Protocole national de prévention et de prise en charge du diabète sucré au Burundi

Objectives

Burundi’s 2020 national diabetes protocol provides a national framework to improve prevention and care, reduce diabetes-related morbidity and mortality, and harmonise management across the health system.[1][2]It addresses diabetes epidemiology, risk factors, diagnosis, therapeutic objectives, treatment, complications, lifestyle adaptation, nutrition, physical activity, pharmacological care and community prevention.[1][3][4]

• Strengthen health workers’ knowledge of diabetes and improve diagnosis of diabetes and its complications.[2]
• Provide treatment pathways differentiated by diabetes type and level of care, including management of uncomplicated disease, acute metabolic emergencies and chronic complications.[2][5][6]
• Prevent or delay type 2 diabetes through healthy diet, weight reduction for people with overweight or obesity, regular physical activity, management of hypertension and dyslipidaemia, smoking cessation and stress management.[7]
• Prioritise prevention and screening among people over 40 years, smokers, alcohol consumers, people with elevated waist circumference or hypertension, and people with personal or family histories of cardiovascular disease, diabetes or kidney disease.[6]
• Prevent hyperglycaemia-related symptoms, acute and chronic complications, and mortality while maintaining patient autonomy; target glycated haemoglobin below 7.0% and fasting blood glucose at or below 125 milligrams per decilitre.[8]
• Promote early detection, referral where necessary and patient information to prevent chronic complications, with glycaemic and blood-pressure control as core measures.[9][10]
• Prevent diabetic-foot ulcers and amputations through risk assessment, foot-care education, appropriate footwear and risk-adapted podiatric care.[10][7]
• Support planned pregnancy and pre-conception glycaemic control for women with diabetes, maintain specified glucose and glycated haemoglobin targets during pregnancy, and prevent neonatal hypoglycaemia.[5]

Implementation

The protocol applies a tiered clinical-delivery model spanning health centres and first-, second- and third-level referral hospitals, combining community prevention, screening, diagnosis, patient education, lifestyle management, medicines, insulin therapy, monitoring and referral.[2][6][11]The Ministry of Public Health and the Fight Against AIDS leads through the General Directorate of Health Services and the Fight Against AIDS, the Directorate of Health Programmes and Projects, and the National Integrated Programme for Non-Communicable Chronic Diseases.[1]

• Organise uncomplicated diabetes care across health facilities, while referring gestational and juvenile diabetes to facilities with a doctor and directing complicated cases to better-equipped services.[6]Manage acute metabolic complications in referral hospitals, while providing hypoglycaemia care at all levels.[6]
• Use clinical symptoms and laboratory testing, including glycated haemoglobin, fasting blood glucose and blood glucose 120 minutes after a 75 gram glucose load, to establish diabetes diagnosis.[12]Diagnose gestational diabetes through a 75 gram oral glucose tolerance test between 24 and 28 weeks of amenorrhoea or by first-trimester fasting blood glucose according to protocol thresholds.[8]
• Assess weight, height, blood pressure, vascular status, feet, eyes and dental health at diagnosis, alongside risk factors and possible complications.[8]Screen people without risk factors every three years and people with identified risk factors every six years.[6]
• Deliver therapeutic education at each consultation by assessing patients’ knowledge and needs, including understanding of diabetes, self-monitoring of blood glucose, nutrition, physical activity and foot-lesion prevention.[13]Promote dietary adaptation and regular activity, with at least 30 minutes of activity daily where possible or at least every other day, and walking specifically encouraged.[14][6]
• Use insulin as the principal treatment for type 1 diabetes and apply a stepped approach for type 2 diabetes, beginning with diet, physical activity and metformin when these measures do not achieve glycaemic targets, then escalating to sulphonylureas, combinations or insulin where indicated.[14][15]Use insulin in pregnancy, severe hyperglycaemia, severe infection, peri-operative care, treatment failure and relevant renal, hepatic or cardiac insufficiency.[15][5]
• Hospitalise urgently and treat diabetic ketoacidosis and hyperosmolar hyperglycaemic states with rehydration and insulin, with basal-bolus subcutaneous therapy considered after clinical improvement.[5][9]Refer renal failure to specialised centres and ensure ophthalmology services can manage diabetic retinopathy, including laser photocoagulation, surgery and intravitreal medication.[9]
• Equip health centres with nurses, community health workers, a head nurse, diabetes educators, clinical guides, urine strips, blood-glucose meters, blood-pressure monitors, scales and measuring tapes.[11]Provide referral hospitals with multidisciplinary personnel, laboratory and glycated-haemoglobin testing, neurological and eye-examination tools, and insulin pumps; strengthen third-level services with specialist care, retinal imaging, laser treatment, cardiovascular investigations, surgery and renal replacement capacity.[11]
• Monitor weight, body mass index and blood pressure at every consultation; examine peripheral pulses and feet every three months; undertake retinal and dental examinations annually; support self-monitoring; measure glycated haemoglobin every six months; and conduct lipid profiling annually.[8]Reassess treatment-algorithm outcomes after 14 days and adjust, maintain or refer care according to blood-glucose results.[10][4]
• Recognise that no formal national monitoring-and-evaluation indicators, reporting system, surveillance register, accountability mechanism, implementation timeline or budget is specified in the supplied extracts.[2][4][11]Diabetes is nevertheless described as generating substantial direct and indirect costs, while global estimates cited attribute 12% of total health expenditure, equivalent to 727 billion US dollars in 2017, to diabetes.[16][2]

