Diabetes in sub-Saharan Africa: from clinical care to health policy

HbA1c performs well in monitoring glucose control even in populations with high prevalence of medical conditions that may alter its reliability: the OPTIMAL observational multicenter study

INTRODUCTION

The utility of HbA1c (glycosylated hemoglobin) to estimate glycemic control in populations of African and other low-resource countries has been questioned because of high prevalence of other medical conditions that may affect its reliability. Using continuous glucose monitoring (CGM), we aimed to determine the comparative performance of HbA1c, fasting plasma glucose (FPG) (within 5 hours of a meal) and random non-fasting glucose (RPG) in assessing glycemic burden.

RESEARCH DESIGN AND METHODS

We assessed the performance of HbA1c, FPG and RPG in comparison to CGM mean glucose in 192 Ugandan participants with type 2 diabetes. Analysis was undertaken in all participants, and in subgroups with and without medical conditions reported to affect HbA1c reliability. We then assessed the performance of FPG and RPG, and optimal thresholds, in comparison to HbA1c in participants without medical conditions thought to alter HbA1c reliability.

RESULTS

32.8% (63/192) of participants had medical conditions that may affect HbA1c reliability: anemia 9.4% (18/192), sickle cell trait and/or hemoglobin C (HbC) 22.4% (43/192), or renal impairment 6.3% (12/192). Despite high prevalence of medical conditions thought to affect HbA1c reliability, HbA1c had the strongest correlation with CGM measured glucose in day-to-day living (0.88, 95% CI 0.84 to 0.91), followed by FPG (0.82, 95% CI 0.76 to 0.86) and RPG (0.76, 95% CI 0.69 to 0.81). Among participants without conditions thought to affect HbA1c reliability, FPG and RPG had a similar diagnostic performance in identifying poor glycemic control defined by a range of HbA1c thresholds. FPG of ≥7.1 mmol/L and RPG of ≥10.5 mmol/L correctly identified 78.2% and 78.8%, respectively, of patients with an HbA1c of ≥7.0%.

CONCLUSIONS

HbA1c is the optimal test for monitoring glucose control even in low-income and middle-income countries where medical conditions that may alter its reliability are prevalent; FPG and RPG are valuable alternatives where HbA1c is not available.

'La Vida Normal': Young people adapting to Type 1 diabetes in Bolivia

OBJECTIVES

To identify challenges and coping strategies of young people with Type 1 diabetes (T1D) and their families in Bolivia through qualitative analysis of interviews with beneficiaries of Centro Vivir con Diabetes (CVCD), a diabetes health center supported by the International Diabetes Federation Life for a Child (LFAC) program.

METHODS

Eighteen young people aged 14-33 and at least one caregiver participated in semi-structured interviews in five cities in Bolivia from May to June 2016. Interviews were recorded, transcribed, and analyzed using inductive thematic analysis.

RESULTS

Participants described needing guidance at diagnosis and facing stigma in communities. Young people expressed that life with T1D was 'la vida normal' (a normal life), although interpretations of normalcy varied. For some, 'la vida normal' meant resistance to T1D; for others it indicated acceptance.

DISCUSSION

Access to interdependent spheres of support allowed young people to form a new normal around T1D. Receiving supplies through the CVCD/LFAC partnership maintained family connection to clinical care, CVCD education helped families share in T1D management, and peer support mitigated stigma for young people. Programs like CVCD that combine supply-based aid with clinical education for whole families, create effective support for young people with T1D in low- and middle-income countries.

Associations between obesity indices and both type 2 diabetes and impaired fasting glucose among West African adults: Results from WHO STEPS surveys

BACKGROUND AND AIM

Various obesity indices such as BMI, waist circumference (WC), waist-hip ratio, (WHR) and waist-to-height ratio (WHtR) are associated with the risk of type 2 Diabetes Mellitus (T2DM). Given few studies examining the strength of the association in this population, we aimed to identify which obesity indices are most strongly associated with T2DM and impaired fasting glucose (IFG) among adults from five West African countries.

METHODS AND RESULTS

Data from 15,520 participants from the World Health Organisation (WHO) STEPs surveys in Burkina Faso, Benin, Mali, Liberia, and Ghana were included in analyses. Multinomial logistic regression was used to calculate the relative risk (RR) per standard deviation (SD) of each anthropometric measure, modelled as both continuous variables and as categorical variables based on established cut-points. In the analyses with continuous variables, the unadjusted RRs for T2DM per SD were 1.30 (1.23, 1.37) for body mass index (BMI); 1.56 (1.46, 1.67) for WC; 2.57 (2.15, 3.09) for WHtR and 1.16 (1.03, 1.31) for WHR. WHtR showed the strongest association with T2DM in all adjusted analyses. For models using categorical variables based on established cut-points, obesity defined using waist circumference (OB-WC) and OB-BMI showed the strongest associations with T2DM, and OB-WHR, the weakest association in all adjusted analyses.

CONCLUSION

WHtR and WC appear to be the indices most strongly associated with T2DM and IFG respectively. Given its simplicity, WC may be the metric that most usefully conveys risk for T2DM in West African adults.

Amankwah J. Diabetes self-management education interventions in the WHO African Region: A scoping review

INTRODUCTION

Diabetes mellitus (DM) is one of the commonest chronic diseases worldwide. Self-Management Education (SME) is regarded as a critical element of treatment for all people with diabetes, as well as those at risk of developing the condition. While a great variety of diabetes self-management education (DSME) interventions are available in high-income countries, limited information exists on educational programs for the prevention and management of diabetes complications in Africa. This study, therefore, aimed at synthesizing information in the literature to describe the state of the science of DSME interventions in the WHO African Region.

MATERIALS AND METHODS

The study is a scoping review, which followed the standard PRISMA guidelines for conducting and reporting scoping reviews. A systematic keyword and subject headings searches were conducted on six electronic databases (PubMed, Scopus, MEDLINE, EMBASE, PsychINFO and the Cochrane Central Register of Controlled Trials) to identify relevant English language publications on DSME from 2000 through 2020. Titles and abstracts of the search results were screened to select eligible papers for full text reading. All eligible papers were retrieved and full text screening was done by three independent reviewers to select studies for inclusion in the final analysis.

RESULTS

Nineteen studies were included in the review. The interventions identified were individually oriented, group-based, individually oriented & group-based, and information technology-based DSME programs. Outcomes of the interventions were mixed. While the majority yielded significant positive results on HbA1c, diabetes knowledge, blood pressure, blood sugar and foot care practices; few demonstrated positive outcomes on self-efficacy, BMI, physical activity; self-monitoring of blood glucose, medication adherence, smoking and alcohol consumption.

CONCLUSIONS

The limited studies available indicate that DSME interventions in the WHO African Region have mixed effects on patient behaviors and health outcomes. That notwithstanding, the majority of the interventions demonstrated statistically significant positive effects on HbA1c, the main outcome measure in most DSME intervention studies.

HbA1c variability and the development of nephropathy in individuals with type 1 diabetes mellitus from Rwanda

AIM

To estimate the incidence and prevalence of nephropathy and investigate whether high and fluctuating HbA_1c levels were associated with development of nephropathy among T1 diabetes individuals in Rwanda.

METHODS

From 2009 to 2018, 471 T1 diabetes individuals from Rwanda were assessed for nephropathy (albumin-creatinine ratio (ACR) ≥ 30 mg/g). We calculated the mean HbA_1c (HbA_1c-MEAN) and two measures of HbA_1c variability, i.e. A): intra-individual standard deviation (HbA_1c-SD), adjusted for HbA_1c assessments (HbA_1c-AdjSD) and coefficient of variation (HbA_1c-CV) and B): (number of HbA_1c variability measures > 11 mmol/mol between two measures/number of comparisons between measurements)*100. We followed individuals from first ACR-measurement (baseline) until nephropathy, death or last ACR-measurement (end-of-follow-up), and calculated HRs for developing nephropathy using Cox-regression.

RESULTS

The incidence and prevalence of nephropathy were 25% and 40%, respectively. All HbA_1c variability measures were associated with lower HRs of developing nephropathy, i.e. individuals with HbA1c-AdjSD levels of 0.8-1.5%, 1.5-2.1% and > 4.1% had 53% (95 %CI:0.26;0.86), 55% (95 %CI:0.25;0.82) and 53% (95 %CI:0.26;0.84) lower HRs, respectively, of nephropathy compared to individuals with HbA1c-AdjSD < 0.8%. Results did not change after adjustments, though some estimates were no longer significant. Individuals with adjusted HbA_1c-MEAN 9.9-11.4% and > 11.4% had HRs of 1.7 (95 %CI: 0.87;3.32) and 1.8 (95 %CI: 0.94;3.50) compared to individuals with HbA_1c-MEAN of 4.9-8.5%.

CONCLUSION

The incidence and prevalence of nephropathy was high. Higher mean HbA_1c was associated with higher HRs of developing nephropathy whereas higher HbA_1c variability was associated with lower HRs of nephropathy. This indicates that higher HbA_1c levels rather than fluctuating HbA_1c levels is a risk factor for developing nephropathy.

A nurse-led, community-based self management program for people living with type 2 diabetes in Western Ethiopia: A feasibility and pilot study protocol

AIM

To develop and examine the preliminary effects of a nurse-led, community-based diabetes self management education and support program on clinical outcomes, self care behaviours, quality of life and family support through a pilot randomized controlled trial among adults living with type 2 diabetes in Western Ethiopia.

