Systematic review of current and emerging strategies for reducing morbidity from malaria in sickle cell disease

Sickle cell disease (SCD) is a chronic debilitating disorder affecting erythrocytes, which is especially prevalent throughout Sub-Saharan Africa and among individuals of African descent. Because malaria is thought to be a significant cause of morbidity and mortality in patients with SCD, malaria chemoprophylaxis is often recommended for these patients. In SCD, malaria chemoprophylaxis reduces malaria parasite count, anaemia and the need for blood transfusion, and improves clinical outcomes. However, the effectiveness of malaria chemoprophylaxis in the setting of SCD is based on a few studies conducted prior to the emergence of widespread antimalarial drug resistance. Consequently, it is uncertain what the optimal strategy for managing patients with SCD in malarious areas should be. Despite the widespread use of hydroxyurea in non-malarious regions, little is known about its effect in malaria-endemic areas or on malaria-related outcomes. On the one hand, hydroxyurea upregulates intercellular cell adhesion molecule 1 (ICAM-1), the cell surface receptor for adhesion of Plasmodium falciparum-infected erythrocytes, and theoretically, it could enhance parasite replication. On the other hand, hydroxyurea increases levels of foetal haemoglobin, which is protective against malaria. We explore what is currently known about the interactions between SCD and malaria and review the published literature on the efficacy of malaria chemoprophylaxis in SCD. We also consider alternative strategies, including hydroxyurea, in the reduction of malaria-associated morbidity and mortality in patients with SCD.