Abstract
BackgroundIn sub-Saharan Africa, where infectious diseases and nutritional deficiencies are common, severe anaemia is a common cause of paediatric hospital admission, yet the evidence to support current treatment recommendations is limited. To avert overuse of blood products, the World Health Organisation advocates a conservative transfusion policy and recommends iron, folate and anti-helminthics at discharge. Outcomes are unsatisfactory with high rates of in-hospital mortality (9–10 %), 6-month mortality and relapse (6 %). A definitive trial to establish best transfusion and treatment strategies to prevent both early and delayed mortality and relapse is warranted.Methods/DesignTRACT is a multicentre randomised controlled trial of 3954 children aged 2 months to 12 years admitted to hospital with severe anaemia (haemoglobin < 6 g/dl). Children will be enrolled over 2 years in 4 centres in Uganda and Malawi and followed for 6 months. The trial will simultaneously evaluate (in a factorial trial with a 3 x 2 x 2 design) 3 ways to reduce short-term and longer-term mortality and morbidity following admission to hospital with severe anaemia in African children.The trial will compare: (i) R1: liberal transfusion (30 ml/kg whole blood) versus conservative transfusion (20 ml/kg) versus no transfusion (control). The control is only for children with uncomplicated severe anaemia (haemoglobin 4–6 g/dl); (ii) R2: post-discharge multi-vitamin multi-mineral supplementation (including folate and iron) versus routine care (folate and iron) for 3 months; (iii) R3: post-discharge cotrimoxazole prophylaxis for 3 months versus no prophylaxis. All randomisations are open. Enrolment to the trial started September 2014 and is currently ongoing. Primary outcome is cumulative mortality to 4 weeks for the transfusion strategy comparisons, and to 6 months for the nutritional support/antibiotic prophylaxis comparisons. Secondary outcomes include mortality, morbidity (haematological correction, nutritional and infectious), safety and cost-effectiveness.DiscussionIf confirmed by the trial, a cheap and widely available ‘bundle’ of effective interventions, directed at immediate and downstream consequences of severe anaemia, could lead to substantial reductions in mortality in a substantial number of African children hospitalised with severe anaemia every year, if widely implemented.Trial registrationCurrent Controlled Trials ISRCTN84086586, Approved 11 February 2013
Highlights
In sub-Saharan Africa, where infectious diseases and nutritional deficiencies are common, severe anaemia is a common cause of paediatric hospital admission, yet the evidence to support current treatment recommendations is limited
If confirmed by the trial, a cheap and widely available ‘bundle’ of effective interventions, directed at immediate and downstream consequences of severe anaemia, could lead to substantial reductions in mortality in a substantial number of African children hospitalised with severe anaemia every year, if widely implemented
The data are very old and not comprehensive the World Health Organisation (WHO) estimates that the minimum blood requirement for countries in sub-Saharan Africa to be 10 to 20 units per 1000 population per year; yet on average only 2.3 units of blood are donated per 1000 population [42, 43]
Summary
The operationalisation of a transfusion trial, investigating more liberal strategies in terms of which children with SA would benefit from a transfusion and how much to transfuse (in terms of volume), resulted in a number of logistic, scientific and ethical challenges. The data are very old and not comprehensive (from 2004) the WHO estimates that the minimum blood requirement for countries in sub-Saharan Africa to be 10 to 20 units per 1000 population per year; yet on average only 2.3 units of blood are donated per 1000 population [42, 43] This poses a major threat to the operational feasibility of the trial reliant upon busy, over-burdened blood transfusion services that face acute shortages of blood when demand is high, especially during malaria seasons [44]. The initial volume infused followed randomisation strategy (within 5 ml/kg) in 80 (98 %) patients in the 20 ml/kg arm and 75 (96 %) in the 70 ml/kg arm [41] We believe these additional data provide reassuring support for safety and feasibility of the TRACT trial. The funders (Medical Research Council) and the sponsor (Imperial College, London) had no role in study design or report writing
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