METHODS

A two-arm parallel-group pilot randomized controlled trial involving participant-caregiver dyads will be conducted. A total of 76 dyads will be recruited, with 38 dyads randomly allocated to the intervention arm receiving six sessions of the diabetes self management education and support program supported by an educational handbook, flier and video on top of the usual care; the control arm will continue to receive the usual care. The intervention will be guided by social cognitive theory and related international guidelines for diabetes management, addressing misconceptions, using culturally tailored foods and involving family members in the intervention. Participants will be recruited at Nekemte Specialized Hospital over 2 months. Nurses will deliver the intervention in the community in Nekemte, western Ethiopia. Diabetes self​ care behaviour, quality of life, family support, glycosylated haemoglobin, body mass index, blood pressure and lipid profiles will be assessed. Descriptive statistics will summarize the sociodemographic variables of the dyads; people living with diabetes' clinical outcomes, self care behaviours, quality of life and the level of family support; family caregivers' behaviours; and the acceptability level. Cohen's d will be computed to estimate the effect size.

TRIAL REGISTRATION

The Chinese Clinical Trial Registry prospectively registered the trial, and the registration number was ChiCTR2000040292.

Educational films for improving screening and self-management of gestational diabetes in India and Uganda (GUIDES): study protocol for a cluster-randomised controlled trial

BACKGROUND

The prevalence of gestational diabetes mellitus (GDM) is rising rapidly in many low- and middle-income countries (LMICs). Most women with GDM in LMICs are undiagnosed and/or inadequately managed due to a lack of knowledge and skills about GDM on the part of both providers and patients. Following contextual analysis, we developed an educational/behavioural intervention for GDM delivered through a package of culturally tailored films. This trial aims to evaluate whether the intervention can improve the timely detection and management of GDM in two LMIC settings.

METHODS

Two independent cluster randomised controlled trials, one each to be conducted in Uganda and India. Thirty maternity facilities in each country have been recruited to the study and randomised in a 1:1 ratio to the intervention and control arms. The intervention comprises of three interconnected sets of films with the following aims: to improve knowledge of GDM guidelines and skills of health providers, to raise awareness of GDM screening among pregnant women and their families, and to improve confidence and skills in self-management among those diagnosed with GDM. In facilities randomised to the intervention arm, a GDM awareness-raising film will be shown in antenatal care waiting rooms, and four films for pregnant women with GDM will be shown in group settings and made available for viewing on mobile devices. Short films for doctors and nurses will be presented at professional development meetings. Data will be collected on approximately 10,000 pregnant women receiving care at participating facilities, with follow-up at 32 weeks gestational age and 6 weeks postnatally. Women who self-report a GDM diagnosis will be invited for a clinic visit at 34 weeks. Primary outcomes are (a) the proportion of women who report a GDM diagnosis by 32 weeks of pregnancy and (b) glycaemic control (fasting glucose and HbA1C) in women with GDM at ~34 weeks of pregnancy. The secondary outcome is a composite measure of GDM-related adverse perinatal-neonatal outcome.

DISCUSSION

Screening and management of GDM are suboptimal in most LMICs. We hypothesise that a scalable film-based intervention has the potential to improve the timely detection and management of GDM in varied LMIC settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03937050 , registered on 3 May 2019. Clinical Trials Registry India CTRI/2020/02/023605 , registered on 26 February 2020.

Diabetes comorbidities in low- and middle-income countries: An umbrella review

Background

Diabetes mellitus, particularly type 2 diabetes, is a major public health burden globally. Diabetes is known to be associated with several comorbidities in high-income countries. However, our understanding of these associations in low- and middle-income countries (LMICs), where the epidemiological transition is leading to a growing dual burden of non-communicable and communicable disease, is less clear. We therefore conducted an umbrella review to systematically identify, appraise and synthesise reviews reporting the association between diabetes and multiple key comorbidities in LMICs.

Methods

We searched Medline, Embase, Global Health, and Global Index Medicus from inception to 14 November 2020 for systematic reviews, with or without meta-analyses, of cohort, case-control or cross-sectional studies investigating the associations between diabetes and cardiovascular disease (CVD), chronic kidney disease (CKD), depression, dengue, pneumonia, and tuberculosis within LMICs. We sought reviews of studies focused on LMICs, but also included reviews with a mixture of high-income and at least two LMIC studies, extracting data from LMIC studies only. We conducted quality assessment of identified reviews using an adapted AMSTAR 2 checklist. Where appropriate, we re-ran meta-analyses to pool LMIC study estimates and conduct subgroup analyses.

Results

From 11 001 articles, we identified 14 systematic reviews on the association between diabetes and CVD, CKD, depression, or tuberculosis. We did not identify any eligible systematic reviews on diabetes and pneumonia or dengue. We included 269 studies from 29 LMICs representing over 3 943 083 participants. Diabetes was positively associated with all comorbidities, with tuberculosis having the most robust evidence (16 of 26 cohort studies identified in total) and depression being the most studied (186 of 269 studies). The majority (81%) of studies included were cross-sectional. Heterogeneity was substantial for almost all secondary meta-analyses conducted, and there were too few studies for many subgroup analyses.

Conclusions

Diabetes has been shown to be associated with several comorbidities in LMICs, but the nature of the associations is uncertain because of the large proportion of cross-sectional study designs. This demonstrates the need to conduct further primary research in LMICs, to improve, and address current gaps in, our understanding of diabetes comorbidities and complications in LMICs.

Oral Limonite Supplement Ameliorates Glucose Intolerance in Diabetic and Obese Mice

Introduction

Diabetes mellitus is a serious threat to public health worldwide. It causes a substantial economic burden, mental and physical disabilities, poor quality of life, and high mortality. Limonite is formed when iron-rich materials from the underground emerge and oxidized on the ground surface. It is currently used to purify contaminated water, absorption of irritant gases, and improve livestock breeding. Limonite can change the composition of environmental microbial communities. In the present study, we evaluated whether limonite can ameliorate glucose metabolism abnormalities by remodeling the gut microbiome.

Methods

The investigation was performed using mouse models of streptozotocin-induced diabetes mellitus and high-calorie diet-induced metabolic syndrome.

Results

Oral limonite supplement was associated with significant body weight recovery, reduced glycemia with improved insulin secretion, increased number of regulatory T cells, and abundant beneficial gut microbial populations in mice with diabetes mellitus compared to control. Similarly, mice with obesity fed with limonite supplements had significantly reduced body weight, insulin resistance, steatohepatitis, and systemic inflammatory response with significant gut microbiome remodeling.

Conclusion

This study demonstrates that limonite supplement ameliorates abnormal glucose metabolism in diabetes mellitus and obesity. Gut microbiome remodeling, inhibition of inflammatory cytokines, and the host immune response regulation may explain the limonite’s beneficial activity under pathological conditions in vivo.

Prevalence and risk factors for hypertension and diabetes among those screened in a refugee settlement in Uganda

Background

Diabetes and hypertension are increasingly prevalent in low and middle income countries, but they are not well documented in refugee settlements in these settings. We sought to estimate the prevalence and associated characteristics of diabetes and hypertension among adults presenting for clinic-based HIV testing in Nakivale Refugee Settlement in Uganda.

Methods

HIV-negative adults presenting to outpatient clinics for HIV testing at three health centers in Nakivale Refugee Settlement were enrolled from January 2019 through January 2020. Multi-lingual research assistants administered questionnaires aloud to ascertain medical history and sociodemographic information. The research assistants used standardized procedures to measure participants’ blood pressure to detect hypertension (systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg), and conduct a point-of-care blood glucose test for diabetes (random blood glucose ≥11.1 mmol/L with self-reported frequent urination or thirst, or fasting blood glucose ≥7.0 mmol/L regardless of symptoms), as per Uganda Ministry of Health guidelines. We used χ-square or Fisher’s exact test to test for differences in disease prevalence by refugee status and log-binomial or Poisson regression models to estimate associations of immigration status and country of origin, respectively, with hypertension and diabetes while controlling for age, sex, education level, and body mass index.

Results

Among 2127 participants, 1379 (65%) were refugees or asylum seekers and 748 (35%) were Ugandan nationals. Overall, 32 participants met criteria for diabetes (1.5%, 95% CI 1.1–2.1%) and the period prevalence was 2.3% (95% CI 1.7–3.0). There were 1067 (50%, 95% CI 48.0–52.2%) who met the criteria for pre-hypertension and 189 (9%, 95% CI 7.7–10.1%) for hypertension. These proportions did not vary by immigration status or country of origin in univariate tests or multivariable regression models.

Conclusions

Hypertension was common and diabetes was uncommon among those screened in a Ugandan refugee settlement. Routine blood pressure screening should be considered in this setting. Additional research could develop diabetes screening criteria to help identify at risk individuals in this limited resource setting.

