BLOOD INDICATORS AND PERIPHERAL BLOOD COUNTS FOR MALARIA PATIENTS IN AL-HODEIDAH CITY, YEMEN

Jihan Ali Mohammed Al-Thamari1,2image, Khaled Abdulkareem Al-Moyed1,2,3image, 

Mohammed Abdulkader Al-Nuzaili5image, Ahmed Mohammed Al-Haddad4image, 

Hassan Abdulwahab Al-Shamahy1,2*image

1Laboratory Haematology and Blood Bank, The Yemen Council for Medical and Health Specializations, Ministry of Health and Environment, Republic of Yemen. 2Medical Microbiology and Clinical Immunology Department, Faculty of Medicine and Health Sciences, Sana’a University. 3University of 21 September for Medical and applied Sciences, Sana’a, Yemen.

4Department of Medical Laboratories, College of Medicine and Health Sciences, Hadhramout University, Al-Mukalla, Yemen.

5Department of Hematology, Faculty of Medicine and Health Sciences, Sana’a University, Sana’a, Yemen.

 

Abstract

Background and Aims: Malaria patients are particularly susceptible to anaemia, a prevalent health issue in developing nations. Human performance, growth, and development are negatively impacted by this condition, which can become more complex if comorbidity occurs in a holoendemic stratum with strong and persistent malaria parasite transmission, like the west coast region of Yemen. The purpose of the study was to ascertain the prevalence and severity of anaemia in malaria patients residing in a permanent malaria transmission area in Yemen's west coastal region. Changes in blood indicators and peripheral blood cell counts were also examined.

Subjects and Methods: This study included 250 newly diagnosed malaria patients from malaria control centres in Al-Hodeidah Governorate. The sixth version of the EpiInfo statistical software was used to collect and analyse blood parameters. The study's objectives and benefits were explained to the participants, and participation was entirely voluntary. The institution's ethics committee approved the study.

Results: The male patients accounted for 71.6% and the female patients were 28.4%, with the mean age of 28.8 years with an SD equal to 13.5 years, and ages ranged from 2 years to 58 years. Most of our patients were in the age group of 16-25 years (38%). The mean haemoglobin level in malaria patients was 11.5 mg/dl, and 14.4% of the patients were suffering from severe anaemia. Below-normal PCV in the patients was present in 23.6%; the mean RBC count was 4.5x1012/L, and a very low rate (3x1012/L) occurred in 7.2% of the patients. Leucopenia (< 4.5x10⁹/L) occurred in 28.4% of the patients, and neutropenia occurred in 14.4% of the patients. 

Conclusions: Malaria, anaemia, leukopenia, and thrombocytopenia were clearly evident in this study and pose serious public health challenges among the coastal population of Yemen. This emphasises the necessity of uniform policies, initiatives, and actions to stop anaemia and malaria in this area.

Keywords: Al-Hodeidah Governorate, anemia, complete blood count, malaria, Yemen.

 

INTRODUCTION

 

Malaria is an infectious disease carried by mosquitoes that can affect vertebrates. Human malaria typically manifests as headaches, nausea, fever, and fatigue. In severe cases, it can cause jaundice, convulsions, coma, or even death. Symptoms usually occur ten to fifteen days after being bitten by an infected Anopheles mosquito. If they are not properly treated, people may have disease recurrences months later. When someone has recovered from an infection, reinfection usually causes less severe symptoms. This partial resistance disappears over months to years if the person is not regularly exposed to malaria1,2. 

P. ovale and P. malariae usually induce a milder form of malaria. Malaria is typically diagnosed by microscopic examination of blood on blood films or antigen-based quick diagnostic procedures1. Although methods for employing the polymerase chain reaction to identify the parasite's DNA have been developed, their cost and complexity prohibit their widespread application in areas where malaria is common3. Adults who have malaria usually have headache, fatigue, chills, muscle soreness, abdominal pain, and fever. These symptoms usually occur in intense, intermittent episodes that last roughly six hours, after which there is a period of sweating and fever alleviation4..

