Access to Hemoglobin A1c in Rural Africa: A Difficult Reality with Severe Consequences

Challenges in Hb A1c Point-of-Care Testing: Only 6 of 19 Hb A1c Point-of-Care Devices Meet IFCC and NGSP Certification Criteria on Independent Evaluation

BACKGROUND

Access to Hb A1c testing in low- and middle-income countries (LMICs) can be limited, especially in rural areas. This has led to an increased interest in the potential role of point-of-care testing (POCT) for Hb A1c. The analytical performance of many of these devices is poorly understood but accurate and precise measurement is essential for effective diabetes management.

METHODS

Verification of the manufacturers' claims, for accuracy, imprecision, and interference from hemoglobin variants, was performed using protocols based on established guidance using Clinical and Laboratory Standards Institute (CLSI) protocols (EP-15-A3 and EP-9-A3), international quality targets and 4 certified International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) and National Glycohemoglobin Standardization Program (NGSP) Secondary Reference Measurement Procedures (SRMP). Each of the 19 POC devices were assessed for performance against both IFCC and NGSP certification criteria.

RESULTS

Out of 19 Hb A1c POC devices, only 6 (32%) met international quality criteria (IFCC and NGSP with at least one SRMP), 4 (21%) only met IFCC criteria, and 9 (47%) did not meet either IFCC or NGSP criteria, despite most of these devices having an IFCC and/or NGSP certificate at the time of the study. Three devices showed clear interference from Hb variants.

CONCLUSIONS

This study shows the importance of independent evaluations for assessing the performance of Hb A1c POC devices. The analytical performance of the devices was very poor overall, with 68% not meeting both IFCC and NGSP criteria. These evaluations were performed under ideal conditions; performance may worsen further when used in a clinical setting.

The impact of prolonged walking on fasting plasma glucose in type 2 diabetes: A randomised controlled crossover study

AIMS

In many low-income countries, fasting glucose is the primary measure for monitoring glycaemic control. Many patients in these countries walk long distances to the clinic, but the impact of walking on fasting glucose in type 2 diabetes is unknown. We aimed to determine the impact of walking on fasting glucose in people with type 2 diabetes.

METHODS

In a randomised crossover trial, the change in glucose from baseline in the fasting state was compared between walking on a treadmill at a predetermined speed of 4.5 km/h for 1 h and not walking (resting) in people with type 2 diabetes.

RESULTS

In all, 45 participants were enrolled and all completed both visits; 21/45 (46.7%) were women, and the median age was 51. Glucose during and after walking was similar to glucose while at rest; the glucose difference (walking minus rest) was -0.15 (95% CI: -0.55, 0.26) and -0.10 (95% CI: -0.50, 0.31) mmol/L at 1 and 2 h, respectively, p > 0.4 for both.

CONCLUSIONS

Fasting plasma glucose is not meaningfully affected by prolonged walking in participants with type 2 diabetes; therefore, the reliability of fasting glucose for monitoring glycaemic burden is unlikely to be altered in patients who walk to the clinic.

Comparing the effectiveness and cost-effectiveness of alternative type 2 diabetes monitoring intervals in resource limited settings

Type 2 diabetes (T2D) represents a growing disease burden in South Africa. While glycated haemoglobin (HbA1c) testing is the gold standard for long-term blood glucose management, recommendations for HbA1c monitoring frequency are based on expert opinion. This study investigates the effectiveness and cost-effectiveness of alternative HbA1c monitoring intervals in the management of T2D. A Markov model with three health states (HbA1c <7%, HbA1c ≥ 7%, Dead) was used to estimate lifetime costs and quality-adjusted life years (QALYs) of alternative HbA1c monitoring intervals among patients with T2D, using a provider's perspective and a 3% discount rate. HbA1c monitoring strategies (three-monthly, four-monthly, six-monthly and annual tests) were evaluated with respect to the incremental cost-effectiveness ratio (ICER) assessing each comparator against a less costly, undominated alternative. The scope of costs included the direct medical costs of managing diabetes. Transition probabilities were obtained from routinely collected public sector HbA1c data, while health service utilization and health-related-quality-of-life (HRQoL) data were obtained from a local cluster randomized controlled trial. Other parameters were obtained from published studies. Robustness of findings was evaluated using one-way and probabilistic sensitivity analyses. A South African indicative cost-effectiveness threshold of USD2665 was adopted. Annual and lifetime costs of managing diabetes increased with HbA1c monitoring, while increased monitoring provides higher QALYs and life years. For the overall cohort, the ICER for six-monthly vs annual monitoring was cost-effective (USD23 22.37 per QALY gained), whereas the ICER of moving from six-monthly to three-monthly monitoring was not cost effective (USD6437.79 per QALY gained). The ICER for four-monthly vs six-monthly monitoring was extended dominated. The sensitivity analysis showed that the ICERs were most sensitive to health service utilization rates. While the factors influencing glycaemic control are multifactorial, six-monthly monitoring is potentially cost-effective while more frequent monitoring could further improve patient HrQoL.