The Rising Burden of Diabetes-Related Blindness: A Case for Integration of Primary Eye Care into Primary Health Care in Eswatini

There is a rampant increase in diabetes prevalence globally. Sub-Saharan Africa (SSA) is projected to carry the largest burden of diabetes (34.2 million) by 2030. This will inevitably cause a parallel increase in diabetes-associated complications; with the predominant complications being blindness due to diabetic retinopathy and diabetic cataracts. Eye programs in developing countries remain inadequate, existing as stand-alone programs, focused on the provision of acute symptomatic care at secondary and tertiary health levels. Over 60% of people with undiagnosed diabetes report to eye care facilities with already advanced retinopathy. While vision loss due to cataracts is reversible, loss of vision from diabetic retinopathy is irreversible. Developing countries have in the last two decades been significantly impacted by infectious pandemics; with SSA countries committing over 80% of their health budgets towards infectious diseases. Consequently, non-communicable diseases and eye health have been neglected. This paper aimed to highlight the importance of strengthening primary health care services to prevent diabetes-related blindness. In SSA, where economies are strained by infectious disease, the projected rise in diabetes prevalence calls for an urgent need to reorganize health systems to focus on life-long preventative and integrated measures. However, research is critical in determining how best to integrate these without further weakening health systems.

On time horizons in health economic evaluations

The issue of time horizons has received scant attention in discussions pertaining to health economic evaluations unlike discounting or translation of health outcomes into life-cycle measures (e.g. quality-adjusted life years or disability-adjusted life years). The available guidelines do not offer clear and consistent guidance for many problems addressed in health economic evaluations. In practice, variation of time horizons between studies for the same diseases is a matter of concern, as results on cost-effectiveness depend on the time horizon. Our paper contributes to establishing a consistent approach to setting time horizons across common types of health economic evaluations and mitigating potential bias where the choice of a time horizon may affect results of the evaluation. We find that available guidance is clear only for patient-focused interventions, but not in the presence of population-level effects owing to transmission of infections or other linkages. We distinguish between a policy period-over which an intervention is delivered or initiated-and an evaluation period over which the effects are measured. One important challenge in establishing a time horizon for evaluation is that, at least for infectious diseases, the state of the epidemic at the end of the policy period cannot be evaluated precisely and incorporated in the results of an economic evaluation. While longer policy periods partly mitigate this challenge, they are subject to greater uncertainty, and outcomes may not adequately reflect the cost-effectiveness of current policies because outcomes reflect an average over the policy period. Incremental analysis on interventions implemented in sub-periods of the policy period (especially at the beginning) potentially improves accuracy and helps to identify potential for improving cost-effectiveness by varying the path of implementation or the mix of interventions offered over time.

Pathogenesis, diagnosis and clinical management of diabetic sensorimotor peripheral neuropathy

Diabetic sensorimotor peripheral neuropathy (DSPN) is a serious complication of diabetes mellitus and is associated with increased mortality, lower-limb amputations and distressing painful neuropathic symptoms (painful DSPN). Our understanding of the pathophysiology of the disease has largely been derived from animal models, which have identified key potential mechanisms. However, effective therapies in preclinical models have not translated into clinical trials and we have no universally accepted disease-modifying treatments. Moreover, the condition is generally diagnosed late when irreversible nerve damage has already taken place. Innovative point-of-care devices have great potential to enable the early diagnosis of DSPN when the condition might be more amenable to treatment. The management of painful DSPN remains less than optimal; however, studies suggest that a mechanism-based approach might offer an enhanced benefit in certain pain phenotypes. The management of patients with DSPN involves the control of individualized cardiometabolic targets, a multidisciplinary approach aimed at the prevention and management of foot complications, and the timely diagnosis and management of neuropathic pain. Here, we discuss the latest advances in the mechanisms of DSPN and painful DSPN, originating both from the periphery and the central nervous system, as well as the emerging diagnostics and treatments.

Estimating the burden of cardiovascular risk in community dwellers over 40 years old in South Africa, Kenya, Burkina Faso and Ghana

Introduction

Cardiovascular disease (CVD) risk factors are increasing in sub-Saharan Africa. The impact of these risk factors on future CVD outcomes and burden is poorly understood. We examined the magnitude of modifiable risk factors, estimated future CVD risk and compared results between three commonly used 10-year CVD risk factor algorithms and their variants in four African countries.

Methods

In the Africa-Wits-INDEPTH partnership for Genomic studies (the AWI-Gen Study), 10 349 randomly sampled individuals aged 40–60 years from six sites participated in a survey, with blood pressure, blood glucose and lipid levels measured. Using these data, 10-year CVD risk estimates using Framingham, Globorisk and WHO-CVD and their office-based variants were generated. Differences in future CVD risk and results by algorithm are described using kappa and coefficients to examine agreement and correlations, respectively.

Results

The 10-year CVD risk across all participants in all sites varied from 2.6% (95% CI: 1.6% to 4.1%) using the WHO-CVD lab algorithm to 6.5% (95% CI: 3.7% to 11.4%) using the Framingham office algorithm, with substantial differences in risk between sites. The highest risk was in South African settings (in urban Soweto: 8.9% (IQR: 5.3–15.3)). Agreement between algorithms was low to moderate (kappa from 0.03 to 0.55) and correlations ranged between 0.28 and 0.70. Depending on the algorithm used, those at high risk (defined as risk of 10-year CVD event >20%) who were under treatment for a modifiable risk factor ranged from 19.2% to 33.9%, with substantial variation by both sex and site.

Conclusion

The African sites in this study are at different stages of an ongoing epidemiological transition as evidenced by both risk factor levels and estimated 10-year CVD risk. There is low correlation and disparate levels of population risk, predicted by different risk algorithms, within sites. Validating existing risk algorithms or designing context-specific 10-year CVD risk algorithms is essential for accurately defining population risk and targeting national policies and individual CVD treatment on the African continent.

The Current Situation Regarding Long-Acting Insulin Analogues Including Biosimilars Among African, Asian, European, and South American Countries; Findings and Implications for the Future

Background: Diabetes mellitus rates continue to rise, which coupled with increasing costs of associated complications has appreciably increased global expenditure in recent years. The risk of complications are enhanced by poor glycaemic control including hypoglycaemia. Long-acting insulin analogues were developed to reduce hypoglycaemia and improve adherence. Their considerably higher costs though have impacted their funding and use. Biosimilars can help reduce medicine costs. However, their introduction has been affected by a number of factors. These include the originator company dropping its price as well as promoting patented higher strength 300 IU/ml insulin glargine. There can also be concerns with different devices between the manufacturers. Objective: To assess current utilisation rates for insulins, especially long-acting insulin analogues, and the rationale for patterns seen, across multiple countries to inform strategies to enhance future utilisation of long-acting insulin analogue biosimilars to benefit all key stakeholders. Our approach: Multiple approaches including assessing the utilisation, expenditure and prices of insulins, including biosimilar insulin glargine, across multiple continents and countries. Results: There was considerable variation in the use of long-acting insulin analogues as a percentage of all insulins prescribed and dispensed across countries and continents. This ranged from limited use of long-acting insulin analogues among African countries compared to routine funding and use across Europe in view of their perceived benefits. Increasing use was also seen among Asian countries including Bangladesh and India for similar reasons. However, concerns with costs and value limited their use across Africa, Brazil and Pakistan. There was though limited use of biosimilar insulin glargine 100 IU/ml compared with other recent biosimilars especially among European countries and Korea. This was principally driven by small price differences in reality between the originator and biosimilars coupled with increasing use of the patented 300 IU/ml formulation. A number of activities were identified to enhance future biosimilar use. These included only reimbursing biosimilar long-acting insulin analogues, introducing prescribing targets and increasing competition among manufacturers including stimulating local production. Conclusions: There are concerns with the availability and use of insulin glargine biosimilars despite lower costs. This can be addressed by multiple activities.

Integration of non-communicable disease and HIV/AIDS management: a review of healthcare policies and plans in East Africa

Background

Low-income and middle-income countries are struggling to manage growing numbers of patients with chronic non-communicable diseases (NCDs), while services for patients with HIV infection are well established. There have been calls for integration of HIV and NCD services to increase efficiency and improve coverage of NCD care, although evidence of effectiveness remains unclear. In this review, we assess the extent to which National HIV and NCD policies in East Africa reflect the calls for HIV-NCD service integration.

Methods

Between April 2018 and December 2020, we searched for policies, strategies and guidelines associated with HIV and NCDs programmes in Burundi, Kenya, Rwanda, South Sudan, Tanzania and Uganda. Documents were searched manually for plans for integration of HIV and NCD services. Data were analysed qualitatively using document analysis.

Results

Thirty-one documents were screened, and 13 contained action plans for HIV and NCDs service integration. Integrated delivery of HIV and NCD care is recommended in high level health policies and treatment guidelines in four countries in the East African region; Kenya, Rwanda, Tanzania and Uganda, mostly relating to integrating NCD care into HIV programmes. The increasing burden of NCDs, as well as a move towards person-centred differentiated delivery of services for people living with HIV, is a factor in the recent adoption of integrated HIV and NCD service delivery plans. Both South Sudan and Burundi report a focus on building their healthcare infrastructure and improving coverage and quality of healthcare provision, with no reported plans for HIV and NCD care integration.

Conclusion

Despite the limited evidence of effectiveness, some East African countries have already taken steps towards HIV and NCD service integration. Close monitoring and evaluation of the integrated HIV and NCD programmes is necessary to provide insight into the associated benefits and risks, and to inform future service developments.

Enhanced virulence of Plasmodium falciparum in blood of diabetic patients

Rising prevalence of diabetes in sub-Saharan Africa, coupled with continued malaria transmission, has resulted more patients dealing with both communicable and non-communicable diseases. We previously reported that travelers with type 2 diabetes mellitus (T2DM) infected with Plasmodium falciparum were three times more likely to develop severe malaria than non-diabetics. Here we explore the biological basis for this by testing blood from uninfected subjects with type 1 and type 2 diabetes, ex vivo, for their effects on parasite growth and rosetting (binding of infected erythrocytes to uninfected erythrocytes). Rosetting was associated with type 2 diabetes, blood glucose and erythrocyte sedimentation rate (ESR), while parasite growth was positively associated with blood glucose, glycated hemoglobin (HbA1c), body mass index (BMI), fibrinogen and triglycerides. This study establishes a link between diabetes and malaria virulence assays, potentially explaining the protective effect of good glycemic control against severe malaria in subjects with diabetes.

