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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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Arji EE, Eze UJ, Ezenwaka GO, Kennedy N. Evidence-based interventions for reducing sickle cell disease-associated morbidity and mortality in sub-Saharan Africa: A scoping review. SAGE Open Med 2023; 11:20503121231197866. [PMID: 37719166 PMCID: PMC10504846 DOI: 10.1177/20503121231197866] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/11/2023] [Indexed: 09/19/2023] Open
Abstract
Objective Sickle cell disease is a lifelong illness affecting millions of people globally, but predominantly burdensome in sub-Saharan Africa, where most affected children do not live to adulthood, despite available evidence-based interventions that reduce the disease burden in high-income countries. Method We reviewed studies evaluating evidence-based interventions that decrease sickle cell disease-related morbidity and mortality among children living in sub-Saharan Africa. We used the Joanna Briggs scoping review methodological framework and grouped identified evidence-based interventions into preventative pharmacotherapeutic agents, newborn screening and comprehensive healthcare, disease-modifying agents, nutritional supplementation, systemic treatment, supportive agents and patient/carer/population education. Results We included 36 studies: 18 randomized controlled trials, 11 observational studies, 5 before-and-after studies and 2 economic evaluation studies, with most of the studies performed in West African countries. Included studies suggest evidence-based interventions effectively to reduce the common morbidities associated with sickle cell disease such as stroke, vaso-occlusive crisis, acute chest syndrome, severe anaemia and malaria infection. Evidence-based interventions also improve survival among study participants. Specifically, our review shows hydroxyurea increases haemoglobin and foetal haemoglobin levels, a finding with practical implications given the challenges with blood transfusion in this setting. The feasibility of implementing individual interventions is hampered by challenges such as affordability, accessibility and the availability of financial and human resources. Conclusion Our review suggests that regular use of low-dose hydroxyurea therapy, sulphadoxine-pyrimethamine chemoprophylaxis, L-arginine and Omega-3 fatty acid supplementation and establishment of specialist stand-alone sickle cell clinics could reduce the sickle cell disease-associated morbidity and mortality in sub-Saharan Africa countries.
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Affiliation(s)
- Emmanuel Emenike Arji
- School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, UK
| | - Ujunwa Justina Eze
- Department of Family Medicine, WellSpan Good Samaritan Hospital, Lebanon, PA, USA
| | - Gloria Oluchukwu Ezenwaka
- Department of Paediatrics, Enugu State University Teaching Hospital, Parklane, Enugu, Enugu State, Nigeria
| | - Neil Kennedy
- School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, UK
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Hafiz TA, Aldharman SS, AlSubaie RN, Alzahrani LD, Albalawi IAJ, Alali YA, Yousuf MM, Alharbi HM, Alamri NS, Jamil SF. Blood Transfusion Vs. Hydroxyurea for Stroke Prevention in Children With Sickle Cell Anemia: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e31778. [PMID: 36569706 PMCID: PMC9774052 DOI: 10.7759/cureus.31778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 11/23/2022] Open
Abstract
Sickle cell anemia (SCA) is a hereditary condition that can lead to severe complications in children such as acute coronary syndrome, splenic sequestration, renal failure, and stroke. Blood transfusion and hydroxyurea (HU) therapy are used to prevent stroke in children with sickle cell disease (SCD). Preliminary data show considerable variation and inconsistency in the use of these two therapeutic interventions. Therefore, this systematic review was carried out to compare the effects of blood transfusion to HU therapy in preventing stroke for children with sickle cell disease. There was an extensive literature search in reliable and authentic databases like PubMed, Medline, Scopus, Cochrane, and Science Direct to obtain relevant articles. This study used the standards and guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). During the systematic review, data were obtained focusing on the following parameters: the size of the sample in the study, the age of the subjects involved in the study, the type of Intervention, and the outcome. After an initial search of 163 papers, 25 studies were included. The results of the research give the first evidence that HU is effective in the treatment of cerebrovascular problems in children with SCD. However, it is unclear under what circumstances HU may prevent a second stroke. It can be concluded that children with SCA can effectively avoid primary strokes through chronic blood transfusions and HU.
