This short report describes the problem of foot complications in patients with diabetes in Tanzania. It focuses on the scope of the problem, the barriers to effective care that have led to this situation and the introduction of an integrated programme for improving outcomes, involving active surveillance, microbiology and staff training.

INTRODUCTION

For people with diabetes in Tanzania, foot complications, such as ulceration, infection or gangrene lead to considerable morbidity, long-term disability or premature mortality. Peripheral neuropathy is the underlying cause of most of these complications, although the occurrence of peripheral vascular disease appears to be rising in parallel with increasing urbanisation. Published data from Tanzania shows mortality rates at >50% among patients with severe foot ulcers who do not undergo surgery [1].

INTEGRATED PROGRAMME

To address these emergent problems, we instituted an integrated programme that included:

• Surveillance for limb complications (Tanzania Diabetic Ulcer Surveillance System or TANDUSS)
• Ongoing follow-up where patients with limb complications are managed medically or surgically as deemed appropriate, and outcomes documented
• Epidemiologic, clinical and microbiology studies
• Enhancement of microbiology services.

DATA ANALYSIS

Our surveillance data indicated that 15% of people with diabetes admitted to Muhimbili National Hospital in Dar es Salaam had foot ulcers, with 80% of these being first-time occurrences. Despite a low prevalence of peripheral vascular disease, amputation was a frequent outcome (33%). The highest in-hospital mortality (50%) was observed in patients with a Wagner score of >4, whose inpatient management did not include surgery with amputation. 

More recent analyses of our data suggest:

• Morbidity and mortality may be related to underlying chronic osteomyelitis in the lower limb
• Surgical intervention after the onset of gangrene may be too late to significantly reduce mortality
• Infections are playing a greater role in the pathogenesis of foot ulcer disease than was previously thought.
• A Gram stain of a deep tissue biopsy of an ulcer is significantly predictive of the microorganism responsible for infection.