Mortality by sickle cell disease in Brazil

Mortality trends and sociodemographic factors associated with early death in sickle cell disease patients in the state of São Paulo

OBJECTIVE

To estimate trends in mortality rate and average age of death, and identify sociodemographic factors associated with early death in patients with sickle cell disease (SCD).

METHODS

An ecological and cross-sectional study was conducted using data from the Mortality Information System. All deaths of patients residing in the state of São Paulo from 1996 to 2015 with at least one International Disease Code for SCD in any field of the death certificate were included. Simple linear regression was used to estimate trends. The Log-rank test and multiple Cox regression were used to identify factors associated with early death.

RESULTS

The age-standardized mortality rate per million inhabitants increased by 0.080 per year (R2=0.761; p<0.001). When the events were stratified by age at death, the increase was 0.108 per year for those occurring at age 20 years or older, (R2=0.789; p<0.001) and 0.023 per year for those occurring before age 20 years old (R2=0.188; p=0.056). The average age at death increased by 0.617 years (7.4 months) per year (R2=0.835; p<0.001). Sociodemographic factors associated with early death identified were male gender (hazard ratio - HR=1.30), white race (HR=1.16), death occurring in the hospital (HR=1.29), and living in the Greater São Paulo (HR=1.13).

CONCLUSIONS

The mortality rate and the average age of death in patients with SCD have increased over the last two decades. Sociodemographic factors such as gender, race, place of occurrence, and residence were found to be associated with early death.

Sleep experiences of parents of children 18 years or younger with sickle cell disease during the COVID-19 pandemic: a qualitative study

STUDY OBJECTIVES

The coronavirus disease pandemic has highlighted disparities in health care. Parents assist in sickle cell disease management in children. Understanding sleep in parents of children who are diagnosed with sickle cell disease is an important facet of disease management. Our objectives were to identify sleep characteristics of parents of children with sickle cell disease age 18 years or younger during the coronavirus disease pandemic, to investigate measures used by parents to achieve restful sleep, and to discuss how sleep may be improved in parents of children diagnosed with sickle cell disease.

METHODS

This study conducted 14 face-to-face semistructured interviews with parents of children diagnosed with sickle cell disease. A majority of the interviews (93%) were conducted at a hematology clinic. Qualitative thematic analysis was used to analyze data.

RESULTS

All parents reported that their child experienced pain because of sickle cell disease. Most parents (86.7%) reported that their child was diagnosed with sickle cell anemia. Four themes were identified: difficulty obtaining restful sleep during their child's sickle cell crisis, sleep during the coronavirus disease pandemic, factors affecting sleep, and effects of sleep disturbance and deprivation on parental performance.

CONCLUSIONS

This research has highlighted some of the difficulties experienced by parents of children who are diagnosed with sickle cell disease and allows for additional insight into the sleep experiences of parents as they attempt to manage their child's disease.

CITATION

Osborne JC, Odlum M, Sedrak A. Sleep experiences of parents of children 18 years or younger with sickle cell disease during the COVID-19 pandemic: a qualitative study. J Clin Sleep Med. 2024;20(5):777-782.

Characterization of a cohort of Angolan children with sickle cell anemia treated with hydroxyurea

BACKGROUND

Sickle Cell Anemia (SCA) is a monogenic disease, although its severity and response to treatment are very heterogeneous.

OBJECTIVES

This study aims to characterize a cohort of Angolan children with SCA and evaluate their response to hydroxyurea (HU) treatment and the potential side effects and toxicity.

METHODS

The study enrolled 215 patients between 3 and 12 years old before and after the administration of HU, at a fix dose of 20 mg/kg/day for 12 months.