Rapid increases in observed incidence and prevalence of Type 1 diabetes in children and youth in Mali, 2007-2016

AIMS

Determine incidence, prevalence and mortality of Type 1 diabetes (T1D) in children and youth <25 years (y) in Mali during the first 10 years of the Santé Diabète/Life for a Child program.

METHODS

Data were collected from the prospective program register. Diagnosis of T1D was clinical, based on presentation, clinical features, immediate requirement for insulin, and no suggestion of other diabetes types.

RESULTS

Total of 460 cases were diagnosed with T1D <25 years in 2007-2016. Male-to-female ratio was 1.04:1. Peak age at onset was 15-16 years (range 1.1-24 years). T1D incidence <25 years per 100,000 population/year increased from 0.12 in 2007 to 0.74 in 2016 (an 18% annualized increase, p < 0.001). Incidence peaked at 0.80 in 2014, the year after an education campaign was conducted. Incidence <15 years rose from 0.12 to 0.35 per 100,000/year in 2007 and 2016, respectively, (14% annualized increase, p < 0.001). There was a steep, consistent increase in prevalence (per 100,000) from 0.43 in 2007 to 2.90 in 2016 (p < 0.001). Prevalence <15 years was 0.34/100,000 in 2007 and 1.02/100,000 by 2016 (p < 0.001). Overall crude mortality rate was 30.0/1000 patient years, equating to a standardized mortality rate of 9.0, with vital status known for 99.8% of cases.

CONCLUSION

Known incidence and prevalence of diabetes in Mali increased rapidly from 2007 to 2016, contemporaneous with the introduction and development of the Santé Diabète/Life for a Child program. Improved diagnosis and care resulting in lower mortality are likely contributors. True incidence may still be underestimated, with some cases still dying undiagnosed and full study ascertainment being uncertain.

A global perspective on the issue of access to insulin

The discovery of insulin in 1921 changed the prognosis for people with type 1 diabetes. A century later, availability and affordability of insulin remain a challenge in many parts of the globe. Using the WHO's framework on understanding the life cycle of medicines, this review details the global and national challenges that affect patients' abilities to access and afford insulin. Current research and development in diabetes has seen some innovations, but none of these have truly been game-changing. Currently, three multinational companies control over 95% of global insulin supply. The inclusion of insulin on the WHO's Prequalification Programme is an opportunity to facilitate entry of new companies into the market. Many governments lack policies on the selection, procurement, supply, pricing and reimbursement of insulin. Moreover, mark-ups in the supply chain also affect the final price to the consumer. Whilst expenses related to diabetes are mostly covered by insurance in high-income countries, many patients from low- and middle-income countries have to pay out of their own pockets. The organisation of diabetes management within the healthcare system also affects patient access to insulin. The challenges affecting access to insulin are complex and require a wide range of solutions. Given that 2021 marks the centenary of the discovery of insulin, there is need for global advocacy to ensure that the benefits of insulin and innovations in diabetes care reach all individuals living with diabetes.

Seeding COVID-19 across Sub-Saharan Africa: An Analysis of Reported Importation Events across 49 Countries

The first case of COVID-19 in sub-Saharan Africa (SSA) was reported by Nigeria on February 27, 2020. Whereas case counts in the entire region remain considerably less than those being reported by individual countries in Europe, Asia, and the Americas, variation in preparedness and response capacity as well as in data availability has raised concerns about undetected transmission events in the SSA region. To capture epidemiological details related to early transmission events into and within countries, a line list was developed from publicly available data on institutional websites, situation reports, press releases, and social media accounts. The availability of indicators-gender, age, travel history, date of arrival in country, reporting date of confirmation, and how detected-for each imported case was assessed. We evaluated the relationship between the time to first reported importation and the Global Health Security Index (GHSI) overall score; 13,201 confirmed cases of COVID-19 were reported by 48 countries in SSA during the 54 days following the first known introduction to the region. Of the 2,516 cases for which travel history information was publicly available, 1,129 (44.9%) were considered importation events. Imported cases tended to be male (65.0%), with a median age of 41.0 years (range: 6 weeks-88 years; IQR: 31-54 years). A country's time to report its first importation was not related to the GHSI overall score, after controlling for air traffic. Countries in SSA generally reported with less publicly available detail over time and tended to have greater information on imported than local cases.

Predictors of severe hypoxemia among COVID-19 patients in Burkina Faso (West Africa): Findings from hospital based cross-sectional study

Introduction

COVID-19 is one of the world’s major health crises. The objective of this study was to determine the predictive factors of severe hypoxemia in patients hospitalized in COVID-19 health facilities in Burkina Faso.

Patients and method

This study was a hospital-based cross-sectional study. The data collected relate to the period of the first wave of the epidemic (March 9 to June 30, 2020). All patients hospitalized for COVID-19 in the requisitioned health facilities of Ouagadougou were included in this study. Predictors of severe hypoxemia were identified using a multivariate logistic regression model.

Results

During the study period, 442 patients were included, representing 45.7% of the total number of positive patients in the entire country. The most common co-morbidities were diabetes (55; 12.4%) and arterial hypertension (97; 21.9%). Severe hypoxemia (SpO2 < 90%) was observed in 64 patients (14.5%). Age over 65 years (OR = 8.24; 95% CI: 2.83–24.01) and diabetes (OR = 2.43; 95% CI: 1.17–5.06) were the predictors for occurrence of severe hypoxemia in multivariate analysis.

Conclusion

The predictive factors of COVID-19 are similar in African and Caucasian populations. The surveillance of COVID-19 in risk groups should be strengthened to reduce their morbidity and mortality.

Pathways to Care for Patients With Type 2 Diabetes and HIV/AIDS Comorbidities in Soweto, South Africa: An Ethnographic Study

Patients with type 2 diabetes are referred to tertiary hospitals in Soweto although their care could be managed at primary health care clinics. Primary health care needs to be strengthened by addressing health systemic challenges to provide integrated care for comorbid type 2 diabetes and HIV/AIDS.

Background:

South Africa is experiencing colliding epidemics of HIV/AIDS and noncommunicable diseases. In response, the National Department of Health has implemented integrated chronic disease management aimed at strengthening primary health care (PHC) facilities to manage chronic illnesses. However, chronic care is still fragmented. This study explored how the health system functions to care for patients with comorbid type 2 diabetes (T2DM) and HIV/AIDS at a tertiary hospital in Soweto, South Africa.

Methods:

We employed ethnographic methods encompassing clinical observations and qualitative interviews with health care providers at the hospital (n=30). Data were transcribed verbatim and thematically analyzed using QSR NVivo 12 software.

Findings:

Health systemic challenges such as the lack of medication, untrained nurses, and a limited number of doctors at PHC clinics necessitated patient referrals to a tertiary hospital. At the hospital, patients with T2DM were managed first at the medical outpatient clinic before they were referred to a specialty clinic. Those with comorbidities attended different clinics at the hospital partly due to the structure of the tertiary hospital that offers specialized care. In addition, little to no collaboration occurred among health care providers due to poor communication, noncentralized patient information, and staff shortage. As a result, patients experienced disjointed care.

Conclusion:

PHC clinics in Soweto need to be strengthened by training nurses to diagnose and manage patients with T2DM and also by ensuring adequate medical supplies. We recommend that the medical outpatient clinic at a tertiary hospital should also be strengthened to offer integrated and collaborative care to patients with T2DM and other comorbidities. Addressing key systemic challenges such as staff shortages and noncentralized patient information will create a patient-centered as opposed to disease-specific approach to care.

Glycemic control and complications of type 1 diabetes among children in Tanzania

Introduction

Knowledge on Type 1 Diabetes (T1D) in sub-Saharan Africa is scarce. This study aimed at assessing microvascular complications of Type 1 diabetes in young patients.

Method

A retrospective study based on medical recordings from 2010–2016 was done. 604 children and young adults with T1D were recruited from five hospitals with pediatric diabetes clinics. 559 patients aged 2–35 years with known date of birth were included. Clinical data on retinopathy and neuropathy were analyzed. There was no information on renal function/ nephropathy.

Results

Most data were missing. There was documentation on HbA1C, plasma glucose and complications in less than half of the patient files. Of those with registered HbA1c values (42.2%), 36% had HbA1c > 12.5%. There was high prevalence of retinopathy (21.5%) and neuropathy (29.4%) in spite of short mean duration of diabetes (6.2 ± 4.1 years).

Conclusion

Many patients with T1D in Tanzania have poor metabolic control. Microvascular complications are common already after a short duration of diabetes, but the results have to be interpreted with great caution because of study limitations. Better pediatric diabetes care as well as increased awareness of diabetes is needed. Studies in resource-poor countries need careful planning, if possible with prospective design.

The clinical profiles and outcomes of HIV-negative cryptococcal meningitis patients in type II diabetes mellitus

Background

The clinical profiles and outcomes of cryptococcal meningitis have been shown to vary depending on the underlying condition. The aim of this study was to investigate clinical characteristics and outcomes in patients with and without type II diabetes mellitus.

