Sudan Journal of Medical Sciences Volume 14, Issue no. 3, DOI 10.18502/sjms.v14i3.5210 Production and Hosting by Knowledge E Research Article Hemogram Abnormalities in Apparently Healthy First-time Blood Donors in Libreville, Gabon Cyrille Bisseye1, Jophrette Mireille Ntsame Ndong2, Landry Erik Mombo1, Hornéla Christine Minkoue Mambéri1,2, Guy Mouelet Migolet2, Gemael Cedrick Taty-Taty1, and Bolni Marius Nagalo1,3 1Laboratory of Molecular and Cellular Biology (LABMC), University of Science and Technology of Masuku (USTM), P.O. Box 943, Franceville, Gabon 2National Blood Transfusion Center (NBTC), P.O. Box 13895, Libreville, Gabon 3Division of Hematology and Oncology, Mayo Clinic, 13400 E. Shea Blvd. Scottsdale, 85259 AZ, USA Abstract Background: The objective of this study was to determine complete blood count (CBC) abnormalities in Libreville blood donors to advocate for hemoglobin pre-donation implementation and to take into account CBC results in blood donation qualification. Methods: This retrospective study was conducted with 4,573 blood donors in March 2016 and from January to April 2017. CBC was performed using SysmexXP-300TM hematology analyzer (SYSMEX Corporation, Kobe, Japan). Results: Blood donors were predominantly males (83.7%) with an age ranging from 18 to 59 yrs. The abnormalities of leukocyte, platelet, and erythrocyte counts were determined in blood donors. Leukopenia and thrombocytopenia were significantly more common in men than women (29.02% vs 24.4%, p = 0.011 and 16.2% vs 7.5%, p < 0.001). Only 1.0% of women and 0.84% of men had leukocytosis, and 0.7% of women and 0.2% of men had thrombocytosis. Anemia was significantly more common in women compared to men (69.4% vs 45.0%, p < 0.001). Normocytic normochromic and normocytic hypochromic anemia were most common among Libreville blood donors with 39.4% and 23.6%; followed by microcytic normochromic (18.7%) and microcytic hypochromic (13.2%) anemia. Normocytic normochromic and normocytic hypochromic anemia were significantly more common in men than in women, whereas microcytic normochromic anemia was more prevalent among women compared to men (34.6% vs 13.9%, p < 0.001). Conclusions: The results of this study clearly show the need to perform a pre-donation hemoglobin test in blood donors and to take into account their hemogram in the blood donation selection process at the Libreville National Blood Transfusion Center. Keywords: hemogram, anemia, blood donors, Libreville, Gabon 1. Introduction Blood transfusion is a therapeutic procedure that saves lives by providing patients with the blood products they need according to their disease. It remains an essential How to cite this article: Cyrille Bisseye, Jophrette Mireille Ntsame Ndong, Landry Erik Mombo, Hornéla Christine Minkoue Mambéri, Guy Mouelet Migolet, Gemael Cedrick Taty-Taty, and Bolni Marius Nagalo (2019) “Hemogram Abnormalities in Apparently Healthy First-time Blood Donors in Libreville, Gabon,” Sudan Journal of Medical Sciences, vol. 14, issue no. 3, pages 103–115. DOI 10.18502/sjms.v14i3.5210 Page 103 Corresponding Author: Cyrille Bisseye; email: cbisseye@gmail.com Received 21 February 2019 Accepted 12 May 2019 Published 30 September 2019 Production and Hosting by Knowledge E Cyrille Bisseye et al. This article is distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use and redistribution provided that the original author and source are credited. Editor-in-Chief: Prof. Mohammad A. M. Ibnouf http://www.knowledgee.com mailto:cbisseye@gmail.com https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ Sudan Journal of Medical Sciences Cyrille Bisseye et al component in the treatment of hemoglobinopathies, particularly sickle cell disease [1]. The stages of the transfusion chain that begin with the reception of the blood donor and end with the transfusion of the compatible blood product to the recipient are essential to observe in order to guarantee the