The prevalence of Diabetes mellitus is increasing globally and in 2019, approximately 463 million adults (20-79 years) were living with diabetes; by 2045 this will rise to 700 million (IDF, 2019). Myanmar, now in the epidemical transition period having population of over 51 million (51, 486, 253) (Census 2014), has a high prevalence of diabetes with approximately 2.5 million (10.5% of population) and 5 million (19.7%) with prediabetes (WHO STEPS survey, 2014).
Diabetes mellitus is the main underlying aetiology of chronic non-communicable diseases (NCDs) which are among the leading causes of death and disability worldwide (WHO NCDs data, 2018). Diabetes mellitus can be complicated by the development of stroke, cardiovascular disease (CVD), and peripheral vascular disease resulting in gangrene and amputation of limbs, blindness due to the diabetes retinopathy, diabetes nephropathy resulting in chronic renal failure, peripheral neuropathy with the loss of sensation in legs and hands, skin infections and delayed wound healing. Moreover, due to the gestational diabetes mellitus, there can be congenital anomalies, macrosomia, increased perinatal death, abortion and increased incidence to birth trauma, and the baby has increased risk of developing type 2 diabetes in later life. One of the cost effective interventions (Best Buys) for preventing diabetes and related NCD is to provide counseling and multiple drug therapy (including glycaemic control for diabetes mellitus) for people with 10-year cardiovascular risk > 30% (WHO NCDs in SEAR 2011 Situation and Response).
About 70% of Myanmar people live in rural areas and under primary health care. Because of different geographical patterns of Myanmar, medical officers are not always present in these far and remote areas. Therefore, for the rural people, primary health care (PHC) services for Diabetes by doctors are not accessible easily. To narrow the gap between primary and tertiary level, Ministry of Health Sports (MoHS) has adopted the WHO Package of Essential Non-communicable Disease – (PEN) Intervention, with the concept to integrate Non Communicable Diseases (NCDs) into primary health care.
PEN implementation (2016-19) process includes TOT Training of Township Medical Officers (TMO) and Multiplier training for Basic Health Staffs (BHS) (Midwives, Public Health Supervisors, Lady Health Visitors, Health Assistants), Advocacy Meetings, PEN implementation at Rural Health Centers and Sub-centers and Supervision trips and Monitoring and Evaluation (M&E) and these activities are led by NCD department and DM project, funded by EU. Equipments (Thermometers, Stethoscopes, Blood pressure cuffs, Measuring tapes, Weighing machines, Glucometers, Blood glucose test strips, Lancets and needles, Urine test strips and WHO cardiovascular disease risk assessment charts) and essential medicines (Metformin, Gliclazide, Insulin, Amlodipine, Atenolol, Atorvastatin, Aspirin) are supplied by Department of Public Health, MoHS to all over the country. These inexpensive medications are useful in prevention of heart attack, stroke and DM and also in treatment of DM, hypertension and dyslipidaemia.
The Myanmar PEN intervention targets on screening, treatment and referral for major NCDs, mainly diabetes and hypertension. Cardiovascular disease (CVD) risk management using WHO cardiovascular disease risk assessment charts, Diabetes foot care and Healthliteracy promotion are also carried out. These services have been provided by BHS under supervision of Medical Officers in Wednesday Clinics.
With the leadership of CVD project and DM project, TOT trainings on ‘Preventive Cardiology, DM Emergency, High risk Management and Proper Referral’ was given to the physicians of all States and Division in 2019. The attended physicians furthergave Multiplier trainings to Township Medical Officers (TMO), Station Medical Officers (SMO), Civil Assistant Surgeons (CAS) at sixteen States and Divisions. Also with Myanmar Diabetes Care Program (MCDP) supported by Novo Nordisk Pharmaceutical Company Ltd., Denmark, the teaching faculties from Department of Diabetes and Endocrinology of University of Medicine 1, 2 and Mandalay gave on Diabetes Care trainings to all medical officers and nurses of both Public and Private Hospitals at all three levels. The outcome is aimed for these medical officers to acquire up to date knowledge of current standard international guidelines so that Cardiac and Diabetes patients shall receive Standard Primary Medical Cares, Effective Clinical Management, Insulin therapies in those needed and Early Referral Practices.
The MCDP has also been supporting to open Type 1 diabetes clinics in Yangon Children Hospital (YCH) and University of Medicine 1, 2 and Mandalay and to establish Diabetes Center of excellence in tertiary hospitals of all states and divisions for Comprehensive Diabetes Care. Diabetes education programs on Patient Dialogues (including Six Diabetes Subjects with Audiovisual animations in Myanmar Version) and Diabetes Wikipedia (Ten Subjects in English) have been inserted in the mobile tablets distributed by MoHS to all medical officers, nurses and BHS thus the former can be utilized for health education programs and the latter can be taken as references for BHS.
With the project of Diabetes Foot Clinic supported by World Diabetes Federation (WDF), the project activities have been carried out to improve the awareness, prevention, early detection and management of diabetic foot problems in Myanmar. The diabetic foot care services and diabetic foot care education sessions are now established in university hospitals, the capacity building on diabetic foot care for health care providers has been giving, the public awareness of diabetic foot care in Myanmar has been rising by the public talks, disseminating posters and pamphlets and mobile foot care clinics within three years.
The Diabetes Project under MOHS and NCD department, funded and cooperated by WHO is situated in Department of Diabetes and Endocrinology, University of Medicine 2. Apart from leading and organizing, the activities include: continually produce Information; Education and Communication (IEC) materials, conducts National surveys and research; proceeds Public talks; conduct Mass screening programmes; provide Academic Training of Medical Officers, General Practitioners, Nurses and BHS and celebrate World Diabetes day (Nov 14) annually. The Myanmar Diabetes Association (MMDA) is a public non- profitable organization leading public awareness campaigns, activities and talks, celebrating World diabetes day annually, issuing news – letters quarterly and producing TV health shows and CME talks. The Myanmar Society of Endocrinology and Metabolism (MSEM) is the Professional Body actively involved in training of primary care physician for diabetes and endocrine care, organizing AFES 2017 in Myanmar, in collaboration with the Endocrine society US, International society of Endocrinology, UK and also participating Public awareness talk, campaign, screening, touring, Guideline development and CME talks.
In conclusion, upgraded knowledge and skillful diabetes management proficiencies are needed for all practicing doctors and it is the right time and the needed occasion to issue this month journal including a series of topics on diabetes management which will be fruitful and useful for all primary care physicians.
Prevention and Control of Diabetes Project (DM Project), Myanmar