Methods

A retrospective study was performed. Clinical data of HIV-negative cryptococcal meningitis patients with type II diabetes mellitus (n = 26) and without type II diabetes mellitus (n = 52) referring to the Jiangxi Chest Hospital between January 2012 to December 2018 were analyzed. The data were analyzed using chi square, none-parametric tests, and logistic regression. P-values < 0.05 were considered significant.

Results

In this study, cryptococcal meningitis patients suffering from type II diabetes mellitus had a higher mortality (23.08% vs. 7.69%; P = 0.055), and required longer hospitalization (59.58 vs. 42.88 days; P = 0.132). Moreover, cerebrospinal fluid examinations revealed that cryptococcal meningitis patients with type II diabetes mellitus had higher opening pressure (271.54 vs. 234.23 mmH₂O; P = 0.125).The results of multivariate regression analysis revealed that cryptococcal meningitis patients with type II diabetes were more often presented with visual disorders (28.54% vs. 11.54%; [95% CI 0.056–0.705]; p = 0.012), and had higher cerebrospinal fluid protein levels (1027.62 ± 594.16 vs. 705.72 ± 373.88 mg/l; [95% CI 1.000–1.002]; p = 0.016). Among patients with type II diabetes mellitus, nausea and vomiting was more frequent at the initial visit in those died (100% vs. 50%; p = 0.027), and 66% of died type II diabetes mellitus patients were poorly controlled blood glucose level, compared with 30% in survival type II diabetes mellitus patients.

Conclusion

This study suggests that cryptococcal meningitis patients with type II diabetes mellitus differ significantly from cryptococcal meningitis patients without type II diabetes mellitus with respect to clinical symptoms such as visual disorders and cerebrospinal fluid examination. The presence of nausea and vomiting among type II diabetes mellitus patients could have implication in mortality.

Non-adherence to self-care and associated factors among diabetes adult population in Ethiopian: A systemic review with meta-analysis

BACKGROUND

Self-care practice among people with diabetes is not well-implemented in Ethiopia. So far, in Ethiopia, several observational studies have been done on self-care practice and its determinants in people with diabetes. However, a comprehensive review that would have a lot of strong evidence for designing intervention is lacking. So, this review with a meta-analysis was conducted to bridge this gap.

METHODS

A systematic review of an observational study is conducted following the PRISMA checklist. Three reviewers have been searched and extracted from the World Health Organization's Hinari portal (SCOPUS, African Index Medicus, and African Journals Online databases), PubMed, Google Scholar and EMBASE. Articles' quality was assessed using the Newcastle-Ottawa Scale by two independent reviewers, and only studies with low and moderate risk were included in the final analysis. The review presented the pooled proportion of non-adherence to self-care practice in people with diabetes and the odds ratios of risk factors hindering to self-care practice after checking for heterogeneity and publication bias. The review has been registered in PROSPERO with protocol number CRD 42020149478.

RESULTS

We included 21 primary studies (with 7,134 participants) in this meta-analysis. The pooled proportion of non-adherence to self-care in the diabetes population was 49.91 (95% CI: 44.73-55.08, I2 = 89.8%). Male (Pooled Odds Ratio (POR): 1.84 95%CI; 1.04-2.64, I2 = 15.0%), having private glucometer (POR: 2.71; 95%CI: 1.46-3.95, I2 = 0.0%), short-term Diabetes Mellitus (DM) duration (POR: 3.69; 95%CI: 1.86-5.52, I2 = 0.0%), DM complication (POR: 2.22; 95%CI: 1.48-2.95, I2 = 0.0%), treatment satisfaction (POR: 1.8; 95% CI: 1.15-2.44, I2 = 0.0%), received diabetes self-management education (POR: 2.71; 95% CI: 1.46-3.95, I2 = 0.0%) and poor self-efficacy (POR: 3.09; 95% CI: 1.70-4.48, I2 = 0.0%) were statistically significant factors of non-adherence to self-care practice.

CONCLUSIONS

The overall pooled proportion of non-adherence to self-care among adult diabetes in Ethiopia was high. Further works would be needed to improve self-care practice in the diabetes population. So, factors that were identified might help to revise the plan set by the country, and further research might be required to health facility fidelity and each domain of self-care practice according to diabetes self-management guideline.

Implementation and evaluation of a specialized diabetes clinic in Guinea-Bissau: lessons learnt from the field

Introduction

diabetes care in Guinea-Bissau (GB) is characterized by a lack of properly trained healthcare professionals (HCPs) and guidelines for diagnosis, treatment and follow up of patients. To address these issues, this project was launched with the objective to train HCPs in the management of diabetic patients and establish a specialized diabetes clinic in the Hospital Nacional Simão Mendes, a public tertiary care hospital in Bissau, capital of GB. This project is led by the Geneva University Hospitals (HUG) in collaboration with the Swiss Association for the Aid to Diabetic People in Guinea-Bissau, with the support of the International Solidairty Office (SSI) of the State of Geneva, and AIDA (Ayuda, Intercambio y Desarrollo).

Methods

specialists from the HUG in collaboration with local experts in GB developed and delivered a culturally and contextually adapted training course pertaining to diabetes care to HCPs in this hospital. Pre and post training tests were conducted to assess differences in knowledge and practices. Following the training program, a diabetes clinic was set up and an audit was conducted to assess its performance.

Results

a total of 24 HCP attended the training program and exhibited statistically significant improvements in their knowledge pertaining to diabetes care (mean difference between pre and post-test = 14.53, SD 11.60, t=-4.8, p < 0.001). The diabetes clinic was established and provided consultations 2 days per week. A total of 63 patients consulted at this clinic, of which 49 had type two diabetes treated with oral antidiabetic drugs and 14 were type 1 diabetics treated with insulin. Patients had blood glucose measurements and received therapeutic, dietary and physical activity counselling. Several barriers leading to occasional interruptions of service were encountered, including a political instability in the country and strikes of healthcare staff demanding better wages and working conditions.

Conclusion:

this study delineates the feasibility of setting up a diabetes consultation clinic in GB despite important barriers. To ensure successful running of such consultation clinics, continued buy-in and support from stakeholders should be ensured. Diabetes training should be incorporated in pre-and post-graduate training curriculums of all HCP to help shape a better workforce.

Designing an integrated, nurse-driven and home-based digital intervention to improve insulin management in under-resourced settings

BACKGROUND

In South Africa, initiating insulin for people with type 2 diabetes and subsequent titration is a major challenge for the resource-constrained healthcare system. Inadequate support systems in primary care, including not being able to access blood glucose monitors and test strips for self-monitoring of blood glucose, results in patients with type 2 diabetes being referred to higher levels of care. In primary care, initiation of insulin may be delayed due to a shortage of healthcare workers. The delayed initiation of insulin is also exacerbated by the reported resistance of both healthcare providers and people with type 2 diabetes to start insulin. In South Africa, telehealth provides an opportunity to overcome these challenges and manage insulin therapy in primary care.

METHODS

We describe the development of a digital health intervention including the framework used, the theoretical approach and subsequent implementation strategies.

RESULTS

This intervention is an innovative, nurse-driven and app-enabled intervention called 'the Tshwane Insulin Project intervention'. The Tshwane Insulin Project intervention was designed and evaluated using the framework recommended by the Medical Research Council for complex interventions. The Tshwane Insulin Project intervention was developed in four sequential phases: planning, design, implementation and evaluation. The Tshwane Insulin Project intervention followed the Integrated Chronic Disease Management framework to facilitate implementation and acceptability. The Tshwane Insulin Project comprises a facility-level intervention, where nurses evaluate patients and initiate insulin, an individual-level intervention where community healthcare workers visit patients at their homes to follow-up and provide educational information, while using telehealth to enable physician-directed insulin titration if needed, and a community-level intervention aimed at empowering community healthcare workers to support people living with diabetes and raise awareness of diabetes.

CONCLUSION

The technological advancements in digital health and telemedicine present an opportunity to improve diabetes care in resource-limited countries. This work can inform those intending to develop and implement complex interventions in primary healthcare in developing countries.

African Cuisine-Centered Insulin Therapy: Expert Opinion on the Management of Hyperglycaemia in Adult Patients with Type 2 Diabetes Mellitus

The prevalence of diabetes in sub-Saharan Africa (SSA) is growing rapidly, and a steadily increasing number of adults are estimated to be living with type 2 diabetes mellitus (T2DM). Insulin therapy is the treatment of choice in patients who present with severe hyperglycaemia and in most of those who do not achieve target goals on oral hypoglycaemic agents. Initiating treatment with the appropriate type of insulin based on the meal patterns and lifestyle of the individual patient is a strategy that is more likely than others to improve glycaemic control and adherence. African cuisine typically has a high carbohydrate load. Given these predominantly carbohydrate-rich food habits, it is essential to modify this dietary pattern whilst at the same time ensuring that insulin therapy is initiated, titrated and maintained in a timely manner, as needed to suit the patient's habits. To date, there are no published clinical guidelines to guide practitioners and patients on tailoring insulin to match the high carbohydrate content in African cuisine. To address this gap, we have reviewed current insulin therapy practices and propose a patient-centric guide to insulin therapy based on African cuisine. A literature search was conducted for studies published in English up to November 2019 that focused on the choice of insulin and its dosing in relation to African foods. All articles extracted were reviewed by an expert group. The recommendation of the expert group was that basal-bolus and premix insulin regimens are best suited to manage post-meal glycaemia in African cuisine. The timing and constituents of the meal, portion sizes, glycaemic load and glycaemic index of meals should be considered when choosing the type of insulin and insulin regimen. Assessment of individual preferences and comorbidities should be prioritised and form an integral part of diabetes management.

