An accurate and affordable test for the rapid diagnosis of sickle cell disease could revolutionize the outlook for affected children born in resource-limited settings

The implementation of a community-centered first aid education program for older adults-community health workers perceived barriers

BACKGROUND

Older adults are a high-risk group for accidental injuries, and strengthening training in first aid for older adults can improve their first aid capabilities and minimize their post-accident mortality. Community health workers are the greatest option to equip older adults with first aid instruction and training. However, the development of first aid education for the public by community health workers fails to take into account the elderly population. In view of this, this study aims to explore the barriers and challenges of first aid training for older adults from the perspective of community health workers and to provide a basis for better first-aid training for older adults in the community.

METHODS

This study adopted a qualitative research design. A total of 18 community health workers were recruited from two community health service centers in Qujing and one community health service center in Guangzhou from May to July 2022 to participate in the study. Participants were interviewed face-to-face using semi-structured in-depth interviews. The interview data were analyzed using Krippendorff's thematic clustering technique.

RESULTS

The results of the study identified community health workers' perceived challenges and barriers to providing first aid training to older adults in the community as older adults-level barriers, community health workers-level barriers, management systems-level barriers, and society-level barriers.

CONCLUSIONS

Community health workers are highly aware of multiple barriers and challenges in providing first aid training to community-based elderly populations. In particular, lack of professional training, heavy workloads, and limited resources and financial support. Therefore, supportive training, policies, and government funding are crucial for community health workers to conduct first aid training for older adults.

Caregivers' Perspective on the Psychological Burden of Living with Children Affected by Sickle Cell Disease in Kinshasa, the Democratic Republic of Congo

There is limited information on knowledge, perceptions, and management of sickle cell disease (SCD) in Africa in general and in the Democratic Republic of the Congo (DRC) in particular. This study explored knowledge, perceptions, and burden of 26 parents/caregivers of children with SCD in three selected hospitals in Kinshasa, DRC. We conducted a focus group with in-depth interviews with parents/caregivers of children affected with SCD. Four themes were discussed, including knowledge and perceptions, diagnosis and management, society's perceptions, and the psychosocial burden and the quality of life of the family affected by SCD. The majority of participants/caregivers felt that society, in general, had negative perceptions of, attitudes toward, and knowledge about SCD. They reported that children with sickle cell are often marginalized, ignored, and excluded from society or school. They face a number of challenges related to care, management, financial difficulties, and a lack of psychological support. The results suggest the need to promote measures and strategies to improve knowledge and management of SCD in Kinshasa, DRC.

Mediation of pain in the association of sleep problems with falls among older adults in India

Body pain, sleep problems and falls are commonly reported among the elderly population. This study aimed to explore the mediating role of pain in the association of sleep problems with fall-outcomes (falls, fall-injury, and multiple falls) among older adults. Cross-sectional data from the baseline survey of Longitudinal Aging Study in India (LASI), 2017-18 were used. The total sample size for the study was 28,285 older adults aged 60 years and above. Falls and fall-related injuries among older adults in the last two years were self-reported. The Jenkins Sleep Scale (JSS-4) was used to assess sleep problems while pain was assessed using questions on whether respondents reported that they were troubled by pain and they required some form of medication or treatment for the relief of pain. Multivariable logistic regression and mediation analyses were conducted to fulfill the study objectives. While 13% older adults suffered from sleep problems, 38.83% were troubled with pain. Additionally, 12.63%, 5.64% and 5.76% older adults reported falls, fall-injury and multiple falls respectively. Older adults who suffered from sleep problems had higher odds of falls [adjusted odds ratio (aOR): 1.43, confidence interval (CI): 1.30-1.58], fall-injuries, [aOR:1.50,CI:1.30-1.73] and multiple falls [aOR:1.41,CI:1.24-1.62]. Similarly, older adults who were troubled with pain were more likely to report falls [aOR:1.80, CI:1.67-1.95], fall-injuries [aOR:1.66, CI:1.48-1.87] and multiple falls [aOR:1.90,CI:1.69-2.12]. The percent of the mediated effect of pain when examining the association between sleep problems and fall outcomes were reported to be 17.10%, 13.56% and 18.78% in case of falls, fall-injuries and multiple falls respectively. The current study finds evidence that pain mediates the association of sleep problems and falls, fall-injuries, and multiple falls among older Indian adults. Both sleep problems and pain are modifiable risk factors that need attention for fall prevention strategies.

