Bakhubaira, J Clin Exp Pathol 2013, 3:3

http://dx.doi.org/10.4172/2161-0681.1000149

Clinical & Experimental Pathology

Research Article Open Access

Automated Versus Manual Platelet Count in Aden

Sawsan Bakhubaira*
Department of Clinical hematology, National Center of Public Health Laboratories, Aden, Yemen

Abstract
This is a cross sectional study conducted in the National Center of Public Health Laboratories (NCPHL) of Aden –
Yemen, during October-December 2011, with an overall aim to compare the results of platelet count by the automated
versus the manual methods.
Study included 190 random samples, examined with confirmatory platelet estimate done by the stained thin blood
film. The mean platelets count estimated by the manual method was 225.2 ± 95.4 × 109/L, while that estimated by the
automated method was 245.7 ± 109.8 × 109/L, with no significant statistical difference between both means (p>0.05).
The Pearson correlation test showed significant positive correlation between both methods (r: 0.563), this
correlation remained significant when the samples of normal count by the two methods were correlated (r: 0.359), but
it was insignificant negative correlation when the samples of low or high counts by the two methods were correlated
(r: -0.151 and -0.559) respectively.
This study concluded that significant positive correlation is present between the manual and the automated
counting methods of platelets and recommended that platelet count is not varied when done by manual or automated
methods, but in every method, it should be accompanied by platelet estimate, especially with abnormal counts.

Keywords: Platelet counting; Manual method; Automated method Methods

Introduction
Platelets have proved more difficult to count than red or white
cells [1]. For many years the Brecher and Cronkite method [2],
originally described in 1950 was considered to represent the optimum
compromise between accuracy, time and cost, and until comparatively
recently, was the reference against which semi-automated and
automated methods were compared.
The reasons for improving platelet counting, particularly in severely
thrombocytopenic patients, stem from current hemato-oncological
practice in relation to post chemotherapy bleeding and prophylactic
platelet transfusions. This was very adequately summarized in the
‘Consensus Statement on Platelet Transfusion Therapy’ by the Royal
College of Physicians Consensus Conference [3].
In the daily practice, an increasing request for platelet count in the
NCPHL was observed, as well as a need for accurate count by some
physicians which is attributed to the presence of increasing cases of
thrombocytopenia associated with various conditions such as leukemia,
chemotherapy for various malignancies and viral diseases (mainly
Dengue Fever) which was reported last years in some governorates in
Yemen.
In the NCPHL, some results of electronic platelets counts were
not accepted by physicians, especially for hematology and oncology
patients. Some physicians request the repeat of platelet count manually
once the result of electronic count does not correlate with the clinical
condition of the patient, and others prefer the automated count since
they lost credibility in the results of manual counting method. It was
decided to conduct this study by counting platelets manually (by the
use of hemocytometer chamber) confirmed with platelet estimate
by the stained thin blood film, and comparing the result with the
automated platelet count for the same sample at the same time to give
conclusive advice that will help in evaluation of patients with abnormal
platelets count.
Objective
To compare the results of the automated with the manual methods
of platelet count in the NCPHL of Aden.
This is a cross-sectional study, involved randomly selected blood
samples of patients attending the NCPHL in Aden during October
through December 2011.
The randomly selected samples were 190 blood samples of patients
attending the NCPHL with any diagnosis during the study period.
Selection was by the simple random sampling, blood samples were
taken each day by the even numbers, i.e. samples number 2, 4, 6, 8…
etc.
Data of age and sex of patients were taken from the laboratory
forms without meeting patients. Samples were examined by the
trained hematology technicians in the NCPHL, processed by the
automated counter using the Sysmex® KX-21N and manually by the
hemocytometer at the same time, in addition to platelet estimate by the
thin blood film, stained with Lishman’s Stains.
Data processing was performed by the Statistical Program (SPSS
18). Data were tested by the student t-test for two means and the
hypothesis test for two proportions. Simple regression analysis and
coefficient of determination (r) for correlation analysis between the two
methods was used [4]. All tests were applied at a level of significance
(α=0.05). P-values of ≤0.05 were considered as statistically significant.
Ethical Considerations
This study was approved by the ethical committee of Ministry
*Corresponding author: Sawsan Bakhubaira, Department of Clinical hematology,
National Center of Public Health Laboratories, Aden, Yemen, Tel: 00967-
777109290; E-mail: drsawson@yahoo.com
Received August 21, 2013; Accepted November 12, 2013; Published November
14, 2013
Citation: Bakhubaira S (2013) Automated Versus Manual Platelet Count in Aden.
J Clin Exp Pathol 3: 149. doi:10.4172/2161-0681.1000149
Copyright: © 2013 Bakhubaira S. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.