Infection with parasites belonging to the genus Plasmodium causes malaria. 2 Six Plasmodium species, P. falciparum, P. malariae, P. ovalecurtisi, P. ovalewallikeri, P. vivax, and P. knowlesi, cause malaria in humans.5P. falciparum is the most often found species (~75%) among those affected, followed by P. vivax (~20%)3. While P. falciparum has historically been the primary cause of death, new research indicates that P. vivax malaria is almost as frequently linked to potentially fatal illnesses as P. falciparum infection diagnoses. 6 Regardless of the presence of an illness, mass drug administration (MDA) entails giving medication to every member of the local community. 6. According to a 2021 Cochrane review, there has been no discernible decrease in the incidence of malaria transmission with community administration of ivermectin, based on low-quality evidence7. Vaccines against malaria have been another research objective. In 1967, the first encouraging trials showing the possibility of a malaria vaccine were carried out by immunising mice with live, radiation-attenuated sporozoites. This gave the mice a considerable level of protection when they were later injected with normal, living sporozoites. Considerable progress has been made in creating comparable human immunisation programmes since the 1970s8. With the long-term objective of eliminating malaria, WHO and the malaria vaccine funders group set a goal in 2013 to produce vaccinations intended to stop the disease's spread9. In 2015, European regulators approved the first vaccination, known as RTS, S10. There are two malaria vaccines that are approved for usage as of 202311. Maintaining surveillance will also be critical to preventing the resurgence of malaria in nations that have eradicated the illness12. Antimalarial drugs are used to treat malaria; which ones are used depends on the kind and severity of the illness13. Although fever-reducing drugs are frequently prescribed, it is unclear how they affect the final result14,15. In South-east Asia, malaria that was partially resistant to artemisinins first appeared in the 2000s (decade)16,17. According to WHO predictions, in 2021, there were 247 million cases of malaria worldwide, resulting in 619,000 deaths. 11In Sub-Saharan Africa, where an estimated 125 million pregnant women are at risk of infection, maternal malaria is assumed to be the cause of up to 200,000 estimated child fatalities each year18.

Anaemia is a serious and often fatal complication of malaria, particularly in children and pregnant women. It results from the massive destruction (haemolysis) of both infected and uninfected red blood cells and a decrease in their production in the bone marrow. This leads to low haemoglobin levels, causing severe weakness, organ damage, and the need for immediate treatment with antimalarial drugs, iron supplements, and sometimes blood transfusions1,2,18. In Yemen, several studies have been conducted on anaemia and blood pictures in adult heart failure patients19, patients with acute lymphoblastic leukaemia undergoing chemotherapy20, pregnant women21, malnourished children under five years of age22, pregnant women with pre-eclampsia23, anaemia in HIV patients24, severe anaemia associated with intestinal parasites25,26 and anaemia in dialysis patients27. However, no studies have been conducted on anaemia in malaria patients in malaria-endemic areas. Therefore, the study aimed to determine the prevalence and severity of anaemia in patients suffering from malaria living in a permanent malaria transmission area in the west coastal region of Yemen. The study also focused on changes in peripheral blood cell counts and blood markers.

 

SUBJECTS AND METHODS

 

Study design

This descriptive cross-sectional study was based on a sample of 250 patients with newly diagnosed malaria in malaria centres in the Hodeida Governorate. The mass diagnosis was formed in line with standard laboratory methods, one of them being blood film, together with a prepared thin and thick blood smear to detect malaria. The observed blood markers through Sysmex included haemoglobin level, PCV, RBC counts, WBC counts, WBC differential counts, RBC index (MCV, MCH, and MCHC) and platelet counts over a period of one year from 1st January 2023 to 31st December 2023.

Data collection

A pre-made questionnaire was used to gather individual data, including test results, clinical information, and demographic information.

Statistical analysis

The data was analysed using the Epi Info statistical tool version 6 (CDC, Atlanta, USA). When the data was regularly distributed, the quantitative data was expressed as mean values or standard deviation (SD). using percentages to express the qualitative data.

Ethical consideration

The institution's ethical review committee approved data collection before it began. Prior to participation, the objectives and benefits of the study were explained to all participants and/or their guardians, and their verbal informed consent was acquired. Additionally, participants and their families were informed that participation was entirely voluntary and that they might withdraw without providing an explanation.

 

RESULTS

 