Implementing HbA1c monitoring in sub-Saharan Africa: Lessons learnt from a pilot project in Mozambique

Aims

We aimed to evaluate lesson learnt from a pilot project in Mozambique focused on point-of-care (POC) HbA1c testing for diabetes management in primary health care facilities.

Methods

Over a three-year period, several health centers were equipped with POC HbA1c testing machines. The evaluation involved 12 months of data collection, interviews with patients and staff, and regular supervision visits.

Results

The project screened over 22,000 individuals and provided HbA1c testing to 2362 diabetes patients. Among the analyzed results, 65.7 % had HbA1c levels below 7 %, 10.9 % between 7 % and 8.5 %, and 23.4 % above 8.5 %. POC testing showed advantages such as reduced costs and improved workload management.

Conclusions

Limited access to HbA1c testing remains a challenge in African countries. The pilot project demonstrated the feasibility of POC HbA1c testing and highlighted the need for increased efforts to make it more widely available, leading to improved diabetes management and patient outcomes.

Evaluation of Red Blood Cell Indices for Prediction of Glycemic Control in People Living with Type 2 Diabetes

Background

Achieving target glycemic control in people living with diabetes lessens most of the diabetes-related complications and hemoglobin A1C is the gold standard test for assessing the long-term glycemic control. However, the expensive cost, and its limited access are problematic for routine use in developing countries, demanding an urgent alternative solution. Hence, this study aimed to assess the potential of red blood cell indices in predicting glycemic control among people living with type 2 diabetes at Dilla University Hospital.

Methods

A cross-sectional study was conducted among 207 participants with type 2 diabetes. Red blood cell indices were compared between the poor and good glycemic control groups using the t-test. Performance of red cell indices in discriminating poor glycemic control was assessed using receiver operating characteristic analysis.

Results

The prevalence of poor glycemic control among the participants was 91.8%. Higher mean hemoglobin (p=0.002) and mean corpuscular hemoglobin (p=0.015) was found in the good glycemic control group. An inverse correlation was also observed between hemoglobin A1C and mean corpuscular hemoglobin (r=-0.158; P=0.023). The area under the curve to discriminate poor glycemic control from good was statistically significant for hemoglobin, hematocrit, and mean corpuscular hemoglobin. However, hemoglobin had the highest discrimination ability at a cutoff ≤14.8 g/dL; area under the curve was 0.738 (P=0.001), sensitivity, specificity, and positive predictive value were 68.95%, 82.35%, and 97.77%, respectively.

Conclusion

This study revealed that hemoglobin can potentially be used to assess glycemic control among people with type 2 diabetes but the interpretation needs to be cautious.

Global variation in diabetes diagnosis and prevalence based on fasting glucose and hemoglobin A1c

Fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) are both used to diagnose diabetes, but these measurements can identify different people as having diabetes. We used data from 117 population-based studies and quantified, in different world regions, the prevalence of diagnosed diabetes, and whether those who were previously undiagnosed and detected as having diabetes in survey screening, had elevated FPG, HbA1c or both. We developed prediction equations for estimating the probability that a person without previously diagnosed diabetes, and at a specific level of FPG, had elevated HbA1c, and vice versa. The age-standardized proportion of diabetes that was previously undiagnosed and detected in survey screening ranged from 30% in the high-income western region to 66% in south Asia. Among those with screen-detected diabetes with either test, the age-standardized proportion who had elevated levels of both FPG and HbA1c was 29-39% across regions; the remainder had discordant elevation of FPG or HbA1c. In most low- and middle-income regions, isolated elevated HbA1c was more common than isolated elevated FPG. In these regions, the use of FPG alone may delay diabetes diagnosis and underestimate diabetes prevalence. Our prediction equations help allocate finite resources for measuring HbA1c to reduce the global shortfall in diabetes diagnosis and surveillance.

Accessibility and utilization of healthcare services among diabetic patients: Is diabetes a poor man's ailment?

Diabetes is a non-communicable ailment that has adverse effects on the individual's overall well-being and productivity in society. The main objective of this study was to examine the empirical literature concerning the association between diabetes and poverty and the accessibility and utilization of medical care services among diabetic patients. The diabetes literature was explored using a literature review approach. This review revealed that diabetes is an ailment that affects all individuals irrespective of socioeconomic status; however, its pre-valence is high in low-income countries. Hence, despite the higher prevalence of diabetes in developing countries compared with developed countries, diabetes is not a poor man's ailment because it affects individuals of all incomes. While the number of diabetic patients that access and utilize diabetes medical care services has increased over the years, some personal and institutional factors still limit patients' access to the use of diabetes care. Also, there is a lacuna in the diabetes literature concerning the extent of utilization of available healthcare services by diabetic patients.

