E-ISSN 1858-8360 | ISSN 0256-4408
 

Original Article 


SUDANESE JOURNAL OF PAEDIATRICS

2020; Vol 20, Issue No. 2

ORIGINAL ARTICLE

Incidence and prevalence of type 1 diabetes mellitus in children and adolescents aged 6 months–19 years in Khartoum State, Sudan

Fadwa Mohammed Saad (1), Lubna Abdalla Mahmoud (2), Amna Mamoon Mohammed Ali (2), Ilham Mohammed Omer (3), Mohammed Ahmed Abdullah (3)

(1) Department of Community Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan

(2) Pediatrics Specialist, Sudan Childhood Diabetes Centre, Khartoum, Sudan

(3) Department of Paediatrics and Child Health, Faculty of Medicine, University of Khartoum, Khartoum, Sudan

Correspondence to:

Fadwa Mohammed Saad

Department of Community Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan

Email: Fadwamdsaad [at] gmail.com

Received: 23 April 2020 | Accepted: 12 May 2020

How to cite this article:

Saad FM, Mahmoud LA, Mohammedali AM, Abdullah MA, Omer IM. Incidence and prevalence of type 1 diabetes mellitus in children and adolescents aged 6 months–19 years in Khartoum State, Sudan. Sudan J Paediatr. 2020;20(2):163–169.

https://doi.org/10.24911/SJP.106-1587542600


ABSTRACT

The aim of this study is to measure the incidence and prevalence of type 1 diabetes mellitus in children and adolescents in Khartoum State, Sudan. Records of all patients aged 6 months–19 years, living in Khartoum State and who were known to have or newly diagnosed with type 1 diabetes in all health institutes (both governmental and private) during the period January to December 2015, were reviewed. In addition to the records, interviews with patients and caregivers attending the clinics were conducted. Names were double-checked with the Sudanese Childhood Diabetes Association’s central registry. Data were analysed using the Statistical Package for the Social Sciences software (SPSS 20). A total of 2,393 children were identified. Males were 1,117 (46.6%) and females were 1,276 (53.3%) with a ratio of 1:1.4, with no significant difference. The prevalence rate was 0.74/1,000. The overall incidence rate was 10.1/100,000. The peak incidence age was between 11 and 15 years (15.9/100,000). The incidence rates in below 5 years and 16–19 years were 8.4 and 7.7/100,000, respectively. There was no significant difference between males and females. In most of the cases, the onset was in the winter months. The commonest month of birth was June.The incidence of type 1 diabetes in Sudan is still considered among the high rate group in the world and in the region. There was an obvious increase in the incidence among the below-5 years age group (8.4/100,000) compared to a figure of 3.5 which was reported earlier from Sudan. For the first time, we report the incidence among the 16–19 age group (7.7/100,000).


KEYWORDS

Type 1 diabetes; Sudan; Incidence; Prevalence.


INTRODUCTION

Type 1 diabetes mellitus (T1DM) is one of the most common endocrine and metabolic conditions in childhood. Data from the International Diabetes Federation (IDF) reported that the estimated number of children and adolescents with T1DM aged 0–20 years was 1.1 million, with about 128,900 new cases diagnosed every year [1]. The estimated annual increase in T1DM is 3% [1].The worldwide geographic variation in the incidence of T1DM is striking. The highest figure of incidence per 100,000 is in Finland (62.3). The estimated number of children and adolescents (<20 years) with T1DM in the Middle East and North Africa was 175,800 in 2017 [1]. Kuwait (41.7), Saudi Arabia (31.4) and Qatar (21.4) are among the top ten countries with the highest incidence rates worldwide [1].The IDF estimates that about 50,200 children and adolescents with T1DM currently live in Africa [1,2]

Epidemiological studies for T1DM from Sudan are scarce. In a prospective hospital-based registry in Khartoum City between 1987 and 1990, the incidence of T1DM in children below 15 years increased from 5.9 in 1987 to 10.1/10,000 in 1990, with a mean annual incidence rate of 7.9 [3]. In another study between 1991 and 1995, the mean annual incidence rate increased to 10.1 [4], and since then, no studies were published from Sudan. The childhood diabetes care situation is different in Sudan. Since 2005, the Sudanese Childhood Diabetes Association has established more than 25 clinics in all states of Sudan with multidisciplinary teams. Insulin, meters and strips are provided free and, therefore, almost all children are seen in these clinics. Out of these there are eight in Khartoum State. All children in these clinics are centrally registered in the Sudanese Childhood Diabetes Association’s registry. This study aims to measure the incidence and prevalence of T1DM in children and adolescents aged 6 months–19 years, in 2015, in Khartoum State.


