfusions . Paediatric admissions for severe malarial anaemia are a subset of all paediatric malaria admissions. This result suggests that a patient admitted for severe malarial anaemia receives one blood transfusion, with some admitted patients receiving more than one blood transfusion during their stay. It also demonstrates that the paediatric admissions for severe malarial anaemia largely explain total use of blood transfusions in the paediatric ward. The interaction terms (identifying the 2004–2008 period) are not statistically significant for paediatric malaria outpatient visits and paediatric malaria inpatient admissions (columns 2 and 4). This means that the relationship between malaria cases (outpatient visits and admissions) relative to the use of paediatric blood transfusions does not change over time, as malaria control is scaled-up. However, the interaction term is statistically significant for paediatric admissions for severe malarial anaemia (column 6). These results imply that, 2004–2008, there were 0.45 additional paediatric blood transfusions for every additional paediatric admission for severe malarial anaemia  and the coefficient for the interaction term (−0.60)). Yet during the 2000–2003 period there were 1.05 additional paediatric blood transfusions for every additional paediatric admission for severe malarial anaemia. These findings indicate that, during the 2000–2003 period, if there was one less paediatric admission for severe malarial anaemia, there was one less paediatric blood transfusion used, compared to a decrease of one half during the 2004–2008 period.The main results Table  show thap < 0.01). During the 2004–2008 period, the rate of use remained constant over time since the variable representing the monthly trend for the 2004–2008 period is not statistically significant. However, the difference in monthly use during the 2004–2008 period is statistically significant. During the 2004–2008 period, there were, on average, 10.6 fewer paediatric blood transfusions per month compared to the 2000–2003 period . From an average of 38 paediatric blood transfusions during the 2000–2003 period, this represents a 28% reduction. In the second specification, the malaria control scale-up periods are separated to identify differences in effects during the 2004–2006 and 2007–2008 periods. During the 2000–2003 period, the rate of paediatric blood transfusion use decreased by 0.52 per month . Average monthly use of paediatric blood transfusions during the 2004–2006 fell by 19.06, representing a 50% reduction in monthly paediatric blood use compared to 2000–2003 period. However, the rate of paediatric blood use during this period increased by 0.34 per month . During the 2007–2008 period, average monthly use of paediatric blood transfusions fell by 27.5 , representing a 72% reduction compared to the 2000–2003 period. The rate of blood use during the period 2007–2008 remains constant. The results in all analyses are not explained by seasonal differences in blood transfusions, because the analyses control for average monthly differences in paediatric blood transfusions, driven by factors such as malaria transmission related to rainfall.The next analyses Table  show thaet al. find that this lag occurs because the highest proportion of mosquitoes is actively transmitting at the end of the rainy season [There is evidence of seasonal effects on use of paediatric blood transfusions Table . Over thy season .Table 5p < 0.01). During the 2004–2008 period, the rate of paediatric outpatient malaria visits decreased at a higher rate, with 1.41 fewer malaria outpatient visits per month . There were also, on average, 309.4 fewer paediatric outpatient malaria visits per month during the 2004–2008 period, representing a 68% decrease compared to the 2000–2003 period. The same analyses, looking instead at paediatric malaria admissions, could not be conducted because there is only one year of pre-malaria control data, insufficient to conduct an interrupted time series analysis.The next results Table  show thap < 0.01). The second regression includes a control variable for the 2004–2008 period and an interaction term to identify whether this relationship changes with during this period, relative to 2000–2003 period. This relationship does not change during the 2004–2008 period as the interaction term is not statistically significant. The relationship does change though for paediatric admissions for severe malarial anaemia (column 4) since the interaction term is statistically significant. During the 2000–2003 period, for every additional paediatric malaria outpatient visit, there were 0.05 additional paediatric admissions for severe malarial anaemia . During the 2004–2008 period, there were 0.11 additional pediatric admissions for severe malarial anaemia; this result is the linear combination of the coefficient for outpatient malaria visits (0.05) plus the coefficient with the interaction term (0.06). This results means that the number of severe malarial admissions did not fall at the same rate as the number of outpatient malaria visits, even though both of these fell substantially during the post-malaria control scale-up period. During the post-malaria control scale-up period, the proportion of admissions for severe