quality of the transfused products [2]. One of these most important steps is the blood donation qualification by the transfusion physician during the pre-donation interview [3]. The qualification for blood donation is done by checking the donor for certain clinical and hematological parameters to evaluate their ability to donate. The measurement of hematological parameters in transfusion medicine is important in that it allows the detection of quantitative abnormalities of the cellular elements of the blood. However, according to the report of the transfusion research group in French-speaking Africa, the measurement of these parameters is very little done in sub-Saharan Africa during the biological testing of a blood donation [4]. The measurement of hemoglobin is the only pre-donation screening preventing the occurrence of donation-induced anemia. It also avoids bleeding in an already anemic donor. Various factors are known to cause changes in the rate of red blood cells in an individual, such as sex, age, pregnancy, altitude, and ethnicity [5]. The measurement of hemoglobin and the assessment of anemia should be corrected taking into account ethnicity. Indeed, it has been shown that the average values of hemoglobin levels of African-American subjects are lower than those of American subjects of other ethnic origins [6]. A recent report has shown lower hemoglobin values in Africans compared to Caucasians [7]. Most blood centers perform hemoglobin testing during the pre-donation interview using the copper sulfate method in relation to its very low cost. However, previous studies have shown that anemia was observed in 42% of blood donors in Africa [8, 9]. While progress has been observed at the National Blood Transfusion Center in Libreville in terms of reducing the post-transfusion risk of transfusion-transmissible infections, measures taken to improve the blood donation qualification during the medical interview need to be improved [10–12]. Indeed, the hematological parameters of the donor are verified post-donation and are only clinical information for the donor. The measurement of the hemoglobin level that represents the hematological parameter of eligibility for donation is not yet done during the pre-donation medical interview. This study was designed to evaluate the erythrocyte, leukocyte, and platelet counts of first- time blood donors of Libreville to determine the prevalence and characteristics of their abnormalities. DOI 10.18502/sjms.v14i3.5210 Page 104 Sudan Journal of Medical Sciences Cyrille Bisseye et al 2. Methods 2.1. Blood donors A cross-sectional analysis of blood donor data collected first in March 2016 and second between January and April 2017 was conducted at the National Blood Transfusion Center (NBTC). All apparently healthy voluntary non-remunerated donors (VNRD) and family/replacement donors (FRD) were selected after responding to a range of questions including medical history. Individuals aged 18 to 59 yrs and weighing ≥ 50 kg were eligible for blood donations. All candidate donors responded to questions aiming at the exclusion of transfusion recipients, individuals who had jaundice or signs of hepatitis, pregnant women, and persons with unsafe sexual behavior during the six months prior to blood donation. Blood donors signed a written informed consent forms prior to blood collection. Venous blood was collected in the blood bags following standard procedures. 2.2. Hemogram profile determination The complete blood count (CBC) was performed using an automated Hematology Analyzer Sysmex XP-300TM (SYSMEX Corporation, Kobe, Japan) according to the man- ufacturer’s instructions. The instrument automatically counts and gives a printout result of absolute numbers of erythrocytes (RBC) (1012/L), hemoglobin (g/dL), hematocrit (%), MCV (fl), MCHC (g/dL), leukocytes (WBC) (109/L), and platelets (109/L). 