TYPE 1 DIABETES

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TYPE 1 DIABETES - A FATAL DISEASE IN
SUB-SAHARAN AFRICA
Professor John S Yudkin Chairman International
Insulin Foundation Professor of Medicine, UCL
Royal Society of Medicine Thursday 12th February
2004
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• Introduction
• Dearth of information regarding Type 1 Diabetes
  in sub-Saharan Africa
• Need for instrument to assess patterns of disease
  and health care
• Development of a Rapid Assessment Protocol for
  Insulin Access
• Findings of RAPIA process in Mozambique and
  Zambia
• Insights into effectiveness of health systems

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DIABETES AND INSULIN IN AFRICA

• 108,000 people with Type 1 diabetes in Africa
  (International Diabetes Federation)
• Lack of attention to diabetes versus HIV/AIDS, TB
  and Malaria.
• Financial constraints
• Cost of care
• Cost of insulin

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COMPARISON MOZAMBIQUE AND ZAMBIA VERSUS THE UK
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HOW TO MEASURE ACCESS?
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RAPID ASSESSMENT PROTOCOL FOR INSULIN ACCESS
(RAPIA)

• Macro
• Ministry of Health
• Ministry of Trade
• Ministry of Finance
• Central Medical Store
• National Diabetes Association
• Private/Public drug importer
• Educators

• Meso (3 areas)
• Regional Health Organisation
• Hospitals, Health Centres, etc.
• Pharmacies, Drug Dispensaries

• Micro (3 areas)
• Healthcare Workers
• Traditional Doctors
• Patients

Perspectives on the problem of access to insulin
and diabetes care
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WHAT INFORMATION DOES THE RAPIA PROVIDE?

• Study the path of insulin from its arrival in the
  country
• Study patterns of care
• Other problems faced by health care workers,
  patients

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HOW INFORMATION IS COLLECTED

• Interviews
• Document reviews
• Observations
• Mozambique
• - 76 interviews
• Zambia
• - 182 interviews

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EXPENDITURE ON MEDICINES
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INSULIN PURCHASE AND DISTRIBUTION IN MOZAMBIQUE
Annual purchase - Central Stores 59,700
vials Distribution - Maputo City/Province 46,100
vials - Other 9 Provinces 1100-3390
vials
About 80 vials of expired Insulin
1,000 vials Rapid Insulin
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Prices of Insulin in Mozambique

Price US
Price to Patient Public Sector Price to Patient
Private Sector Price to State Pharmacy Importer
price from producer Importer price to Private
pharmacies
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24.2
20
19.2
16.7
15
US 4.1 National Importer Price
10.2
10
8.9
6.4
6.1
5
2.7
1.5
0.5
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AM MALE 20
Type 1 Diabetes 3 years Lives 90 minute bus
journey from Hospital Buys insulin from pharmacy
- not available in Hospital for most of
year Cost US 10 per vial from pharmacy
2.50 per vial from Centre Uses 1 vial
every 3 weeks 170 per year Family income
600 per year Regularly reduces dose or omits
insulin
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DIABETES CARE IN MOZAMBIQUE AND ZAMBIA

• Only at hospitals (Mozambique)
• No guidelines or referral system
• Lack of organisation and control of patients and
  medicines
• Patients face different challenges depending on
  the location where they live, their
  socio-economic status, family structure, etc.
• Mozambique Diabetes Association (only Capital)

Patient
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HEALTH CARE FACILITIES FOR TYPE 1 DIABETES IN
MOZAMBIQUE AND ZAMBIA
Mozambique
Zambia
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TYPE 1 DIABETES IN MOZAMBIQUE AND ZAMBIA
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ANNUAL INCIDENCE OF TYPE 1 DIABETES Dar es
Salaam, Tanzania Age 0-4 yrs -
0.6/100,000/yr Age 5-9 yrs -
0.5/100,000/yr Age 10-14 yrs -
2.2/100,000/yr Age 15-19 yrs -
3.4/100,000/yr Swai, Lutale and McLarty,
1993
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TYPE 1 DIABETES IN MOZAMBIQUE
Life expectancy for newly diagnosed patient
Lichinga - rural area - 1.5 years Maputo -
capital city - 20 years
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DIABETES - DIAGNOSIS
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Prognosis of Type 1 Diabetes - Boston and
Mozambique
Pre-Insulin Era Insulin Era A 1897-1913
C 1922-25 B 1914-22 D
1926-28 E 1929-38 F
1939-45
20.0
3.8 0.6
2.9
Rural Urban Mozambique age 10-14
Rural Urban Mozambique age 15
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LIFE EXPECTANCY FOR TYPE 1 DIABETES IN MOZAMBIQUE
AND ZAMBIA
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ZAMBIA 11/100,000
Copperbelt 13/100,000 Lusaka
18/100,000 Eastern
Zambia 9/100,000
Dar es Salaam, Tanzania 28/100,000
MOZAMBIQUE 5/100,000
Lichinga 1.3/100,000 Beira 5/100,000 Maputo
9/100,000
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ZAMBIA 11/100,000
ZAMBIA HIV 11,642/100,000
Copperbelt 13/100,000 Lusaka
18/100,000 Eastern
Zambia 9/100,000
Dar es Salaam, Tanzania 28/100,000
MOZAMBIQUE 5/100,000
Lichinga 1.3/100,000 Beira 5/100,000 Maputo
9/100,000
MOZAMBIQUE HIV 6,293/100,000
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TYPE 1 DIABETES PREREQUISITES FOR SURVIVAL
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TYPE 1 DIABETES
A tracer condition for effective health care
systems
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WHAT IS THE IIF DOING?

• Recommendations presented to the Ministry of
  Health in Mozambique
• Inclusion of NCDs in WHO surveillance
• Discussion between MoH and Diabetes Association
• Planning of future projects in collaboration with
  MoH and Diabetes Association in both Mozambique
  and Zambia

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• Conclusions
• Type 1 Diabetes is a rare disease in sub-Saharan
  Africa
• Consequence of poor prognosis rather than low
  incidence
• Marked geographical differences in prevalence
  correlate with patterns of health care delivery
• Many patients likely to die without diagnosis
• Improving health care systems likely to benefit
  chronic infections as well as other NCDs