A predictive algorithm for identifying children with sickle cell anemia among children admitted to hospital with severe anemia in Africa

Sickle cell anemia (SCA) is common in sub-Saharan Africa where approximately 1% of births are affected. Severe anemia is a common cause for hospital admission within the region yet few studies have investigated the contribution made by SCA. The Transfusion and Treatment of severe anemia in African Children Trial (ISRCTN84086586) investigated various treatment strategies in 3983 children admitted with severe anemia (hemoglobin < 6.0 g/dl) based on two severity strata to four hospitals in Africa (three Uganda and one Malawi). Children with known-SCA were excluded from the uncomplicated stratum and capped at 25% in the complicated stratum. All participants were genotyped for SCA at trial completion. SCA was rare in Malawi (six patients overall), so here we focus on the participants recruited in Uganda. We present baseline characteristics by SCA status and propose an algorithm for identifying children with unknown-SCA. Overall, 430 (12%) and 608 (17%) of the 3483 Ugandan participants had known- or unknown-SCA, respectively. Children with SCA were less likely to be malaria-positive and more likely to have an affected sibling, have gross splenomegaly, or to have received a previous blood transfusion. Most outcomes, including mortality and readmission, were better in children with either known or unknown-SCA than non-SCA children. A simple algorithm based on seven admission criteria detected 73% of all children with unknown-SCA with a number needed to test to identify one new SCA case of only two. Our proposed algorithm offers an efficient and cost-effective approach to identifying children with unknown-SCA among all children admitted with severe anemia to African hospitals where screening is not widely available.

Association between daily activities and fall in older adults: an analysis of longitudinal ageing study in India (2017-18)

Background

Declining functionality affects an individual’s musculoskeletal integrity increasing the risk of fall and disability. Individuals with severe functional limitations are 5 times more likely to experience a fall. Thus, this paper investigated the association between functional decline and falls in older adults.

Methods

This study uses secondary data from the Longitudinal Aging Study in India (2017–18). A total of 31,477 people over the age of 60 are included in the study. Descriptive statistics and bivariate analysis were performed to determine the association between activities of daily living (ADL), instrumental activities of daily living (IADL) and fall. Adjusted odds ratio was used to determine the association of ADL and IADL with fall while controlling for age, gender, balance and gait impairments.

Results

The study reported 6352 fall episodes in 3270 participants aged 60 and above, over a period of 2 years. More than 30% of participants reported difficulty in ADL and IADL. Age and gender adjusted odds of fall were higher in participants with difficulty in more than 4 ADLs (AOR:1.32; CI:1.08 – 1.67) and in more than 2 IADL (AOR: 1.39; CI:1.02 – 1.89). Similarly, the odds of fall were higher for difficulty in ADL (AOR:1.31; CI:1.11 – 1.73) and IADL (AOR of 1.18; CI:1.07 – 1.29) controlling for gait and balance impairment. Difficulty in pushing-pulling objects (AOR: 1.30; CI: 1.15 – 1.46 & AOR: 1.40; CI: 1.21–1.61) and getting up from the chair (AOR: 1.12; CI:1.01–1.26 & AOR: 1.27; CI: 0.99 – 1.26) was significantly associated with fall when adjusted for age, gender and balance and gait parameters.

Conclusions

This study provides the new insights into the association of fall and risk of functional decline, especially difficulty in pushing and pulling objects and getting up from a chair, can be incorporated in the primary screening of fall risk assessment.