MATERIALS AND METHODS

This descriptive, cross-sectional survey was carried out in 2015 in Khartoum State in Sudan. Sources that provided us with information for this study were clinical records of 17 government hospitals, three private specialised paediatrics endocrine clinics, in addition to the Sudanese Childhood Diabetes Center. The government hospitals included were five paediatric hospitals and 12 general hospitals. Two other general paediatric clinics in Dar Al Elag and Royal Care private hospitals were also approached; however, they referred the cases to paediatrics clinic two. Another private hospital (Garash International Specialised Hospital) was out of service at the time of data collection. Hospital records of the Sudanese Childhood Diabetes Association’s registry and health insurance records were secondary sources of ascertainment. Review of patients’ names, surnames, date of onset, tribe and residency was conducted to avoid duplication.

All children with T1DM who were under follow-up during the period from 1 January up to 31 December 2015 were included. Any child who was on insulin and was labelled by the treating doctor as having type 1 diabetes was included. Children who were diagnosed as having diabetes below 6 months or having other types of diabetes, such as type 2, were excluded from this study. Also, children living outside Khartoum State were excluded.

The incidence was calculated from all cases aged 6 months–19 years who were newly diagnosed during 2015 and were in Khartoum at the onset divided by the total population in the same age group. The prevalence was calculated from all new and old cases aged 6 months–19 years who were living in Khartoum State during the study period divided by the total population in the same age group.

The data for the population statistics which were used as the denominator for both the prevalence and incidence were obtained from the Central Bureau of Statistics, Sudan. The numbers are projections for the year 2015 for Khartoum State and from the last census carried out in Sudan in 2008. The data collected included age, sex, residence, tribe, date of birth and date of diabetes onset. The Statistical Package for the Social Sciences software software 20.0 for Windows® package was used in the statistical analysis. Data were expressed as frequencies [n (%)]. The chi-squared test was used to test the statistical associations and a p-value less than 0.05 was considered statistically significant.


RESULTS

A total of 2,393 patients in the 6 months–19 years age group in Khartoum State were found to have T1DM. The distribution of the patients in the different hospitals/clinics is shown in Table 1. The age and sex distribution of the study population are shown in Table 2. The majority of the patients were female (53.3%). The female to male ratio was .1.14.:1, in favour of females. But this female predominance was not statistically significant (p = 0.116). Almost 70% of the cases were in the 11–19 years age group and 8.5% were below 5 years (Table 2).

Table 3 shows the prevalence and incidence rates. The prevalence was 0.74/1,000 population/year, with the highest prevalence in the 6–10 years age group. The total number of new cases was 326 and the incidence rate was 10.1/100,000 population/year, with the highest incidence among the 11–15 years age group. The incidence among the children below 5 years was 8.4/100,000. The frequency of newly diagnosed T1DM cases was found to be significantly increased with age, reaching a peak in the 11–15 years age group and a lower rate in the 6 months–5 years age group (p = 0.000).

Figure 1 shows the month of birth in our study population. The commonest month of birth was June (summer). However, there was no statistically significant difference among the months (p = 0.455).

Table 1. Distribution of the patients’ records according to hospitals/clinics (n = 2,391).