Impact of Lockdown Measures on Health Outcomes of Adults with Type 2 Diabetes Mellitus in Bangladesh

COVID-19 lockdown measures appreciably affected patients' lifestyles, negatively impacting on their health. This includes patients with Type 2 Diabetes Mellitus (T2DM). Care of these patients was also negatively impacted due to a priority to treat patients with COVID-19, certainly initially, within hospitals and clinics in Bangladesh, combined with a lack of access to clinics and physicians due to lockdown and other measures. This is a concern in Bangladesh with growing rates of T2DM and subsequent complications. Consequently, we sought to critically analyze the situation among patients with T2DM in Bangladesh during the initial stages of the pandemic to address this information gap and provide future direction. Overall, 731 patients were recruited by a simple random sampling method among patients attending hospitals in Bangladesh, with data collected over 3 timescales: before lockdown, during the pandemic, and after lockdown. Data extracted from patients' notes included current prescribed medicines and key parameters, including blood sugar levels, blood pressure, and comorbidities. In addition, the extent of record keeping. The glycemic status of patients deteriorated during lockdown, and comorbidities as well as complications related to T2DM increased during this period. Overall, a significant proportion of key datasets were not recorded in patients' notes by their physician before and during lockdown. This started to change after lockdown measures eased. In conclusion, lockdown measures critically affected the management of patients with T2DM in Bangladesh, building on previous concerns. Extending internet coverage for telemedicine, introduction of structured guidelines, and appreciably increasing data recording during consultations is of the utmost priority to improve the care of T2DM patients in Bangladesh.

Factors associated with poor glycemic control among adult patients with type 2 diabetes mellitus in Gamo and Gofa zone public hospitals, Southern Ethiopia: A case-control study

BACKGROUND

Diabetes mellitus is a serious global public health problem that affects the whole life of people in terms of their biological, psychological, and social effects. Complications and death from diabetes occur from poorly controlled blood glucose levels. Thus, dealing with glycemic control is essential for controlling the development of devastating acute and chronic complications related to diabetes. Therefore, this study aims to assess factors associated with poor glycemic control among type2 diabetes patients in public hospitals of Gamo and Gofa zone southern, Ethiopia, 2021.

METHODS

An institution-based unmatched case-control study was employed among 312 randomly selected participants using a pre-tested, interviewer-administered, and structured questionnaire. Bivariate and multivariable logistic regression analysis was conducted to identify factors associated with poor glycemic control using IBM SPSS version 25. The strength of association was assessed by using an Adjusted odds ratio (AOR) with a 95% confidence interval (CI).

RESULT

Factors associated with poor glycemic control based on multivariable analysis were, having comorbidity (AOR = 2.35, 95% CI (1.39-3.95)), adhering to dietary recommendations (AOR = 0.31, 95% CI (089-0.51)), poor social support (AOR = 3.31, 95% CI (1.59-6.85)), physical exercise (AOR = 1.86 95% CI (1.11-3.12)), and having poly-pharmacy (AOR = 2.83, 95% CI (1.39-5.74)).

CONCLUSION AND RECOMMENDATION

This study indicated a significant association of comorbidity, physical exercise, poly-pharmacy, low social support, and adherence to dietary recommendations with poor glycemic control. We suggest that the health care providers and concerned bodies encourage patients to have regular check-ups and work on providing necessary social support.

Factors Influencing the Utilization of Diabetes Complication Tests Under the COVID-19 Pandemic: Machine Learning Approach

OBJECTIVE

There are still not enough studies on the prediction of non-utilization of a complication test or a glycated hemoglobin test for preventing diabetes complications by using large-scale community-based big data. This study identified the ratio of not taking a diabetes complication test (fundus examination and microprotein urination test) among adult diabetic patients over 19 years using a national survey conducted in South Korea and developed a model for predicting the probability of not taking a diabetes complication test based on it.

METHODS

This study analyzed 25,811 subjects who responded that they had been diagnosed with diabetes by a doctor in the 2020 Community Health Survey. Outcome variables were defined as the utilization of the microprotein urination test and the fundus examination during the past year. This study developed a model for predicting the utilization of a diabetes complication test using logistic regression analysis and nomogram to understand the relationship of predictive factors on the utilization of a diabetes complication test.

