Dealing With Diabetes in Disaster Zones: Planning Is Vital

December 07, 2017

ABU DHABI, United Arab Emirates — To improve the care of people with diabetes during disasters, whether natural or caused by humans, there needs to be much better coordination between agencies such as the International Diabetes Federation (IDF), Médecins Sans Frontières (MSF), World Diabetes Foundation, UNHCR, and Insulin-for-Life, among others.

That was the verdict of representatives from many of these organization during a roundtable discussion on "building a diabetes and disasters response network" here at the International Diabetes Federation (IDF) Congress 2017. For the first time, diabetes and disasters was made a separate "track" at the meeting.

"It's very important that we share our experiences," said endocrinologist Nizar Al Bache, from Diabetes Center, Doha, Qatar, representing IDF. "We have the same purpose, helping people with diabetes during conflicts or disasters. But we repeat the same mistakes.

"For those living with diabetes, it's important they know there are people thinking about them. But we cannot do it alone, we have to work together," he stressed.

The meeting heard that, at any one time, there are about 50 million people worldwide violently uprooted from their homes, which includes about 250,000 with type 1 diabetes who, without insulin for more than a few days, will develop diabetic ketoacidosis and die.

People who live with all forms of diabetes face many difficulties getting essential medicines and supplies, such as insulin, blood glucose test strips, adequate nutrition, and physical activity, and addressing other comorbidities such as hypertension and dyslipidemia.

So there is an urgent need for protocols. For humanitarian workers and healthcare providers, the greatest obstacles are lack of predisaster plans and poor local resources.

Planning and Preparedness Is Vital

Dr Al Bache said it's key that plans are in place to "prepare and know when to act before a catastrophe" wherever possible. Alicia Jenkins, an endocrinologist from the University of Sydney, Australia, also working for IDF Western Pacific Region, agreed.

"It's not if, but when — globally there are about 40 major disasters every year." Planning is paramount, and "preparedness lessens the negative impact of disasters," she explained. "We need to prepare, update, and rehearse our local guidelines."

And there are many things to prepare for. Loss of power, communications, shelter, transport, and sometimes law and order. Then there is the issue of sanitation, safe water, a healthy food supply, medications, and what treatment facilities remain available.

And there are multiple levels to consider: that of the person with diabetes and their family; healthcare professionals; the local and national community; and international aid agencies.

IDF is in the process of developing recommendations for diabetes during disasters, based on the existing IDF Western Pacific Region Program for Diabetes Management in Natural Disaster,

IDF also currently has a summary online of guidance for patients with diabetes advising them how to prepare for and what to do in a disaster situation, in 17 languages .

There is also advice from Australia, from 2016, called "Make a Plan: Manage Your Diabetes in an Emergency," said Dr Jenkins.

Stakeholders are numerous, and there are many that are often forgotten, she said. For example, while many people would think of emergency responders such as ambulance, fire brigade, police, and military, if phone and internet services are down, "ham radio operators" can become key, she noted.

"When your technology is knocked out, you still need a plan, a more basic form of communication."

One attendee, Debbie Jones, diabetes nurse educator at Bermuda Hospitals Board previously involved with IDF, said simple things can make a huge difference in disaster zones. For example, during the hurricanes in the Caribbean this summer, there was no one "central point" to go to online to obtain the names of people locally who could help, she noted.

"There needs to be a website with every single member association listed, with contact details (eg, cellphone numbers, ham radio, and email)."

Dr Jenkins agreed, noting it's also important that these contacts are regularly checked — for example, yearly — and updated where necessary.

Diabetes Now Included as Part of Emergency Response

In any disaster, there is always an acute phase, with those whose lives are immediately threatened being the number-one priority. For diabetes patients, this includes those with type 1 who are experiencing diabetic ketoacidosis and any diabetes patients with kidney disease on dialysis.

MSF has a "relatively new" commitment to include diabetes "in our emergency response," explained Philippa Boulle, an endocrinologist who is noncommunicable diseases advisor and chronic disease team leader with MSF in Switzerland.

"Diabetes is an extremely important thing to respond to," she added, noting that insulin and other diabetes drugs have recently been added to MSF's emergency-response drug kit.

Describing his many years of working with the United Nations Relief and Works Agency (UNRWA) for Palestine refugees in the Near East, the director of health of UNRWA, Akihiro Seito, said that "diabetes is a major health problem" among this population. In 2016, UNWRA diagnosed and treated a total of 120,000 diabetes patients, and medicines for diabetes account for 25% of the entire cost of medicines obtained by the agency, he noted.

Realizing that there is a similar, immense burden among other refugee populations, particularly those from Syria, UNRWA organized an international conference on the topic, held in Jordan earlier this year he noted.

One important call was to include diabetes as part of both acute and protracted emergency responses, he said.

Insulin Can Be Used in Absence of Refrigeration

One important point for healthcare workers, patients, and others to know is with regard to insulin and the fact that "it can still be used in the absence of refrigeration," Neil Donelan, of Insulin for Life Global, explained to delegates.

"There's no power and no cold storage, so what do you do with insulin? You take a shovel and dig a hole and put in in the ground," he said. Other options include some "traditional" means of cooling, such as clay pots or wet goat skins, said Dr Jenkins.

"Lack of refrigeration shouldn't be a barrier to lack of use of insulin," stressed Dr Donelan.

There's also the option of solar-powered refrigeration, and industry is working to develop incredibly heat-stable insulins, although there remains the issue of whether they will be made affordable for use in humanitarian situations, the speakers agreed.

"Patient Passport": Diabetes Patients Should Know Their Medications

The next phase of response is the continuity of care for preexisting disease, and diabetes is the second most common of these, after hypertension, said Dr Boulle.

In order to help with administration of this, it's vital, whenever possible, for diabetes patients to know the names of the medications they are taking, rather than turning up saying they are taking "pink or blue pills," all the speakers agreed.

"Ideally everyone would have a 'patient passport' with key information on it such as drugs they are taking, their blood sugar levels, blood pressure," she noted, with others concurring and saying this information could also be stored in a smartphone.

Key during this second phase of response is continued collaboration between existing agencies, said Dr Boulle. "We need to harmonize response elements and overlap."

It's also key in such situations to have people on the ground who can be trusted, said Dr Al Bache. "Names are important. Sometimes you can inadvertently enter into local turf wars. You have to make sure things get into the right hands."

This is where a proper assessment at the beginning of the disaster can help immensely on many levels and where continued communication is key, noted Dr Boulle.

Indeed, cochair of the session, Sidartawan Soegondo, of the University of Indonesia, Jakarta, had a cautionary tale.

During the tsunami in Indonesia in 2004, "the Japanese Diabetes Society sent us thousands of dollars in aid, but there was no good communication. We never received the money, and it was eventually sent back to Japan," he explained.  

International Diabetes Federation (IDF) Congress 2017. December 7, 2017; Abu Dhabi, United Arab Emirates. Abstract 353, Abstract 354, Abstract 356, Abstract 357Abstract 358

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