J Clin Exp Pathol Volume 3 • Issue 3 • 1000149

ISSN: 2161-0681 JCEP, an open access journal
Citation: Bakhubaira S (2013) Automated Versus Manual Platelet Count in Aden. J Clin Exp Pathol 3: 149. doi:10.4172/2161-0681.1000149

Page 2 of 4

of Public Health and Population. The study was dealing with blood automated counter. By the automated method, 35 samples showed low
samples from the lab. All the obtained data were handled confidentially, count, while 15 samples with normal count showed low count by the
instead of reporting the name of patients, serial numbers were used. manual method (Table 2).

Results About 12 samples showed high platelet count by either method, 2

When relating the mean platelets count by both methods to the sex
of the studied patients, it was found that the estimated mean platelets
count did not show significant difference between the two methods in
males as well as in females (Table 1).
In relation to the age of patients, the mean platelets count did not
show significant difference between the two methods in all age groups
(Table 1).
samples were missed by the automated method, and 6 samples were
missed by the manual method (Table 2).
Statistically, there is no significant difference between the number
of samples estimated with low count or with normal count by the
two methods (p>0.05). However, in samples with high count, there
is significant statistical difference between the two methods (p<0.05)
(Table 2).

By using the Pearson correlation test, there is significant positive When the correlation test was applied for the 128 samples with
correlation between the result of both methods for the whole samples normal count by both methods, there is positive correlation between
(r=0.563, p<0.001) (Figure 1). the result of both methods (r=0.359, p<0.001 (Figure 2).

About 50 samples from the studied 190 samples were found with When the correlation test was applied for the 50 samples with low
low count by either method, by the manual method they were 34 count by either method, there is negative correlation between the result
samples while 16 samples with normal count showed low count by the of both methods (r=-0.151, p=0.29) (Figure 3).

Platelet count (×109/L)

Statistics
Variable No. Manual method Automated method
Mean SD Mean SD F p
Sex of patients:
Male 101 226.7 91.4 253.8 117.7 27.1 0.86
Female 89 223.8 99.4 238.2 102.0 14.4 0.92
Age of patients (years):
≤20 84 272.5 115.6 255.4 112.5 47.1 0.77
21-40 50 299.5 111.2 284.5 131.5 15.0 0.93
41-60 40 288.3 132.9 306.3 118.2 18.0 0.92
>60 16 249.7 426.7 255.3 681.6 5.6 0.99
Total 190 225.2 95.4 245.7 109.8 20.5 0.44
p-value<0.05 is statistically significant, SD: Standard Deviation.

Table 1: The mean platelet count by manual versus automated methods according to sex and age of patients.

Figure 1: Correlation of platelet count by manual vs. automated methods (n=190).

J Clin Exp Pathol Volume 3 • Issue 3 • 1000149

ISSN: 2161-0681 JCEP, an open access journal
Citation: Bakhubaira S (2013) Automated Versus Manual Platelet Count in Aden. J Clin Exp Pathol 3: 149. doi:10.4172/2161-0681.1000149

Page 3 of 4

Automated statistical difference (p=0.44). This means that both methods can be
Proved Manual method
Platelet count
samples# (n=190)*
method Statistics used to count platelets without producing a significant difference in
(×10 /L)
9 (n=190)** results [5,6].
(n=190)
No. % No. % Z p
Low count Even when the samples are separated according to sex and age
50 34 17.9 35 18.4 0.21 0.41
(<140.0) of patients, we did not obtain any significant difference in counting
Normal count
128 128 67.4 128 67.4 - - platelets manually or automatically in males or in females, in younger
(140.0-450.0) or in older patients.
High count
12 6 3.2 10 5.3 1.7 0.041
(>450.0) When all the samples were analyzed by the Pearson correlation
#
Samples proved by repeated counts with blood film estimate, tested by NCPHL test, we observed significant positive correlation between the result of
hematology team with the help of hematologists. both methods (r=0.563, p=0.000). But when we correlated between low
*
22 samples were missed and not detected by this method. count samples alone as well as high count samples alone, the Pearson
**
17 samples were missed and not detected by this method.
p-Value<0.05 is statistically significant.
correlation test showed negative correlations (r: -0.151, r: -0.559)
respectively.
Table 2: Variation of platelet count estimated by manual vs. automated methods.
These findings may be attributed to the presence of high number of
samples with normal count (about 128 samples were normal by both

Figure 3: Correlation between samples of low platelet count by manual vs.

