Comprehensive Care Model for Sickle Cell Disease Management

 
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Dr Doreen Karimi Mutua
Pediatric Hematologist/Oncologist
Gertrude’s Children’s Hospital
 
Outline
 
History
Status of Sickle Cell Disease Care
Rationale of Comprehensive Care in Sickle Cell Disease
Landmark studies
Components of Comprehensive Sickle cell Care
Action Plan for Kenya
Summary
 
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Another sickness of the spleen.  It comes on mainly in the
springtime and is caused by the blood.  The 
spleen becomes
engorged with blood
, which evacuates into the stomach. 
Shooting
pains in the spleen, the breast, the clavicle, the shoulder, and
beneath the shoulder blade
.  The body’s coloration resembles lead.
Sores form on the leg and become large ulcerations
.  The discharges
with the feces are bloody and bluish green.  The belly hardens and
the spleen is like a stone.  
This one is more murderous than the one
before, and few survive it.”
 
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SCD is the commonest haemoglobinopathy in the world
There are about 300,000 children born with SCD every year, 70-75% are in
Africa
Estimated life expectancy for SCD in high income countries is 45-50years
but in low and Medium income countries more than 50 % of these children
die before their 5
th
 birthday
70% of the deaths in SCD are preventable
Challenges:  Lack of basic facilities to manage patients, absence of systemic
screening for SCD, poor research, documentation, and intervention
protocols
 
 
 
 
 
Hsu L, Nnodu OE et al. White Paper: Pathways to Progress in Newborn Screening for Sickle Cell Disease in Sub-Saharan Africa. J Trop Dis Public Heath.
2018;6(2):260
Wastnedge E, Waters D, Patel S.The global burden of sickle cell disease in children under five years of age: a systematic review and meta-analysis. J Glob
Health. 2018 Dec;8(2):021103
 
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Comprehensive care plan has led to a marked increase in survival for children with
SCD
 It is now rare for children with SCD to die in developed countries, with a reported
survival into adulthood of 94% in the United States and up to 99% in England
The 59th World Health Assembly (WHA) in 2006, identified SCD as a significant
public health problem in Africa that may contribute to up to 16% of under-5
mortality in some countries
WHA resolution 59.20 urged African nations with high burdens of SCD to design
and implement national SCD programs with a focus on
Widespread awareness-raising
Early identification by Newborn screening(NBS)
Early access to adequate preventative care, and training of medical professionals on SCD
 June 19
th
 as World Sickle Cell Day: the United Nations issued a call for action among African
nations to address the unmet burden of SCD
 
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Cooperative Study on Sickle Cell Disease(CSSD)
Natural history of SCD
Newborn cohort- majority of deaths occurring in the first six months
of life
Major events in children: infections, anemia
Increased Hb F associated with mild disease
50% of adults died before 5
th
 decade: acute pain, acute chest
syndrome, stroke
Hydroxyurea use reduces pain episode by 45%, acute chest
syndrome by 44% and blood transfusion by 30%
 
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Prophylatic Penicillin Study(PROPS)
Despite universal coverage of the pneumococcal vaccine,
Streptococcal infections significantly caused morbidity and
mortality until Penicillin prophylaxis was introduced
 
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Ped- HUG trial
 
 
 
 
Baby- HUG trial
 
 
 
lower rates of initial and recurrent episodes of pain, dactylitis, acute chest
syndrome, and hospitalization, Reduction in hemolysis, Increased Hb F,
Reversible and predictable adverse effects of Hydr
oxyurea
Beneficial effects on splenic function preservation
?effect on proteinuria, hypoxemia
No safety concerns
 
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STOP Trials
 
 
SWiTCH trial
 
 
TWITCH
Chronic transfusion in primary and secondary stroke
prevention
Chronic transfusion and chelation therapy superior to
Hydroxyurea/phlebotomy in stroke prevention
Hydroxyurea is effective in stroke prevention in
patients with abnormal transcranial ultrasound
velocity
 
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REACH trial (Kenya amongst 4 countries involved)
 
Among sub-Saharan African children with sickle cell anemia (SCA) treated
with hydroxyurea, 5.1% experienced dose-limiting toxic events, well below
the protocol-specified allowable rate of 30%.
 Compared to pretreatment rates, children treated with hydroxyurea had
significantly reduced rates of vaso-occlusive pain, infection, malaria,
transfusion, and death after one year.
 
