Anaemia is an important public health concern that has negative impact on an individual’s health as well as the economic potential of the population [
Preoperative anaemia is not an uncommon finding, and depending on the cohort being investigated, the prevalence can be as high as 75% [
Allogeneic blood transfusion is independently associated with increased risk of infection and other adverse postoperative outcomes, especially in countries with low or medium human development index [
Malaria, a multiorgan systemic disease, can cause and aggravate anaemia, constituting an additional risk in surgical procedures. Studies have demonstrated high rates of morbidity and mortality after surgery in anaemic patients with
Preoperative haemoglobin levels are checked before surgery in most patients in Ghana. As far as we are aware, no studies have explored the implications of preoperative anaemia on postoperative outcomes in Ghana. This study was therefore carried out to determine the prevalence of preoperative anaemia in unselected noncardiac surgery patients and their outcomes following surgery in the Central Region of Ghana.
This study was designed as an observational study and was carried out from June 2015 to July 2016 in two selected hospitals in the Central Region of Ghana. Ethical approval for the study was obtained from the Institutional Review Board of the University of Cape Coast (approval reference: UCC/IRB/3/1). Written permission was also sought from the Management of the Cape Coast Teaching Hospital, Cape Coast, and Saint Luke’s Catholic Hospital, Apam. Written informed consent was obtained from individual patients or their guardians. Eligible patients aged 15 and above had a preoperative assessment within 40 days prior to surgery with at least one preoperative haemoglobin (Hb) level to undergo elective or emergency surgery were recruited. Exclusion criteria included planned day-case surgery and obstetric procedures [
Data were collected on patients’ characteristics (sex and age), date of admission, date of surgery, date of discharge, preoperative full blood count result, type of anaesthesia (general or regional), type of surgery done, duration of surgery, comorbidity, sickling status, presence of malaria parasites, date of inhospital mortality, complications before discharge, and date of RBC transfusion. The primary outcome measured was preoperative anaemia. Secondary outcomes were postoperative adverse events resulting in complications before discharge, prolongation of hospitalization, the prevalence of perioperative allogeneic blood transfused, and inhospital mortality. Patients were followed up until they were discharged from the hospital. Complete patient confidentiality was maintained.
Preoperative haemoglobin (Hb) levels were the last Hb estimated within 40 days prior to the index operation; majority of the participants 773 (86.6%) had their last Hb estimated within two weeks prior to the index surgery. The World Health Organization (WHO) criteria for anaemia (women 12.0 g/dl and men 13.0 g/dl) and its subclassifications (nonpregnant women 15 years of age and above: mild: 11.0–11.9 g/dl, moderate: 8.0–10.9 g/dl, severe: lower than 8.0 g/dl; men 15 years of age and above: mild: 11.0–12.9 g/dl, moderate: 8.0–10.9 g/dl, severe: lower than 8.0 g/dl) were used [
Postoperative outcomes included inhospital mortality, prolonged length of hospital stay (LOS) after surgery, and the development of postoperative infection or other complications such as cardiogenic shock before discharge and perioperative blood transfusion. Prolonged LOS was categorized as the proportion of patients with hospital stay greater than the 75th percentile (8.0 days), as used by other studies [
Descriptive statistical analysis: continuous data were presented as mean, standard deviation (SD), or minimum and maximum values; categorical data were presented as the number and percentage of individuals in each category; and Pearson’s chi-square test was used to compare the proportions between two groups.
Binary logistic regression models were performed using adjusted odds ratios (ORadj) to assess the independent effects of preoperative anaemia on length of hospital stay, postoperative complications, inhospital mortality, and perioperative RBC transfusion. Only factors remaining statistically significant (
Analysis was performed with IBM SPSS statistical package version 21.0, USA.
In all, 953 eligible patients were enrolled in the study. 60 (6.3%) patients were excluded. The excluded patients included patients whose period of admission days was outside those used in the analysis (48), patients with incomplete data (6), and patients with miscellaneous reasons such as high Hb (6). Hence, after data cleaning, 781 (87.5%) patients from a tertiary hospital and 112 (12.5%) from a mission hospital were included in the analysis. The details of the patient’s characteristics are shown in Tables
Patient baseline characteristics.