RESULTS

A total of 157 patients started HU medication and 141 of them completed the 12-month treatment. After initiating HU treatment, the frequency of clinical events decreased (transfusions 53.4 %, hospitalizations 47.1 %). The response to HU medication varied among patients, with some experiencing an increase in fetal hemoglobin (HbF) of <5 %. The mean increase in HbF was 11.9 %, ranging from 1.8 % to 31 %. Responders to HU treatment were 57 %, inadequate responders 38.7 % and non-adherent 4.2 %. No clinical side effects related to HU were reported. Hematological toxicities were transient and reversible. Children naïve to HU and with lower HbF reported higher number of hospitalizations caused by malaria infection. During HU treatment, the frequency of malaria episodes did not appear to be affected by HbF levels.

CONCLUSIONS

the present study provided a valuable contribution to the understanding of the clinical and laboratory profiles of Angolan children with SCA. These findings support the evidence that the implementation of prophylactic measures and treatment with HU is associated with increased survival in children with SCA.

Assessment of the developmental defects of the enamel in children and adolescents with sickle cell disease: A comparative study

BACKGROUND

Sickle cell disease (SCD) is the most important hemoglobinopathy in terms of frequency and social impact and can affect the stomatognathic system.

AIM

To assess and compare the developmental defects of the enamel (DDE) in children and adolescents with and without SCD.

DESIGN

This was a cross-sectional, analytical, and comparative study of 210 children and adolescents aged 5-18 years, who visited the Hematology and Hemotherapy Hospital of Pernambuco.

RESULTS

Developmental defects of the enamel were observed in 55.2% of the SCD patients and 35.2% of the non-SCD patients (healthy group; p < .05). In the SCD group, DDE were more common in females than in males (69.1% vs. 40.0%; p < .05). The incidence of DDE in the permanent teeth was higher in the upper arch than in the lower arch (SCD group, 13.1% vs. 4.6%; healthy group, 8.9% vs. 3.6%; p < .05).

CONCLUSION

Compared with the healthy group, the SCD patients were almost twice as likely to develop DDE, mostly affecting females and the permanent teeth. These findings suggest that individuals with SCD need early dental care to avoid future oral problems.

Social inequalities in the temporal trend of mortality from sickle cell disease in Brazil, 1996-2019

Contrary to international trends, the mortality rate of sickle cell disease increased in Brazil after the implementation of the neonatal screening program, probably due to improving access to diagnosis. This study aimed to assess differences in the temporal trend of the mortality rate and median age at death from sickle cell disease in Brazil, considering implemented measures to expand diagnosis, and improve health care access in-country and in the international scenario. Time series were extracted from the Brazilian Mortality Information System from 1996 to 2019. Changes in the mortality rate and median age at death were verified via segmented regression models, which were stratified by sex, region of residence, and age. Most deaths occurred in non-white people, young adults, and the Southeast and Northeast population. Sickle cell disease mortality rate increased until 2010 (13.31%; 95%CI: 6.37; 20.70), particularly in individuals aged 30 years or more (12.78%; 95%CI: 2.98; 23.53) and in the Northeast (12.27%; 95%CI: 8.92; 15.72). Most deaths occurred in the second decade of life (3.01 deaths/million), with a 59% increase in the median age of death in Brazil, from 27.6 to 30.3 years, more pronounced in females and the North Region. The observed gain in the survival of sickle cell disease in Brazil is still much lower than in developed countries and presents regional disparities, probably due to the lack of access to health care and recent treatments, such as hydroxyurea, still restricted to hematological referral centers in Brazilian capitals.

Mortality attributed to sickle cell disease in children and adolescents in Brazil, 2000-2019

OBJECTIVE

Estimate rates and describe mortality trends attributed to sickle cell disease in children and adolescents in Brazil from 2000 to 2019.

METHODS

This is an ecological study of the time-trend of mortality rates that used the autoregressive method, proposed by Prais-Winsten, to evaluate trends in the estimated rates of sickle cell disease deaths in children and adolescents in Brazil. Deaths with code D57 were obtained from the Mortality Information System, considering age groups (0–4, 5–9, 10–14, 15–19 years) and were used to estimate age-specific and standardized rates by gender and age.

