Mortality amongst children and adolescents with type 1 diabetes in sub-Saharan Africa: The case study of the Changing Diabetes in Children program in Cameroon

Introduction: Type 1 diabetes in Africa has been associated with high mortality attributed mainly to poor insulin access. Free insulin provision programs for people with type 1 diabetes have been introduced across Africa recently. We aimed to determine the mortality rate and associated factors in a cohort of children and adolescents with type 1 diabetes who receive free insulin treatment in sub-Saharan Africa. Methods: We conducted a retrospective analysis using the Changing Diabetes in Children (CDiC) medical records in Cameroon between 2011 and 2015. Results: The overall mortality rate was 33.0 per 1000 person-years (95% CI 25.2–43.2). Most deaths (71.7%) occurred outside of the hospital setting, and the cause of death was known only in 13/53 (24.5%). Mortality was substantially higher in CDiC participants followed up in regional clinics compared to the main urban CDiC clinic in Yaounde; 41 per 1000 years (95% CI 30.8–56.0) versus 17.5 per 1000 years (95% CI 9.4–32.5), and in those with no formal education compared to those who had some level of education; 68.0 per 1000 years (95% CI 45.1–102.2) versus 23.6 per 1000 years (95% CI 16.5–33.8). In Cox proportional multivariable analysis, urban place of care (HR = 0.23, 95% CI 0.09–0.57; p = 0.002) and formal education (HR = 0.42, 95% CI 0.22–0.79; p = 0.007) were independently associated with mortality. Conclusion: Despite free insulin provision, mortality remains high in children and adolescents with type 1 diabetes in Cameroon and is substantially higher in rural settings and those with no formal education.