2.3. Statistical analysis Statistical analyses were performed with the software EpiInfo version 6 and SPSS version 20; p ≤ 0.05 was considered significant. 3. Results 3.1. Demographic characteristics of the study population This study involved 4,573 blood donors at the NBTC in Libreville. Blood donors were predominantly males (83.7%). The male/female sex ratio was 5/1. The age of blood DOI 10.18502/sjms.v14i3.5210 Page 105 Sudan Journal of Medical Sciences Cyrille Bisseye et al donors ranged from 18 to 49 yrs for women and 18 to 59 yrs for men. The age groups 20–29 and 30–39 yrs were the most represented in both women (52.2% and 34.9%) and men (48.4% and 35.8%) (Table 1). Table 1: Repartition of blood donors by age groups. Female Male Age groups Number Percentage Number Percentage < 20 yrs 12 1.6 37 1.0 20–29 yrs 389 52.2 1,851 48.4 30–39 yrs 260 34.9 1,369 35.8 40–49 yrs 84 11.3 504 13.2 50–59 yrs – – 67 1.8 Total 745 3,828 3.2. Mean values of the blood count in blood donors The mean values of hematological parameters such as RBC, Hb, HCT, MCV, MCHC, WBC, and PLT are presented in Table 2. The mean values of erythrocyte parameters (RBC, Hb, HCT, and MCV) were significantly higher in men compared to women (Table 2). Only MCHC was higher in women compared to men (p = 0.009). In contrast, the mean value of PLT was significantly higher in women compared to men (p < 0.001), while the WBC average was similar for both sexes (p = 0.068). 3.3. Abnormalities of blood donors’ blood count by gender The abnormalities of the hemogram of blood donors have been observed mainly in the erythrocytes. In fact, 69.4% and 84.4% of women had lower Hb and HCT levels, respectively, while 32.3% and 24.4% of them had MCV and MCHC values lower than the lower limits, respectively. Leukocyte and platelet counts showed little abnormality with 74.4% and 91.8% of female blood donors with WBC and PLT levels between baseline values (Table 3). In male blood donors, the abnormalities of the blood count mainly concerned ery- throcytes with 45%, 52.2% and 28.6% with Hb, HCT, and MCHC levels below the lower limit and only 0.2%, 0.5%, and 1.7% of these had Hb, HCT, and MCHC levels above the upper limit (Table 3). With respect to leukocytes and platelets, 29.02% and 16.2% of DOI 10.18502/sjms.v14i3.5210 Page 106 Sudan Journal of Medical Sciences Cyrille Bisseye et al Table 2: Comparison of mean values of complete blood count (CBC) in female and male blood donors. Hematological parameters Female Male Mean ± SD Mean ± SD P-value* RBC x 1012/L 4.049 ± 0.531 4.878 ± 7.425 < 0.001 Hb (g/dL) 10.802 ± 1.478 13.092 ± 1.538 < 0.001 HCT (%) 32.860 ± 4.433 39.813 ± 4.538 < 0.001 MCV (ƒL) 81.294 ± 8.261 84.586 ± 6.953 < 0.001 MCHC (%) 32.977 ± 2.804 32.975 ± 2.708 0.009 WBC x 109/L 5.035 ± 1.911 4.915 ± 1.512 0.068 PLT x 109/L 239.168 ± 68.931 203.015 ± 59.690 < 0.001 RBC: Red blood cell; Hb: Hemoglobin; HCT: Hematocrit; MCV: Mean corpuscular volume; MCHC: Mean corpuscular hemoglobin concentration; WBC: White blood cell; PLT: Platelets. *Mann–Whitney test Table 3: Distribution of erythrocyte, leukocyte, and platelet parameters of female versus male blood donors according to Reference and threshold values. Hematolog- ical parameters Reference values Number of female vs male donors whose value is below the lower limit Number of female vs male donors whose value is in the reference range Number of female vs male donors whose value is greater than the upper limit Numbers % Numbers % Numbers % RBC (x 1012/L) F: 4 < RBC < 5.3 M: 4.2 < RBC < 5.7 359/707 48.2/18.5 359/2859 48.2/74.7 27/262 3.6/6.8 Hb (g/dL) F : 12 < Hb < 16 M : 13 < Hb < 18 517/1724 69.4/45.0 224/2098 30.0/54.8 4/6 0.6/0.2 HCT (%) F : 37 < HCT < 46 M : 40 < HCT < 52 629/1998 84.4/52.2 112/1812 15.0/47.3 4/18 0.5/0.5 MCV (fL) 80 ≤ MCV ≤ 100 241/494 32.3/12.9 498/3302 66.8/86.3 6/32 0.8/0.8 MCHC (%) 32 ≤ MCHC ≤ 36 182/1094 24.4/28.6 527/2669 70.7/69.7 36/65 4.8/1.7 WBC (x 109/L) 4 < WBC < 10 183/1111 24.6/29.02 554/2685 74.4/70.14 8/32 1.0/0.84 PLT (x 