Use of Medical Services and Medicines Attributable to Diabetes in Sub-Saharan Africa

Background

Although the large majority of persons with diabetes and other non-communicable diseases (NCDs) lives and dies in low- and middle-income countries, the prevention and treatment of diabetes and other NCDs is widely neglected in these areas. A contributing reason may be that, unlike the impacts of acute and communicable diseases, the demands on resources imposed by diabetes is not superficially obvious, and studies capable of detecting these impacts have not be done.

Methods

To ascertain recent use of medical services and medicines and other information about the impact of ill-health, we in 2008–2009 conducted structured, personal interviews with 1,780 persons with diagnosed diabetes (DMs) and 1,770 matched comparison subjects (MCs) without diabetes in Cameroon, Mali, Tanzania and South Africa. We sampled DMs from diabetes registries and, in Cameroon and South Africa, from attendees at outpatient diabetes clinics. To recruit MCs, we asked subjects with diabetes to identify five persons living nearest to them who were of the same sex and approximate age. We estimated diabetes impact on medical services use by calculating ratios and differences between DMs and MCs, testing for statistical significance using two-stage multivariable hurdle models.

Findings

DMs consumed 12.95 times more days of inpatient treatment, 7.54 times more outpatient visits, and 5.61 times more medications than MCs (all p<0.001). DMs used an estimated 3.44 inpatient days per person per year, made 10.72 outpatient visits per person per year (excluding traditional healers), and were taking an average of 2.49 prescribed medicines when interviewed.

Conclusions

In Sub-Saharan Africa, the relative incremental use of medical care and medicines associated with diagnosed diabetes is much greater than in industrialized countries and in China. Published calculations of the health-system impact of diabetes in Africa are dramatic underestimates. Although non-communicable diseases like diabetes are commonly thought to be minor problems for health systems and patients in Africa, our data demonstrate the opposite.     

Decreasing the Burden of Type 2 Diabetes in South Africa: The Impact of Taxing Sugar-Sweetened Beverages

Introduction

Type 2 diabetes poses an increasing public health burden in South Africa (SA) with obesity as the main driver of the epidemic. Consumption of sugar sweetened beverages (SSBs) is linked to weight gain and reducing SSB consumption may significantly impact the prevalence of obesity and related diseases. We estimated the effect of a 20% SSB tax on the burden of diabetes in SA.

Methods and Findings

We constructed a life table-based model in Microsoft Excel (2010). Consumption data from the 2012 SA National Health and Nutrition Examination Survey, previously published own- and cross-price elasticities of SSBs and energy balance equations were used to estimate changes in daily energy intake and its projected impact on BMI arising from increased SSB prices. Diabetes relative risk and prevalent years lived with disability estimates from the Global Burden of Disease Study and modelled disease epidemiology estimates from a previous study were used to estimate the effect of the BMI changes on diabetes burden. Diabetes cost estimates were obtained from the South African Council for Medical Schemes. Over 20 years, a 20% SSB tax could reduce diabetes incident cases by 106 000 in women (95% uncertainty interval (UI) 70 000–142 000) and by 54 000 in men (95% UI: 33 000–80 000); and prevalence in all adults by 4.0% (95% UI: 2.7%-5.3%). Cumulatively over twenty years, approximately 21 000 (95% UI: 14 000–29 000) adult T2DM-related deaths, 374 000 DALYs attributed to T2DM (95% UI: 299 000–463 000) and over ZAR10 billion T2DM healthcare costs (95% UI: ZAR6.8–14.0 billion) equivalent to USD860 million (95% UI: USD570 million–USD1.2 billion) may be averted.

Conclusion

Fiscal policy on SSBs has the potential to mitigate the diabetes epidemic in South Africa and contribute to the National Department of Health goals stated in the National NCD strategic plan.     

Diabetes in tropical Africa: a prospective study, 1981-7. II. Course and prognosis.

OBJECTIVE--To determine the clinical course of diabetes mellitus in tropical Africa. DESIGN--Continuing care and follow up until 31 March 1989 of all newly diagnosed diabetic patients registered at one hospital between 1 June 1981 and 31 May 1987. SETTING--Muhimbili Medical Centre, Dar es Salaam, Tanzania. SUBJECTS--1250 Newly diagnosed diabetic patients seen over a six year period. 272 (21.8%) Had diabetes requiring insulin, 825 (66.0%) diabetes not requiring insulin, and 153 (12.2%) diabetes of uncertain type. MAIN OUTCOME MEASURES--Survival rates during each year of follow up. RESULTS--205 (16.4%) Patients were known to have died, 126 (61.5%) in hospital and 79 (38.5%) in the community. At least a further 71 patients were likely to have died. The five year survival rates (95% confidence intervals) for patients with diabetes requiring and not requiring insulin were 71% (62% to 80%) and 84% (80% to 89%) respectively for known deaths and 60% (51% to 69%) and 82% (77% to 86%) respectively for known plus probable deaths. 49 (3.9%) Patients died at the time of presentation. Severe diabetic ketoacidosis and infection were responsible for most deaths in patients with diabetes requiring insulin. Infection was responsible for 24% of deaths in patients with diabetes not requiring insulin and was the main cause of death in the group with uncertain type of diabetes. Cardiovascular and renal causes were responsible for 24% of hospital deaths of patients with diabetes not requiring insulin. Diabetes requiring insulin, young age, and ketonuria at presentation were associated with a significantly worse five year survival on multivariate analysis. On univariate analysis underweight, female sex, low educational background, and manual occupations were additional factors with a worse prognosis. CONCLUSION--Diabetes in sub-Saharan Africa is, in many patients, a serious disease with a poor prognosis. Most deaths, however, are due to preventable causes. More effort is therefore required to increase public awareness of diabetes and to improve patient detection, management, and follow up.     

Blastomycosis in Africa

The known African cases of blastomycosis to 1987 are presented, including thirteen previously undescribed cases. This brings to 81 the total number of cases known to have occurred in Africa. The question of whether the disease in Africa is the same in all respects as that in North America is addressed; the age and sex distributions of patients are similar. Minor differences in the clinical features relate particularly to the type of skin lesion, the more frequent bone involvement and the less frequent central nervous system involvement in the African patient. Little is known about the epidemiology of blastomycosis in Africa; one noteworthy feature is the apparent absence of the disease in dogs. Isolates of Blastomyces dermatitidis from the two continents, although closely related, differ in some respects.