RESULTS

From 2000 to 2019, Brazil had 2,422 deaths from sickle cell disease in people under 20 years of age, with higher frequency in the Northeast (40.46%), followed by the Southeast (39.02%), Midwest (9.58%), North (7.84%), and South (3.10%). The main victims were people of Black skin/race (78.73%). In Brazil, the global standardized average rate was 0.20/100,000 people-year, with an elevation trend (annual percentage change – APC = 5.44%; confidence interval – 95%CI: 2.57–8.39). The pattern was repeated in males (APC = 4.38%; 95%CI: 2.17–6.64) and females (APC = 6.96%; 95%CI: 3.05–11.01). Elaborating age-specific rates showed that the range up to four years experienced the highest rates, without distinction by region. The age group of 15 and 19 years was the second most affected in Brazil and in the Northeast, Southeast, and Midwest regions.

CONCLUSION

Deaths due to sickle cell disorders showed an elevation trend in children and adolescents. Considering that the magnitude of deaths was more evident in the first years (0–4) and late adolescence (15–19), the study suggests that age-specific approaches may impact the control of fatal outcomes caused by sickle cell disease in Brazil.

Economic burden of sickle cell disease in Brazil

Background

Sickle cell disease (SCD) may cause several impacts to patients and the whole society. About 4% of the population has the sickle cell trait in Brazil, and 60,000 to 100,000 have SCD. However, despite recognizing the significant burden of disease, little is known about SCD costs.

Objective

To estimate SCD societal costs based on disease burden modelling, under Brazilian societal perspective.

Methods

A disease burden model was built considering the societal perspective and a one-year time horizon, including direct medical and indirect costs (morbidity and mortality). The sum of life lost and disability years was considered to estimate disability-adjusted life years (DALYs). Data from a public database (DATASUS) and the prevalence obtained from literature or medical experts were used to define complications prevalence and duration. Costs were defined using data from the Brazilian public healthcare system table of procedures and medications (SIGTAP) and the human capital method.

Results

Annual SCD cost was 413,639,180 USD. Indirect cost accounted for the majority of burden (70.1% of the total; 290,158,365 USD vs 123,480,816 USD). Standard of care and chronic complications were the main source of direct costs among adults, while acute conditions were the main source among children. Vaso-occlusive crisis represented the complication with the highest total cost per year in both populations, 11,400,410 USD among adults and 11,510,960 USD among children.

Conclusions

SCD management may impose an important economic burden on Brazilian society that may reach more than 400 million USD per year.

Incidence of hemoglobinopathies and spatialization of newborns with sickle cell trait in Mato Grosso do Sul, Brazil

Objective

To evaluate the incidence of variant hemoglobins of newborn samples from the Neonatal Screening Center in the state of Mato Grosso do Sul, Brazil, and to analyze the distribution and spatial autocorrelation of newborns with sickle cell trait.

Methods

Samples from 35,858 newborns screened by the Neonatal Screening Center. The samples with inconclusive diagnosis were submitted to electrophoretic, chromatographic, cytological and molecular analyses. The spatial distribution analysis of newborns with sickle cell trait was performed by spatial autocorrelation.

Results

A total of 919 newborns showed an abnormal hemoglobin profile; in that, ten genotypes had significant clinical impacts identified. Among the asymptomatic newborns, the sickle cell trait was the most frequent (incidence of 1.885 cases/100 newborns). The highest incidence rates were registered in the municipalities of Terenos, Figueirão, Corguinho and Selvíria. There was positive spatial autocorrelation between the proportion of declared individuals of black race/color and the incidence of newborns with sickle cell trait.

Conclusion

The early diagnosis by neonatal screening and laboratory tests was very important to identify abnormal hemoglobin profiles and guide the spatial autocorrelation analysis of sickle cell trait newborns in Mato Grosso do Sul, serving as a support to anticipate health measures aimed to discuss efficient therapeutic behaviors and effective planning of municipalities with the greatest need for care, monitoring and orientations for affected families.

Clinical-Epidemiological Characteristics and Mortality in Patients with Sickle Cell Anemia: A Retrospective Cohort Study of 1980 at 2018

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.

