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Drown L, Osei M, Thapa A, Boudreaux C, Archer N, Bukhman G, Adler AJ. Models of care for sickle cell disease in low-income and lower-middle-income countries: a scoping review. Lancet Haematol 2024; 11:e299-e308. [PMID: 38432241 DOI: 10.1016/s2352-3026(24)00007-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 03/05/2024]
Abstract
Sickle cell disease has a growing global burden falling primarily on low-income countries (LICs) and lower-middle-income countries (LMICs) where comprehensive care is often insufficient, particularly in rural areas. Integrated care models might be beneficial for improving access to care in areas with human resource and infrastructure constraints. As part of the Centre for Integration Science's ongoing efforts to define, systematise, and implement integrated care delivery models for non-communicable diseases (NCDs), this Review explores models of care for sickle cell disease in LICs and LMICs. We identified 99 models from 136 studies, primarily done in tertiary, urban facilities in LMICs. Except for two models of integrated care for concurrent treatment of other conditions, sickle cell disease care was mostly provided in specialised clinics, which are low in number and accessibility. The scarcity of published evidence of models of care for sickle cell disease and integrated care in rural settings of LICs and LMICs shows a need to implement more integrated models to improve access, particularly in rural areas. PEN-Plus, a model of decentralised, integrated care for severe chronic non-communicable diseases, provides an approach to service integration that could fill gaps in access to comprehensive sickle cell disease care in LICs and LMICs.
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Affiliation(s)
- Laura Drown
- Center for Integration Science in Global Health Equity, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Miriam Osei
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ada Thapa
- Center for Integration Science in Global Health Equity, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Chantelle Boudreaux
- Center for Integration Science in Global Health Equity, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Natasha Archer
- Harvard Medical School, Harvard University, Boston, MA, USA; Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Gene Bukhman
- Center for Integration Science in Global Health Equity, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Program in Global Noncommunicable Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Alma J Adler
- Center for Integration Science in Global Health Equity, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Ally M, Balandya E. Current challenges and new approaches to implementing optimal management of sickle cell disease in sub-Saharan Africa. Semin Hematol 2023; 60:192-199. [PMID: 37730472 PMCID: PMC10909340 DOI: 10.1053/j.seminhematol.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 08/01/2023] [Accepted: 08/21/2023] [Indexed: 09/22/2023]
Abstract
Sickle cell disease (SCD) is the most common life-threatening monogenic disorder in the world. The disease is highly prevalent in malaria endemic areas with over 75% of patients residing in Sub-Saharan Africa (SSA). It is estimated that, without proper care, up to 90% of children with SCD will not celebrate their fifth birthday. Early identification and enrolment into comprehensive care has been shown to reduce the morbidity and mortality related with SCD complications. However, due to resource constraints, the SSA is yet to implement universal newborn screening programs for SCD. Furthermore, care for patients with SCD in the region is hampered by the shortage of qualified healthcare workers, lack of guidelines for the clinical management of SCD, limited infrastructure for inpatient and outpatient care, and limited access to blood and disease modifying drugs such as Hydroxyurea which contribute to poor clinical outcomes. Curative options such as bone marrow transplant and gene therapy are expensive and not available in many SSA countries. In addressing these challenges, various initiatives are ongoing in SSA which aim to enhance awareness on SCD, improve patient identification and retention to care, harmonize the standards of care for SCD, improve the skills of healthcare workers and conduct research on pertinent areas in SCD in the SSA context. Fortifying these measures is paramount to improving the outcomes of SCD in SSA.
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Affiliation(s)
- Mwashungi Ally
- Sickle Pan African Research Consortium, Tanzania site Sickle Cell Program Department of Hematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences Dar es Salaam Tanzania.
| | - Emmanuel Balandya
- Sickle Pan African Research Consortium, Tanzania site Sickle Cell Program Department of Hematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences Dar es Salaam Tanzania
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Hamzaoui A, Louhaichi S, Hamdi B. [Lung manifestations of sickle-cell disease]. Rev Mal Respir 2023:S0761-8425(23)00107-9. [PMID: 37059617 DOI: 10.1016/j.rmr.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 03/04/2023] [Indexed: 04/16/2023]
Abstract
Sickle-cell disease is an autosomal recessive genetic disorder of hemoglobin that causes systemic damage. Hypoxia is the main actor of sickle-cell disease. It initiates acutely the pathogenic cascade leading to tissue damages that in turn induce chronic hypoxia. Lung lesions represent the major risk of morbidity and mortality. Management of sickle-cell disease requires a tight collaboration between hematologists, intensivists and chest physicians. Recurrent episodes of thrombosis and hemolysis characterize the disease. New therapeutic protocols, associating hydroxyurea, transfusion program and stem cell transplantation in severe cases allow a prolonged survival until the fifth decade. However, recurrent pain, crisis, frequent hospital admissions due to infection, anemia or acute chest syndrome and chronic complications leading to organ deficiencies degrade the patients' quality of life. In low-income countries where the majority of sickle-cell patients are living, the disease is still associated with a high mortality in childhood. This paper focuses on acute chest syndrome and chronic lung manifestations.