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Affiliation(s)
- Tamara A Hafiz
- Public Health & Informatics, Umm Al-Qura University, Makkah, SAU
| | - Sarah S Aldharman
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | | | | | | | - Yara A Alali
- College of Medicine, University of Tabuk, Tabuk, SAU
| | | | | | - Nawaf S Alamri
- Collage of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Syed F Jamil
- Research, King Abdullah International Medical Research Center, Riyadh, SAU
- College of Medicine, King Abdulaziz University for Health Sciences, Riyadh, SAU
- Pedaitrics, King Abdullah Specialized Children's Hospital, Riyadh, SAU
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Egesa WI, Nakalema G, Waibi WM, Turyasiima M, Amuje E, Kiconco G, Odoch S, Kumbakulu PK, Abdirashid S, Asiimwe D. Sickle Cell Disease in Children and Adolescents: A Review of the Historical, Clinical, and Public Health Perspective of Sub-Saharan Africa and Beyond. Int J Pediatr 2022; 2022:3885979. [PMID: 36254264 PMCID: PMC9569228 DOI: 10.1155/2022/3885979] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/19/2022] [Indexed: 11/24/2022] Open
Abstract
Sickle cell disease (SCD) is an umbrella term for a group of life-long debilitating autosomal recessive disorders that are caused by a single-point mutation (Glu→Val) that results in polymerization of hemoglobin (Hb) and reversible sickle-shape deformation of erythrocytes. This leads to increased hemolysis of erythrocytes and microvascular occlusion, ischemia-reperfusion injury, and tissue infarction, ultimately causing multisystem end-organ complications. Sickle cell anemia (HbSS) is the most common and most severe genotype of SCD, followed by HbSC, HbSβ 0thalassemia, HbSβ+thalassemia, and rare and benign genotypes. Clinical manifestations of SCD occur early in life, are variable, and are modified by several genetic and environmental factors. Nearly 500 children with SCD continue to die prematurely every day, due to delayed diagnosis and/or lack of access to comprehensive care in sub-Saharan Africa (SSA), a trend that needs to be urgently reversed. Despite proven efficacy in developed countries, newborn screening programs are not universal in SSA. This calls for a consolidated effort to make this possible, through the use of rapid, accurate, and cheap point-of-care test kits which require minimal training. For almost two decades, hydroxyurea (hydroxycarbamide), a century-old drug, was the only disease-modifying therapy approved by the U.S. Food and Drug Administration. Recently, the list expanded to L-glutamine, crizanlizumab, and voxelotor, with several promising novel therapies in the pipeline. Despite its several limitations, hematopoietic stem cell transplant (HSCT) remains the only curative intervention for SCD. Meanwhile, recent advances in gene therapy trials offer a glimpse of hope for the near future, although its use maybe limited to developed countries for several decades.
