Continuing Program Evaluation for Life For a Child-Pitt Initiative Program in Rwanda

Vineeta Sharma

Faculty advisor and Site preceptor: Dr. Trevor Orchard

Diabetes • Diabetes, is a group of diseases characterized by high blood

glucose levels that result from defects in the body's ability to produce and/or use insulin.

• Insulin is a hormone produced by the pancreas to control blood sugar and allows the body to use sugar for energy. The deficiency of insulin leads to increased blood glucose levels which can then lead to various complications.

• Chronic diabetes conditions include:– Type1 diabetes is an autoimmune disorder in which the pancreas does

not produce insulin – Type2 diabetes in which there is insufficient production of insulin or

insulin-resistance due to which the body is unable to recognize and use insulin properly.

Diabetes Complications

• If not controlled, diabetes can cause a host of complications that can affect nearly every organ in the body. Diabetes complications include: – Retinopathy– Neuropathy– Nephropathy– Ketoacidosis– Peripheral Arterial Disease– Amputation of limbs– Stroke– Stress– Skin complications

Diagnosis and Control• A random blood glucose level of 200 mg/dL or higher, plus the

presence of the following symptoms, can mean a person has diabetes:– increased urination, increased thirst, increased hunger, unexplained weight

loss or sores that do not heal• A fasting plasma blood glucose level in a person who has not eaten

anything for at least 8 hours:– 99mg/dL or less is considered normal– 100-125mg/dL is considered pre-diabetes– 126mg/dL or above is considered diabetes

• Diabetes can be controlled by:– Physical activity– Diet control– Hypoglycemic drugs or insulin

Life For a Child ProgramIn 2001, the International Diabetes Federation (IDF) launched the Life for a Child Program to provide children in developing countries with the diabetes supplies, care and education they need to survive. It is run in partnership with Diabetes Australia-NSW and HOPE worldwide. This IDF program works to strengthen existing pediatric diabetes services so that they can provide the best possible care, given local circumstances, to all young people with diabetes in their area. The LFAC is currently supporting 4000 children in 26 countries. Most of the funding for this program comes through individual donations and donation of supplies from companies.

Life for a Child-Pitt Initiative in Rwanda

• University of Pittsburgh provides assistance with education, training and implementation of LFAC program in Rwanda.

• Every year University of Pittsburgh sends out an intern to assist the LFAC program in Rwanda. The internship includes filling out the annual LFAC forms, performing comprehensive clinical exams along with updating the data-base.

• I was the second student after Sarah Marshall (2009 MPH student and current doctoral student) who helped with the program as a part of the MPH Practicum.

ARD And The Diabetes Center

The diabetes centre started last year by Gishoma and his wife is a training/support center for children with diabetes. Children enroll here for a period of 6-months and learn how to manage their diabetes along with learning livelihood skills such as tailoring etc.

Association Rwandaise des Diabetique (ARD) headed by Mr. Francois Gishoma is the implementing in-country partner for LFAC program. As an established center of care for diabetics, the ARD helps with the treatment, education and management of diabetes. Located in the capital city Kigali, it not only caters to diabetics in Kigali but all around the country.

My Trip On May 19th 2010, Sarah Marshall and I, arrived at the ARD to see children with diabetes. Having oriented me to the local situation and the ARD personnel, Sarah left on 1st June. But before she left, we conducted clinical exams and filled out LFAC forms for 60 children. Most of these children were examined at the ARD while the rest were examined at the 4 regional hospitals (located at Butare, Kigeme, Kabagayi and Kilinda) we travelled to between 19th and 30th May.

Clinical Exams

As a part of the established LFAC protocol, we conducted comprehensive clinical exams on children to assess the following:– Height, weight, blood

pressure– Neuropathy: assessed by

examining the feet using a monofilament and a tuning fork.

– Visual acuity: assessed by a Snellen chart

Clinical Exams– HbA1C: glycated hemoglobin

measured by running blood samples on the DCA-Vantage Analyzer• < 6% is normal, >6.5% is the

newly recommended criteria for diagnosing diabetes, diabetics advised to keep levels <7%

– Microalbumin: microalbumin and creatinine levels measured by running urine samples on the DCA-Vantage Analyzer• Microalbuminuria if albumin

between 30-299 mg/L or A/C ratio of 30-300 mg/gm

The LFAC forms (such as the one shown on the left) were used for data collection.

My Trip

• On 3rd June, Dr. Trevor Orchard and Dr. Deborah Edidin arrived at Kigali and continued to follow up children at the ARD. During this time, we also started collecting data on the patterns of insulin use among the children supported through the LFAC program.

• After their departure on 8th June, I was left with the goal of fulfilling my mission of continuing program evaluation, visiting the children at the regional hospitals, implementing quality control for machines along with updating the data-system.

Travelling To Regional Hospitals

• A total of 27 children (both new and previously registered) were examined at these 3 locations and LFAC forms completed for all of them.

• From June 9th to June 14th, the nurse from ARD-Vedaste Kaberuka and I travelled to two more regional hospitals (located at Gisenyi and Kibungo) along with a second visit to the diabetes centre ( at Mwururi) to examine the children there.

Brief Summary of LFAC-2010• Males = 61, Females = 80• Mean age = 19.05, range 4-25 • Mean height= 155 cm Mean weight= 49.8 kg• Mean age at diagnosis=15.04 years; range 0-25• Mean duration = 3.3 years, range 0-13 • Mean glucose monitors/week= 1.39; range 0-21• Mean insulin shots per day= 1.85; range 1-2• Mean units of insulin per day = 34.83 • Mean HbA1c = 10.27% ; 19 (13.47%) have reading of >14.0% • Microalbuminuria = 11 patients (7.8%) have at least microalbuminuria, 3 (2.1%)

had overt nephropathy • Number of children missing/behind in school due to diabetes = 62 (43.97%) • Mean random blood glucose measurement = 245.3 mg/dL; range 38 – 600+

mg/dL

Summary Of Patterns of Insulin Use

• Children on Lantus only: 10• Children on Lantus and Actrapid: 2• Children on Lantus and Humulin-R: 2• Children on Levemir only: 2• Children on Lente only: 7• Children on Lente and Actrapid: 195• Children on Lente and Humulin-R: 11• Children on Premix only: 67• Children on NPH and Humulin-R: 50• Children on Actrapid only: 2

The Thousand Hills Chronicle

Rwanda, popularly known as the “Land of Thousand Hills” is a beautiful country of

wonderful people. Despite a tragic history, the upbeat attitude of the Rwandans is

truly inspiring. Even in the face of scarce resources, the people of Rwanda are

striving to help their nation’s children- many orphaned by decades of strife. These children are the country’s rays of hope as this nation gears up for a brighter future.

When I embarked on this journey, little did I expect what valuable lessons awaited me there. The six weeks I spent there

have truly been one of the most memorable, humbling and educative

experiences of my life………….

References

“Life for a child”. IDF. Available online. Accessed Sept 16, 2010.

http://www.lifeforachild.idf.org/en/node. “Diagnosis of Diabetes.” National Diabetes Information

Clearinghouse. Available. Online. http://diabetes.niddk.nih.gov/index.htm. Accessed Sept 16, 2010.

“Diabetes”. Medline plus. Available online. Accessed Sept 12, 2010.

http://www.nlm.nih.gov/medlineplus/ency/article/001214.htm