Abdullahi, SU

Abubakar, S

Aliyu, MH

Bello-Manga, H

Belonwu, R

Covert, BV

DeBaun, MR

Galadanci, AA

Galadanci, NA

Gambo, S

Jibir, BW

Jordan, LC

Kassim, AA

Kirkham, F

Neville, K

Phillips, S

Salihu, A

Shyr, Y

Suwaid, S

Tabari, MA

Trevathan, E

Vance, LD

English

UCL Discovery

GLOBAL CAPACITY-BUILDING SHOWCASEImplementing a standard-of-care clinic for stroke prevention in childrenwith sickle cell disease in Nigeria: a feasible strategy outside a clinicaltrial settingNajibah A. Galadanci,1 Shehu U. Abdullahi,2 Leah D. Vance,3 Musa A. Tabari,4 Shehi Abubakar,4 Raymond Belonwu,2 Auwal Salihu,5Aisha A. Galadanci,1 Binta W. Jibir,6 Safiya Gambo,6 Salma Suwaid,7 Halima Bello-Manga,8 Kathleen Neville,9 Fenella Kirkham,10 Yu Shyr,11Sharon Phillips,11 Brittany V. Covert,12 Adetola A. Kassim,13 Edwin Trevathan,12 Lori C. Jordan,12 Muktar H. Aliyu,14 andMichael R. DeBaun121Department of Hematology and Blood Transfusion, and 2Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria; 3Department ofPediatrics, Hasiya Bayero Pediatric Hospital Kano, Nigeria; 4Department of Radiology, and 5Department of Psychiatry, Bayero University/Aminu Kano Teaching Hospital, Kano,Nigeria; 6Murtala Mohammed Specialist Hospital, Kano, Nigeria; 7Mohammed Abdullahi Wase Specialist Hospital, Kano, Nigeria; 8Department of Hematology and BloodTransfusion, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria; 9Department of Pediatrics, University of Arkansas for Medical Sciences/ArkansasChildren’s Hospital, Little Rock, AR; 10Developmental Neurosciences, UCL Institute of Child Health, London, UK; and 11Department of Biostatistics, 12Department ofPediatrics, 13Division of Hematology/Oncology Department of Medicine, and 14Department of Health Policy, Vanderbilt Institute for Global Health, Vanderbilt University Schoolof Medicine, Nashville, TNIntroductionStroke is a devastating, preventable complication of sickle cell anemia (SCA).1 In a tertiary care centerfor children with SCA, screening for elevated transcranial Doppler (TCD) velocity coupled with regularblood transfusion therapy for those with abnormal values decreased the stroke rate from 0.67 to 0.06strokes per 100 patient-years.2 Despite evidence of preventing strokes and high morbidity and mortalityassociated with SCA (#30%),1 primary stroke prevention teams for children with SCA are lacking inAfrica.To decrease the incidence of strokes in the general population of children with SCA, we establishedprimary stroke prevention teams, as part of routine medical care, in 4 tertiary care hospitals in Kano,Nigeria. Collectively the 4 hospitals serve.20 000 children with SCA. We report the implementation ofprimary stroke prevention teams in a low-resource setting in Nigeria.ProcedureAt each of the 4 hospital-based sickle clinics, we identified the number of children with SCA and clinicpersonnel required to work with the team. The research team and hospital leadership identified apediatrician, a nurse, and a radiologist to set up the primary stroke prevention teams. We initiallyconducted TCD training for all the radiologists using our TCD training protocol established for the SPINtrial. Each trainee radiologist and the trainer radiologist performed 40 paired TCD evaluations of the rightand left middle cerebral arteries. The minimum acceptable correlation coefficient between the trainerand trainee was 0.76 for each side (85% of the trainer correlation in the same individual performed onlyhours apart).3 We conducted 3 education workshops based on National Heart Lung and Blood Institutesickle cell disease (SCD) management guidelines for primary care providers,4,5 and adapted for medicalcare in low-resource settings, we also trained$2 nurses and community health workers per clinic on themanagement of children with SCA. A child neurologist provided instructions on how to detect a strokeand stroke-related comorbidities (e.g., seizures) at 2 of 3 workshops. To ensure project sustainability andcommunity ownership, we developed a memorandum of understanding with the Kano State governmenton 4 elements: (1) training hospital staff on identifying strokes with a commitment to keep the teamtogether after the training; (2) training and certifying physicians and nurses in TCD techniques; (3)provision of free hydroxyurea therapy for children with abnormal TCD measurements; and (4) creation ofan electronic patient care database for persons receiving