RESULTS

The results of this study confirmed that age, education level, the recognition of own blood glucose level, current diabetes treatment, diabetes management education, not conducting the glycated hemoglobin test in the past year, smoking, single-person household, subjectively good health, and living in the rural area were independently related to the non-utilization of diabetes complication test after the COVID-19 pandemic.

CONCLUSION

Additional longitudinal studies are required to confirm the causality of the non-utilization of diabetes complication screening tests.

Significance of Educational Literature and Diabetes Log Sheet on Hemoglobin A1c

Diabetes mellitus (DM) is a major cause of morbidity worldwide. The prevalence of DM has doubled over the last 35 years and is escalating. Various complications and manifestations of diabetes have caused numerous deaths worldwide, with numbers increasing every year. There have been many advances and breakthroughs over the past decade in the management of DM. The major focus of many research studies has been to evaluate effective medication combinations, preventative measures, and the way to control such morbid conditions. Our focus in this review is to discuss specific secondary prevention techniques with the diabetes log sheet and educational literature on its effectiveness in controlling diabetes. Hemoglobin A1c (HbA1c) has been accepted as a diabetes control measure in many resources worldwide. Here, we have assessed articles on the effectiveness of the diabetes log sheet and educational literature on HbA1c levels. We will begin with a few key points to acknowledge diabetes initially, followed by discussing the effectiveness of the diabetes log sheet and literature on HbA1c.

Prevalence and sociodemographic correlates of diabetes among adults in Namibia and South Africa

OBJECTIVE

The aims of this study were to understand the prevalence and sociodemographic characteristics associated with diabetes among adults in Namibia and South Africa.

METHODS

Data from the Demographic and Health Survey for Namibia (2013) and South Africa (2016) were analyzed. The dependent variable, diabetes, was defined using lab values for blood glucose≥ 126 for Namibia, and hemoglobin A1c (HbA1c) ≥ 6.5% for South Africa. Logistic regression was used to identify independent correlates of diabetes for each country. Demographic (age, sex, geographic location, number of children), economic (wealth index, education level), and cultural (religion - Namibia, ethnicity - South Africa) factors were added in blocks to the models.

RESULTS

In Namibia, 4.6% had diabetes based on blood glucose, and 14.6% had diabetes based on HbA1c in South Africa. In Namibia, after adjustment, higher wealth was independently associated with diabetes (OR:1.67; 95% CI: 1.11, 2.50). In South Africa, after adjustment, those who were older (OR: 1.06; 95% CI: 1.04, 1.07), female (OR: 1.25; 95% CI: 1.03, 1.52), lived in a rural area (OR: 1.54; 95% CI: 1.20, 1.96), and Black (OR: 2.27; 95% CI: 1.17, 4.42) or Other (OR: 5.74; 95% CI: 2.50, 13.20) compared to White, had increased odds of diabetes.

CONCLUSIONS

Prevalence of diabetes is high in South Africa and relatively low in Namibia using reliable laboratory diagnostic indices. Strategies to address the rising burden of non-communicable diseases like diabetes are needed in sub-Saharan Africa.

The Role of the Integrated District Hospital Based Non Communicable Diseases' Clinics in Cardiovascular Disease Control: Preliminary Data from Rwanda

INTRODUCTION

Noncommunicable diseases (NCDs), remain the leading cause of death worldwide and represent an emerging global health threat. In Rwanda and elsewhere, the prevalence of cardiovascular diseases is increasing. To address this global health threat, Rwanda launched integrated nurse-led NCD clinics in all the forty-five District Hospitals across the country in 2006, but no evaluation study has been conducted so far for the added value of this program. The main goal of this study was to assess the impact of NCD clinics on disease control in Rwanda.

METHODS

This was a retrospective ambulatory patient chart review at a rural district hospital and an urban teaching hospital; which enrolled patients with diabetes and/or hypertension who consulted in a period of 1 month with retrospective data of one year.

RESULTS

A total of 199 patients' electronic health records were reviewed from the University Teaching Hospital of Kigali (CHUK) (53%) and Nyamata District Hospital (47%). Among them, 31% had diabetes, 38% had hypertension and 31% had both diseases. The mean age for the total cohort was 60 years and was predominantly female at 70%. Throughout the year, about 59% patients with hypertension had blood pressure control at the district hospital as opposed to 38% at the referral hospital. The rate of diabetes control was 20% at the referral hospital, but no comparison could be established between the two health facilities as the follow up laboratory markers were not available at the district hospital.

CONCLUSION

There was a consistent blood pressure control at the district hospital. Diabetes control was not optimal at the referral hospital despite the presence of human resources and logistics required for diabetes care. The situation was even worse at the district hospital where the follow up markers were rarely available.