No. Hospital/clinic name Hospital/clinic type Number(%) of records
Sudan Childhood Diabetes Center Non-governmental Non-profit 284 (11.8%)
Jafar Ibn Auf Paediatric Hospital Governmental 331(13.8%)
Ahmed Gasim Paediatric Teaching Hospital Governmental 76 (3.1%)
Alturky General Hospital Governmental 14 (0.5%)
Bashaeer General Hospital Governmental 1(0.04%)
Endocrinology Clinic 1 (Dr. Basheer Alwasela) Private 47 (1.9%)
Ibrahim Malik Teaching Hospital Governmental 16 (0.6%)
Omdurman Paediatrice Teaching Hospital Governmental 231(9.6%)
Sharg Alneel General Hospital Governmental 79 (3.3%)
Al Buluk Paediatric Teaching Hospital Governmental 782 (32.7%)
Alban Jadeed General Hospital Governmental 27 (1.1%)
Military General Hospital Governmental 65 (2.7%)
Alacademey General Hospital Governmental 29 (1.2%)
Bahry General Hospital Governmental 17 (0.7%)
Endocrinology clinic 2 (Prof. Mohammed A. Abdullah) Private 323 (13.5%)
Abu Sead Paediatric Teaching Hospital Governmental 5 (0.2%)
Alimam Abd AlRahman General Hospital Governmental 1(0.04%)
Soba University Hospital University Hospital 31 (1.2%)
Ali AbdAlFattah General Hospital Governmental 12 (0.5%)
Omdawanban General Hospital Governmental 10 (0.4%)
Endocrinology Clinic 3 (Dr. Mohammed Abd AlRahman) Private 10 (0.4%)
Total 2,391a

*Data is missing for two records

Figure 2 shows the month of onset of diabetes in our study population. Although relatively larger numbers were born in January (winter), there was no statistically significant difference among the months (p = 0.096).


DISCUSSION

This is the first study since 1995 [4] on the epidemiology of T1DM in Khartoum State, Sudan, and it included 2393 children and adolescents aged 6 months–19 years. The incidence was 10.1/100,000, which is considered to be lower when compared to the figures from European countries, like Finland (62.3) and the United Kingdom (25.9/100,000) [1]. This variation could be due to genetic and environmental differences. While under-reporting could be a problem in other parts of Sudan, it is unlikely to be an important factor in Khartoum State because there are well-established childhood diabetes services, and all cases are registered centrally and in all childhood diabetes clinics. Nevertheless, our incidence is higher compared to Turkey (7.2/100,000) [5]. Compared to North Africa and the Middle East, the current incidence rate in Sudan is lower than those reported from Kuwait (41.7), Saudi Arabia (31.4) and Qatar (21.4), but higher than most of the other countries, including Egypt [1,6].

Table 2. Age and sex distribution of the study population (n = 2,393).

Variable Frequency (%)
Sex
Male
Female
1,117 (46.6%)
1,276 (53.3%)
Age group:
0.5 – 5 years
6 – 10
11 – 15
16 – 19
205 (8.5%)
499 (20.9%)
895 (37.4%)
794 (33.2%)
Total 2,393

Table 3. Prevalence and incidence among the study population (n = 2,393).

Age category Prevalence/1000 population per year Incidence/100,000 population per year
0.5 – 5 years 0.23 8.4
6 – 10 years 0.61 9
11 – 15 years 1.13 15.5
16 – 19 years 1.30 7.7
Total 0.74 10.1

Published data on the incidence of T1DM in children from Africa are scarce; however, our figure of 10.1 is higher than the figures of 0.3–2.9 that have been previously reported from Sub-Saharan countries [2,7]. However, this low incidence in Sub-Saharan Africa is expected to be underestimated due to under-reporting and lack of awareness about diabetes among patients, parents and the healthcare staff [7].

This figure is similar to a previous study carried out in Sudan (10.1/100,000) in 1991–1995 [4]. However, the previous study included patients from two registries only, while in our study we included all governmental and private registries in Khartoum State. We also included children and adolescents aged up to 19 years, while the previous study included children aged up to 15 years. In addition, the previous study gave an overall incidence of 5 years [4]. We think our figures are more accurate for the above-mentioned reasons for the situation of diabetes services and registration. Although 5 years of data are more informative, giving cumulative means, a lot of previously published reports were conducted over 1 year [6].

The incidence of childhood type 1diabetes varies with age. In most studies, the typical pattern of type 1 diabetes occurrence by age showed that the incidence increases with age and peaks generally in the peri-pubertal period with the associated gender effect, which starts 1–2 years earlier in girls compared to boys [8]. In our study, T1DM occurrence increased significantly with age, reaching a peak in the 11–15 years age group, before falling to a much lower rate in the 16–19 years age group, similar to a study done in Turkey (males only) [5], which showed that the incidence of T1DM peaked in the 10–14 years age group and peaked in the 5–9 years age group in Turkish females only [5]. In this study, there was an obvious increase in the incidence among the below-5 years age group (8.4/100,000) compared to a figure of 3.5/100,000, which was reported earlier from Sudan [4]. However, this pattern of age variation is similar to the results of a review which found that the peak age of onset in Sub-Saharan Africa was around late teen years, unlike western countries in which the peak of onset occurs around the age of 12 [2,7]. They explained this difference by better chances of detecting diabetes in older children and the changing environmental factors in Europe, which may have accelerated the onset of the disease [2,7].

