Integrated management of Type 1 DM children, CDiC, DRC

Objectives

The frequency of diabetes is rising throughout the world and many countries are documenting increasing numbers of newly diagnosed cases even of type 1 diabetes in children. While the burden of type 1 diabetes is low in many developing countries, the level of awareness is even lower. As a consequence, many children die even before they are diagnosed. And those who get diagnosed have a limited life span.

Unfortunately, a child dying of diabetes without knowing he or she had the disease is not an isolated story in developing countries. Even children diagnosed have a short life or experience early onset of complications due to poor management of the disease. However, it is possible to prevent children from suffering a cruel fate like this by greater awareness about type 1 diabetes and proper education for the health care professionals and care givers.

A recent study documents the above mentioned example. A review of medical files in a major children's hospital in Kinshasa did not identify a single child with diabetes over a period of 10 years. In sub-Saharan Africa, the information and treatment of children with type 1 diabetes is limited, and the Democratic Republic of Congo (DRC) is no exception.

The aim is to improve the management of type 1 diabetes among children by establishing a systematic approach.

Approach

Kinshasa only has one clinic for children with diabetes (supported by the International Diabetes Federation). This clinic is experiencing major challenges in managing the children and is dealing with insufficient amounts of insulin and other diabetes supplies such as monitoring equipment etc. With this project, Bureau Diocésain des Oeuvres Médicales (BDOM) in Kinshasa is implementing a system for comprehensive management of diabetes with support from the Ministry of Health and collaboration with Novo Nordisk and Roche Diagnostics. Novo Nordisk will provide insulin for all children included in the project for the three (potentially five) years the project runs. Similarly, Roche Diagnostics will support the project through supply of monitoring equipment etc. This project is connected to the projects WDF02-041 and WDF05-128, both situated in DRC.

The project will use an approach called "Hub and Spoke" to establish the clinics, containing four components:
1. Establishment of specialised clinics for children
2. Education and training of doctors and nurses
3. Education of children with type 1 diabetes and their families
4. Raising community awareness about the problem of diabetes in children

The first component will include establishment of two clinics (hubs) in Kinshasa for children with type 1 diabetes; one at Hospital St Joseph and one at the Salvation Army Medical Centre. Further, two satellite centres (spokes) will be established and supervised by the two initial clinics. One satellite centre will be placed at Centre Hospitalier Lukunga in Ngaliema County and the other at Centre Hospitalier Lisungi in Mont Ngafula County. The clinics will be renovated and provided with basic medical and laboratory equipment and refrigerators for proper storage of insulin and strips.

The centres will be endowed with IT equipment and software for data collection and reporting with the purpose of establishing a comprehensive registry of children with diabetes. The registry will enable proper surveillance and follow-up of the children attending the clinics, thereby improving the quality and consistence of the diabetes control. 400 children are expected to benefit from this initiative.

Training of doctors and nurses in the diagnosis and management of children with type 1 diabetes will ensure the quality of the treatment. The training will be based on the "Guidelines for comprehensive management of type 1 diabetes in children in resource poor settings", which is a modified version of International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines adapted to sub-Saharan Africa edited by a network of African health care professionals. A core group of eight doctors and 16 nurses will be identified in collaboration with the Ministry of Health. These doctors and nurses will be managing children with type 1 diabetes and receive training each year, starting the first year with a three-day course. The second year they will receive a two-day refresher course followed by a one-day refresher course in the third year.

The third component, relating to education of children and their families, will be approached by reviewing existing education materials on diabetes and adapt it to children and the situation in the Democratic Republic of Congo. Education on diabetes for children and their families will improve the children's self-management and adherence to treatment. To meet this component, education workshops will be prepared at each centre and peer education support will be strengthened.

Organisation of diabetes camps will bring a feeling of comradeship amongst children and families with diabetes and help form support groups to further create advocacy. In addition, the camps will provide the opportunity for children and parents to learn from each other in a supervised fun environment. The project is expected to have a multiplier effect in other health facilities in Kinshasa and in the rest of the country. Furthermore, the project may have an impact on the formal training programme for future doctors and nurses.

Results at completion

• 4 clinics established
• 9 doctors and 14 nurses trained
• 411 children received comprehensive diabetes care
• 3 maps conducted for children with T1DM and their parents
• Education material distributed to children, parents and national authorities
• Increased awareness in the community