Socioeconomic Factors Associated With Glycemic Measurement and Poor HbA1c Control in People With Type 2 Diabetes: The Global DISCOVER Study

DISCOVER is a 3-year observational study program of 15,983 people with type 2 diabetes initiating second-line glucose-lowering therapy in 38 countries. We investigated the association between socioeconomic status and both the availability of a baseline glycated hemoglobin (HbA1c) measurement and poor glycemic control (HbA1c level ≥ 9.0%) in participants enrolled in DISCOVER. Factors associated with a lack of baseline HbA1c measurement or an HbA1c level ≥ 9.0% were assessed using three-level hierarchical logistic models. Overall, 19.1% of participants did not have a baseline HbA1c measurement recorded. Lower-middle country income (vs. high) and primary/no formal education (vs. university education) were independently associated with a reduced likelihood of having a baseline HbA1c measurement (odds ratio [95% confidence interval]: 0.11 [0.03-0.49] and 0.81 [0.66-0.98], respectively. Of the participants with an available HbA1c measurement, 26.9% had an HbA1c level ≥ 9.0%; 68.7% of these individuals were from lower- or upper-middle-income countries. Factors associated with an increased likelihood of poor glycemic control included low country income, treatment at a site with public and/or governmental funding (vs. private funding) and having public or no health insurance (vs. private). A substantial proportion of DISCOVER participants did not have an HbA1c measurement; more than one-quarter of these participants had poorly controlled type 2 diabetes. Both individual- and country-level socioeconomic factors are associated with the quality of care regarding glycemic control. Awareness of these factors could help improve the management of patients with type 2 diabetes.

Evaluation of Red Blood Cell Parameters as a Biomarker for Long-Term Glycemic Control Monitoring Among Type 2 Diabetic Patients in Southwest Ethiopia: A Cross-Sectional Study

OBJECTIVE

The main aim of this study was to assess red blood cell parameters as a biomarker for long-term glycemic monitoring among T2 DM patients.

METHODS

Facility-based cross-sectional study through a consecutive sampling technique was conducted among 124 T2 DM patients at the chronic illness follow-up clinic of Jimma Medical Center (JMC) from July 27 to August 31, 2020. A structured questionnaire was used to collect socio-demographic and clinical-related data. Five milliliters of the blood specimen were collected from each eligible T2 DM patient. Glycated hemoglobin (HbA1c) and red blood cell parameters were determined by Cobas 6000 and DxH 800 fully automated analyzers, respectively. Data were entered into EpiData software version 3.1 and exported to SPSS 25 version for analysis. Independent t-test and Pearson's correlation coefficient were used to address the research questions. A P-value <0.05 was considered statistically significant.

RESULTS

The mean age of study participants was 51.84± 11.6 years. Moreover, 60.5% of T2 DM patients were in poor glycemic control. There was a significant mean difference between good and poor glycemic controlled T2 DM patients in red blood cell count (4.79±0.5 vs 4.38±0.8), hemoglobin (14.13±1.4 vs 13.60±1.6), mean corpuscular volume (89.52±4.7 vs 92.62±7.5), mean corpuscular hemoglobin (29.63±1.6 vs 30.77±2.9), and red cell distribution width (13.68±1.1 vs 14.63±1.2) respectively. Red blood cell count was inversely correlated (r=-0.280, p=0.002) with HbA1c while mean corpuscular volume (r=0.267, p=0.003), mean corpuscular hemoglobin (r=0.231, p=0.010), and red cell distribution width (r= 0.496, p=0.000) were positively correlated with level of HbA1c.

CONCLUSION

Red cell count, mean corpuscular volume, mean corpuscular hemoglobin, and red cell distribution width could be useful indicators to monitor the glycemic status of T2 DM patients instead of HbA1c, though large prospective studies should be considered.

Integrating health services for HIV infection, diabetes and hypertension in sub-Saharan Africa: a cohort study

BACKGROUND

HIV, diabetes and hypertension have a high disease burden in sub-Saharan Africa. Healthcare is organised in separate clinics, which may be inefficient. In a cohort study, we evaluated integrated management of these conditions from a single chronic care clinic.

OBJECTIVES

To determined the feasibility and acceptability of integrated management of chronic conditions in terms of retention in care and clinical indicators.

DESIGN AND SETTING

Prospective cohort study comprising patients attending 10 health facilities offering primary care in Dar es Salaam and Kampala.

INTERVENTION

Clinics within health facilities were set up to provide integrated care. Patients with either HIV, diabetes or hypertension had the same waiting areas, the same pharmacy, were seen by the same clinical staff, had similar provision of adherence counselling and tracking if they failed to attend appointments.

PRIMARY OUTCOME MEASURES

Retention in care, plasma viral load.