Table 1 shows the age and sex distribution of malaria patients in Al-Hodeidah city, Yemen, arriving at malaria centres in Al-Hodeidah city. The male patients' counts were 71.6%, and the female patients' were 28.4%. The mean age of our patients was 28.8 years, with an SD equal to 13.5 years, and ages ranged from 2 years to 58 years. Most of our patients were in the age group of 16-25 years (38%).  Table 2 shows the haemoglobin level in malaria patients arriving at malaria centres in Al-Hodeidah city.  The mean haemoglobin level in malaria patients was 11.5 mg/dL, the standard deviation level was 2.3 mg/dL and the haemoglobin level ranged from 7 to 15 mg/dL; 14.4% of the patients were suffering from severe anaemia and 30.9% from mild anaemia. Table 3 shows the PCV level of malaria patients in Al-Hodeidah city, Yemen. Below normal PCV in the patients was present in 23.6%; the PCV level reached 30-40 in 47.6% of patients, and 28.8% of the patients had a > 40 level.  Table 4 shows the number of red blood cells in patients with malaria in Al-Hodeidah city, Yemen (cell x 106/μl). The mean RBC count was 4.5 cells × 106/μl. A very low rate (<3 cells x 106/μl) occurred in 7.2% of the patients. The result showed that only 26.2% of the patients had a normal value. Table 5 shows the white blood cell count in malaria patients (cell x 109/L). Leucopenia (< 4.5 cell x 109/L) occurred in 28.4% of the patients. The mean white blood cell count was 7.8 cells x 109/L with an SD of 8.2 and ranged from 2.5 to 15 cells x 109/L. Table 6 shows that neutropenia occurred in 14.4% of the malarial patients.  The mean neutrophil percentage was 61.9% with an SD of 19 and ranged from 14 to 93%.  Table 7 shows the mean lymphocyte percentage was 30.1% with an SD of 17.2 and ranged from 5 to 75%. Table 8 shows the mean monocyte percentage was 5.5% with an SD of 2.7 and ranged from 0 to 10%.  Table 9 shows the mean eosinophil percentage was 2.2% with an SD of 1.8 and ranged from 0 to 7%.  Table 10 shows the mean basophil percentage was 1.0% with an SD of 0.7 and ranged from 0 to 7%. Table 11 shows the MCV level in malaria patients.

Below 80 fl (femtoliters) occurred in 47.6% of our patients who have microcytic anaemia. The mean MCV was 78.3 fl with SD equal to 11.8 fl, and the MCV ranged from 21.6 fl to 95 fl.  Table 12 shows the MCH was 27.5 picograms per cell with SD equal to 9.7, and the MCH ranged from 17 to 87. More than 59% of the patients had less than 27 picograms per cell, indicating iron deficiency anaemia, while 7% had >31 picograms per cell, indicating anaemia due to low levels of folic acid or vitamin B12.  Table 13 shows the mean MCHC was 32.1 g/dL with SD equal to 2.1, and the MCHC ranged from 28 to 36.7. The platelet counts of malaria patients are displayed in Table 14; the platelet counts of our patients ranged from 35 to 553 cells per microlitre (mL), with a mean of 206.6 cells per mL and an SD of 125 cells per mL. Thrombocytopenia occurred in 42.8% of our patients. Table 15 shows the number of malaria recurrences during the past year. Malaria infection occurred for the first time in 35.6% of patients; 28.7% of patients had a second infection, 26.2% had a third infection, and 9.2% had a fourth infection. 

DISCUSSION

 

This study characterises the demographic and comprehensive haematological profile of malaria patients attending malaria centres in Al-Hodeidah city, Yemen. The pronounced male predominance (71.6%) and concentration of cases among young adults aged 16-25 years (38%) reflect well-documented exposure patterns in endemic regions. This sex disparity is consistent with findings from Yemen and similar settings, where males engage more frequently in outdoor occupations such as agriculture and fishing during peak Anopheles biting hours, thereby increasing infection risk28,29. Studies from Yemen and similar endemic areas consistently report higher malaria prevalence among males due to occupational and behavioural factors30.  

The mean age of 28.8±13.5 years further supports the epidemiological transition observed in areas of moderate endemicity, where repeated exposure has not yet conferred complete immunity, shifting the burden towards older children and young adults rather than preschool children as seen in holoendemic regions. Males in Yemen are more likely to engage in outdoor occupations (farming, fishing, and daily labour) that increase exposure to Anopheles mosquito bites, particularly during evening and night hours when vector activity peaks11. This demographic profile has significant socioeconomic implications, as malaria-related morbidity in the economically active population can exacerbate poverty and hinder development in already vulnerable communities.

The haematological findings demonstrate a substantial anaemia burden, with a mean haemoglobin of 11.5±2.3 g/dL and 45.3% of patients exhibiting mild or severe anaemia. This aligns with the multifactorial patho-physiology of malarial anaemia, involving parasite-mediated hemolysis, immune destruction of uninfected erythrocytes, bone marrow suppression, and nutritional deficiencies31,32. The microcytic pattern observed in 47.6% of patients (MCV <80 fL) and low MCH in 59% suggests concomitant iron deficiency, which is highly prevalent in Yemen due to dietary limitations and chronic infections33,34.