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Affiliation(s)
- Walufu Ivan Egesa
- Department of Pediatrics, Nile International Hospital, Jinja District, Uganda
- Department of Pediatrics & Child Health, Faculty of Clinical Medicine & Dentistry, Kampala International University, Bushenyi District, Uganda
| | - Gloria Nakalema
- Department of Pediatrics & Child Health, Faculty of Clinical Medicine & Dentistry, Kampala International University, Bushenyi District, Uganda
- Department of Pediatrics, Luweero Hospital, Luwero District, Uganda
| | - William M. Waibi
- Department of Pediatrics & Child Health, Faculty of Clinical Medicine & Dentistry, Kampala International University, Bushenyi District, Uganda
| | - Munanura Turyasiima
- Department of Pediatrics & Child Health, Faculty of Clinical Medicine & Dentistry, Kampala International University, Bushenyi District, Uganda
- Standards Compliance Accreditation and Patient Protection (SCAPP) Department, Governance and Regulation Directorate, Ministry of Health, Kampala, Uganda
| | - Emmanuel Amuje
- Department of Pediatrics, Nile International Hospital, Jinja District, Uganda
| | - Gloria Kiconco
- Department of Pediatrics & Child Health, Faculty of Clinical Medicine & Dentistry, Kampala International University, Bushenyi District, Uganda
- Department of Pediatrics, Fort Portal Regional Referral Hospital, Kabarole District, Uganda
| | - Simon Odoch
- Department of Pediatrics & Child Health, Faculty of Clinical Medicine & Dentistry, Kampala International University, Bushenyi District, Uganda
| | - Patrick Kumbowi Kumbakulu
- Department of Pediatrics & Child Health, Faculty of Clinical Medicine & Dentistry, Kampala International University, Bushenyi District, Uganda
| | - Said Abdirashid
- Department of Pediatrics & Child Health, Faculty of Clinical Medicine & Dentistry, Kampala International University, Bushenyi District, Uganda
| | - Daniel Asiimwe
- Department of Surgery, Faculty of Clinical Medicine & Dentistry, Kampala International University, Bushenyi District, Uganda
- Department of Surgery, Holy Family Virika hospital, Kabarole District, Uganda
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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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Pompeo CM, Ferreira Júnior MA, Cardoso AIDQ, Souza MDC, Frota OP, Mota FM, Ivo ML. Clinical-Epidemiological Characteristics and Mortality in Patients with Sickle Cell Anemia: A Retrospective Cohort Study of 1980 at 2018. Int J Gen Med 2022; 15:1057-1074. [PMID: 35140508 PMCID: PMC8818769 DOI: 10.2147/ijgm.s342971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/07/2021] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To analyze the clinical-epidemiological characteristics and mortality in patients with sickle-cell anemia (SCA). PATIENTS AND METHODS A cohort study with retrospective data, conducted in two reference hospitals for SCA treatment from January 1980 to December 2018, recorded in two reference services. With a 5% significance level, the Chi-Square and Student's t-tests were employed in the inferential statistical analysis. RESULTS A total of 128 patients with SCA were studied. Diagnosis up to the fifth day of life was made in 10 patients. There were 19 deaths, of which 12 (63.2%) were female, and the average age at death was 27.05 (± 14.78) years. The leading causes of death were septic shock and cardiogenic shock. The use of invasive medical devices was considered a risk factor for death (RR=2.63; 95% CI=1.16-5.96; p=0.018), and monitoring time up to 20 years presented a 31% reduction in the risk of dying (RR=0.31; 95% CI=0.12-0.82; p=0.011) when compared to the monitoring of more than 20 years. CONCLUSION These findings are to be considered in the treatment of patients with SCA, mainly regarding early diagnosis and access to the treatment immediately afterward, since they are fundamental in improving survival and reducing severe complications.
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Affiliation(s)
- Carolina Mariano Pompeo
- Integrated Institute of Health, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
| | | | | | - Mercy da Costa Souza
- Graduate Program in Health and Development in the Midwest Region, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
| | - Oleci Pereira Frota
- Integrated Institute of Health, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
| | - Felipe Machado Mota
- Integrated Institute of Health, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
| | - Maria Lúcia Ivo
- Graduate Program in Health and Development in the Midwest Region, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
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McNair D, Lumpkin M, Kern S, Hartman D. Use of RWE to Inform Regulatory, Public Health Policy, and Intervention Priorities for the Developing World. Clin Pharmacol Ther 2021; 111:44-51. [PMID: 34655224 PMCID: PMC9298255 DOI: 10.1002/cpt.2449] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 10/05/2021] [Indexed: 12/28/2022]
Abstract
For low‐ and middle‐income countries (LMICs) to benefit from real‐world evidence (RWE)/real‐world data (RWD) in both product registration (“regulatory”) decision making and in product utilization policy (“policy”) decision making, they need to overcome several challenges. They need to deploy more electronic health records systems (EHRs), adjust for confounder variables, build trust between stakeholders, and create laws and regulations for local generation of data that are assented for secondary use. The role of procurers and their use of RWE/RWD in the LMIC context likewise is in a state of ongoing development. Procurers of health products are strong players currently in the “access” chain as LMICs continue to work on strengthening governmental health technology assessment (HTA) bodies. Procurers’ use of RWE is presently at an early stage and is mostly indirect, leveraging RWE results that are produced by researchers in high‐income countries (HICs), often under considerably different regulatory and policy objectives and constraints compared to LMICs’ epidemiology and priorities. Pending wider deployment of EHRs and other RWE sources, stakeholders must realize that populations from HIC RWE (i) can be devised to closely resemble phenotypic patterns in LMIC populations and (ii) can be analyzed to align with LMICs’ unmet needs.