FINDINGS

Between 5 August 2018 and 21 May 2019, 2640 patients were screened of whom 2273 (86%) were enrolled into integrated care (832 with HIV infection, 313 with diabetes, 546 with hypertension and 582 with multiple conditions). They were followed up to 30 January 2020. Overall, 1615 (71.1%)/2273 were female and 1689 (74.5%)/2266 had been in care for 6 months or more. The proportions of people retained in care were 686/832 (82.5%, 95% CI: 79.9% to 85.1%) among those with HIV infection, 266/313 (85.0%, 95% CI: 81.1% to 89.0%) among those with diabetes, 430/546 (78.8%, 95% CI: 75.4% to 82.3%) among those with hypertension and 529/582 (90.9%, 95% CI: 88.6 to 93.3) among those with multimorbidity. Among those with HIV infection, the proportion with plasma viral load <100 copies/mL was 423(88.5%)/478.

CONCLUSION

Integrated management of chronic diseases is a feasible strategy for the control of HIV, diabetes and hypertension in Africa and needs evaluation in a comparative study.

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.

Serum fructosamine and glycemic status in the presence of the sickle cell mutation

AIMS

The glycated hemoglobin (HbA1c) test can be unreliable in the presence of hemoglobinopathies. The co-existence of type 2 diabetes (T2D) with sickle cell anemia calls for alternative tests. Therefore, we established a reference interval for serum fructosamine and evaluated its utility as a potential glycemic biomarker that is not affected by abnormal hemoglobin.

METHODS

The accuracies of serum fructosamine in monitoring and diagnosing T2D were evaluated using the Area under the Receiver Operating Characteristics and other measures in 618 Nigerians with or without sickle cell trait. The estimated diagnostic cut-off for serum fructosamine was then validated in an independent multi-ethnic cohort of 634 West Africans.

RESULTS

Serum fructosamine was similar between individuals with or without sickle cell trait (median: 287 vs 275 umol/L, p = 0·11, respectively) despite statistically different HbA1c. Fructosamine was highly correlated with both HbA1c and fasting glucose independently of sickle cell trait. The areas under the curve (AUC) of serum fructosamine in identifying individuals with uncontrolled glycemia and individuals with T2D were similar and independent of sickle cell trait: 0·92 (95% confidence interval [95% CI ], 0·88-0·95 and 0.92 (95% CI, (0.89-0.95) respectively.

CONCLUSIONS

Serum fructosamine is a good alternative to HbA1c for monitoring and diagnosing T2D in the presence of sickle cell trait.

Examining social determinants of undiagnosed diabetes in Namibia and South Africa using a behavioral model of health services use

AIMS

To examine factors associated with undiagnosed diabetes in Namibia and South Africa.

METHODS

This study used the most recent Demographic and Health Surveys (DHS) from Namibia (2013) and South Africa (2016). This study focused on adults at 35-64 years old. Using Andersen's Behavioral Model, potential contributing factors were categorized into predisposing factors (sex and education), enabling factors (wealth, health insurance, and residence), and a need factor (age, BMI, and high blood pressure). Separate multivariable logistic regression models were used to examine factors associated with undiagnosed diabetes in Namibia (N = 242) and South Africa (N = 525).

RESULTS

In Namibia, higher odds of having undiagnosed diabetes were associated with rural residence (adjusted odds ratio (aOR) = 2.21) and age younger than 45 years old (aOR = 3.20). In South Africa, odds of having undiagnosed diabetes were higher among the poorest-to-poorer group than it was in the richer-to-richest group (aOR = 2.33). In both countries, having high blood pressure was associated with lower odds of having undiagnosed diabetes (aOR = 0.31 in Namibia; aOR = 0.21 in South Africa).

DISCUSSION

Different enabling and need factors were associated with undiagnosed diabetes in these two countries, which implies potentially-different mechanisms driving the high prevalence of undiagnosed diabetes, as well as the needs for different solutions.

Quality of life among adult patients living with diabetes in Rwanda: a cross-sectional study in outpatient clinics

OBJECTIVES

To report on the disease-related quality of life of patients living with diabetes mellitus in Rwanda and identify its predictors.

DESIGN

Cross-sectional study, part of the baseline assessment of a cluster-randomised controlled trial.

SETTING

Outpatient clinics for non-communicable diseases of nine hospitals across Rwanda.

PARTICIPANTS

Between January and August 2019, 206 patients were recruited as part of the clinical trial. Eligible participants were those aged 21-80 years and with a diagnosis of diabetes mellitus for at least 6 months. Illiterate patients, those with severe hearing or visual impairments, those with severe mental health conditions, terminally ill, and those pregnant or in the postpartum period were excluded PRIMARY AND SECONDARY OUTCOME MEASURES: Disease-specific quality of life was measured with the Kinyarwanda version of the Diabetes-39 (D-39) questionnaire. A glycated haemoglobin (HbA1c) test was performed on all patients. Sociodemographic and clinical data were collected, including medical history, disease-related complications and comorbidities.