Figure 2: Correlation between samples of normal platelet count by manual vs.
automated methods (n=50).
automated methods (n=128).

When the correlation test was applied for the 12 samples with high
count by either method, there is negative correlation between the result
of both methods (r=-0.559, p=0.06) (Figure 4).

Discussion
Up to date, the only “Gold Standard” in platelet counting available
to assess any degree of accuracy of the automated count has been the
manual phase-contrast microscopic method. The manual method itself
has significant limitations in terms of performance, particularly in the
area of imprecision. Recently, a joint Task Force of the ISLH and the
ICSH recommended a new immunologically based reference method
[3]. This immunological method is not available in our labs and so we
are still depending on the manual method and in need to confirm the
results once there is an abnormal count. Because of that we conducted
this study by the help of platelet estimate on blood film which is an
arbitrary method of assurance in the absence of new immunological
methods.
The studied samples represented patients who are complaining of
various diseases, which may or may not affect platelet count. The mean
platelets count estimated by the manual method and the automated Figure 4: Correlation between samples of high platelet count by manual vs.
automated methods (n=12).
method for all the studied samples (n=190) did not show significant

J Clin Exp Pathol Volume 3 • Issue 3 • 1000149

ISSN: 2161-0681 JCEP, an open access journal
Citation: Bakhubaira S (2013) Automated Versus Manual Platelet Count in Aden. J Clin Exp Pathol 3: 149. doi:10.4172/2161-0681.1000149
methods). This large number dominates in the correlation of all sample
and yields positive correlation. Meanwhile, samples of low count (50
samples) or those of high count (12 samples) may not be enough to
show such positive correlation, and so we cannot rely on either method
alone once there is suspicion of low or high count and the performance
of platelet estimate is mandatory in such situations.
In the study of Charie LA et al. [7], when they evaluated 88
specimens with platelet counts of ≤ 20 × 109/L tested in 3 studies,
the automated analyzer counts matched the platelet reference count
method in 87 cases, representing an agreement of 98.9%. That is in
low platelet counts there should be another reference method which is
reliable like the method used by Charie LA et al. [7] (immunologically
based method). However, due to the low technical ability in the CPHL
in Aden, our physicians should rely on the results obtained by the
automated analyzer once there is an additional confirmatory platelet
estimate.
Physicians are advised to rely on the NCPHL analyzer results, in
such lab, experience technicians are responsible for the daily work in
addition to a periodic quality control measures are applied. Medical
decisions should not be delayed awaiting for repeat or confirmation as
Steele BW et al. [8] reported in their study (2001), where they found
that analyzer results can be used for medical decision making without
long delays for repeat and confirmatory testing.
Conclusion
The mean platelets count estimated by the manual method was not
significantly differing from that estimated by the electronic method.
In counting platelets by manual or electronic methods, the sex
and age of patients are not associated with significant difference in the
count.
Platelet estimate is an important step in assessment of platelet count
and it should be done for every sample of platelet count, especially
when the count is lower or higher than normal by any method.
A significant positive correlation is present between the manual
Citation: Bakhubaira S (2013) Automated Versus Manual Platelet Count in
Aden. J Clin Exp Pathol 3: 149. doi:10.4172/2161-0681.1000149
J Clin Exp Pathol
ISSN: 2161-0681 JCEP, an open access journal
Page 4 of 4
and the electronic counting methods of platelets. This correlation is not
valid for samples of low or high counts.
Recommendation
This study recommends that platelet count is not varied when done
by manual or electronic methods, but in every method, it should be
accompanied by platelet estimate.
Acknowledgement
It is important to acknowledge the efforts of all members in the department of
hematology in the NCPHL of Aden.
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