Parameter | Total ( |
Preoperative anaemia ( |
No preoperative anaemia ( |
|
---|---|---|---|---|
|
44.2 (16–90) | 45.3 (16–90) | 43.0 (16–85) | 0.326 |
15–49 years | 565 (63.3%) | 297 (61.2%) | 268 (65.7%) | 0.370 |
50 years and above | 328 (36.7%) | 188 (38.8%) | 140 (34.3%) | — |
|
<0.001 | |||
Females | 454 (50.8%) | 293 (60.4%) | 161 (39.5%) | — |
Males | 439 (49.2%) | 192 (39.6%) | 247 (60.5%) | — |
|
||||
Mean Hb ± SD | 12.0 + 2.5 g/dl | 10.3 ± 1.8 g/dl | 14.1 ± 1.3 g/dl | <0.001 |
|
|
|
|
<0.001 |
Microcytic and/or hypochromatic | 396 (49.3%) | 245 (57.2%) | 151 (40.2%) | — |
Normocytic normochromic | 400 (49.7%) | 179 (41.8%) | 221 (58.8%) | — |
Macrocytic | 8 (1.0%) | 4 (0.9%) | 4 (1.1%) | — |
|
0.360 | |||
Minor | 31 (3.5%) | 17 (3.5%) | 14 (3.4%) | — |
Intermediate | 180 (20.2%) | 103 (21.2%) | 77 (18.9%) | — |
Major | 672 (75.3%) | 360 (74.2%) | 312 (76.5%) | — |
Complex major | 10 (1.1%) | 5 (1.0%) | 5 (1.2%) | — |
|
<0.001 | |||
General surgery | 583 (65.3%) | 290 (59.8%) | 293 (71.8%) | — |
Gynaecology | 147 (16.5%) | 119 (24.5%) | 28 (6.9%) | — |
Orthopaedics | 49 (5.5%) | 19 (3.9%) | 30 (7.4%) | — |
Urology | 51 (5.7%) | 26 (5.4%) | 25 (6.1%) | — |
Plastics | 24 (2.7%) | 12 (2.5%) | 12 (2.9%) | — |
Ear, nose, and throat (ENT) | 24 (2.7%) | 13 (2.7%) | 11 (2.7%) | — |
Maxillofacial | 15 (1.7%) | 6 (1.2%) | 9 (2.2%) | — |
Results are shown as mean (range), mean (±SD), and frequency (percentage); % = percentage of patients; Hb = haemoglobin;
Patient baseline characteristics.
Parameters | Total ( |
Preoperative anaemia ( |
No preoperative anaemia ( |
|
---|---|---|---|---|
|
0.028 | |||
Hypertension | 68 (7.6%) | 40 (8.2%) | 28 (6.8%) | — |
Diabetes mellitus | 28 (3.1%) | 22 (4.5%) | 6 (1.5%) | — |
Diabetes mellitus + hypertension | 27 (3.0%) | 22 (4.5%) | 5 (1.2%) | — |
HIV | 9 (1.0%) | 5 (1.0%) | 4 (1.0%) | — |
Asthma | 6 (0.7%) | 3 (0.6%) | 3 (0.7%) | — |
Hepatitis B | 5 (0.6%) | 3 (0.6%) | 2 (0.5%) | — |
Diabetes mellitus + other conditions |
4 (0.4%) | 2 (0.4%) | 2 (0.5%) | — |
Others‡ | 5 (0.6%) | 3 (0.6%) | 2 (0.5%) | — |
|
50 (5.6%) | 31 (6.4%) | 19 (4.7%) | 0.261 |
|
0.101 | |||
Positive | 52 (10.5%) | 33/262 (12.6%) | 19/235 (8.1%) | — |
Negative | 445 (89.5%) | 229/262 (87.4%) | 216/235 (91.9%) | — |
|
0.456 | |||
Positive | 16 (2.7%) | 10/320 (3.1%) | 6/280 (2.1%) | — |
Negative | 584 (97.3%) | 310/320 (96.9%) | 274/280 (97.9%) | — |
Results are shown as frequency (percentage);
433 (48.5%) patients had general anaesthesia (GA), 434 (48.6%) had subarachnoid spinal block (SAB), 10 (1.1%) had SAB and GA, and 16 (1.8%) had other anaesthesias such as local infiltration. There were a total of 624 (69.9%) elective cases out of which 342 (54.8%) were anaemic, and 269 (30.1%) emergency cases out of which 143 (53.2%) were anaemic. The overall median operating time (interquartile) was 76.0 minutes (50.0,111.0 minutes).