TCD screening (no newborn screening forSCD is performed) (Figure 1).8 DECEMBER 2017 x VOLUME 1 SUPPLEMENT 1 GLOBAL CAPACITY-BUILDING SHOWCASE 23Downloaded from https://ashpublications.org/bloodadvances/article-pdf/1/Suppl/23/879523/advances101266.pdf by guest on 05 April 2020ResultsA survey of medical leadership at each hospital in the fall of 2016indicated that TCD screening was not standard of care for childrenwith SCA. Outside of the clinical trial setting, none of the radiologistshad extensive experience in performing TCD evaluation in childrenwith SCA. Only 1 of 4 hospitals provided hydroxyurea therapyregardless of the ability to pay, but leadership at each hospital agreedthat screening for strokes and providing hydroxyurea should be animportant component of standard care. The primary stroke preventionclinics opened in January 2017. Each of the hospitals trained amultidisciplinary team. The government of Kano State agreed toprovide free hydroxyurea to all eligible patients and provided 2 full-time permanent nurses for each of the 4 clinics.We have trained and certified a hospital radiologist at all 4participating hospitals. Since January 2017, 1249 children withSCA have been screened using TCD; all children were entered in adatabase with basic clinical information facilitating medical care.Abnormal TCD values (TAMMV .200 cm/second in middle cerebralartery confirmed independently by 2 radiologists) were reported in 7%of patients (n 5 82); 73 were referred to participate in the SPRINGTrial (www.clinicaltrials.gov identifier NCT02560935). As standardcare, 7 of the remaining 9 children were started on ;20 mg ofhydroxyurea per kg per day (Figure 2). We fully anticipate that theprimary stroke prevention teams will continue screening and identi-fying children with SCD in 4 major hospitals in Kano, Nigeria, beyondthe funding period of the SPRING Trial.ConclusionsCommunity ownership and partnerships with leaders of participat-ing hospitals and with local governments facilitate the establishmentof sustainable primary stroke prevention teams for children withSCA in low-resource settings.Correspondence: Najibah Aliyu Galadanci, Department of Hema-tology and Blood Transfusion, Aminu Kano Teaching Hospital, 2Zaria Rd, Kano, Nigeria; e-mail: jibaliyu@yahoo.com.Conflict-of-interest disclosure: The authors declare no compet-ing financial interests.Figure 1. Establishment of the primary stroke prevention clinics andmultidisciplinary team.Figure 2. Flow diagram showing results of the primarystroke prevention clinics.24 GLOBAL CAPACITY-BUILDING SHOWCASE 8 DECEMBER 2017 x VOLUME 1 SUPPLEMENT 1Downloaded from https://ashpublications.org/bloodadvances/article-pdf/1/Suppl/23/879523/advances101266.pdf by guest on 05 April 2020References1. Powars D, Wilson B, Imbus C, Pegelow C, Allen J. The natural historyof stroke in sickle cell disease. Am J Med. 1978;65(3):461-471.2. Enninful-Eghan H, Moore RH, Ichord R, Smith-Whitley K,Kwiatkowski JL. Transcranial Doppler ultrasonography andprophylactic transfusion program is effective in preventing overtstroke in children with sickle cell disease. J Pediatr. 2010;157(3):479-484.3. Galadanci NA, Umar Abdullahi S, Vance LD, et al. Feasibility trial forprimary stroke prevention in children with sickle cell anemia in Nigeria(SPIN trial). Am J Hematol. 2017;92(8):780-788.4. Yawn BP, Buchanan GR, Afenyi-Annan AN, et al. Management ofsickle cell disease: summary of the 2014 evidence-based report byexpert panel members. JAMA. 2014;312(10):1033-1048.5. Shook LM, Farrell CB, Kalinyak KA, et al. Translating sickle cellguidelines into practice for primary care providers with Project ECHO.Med Educ Online. 2016;21:33616.DOI 10.1182/bloodadvances.2017GS101266© 2017 by The American Society of Hematology8 DECEMBER 2017 x VOLUME 1 SUPPLEMENT 1 GLOBAL CAPACITY-BUILDING SHOWCASE 25Downloaded from https://ashpublications.org/bloodadvances/article-pdf/1/Suppl/23/879523/advances101266.pdf by guest on 05 April 2020

Implementing a standard-of-care clinic for stroke prevention in children with sickle cell disease in Nigeria: a feasible strategy outside a clinical trial setting

https://discovery.ucl.ac.uk/10094609/1/Galadanci%20advances101266.pdf

Implementing a standard-of-care clinic for stroke prevention in children with sickle cell disease in Nigeria: a feasible strategy outside a clinical trial setting

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