Primary Prevention of Stroke in Children with Sickle Cell Anaemia in Nigeria: Community vs Teaching Hospital

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ABSTRACT Stroke is a frequent complication of sickle cell anemia (SCA) that is associated with increased morbidity and mortality. Without any intervention, ~11% of children with SCA will develop stroke before their 17th birthday. Evidence-based practices for primary stroke prevention include screening for abnormal transcranial Doppler (TCD) measurements coupled with regular blood transfusion therapy for at least one year, then hydroxyurea therapy for an indefinite period. In high-resource countries this strategy has dropped stroke incidence rates by 92%. In Nigeria, approximately 150,000 children with SCA are born annually, accounting for more than half of the total births with SCA worldwide. In comparison, there are only 1,700 affected births of children with SCA in the United States annually. Among each birth cohort, 15,000 children will have stroke annually in Nigeria. In 2016, as part of the capacity building objective of our Stroke Prevention Trial in Nigeria (SPRING,1R01NS094041) at Barau Dikko Teaching Hospital (BDTH) in Kaduna, TCD screening was adopted as standard of care. Before the trial, no TCD screening was performed at our trial site. Currently as standard of care, physicians at BDTH perform TCD screening, however, only 5.4% (1,101/20,040) of the eligible children with SCA living in Kaduna, Nigeria were reached. With just 21 radiologists and only 3 certified in TCD screening in Kaduna State, clearly, to achieve a decrease in stroke incidence among children with SCA living in Kaduna, and elsewhere, we must have a better implementation strategy to increase TCD screening. We therefore propose to initiate a stroke prevention program in a community hospital in Kaduna, Nigeria by task-shifting TCD screening and stroke detection to nurses. The aims of this proposal are to: 1) Identify barriers and facilitators that influence the adaptability of the transported intervention, including implementation process; 2) Build capacity for stroke detection and prevention in SCA in a community hospital; and 3) Conduct a feasibility trial comparing the effectiveness of a physician-based primary stroke prevention program in a teaching hospital to a task-shifted primary stroke prevention program in a community hospital.The proposed training and research will be conducted at Barau Dikko Teaching Hospital and Yusuf Dantsoho Memorial hospital in Kaduna, Nigeria and will provide preliminary data for a definitive randomized clinical trial in implementation science. A mentoring team of senior researchers in United States and Nigeria will supervise the applicant. The mentoring team has extensive research expertise in clinical trials in sickle cell disease and implementation science. The overall research objective is to develop strategies that will improve primary prevention of strokes in children with SCA.