(Lack of) knowledge of mothers about sickle cell trait and disease: a qualitative study

OBJECTIVE

to analyze the understanding of mothers about sickle cell disease and/or trait of the family from a diagnosed child.

METHODS

this is a qualitative study, using a semi-structured interview with 23 mothers, at a sickle cell disease outpatient clinic of a public institution, from October to December 2017. Analysis was thematic.

RESULTS

all participants had sickle cell trait as well as the parents of their children. Twenty children were diagnosed with sickle cell disease by Heel Prick Test, and three, after hospitalization due to the disease. Most did not know how to report the presence of the trait or disease in relatives other than nuclear.

FINAL CONSIDERATIONS

diagnosis cannot be restricted to the result of neonatal screening, requiring that preventive information on sickle cell crises be reinforced. It is recommended to search for other affected relatives to learn about their genetic condition, reflecting on their reproductive decisions.

Anemia falciforme e as consequências nas funções executivas

A anemia falciforme (AF) é reconhecida pela Organização Mundial de Saúde (OMS) como um problema global de saúde pública, sendo a mais comum dentre as doenças hereditárias no Brasil. O objetivo principal desta pesquisa é investigar o desempenho das funções executivas em crianças com anemia falciforme residentes na região Nordeste do país. Participaram 134 crianças, na faixa etária de 6-11 anos, sendo 60 do grupo clínico e 74 do grupo não clínico. Os instrumentos utilizados foram FDT – Teste dos Cinco Dígitos; Teste de Trilhas; Torre de Londres e subteste Dígitos. Os dados foram analisados pelo U de Mann-Whitney indicando diferenças estatísticas (p<0,05) entre os grupos em todos os instrumentos utilizados, exceto no Torre de Londres. Propõe-se que estudos futuros com crianças portadoras de AF detenham-se na intervenção cognitiva de funções afetadas abrangendo pré-escolares e estudantes do ensino fundamental.

Prevalence of priapism in individuals with sickle cell disease and implications on male sexual function

OBJECTIVE

To evaluate epidemiological aspects of priapism in patients with sickle cell disease, and these aspects impact on adult sexual function.

METHODS

This was a cross-sectional study including individuals with sickle cell disease who were evaluated at a reference center for sickle cell. Participants completed a structured questionnaire about their sociodemographic characteristics and priapism events. Sexual function was assessed using validated two instruments, the Erection Hardness Score and one about the sex life satisfaction.

RESULTS

Sixty-four individuals with median aged of 12 (7 to 28) years were interviewed. The prevalence of priapism was 35.9% (23/64). The earliest priapism episode occurred at 2 years of age and the latest at 42 years. The statistical projection was that 71.1% of individuals of the study would have at least one episode of priapism throughout life. Patients with episodes of priapism (10/23) had significantly worse erectile function Erection Hardness Score of 2 [1-3]; p=0.01 and were less satisfied with sexual life 3 [3-5]; p=0.02.

CONCLUSION

Priapism is usually present in childhood, and severe episodes are associated with cavernous damage, impairment in the quality of the erection, and lower sexual satisfaction.

SPATIAL DISTRIBUTION OF NEWBORNS WITH SICKLE CELL TRAIT IN SERGIPE, BRAZIL

Objective:

To use the spatial distribution of the sickle cell trait (SCT) to analyze the frequency of hemoglobin S (HbS) carriers in Sergipe.

Methods:

The sample consisted of all individuals born in Sergipe from October 2011 to October 2012 who underwent neonatal screening in the public health system. Tests were carried out in basic health units and forwarded to the University Hospital laboratory, where they were analyzed. We used spatial autocorrelation (Moran’s index) to assess the spatial distribution of heterozygous individuals with hemoglobinopathies.

Results:

Among 32,906 newborns, 1,202 showed other types of hemoglobin besides Hemoglobin A. We found a positive correlation between the percentage of black and multiracial people and the incidence of SCT. Most SCT cases occurred in the cities of Aracaju (n=273; 22.7%), Nossa Senhora do Socorro (n=102; 8.4%), São Cristóvão (n=58; 4.8%), Itabaiana (n=39; 4.2%), Lagarto (n=37; 4.01%), and Estância (n=46; 4.9%).