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Comprehensive Care SCD
 
 
Newborn
screening
 
Prophylactic Penicillin
Prophylaxis
 
Health Education to
Families
 
Immunization
practices
 
Nutritional
support
 
Malaria infection
prevention
 
Management of
acute complications
 
Screening for Chronic
organ damage
 
Hydroxyurea use
 
Psychosocial
support
 
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Kenya is listed amongst the countries with high burden for SCD
It has been shown that Newborn screening and link to comprehensive care
centers is cost effective
Early introduction of penicillin prophylaxis
Health education to families during the patient visits
Immunization program already active
Ensure availability of Hydroxyurea
Ensure availability of pain medication and safe blood products
Establish multidisciplinary care
Establish guidelines on chronic organ damage screening: Urinalysis,
Transcranial Doppler, Ophthalmology reviews, Iron overload screening,
Echocardiography
 
Summary
 
Children with SCD have the potential to live and let live with decreased
morbidity and mortality
This requires an adoption and commitment to comprehensive care
approach to their management
Lets hear a word from the Kenya Sickle Cell Foundation Chair!
Thank You!
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Comprehensive care is crucial for managing sickle cell disease, the most common haemoglobinopathy worldwide. Despite advancements in high-income countries, challenges persist in low and medium-income nations, leading to preventable deaths, especially in Africa. A comprehensive care approach has significantly improved survival rates, with remarkable results in developed nations. The need for systemic screening, research, and interventions is clear to address the barriers to effective care.

  • Sickle Cell Disease
  • Comprehensive Care
  • Hemoglobinopathy
  • Public Health
  • Africa

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  1. Comprehensive Care Model: A Model Comprehensive Care Model: A Model for Sickle Cell Disease Management for Sickle Cell Disease Management Dr Doreen Karimi Mutua Pediatric Hematologist/Oncologist Gertrude s Children s Hospital

  2. Outline History Status of Sickle Cell Disease Care Rationale of Comprehensive Care in Sickle Cell Disease Landmark studies Components of Comprehensive Sickle cell Care Action Plan for Kenya Summary

  3. Its 100 years already!! It s 100 years already!!

  4. From the Forefathers of Medicine: Hippocrates From the Forefathers of Medicine: Hippocrates (460 (460- -377 B.C.E.) 377 B.C.E.) Another sickness of the spleen. It comes on mainly in the springtime and is caused by the blood. The spleen becomes engorged with blood, which evacuates into the stomach. Shooting pains in the spleen, the breast, the clavicle, the shoulder, and beneath the shoulder blade. The body s coloration resembles lead. Sores form on the leg and become large ulcerations. The discharges with the feces are bloody and bluish green. The belly hardens and the spleen is like a stone. This one is more murderous than the one before, and few survive it.

  5. Sickle Cell disease (SCD) Sickle Cell disease (SCD) SCD is the commonest haemoglobinopathy in the world There are about 300,000 children born with SCD every year, 70-75% are in Africa Estimated life expectancy for SCD in high income countries is 45-50years but in low and Medium income countries more than 50 % of these children die before their 5th birthday 70% of the deaths in SCD are preventable Challenges: Lack of basic facilities to manage patients, absence of systemic screening for SCD, poor research, documentation, and intervention protocols Hsu L, Nnodu OE et al. White Paper: Pathways to Progress in Newborn Screening for Sickle Cell Disease in Sub-Saharan Africa. J Trop Dis Public Heath. 2018;6(2):260 Wastnedge E, Waters D, Patel S.The global burden of sickle cell disease in children under five years of age: a systematic review and meta-analysis. J Glob Health. 2018 Dec;8(2):021103