malarial anaemia relative to outpatient malaria visits is 11% compared to 5% during the pre-malaria control scale-up period.The results also show that the relationship between paediatric outpatient malaria visits and inpatient malaria admissions does not change over time as malaria control is scaled-up. The analysis Table  shows thp < 0.01). For all regressions, a second regression is run which includes a control variable for the 2004–2008 period and an interaction term to identify whether this relationship changes with during this period, relative to 2000–2003 period. For total blood transfusions, the relationship does not change during the 2004–2008 period compared to the 2000–2003. These findings show that there is a one-to-one relationship between the use of paediatric blood transfusions and the overall use of blood transfusions at MMH. The relationships between paediatric blood transfusions and the use of blood transfusions in other patient wards are not statistically significant.As part of the exploratory analyses, the last results Table  show thaIn this study, the results show that the number of paediatric admissions for severe malarial anaemia largely explain the number of paediatric blood transfusions used. This finding highlights that reducing paediatric admissions for severe malarial anaemia lowers the use of paediatric blood transfusions. The results show a one-to-one relationship between paediatric admissions for severe malarial anaemia and paediatric blood transfusion use during the 2000–2003 period. This relationship appears to be affected by malaria control scale-up. As paediatric admissions for severe malarial anaemia decrease during the 2004–2008 period, paediatric blood transfusions continue to decrease but at a slower rate. This result is not due to an increase in use of blood transfusions among these admissions during the 2004–2008 period. Actually, during the 2004–2008 period 86% of these admissions received a blood transfusions compared to 96% during the 2000–2003 period. One possible explanation is that blood transfusions for severe malarial anaemia start to make up a smaller share of all paediatric blood transfusions (28% by 2008). Some of the paediatric blood transfusions are being used for other malaria admissions, specifically malarial anaemia admissions suggesting that a higher threshold may have been used for transfusing. Some paediatric blood transfusions are also for non-malaria patients (55%). The use of paediatric blood transfusions for non-malaria patients follows a similar pattern to the use by malaria patients. The trend in paediatric blood transfusions for non-malaria admissions also follows a similar pattern over time consistent with malaria control scale-up. One probable explanation is that these non-malaria patients may have been treated successfully for malaria at another facility, but were referred to MMH because of severe anaemia as a result of the recent malaria infection. Such patients would have received a blood transfusion if their haemoglobin was less than 5 but the discharge diagnosis would not identify them as malaria patients.The results show that fewer blood transfusions were administered on the paediatric ward in years when malaria control was scaled up in MMH’s catchment area compared to years when malaria control was not scaled up. Compared to the 2000–2003 period when malaria control was relatively limited, there was a 50% reduction in the average monthly use of paediatric blood transfusions from 2004–2006. During this period, ACT was introduced as the first line of treatment and the test-and-treat campaign was implemented (2004 and 2005). Although the monthly number of paediatric blood transfusions is lower in this period compared to 2000–2003, the rate of use was increasing during this period. One of the reasons for the increase in the rate of paediatric blood transfusions during this period is likely due to the countrywide ACT shortage in 2006. This ACT shortage may have led patients to either bypass the health centre or receive hospital referrals because of treatment shortages at the lower levels of care . In addiDuring the period 2007–2008, there was a 72% reduction in the monthly use of paediatric blood transfusions compared to 2000–2003. The ITN distribution campaign was rolled out during this period. The results comparing the 2004–2008 period with the 2000–2003 period are consistent with these findings, but the magnitude of the relationship with paediatric blood transfusions is smaller. This is again likely due to the increase in malaria visits and admissions in 2006 associated with the ACT shortage, which may have dampened the overall relationship. While there may have been some malaria control occurring in 2006 (through ITN distribution), the scale was not equivalent to the widespread distribution of ITNs beginning in 2007. For these reasons, the results for the two separate time periods are used to allow for the effect from these different years to differ. The decrease in the rate of paediatric blood transfusion use during the 2000–2003 suggests that there may have been limited malaria control during this period although much less pronounced than during the scale-up period from 2004 onwards.The substantial decline in paediatric outpatient