Patients with preoperative anaemia accounted for 54.3% of the study population, out of which 209 (23.4%) presented with mild anaemia, 226 (25.3%) with moderate anaemia, and 50 (5.6%) with severe anaemia. The sex distribution, the mean Hb, the severity, and the classification of the anaemia as well as surgical specialty are shown in Table
When excluded data were included in the analysis, prevalence of preoperative anaemia was 55.2%; it did not skew the anaemia prevalence.
The anaemia was
Age and sex stratification.
Males | Females | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
15–49 yrs ( |
≥50 yrs ( |
15–49 yrs ( |
≥50 yrs ( | |||||||||
Parameters | Anaemic | Nonanaemic |
|
Anaemic | Nonanaemic |
|
Anaemic | Nonanaemic |
|
Anaemic | Nonanaemic |
|
|
86 (35.1%) | 159 (64.9%) | <0.001 | 106 (54.6%) | 88 (45.4%) | 0.238 | 211 (65.9%) | 109 (34.1%) | <0.001 | 82 (61.2%) | 52 (38.8%) | <0.001 |
|
7 (8.1%) | 8 (5.0%) | 0.216 | 39 (37.5%) | 16 (18.2%) | 0.003 | 22 (10.4%) | 12 (11.0%) | 0.957 | 32 (39.0%) | 16 (30.7%) | 0.331 |
|
11.0 ± 1.5 | 14.9 ± 1.4 | <0.001 | 10.9 ± 1.7 | 14.4 ± 1.2 | <0.001 | 9.8 ± 1.9 | 13.1 ± 0.9 | <0.001 | 9.9 ± 1.5 | 13.0 ± 0.8 | <0.001 |
|
— | — | <0.001 | — | — | <0.001 | — | — | <0.001 | — | — | <0.001 |
Mild | 48 (55.8%) | 0.0% | — | 61 (57.5%) | 0.0% | — | 70 (33.2%) | 0.0% | — | 30 (36.6%) | 0.0% | — |
Moderate | 34 (38.1%) | 0.0% | — | 41 (38.7%) | 0.0% | — | 109 (51.7%) | 0.0% | — | 42 (51.2%) | 0.0% | — |
Severe | 4 (4.8%) | 0.0% | — | 4 (3.8%) | 0.0% | — | 32 (15.2%) | 0.0% | — | 10 (12.2%) | 0.0% | — |
|
|
|
0.060 |
|
|
0.114 |
|
|
0.003 |
|
|
0.049 |
Microcytic and/or hypochromic | 46 (59.7%) | 64 (44.1%) | — | 40 (42.6%) | 23 (28.4%) | — | 118 (64.1%) | 48 (47.1%) | — | 40 (54.8%) | 16 (33.3%) | — |
Normocytic normochromic | 31 (40.3%) | 81 (55.9%) | — | 52 (55.3%) | 54 (66.7%) | — | 66 (35.9%) | 54 (52.9%) | — | 31 (42.5%) | 32 (66.7%) | — |
Macrocytic | 0 (0.0) | 0 (0.0%) | — | 2 (2.1%) | 4 (4.9%) | — | 0 (0.0%) | 0 (0.0%) | — | 2 (2.7%) | 0 (0.0%) | — |
Results are shown as mean ± SD and frequency (percentage);
Elderly patients (65 years and above) constituted 133 (14.9%) of the study population. The elderly group recorded the highest prevalence of preoperative anaemia 82 (61.7%) compared to those below 65 years (53.0%) (
Evaluation of postoperative outcomes included the length of hospital stay after surgery, postoperative complications before discharge, and inhospital mortality. Length of hospital stay: preoperative anaemia patients had a significantly higher mean length of hospital stay (6.5 days; range: 1–29 days) than nonanaemic patients (4.8 days; range: 1–27 days) ( Complications before discharge: the details of the complications before discharge are shown in Table Inhospital mortality: mortality data were available for the tertiary hospital (781) cases only.
Effects of preoperative anaemia on postoperative outcomes.
Outcome | Preoperative anaemia | |
---|---|---|
ORunadj (95% CI); |
ORadj−1 (95% CI); |
|
Prolonged LOS | 1.72 (1.23–2.41); |
2.12 (1.49–3.10); |
Composite complication | 1.31 (0.88–1.93); |
0.97 (0.63–1.49); |
Inhospital mortality | 1.94 (0.58–6.51); |
1.74 (0.49–6.18); |
Results are shown as odds ratio (95% CI); patients without preoperative anaemia were used as the reference; ORunadj = unadjusted odds ratio; ORadj−1 = odds ratio; LOS = length of hospital stay.