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Affiliation(s)
- A Hamzaoui
- Pavillon B/LR19SP02, hôpital Abderrahmen-Mami, 2080 Ariana, Tunisie; Faculté de médecine de Tunis, 1006 Tunis, Tunisie.
| | - S Louhaichi
- Pavillon B/LR19SP02, hôpital Abderrahmen-Mami, 2080 Ariana, Tunisie; Faculté de médecine de Tunis, 1006 Tunis, Tunisie
| | - B Hamdi
- Pavillon B/LR19SP02, hôpital Abderrahmen-Mami, 2080 Ariana, Tunisie; Faculté de médecine de Tunis, 1006 Tunis, Tunisie
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Lumbala PK, Mbayabo G, Ngole MN, Lumaka A, Race V, Matthijs G, Van Geet C, Lukusa PT, Devriendt K, Mikobi TM. Clinical and laboratory characterization of adult sickle cell anemia patients in Kinshasa. PLoS One 2022; 17:e0278478. [PMID: 36525434 PMCID: PMC9757547 DOI: 10.1371/journal.pone.0278478] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Sickle cell anemia (SCA) is a monogenic hemoglobinopathy associated with severe acute and chronic complications, with the highest incidence worldwide in Sub-Saharan Africa. The wide variability in clinical manifestations suggest that a uniform response to hydroxurea may not be attained. In view of a potential treatment with hydroxyurea (HU), we assessed the variability of clinical and hematological manifestations in a cohort of adults with SCA in Kinshasa, capital of the DR Congo in Central Africa. METHODS A cross-sectional study was conducted in a hospital dedicated to SCA management in Kinshasa. Clinical history of patients was recorded, a complete physical examination performed. The diagnosis was confirmed by means of DNA analysis. A full blood count and hemolysis markers were measured. The severity of the disease was evaluated by means of a previously reported score. RESULTS The study group consisted of 166 genetically confirmed SCA patients. The SCA severity was mild in 28.9%, moderate in 64.5% and severe in 6.6%. The disease severity score increased with patient's age (p ≤ 0.001). The severity was higher in males compared to females (p = 0.012). In males, the severity score was correlated with the presence of priapism (p = 0.045), a manifestation not previously incorporated in the severity score. The severity score was inversely correlated with the fetal hemoglobin (HbF) rate (p = 0.005). Malnutrition (BMI <18.5 kg/m2) was present in 47% of patients and was related to the male sex, hip disease (aOR 3.11; p = 0.019) and severe phenotype (aOR 3.53; p = 0.012). Leg ulcers were more frequent in males than in females (p = 0.001; OR 24.3) and were correlated with the number of days of hospitalization (p = 0.029). Hip disease was related to the increasing age (p = 0.008). CONCLUSION In this selected, hospital-based populations of adults with SCA, severe disease was rare, which may be due to survival bias. However, two thirds had moderate severity of the disease, mostly with a low HbF, and they may benefit from HU treatment. In the Central-African setting the separation between vaso-occlusive and hyperhemolytic sub-phenotypes was not applicable.