Ischaemic heart disease, stroke, and their cardiometabolic risk factors in Africa: current challenges and outlook for the future

INTRODUCTION

Although cardiovascular diseases (CVDs) are among the leading causes of death in Sub-Saharan Africa (SSA), prevention is not a priority and effective treatments are not widely available. This perspective discusses the burden, challenges, and potential opportunities for improvement of CVD prevention and control efforts in SSA.

AREAS COVERED

This paper focuses on ischemic heart disease and stroke, and their key contributors of obesity, hypertension, diabetes and dyslipidaemia which are well-established, rapidly rising, and significant contributors to disease burden in SSA. However, their prevention, detection, treatment and control of are currently disorganized, inconsistent, unreliable, and insufficient with most SSA countries not geared to respond to this growing problem. National policies are frequently lacking or, if available, remain poorly implemented, for the control of these conditions. Primary healthcare systems have not adapted to cope with these rising CVD burdens and remain weak, underfunded and under resourced. Numerous barriers at the healthcare service, healthcare provider, and patient levels prevent optimal CVD risk factor care.

EXPERT OPINION

Innovative approaches such as task-shifting with the reallocation of care to lower-level healthcare workers and the potential use of inexpensive technological options should be encouraged to provide equitable CVD preventive and curative solutions to SSA's poor.

Knowledge and understanding of cardiovascular disease risk factors in Sierra Leone: a qualitative study of patients' and community leaders' perceptions

OBJECTIVES

Prevalence of cardiovascular disease risk factors (CVDRF) is increasing, especially in low-income countries. In Sierra Leone, there are no previous studies on the knowledge and the awareness of these conditions in the community. This study aimed to explore the knowledge and understanding of CVDRF, as well as the perceptions of the barriers and facilitators to accessing care for these conditions, among patients and community leaders in Sierra Leone.

DESIGN

Qualitative study employing semistructured interviews and focus group discussions.

SETTING

Urban and rural Bo District, Sierra Leone.

PARTICIPANTS

Interviews with a purposive sample of 37 patients and two focus groups with six to nine community leaders.

RESULTS

While participants possessed general knowledge of their conditions, the level and complexity of this knowledge varied widely. There were clear gaps in knowledge regarding the coexistence of CVDRF and their consequences, as well as the link between behavioural factors and CVDRF. An overarching theme from the data was the need to create an understanding and awareness of CVDRF in the community in order to prevent and improve management of these conditions. Cost was also seen as a major barrier to accessing care for CVDRFs.

CONCLUSIONS

The knowledge gaps identified in this study highlight the need to design strategies and interventions that improve knowledge and recognition of CVDRF in the community. Interventions should specifically consider how to develop and enhance awareness about CVDRF and their consequences. They should also consider how patients seek help and where they access it.

Level of glycemic control and its associated factors among type II diabetic patients in debre tabor general hospital, northwest Ethiopia

INTRODUCTION

Poor glycemic control is the major risk factor for the development of acute and chronic diabetes complications. There are limited studies on the level of glycemic control and its associated factors among diabetic patients. So, this study aimed to assess the level of glycemic control and its associated factors among type II DM patients in Debre Tabor General Hospital.

METHODS

An institution based cross sectional study was conducted from November 1-30, 2017. Totally, 413 diabetic patients selected by systematic random sampling. The three months average fasting blood glucose was used to determine glycemic control. Regressions were fitted to identify associated factors. A p-value <0.05 was used to declare statistical significance.

RESULT

A total of 398 study participants were participated in the study with a response rate of 96.4%. Among 398 type II DM patients, 284 (71.4%) had poor glycemic control. Patient's educational status (able to read and write; AOR = 3.0, 95%CI (1.5, 5.7), (primary education; AOR = 4.5, 95%CI (1.8, 10.9), and (secondary education; AOR = 5.7, 95% CI (2.9, 11.2)))), family history of DM (AOR = 2.3, 95%CI (1.4, 3.9)), duration of DM since diagnosis (AOR = 0.3, 95% CI (0.1, 0.9)), and dietary adherence (AOR = 2.4, 95% CI (1.4, 4.1)) were associated factors to had good glycemic control.

CONCLUSION

Poor glycemic control was high. Educational status, family history of DM, duration of DM, and dietary adherence were the associated factors of glycemic control. Appropriate attention shall be given for glycemic control especially for patients with a longer duration. Health promotion related to medical recommendations is a cross-cutting intervention for diabetic patients and should be provided for all type II diabetic patients.

Telemedicine to deliver diabetes care in low- and middle-income countries: a systematic review and meta-analysis

Objective

To determine the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries.

Methods

We searched seven databases up to July 2020 for randomized controlled trials investigating the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries. We extracted data on the study characteristics, primary end-points and effect sizes of outcomes. Using random effects analyses, we ran a series of meta-analyses for both biochemical outcomes and related patient properties.

Findings

We included 31 interventions in our meta-analysis. We observed significant standardized mean differences of −0.38 for glycated haemoglobin (95% confidence interval, CI: −0.52 to −0.23; I² = 86.70%), −0.20 for fasting blood sugar (95% CI: −0.32 to −0.08; I² = 64.28%), 0.81 for adherence to treatment (95% CI: 0.19 to 1.42; I² = 93.75%), 0.55 for diabetes knowledge (95% CI: −0.10 to 1.20; I² = 92.65%) and 1.68 for self-efficacy (95% CI: 1.06 to 2.30; I² = 97.15%). We observed no significant treatment effects for other outcomes, with standardized mean differences of −0.04 for body mass index (95% CI: −0.13 to 0.05; I² = 35.94%), −0.06 for total cholesterol (95% CI: −0.16 to 0.04; I² = 59.93%) and −0.02 for triglycerides (95% CI: −0.12 to 0.09; I² = 0%). Interventions via telephone and short message service yielded the highest treatment effects compared with services based on telemetry and smartphone applications.

Conclusion

Although we determined that telemedicine is effective in improving several diabetes-related outcomes, the certainty of evidence was very low due to substantial heterogeneity and risk of bias.

Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: A multicountry analysis of survey data

BACKGROUND

Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care.

METHODS AND FINDINGS

We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes.

CONCLUSION

In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

Health system interventions for adults with type 2 diabetes in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Effective health system interventions may help address the disproportionate burden of diabetes in low- and middle-income countries (LMICs). We assessed the impact of health system interventions to improve outcomes for adults with type 2 diabetes in LMICs.

METHODS AND FINDINGS

We searched Ovid MEDLINE, Cochrane Library, EMBASE, African Index Medicus, LILACS, and Global Index Medicus from inception of each database through February 24, 2020. We included randomized controlled trials (RCTs) of health system interventions targeting adults with type 2 diabetes in LMICs. Eligible studies reported at least 1 of the following outcomes: glycemic change, mortality, quality of life, or cost-effectiveness. We conducted a meta-analysis for the glycemic outcome of hemoglobin A1c (HbA1c). GRADE and Cochrane Effective Practice and Organisation of Care methods were used to assess risk of bias for the glycemic outcome and to prepare a summary of findings table. Of the 12,921 references identified in searches, we included 39 studies in the narrative review of which 19 were cluster RCTs and 20 were individual RCTs. The greatest number of studies were conducted in the East Asia and Pacific region (n = 20) followed by South Asia (n = 7). There were 21,080 total participants enrolled across included studies and 10,060 total participants in the meta-analysis of HbA1c when accounting for the design effect of cluster RCTs. Non-glycemic outcomes of mortality, health-related quality of life, and cost-effectiveness had sparse data availability that precluded quantitative pooling. In the meta-analysis of HbA1c from 35 of the included studies, the mean difference was -0.46% (95% CI -0.60% to -0.31%, I2 87.8%, p < 0.001) overall, -0.37% (95% CI -0.64% to -0.10%, I2 60.0%, n = 7, p = 0.020) in multicomponent clinic-based interventions, -0.87% (-1.20% to -0.53%, I2 91.0%, n = 13, p < 0.001) in pharmacist task-sharing studies, and -0.27% (-0.50% to -0.04%, I2 64.1%, n = 7, p = 0.010) in trials of diabetes education or support alone. Other types of interventions had few included studies. Eight studies were at low risk of bias for the summary assessment of glycemic control, 15 studies were at unclear risk, and 16 studies were at high risk. The certainty of evidence for glycemic control by subgroup was moderate for multicomponent clinic-based interventions but was low or very low for other intervention types. Limitations include the lack of consensus definitions for health system interventions, differences in the quality of underlying studies, and sparse data availability for non-glycemic outcomes.

CONCLUSIONS

In this meta-analysis, we found that health system interventions for type 2 diabetes may be effective in improving glycemic control in LMICs, but few studies are available from rural areas or low- or lower-middle-income countries. Multicomponent clinic-based interventions had the strongest evidence for glycemic benefit among intervention types. Further research is needed to assess non-glycemic outcomes and to study implementation in rural and low-income settings.

