Diabetes in humanitarian crises: the Boston Declaration

Burden of Disease in Refugee Patients with Diabetes on the Island of Lesvos-The Experience of a Frontline General Hospital

Diabetes mellitus is a non-communicable disease which poses a great burden on refugee populations, who are confronted with limited access to healthcare services and disruption of pre-existing pharmacological treatment.

AIMS

We sought to evaluate the degree of hyperglycaemia in refugees with known or recently diagnosed diabetes, to assess cardiovascular comorbidities and diabetes complications, to review and provide available therapeutic options, and to compare, if possible, the situation in Lesvos with other locations hosting refugee populations, thus raising our awareness towards barriers to accessing healthcare and managing diabetes in these vulnerable populations and to propose follow-up strategies.

METHODS

We retrospectively studied 69 refugee patients (68% of Afghan origin, 64% female) with diabetes mellitus (81% with type 2 diabetes), who were referred to the diabetes outpatient clinics of the General Hospital of Mytilene, Lesvos, Greece, between June 2019 and December 2020. Age, Body Mass Index, diabetes duration, glycaemic control (HbA1c and random glucose), blood pressure, estimated renal function, lipid profile, diabetes complications and current medication were documented at presentation and during subsequent visits.

RESULTS

For all patients with type 1 diabetes and type 2 diabetes, age at presentation was 17.7 and 48.1 years, BMI 19.6 kg/m2 and 28.9 kg/m2 and HbA1c 9.6% and 8.7%, respectively (all medians). One-third (29%) of patients with type 2 diabetes presented either with interrupted or with no previous pharmacological treatment. Insulin was administered to only 21% of refugees with poorly controlled type 2 diabetes. Only half of the patients (48%) with hypertension were taking antihypertensive medication and one-sixth (17%) were taking lipid-lowering medication. Forty-two per cent (42%) of patients were lost to follow-up.

CONCLUSIONS

Our results showed that a significant portion of refugees with diabetes have either no treatment at all or have had their treatment discontinued, that insulin is still underutilised and that a significant portion of patients are lost to follow-up. It is essential to enhance our ability to identify refugees who may be at risk of developing diabetes or experiencing complications related to the disease. Additionally, it is important to expand access to crucial treatment and monitoring services. By improving our policies for managing non-communicable diseases, we can better support the health and well-being of these vulnerable populations. Furthermore, it is vital to recognize that Greece cannot bear the burden of the refugee crisis alone; international support and collaboration are necessary to address these challenges effectively.

The diabetes care continuum in Venezuela: Cross-sectional and longitudinal analyses to evaluate engagement and retention in care

The impact of the humanitarian crisis in Venezuela on care for noncommunicable diseases (NCDs) such as diabetes is unknown. This study aims to document health system performance for diabetes management in Venezuela during the humanitarian crisis. This longitudinal study on NCDs is nationally representative at baseline (2014-2017) and has follow-up (2018-2020) data on 35% of participants. Separate analyses of the baseline population with diabetes (n = 585) and the longitudinal population with diabetes (n = 210) were conducted. Baseline analyses constructed a weighted care continuum: all diabetes; diagnosed; treated; achieved glycaemic control; achieved blood pressure, cholesterol, and glycaemic control; and achieved aforementioned control plus non-smoking. Weighted multinomial regression models controlling for region were used to estimate the association between socio-demographic characteristics and care continuum stage. Longitudinal analyses constructed an unweighted care continuum: all diabetes; diagnosed; treated; and achieved glycaemic control. Unweighted multinomial regression models controlling for region were used to estimate the association between socio-demographic characteristics and changes in care continuum stage. Among 585 participants with diabetes at baseline, 71% were diagnosed, 51% were on treatment, and 32% had achieved glycaemic control. Among 210 participants with diabetes in the longitudinal population, 50 (24%) participants' diabetes management worsened, while 40 (19%) participants improved. Specifically, the proportion of those treated decreased (60% in 2014-2017 to 51% in 2018-2020), while the proportion of participants achieving glycaemic control did not change. Although treatment rates have declined substantially among people with diabetes in Venezuela, management changed less than expected during the crisis.

Diabetes Care in Humanitarian Settings

Despite the increasing prevalence of diabetes in populations experiencing humanitarian crisis, along with evidence that people living with diabetes are at higher risk for poor outcomes in a crisis, diabetes care is not routinely included in humanitarian health interventions. We here describe 4 factors that have contributed to the inequities and lack of diabetes inclusion in humanitarian programmes: (1) evolving paradigms in humanitarian health care, (2) complexities of diabetes service provision in humanitarian settings, (3) social and cultural challenges, and (4) lack of financing. We also outline opportunities and possible interventions to address these challenges and improve diabetes care among crisis-affected populations.