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Affiliation(s)
- Douglas McNair
- Global Health, Integrated Development, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Murray Lumpkin
- Global Health, Integrated Development, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Steven Kern
- Global Health, Integrated Development, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Daniel Hartman
- Global Health, Integrated Development, Bill & Melinda Gates Foundation, Seattle, Washington, USA
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Tegha G, Topazian HM, Kamthunzi P, Howard T, Tembo Z, Mvalo T, Chome N, Kumwenda W, Mkochi T, Hernandez A, Ataga KI, Hoffman IF, Ware RE. Prospective Newborn Screening for Sickle Cell Disease and Other Inherited Blood Disorders in Central Malawi. Int J Public Health 2021; 66:629338. [PMID: 34335138 PMCID: PMC8284589 DOI: 10.3389/ijph.2021.629338] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 06/11/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Newborn screening in the United States and Europe allows early identification of congenital disorders but does not yet exist in most low-resource settings, especially in sub-Saharan Africa. Newborn screening can identify multiple inherited hematological disorders, but feasibility and effectiveness for Africa are not fully determined. Methods: Surplus dried blood spot collected in Central Malawi through the HIV Early Infant Diagnosis surveillance program were repurposed and tested by isoelectric focusing for sickle cell disease and trait. Additional genetic testing identified G6PD deficiency and alpha thalassemia. Results: Testing of 10,529 cards revealed an overall sickle cell trait prevalence of 7.0% (range 3.9-9.7% by district); 10 of 14 infants identified with sickle cell disease (prevalence 0.1%) were located and received care at a specialized clinic. Subsequent testing of 1,329 randomly selected cards identified alpha thalassemia trait in 45.7% of samples, and G6PD deficiency in 20.4% of males and 3.4% of females, with 29.0% of females as heterozygous carriers. Conclusion: Inherited hematological disorders are common in Central Malawi; early identification through newborn screening can improve clinical outcomes and should be supported throughout Africa.
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Affiliation(s)
- Gerald Tegha
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Hillary M. Topazian
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, United States
| | - Portia Kamthunzi
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, United States
| | - Thad Howard
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Zondwayo Tembo
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Tisungane Mvalo
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, United States
| | - Nelecy Chome
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Wiza Kumwenda
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Tawonga Mkochi
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Arielle Hernandez
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Kenneth I. Ataga
- Center for Sickle Cell Disease, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Irving F. Hoffman
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, United States
| | - Russell E. Ware
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
- Global Health Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
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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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10
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Mbiya BM, Kalombo DK, Mukendi YN, Daubie V, Mpoyi JK, Biboyi PM, Disashi GT, Gulbis B. Improvement of SCD morbimortality in children: experience in a remote area of an African country. BMC Health Serv Res 2021; 21:294. [PMID: 33794895 PMCID: PMC8017617 DOI: 10.1186/s12913-021-06286-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/16/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Sickle cell disease (SCD) is a public health problem in the Democratic Republic of Congo. While reference sickle cell centers have been implemented in capital cities of African countries and have proven to be beneficial for SCD patients. In the Democratic Republic of Congo, they have never been set up in remote areas for families with low or very low sources of income. METHOD A cohort of 143 children with SCD aged 10 years old (IQR (interquartile range): 6-15 years) (sex ratio male/female = 1.3) were clinically followed for 12 months without any specific intervention aside from the management of acute events, and then for 12 months with a monthly medical visit, biological follow-up, and chemoprophylaxis (folic acid/penicillin), adequate fluids and malaria prevention. RESULTS The median age of patients at the diagnosis of SCD was 2 years (IQR: 1-5). The implementation of standardized and regular follow-ups in a new sickle cell reference center in a remote city showed an increase in the annual mean hemoglobin level from 50 to 70 g/L (p = 0.001), and a decrease in the lymphocyte count and spleen size (p < 0.001). A significant decrease (p < 0.001) in the average annual number of hospitalizations and episodes of vaso-occlusive crises, blood transfusions, infections, and acute chest syndromes were also observed. CONCLUSIONS The creation of a sickle cell reference center and the regular follow-up of children with sickle cell disease are possible and applicable in the context of a remote city of an African country and represent simple and accessible measures that can reduce the morbimortality of children with sickle cell disease.
