World J Diabetes 2020; 11: 358369. https://dx.doi.org/10.4239/wjd.v11.i8.358
To assess access to insulin delivery devices and HbA1c in 41 countries supported by the Life for a Child (LFAC) program Syringes (83.1%), insulin pens (16.7%) and pumps (0.2%) were used for insulin delivery If supplies were not donated, there was variable access to HbA1c testing within public health facilities and cost was usually covered by the patient
This article highlights how the high costs (extremely variable from country to country) and low availability of basic necessities (insulin, blood glucose monitoring and HbA1c) for a patient with Type 1 diabetes living in a low resource setting can lead to difficult or unsafe choices. The 2018 ISPAD guidelines (1) include a section on Limited Care Guidance that makes suggestions for patients who need to prioritize several aspects of the care. Arguably, the priority is to ensure access to insulin and food. Blood glucose monitoring, while preferred, can be performed 3-4 times a day several days a week when possible, or substituted for urine glucose monitoring. HbA1c should be performed at least once a year in a reliable laboratory. Implementing such recommendations requires training of allied health professionals who can address diabetes management when there is no food security, understand how to manage a patient when only limited types of insulins (such as premix insulin) are available, be knowledgeable in the interpretation of urine and blood glucose monitoring and work with the local laboratory to ensure that HbA1c measurements are accurate. This information is not commonly found in textbooks published in high-income countries. Such courses are presently being developed in Africa through an initiative of ISPAD-LFAC and in Sudan through an initiative of the Sudanese Center for Diabetes in Children, in collaboration with Global Pediatric Endocrinology and Diabetes (GPED) and thanks to funding from the World Diabetes Foundation.
References: 1. Codner E, Acerini CL, Craig ME, Hofer SE, Maahs DM. ISPAD Clinical Practice Consensus Guidelines 2018: Limited Care Guidance Appendix. Pediatr Diabetes 2018; 19 (Suppl. 27): 328338. doi: 10.1111/pedi.12767.