Strengthening integration of chronic care in Africa: protocol for the qualitative process evaluation of integrated HIV, diabetes and hypertension care in a cluster randomised controlled trial in Tanzania and Uganda

INTRODUCTION

In sub-Saharan Africa, the burden of non-communicable diseases (NCDs), particularly diabetes mellitus (DM) and hypertension, has increased rapidly in recent years, although HIV infection remains a leading cause of death among young-middle-aged adults. Health service coverage for NCDs remains very low in contrast to HIV, despite the increasing prevalence of comorbidity of NCDs with HIV. There is an urgent need to expand healthcare capacity to provide integrated services to address these chronic conditions.

METHODS AND ANALYSIS

This protocol describes procedures for a qualitative process evaluation of INTE-AFRICA, a cluster randomised trial comparing integrated health service provision for HIV infection, DM and hypertension, to the current stand-alone vertical care. Interviews, focus group discussions and observations of consultations and other care processes in two clinics (in Tanzania, Uganda) will be used to explore the experiences of stakeholders. These stakeholders will include health service users, policy-makers, healthcare providers, community leaders and members, researchers, non-governmental and international organisations. The exploration will be carried out during the implementation of the project, alongside an understanding of the impact of broader structural and contextual factors.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Liverpool School of Tropical Medicine (UK), the National Institute of Medical Research (Tanzania) and TASO Research Ethics Committee (Uganda) in 2020. The evaluation will provide the opportunity to document the implementation of integration over several timepoints (6, 12 and 18 months) and refine integrated service provision prior to scale up. This synergistic approach to evaluate, understand and respond will support service integration and inform monitoring, policy and practice development efforts to involve and educate communities in Tanzania and Uganda. It will create a model of care and a platform of good practices and lessons learnt for other countries implementing integrated and decentralised community health services.

TRIAL REGISTRATION NUMBER

ISRCTN43896688; Pre-results.

Identifying Africans with undiagnosed diabetes: Fasting plasma glucose is similar to the hemoglobin A1C updated Atherosclerosis Risk in Communities diabetes prediction equation

AIMS

Seventy percent of Africans living with diabetes are undiagnosed. Identifying who should be referred for testing is critical. Therefore we evaluated the ability of the Atherosclerosis Risk in Communities (ARIC) diabetes prediction equation with A1C added (ARIC + A1C) to identify diabetes in 451 African-born blacks living in America (66% male; age 38 ± 10y (mean ± SD); BMI 27.5 ± 4.4 kg/m²).

METHODS

All participants denied a history of diabetes. OGTTs were performed. Diabetes diagnosis required 2-h glucose ≥200 mg/dL. The five non-invasive (Age, parent history of diabetes, waist circumference, height, systolic blood pressure) and four invasive variables (Fasting glucose (FPG), A1C, triglycerides (TG), HDL) were obtained. Four models were tested: Model-1: Full ARIC + A1C equation; Model-2: All five non-invasive variables with one invasive variable excluded at a time; Model-3: All five non-invasive variables with one invasive variable included at a time; Model-4: Each invasive variable singly. Area under the receiver operator characteristic curve (AROC) predicted diabetes. Youden Index identified optimal cut-points.

RESULTS

Diabetes occurred in 7% (30/451). Model-1, the full ARIC + A1C equation, AROC = 0.83. Model-2: With FPG excluded, AROC = 0.77 (P = 0.038), but when A1C, HDL or TG were excluded AROC remained unchanged. Model-3 with all non-invasive variables and FPG alone, AROC=0.87; but with A1C, TG or HDL included AROC declined to ≤0.76. Model-4: FPG as a single predictor, AROC = 0.87. A1C, TG, or HDL as single predictors all had AROC ≤ 0.74. Optimal cut-point for FPG was 100 mg/dL.

CONCLUSIONS

To detect diabetes, FPG performed as well as the nine-variable updated ARIC + A1C equation.

Effect of diabetes mellitus on TB drug concentrations in Tanzanian patients

BACKGROUND

Diabetes mellitus (DM) is associated with poor TB treatment outcome. Previous studies examining the effect of DM on TB drug concentrations yielded conflicting results. No studies have been conducted to date in an African population.

OBJECTIVES

To compare exposure to TB drugs in Tanzanian TB patients with and without DM.

PATIENTS AND METHODS

A prospective pharmacokinetic study was performed among 20 diabetic and 20 non-diabetic Tanzanian TB patients during the intensive phase of TB treatment. Plasma pharmacokinetic parameters of isoniazid, rifampicin, pyrazinamide and ethambutol were compared using an independent-sample t-test on log-transformed data. Multiple linear regression analysis was performed to assess the effects of DM, gender, age, weight, HIV status and acetylator status on exposure to TB drugs.

RESULTS

A trend was shown for 25% lower total exposure (AUC0-24) to rifampicin among diabetics versus non-diabetics (29.9 versus 39.9 mg·h/L, P=0.052). The AUC0-24 and peak concentration (Cmax) of isoniazid were also lower in diabetic TB patients (5.4 versus 10.6 mg·h/L, P=0.015 and 1.6 versus 2.8 mg/L, P=0.013). Pyrazinamide AUC0-24 and Cmax values were non-significantly lower among diabetics (P=0.08 and 0.09). In multivariate analyses, DM remained an independent predictor of exposure to isoniazid and rifampicin, next to acetylator status for isoniazid.

CONCLUSIONS

There is a need for individualized dosing of isoniazid and rifampicin based on plasma concentration measurements (therapeutic drug monitoring) and for clinical trials on higher doses of these TB drugs in patients with TB and DM.

Integrated care for human immunodeficiency virus, diabetes and hypertension in Africa

The rising burden from non-communicable diseases (NCDs) poses a huge challenge for health care delivery in Africa, where health systems are already struggling with the long-term care requirements for the millions of people now on antiretroviral therapy requiring regular visits to health facilities for monitoring, adherence support and drugs. The HIV chronic disease management programme is comparatively well-funded, well-organised and well-informed and offers many insights and opportunities for the expansion of NCD prevention and treatment services. Some degree of human immunodeficiency virus (HIV) and NCD service integration is essential, but how to do this without risking the HIV treatment gains is unclear. Both HIV and NCD services must expand within a resource-constrained environment and policymakers are in urgent need of evidence to guide cost-effective and acceptable changes in these health services.

Spreading of SARS-CoV-2 in West Africa and assessment of risk factors

Although the African continent is, for the moment, less impacted than the rest of the world, it still faces the risk of a spread of COVID-19. In this study, we have conducted a systematic review of the information available in the literature in order to provide an overview of the epidemiological and clinical features of COVID-19 pandemic in West Africa and of the impact of risk factors such as comorbidities, climatic conditions and demography on the pandemic. Burkina Faso is used as a case study to better describe the situation in West Africa. The epidemiological situation of COVID-19 in West Africa is marked by a continuous increase in the numbers of confirmed cases. This geographic area had on 29 July 2020, 131 049 confirmed cases by polymerase chain reaction, 88 305 recoveries and 2102 deaths. Several factors may influence the SARS-CoV-2 circulation in Africa: (i) comorbidities: diabetes mellitus and high blood pressure could lead to an increase in the number of severe cases of SARS-CoV-2; (ii) climatic factors: the high temperatures could be a factor contributing to slow the spread of the virus and (iii) demography: the West Africa population is very young and this could be a factor limiting the occurrence of severe forms of SARS-CoV-2 infection. Although the spread of the SARS-CoV-2 epidemic in West Africa is relatively slow compared to European countries, vigilance must remain. Difficulties in access to diagnostic tests, lack of hospital equipment, but also the large number of people working in the informal sector (such as trading, businesses, transport and restoration) makes it difficult to apply preventive measures, namely physical distancing and containment.

Hypertension and diabetes in Zanzibar - prevalence and access to care

BACKGROUND

Cardiovascular diseases are among the most common causes of hospital admissions and deaths in Zanzibar. This study assessed prevalence of, and antecedent factors and care access for the two common cardiovascular risk factors, hypertension and diabetes, to support health system improvements.

METHODS

Data was from a population based nationally representative survey. Prevalence of hypertension was defined as systolic blood pressure ≥ 140 mmHg, diastolic blood pressure ≥ 90 mmHg or a self-reported diagnosis of hypertension; diabetes was defined as a fasting blood glucose ≥6.1 mmol/L or a self-reported diagnosis of diabetes. Care-cascades for hypertension and diabetes were created with four stages: being tested, diagnosed, treated, and achieving control. Multivariable logistic regression models were constructed to evaluate individual-level factors - including symptoms of mental illness - associated with having hypertension or diabetes, and with progressing through the hypertension care cascade. Whether people at overt increased risk of hypertension or diabetes (defined as > 50 years old, BMI > 30 kg/m2, or currently smoking) were more likely to be tested was assessed using chi squared.

RESULTS

Prevalence of hypertension was 33.5% (CI 30.6-36.5). Older age (OR 7.7, CI 4.93-12.02), some education (OR 0.6, CI 0.44-0.89), obesity (OR 3.1, CI 2.12-4.44), and raised fasting blood glucose (OR 2.4, CI 2.38) were significantly independently associated with hypertension. Only 10.9% (CI 8.6-13.8) of the entire hypertensive population achieved blood pressure control, associated factors were being female (OR 4.8, CI 2.33-9.88), formally employed (OR 3.0, CI 1.26-7.17), and overweight (OR 2.5, CI 1.29-4.76). The prevalence of diabetes was 4.4% (CI 3.4-5.5), and associated with old age (OR 14.1, CI 6.05-32.65) and almost significantly with obesity (OR 2.1, CI 1.00-4.37). Only 11.9% (CI 6.6-20.6) of the diabetic population had achieved control. Individuals at overt increased risk were more likely to have been tested for hypertension (chi2 19.4) or diabetes (chi2 33.2) compared to the rest of the population. Symptoms of mental illness were not associated with prevalence of disease or progress through the cascade.