Healthcare Workers' Knowledge and Resource Availability for Care of Sickle Cell Disease in Dar es Salaam, Tanzania

Background: Sickle cell disease (SCD) is a global public health priority due to its high morbidity and mortality. In Tanzania, SCD accounts for 7% of under-five mortality. Cost-effective interventions such as early diagnosis and linkage to care have been shown to prevent 70% of deaths but require knowledge among healthcare workers and availability of resources at health facilities. In Tanzania, data on these critical determinants are currently lacking. Objective: To assess healthcare workers' knowledge and resource availability for care of SCD at health facilities in Dar es Salaam, Tanzania. Methodology: A facility-based cross-sectional study was conducted between December 2020 and February 2021 among 490 nurses and clinicians at Regional Referral Hospitals (Temeke, Amana, and Mwananyamala) and Muhimbili National Hospital in Dar es Salaam, Tanzania. Data were collected using a pre-tested structured questionnaire consisting of 13 knowledge questions (scored good knowledge if correct response in >7) and an inventory check list to record available resources. Pearson's χ² was used to determine the association between level of knowledge and demographic factors. Multivariate logistic regression was used to ascertain the strength of associations. A two-tailed p-value <0.05 was considered to be statistically significant. Results: Of the 490 participants (median age 28 years [IQR = 26-35]), only 25.1% had good knowledge on SCD. The odds of good knowledge was 82% lower in nurses than clinicians (AOR = 0.177; 95% CI: 0.090, 0.349; p < 0.001); 95% lower in diploma than Master's degree holders (AOR = 0.049; 95% CI: 0.008, 0.300; p = 0.001) and 4.6 times higher in those with 5-9 years than ≥10 years of experience (AOR = 4.564; 95% CI: 1.341, 15.525; p = 0.015). The regional-level hospitals lacked diagnostic tests and hydroxyurea therapy. Conclusion: There was general lack of knowledge on SCD among healthcare workers and limited availability of critical resources for the diagnosis and care of SCD, especially at regional-level hospitals. Efforts are needed for their improvement to enhance care to patients, thus reducing the morbidity and mortality due to SCD in Tanzania.

A retrospective case study of successful translational research: Gazelle Hb variant point-of-care diagnostic device for sickle cell disease

Evaluation researchers at Clinical and Translational Science Award (CTSA) hubs are conducting retrospective case studies to evaluate the translational research process. The objective of this study was to deepen knowledge of the translational process and identify contributors to successful translation. We investigated the successful translation of the HemeChip, a low-cost point-of-care diagnostic device for sickle cell disease, using a protocol for retrospective translational science case studies of health interventions developed by evaluators at the National Health Institutes (NIH) and CTSA hubs. Development of the HemeChip began in 2013 and evidence of device use and impact on public health is growing. Data collection methods included five interviews and a review of press, publications, patents, and grants. Barriers to translation included proving novelty, manufacturing costs, fundraising, and academic-industry relations. Facilitators to translation were CTSA pilot program funding, university resources, entrepreneurship training, due diligence, and collaborations. The barriers to translation, how they were overcome, and the key facilitators identified in this case study pinpoint areas for consideration in future funding mechanisms and the infrastructure required to enable successful translation.

Caring for Africa's sickle cell children: will we rise to the challenge?

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.

Sickle cell disease: Clinical presentation and management of a global health challenge

Sickle cell disease is an autosomal recessive, multisystem disorder, characterised by chronic haemolytic anaemia, painful episodes of vaso-occlusion, progressive organ failure and a reduced life expectancy. Sickle cell disease is the most common monogenetic disease, with millions affected worldwide. In well-resourced countries, comprehensive care programs have increased life expectancy of sickle cell disease patients, with almost all infants surviving into adulthood. Therapeutic options for sickle cell disease patients are however, still scarce. Predictors of sickle cell disease severity and a better understanding of pathophysiology and (epi)genetic modifiers are warranted and could lead to more precise management and treatment. This review provides an extensive summary of the pathophysiology and management of sickle cell disease and encompasses the characteristics, complications and current and future treatment options of the disease.