Figure 1. Distribution of month of birth of children with diabetes in Khartoum state-Sudan 2015, (n = 991)

Figure 2. Distribution of the month of diabetes onset in children with diabetes in Khartoum state-Sudan 2015, (n = 1524).

Our prevalence rate of 0.74 is lower than the figure of 0.95 reported earlier from Khartoum [4].This could be due to recent movements of rural population with low prevalence rates to Khartoum State, the population of which increased from three million at that time to almost eight million now, or because after the establishment of more than 25 clinics of childhood diabetes in all states by the Sudanese Childhood Diabetes Association, cases are now residing and being followed-up there, unlike before when cases used to come and stay in Khartoum for treatment.

This study shows a non-significant female predominance among the total patient population. This result is similar to a previous study from Sudan, which showed only a slight and not significant higher incidence of T1DM in Sudanese females [4]. However, other studies from Turkey [5] and Europe [8] suggested a female predominance in lower-risk populations and a slight increase of males in the high-risk groups, respectively.

Seasonality in T1DM diagnosis has been extensively studied, but the results are conflicting. Some studies have found evidence for seasonality, while others have not [912]. Many studies have shown the month of birth to be in summer and the onset of clinical disease to be in winter. Different suggestions were made to explain seasonality in T1DM diagnosis. Seasonal viral infections (e.g., enteroviruses, rotavirus, mumps, rubella and cytomegalovirus) have been implicated in the aetiology of T1DM [1215]. Seasonality in T1DM diagnosis was not confirmed in our study. There is some variation between the months of T1DM diagnosis, with a high rate during cooler months and peak in January, but this was not statistically significant in contrast to a previous study reported among Sudanese children [4].


CONCLUSION

The results of this study indicate that T1DM incidence (10.1/100,000 population/year) and prevalence (0.74/1,000 population/year) among children aged from 6 months to 19 years living in Khartoum State are still among the highest in Africa, and there is an increase in incidence among the below-5 years age group. Gender predominance and seasonality were not demonstrated. Our recommendation is the need to develop a national registry for T1DM and the need for further multicenter epidemiological research studies covering the whole country to define the nationwide T1DM incidence and the related health data in Sudan.


ACKNOWLEDGEMENTS

The authors thank the manager and the statistics office staff in all the diabetes clinics for their patience and valuable help.


FUNDING

This research was funded by the Sudanese Childhood Diabetes Association which is a non-governmental organisation.


CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.


ETHICAL APPROVAL

This study was approved by the Ethics Committee of the Sudan Childhood Diabetes Center. Permission to access patients records was obtained from hospital authorities, ensuring the confidentiality of all their information.


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  9. Skrodenienė E, Marėiulionytė D, Padaiga Z, Jaėinskienė E, Sadauskaitė-Kuehne V, Sanjeevi CB, et al. HLA class II alleles and haplotypes in Lithuanian children with type 1 diabetes and healthy children (HLA and type 1 diabetes). Medicine (Kaunas). 2010;46:505–10. https://doi.org/10.3390/medicina46080072
  10. Patterson CC, Dahlquist GG, Gyürüs E, Green A, Soltész G: EURODIAB Study Group. Incidence trends for childhood type 1 diabetes in Europe during 1989-2003 and predicted new cases 2005-20: a multicentre prospective registration study. Lancet. 2009;373:2027–33. https://doi.org/10.1016/S0140-6736(09)60568-7
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  12. Spaans EA, van Dijk PR, Groenier KH, Brand PL, Reeser MH, Bilo HJ, et al. Seasonality of diagnosis of type 1 diabetes mellitus in the Netherlands (Young Dudes-2). J Pediatr Endocrinol Metab. 2016;29(6):657–61. https://doi.org/10.1515/jpem-2015-0435
  13. Kalliora MI1, Vazeou A, Delis D, Bozas E, Thymelli I, Bartsocas CS. Seasonal variation of type 1 diabetes mellitus diagnosis in Greek children. Hormones (Athens). 2011;10(1):67–71. https://doi.org/10.14310/horm.2002.1294
  14. TEDDY Study Group. The Environmental Determinants of Diabetes in the Young (TEDDY) Study: study design. Pediatr Diabetes. 2007;8:286–98. https://doi.org/10.1111/j.1399-5448.2007.00269.x
  15. Filippi C, von Herrath M. How viral infections affect the autoimmune process leading to type 1 diabetes. Cell Immunol. 2005;233:125–32. https://doi.org/10.1016/j.cellimm.2005.04.009