CONCLUSION

High prevalence of hypertension and suboptimal management along the care cascades indicates a large unmet need for hypertension and diabetes care in Zanzibar.

Pathogenesis of type 2 diabetes risk in black Africans: a South African perspective

The prevalence of type 2 diabetes (T2D) is higher in black Africans than their European counterparts. This review summarizes the research exploring the pathogenesis of T2D in populations of African ancestry compared to white Europeans and shows that the pathogenesis differs by ethnicity. Black Africans present with a phenotype of low insulin sensitivity and hyperinsulinaemia as a result of increased insulin secretion and reduced hepatic insulin clearance. Whether hyperinsulinaemia precedes insulin resistance or is merely a compensatory mechanism is yet to be determined. Black Africans have lower visceral adipose tissue and ectopic fat deposition and greater peripheral (gluteo-femoral) fat deposition than their European counterparts. This suggests that black Africans are more sensitive to the effects of ectopic fat deposition, or alternatively, that ectopic fat is not an important mediator of T2D in black Africans. Importantly, ethnic disparities in T2D risk factors may be confounded by differences in sociocultural and lifestyle factors. Future longitudinal and dietary intervention studies, in combination with genetic analyses, are needed for a better understanding of the pathophysiology of T2D in black Africans. This will be key for effective prevention and management strategies.

Chronic care service delivery models for people living with type 1 diabetes in low- and lower-middle income countries: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to map the published literature that describes the distribution and organization of chronic care service delivery models for people living with type 1 diabetes (PLWT1D) in low- and lower-middle-income countries (LLMICs).

INTRODUCTION

Type 1 diabetes is an autoimmune condition commonly diagnosed in childhood and early adolescence; it cannot be prevented and is deadly without daily insulin injections. Among PLWT1D, the islet cells in the pancreas produce insufficient amounts of the glucose-regulating hormone, insulin, resulting in the need for chronic insulin replacement therapy. Epidemiological information regarding type 1 diabetes (T1D) is limited in LLMICs. Improving survival for PLWT1D in LLMICs requires early diagnosis and greater access to high quality chronic care service delivery models for T1D. The identification and reporting of service delivery model typologies for PLWT1D will allow for more specific research questions regarding individual typologies in subsequent systematic reviews.

INCLUSION CRITERIA

The review will consider all types of literature on the organization and distribution of chronic care services for the management of PLWT1D provided out of facilities in LLMICs, published from 2000 to the present.

METHODS

The JBI methodology for conducting scoping reviews will be employed. The search will be implemented across PubMed, Embase, and Web of Science. Full texts of the publications selected will be reviewed and data will be extracted through a charting table. The findings will be charted to summarize the results.

CKD and Pregnancy Outcomes in Africa: A Narrative Review

Chronic kidney disease (CKD) is associated with adverse maternal and fetal outcomes and is reported to affect up to 3% of women of reproductive age in high-income countries, but estimated prevalence may be as much as 50% higher in low and middle-income countries (LMICs). All pregnancy complications occur much more frequently in women in LMICs compared with those in high-income countries. Given the anticipated high prevalence of CKD in women of reproductive age and high rates of maternal and fetal adverse events in Africa, we sought to explore the association between CKD and pregnancy outcomes in this setting through a narrative review of the literature. This review demonstrates the paucity of data in this area and highlights the systemic barriers that exist in many African countries that prevent robust management of noncommunicable diseases such as CKD during a woman's reproductive life. This evidence gap highlights the need for further research, starting by sampling normal ranges of serum creatinine concentrations in pregnant and nonpregnant women of reproductive age in the diverse populations of Africa, estimating prevalence of CKD, and understanding associated pregnancy outcomes. Research should then focus on pragmatic interventions that may improve outcomes for women and their infants.

Telemedicine Consultation as an Indicator of Local Telemedicine Champions' Contributions, Health Care System Needs or Both: Tales from Two Continents

Background: Telemedicine systems increase access to care, particularly in remote and developing countries. Nationwide telemedicine programs in Cabo Verde and Albania have been built by the International Virtual e-Hospital Foundation (IVeH) and based on the effective Initiate-Build-Operate-Transfer (IBOT) strategy. The aim of this study was to compare the clinical results between the two programs and examine the relationship between the clinical teleconsultations as an indicator of health care system needs and the contribution of local telemedicine champions. Methods: Data were prospectively collected between 2014 and 2018 from Albania and Cabo Verde. Telemedicine champions were defined as programs, physicians, or hospitals who have contributed at least 100 telemedicine consultations during the study periods. Chi-squared test was utilized to analyze the data. Results: There were 2,442 teleconsultations in Cabo Verde and 2,724 teleconsultations in Albania during the study periods. Using the 100-consultation benchmark as the indicator of telemedicine champion, we identified radiology (n = 1,061), neurotrauma (n = 742), and general neurology or stroke (n = 489) as champion clinical disciplines in Albania. With the same method of 100 consultations, we identified eight champion clinical disciplines in Cabo Verde, including neurology (n = 720), cardiology (n = 313), orthopedics (n = 190), surgery (143), endocrinology (141), otolaryngology (n = 139), urology (n = 139), and dermatology (126). The patient transfer/nontransfer ratio was 0.5 in Cabo Verde and 0.3 in Albania (p < 0.001). Three hospitals in Albania and eight community hospitals/health care centers in Cabo Verde requested the majority of teleconsultations. Two main hospitals in Cabo Verde and Albania responded to the consultations. Conclusion: The successful implementation of a telemedicine program depends on many factors. However, physician champions, who eventually create clinical discipline champions, and represent the hospital champions, are the backbone of the sustainability and progress of any telemedicine program. The number of consultations reflects the lack of local specialty expertise to provide health care service and thus can be used for future planning and investment.

Framework and case study for establishing impactful global health programs through academia - biopharmaceutical industry partnerships

BACKGROUND

The field of global health has grown with multiple different public and private stakeholders engaging in the effort to improve health outcomes for underserved populations around the world. There is, however, only limited published guidance on how to promote successful partnerships between academia and the biopharmaceutical industry.

OBJECTIVE

This analysis will provide a framework for developing successful partnerships around five central principles. This framework will then be applied to two representative pharmacy collaboration case studies focused on training and donations.

FRAMEWORK DESCRIPTION AND CASE STUDY FINDINGS

Within the Academic Model Providing Access to Healthcare (AMPATH), successful collaborations between the biopharmaceutical industry philanthropic entities and academic partners have consistently prioritized 1) contextualization, 2) collaboration, 3) local priorities, 4) institutional commitment, and 5) integration. In the first case study, the application of this framework to clinical pharmacy training activities sponsored by Celgene and implemented by the Purdue Kenya Partnership has helped the program transition from an entirely donor dependent training program to a revenue generating, locally administered program which is now recognized and accredited by the Kenyan government. In the second case study, medication donations from Eli Lilly and Company have been converted from a traditional donation program in one Kenyan health facility to a replicable and sustainable supply chain model which has been expanded to more than 70 public sector facilities across western Kenya.

CONCLUSION

Adherence to the five core principles of the proposed framework can help guide partnerships between academic institutions and the biopharmaceutical industry to advance healthcare services for underserved populations around the world. As large-scale government-based development agencies continue to primarily focus on specific disease states, biopharmaceutical industry-based collaborations can help initiate activities in underfunded therapeutic areas such as non-communicable diseases.

Investigating associations between rural-to-urban migration and cardiometabolic disease in Malawi: a population-level study

Background

The extent to which rural-to-urban migration affects risk for cardiometabolic diseases (CMD) in Africa is not well understood. We investigated prevalence and risk for obesity, diabetes, hypertension and precursor conditions by migration status.

Methods

In a cross-sectional survey in Malawi (February 2013–March 2017), 13 903 rural, 9929 rural-to-urban migrant and 6741 urban residents (≥18 years old) participated. We interviewed participants, measured blood pressure and collected anthropometric data and fasting blood samples to estimate population prevalences and odds ratios, using negative binomial regression, for CMD, by migration status. In a sub-cohort of 131 rural–urban siblings-sets, migration-associated CMD risk was explored using conditional Poisson regression.

Results

In rural, rural-to-urban migrant and urban residents, prevalence estimates were; 8.9, 20.9 and 15.2% in men and 25.4, 43.9 and 39.3% in women for overweight/obesity; 1.4, 2.9 and 1.9% in men and 1.5, 2.8 and 1.7% in women for diabetes; and 13.4, 18.8 and 12.2% in men and 13.7, 15.8 and 10.2% in women for hypertension. Rural-to-urban migrants had the greatest risk for hypertension (adjusted relative risk for men 1.18; 95% confidence interval 1.04–1.34 and women 1.17: 95% confidence interval 1.05–1.29) and were the most screened, diagnosed and treated for CMD, compared with urban residents. Within sibling sets, rural-to-urban migrant siblings had a higher risk for overweight and pre-hypertension, with no evidence for differences by duration of stay.

Conclusions

Rural-to-urban migration is associated with increased CMD risk in Malawi. In a poor country experiencing rapid urbanization, interventions for the prevention and management of CMD, which reach migrant populations, are needed.