Telehealth and cardiometabolic-based chronic disease: optimizing preventive care in forcibly displaced migrant populations

The number of migrants, which includes forcibly displaced refugees, asylum seekers, and undocumented persons, is increasing worldwide. The global migrant population is heterogeneous in terms of medical conditions and vulnerability resulting from non-optimal metabolic risk factors in the country of origin (e.g., abnormal adiposity, dysglycemia, hypertension, and dyslipidemia), adverse travel conditions and the resulting stress, poverty, and anxiety, and varying effects of acculturation and access to healthcare services in the country of destination. Therefore, many of these migrants develop a high risk for cardiovascular disease and face the significant challenge of overcoming economic and health system barriers to accessing quality healthcare. In the host countries, healthcare professionals experience difficulties providing care to migrants, including cultural and language barriers, and limited institutional capacities, especially for those with non-legal status. Telehealth is an effective strategy to mitigate cardiometabolic risk factors primarily by promoting healthy lifestyle changes and pharmacotherapeutic adjustments. In this descriptive review, the role of telehealth in preventing the development and progression of cardiometabolic disease is explored with a specific focus on type 2 diabetes and hypertension in forcibly displaced migrants. Until now, there are few studies showing that culturally adapted telehealth services can decrease the burden of T2D and HTN. Despite study limitations, telehealth outcomes are comparable to those of traditional health care with the advantages of having better accessibility for difficult-to-reach populations such as forcibly displaced migrants and reducing healthcare associated costs. More prospective studies implementing telemedicine strategies to treat cardiometabolic disease burden in migrant populations are needed.

Strengthening Diabetes Care in Humanitarian Crises in Low- and Middle-income Settings

Amid the growing global diabetes epidemic, the scale of forced displacement resulting from armed conflict and humanitarian crises is at record-high levels. More than 80% of the displaced population lives in lower- and middle-income countries, which also host 81% of the global population living with diabetes. Most crises are protracted, often lasting decades, and humanitarian aid organizations are providing long-term primary care to both the local and displaced populations. Humanitarian crises are extremely varied in nature and occur in contexts that are diverse and dynamic. The scope of providing diabetes care varies depending on the phase of the crisis. This paper describes key challenges and possible solutions to improving diabetes care in crisis settings. It focuses on (1) ensuring a reliable supply of life preserving medications and diagnostics, (2) restoring and maintaining access to health care, and (3) adapting service design to the context. These challenges are illustrated through case studies in Ukraine, Mali, the Central African Republic, and Jordan.

Incidence of type 1 diabetes among children and adolescents during peace and war times in Yemen

AIM

To calculate a 30-year incidence rates of type 1 diabetes (T1D) in Sana'a city, Yemen during peace and wartimes.

METHODS

A total of 461 patients aged between 8 months and 18 years with newly diagnosed diabetes were registered between 1989 and 2018. We used a standardized protocol for counting cases over time. The annual incidence rates (cases/100,000/year) were calculated from the number of new reported cases for each year divided by the estimated number of person-years "at risk" resident in Sana'a city, Yemen according to age and sex of the participants of that year.

RESULTS

The mean annual incidence rate of T1D in children aged 0-14 years was 1.83/100,000/year. With the use of 3-year time-periods, the mean annual incidence rate was (5/100,000/year) in the first time-period, fluctuated between 1.2 and 2.3 during subsequent seven time-periods, and declined to (0.5/100,000/year) during the conflict years. The age-specific mean annual incidence rates for age-groups 0-4, 5-9, 10-14, and 15-18 years were 0.83, 1.82, 3.14, and 2.31/100,000/year, respectively.

CONCLUSION

The mean annual incidence rate of T1D in children and adolescents over the observation period in Sana'a city was low. In children aged 0-14 years in particular, the incidence declined to a very low rate during wartime. Interpretation is partly limited by lack of recent census data, and the possibility of death from nondiagnosis at onset.

A human rights-based approach to improve access to insulin and other aspects of diabetes care

Many nations struggle to provide adequate diabetes care. Legal as well as moral obligations may facilitate access. International human rights law places obligations on governments to ensure the accessibility and affordability of insulin (a World Health Organization essential medicine), and other components of diabetes care. Despite this obligation, the global reality is that access remains deficient. A human rights approach facilitating the improvement of diabetes services and equitable access to insulin provides a strong framework, theoretically and practically, for advocacy and policymaking changes. This approach links governments to their international obligations, fosters the ideal of, and adherence to, national essential medicine lists, complements the pursuit of international goals in non-communicable diseases, and should influence the actions of pharmaceutical and device companies. This approach empowers patients, families, and communities living with diabetes, and grounds actions by governments, clinicians, and non-government organisations in the principles of dignity, non-discrimination, and equity of access.

Insulin Storage: A Critical Reappraisal

Insulin, as a peptide hormone drug, is susceptible to changes in stability when exposed to environmental factors under storage. Proper storage according to the manufacturer's recommendations is important to maintain its potency and enable precise dosing for people with diabetes (PwD). While it is reasonable to assume that transport conditions and temperature are well controlled during the supply chain, little is known about insulin storage after dispensing and insulin potency at the moment of administration. Insulin is exposed to various environmental factors when carried by PwD and storage recommendations are often not met when it is stored in household refrigerators. It is difficult to assess changes in insulin potency in clinical practice, and there is a gap in the current scientific literature on insulin stability. Package leaflet recommendations only give limited information on the impact of improper storage conditions on insulin stability and guidelines by health organizations are inconsistent. Given the importance of precise dosing in diabetes care, there is a need for more transparency on insulin stability, awareness for proper storage among health care professionals and PwD as well as clear guidelines and practical storage recommendations from manufacturers and health organizations.