The global burden of sickle cell disease in children under five years of age: a systematic review and meta-analysis

Background

Sickle cell disease (SCD) is a common haematological disorder, affecting millions of people worldwide. It is most prevalent in malarial endemic areas in the tropics where outcomes are often poor due to resource constraints, resulting in most children dying before reaching adulthood. As increasing progress is made towards reducing under 5 mortality from infectious causes, non-communicable diseases (NCDs) including SCD have risen to the forefront of the global health agenda. Despite this, the global mortality burden of SCD remains poorly understood. This study aimed to estimate the incidence and mortality of SCD in children under 5 years of age in order to inform policy and develop sustainable strategies to improve outcomes.

Methodology

We performed a systematic literature search of Medline, EMBASE, Journals@Ovid, and Web of Science for studies on the incidence and mortality of SCD in children under 5, with search dates set from January 1980 and July 2017. We conducted random effects meta-analysis to obtain pooled meta-estimates of birth prevalence and mortality rates globally, and for each World Health Organization (WHO) region.

Results

67 papers were found with relevant data. 52 contained data on incidence and prevalence and 15 contained data on mortality. The overall pooled estimate of mortality from the limited data available was 0.64 per 100 years of child observation (95% CI = 0.28-1.00) with the highest rate seen in Africa 7.3 (95% CI = 4.03-10.57). The global meta-estimate for the birth prevalence of homozygous sickle cell disease was 112 per 100 000 live births (95% CI = 101-123) with a birth prevalence in Africa of 1125 per 100 000 (95% CI = 680.43-1570.54) compared with 43.12 per 100 000 (95% CI = 30.31-55.92) in Europe.

Conclusion

There were a number of limitations in the depth and breadth of available data however it is clear that both the highest prevalence and highest mortality of SCD is in Africa. In order to address this burden, there is a need for national comprehensive newborn screening to identify patients, and the development of holistic SCD care programmes to provide therapeutics and education for families and children with SCD. This targeted funding should form part of a broader increased global focus on NCDs in childhood.

Cost for sickle cell disease screening using isoelectric focusing with dried blood spot samples and estimation of price thresholds for a point-of-care test in Uganda

Background

Early identification through newborn screening is the first step in active management of sickle cell disease (SCD). Uganda currently screens newborns and infants under 2 years for SCD in high HIV-burden districts using isoelectric focusing with dried blood spot samples. Our analysis sought to estimate the costs per child screened for SCD using this method in Uganda and then to use those data to estimate the price threshold for screening with a point-of-care (POC) test.

Methods

We estimated the financial and economic costs per child screened for SCD using data from health facilities and the Central Public Health Laboratory. These costs included sample collection, transportation, and laboratory processing. Price thresholds for a POC test were estimated using two scenarios.

Results

The price threshold of an SCD POC test used for diagnosis would be $3.77 when taking into account only financial costs and $5.14 when taking into account economic costs. Thresholds for a POC test used for screening would be $3.07–$3.51 and $4.38–$5.09, respectively, depending on test specificity.

Conclusion

The price threshold of a POC test for SCD will depend on the assumptions on how it will be used – either as a screening or diagnostic test. If used for screening, test specificity will have significant impact. Results from this type of costing study can allow developers to incorporate quantitatively estimated price thresholds for innovative products into target product profiles early in the product development cycle.

Diagnostic accuracy in field conditions of the sickle SCAN® rapid test for sickle cell disease among children and adults in two West African settings: the DREPATEST study

Background

Sickle cell disease (SCD) accounts for 5% of mortality in African children aged < 5 years. Improving the care management and quality of life of patients with SCD requires a reliable diagnosis in resource-limited settings. We assessed the diagnostic accuracy of the rapid Sickle SCAN® point-of-care (POC) test for SCD used in field conditions in two West-African countries.