RESULTS

The worst affected dimensions of the D-39 were 'anxiety and worry' (mean=51.63, SD=25.51), 'sexual functioning' (mean=44.58, SD=37.02), and 'energy and mobility' (mean=42.71, SD=20.69). Duration of the disease and HbA1c values were not correlated with any of the D-39 dimensions. A moderating effect was identified between use of insulin and achieving a target HbA1c of 7% in the 'diabetes control' scale. The most frequent comorbidity was hypertension (49.0% of participants), which had a greater negative effect on the 'diabetes control' and 'social burden' scales in women. Higher education was a predictor of less impact on the 'social burden' and 'energy and mobility' scales.

CONCLUSIONS

Several variables were identified as predictors for the five dimensions of quality of life that were studied, providing opportunities for tailored preventive programmes. Further prospective studies are needed to determine causal relationships.

TRIAL REGISTRATION NUMBER

NCT03376607.

The Oral Glucose Tolerance Test: 100 Years Later

For over 100 years, the oral glucose tolerance test (OGTT) has been the cornerstone for detecting prediabetes and type 2 diabetes (T2DM). In recent decades, controversies have arisen identifying internationally acceptable cut points using fasting plasma glucose (FPG), 2-h post-load glucose (2-h PG), and/or HbA1c for defining intermediate hyperglycemia (prediabetes). Despite this, there has been a steadfast global consensus of the 2-h PG for defining dysglycemic states during the OGTT. This article reviews the history of the OGTT and recent advances in its application, including the glucose challenge test and mathematical modeling for determining the shape of the glucose curve. Pitfalls of the FPG, 2-h PG during the OGTT, and HbA1c are considered as well. Finally, the associations between the 30-minute and 1-hour plasma glucose (1-h PG) levels derived from the OGTT and incidence of diabetes and its complications will be reviewed. The considerable evidence base supports modifying current screening and diagnostic recommendations with the use of the 1-h PG. Measurement of the 1-h PG level could increase the likelihood of identifying high-risk individuals when the pancreatic ß-cell function is substantially more intact with the added practical advantage of potentially replacing the conventional 2-h OGTT making it more acceptable in the clinical setting.

Access to insulin delivery devices and glycated haemoglobin in lower-income countries

BACKGROUND

Young people with type 1 diabetes in low-and-middle income countries face many challenges in accessing care, with various essential supplies needed for survival and long-term health.

AIM

To study insulin delivery devices and glycated haemoglobin (HbA1c) testing.

METHODS

A survey was conducted in 2019 of leading diabetes centres in 41 countries supported by the Life for a Child Program. The survey covered numerous aspects concerning availability and costs at all levels of the health system, local usage patterns and attitudes, obstacles, and other aspects.

RESULTS

Thirty-seven countries returned the survey (90.2% response rate). Key findings included: Syringe use was most common (83.1%), followed by insulin pens (16.7%) and pumps (0.2%). 48.6% of public health systems did not provide syringes, even with a co-payment. Use of suboptimal syringe/needle combinations was common. Needles were generally reused in almost all countries (94.3%, n = 35). Aside from donated supplies, there was variable access to HbA1c testing within public health facilities, and, when available, patients often had to cover the cost. Provision was further compromised by numerous problems including stock-outs, and challenges with understanding the test, equipment maintenance, and refrigeration.

CONCLUSION

Large gaps exist for adequate access to appropriate insulin delivery devices and HbA1c testing. Public health systems in low-and-middle income countries should increase affordable provision. There are also needs for specific health professional training and diabetes education; elimination of customs duties and taxes; development of inexpensive, robust HbA1c testing methods that do not require refrigeration of testing supplies; differential pricing schemes; and other solutions.

Implementation of blood glucose self-monitoring among insulin-dependent patients with type 2 diabetes in three rural districts in Rwanda: 6 months open randomised controlled trial

INTRODUCTION

Most patients diagnosed with diabetes in sub-Saharan Africa (SSA) present with poorly controlled blood glucose, which is associated with increased risks of complications and greater financial burden on both the patients and health systems. Insulin-dependent patients with diabetes in SSA lack appropriate home-based monitoring technology to inform themselves and clinicians of the daily fluctuations in blood glucose. Without sufficient home-based data, insulin adjustments are not data driven and adopting individual behavioural change for glucose control in SSA does not have a systematic path towards improvement.