109/L) 150 < PLT < 450 56/620 7.5/16.2 684/3199 91.8/83.6 5/9 0.7/0.2 RBC: Red blood cell; Hb: Hemoglobin; HCT: Hematocrit; MCV: Mean corpuscular volume; MCHC: Mean corpuscular hemoglobin concentration; WBC: White blood cell; PLT: Platelets. men had WBC and PLT counts below the lower limit and only 0.84% and 0.2% of these showed WBC and PLT rates above the upper limit (Table 3). DOI 10.18502/sjms.v14i3.5210 Page 107 Sudan Journal of Medical Sciences Cyrille Bisseye et al 3.4. Comparison of blood count abnormalities in blood donors by gender The three hematological parameters that have been taken into account are hemoglobin level (anemia), white blood cells (leukopenia and leukocytosis), and platelets (throm- bocytopenia and thrombocytosis). The results show that women were significantly more frequently anemic than men (69.4% vs 45%, p < 0.001), while leukopenia and thrombocytopenia were significantly more common in men than women (29.02% vs 24.4%, p = 0.011 and 16.2% vs 7.5%, p < 0.001) (Table 4). Only 1.0% of women and 0.84% of men had leukocytosis, and 0.7% of women and 0.2% of men had thrombocytosis (Table 4). Table 4: Comparison of erythrocytes, leucocytes, and platelets abnormalities in blood donors by gender. Female Male Hematological parameters Number Percentage Number Percentage P-value Hb (Female: Hb < 12 ; Male: Hb < 13) 517 69.4 1,742 45.0 < 0.001 WBC Leukopenia (WBC < 4 x 109/L) 182 24.4 1,111 29.02 0.011 Leukocytosis (WBC > 10 x 109/L) 8 1.0 32 0.84 0.778 PLT Thrombocytopenia (PLT < 150 x 109/L) 56 7.5 620 16.2 < 0.001 Thrombocytosis (PLT < 450 x 109/L) 5 0.7 9 0.2 0.073 Hb: Hemoglobin; WBC: White blood cell; PLT: Platelets. 3.5. Characterization of different levels and types of anemia in Libreville blood donors Anemia was significantly more frequent in women compared to men in the age groups < 20 yrs and 20–29 yrs (2.0% vs 1.1%, p = 0.039 and 52.6% vs 46.7%, p = 0.002) (Table 5). In contrast, among blood donors aged 40 to 49 years, anemia was more prevalent in men compared to women (16.1% vs 11.2%, p < 0.001). With regard to the degree of anemia, slight anemia predominated in both women (63.2%) and men (84.8%). Severe or moderate anemia was observed in 4.3% and 32.5% of women and 1.3% and 13.9% of men, respectively. They were significantly more frequent in women compared to men (p < 0.001 and p < 0.001) (Table 5). DOI 10.18502/sjms.v14i3.5210 Page 108 Sudan Journal of Medical Sciences Cyrille Bisseye et al Table 5: Comparison of anemia level among blood donors by gender and age. Female with anemia Male with anemia Parameters Number % Parameters Number % P-value Age groups < 20 yrs 10 2 < 20yrs 19 1.1 0.039 20–29 yrs 272 52.6 20–29yrs 802 46.5 0.002 30–39 yrs 177 34.2 30–39yrs 586 34 0.91 40–49 yrs 58 11.2 40–49yrs 278 16.1 < 0.001 50–59 yrs – – 50–59yrs 39 2.3 Anemia level Severe (Hb < 8) 22 4.3 Severe (Hb < 9) 22 1.3 < 0.001 Mild (8 < Hb < 10) 168 32.5 Mild (9 < Hb < 11) 240 13.9 < 0.001 Slight (10 < Hb < 12) 327 63.2 Slight (11 < Hb < 13) 1,462 84.8 < 0.001 Normocytic normochromic and normocytic hypochromic anemia were most common among Libreville blood donors with 39.4% and 23.6%, respectively. They were followed by microcytic normochromic (18.7%) and microcytic hypochromic (13.2%) anemia. All types of hyperchromic anemia were found in 3.4% (77/2241) of blood donors. The different types of anemia were not associated with age of the blood donors (Table 6). Microcytic normochromic anemia was significantly more frequent in female blood donors compared to male blood donors (p < 0.001). While normocytic hypochromic or normochromic anemia were more prevalent in men than in women (p < 0.001 and p < 0.001) (Table 6). 