In a previous article- Can we say this pandemic is over? I opined at the time that among other things the clinical presentation of COVID-19 aligns closely with that of the hemoglobinopathies. I suggested potential areas to focus our treatment efforts, drug trials, and preventive strategies. Some of these are gradually being supported by emerging evidence in the medical literature and hands-on experience by physicians in our clinics.
In this article, I would further highlight some implications of the emerging similarities between Sickle Cell Disease (SCD) and COVID-19 from the lens of a doctor who grew up with mild symptoms, had met many people who battled with SCD and also witnessed the suffering of many African-Americans in the United States of America who were living with SCD. This discourse would focus on public health interventions that can be adopted immediately in our struggle against COVID-19.
“Sickler” is a derogatory name given to carriers of the sickle cell trait who get ill from time to time, having to visit clinics very often, get admitted into hospitals, miss school days as students, or take frequent sick leaves from work. This dependence on the health system can affect personal and occupational functioning to the extent that peers and community members are some worth justified to say they are sickly without prejudice.
SCD has been a scourge on generations of individuals and families with its unending physical and emotional challenges. A day is set aside yearly as the World Sickle Cell Day (June 19) to create awareness, encourage medical research, and focus on the plight of people with SCD. Despite the many challenges associated with sickle cell disease, it comes with its thin coat of silver linings. The sickle cell trait protects against severe forms of malaria.
SCD also trains survivors perhaps inadvertently in physical and emotional resilience and arts of self-mastery. SCD survivors have been able to hold-up and thrive regardless of the laws of natural selection for long enough which keeps me wondering if we are missing out something; are there other benefits in these genetic variants to look out for, and if there are, what are the benefits?
Quite interestingly, as the clinical presentation of signs and symptoms of COVID-19 continues to mimic those of the Sickle Cell Disease crisis, I foresee areas where the learning curve of COVID-19 can comfortably merge with that of SCD. Like SCD Patients, patients with COVID-19 characteristically fall somewhere on the spectrum of mild-moderate-severe and life-threatening disease at the time they are presenting to care. Also of note for SCD, when intervention is sought early in the course of a crisis and appropriate treatment given, symptoms and signs rarely spiral out of control and patients may be spared lots of pain and anguish.
SCD affects both young and old, it can come with a characteristic physique that tells the story to the trained eye of a physician. It is deadly and debilitating if untreated. Unfortunately, few options are available for effective management of the severe forms of SCD. It results from a genetic mutation, can affect multiple organs and the severity of crisis vary considerably from individual to individual. A chronic disease, acute pain crises are typically triggered by conditions that cause red cells to clump together and die prematurely which includes amongst other factors, infections by viruses, bacteria, or parasites. There exists a vast literature on the etiology and pathophysiology of SCD. However, with the emerging similarities in clinical presentation between SCD and COVID-19, could this hold an opportunity for a rethink about SCD management going forward?
Taking a cue from all that has been mentioned, several public health interventions can be proposed for adoption in our fight against COVID-19.
Active surveillance for COVID-19 holds promise not just for isolation and contact-tracing but also in reducing morbidity and mortality. Early Intervention in the form of patient education, counseling, and support services for patients and carers, regular risk assessment, and early initiation of pharmacotherapy are promising areas in the pro-active case management of COVID-19. With the fast-paced community spread of COVID-19, the door is closing on an eradication agenda hence the new focus on individual responsibility and secondary prevention.
We can learn some lessons from the way survivors of SCD manage themselves. From a clinical and socio-cultural perspective, survivors of SCD have had to strictly follow instructions given to them by their doctors; parents and carers play important roles by adhering to treatment plans until patients gain independence with age. They are advised to keep warm particularly during the cold or rainy season, drink lots of fluid, take supplements, and engage in moderate exercise. Attention is paid to good nutrition and a comfortable living environment. They are expected to visit the clinic regularly, at the University College Hospital, Ibadan the clinic is designated a ‘’day-care’’ emphasizing how closely they need patients to be monitored.
The current trajectory of the COVID-19 pandemic could see a lot of people requiring such ‘’day-care’’ attention at least in the short term. Health systems would need to brace up for the potential increase in demand until such a time when the pandemic is under control. Whether by teleconsultation or face-to-face interaction, it is the prerogative of all who need healthcare to have access to healthcare equitably. The clinical course of COVID-19 from inoculation to convalescence and the risk of re-infection after earlier exposure to the virus are yet to be well delineated. We do not know what to expect with herd immunity. Would COVID-19 take the pattern of the seasonal flu and what factors determine who has a mild disease or who succumbs to the disease? We are getting some answers but a lot is still unknown. In the interim, as we err on the side of caution, I wish to restate the need to have rapid test kits available coupled with a protocol for provider-initiated testing of patients at every point of contact with the health system. A convenient, almost painless, easy to report screening test with results gotten within minutes would be a game-changer for patient management in this era.
As cases of COVID-19 grow world-wide, a friendly caution given to patients with SCD is to watch out for a tendency for a more severe crisis during times of harsh environmental conditions, the flu season is notorious for greater morbidity and mortality from coronaviruses. Therefore, we should take advantage of the heat of the Sahara or the warmth of the summer to strengthen our public health response to the pandemic. Aside from sun rays and the role of Vitamin D in boosting immune response, variations in ambient environmental temperature is a confounding variable we need to pay attention to as we approach the winter and harmattan seasons.
As we have been able to improve the care for sickle cell disease patients, we shall do the same for COVID-19 patients!!
Dr AGBOOLA ADIGUN (MBBS,MPA,MPH)
Writes from Ibadan.
NB: The opinions expressed in this publication are those of the author. They do not purport to reflect the opinions of the PLEACenter or its members.