malaria visits during the 2004–2008 period is consistent with the scale-up of malaria control interventions. This time period is associated with a 68% decrease in paediatric outpatient malaria visits. Although there are no available data on malaria incidence in the hospital’s catchment area, data on outpatient visits were used as a close proxy for malaria incidence. Certain limitations exist in interpreting these data relative to malaria incidence: They do not represent confirmed cases of malaria until RDTs were introduced, and they only include visits to MMH’s outpatient department and not visits to other lower level health centres. Nonetheless, the consistent association between the timing of malaria control scale-up and the decrease in paediatric outpatient malaria visits substantiates the hypothesized pathway through which malaria control scale-up could affect paediatric blood transfusion use. In addition, the analyses show a consistent correlation over time between malaria outpatient visits and malaria inpatient admissions. There is evidence that the rate at which paediatric outpatient malaria visits decreased is greater than the rate of decrease in paediatric malaria admissions. With effective malaria control, the number of outpatient malaria visits may fall faster than admissions because the proportion of cases that present at the health facility are in greater need of admission. Another possible explanation is related to the introduction of RDTs in 2007 at MMH, since prior diagnosis based on clinical presentation has been shown to over-estimate the number of malaria cases . The relThere is also evidence of the seasonal use of paediatric blood transfusions, consistent with the timing of the rainy season. Fewer paediatric blood transfusions are used during dry season months relative to rainy season months, which is consistent with the low and high malaria transmission months. Overall, these findings suggest that the use of paediatric blood transfusions is driven both by differences in malaria transmission resulting from seasonal variation (including severe drought), and by differences in malaria incidence over time resulting from the scale-up of malaria control efforts.In the context of this particular hospital, there are no identified spillover effects (or indirect benefits) from the use of paediatric blood transfusions on the use of blood transfusions in other patient wards. The evidence demonstrates that there is a one-to-one relationship between paediatric blood transfusions and total use of blood transfusions at MMH. This positive correlation suggests that there is not a fixed supply of blood at MMH and/or that the need for blood does not exceed the available supply at this particular facility. Blood does not appear to be rationed between patient wards; this explains why there are no indirect benefits on blood use in other patient wards despite the substantial differences over time in blood use in the paediatric ward. However, it is not possible to completely rule out that there could have been some rationing if paediatric patients were prioritized. The data represent blood transfusions used and not blood transfusions ordered, so it is not feasible to measure the demand or need for blood transfusions during this period. Another reason that there may be no effect is due to the measurement of blood transfusions; these are measured relative to patients and adult patients will require a greater quantity of blood per transfusion relative to paediatric patients. As a result, a large effect on paediatric blood use will translate to a smaller effect for adult patients.The analytical methods in this study are used to demonstrate correlations between the variables of interest, but do not show whether the relationship is causal. One of the main limitations of the study was the absence of district level malaria control coverage data in the study area, preventing quantification of the relationship between particular malaria control interventions (ACT availability and ITN distribution) and the use of paediatric blood transfusions. Another limitation is the absence of malaria incidence data for the specific catchment area, which would strengthen the identification of the relationship between malaria control scale-up and the use of paediatric blood transfusions. Follow-up research with more detailed information about malaria control coverage and malaria incidence could more precisely quantify the relationship between malaria control scale-up and blood transfusion use.There are certain potential confounders in the analysis that could not be controlled for. For example, there may have been changes over time in provider admitting and transfusing behavior or changes in the general quality of care at the hospital. However, changes in these factors would need to be contemporaneous with the malaria control efforts to confound the results. In general, it is unlikely that changes in provider transfusing behavior explain these results because the guidelines for transfusions did not change over this time period at MMH and were consistent with WHO requirements. Nonetheless, there may have been variations by physician in terms of blood transfusion decision-making. The threshold for transfusing a paediatric patient is haemoglobin