  6. Rationale of Comprehensive SCD care Rationale of Comprehensive SCD care Comprehensive care plan has led to a marked increase in survival for children with SCD It is now rare for children with SCD to die in developed countries, with a reported survival into adulthood of 94% in the United States and up to 99% in England The 59th World Health Assembly (WHA) in 2006, identified SCD as a significant public health problem in Africa that may contribute to up to 16% of under-5 mortality in some countries WHA resolution 59.20 urged African nations with high burdens of SCD to design and implement national SCD programs with a focus on Widespread awareness-raising Early identification by Newborn screening(NBS) Early access to adequate preventative care, and training of medical professionals on SCD June 19th as World Sickle Cell Day: the United Nations issued a call for action among African nations to address the unmet burden of SCD

  7. Land mark studies: Natural History of SCD Land mark studies: Natural History of SCD Cooperative Study on Sickle Cell Disease(CSSD) Natural history of SCD Newborn cohort- majority of deaths occurring in the first six months of life Major events in children: infections, anemia Increased Hb F associated with mild disease 50% of adults died before 5th decade: acute pain, acute chest syndrome, stroke Hydroxyurea use reduces pain episode by 45%, acute chest syndrome by 44% and blood transfusion by 30%

  8. Land mark studies: Penicillin prophylaxis Land mark studies: Penicillin prophylaxis Prophylatic Penicillin Study(PROPS) Despite universal coverage of the pneumococcal vaccine, Streptococcal infections significantly caused morbidity and mortality until Penicillin prophylaxis was introduced

  9. Land mark studies: Hydroxyurea use in children Land mark studies: Hydroxyurea use in children Ped- HUG trial lower rates of initial and recurrent episodes of pain, dactylitis, acute chest syndrome, and hospitalization, Reduction in hemolysis, Increased Hb F, Reversible and predictable adverse effects of Hydroxyurea Baby- HUG trial Beneficial effects on splenic function preservation ?effect on proteinuria, hypoxemia No safety concerns

  10. Land mark studies: Stroke in Sickle Cell Disease Land mark studies: Stroke in Sickle Cell Disease Chronic transfusion in primary and secondary stroke prevention STOP Trials Chronic transfusion and chelation therapy superior to Hydroxyurea/phlebotomy in stroke prevention SWiTCH trial TWITCH Hydroxyurea is effective in stroke prevention in patients with abnormal transcranial ultrasound velocity

  11. Land mark studies: Hydroxyurea safe and effective Land mark studies: Hydroxyurea safe and effective for sickle cell anemia in African children for sickle cell anemia in African children REACH trial (Kenya amongst 4 countries involved) Among sub-Saharan African children with sickle cell anemia (SCA) treated with hydroxyurea, 5.1% experienced dose-limiting toxic events, well below the protocol-specified allowable rate of 30%. Compared to pretreatment rates, children treated with hydroxyurea had significantly reduced rates of vaso-occlusive pain, infection, malaria, transfusion, and death after one year.

  12. Components of Comprehensive Care Model Components of Comprehensive Care Model Newborn screening Health Education to Families Nutritional support Prophylactic Penicillin Prophylaxis Psychosocial support Immunization practices Comprehensive Care SCD Malaria infection prevention Screening for Chronic organ damage Management of acute complications Hydroxyurea use

  13. Where do we begin? Where do we begin? Kenya is listed amongst the countries with high burden for SCD It has been shown that Newborn screening and link to comprehensive care centers is cost effective Early introduction of penicillin prophylaxis Health education to families during the patient visits Immunization program already active Ensure availability of Hydroxyurea Ensure availability of pain medication and safe blood products Establish multidisciplinary care Establish guidelines on chronic organ damage screening: Urinalysis, Transcranial Doppler, Ophthalmology reviews, Iron overload screening, Echocardiography

  14. Summary Children with SCD have the potential to live and let live with decreased morbidity and mortality This requires an adoption and commitment to comprehensive care approach to their management Lets hear a word from the Kenya Sickle Cell Foundation Chair! Thank You!

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