Conclusions:

The spatial distribution analysis identified regions in the state with a high frequency of HbS carriers. This information is important health care planning. This method can be applied to detect other places that need health units to guide and care for sickle cell disease patients and their families.

Fatores de risco para mortalidade em pacientes com doença falciforme: uma revisão integrativa

RESUMO Objetivo Sumarizar fatores de risco e indicadores de mortalidade em pacientes com doença falciforme. Método Revisão integrativa em periódicos indexados nas bases de dados CINAHL, PubMed/MEDLINE, Science Direct/SCOPUS, SciELO e Web of Science. A questão norteadora foi elaborada por meio da estratégia Population, variable, outcome (PVO). A busca ocorreu no portal de periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior entre outubro e novembro de 2018. Resultados Dos 19 artigos, 18 eram coorte e um ensaio clínico randomizado. A amostra foi constituída, em sua maioria, pelo sexo feminino e genótipo HbSS. Se repetiram mais a taxa de mortalidade cumulativa e a curva de mortalidade global. Sete estudos identificaram fatores de risco com associação estatisticamente significativa para morte. Os mais frequentes foram o baixo nível de hemoglobina, variáveis hepáticas (enzimas fosfatase alcalina e transaminase glutâmico oxalacética) e cardiovasculares (velocidade de regurgitação da válvula tricúspide ≥ 2,5m/s). Conclusão e implicações para a prática Indicadores de mortalidade constituem ferramentas de manejo de pacientes com doença falciforme e prevenção de riscos e complicações. Há necessidade de estudos sobre os fatores relacionados à mortalidade desses pacientes. A prevenção do óbito, certamente, promoverá uma melhoria na qualidade de vida e na sobrevida dessa população.

Clinical and care profiles of children and adolescents with Sickle Cell Disease in the Brazilian Northeast region

Abstract Objectives: to describe the clinical epidemiological and care profiles of pediatric patients with sickle cell disease. Methods: a descriptive study of all (48) children and adolescents with sickle cell disease, assisted at a public referral hospital in Paraíba State. The information were obtained from the patients’ medical records and interviews were analyzed by using the Epi-Info program 7.2 version, frequency tables were built for the categorical variables and the central measurements and dispersion tendencies were calculated for the variables related to age and hospitalizations. Results: the patients’ age ranged from 15 months to 19 years old (median 8.6 years old); 91.7% considered their skin color mixed/black; 81.3% belong to D and E social class; 48% of the responsible guardians reported to have less than nine years of schooling; 70.9% lived in other cities; 93.8% received late diagnosis and 87.5% had irregular outpatient follow-up, 62,5% had an incomplete or outdated vaccination record. There were 226 hospitalizations; painful crises were the most common causes (55.7%). Each patient was hospitalized, about 5.2 times in the period; the median of total days for being hospitalized was 28. There were no deaths. Cardiac (56.2%) and hepatobiliary (54.3%) were the most common chronic compli-cations. Conclusions: sickle cell disease is a neglected clinical condition in the Brazilian Northeast region, where the appropriate political support for the patients is not fulfilled.

Diagnosing sickle cell disease and iron deficiency anemia in human blood by Raman spectroscopy