below 5; however, a higher threshold may have been used by some physicians and this would explain why more admissions for malarial anaemia received blood transfusions during the 2004–2008 period. There may also have been changes in care-seeking behavior on the patient side with increased awareness about malaria as malaria control was scaled-up. There is no available evidence to assess this potential confounder in this context.The main results are not confounded by seasonal variation in rainfall since the analysis includes control variables for each month. In addition, the ARMA model controls for trends over time in the outcome variable which means that it accounts for average differences such as weather patterns. However, the results may be confounded by the drought that occurred during the 2005 rainy season. Given that this drought coincided with the introduction of ACT in that year, it is not possible to distinguish, for that particular year, between the differential effect of the malaria control interventions relative to the seasonal effects from low rainfall. Nonetheless, both factors would affect malaria admissions in a similar direction.Another potential confounder relates to the changes in blood collection processes at MMH during the study period. Until 2006, MMH managed its own blood collection through blood drives. Starting in 2006, Ministry of Health policy change disallowed local blood collection throughout Zambia, requiring MMH to obtain blood centrally. Anecdotal evidence indicates that this shift did affect blood availability and use and may have resulted in increased blood rationing within the facility. By collecting its own blood collection process prior to 2006, MMH could potentially better manage changes in the blood supply with more immediacy (such as requesting immediate replacement blood donations from family members). A large portion of the data for this study come from the period before the policy change, which suggests that the hospital could better manage blood supply needs across wards when it had its own blood banking. This would also explain the absence of any spillover effects on other patient wards. The lower number of paediatric blood transfusions post-2006 cannot be explained solely by blood supply constraints given that the proportion of blood transfusions used in the paediatric ward relative to other wards also fell, from 73% in 2000 to 22% in 2008.The results of this study are specific to MMH, which may serve a different patient population than a semi-urban or urban hospital or a lower-tiered facility. MMH is also located in an area where malaria has typically been hyperendemic, so the seasonal effects on paediatric blood transfusions may be different than in areas where malaria is holoendemic, mesoendemic or hypoendemic. Finally, the results reflect the relationship between the particular malaria control interventions that were implemented in MMH’s catchment area. The magnitude of the effect of malaria control interventions will depend on the type of intervention and its effectiveness. Nonetheless, the trend in malaria admissions at MMH are similar to the trends in malaria admissions in Southern Province.The efficacy of blood transfusions to save the lives of children with severe malarial anaemia is well understood, and data from several studies show that the majority of paediatric blood transfusions in malaria-endemic countries in SSA are given for this reason. This study provides important insights into the relationship between paediatric malaria visits and admissions and blood transfusion use and how differences in paediatric blood transfusion use are related to the scale-up of malaria control interventions over time.This study demonstrates the extent to which paediatric blood use is lowered as paediatric outpatient malaria visits and paediatric admissions for severe malarial anaemia decrease. It also demonstrates that the significant reduction in paediatric blood transfusion use over time is consistent with the scale-up of malaria control interventions. These interventions appear to decrease the number of malaria visits, an imperfect proxy for malaria incidence. This study is the first to investigate potential spillover effects, or indirect benefits, from reduced blood transfusion use in the paediatric ward on blood use in other patient wards. The results show that, in this particular facility, the blood supply does not appear to be fixed and there does not appear to be substantial effects from differences in blood use in the pediatric ward on blood use in other patient wards. The study paves the way for follow-up research in other facility settings to investigate the potential benefits on health outcomes for non-malaria patients at the facility level, particularly in the context of fixed or limited blood supply. Such studies are particularly relevant in the current context of critical blood supply shortages in many developing countries, where blood supply may not meet clinical demand both for malaria and non-malaria patients.This study was exempted from IRB review by the Abt Associates Institutional Review Board. The study received ethical approval from Eres Converge in Lusaka, Zambia and from the Macha Research Trust IRB. The study was also reviewed by the CDC IRB.