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Affiliation(s)
| | - Gloire Mbayabo
- Department of Pediatrics, University of Kinshasa, Kinshasa, DRC
| | - Mamy Nzita Ngole
- Department of Clinical Biology, University of Kinshasa, Kinshasa, DRC
| | - Aimé Lumaka
- Faculty of Medicine, Center of Human Genetics, University of Kinshasa, Kinshasa, DRC
| | - Valerie Race
- Center for Human Genetics, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - Gert Matthijs
- Center for Human Genetics, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - Chris Van Geet
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium
| | | | - Koenraad Devriendt
- Center for Human Genetics, KU Leuven and University Hospitals Leuven, Leuven, Belgium
- * E-mail: (KD); (TMM)
| | - Tite Minga Mikobi
- Faculty of Medicine, Center of Human Genetics, University of Kinshasa, Kinshasa, DRC
- Faculty of Medicine, Molecular Biology and Human Genetics Department of fundamental sciences, University of Kinshasa, Kinshasa, DRC
- * E-mail: (KD); (TMM)
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Introduction of Hydroxyurea Therapy to a Cohort of Sickle Cell Patients in Northern Haiti. J Pediatr Hematol Oncol 2022; 44:351-353. [PMID: 35180761 DOI: 10.1097/mph.0000000000002431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 01/11/2022] [Indexed: 11/26/2022]
Abstract
Although the prevalence of sickle cell anemia is high in Haiti, treatment with hydroxyurea (HU) is uncommon. HU therapy was started at a hospital in Northern Haiti for children and young adults who had presented with complications of their disease. The patients were followed in clinic for their response to therapy and the principal outcome was hospitalization for complications. There was a 70% decrease in the rate of hospitalization in the cohort with no significant complications or deaths during the study period. Treatment with HU is a proven therapy that reduces the morbidity associated with sickle cell anemia and efforts should be made to assure access and affordability in regions with a high prevalence.
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Nnebe-Agumadu U, Adebayo I, Erigbuem I, James E, Kumode E, Nnodu O, Adekile A. Hydroxyurea in children with sickle cell disease in a resource-poor setting: Monitoring and effects of therapy. A practical perspective. Pediatr Blood Cancer 2021; 68:e28969. [PMID: 33788390 DOI: 10.1002/pbc.28969] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/30/2021] [Accepted: 02/07/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Although effectiveness of hydroxyurea (HU) in sickle cell disease is well established, unanswered questions persist about its use in African children. We determined real-life issues of acceptability, availability, and monitoring of HU use in Nigeria. METHODS A retrospective longitudinal review of laboratory data of patients on HU was done from case files, followed by a cross-sectional survey that captured families' perception of medication and clinic adherence, laboratory tests, benefits, side effects, and acceptability. RESULTS One hundred sixteen patients (1.2-17 years) received HU (mean ± SD = 18.5 ± 4.3 mg/kg/day) in 33 months. Eighty-nine had laboratory analysis. Dose escalation was the initial goal, but only 80% of patients had some form of it. Parents reported improvement in general well-being and reduction in bone pain episodes, hospital admissions, and blood transfusion. While most parents (89.5%) reported satisfaction with HU, 61% reported dissatisfaction with daily drug use, and the frequency and cost of monitoring. Sixteen percent voluntarily stopped therapy. Adherence to daily HU was 88.8%, doctor's appointments 24.5%, hematology tests 18.9%, and organ function tests 37.4%. There were no significant toxicities. Significant increases in hemoglobin, hemoglobin F and mean corpuscular volume, and reduction in absolute neutrophil count occurred despite inconsistent dose escalation. CONCLUSION HU (10-15 mg/kg/day starting dose) is safe and seems effective and acceptable to parents. Parental commitment to therapy, pre-HU education (that continues during therapy), provision of affordable HU, and subsidized laboratory tests are important considerations for initiating therapy. Special HU clinics may facilitate dose escalation and reduce frequency of monitoring. Studies are needed on feasibility of maximum tolerable dose HU protocols in sub-Saharan Africa without compromising safety.
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Affiliation(s)
- Uche Nnebe-Agumadu
- Department of Paediatrics, College of Health Sciences, University of Abuja, Abuja, Nigeria
| | - Innocent Adebayo
- Department of Paediatrics, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Ifeanyi Erigbuem
- Department of Paediatrics, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Esther James
- Department of Paediatrics, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Evelyn Kumode
- Department of Paediatrics, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Obiageli Nnodu
- Department of Hematology, College of Health Sciences, University of Abuja, Abuja, Nigeria
| | - Adekunle Adekile
- Department of Paediatrics, Kuwait University, Kuwait City, Kuwait
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Alzahrani F, Albaz GF, AlSinan F, Alzuhayri J, Barnawi ZM, Melebari N, Al Twairgi TM. Hydroxyurea Use Among Children With Sickle Cell Disease at King Abdulaziz University Hospital in Jeddah City. Cureus 2021; 13:e13453. [PMID: 33767937 PMCID: PMC7984494 DOI: 10.7759/cureus.13453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Sickle cell disease (SCD) is an autosomal recessive hemoglobinopathy that is very common and causes a great burden in Saudi Arabia and worldwide. This study aims to determine the frequency and benefits of using hydroxyurea in treating children with SCD in King Abdulaziz University Hospital (KAUH) in Saudi Arabia. Method This retrospective observational study included all SCD patients, males and females, who were following up in KAUH and were less than 18 years old. Patients on chronic transfusion therapy or who had previous stem cell transplantation were excluded from the study. The study was approved by the unit of biomedical ethics in KAUH, Jeddah. Result The study included 102 SCD patients; the median age of the sample was 7.5±4.2, with the majority being female (58 patients; 56.9%). Hydroxyurea users among participants in the study were 62 patients (60.8%). Thirty-seven (37) of the patients using hydroxyurea had an increase in the mean corpuscular volume (MCV). There was a decrease in the level of white blood cells (WBCs) and neutrophil count from 15.81±10.24 and 48.31±23.23% to 12.48±5.48 and 40.81±15.78%, respectively. Platelet count showed an increase from 345.4±2.1096 to 359.162±199.87 after starting hydroxyurea. The incidence of vaso-occlusive crisis (VOC) increased after hydroxyurea initiation from 4.555±4.08 to 6.288±9.80. Moreover, the frequency of blood transfusion in patients using hydroxyurea was statistically significant as p-value = 0.048. Conclusion In conclusion, our results showed significant clinical and laboratory benefits of hydroxyurea in children with SCD. Hydroxyurea has been shown to reduce the frequency of VOC and blood transfusion in patients with SCD.