METHODS AND ANALYSIS

This study explores the feasibility and impact of implementing self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes in rural Rwandan districts. This is an open randomised controlled trial comprising of two arms: (1) Intervention group-participants will receive a glucose metre, blood test strips, logbook, waste management box and training on how to conduct SMBG in additional to usual care and (2) Control group-participants will receive usual care, comprising of clinical consultations and routine monthly follow-up. We will conduct qualitative interviews at enrolment and at the end of the study to assess knowledge of diabetes. At the end of the study period, we will interview clinicians and participants to assess the perceived usefulness, facilitators and barriers of SMBG. The primary outcomes are change in haemoglobin A1c, fidelity to SMBG protocol by patients, appropriateness and adverse effects resulting from SMBG. Secondary outcomes include reliability and acceptability of SMBG and change in the quality of life of the participants.

ETHICS AND DISSEMINATION

This study has been approved by the Rwanda National Ethics Committee (Kigali, Rwanda No.102/RNEC/2018). We will disseminate the findings of this study through presentations within our study settings, scientific conferences and publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

PACTR201905538846394; pre-results.

Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa; implications for the future

BACKGROUND

Currently about 19 million people in Africa are known to be living with diabetes, mainly Type 2 diabetes (T2DM) (95%), estimated to grow to 47 million people by 2045. However, there are concerns with early diagnosis of patients with Type 1 diabetes (T1DM) as often patients present late with complications. There are also challenges with access and affordability of insulin, monitoring equipment and test strips with typically high patient co-payments, which can be catastrophic for families. These challenges negatively impact on the quality of care of patients with T1DM increasing morbidity and mortality. There are also issues of patient education and psychosocial support adversely affecting patients' quality of life. These challenges need to be debated and potential future activities discussed to improve the future care of patients with T1DM across Africa.

METHODOLOGY

Documentation of the current situation across Africa for patients with T1DM including the epidemiology, economics, and available treatments within public healthcare systems as well as ongoing activities to improve their future care. Subsequently, provide guidance to all key stakeholder groups going forward utilizing input from senior-level government, academic and other professionals from across Africa.

RESULTS

Whilst prevalence rates for T1DM are considerably lower than T2DM, there are concerns with late diagnosis as well as the routine provision of insulin and monitoring equipment across Africa. High patient co-payments exacerbate the situation. However, there are ongoing developments to address the multiple challenges including the instigation of universal health care and partnerships with non-governmental organizations, patient organizations, and pharmaceutical companies. Their impact though remains to be seen. In the meantime, a range of activities has been documented for all key stakeholder groups to improve future care.

CONCLUSION

There are concerns with the management of patients with T1DM across Africa. A number of activities has been suggested to address this and will be monitored.

Introduction of a national program for HbA1c testing in Guyana South America and initial results

Diabetes is an increasing challenge for low- and middle-income countries (LMIC) and access to HbA1c testing is limited. HbA1c, a measure of glycaemic control averaged over 3 months, provides both clinicians and policymakers with a tool to identify the risk of long-term diabetes comorbidity. We describe the steps used to implement standardised testing in Guyana South America and the initial results according to a locally developed protocol as part of a country-wide project to improve the care of people with all forms of diabetes The steps identified include: a standardised method traceable to a recognized international reference standard, participation in a quality control cycle with an international reference laboratory, a clinical pathway for testing to reduce inappropriate use and minimize resource wastage, training of technicians in operation and maintenance of equipment, identification of a suitable space with constant power supply, a reliable procurement system, education of healthcare professionals on interpretation and follow-up of results and feedback of programme results to improve clinical practice. Some steps for implementation of the national HbA1c testing program were initiated better than others. Initial unreliability of the service undermined confidence in the system. Failure to follow the testing protocol led to some patients being tested too soon and others too late. Cost of reagents was about 5.60 USD/test. We trained 340 people in diabetes care and knowledge was improved but were unable to assess whether it was appropriately applied. Over one third of people tested in the 30-70 age group had an HbA1c over 9% (75 mmol/mol) and this did not improve over the 5 years of testing. Despite the difficulties we think our unique experience of implementation of a nationwide HbA1c testing programme has important lessons for other LMICs.

Diabetes mellitus and laboratory medicine in sub-Saharan Africa: challenges and perspectives

Diabetes mellitus is an increasing public health problem in sub-Saharan Africa with a substantial socioeconomic burden. Although laboratory medicine has been recognized as one of the six key public health functions, there are still gaps in strengthening of laboratory services in developing countries. In the last decades, a lot of progress has been made in the diagnostic field of infectious diseases, whereas the diagnosis of noncommunicable diseases is still insufficient and uneven. This article analyses the challenges encountered in diagnosing and monitoring of diabetes mellitus in sub-Saharan Africa and explores new alternative diagnostic tools.