Abstract
Background: Red blood cell (RBC) transfusions play a critical role in managing severe acute complications in patients with sickle cell disease (SCD). Evidence from high-income countries (HICs) has also demonstrated the effectiveness of regular transfusions, particularly in preventing stroke in children. However, implementing such protocols in resource-limited countries, such as those in sub-Saharan Africa (SSA), remains challenging due to limited access to blood products and different safety standards. Moreover, data on transfusion practices in these regions are scarce.
Objective: To assess the availability of blood products, immunohematological testing, and transfusion practices in French-speaking SSA.
Methods: An online survey was conducted by the non-governmental organization (NGO) DrepAfrique between April 12, 2025, and May 8, 2025. A standardized computerized questionnaire, developed by members of the NGO's scientific council, was emailed to 1,960 SSA physicians involved in the care of patients with SCD.
Results: A total of 144 practitioners from 16 French-speaking SSA countries participated in the survey. The Democratic Republic of Congo was the most represented country, accounting for 40 respondents (27.8%). Most respondents worked in non-university settings (83/144, 57.6%); 79 (55%) practiced in a SCD referral center. The cumulative number of homozygous SS patients followed in these centers was estimated at approximately 86,000. Each respondent reported having seen a median of 10 [IQR 5; 23] SS patients in the preceding 15 days and having performed a transfusion for 2 [1; 5] of them. Only 38/144 practitioners (26.4%) reported performing phlebotomy prior to transfusion in SS patients with hemoglobin (Hb) >9 g/dL, and 13/144 (9%) had access to erythrocytapheresis.
Regarding transfusion indications (suggested from a predefined list), most respondents used transfusions during a vaso-occlusive crisis (VOC) with acute malaria and Hb <6 g/dL (93/144, 64.6%); in cases of anemia with Hb <5 g/dL for 90 of them (62.5%); and when a drop of more than 2 g/dL from baseline Hb occurred for 71 (49.3%). Surprisingly, the use of transfusion was less frequently reported in case of stroke (58/144, 40.3%) or severe acute chest syndrome (53/144, 36.8%). In response to a clinical scenario describing a 7-year-old child with SCD and Hb of 9.4 g/dL (baseline level) presenting with acute hemiplegia and normal brain CT-scan (suggestive of ischemic stroke) in the absence of malaria, only 93/144 respondents (64.6%) indicated that they would perform an immediate transfusion (83 of them (89.2%) with prior phlebotomy). For long-term management of this stroke, 58/144 (40.3%) would initiate a combined treatment of hydroxyurea (HU) and chronic transfusions within the following 6 months, while 51/144 (35.4%) would recommend HU alone.
Regarding red cell product type, 138 (95.8%) practitioners reported performing phenotyping of transfused bags, limited to the ABO-RhD systems for 86 (62.3%) of them, and ABO alone for 18 (13%). Only 34/144 (23.6%) practitioners reported screening patients for RBC antibodies before transfusion. The most commonly used blood products (reported as being used “often” or “always”) included whole blood (54/144, 37.6%), ABO-RhD phenotyped packed red blood cells (PRBCs) (73/144, 50.7%), and more rarely ABO-RhDCE-Kell phenotyped PRBCs (23/144, 16%). The limited use of high-quality RBC products or immunohematological testing was primarily due to cost constraints and/or limited availability.
Conclusion: This study provides valuable data from one of the largest surveys on transfusion practices for SCD in 16 French-speaking SSA countries. Key challenges include the absence of systematic RBC antibodies screening, the use of RBC products with limited phenotyping, a frequent reliance on whole blood, and difficulties in performing pre-transfusion phlebotomy. These findings call for caution when extrapolating to SSA countries chronic transfusion programs developed in HICs, which are based on significantly higher standards of transfusion safety. This study highlights the urgent need for context-appropriate training programs to optimize transfusion practices and decision-making processes in SSA, particularly in the acute management of stroke. In light of these constraints, a wider use of HU should be strongly encouraged.