Methods

We conducted a case-control study in Bamako (Mali) and Lomé (Togo). Known cases of sickle cell disease (HbSS, HbSC), trait (HbAS), HbC heterozygotes (HbAC) and homozygous (HbCC), aged ≥6 months were compared to Controls (HbAA), recruited by convenience. All subjects received both an index rapid POC test and a gold standard (high-performance liquid chromatography in Bamako; capillary electrophoresis in Lomé). Personnel conducting tests were blinded from subjects' SCD status. Sensitivity and specificity were calculated for each phenotype. Practicality was assessed by local healthcare professionals familiar with national diagnostic methods and their associated constraints.

Results

In Togo, 209 Cases (45 HbAS, 39 HbAC, 41 HbSS, 44 HbSC and 40 HbCC phenotypes) were compared to 86 Controls (HbAA). 100% sensitivity and specificity were observed for AA Controls and HbCC cases. Estimated sensitivity was 97.7% [95% confidence interval: 88.0-99.9], 97.6% [87.1-99.9%], 95.6% [84.8-99.5%], and 94.9% [82.7-99.4], for HbSC, HbSS, HbAS, and HbAC, respectively. Specificity exceeded 99.2% for all phenotypes. Among 160 cases and 80 controls in Mali, rapid testing was 100% sensitive and specific. Rapid testing was well accepted by local healthcare professionals.

Conclusion

Rapid POC testing is 100% accurate for homozygote healthy people and excellent (Togo) or perfect (Mali) for sickle cell trait and disease patients. In addition to its comparable diagnostic performance, this test is cheaper, easier to implement, and logistically more convenient than the current standard diagnostic methods in use. Its predictive value indicators and diagnostic accuracy in newborns should be further evaluated prior to implementation in large-scale screening programs in resource-limited settings where SCD is prevalent.

Preliminary Evaluation of a Point-of-Care Testing Device (SickleSCAN™) in Screening for Sickle Cell Disease

Sickle cell disease affects about 150,000 births annually in Nigeria. Early diagnosis is hampered by factors such as centralized and urban localization of laboratories, high cost of diagnostic equipment and inadequate skilled manpower to operate them. The need for a low-cost, portable, easy-to-use diagnostic test for sickle cell disease is critical, especially in resource-poor countries. In this study, we evaluated the performance characteristics of a novel point-of-care testing device (SickleSCAN™), and its acceptability and feasibility, as a possible screening tool for sickle cell disease. In the first phase, we assessed the performance characteristics of SickleSCAN™ by evaluating 57 subjects comprising both children and adults attending a primary health center, for Hb SS (β^S/β^S; HBB: c.20A>T), Hb SC (β^S/β^C; HBB: c.19G>A) and Hb AS (β^A/β^S) using SickleSCAN™, cellulose acetate electrophoresis (CAE) and high performance liquid chromatography (HPLC). Performance characteristics such as diagnostic sensitivity and specificity were compared to HPLC as a standard method. We subsequently undertook a second phase wherein the acceptability and feasibility of the device for sickle cell disease screening, was evaluated using semi-structured and structured questionnaires among 197 healthcare personnel and 221 subjects, respectively. Sickle cell disease was carried by 3.4% of the subjects. The diagnostic sensitivity, specificity and test efficiency of SickleSCAN™ for sickle cell disease (Hb SS and Hb SC), were 100.0, 98.2 and 98.2%, respectively. Findings from this study showed SickleSCAN™ to be a viable screening tool that can easily be applied in community-based screening for early diagnosis of sickle cell disease with little expertise and low cost.

Hematology in Africa

This review of hematology in Africa highlights areas of current practice and the immediate needs for development and clinical research. Acute hematological practice is dominated by anemia, sickle cell disease, and the need to provide a safe and rapidly available supply of blood. There is a growing need for specialist services for bleeding and coagulation, hematological malignancy, and palliative care. There are many areas of practice where straightforward measures could yield large gains in patient care. There is an urgent need for good clinical research to describe the epidemiology, natural history, and management of hematological diseases in Africa.