How to Cite this Article
Pubmed Style

Saad FM, Mahmoud LA, Ali AMM, Omer IM, Abdullah MA. Incidence and prevalence of type 1 diabetes mellitus in children and adolescents aged 6 months–19 years in Khartoum State, Sudan. Sudan J Paed. 2020; 20(2): 163-169. doi:10.24911/SJP.106-1587542600


Web Style

Saad FM, Mahmoud LA, Ali AMM, Omer IM, Abdullah MA. Incidence and prevalence of type 1 diabetes mellitus in children and adolescents aged 6 months–19 years in Khartoum State, Sudan. http://www.sudanjp.com/?mno=101148 [Access: October 29, 2020]. doi:10.24911/SJP.106-1587542600


AMA (American Medical Association) Style

Saad FM, Mahmoud LA, Ali AMM, Omer IM, Abdullah MA. Incidence and prevalence of type 1 diabetes mellitus in children and adolescents aged 6 months–19 years in Khartoum State, Sudan. Sudan J Paed. 2020; 20(2): 163-169. doi:10.24911/SJP.106-1587542600



Vancouver/ICMJE Style

Saad FM, Mahmoud LA, Ali AMM, Omer IM, Abdullah MA. Incidence and prevalence of type 1 diabetes mellitus in children and adolescents aged 6 months–19 years in Khartoum State, Sudan. Sudan J Paed. (2020), [cited October 29, 2020]; 20(2): 163-169. doi:10.24911/SJP.106-1587542600



Harvard Style

Saad, F. M., Mahmoud, . L. A., Ali, . A. M. M., Omer, . I. M. & Abdullah, . M. A. (2020) Incidence and prevalence of type 1 diabetes mellitus in children and adolescents aged 6 months–19 years in Khartoum State, Sudan. Sudan J Paed, 20 (2), 163-169. doi:10.24911/SJP.106-1587542600



Turabian Style

Saad, Fadwa Mohammed, Lubna Abdalla Mahmoud, Amna Mamoon Mohammed Ali, Ilham Mohammed Omer, and Mohammed Ahmed Abdullah. 2020. Incidence and prevalence of type 1 diabetes mellitus in children and adolescents aged 6 months–19 years in Khartoum State, Sudan. Sudanese Journal of Paediatrics, 20 (2), 163-169. doi:10.24911/SJP.106-1587542600



Chicago Style

Saad, Fadwa Mohammed, Lubna Abdalla Mahmoud, Amna Mamoon Mohammed Ali, Ilham Mohammed Omer, and Mohammed Ahmed Abdullah. "Incidence and prevalence of type 1 diabetes mellitus in children and adolescents aged 6 months–19 years in Khartoum State, Sudan." Sudanese Journal of Paediatrics 20 (2020), 163-169. doi:10.24911/SJP.106-1587542600



MLA (The Modern Language Association) Style

Saad, Fadwa Mohammed, Lubna Abdalla Mahmoud, Amna Mamoon Mohammed Ali, Ilham Mohammed Omer, and Mohammed Ahmed Abdullah. "Incidence and prevalence of type 1 diabetes mellitus in children and adolescents aged 6 months–19 years in Khartoum State, Sudan." Sudanese Journal of Paediatrics 20.2 (2020), 163-169. Print. doi:10.24911/SJP.106-1587542600



APA (American Psychological Association) Style

Saad, F. M., Mahmoud, . L. A., Ali, . A. M. M., Omer, . I. M. & Abdullah, . M. A. (2020) Incidence and prevalence of type 1 diabetes mellitus in children and adolescents aged 6 months–19 years in Khartoum State, Sudan. Sudanese Journal of Paediatrics, 20 (2), 163-169. doi:10.24911/SJP.106-1587542600





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