Postoperative complications.
Parameter | Total ( |
Preoperative anaemia ( |
No preoperative anaemia ( |
|
---|---|---|---|---|
|
0.101 | |||
Pain at incision site | 76 (8.5%) | 42 (8.7%) | 34 (8.3%) | — |
Surgical site infection | 22 (2.5%) | 17 (3.5%) | 5 (1.2%) | — |
Difficulty in breathing | 5 (0.6%) | 3 (0.6%) | 2 (0.5%) | — |
Fever | 7 (0.8) | 2 (0.4%) | 5 (1.2%) | — |
Palpitations | 4 (0.4%) | 4 (0.8%) | 0 (0.0) | — |
Others | 6 (0.7%) | 4 (0.8%) | 2 (0.5%) | — |
Results are shown as frequency (percentage); others = hypoventilation and cardiogenic shock.
Perioperative anaemia was treated mainly with allogeneic RBC transfusion followed by haematinics. Overall, 172 (19.3%) patients received a total of 347 units of allogeneic RBC transfusion, 73 (8.2%) patients received two units of RBCs, followed by 1 unit for 55 (6.2%) patients, with the remaining patients receiving between 3 and 5 units. Overall, patients with preoperative anaemia received more perioperative transfusion than nonanaemic patients (30.7% versus 5.6%,
By binary logistic regression analysis, independent predictors of RBC transfusion were severity of preoperative anaemia, severe and moderate anaemia (OR 16.83, 95% CI (9.16–30.89),
Effects of red blood cell transfusion on outcome.
Logistic regression analyses (adjusted) | ORunadj (95% CI); |
ORadj−1 (95% CI); |
---|---|---|
P-LOS association with RBC transfusion | 3.81 (2.64–5.50); |
4.48 (2.67–7.51), |
Composite complication association with RBC transfusion | 1.73 (1.11–2.69); |
1.32 (0.74–2.36); |
Inhospital mortality association with RBC transfusion | 5.80 (1.82–18.53); |
0.52 (0.19–1.46); |
Results are shown as odds ratio (95% CI); no RBC transfusion was used as a reference; ORadj−1 = odds ratio adjusted for severity of anaemia, age, sex, comorbid conditions, surgical specialty, grade of surgery, and cancer; CI = confidence interval; P-LOS = prolonged length of hospital stay; RBC = red blood cell.
For preoperative transfusion, 61/65 (93.8%) of patients were haemo transfused within 2 weeks to the surgery. Additionally, 70/98 (71.4%) of patients received their postoperative transfusion within 2 days after surgery. Some patients (14/65; 21.5%) were transfused before hospital admission. The blood bank recorded two autologous predonations during the study period. However, the patients involved were not transfused; hence, all transfusions were allogeneic.
Data available from the blood bank records at the tertiary hospital and interview with patients indicated an approximate cost of 160.0 Ghanaian cedis (approximately 38.0 USD) for obtaining and processing one unit of replacement donation.
180 (20.2%) patients were treated with perioperative haematinics: 151 (31.1%) for anaemic as compared to 28 (6.9%) for nonanaemic patients (
Perioperative use of haematinics in the patients.
Parameter | Patients total ( |
Oral iron | Folate | Oral iron + folate | Others |
---|---|---|---|---|---|
|
893 | 74 (8.3%) | 29 (3.2%) | 38 (4.3%) | 40 (4.5%) |
|
|||||
Preoperative anaemiaa | 485 | 28 (5.8%) | 7 (1.4%) | 9 (1.9%) | 14 (2.9%) |
No preop. anaemiaa | 408 | 2 (0.5%) | 1 (0.2%) | 0.0% | 2 (0.5%) |
|
|||||
Preoperative anaemiaa | 485 | 47 (9.7%) | 26 (5.4%) | 39 (8.0%) | 23 (4.7%) |
No preop. anaemiaa | 408 | 7 (1.7%) | 5 (1.2%) | 5 (1.2%) | 17 (4.2%) |
Results are presented as percentages; a more than one treatment per patient is possible, that is, some patients received a combination of pre- and/or posthaematinics treatments; others = oral iron and/or folate administered with vitamin B12, erythropoietin, or zinc; no patient received haematinics intraoperatively.
Excluded data did not skew the overall data, when analysed as shown in Table
Analysis of excluded data.