The correlation between low RBC counts (only 26.2% normal) and reduced PCV further confirms malaria's profound impact on erythropoiesis. These findings underscore the necessity of integrating anaemia screening and nutritional assessment into routine malaria case management, particularly in resource-limited settings where severe anaemia carries high mortality risk35,36. Leukopenia was observed in 28.4% of patients, with neutropenia in 14.4%, consistent with malaria-associated bone marrow suppression and peripheral sequestration of leukocytes26. The mean total WBC count of 7.8±8.2x10⁹/L showed wide variability, reflecting the heterogeneous immune response to infection. Lymphocyte percentages (mean 30.1%) were within expected ranges, while eosinophil and basophil counts remained low, as is typically reported in acute malaria, where these cell lines are not primarily involved in the anti-parasitic response35. 

These alterations in white cell dynamics may serve as adjunctive diagnostic markers in settings with limited parasitological confirmation capacity, though they lack specificity and must be interpreted alongside clinical and epidemiological context37. Thrombocytopenia occurred in 42.8% of patients, with a mean platelet count of 206.6±125 x 10³/μL. This finding is highly consistent with malaria literature, where thrombo-cytopenia is recognised as one of the most frequent haematological abnormalities, resulting from platelet activation, consumption, and immune-mediated destruction38. Although rarely causing spontaneous bleeding in uncomplicated malaria, thrombocytopenia may serve as a useful supportive diagnostic indicator and warrants monitoring in severe cases where coagulopathy can develop38. The relatively preserved mean platelet count in this cohort suggests most presentations were uncomplicated, though the wide range (35-553x10³/μL) indicates substantial individual variability requiring clinical correlation.

The high recurrence rate, with 64.4% of patients reporting at least one prior infection and 9.2% experiencing four infections within one year, highlights ongoing transmission and potential challenges in treatment efficacy or prevention adherence. This pattern is concerning in the Yemeni context, where conflict-related disruptions to health services, inconsistent vector control, and limited access to quality-assured antimalarials may contribute to repeated infections38. Recurrent malaria not only increases cumulative anaemia risk with a reduction in haemoglobin levels but also suggests possible gaps in community-level prevention strategies, emphasising the need for strengthened surveillance, prompt case management, and targeted vector control interventions33,39. 

Limitations of study

Studies of hematological parameters and peripheral blood counts in malaria patients in Hodeidah, Yemen, are severely constrained by the ongoing conflict, resulting in significant limitations on data accuracy, study scope, and methodology. Key limitations include a high incidence of co-infection with other acute febrile illnesses (such as dengue fever), which can affect hematological test results; the prevalence of hypoparasites, which may go undetected by standard diagnostic criteria; and reliance on cross-sectional study designs that do not allow for tracking patient outcomes over time.

 

CONCLUSIONS AND RECOMMENDATIONS

 

In Yemen's coastal regions, malaria, anaemia, leucopenia, and thrombocytopenia continue to be serious public health issues. In order to prevent malaria and anaemia in the local community, this highlights the necessity of implementing consistent policies, initiatives, and actions. One of the major obstacles to malaria control and the progression of anaemia is delay in diagnosis. For malaria to be effectively controlled, new and improved diagnostics are crucial. As they have been for the previous century, the most accurate methods for diagnosing malaria today are labor-intensive and depend on highly skilled personnel analysing blood smears under microscopes. Drug resistance cannot be detected by such microscopic analysis, which is time-consuming, inconsistent in quality, and challenging to apply in field settings with limited resources. For the purpose of controlling malaria and avoiding consequences like anaemia, it is crucial to fund research into the development of simple tests to identify the malaria parasite and identify its drug resistance pattern.

 

ACKNOWLEDGEMENTS


 The authors also extend their thanks to the Ministry of Population and Health, and malaria centers in Hodeida Governorate, Yemen for their assistance.

 

AUTHOR’S CONTRIBUTIONS

 

Al-Thamari JAM: writing the original draft, methodology, investigation. Al-Moyed KA: writing the original draft, methodology, investigation. Al-Nuzaili MA: formal analysis, data curation, conceptualisation. Al-Haddad AM: writing, review and editing, methodology. Al-shamahy HA: formal analysis, data curation. Final manuscript was checked and approved by all authors.       

 

DATA AVAILABILITY

 

The empirical data used to support the study's conclusions are available upon request from the corresponding author.

 

CONFLICT OF INTEREST 


This study is not connected to any conflicts of interest.

 

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