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Affiliation(s)
- Benoît Mukinayi Mbiya
- Pediatrics Department, Faculty of Medicine, University of Mbujimayi, 06201, Mbujimayi, Democratic Republic of Congo
- Sickle Cell Reference Center, Clinique Pédiatrique de Mbujimayi, Pediatrics Clinic of Mbujimayi, 06201, Mbujimayi, Democratic Republic of Congo
| | - Didier Kalenda Kalombo
- Pediatrics Department, Faculty of Medicine, University of Mbujimayi, 06201, Mbujimayi, Democratic Republic of Congo
- Sickle Cell Reference Center, Clinique Pédiatrique de Mbujimayi, Pediatrics Clinic of Mbujimayi, 06201, Mbujimayi, Democratic Republic of Congo
| | - Yannick Nkesu Mukendi
- Pediatrics Department, Faculty of Medicine, University of Mbujimayi, 06201, Mbujimayi, Democratic Republic of Congo
- Sickle Cell Reference Center, Clinique Pédiatrique de Mbujimayi, Pediatrics Clinic of Mbujimayi, 06201, Mbujimayi, Democratic Republic of Congo
| | - Valery Daubie
- Clinical Biology Department, LHUB-ULB, Université Libre de Bruxelles, 1070, Brussels, Belgium
| | - John Kalenda Mpoyi
- Sickle Cell Reference Center, Clinique Pédiatrique de Mbujimayi, Pediatrics Clinic of Mbujimayi, 06201, Mbujimayi, Democratic Republic of Congo
| | - Parola Mukendi Biboyi
- Sickle Cell Reference Center, Clinique Pédiatrique de Mbujimayi, Pediatrics Clinic of Mbujimayi, 06201, Mbujimayi, Democratic Republic of Congo
| | - Ghislain Tumba Disashi
- Internal Medicine Department, Faculty of Medicine, University of Mbujimayi, 06201, Mbujimayi, Democratic Republic of Congo
| | - Béatrice Gulbis
- Clinical Chemistry Department, Hereditary Red Blood Cell Disorders, LHUB-ULB, Université Libre de Bruxelles, 1070, Brussels, Belgium.