4. Discussion This study was conducted with the aim of improving the qualification criteria for blood donation at the NBTC located in Libreville by including the results of the CBC in the transfusion process. The measurement of hematological parameters in blood donors by CBC allows the diagnosis of certain existing blood abnormalities in the donor to establish a first barrier against transmitted-transfusion infections. In Libreville blood donors, we observed that red cell parameters (RBC, Hb, HCT, and MCV) were higher in men compared to women. The mean of WBC was similar for both sexes. In contrast, the mean of PLT was higher among women than men which is in agreement with previous DOI 10.18502/sjms.v14i3.5210 Page 109 Sudan Journal of Medical Sciences Cyrille Bisseye et al Table 6: Comparison of anemia type among blood donors by gender and age. Type of anemia MAHA MAHyA MANA MIHA MIHyA MINA NHA NHyA NNA N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) Gender Female 0 (0.0) 6 (1.2) 0 (0.0) 5 (1.0) 57 (11.0) 179 (34.6) 7 (1.4) 93 (18.0) 170 (32.9) Male 1 (0.1) 28 (1.6) 3 (0.2) 15 (0.9) 239 (13.9) 240 (13.9) 49 (2.8) 435 (25.2) 714 (41.4) P-value NC NS NC NS NS < 0.001 NS < 0.001 < 0.001 Age groups < 20 yrs 0 (0.0) 0 (0.0) 0 (0.0) 1 (3.4) 3 (10.3) 8 (27.6) 1 (3.4) 8 (27.6) 8 (27.6) 20–29 yrs 0 (0.0) 17 (1.6) 1 (0.1) 12 (1.1) 147 (13.7) 211 (19.6) 28 (2.6) 231 (21.5) 427 (39.8) 30–39 yrs 0 (0.0) 9 (1.2) 1 (0.1) 4 (0.5) 87 (11.4) 148 (19.4) 17 (2.2) 188 (24.6) 309 (40.5) 40–49 yrs 1 (0.3) 6 (1.8) 1 (0.3) 3 (0.9) 56 (16.7) 47 (14.0) 9 (2.7) 87 (25.9) 126 (37.5) 50–59 yrs 0 (0.0) 2 (5.1) 0 (0.0) 0 (0.0) 3 (7.7) 5 (12.8) 1 (2.6) 14 (35.9) 14 (35.9) P-value NC NS NC NS NS NS NS NS NS MAHA: Macrocytic hyperchromic anemia; MAHyA: Macrocytic hypochromic anemia; MANA: Macrocytic normochromic anemia; MIHA: Microcytic hyperchromic anemia; MIHyA: Microcytic hypochromic anemia; MINA: Microcytic normochromic anemia; NHA: Normocytic hyperchromic anemia; NHyA: Normocytic hypochromic anemia; NNA: Normocytic normochromic anemia. studies [13–15]. The mean values of red cell parameters vary with age and sex [16]. Indeed, values are higher in men compared to women, which is in agreement with the results of a recent report [7]. On the other hand, no difference between women and men was found for the leukocyte count as previously reported [17, 18]. Leukocyte, platelet, and erythrocyte abnormalities of blood donors were assessed. CBC of blood donors showed that 70.8% of these showed no leucocyte abnormality. However, leukopenia was the most frequently observed WBC abnormality with a prevalence of 28.3%. Two previous studies in Nigeria and Cameroon reported the prevalence of leukopenia of 12.5% and 14.96% in blood donors [19, 20]. Leukopenia was significantly more prevalent in men than in women. Leukocytosis was present in only 0.9% of Libreville blood donors, while it was the most observed leukocyte abnormality in Morocco with 5.27% [18]. With respect to platelet count, 84.9% of blood donors had no platelet count abnor- malities. Thrombocytopenia (14.8%) was the most observed abnormality compared to thrombocytosis (0.3%). Thrombocytopenia was significantly higher in men compared to DOI 10.18502/sjms.v14i3.5210 Page 110 Sudan Journal of Medical Sciences Cyrille Bisseye et al women. Thrombocytopenia may be central or peripheral due to destruction or excessive consumption of platelets. In this study, thrombocytosis was higher in women than in men as reported previously [21, 22]. But the difference observed was not significant. The observed thrombocytosis may be due in part to infections or iron deficiency [23]. With regard to the erythrocyte, anemia was found in 49% of blood donors. The prevalence of anemia found in our study is significantly higher than those of 36.5% and 28% observed, respectively, in Congo and Cameroon [20, 24]. Lower anemia prevalences of 8.6% has been reported in North Africa, particularly in Tunisia [25]. The most anemic age group was 20 to 29 yrs, with rates of 52.6% and 46.5%, respectively, for women and men. In Morocco, anemia rates of 43.5% and 42.5% were reported in the age group 30–39 yrs for both women and men [18]. In Congo, however, the