Parameter | Total∗ ( |
PA ( |
No PA ( |
|
---|---|---|---|---|
|
44.2 (16–90) | 47.0 (15–86) | 46.0 (16–83) | 0.027 |
|
0.347 | |||
Females | 21 (35.6%) | 13 (31.7%) | 8 (44.4%) | — |
Males | 38 (64.4%) | 28 (68.3%) | 10 (55.6%) | — |
|
||||
Mean Hb ± SD | 11.2 ± 2.5 g/dl | 9.9 ± 1.8 g/dl | 14.0 ± 1.1 g/dl | <0.001 |
Mild anaemia | — | 13 (21.0%) | — | — |
Moderate anaemia | — | 24 (40.7%) | — | — |
Severe anaemia | — | 4 (6.8%) | — | — |
|
0.670 | |||
General surgery | 33 (55.9%) | 23 (56.1%) | 10 (55.6%) | — |
Gynaecology | 1 (1.7%) | 1 (2.4%) | 0 (0.0%) | — |
Orthopaedics | 16 (27.1%) | 13 (31.7%) | 5 (27.8%) | — |
Urology | 4 (6.8%) | 3 (7.3%) | 1 (5.6%) | — |
Plastics | 2 (3.4%) | 1 (2.4%) | 1 (5.6%) | — |
Ear, nose, and throat (ENT) | 24 (2.7%) | 13 (2.7%) | 11 (2.7%) | — |
Neurosurgery | 1 (1.7%) | 0 (0.0%) | 1 (5.6%) | — |
|
0.746 | |||
Positive | 8 (20.8%) | 3 (16.7%) | 2 (33.3%) | — |
Negative | 19 (79.2%) | 15 (83.3%) | 4 (66.7%) | — |
|
0.245 | |||
Yes | 15 (27.8%) | 13 (33.3%) | 2 (13.3%) | — |
No | 39 (72.2%) | 26 (66.7%) | 13 (86.7%) | — |
|
33.3 ± 17.8 | 35.8 ± 17.0 | 27.7 ± 19.0 | 0.632 |
|
0.675 | |||
Yes | 2 (3.7%) | 2 (5.3%) | 0 (0.0%) | — |
|
0.797 | |||
Yes | 21 (38.9%) | 14 (36.8%) | 7 (43.8%) | — |
|
0.499 | |||
Yes | 19 (34.5) | 15 (39.5%) | 4 (23.5%) | — |
∗One patient had a high Hb level; hence, that patient was not included in the analysis; 59 samples were analysed; LOS = length of hospital stay, PA = preoperative anaemia.
Postoperative malaria parasitaemia data were available for 423 patients. Positive patients who were symptomatic were treated before surgery. The prevalence rate of malaria parasitaemia in the entire study population increased from 2.5% preoperatively to 3.5% postoperatively (
A high prevalence of preoperative anaemia (approximately 54%) in unselected noncardiac surgical patients was observed in our study, but most had moderate anaemia. Overall, 57% of anaemic admissions had microcytic and/or hypochromic indices, consistent with possible iron deficiency, but normocytic normochromic indices were prevalent in the elderly (65 years and above) together with a significantly higher comorbidities, indicating a possible anaemia of chronic disease or inflammation. The preoperative anaemia resulted in prolonged postoperative hospital stay when compared with the nonanaemic patients. Composite complications and inhospital mortality were more frequent among the anaemic patients though not statistically significant. In this study, about 31% of preoperative anaemia patients received perioperative transfusion with an overall mean of two units per patient. The independent determinants for blood transfusion were the severity of the preoperative anaemia and comorbid condition. Perioperative transfusion was significantly associated with poor postoperative outcomes.
This study is in agreement with other studies showing high levels of preoperative anaemia among unselected surgical patients [
Saleh and colleagues [
61% of the elderly patients had anaemia which was mostly mild with normocytic normochromic indices. They also had significant comorbidities suggesting possible anaemia of chronic disease or inflammation.