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Cortabarria ASDV, Makhoul L, Strouboulis J, Lombardi G, Oteng-Ntim E, Shangaris P. In utero Therapy for the Treatment of Sickle Cell Disease: Taking Advantage of the Fetal Immune System. Front Cell Dev Biol 2021; 8:624477. [PMID: 33553164 PMCID: PMC7862553 DOI: 10.3389/fcell.2020.624477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/23/2020] [Indexed: 01/16/2023] Open
Abstract
Sickle Cell Disease (SCD) is an autosomal recessive disorder resulting from a β-globin gene missense mutation and is among the most prevalent severe monogenic disorders worldwide. Haematopoietic stem cell transplantation remains the only curative option for the disease, as most management options focus solely on symptom control. Progress in prenatal diagnosis and fetal therapeutic intervention raises the possibility of in utero treatment. SCD can be diagnosed prenatally in high-risk patients using chorionic villus sampling. Among the possible prenatal treatments, in utero stem cell transplantation (IUSCT) shows the most promise. IUSCT is a non-myeloablative, non-immunosuppressive alternative conferring various unique advantages and may also offer safer postnatal management. Fetal immunologic immaturity could allow engraftment of allogeneic cells before fetal immune system maturation, donor-specific tolerance and lifelong chimerism. In this review, we will discuss SCD, screening and current treatments. We will present the therapeutic rationale for IUSCT, examine the early experimental work and initial human experience, as well as consider primary barriers of clinically implementing IUSCT and the promising approaches to address them.
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Affiliation(s)
| | - Laura Makhoul
- GKT School of Medical Education, King's College London, London, United Kingdom
| | - John Strouboulis
- School of Cancer & Pharmaceutical Sciences, Kings College London, London, United Kingdom
| | - Giovanna Lombardi
- School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Eugene Oteng-Ntim
- School of Life Course Sciences, Kings College London, London, United Kingdom
| | - Panicos Shangaris
- School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
- School of Life Course Sciences, Kings College London, London, United Kingdom
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12
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Ryan N, Dike L, Ojo T, Vieira D, Nnodu O, Gyamfi J, Peprah E. Implementation of the therapeutic use of hydroxyurea for sickle cell disease management in resource-constrained settings: a systematic review of adoption, cost and acceptability. BMJ Open 2020; 10:e038685. [PMID: 33168553 PMCID: PMC7654121 DOI: 10.1136/bmjopen-2020-038685] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/24/2020] [Accepted: 09/08/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Mortality associated with sickle cell disease (SCD) is high in many low- and middle-income countries (LMICs). Hydroxyurea, a medicine to effectively manage SCD, is not widely available in resource-constrained settings. We identified and synthesised the reported implementation outcomes for the therapeutic use of hydroxyurea for SCD in these settings. DESIGN Systematic review. DATA SOURCES PubMed, Embase, Cochrane, Web of Science Plus, Global Health, CINAHL, and PsycINFO were searched February through May 2019 without any restrictions on publication date. ELIGIBILITY CRITERIA We included empirical studies of hydroxyurea for management of SCD that were carried out in LMICs and reported on implementation outcomes. DATA EXTRACTION AND SYNTHESIS Two reviewers independently assessed studies for inclusion, carried out data extraction using Proctor et al.'s implementation and health service outcomes, and assessed the risk of bias using ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions). RESULTS Two cross-sectional surveys (n=2) and one cohort study (n=1) reported implementation of hydroxyurea for SCD management, namely regarding outcomes of adoption (n=3), cost (n=3) and acceptability (n=1). These studies were conducted exclusively among paediatric and adults populations in clinical settings in Nigeria (n=2) or Jamaica (n=1). Adoption is low, as observed through reported provider practices and patient adherence, in part shaped by misinformation and fear of side effects among patients, provider beliefs regarding affordability and organisational challenges with procuring the medicine. There was no difference in the cost of hydroxyurea therapy compared with blood transfusion in the paediatric population in urban Jamaica. Risk of bias was low or moderate across the included studies. CONCLUSIONS This review rigorously and systematically assessed the evidence on implementation of hydroxyurea in resource-constrained settings such as LMICs. Findings suggest that knowledge regarding implementation is low. To address the know-do gap and guide clinical practice, implementation research is needed. Integrating effective interventions into existing health systems to improve hydroxyurea uptake is essential to reducing SCD-associated mortality. PROSPERO REGISTRATION NUMBER CRD42020155953.