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Affiliation(s)
| | | | - Fatima AlSinan
- College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, SAU
| | - Jumana Alzuhayri
- Faculty of Science: Biochemistry, King Abdul-Aziz University, Jeddah, SAU
| | | | - Nouf Melebari
- Health Education, Umm Al Qura University, Makkah, SAU
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Oron AP, Chao DL, Ezeanolue EE, Ezenwa LN, Piel FB, Ojogun OT, Uyoga S, Williams TN, Nnodu OE. Caring for Africa's sickle cell children: will we rise to the challenge? BMC Med 2020; 18:92. [PMID: 32340612 PMCID: PMC7187492 DOI: 10.1186/s12916-020-01557-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 03/12/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Most of the world's sickle cell disease (SCD) burden is in Africa, where it is a major contributor to child morbidity and mortality. Despite the low cost of many preventive SCD interventions, insufficient resources have been allocated, and progress in alleviating the SCD burden has lagged behind other public-health efforts in Africa. The recent announcement of massive new funding for research into curative SCD therapies is encouraging in the long term, but over the next few decades, it is unlikely to help Africa's SCD children substantially. MAIN DISCUSSION A major barrier to progress has been the absence of large-scale early-life screening. Most SCD deaths in Africa probably occur before cases are even diagnosed. In the last few years, novel inexpensive SCD point-of-care test kits have become widely available and have been deployed successfully in African field settings. These kits could potentially enable universal early SCD screening. Other recent developments are the expansion of the pneumococcal conjugate vaccine towards near-universal coverage, and the demonstrated safety, efficacy, and increasing availability and affordability of hydroxyurea across the continent. Most elements of standard healthcare for SCD children that are already proven to work in the West, could and should now be implemented at scale in Africa. National and continental SCD research and care networks in Africa have also made substantial progress, assembling care guidelines and enabling the deployment and scale-up of SCD public-health systems. Substantial logistical, cultural, and awareness barriers remain, but with sufficient financial and political will, similar barriers have already been overcome in efforts to control other diseases in Africa. CONCLUSION AND RECOMMENDATIONS Despite remaining challenges, several high-SCD-burden African countries have the political will and infrastructure for the rapid implementation and scale-up of comprehensive SCD childcare programs. A globally funded effort starting with these countries and expanding elsewhere in Africa and to other high-burden countries, including India, could transform the lives of SCD children worldwide and help countries to attain their Sustainable Development Goals. This endeavor would also require ongoing research focused on the unique needs and challenges of SCD patients, and children in particular, in regions of high prevalence.
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Affiliation(s)
- Assaf P Oron
- Maternal, Newborn and Child Health, Institute for Disease Modeling, Bellevue, WA, USA
| | - Dennis L Chao
- Maternal, Newborn and Child Health, Institute for Disease Modeling, Bellevue, WA, USA
| | - Echezona E Ezeanolue
- Healthy Sunrise Foundation, Las Vegas, NV, USA
- College of Medicine, University of Nigeria, Nsukka, Nigeria
| | | | - Frédéric B Piel
- Department of Epidemiology & Biostatistics, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | | | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | | | - Obiageli E Nnodu
- Centre of Excellence for Sickle Cell Disease Research & Training, University of Abuja, Abuja, Nigeria
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