This work proposed the diagnosis of iron deficiency anemia (IDA) and sickle cell disease (SCD) in human blood caused by iron deficiency and hemoglobin S (HbS), which are among the most common anemias, by means of Raman spectroscopy. Whole blood samples from patients diagnosed with IDA and HbS, as well as from normal subjects (HbA), were obtained and submitted to Raman spectroscopy (830 nm, 150 mW, 400-1800 cm^-1 spectral range, 4 cm^-1 resolution). Difference spectra of IDA-HbA showed spectral features of hemoglobin with less intensity in the IDA, whereas the difference spectra of SCD-HbA showed spectral features of deoxyhemoglobin increased and of oxyhemoglobin decreased in SCD. An exploratory analysis by principal components analysis (PCA) showed that the peaks referred to oxy- and deoxyhemoglobin markedly differentiated SCD and HbA, as well as the increased amount of hemoglobin features in the SCD group, suggesting increased erythropoiesis. The IDA group showed hemoglobin features with lower intensities as well as peaks referred to the iron bonding to the porphyrin ring with reduced intensities when compared to the HbA. Discriminant analysis based on partial least squares (PLS-DA) and PCA (PCA-DA) showed that the IDA and SCD anemias could be discriminated from the HbA spectra with 95.0% and 93.8% of accuracy, for the PLS and PCA respectively, with sensitivity/specificity of 93.8%/95.7% for the PLS-DA model. The iron depletion and the sickling of erythrocytes could be identified by Raman spectroscopy and a spectral model based on PLS accurately discriminated these IDA and SCD samples from the normal HbA.

Differential gene expression analysis of sickle cell anemia in steady and crisis state

Sickle cell anemia is one of the most prevalent genetic diseases worldwide, showing great clinical heterogeneity. This study compared the gene expression patterns between sickle cell anemia pediatric patients in steady state and in crisis state, as compared to age-paired, healthy individuals. RNA sequencing was performed from these groups of patients/controls using Illumina HiSeq 2500 equipment. The resulting differentially expressed genes were loaded into QIAGEN's ingenuity pathway analysis. The results showed that EIF2 pathway and NRF2-mediated oxidative stress-response pathways were more highly activated both in steady state and in crisis patients, as compared to healthy individuals. In addition, we found increased activation of eIF4 and p70S6K signaling pathways in crisis state compared to healthy individuals. The transcription factor GATA-1 was found exclusively in steady state while SPI was found exclusively in crisis state. IL6 and VEGFA were found only in crisis state, while IL-1B was found exclusively in steady state. The regulator effects analysis revealed IgG1 as an upstream regulator in steady state compared to healthy individuals, resulting in invasion of prostate cancer cell lines as the disease/function outcome. For crisis-state patients versus healthy individuals, two networks of regulator effects revealed STAT1, CD40LG, TGM2, IRF7, IRF4, and IRF1 acting as upstream regulators, resulting in disease/function outcomes, including engulfment of cells and aggregation of blood cells and inflammation of joints. Our results indicated genes and pathways that can provide clues on the molecular events involved in the severity of sickle cell disease.

Rare diseases mortality in Colombia, 2008-2013

Introduction: Rare diseases are characterized by their low prevalence, often of genetic origin, degenerative and life threatening. Objective: To describe mortality by orphan diseases and to analyze its trends in Colombia from 2008 to 2013. Materials and methods: We conducted a descriptive study to analyze mortality rate trends from the death certificates between 2008 and 2013. We calculated specific mortality rates and adjusted by age and sex. Results: Seven thousand one hundred and thirty five deaths were attributed to orphan diseases, and 51.4 % of them occurred among men of all ages. The mean mortality rate during the study period was 2.53 deaths per 100,000 people. Overall, the trend showed an increasing pattern of mortality although very heterogeneous across the country. Mortality rates were higher in Bogotá (20), and the Andes and the Caribbean regions (5.3 and 3.7 deaths per 100,000 population). The five most important causes of mortality among men were: acute lymphoblastic leukemia, muscular dystrophy, bronchopulmonary dysplasia originating in the perinatal period, multiple sclerosis, Guillain-Barré syndrome and gastroschisis, and among women: multiple sclerosis, acute lymphoblastic leukemia, gastroschisis, bronchopulmonary dysplasia originating in the perinatal period, Guillain-Barré syndrome and acute myeloid leukemia. The mean mortality rate by acute lymphoblastic leukemia was 0.17 deaths per 100,000 men younger than 15 years and that of multiple sclerosis was 0.16 in women over 40 years of age. Conclusion: The causes of death showed a similar pattern in both sexes. However, the burden of mortality was higher among men of all ages in Bogota.