prevalence of anemia was higher in the 40–49 age group, with 42.7% in both sexes [24]. The high prevalence of anemia found in this study could be explained by the high prevalence of hemoglobinopathies in Gabon such as alpha and beta thalassemias, sickle cell anemia, and Glucose-6-Phosphate Deshydrogenase deficiency [26–28]. In this study, we found that women (69.4%) were more frequently anemic than men (45.0%). Many studies in Africa have also reported variable prevalence of anemia among women ranging from 49% in Tanzania to 16.9% in Tunisia [25, 29]. Slight anemia was found in 84.8% of men and 63.2% of women. These results suggest that anemia, according to thresholds established by the WHO, is probably well tolerated by blood donors in Gabon as few adverse events following blood donation in Libreville have been reported among blood donors. Therefore, it could be more appropriate to establish threshold hemoglobin values specific to the Gabonese population in particular and to populations of color in sub-Saharan Africa in general to define anemia. In this study, the most common anemias in Libreville blood donors were normocytic normochromic (39.4%) and normocytic hypochromic (23.6%). The highest prevalence of normocytic normochromic anemia observed in Libreville blood donors is consistent with the prevalence of 46.74% reported previously in Ghana [30]. The distribution of these two types of anemia was not identical in both sexes. Normocytic normochromic and normocytic hypochromic anemia were significantly more frequent in men than in women. In contrast of the studies of Bakrim et al. in Morocco and Nzengu-Lukusa in Demo- cratic Republic of Congo (DRC) [18, 24], who found high prevalence of microcytic anemia in blood donors, we observed microcytic normocytic and microcytic hypochromic ane- mia, respectively, in 18.7% and 13.2% of blood donors. Microcytic normochromic anemia DOI 10.18502/sjms.v14i3.5210 Page 111 Sudan Journal of Medical Sciences Cyrille Bisseye et al was significantly more frequent in women (34.6%) than men (13.9%). In this study, we did not perform iron assessment. However, the prevalence of 13.2% microcytic hypochromic anemia observed in Libreville blood donors may be associated with iron deficiency. Indeed, previous studies in Burkina Faso, Tunisia, and India have shown the association between microcytosis and Iron deficiency anemia [25, 31, 32]. 5. Conclusion The aim of this study was to provide reliable data to advocate for pre-donation hemoglobin measurement in Libreville blood donors and to take into account CBC results in blood donation qualification. It appears that blood count abnormalities frequently encountered in blood donors were leucopenia, thrombocytopenia, and normocytic normochromic anemia. Since anemia is present in about half of the blood donor population, a specific hemoglobin threshold in Gabon from which a donation could be authorized should be defined. Ethical Approval This study was approved by the CNTS Ethics Committee. Acknowledgments The authors would like to thank all the participants of this study, the CNTS’ staff Ripaire Mboumba and JPA for critically reading the manuscript. Funding The authors are grateful to the NBTC for its financial support through le programme de support à la recherche. Conflict of Interest The authors declare that there is no conflict of interest. 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DOI 10.18502/sjms.v14i3.5210 Page 115 Introduction Methods Blood donors Hemogram profile determination Statistical analysis Results Demographic characteristics of the study population Mean values of the blood count in blood donors Abnormalities of blood donors' blood count by gender Comparison of blood count abnormalities in blood donors by gender Characterization of different levels and types of anemia in Libreville blood donors Discussion Conclusion Ethical Approval Acknowledgments Funding Conflict of Interest References