Regarding outcomes, preoperative anaemia remained an independent risk factor for prolonged hospital stay after adjusting for potential confounders. Some observational studies in noncardiac surgical patients emphasize this association [
The overall composite complication before discharge was 13.4%. Although comorbidity was significantly greater in preoperative anaemia patients, the anaemia did not significantly modify the composite complication. However, other studies have found anaemia to be an independent predictor for postoperative complications [
Our study did not show a significant association between preoperative anaemia and inhospital mortality. This agrees with the findings of Greenky and colleagues [
Our study is also in agreement with previous studies showing preoperative anaemia to be an independent and strong predictor for increased perioperative RBC transfusion [
This study recorded a relatively low perioperative transfusion rates compared to the high prevalence of preoperative anaemia. This may be reflective of the type of surgery, the sample size, and amounts of blood loss (which was not captured). Some patients could not get replacement donors and had to be discharged with fewer units of blood transfused or without being transfused when the Hb level was not life-threatening. In the hospitals where the research was carried out, voluntary blood donation is not common; hence, patients have to rely on replacement donation which can be difficult to obtain. Transfusion attracts an extra financial burden on the patient which most cannot afford.
Despite recent recommendations advising investigating the cause of anaemia and treating it preoperatively to minimise transfusion requirements in elective surgical patients, the percentage of anaemic patients treated preoperatively was very low, about 12%. Preoperative oral or parenteral iron or postoperative parenteral iron with or without erythropoietin-stimulating therapy is useful for the management of perioperative anaemia [
Traumatic events like tissue damage, blood loss, and surgery trigger cascades of inflammatory mediators to cause immunodepression with increased risk to develop malaria parasitaemia [
About 1.5% of the preoperative Hb concentrations were obtained more than 28 days prior to the surgery and may not have represented the actual Hb level at the time of surgery. Approximately 6.8% of the patients were on preoperative haematinics, and 7.3% were transfused prior to the surgery; however, there was no repeat of the Hb levels for a number of the patients after the initial assessment.
Postoperative Hb levels were not available for most patients; hence, their effects could not be analysed.
Also, anaemia was classified based on only mean corpuscular volume (MCV) and mean corpuscular haemoglobin (MCH); increased reticulocyte count due to compensatory response to anaemia and/or the preoperative haematinics administered to some patients can spuriously raise the MCV value masking microcytosis. Confirmatory tests such as ferritin or soluble transferrin receptor measurement for the diagnosis of iron deficiency are not routinely performed at the selected centres. Additionally, data on renal and liver function were not uniformly available for most patients and hence not captured.
Preoperative anaemia is common among noncardiac surgery patients. It is independently and significantly associated with prolonged hospital stay leading to increased healthcare resource use. It is also the main predictor for perioperative allogeneic blood transfusions and the use of haematinics.
This study has potential implications for improving the perioperative management of noncardiac surgery patients in the Central Region and Ghana as a whole. It will enhance adequate preparation and comprehensive care to minimise known complications associated with preoperative anaemia. It will also serve as a pilot for a wider national study on postoperative outcomes among noncardiac surgery patients.
Haemoglobin
Red blood cells
Mean corpuscular volume
Mean corpuscular haemoglobin.
The study was approved by the Institutional Review Board of the University of Cape Coast (approval reference: UCC/IRB/3/1).
Written permission was sought from the Management of the Cape Coast Teaching Hospital and Saint Luke’s Catholic Hospital, Apam. Written informed consent was obtained from all individual patients or their guardians.
Gladys Amponsah is currently at School of Anaesthesia, Greater Accra Regional Hospital, Accra, Ghana.
The authors declare that there are no conflicts of interest regarding the publication of this paper.
Both authors contributed equally and read and approved the final manuscript.
The authors are extremely grateful to Professor Samuel Debrah, the then Head of the Department of Surgery, for reviewing and editing the proposal and the manuscript. The authors are also thankful to the entire surgical suite staff, all surgeons, clinicians, nurse anaesthetists, and nurses for helping in retrieving data from the patients’ medical records. The authors thank the diagnostic laboratory unit for assisting with the sickling test. The authors also thank Dr. Daniel Asare, the CEO of Cape Coast Teaching Hospital, and Dr. Samuel Kwashie, Central Regional Director Ghana Health Services, for donating the malaria rapid test kits used for the study and Sister Mary Magdalene Mary Arthur, Matron of Saint Luke’s Catholic Hospital, Apam, for her support. Special thanks are due to Mr. Joseph Obodai who assisted with the data collection; Dr. Kingsley Kwadwo Asare Pereko of the Department of Community Medicine, University of Cape Coast, School of Medical Sciences, and Dr. Michael Owusu of KCCR, Kumasi, for assisting with the data analysis; and Dr. Yvonne Dei-Adomakoh, a clinical haematologist, for reviewing the manuscript.