Monitoring & Evaluation

Monitoring is principally clinical and follow-up based, with specified screening intervals, routine examinations, laboratory tests, self-monitoring and reassessment points. The extracts do not set out a national monitoring and evaluation framework, aggregate indicators, reporting requirements, surveillance register, evaluation timetable or formal accountability arrangements.[17][2][13][18][10][4][6][19]

• Screen people without identified risk factors every three years and those with risk factors every six years; priority groups include people aged over 40 years, smokers, alcohol consumers, people with raised waist circumference or hypertension, and people with relevant personal or family histories.[6]
• Measure weight, height, body mass index and blood pressure at every consultation, and examine peripheral pulses and feet every three months.[8]
• Conduct retinal and dental examinations annually, with retinal assessment undertaken at second- and third-level care and dental assessment available at all levels.[8]
• Support self-monitoring of blood glucose, measure glycated haemoglobin every six months, and undertake lipid profiling every 12 months.[8]
• Monitor plasma creatinine and creatinine clearance annually, microalbuminuria every six months, liver tests at baseline and annually thereafter, and electrocardiography at baseline and annually thereafter.[13]
• Assess at each consultation patients’ socioeconomic difficulties, understanding and experience of diabetes and treatment, and barriers or successes in adhering to treatment and recommended actions.[13]
• Undertake frequent daily blood-glucose self-monitoring when using a basal-bolus insulin regimen so that doses can be adjusted.[18]
• Test blood glucose and glycated haemoglobin three months after gestational diabetes and annually thereafter to detect subsequent diabetes.[5]
• Recognise and screen for chronic complications, explain risks to patients and provide preventive advice; an annual eye examination is also recommended because retinopathy may remain asymptomatic for a prolonged period.[9][20]
• Assess peripheral pulses and intermittent claudication, and enquire about angina and erectile dysfunction at each consultation; use electrocardiography when clinically indicated and annual exercise testing in referral centres for possible coronary disease.[10]
• Reassess people managed through treatment algorithms after 14 days, using blood-glucose results to maintain, intensify or refer treatment.[10][21][4]
• Use fasting and post-prandial blood glucose, ketonuria, symptoms, resolution of acetonuria and normalisation of blood glucose to monitor acute metabolic complications, particularly ketoacidosis.[4]
• Monitor preventive management of chronic complications through glycaemic and blood-pressure control, strict glycaemic control for retinopathy and neuropathy, and assessment of diabetic-foot risk.[7]

Costing & Financing

The extracts provide no Burundi-specific costing, budget, financing plan, allocation, funding source, resource-mobilisation strategy, funding-gap assessment or economic assumptions for implementing the diabetes protocol. They nonetheless identify potentially substantial resource needs for clinical monitoring, medicines, specialist referral, equipment and workforce capacity.[2][13][18][6][11][19]

• Recognise that diabetes-related complications generate substantial direct and indirect costs for patients, society and the country, although no national monetary estimate is provided.[2]
• Note international estimates that diabetes represented 12% of total health expenditure in 2017, equivalent to 727 billion US dollars globally.[16]
• Identify combination treatment with metformin, glucagon-like peptide-1 analogues and dipeptidyl peptidase-4 inhibitors as very expensive, without a quantified price.[15]
• Provide minimum staffing and equipment across health-system levels, including glucose meters, test strips, glycated haemoglobin testing, insulin pumps, retinal imaging and laser treatment, laboratory capacity, haemodialysis and possible renal transplantation capacity; no monetary valuation accompanies these requirements.[11]
• Maintain specialist capacity for diabetic retinopathy treatment, including laser photocoagulation, surgery and intravitreal medicines, while noting that associated costs are not specified.[9]