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Affiliation(s)
- Nessa Ryan
- New York University School of Global Pubic Health, New York, NY, USA
| | - Lotanna Dike
- New York University School of Global Pubic Health, New York, NY, USA
| | - Temitope Ojo
- New York University School of Global Pubic Health, New York, NY, USA
| | - Dorice Vieira
- NYU Health Sciences Library, Grossman School of Medicine, New York University, New York, NY, USA
| | - Obiageli Nnodu
- Department of Haematology & Blood Transfusion, Center of Excellence for Sickle Cell Disease Research and Training, Abuja, Nigeria
| | - Joyce Gyamfi
- New York University School of Global Pubic Health, New York, NY, USA
| | - Emmanuel Peprah
- New York University School of Global Pubic Health, New York, NY, USA
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13
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Curative vs targeted therapy for SCD: does it make more sense to address the root cause than target downstream events? Blood Adv 2020; 4:3457-3465. [PMID: 32722787 DOI: 10.1182/bloodadvances.2020001469] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/15/2020] [Indexed: 12/14/2022] Open
Abstract
Sickle cell disease (SCD) places a heavy burden on a global and increasing population predominantly resident in resource-poor and developing countries. Progress continues to be made in preventing childhood mortality, and increasing numbers of chronically ill adults with disease are requiring care for disease sequelae. Curative therapies for SCD are therefore attractive to physicians and investigators focused on SCD. Gene therapies are being developed, and several are now in various stages of early-phase human clinical trials. However, we must also pursue avenues through which we can do the most good for the most people alive today. Such efforts include improving our understanding of disease mechanisms and which disease sequelae most strongly affect survival and interfere with quality of life. The pathways leading to disease sequelae are multiple, complex, and highly interactive. Four drugs have now been approved by the US Food and Drug Administration for SCD; however, each has a distinct mechanism and a measurable but limited effect on the many clinical sequelae of SCD. We therefore need to learn how to approach multi-agent therapy for SCD. The order of addition of each agent to treat a specific patient will need to be guided by response to previous therapy, risk factors identified for specific disease outcomes, and clinical studies to determine more comprehensively how the 4 currently approved drugs might interact and produce (or not) additive effects. Moreover, this will have to be accomplished with defined end points in mind, according to which pose the greatest threats to quality of life as well as survival.
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14
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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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Aygun B. Hydroxyurea for ALL children with sickle cell anemia: What can we learn from Africa? Pediatr Blood Cancer 2020; 67:e28164. [PMID: 31925887 DOI: 10.1002/pbc.28164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/16/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Banu Aygun
- Division of Pediatric Hematology/Oncology and Stem Cell Transplantation, Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York
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16
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Ballas SK. The Evolving Pharmacotherapeutic Landscape for the Treatment of Sickle Cell Disease. Mediterr J Hematol Infect Dis 2020; 12:e2020010. [PMID: 31934320 PMCID: PMC6951351 DOI: 10.4084/mjhid.2020.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 12/17/2019] [Indexed: 01/02/2023] Open
Abstract
Sickle cell disease (SCD) is an extremely heterogeneous disease that has been associated with global morbidity and early mortality. More effective and inexpensive therapies are needed. During the last five years, the landscape of the pharmacotherapy of SCD has changed dramatically. Currently, 54 drugs have been used or under consideration to use for the treatment of SCD. These fall into 3 categories: the first category includes the four drugs (Hydroxyurea, L-Glutamine, Crizanlizumab tmca and Voxelotor) that have been approved by the United States Food and Drug Administration (FDA) based on successful clinical trials. The second category includes 22 drugs that failed, discontinued or terminated for now and the third category includes 28 drugs that are actively being considered for the treatment of SCD. Crizanlizumab and Voxelotor are included in the first and third categories because they have been used in more than one trial. New therapies targeting multiple pathways in the complex pathophysiology of SCD have been achieved or are under continued investigation. The emerging trend seems to be the use of multimodal drugs (i.e. drugs that have different mechanisms of action) to treat SCD similar to the use of multiple chemotherapeutic agents to treat cancer.
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Affiliation(s)
- Samir K Ballas
- Cardeza Foundation for Hematologic Research, Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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