1. Implementation of home-based insulin management (HIM) without refrigeration in Dagahaley refugee camp, Kenya
Said Abdullahi Hassan1, Abdijabir Adan1, Bashir Abdiweli1, Rachel Kamau1, Dzhamila Rakhmatbekova1, Susana Cristofani1, Iza Ciglenecki1, Philippa Boulle1
1Medecins Sans Frontieres (MSF), Geneva, Switzerland
Said Abdullahi, MSF. Home Insulin Management without refrigeration

2. Background Dagahaley camp
Population : mostly Somali refugees (UNHCR April 2017)
810 MSF NCD patients (1.2% camp population)
- 21.9% DM and 54% HTN
MSF Operations
March 2009: primary health care (PHC)
August 2011: added secondary health care
NCD care is integrated into PHC
Patients using insulin received it twice daily at the emergency room of the camp hospital
High insecurity. MSF is the only medical organization.
Said Abdullahi, MSF. Home Insulin Management without refrigeration

3. WHY WAS THE PROGRAM STARTED?
Increasing number of patients requiring insulin
Distance and insecurity
Poor glycemic control (due to non-adherence)
Frequent admissions due to acute complications.
Msf.org
Said Abdullahi, MSF. Home Insulin Management without refrigeration

4. Objectives
Assess the feasibility of home-based insulin management in a complex humanitarian setting without refrigeration
Improve access to and adherence with insulin use
Prevent acute complications
Decongest emergency room and reduce ward admissions
Improve diabetes control and patient outcomes.
Said Abdullahi, MSF. Home Insulin Management without refrigeration

5. Methodology Descriptive study
Retrospective analysis of routine program data
Meets exemption criteria set by MSF-ERB (ethics review board)
Said Abdullahi, MSF. Home Insulin Management without refrigeration

6. Steps in implementation
SOPs development
Eligibility criteria, Medical care
Follow-up, monitoring and evaluation
Community and patient sensitization & awareness
Insulin thermostability study
Said Abdullahi, MSF. Home Insulin Management without refrigeration

7. Eligibility criteria for HIM
All diabetic patients requiring insulin management
Willing to inject insulin and to check own blood sugars
Willing to be admitted for insulin optimisation, education, and come for follow up
Able to read, write and understand numbers (or caretaker to do so)
Possessing sufficient manual dexterity (or caretaker to do so)
Said Abdullahi, MSF. Home Insulin Management without refrigeration

8. Competency & CHW home visit check
Done on discharge from the ward and at 6 months in the program
Key components:-
Signs & symptoms of Hypo/hyperglycemia and how to react
Insulin storage
Hygiene
Injection technique and dosing
Sick day rules
Infection prevention and safety
Food availability
Said Abdullahi, MSF. Home Insulin Management without refrigeration

9. to self-inject my insulin dose”
“Am happy, I now know how
to self-inject my insulin dose”
Child with diabetes
Discharge package
Said Abdullahi, MSF. Home Insulin Management without refrigeration

10. Charcoal cooler “QABOOJIE”
Said Hassan/MSF
Said Hassan/MSF
Said Abdullahi, MSF. Home Insulin Management without refrigeration

11. Results - patient characteristics
We started with 24 patients
8 new patients joined the program in 2016
6 exits (5 relocation and 1 death of an unrelated reason)
1 to 65 years (mean 20.4, SD13.38)
11 patients <18 years
10 (41.7%) Female
Age n %
0-4 2
8.3
5-14 4
16.7
15-49 17
70.8
50+ 1
4.2
Sex n %
Male 14
58.3
Female 10
41.7
Said Abdullahi, MSF. Home Insulin Management without refrigeration

12. Results- patient characteristics
25% of the cohort had a comorbidity
Time since diagnosis ranged from 1 month to 12 years (mean 4.34 years, SD2.97)
Comorbidity
No (%)
DM T1/HTN
1(4.2%)
DM T2/HTN
2(8.3)
DM/renal impairment
DM/ eye complication
Said Abdullahi, MSF. Home Insulin Management without refrigeration

13. Results-patient outcome HbA1c analysis
Initial
12 months n %
< 8.5 5
20.8 4
22.2
8.6-11 11
45.8 7
38.9
>11 8
33.4
HbA1c = a measure of patients’ diabetes control (target < 8.5% for this program)
Done at enrolment, 3, 6, 9, 12 months
At enrolment: to 14%
(mean 10.4 SD0.02)
At 12 month in 18 patients: 7.0 to 14%
(mean 10.2, SD1.86)
44.4% improved
Said Abdullahi, MSF. Home Insulin Management without refrigeration

14. HbA1c Analyzer
Said Abdullahi, MSF. Home Insulin Management without refrigeration

15. Results- ER consultation and hospitalization
Hospital diabetes admissions
Emergency stabilization
Said Abdullahi, MSF. Home Insulin Management without refrigeration

16. Results- insulin recovery rates
33 residual insulin samples sent for potency analysis:
32 analysed
12-31 days period of storage
all samples within targeted range of 100+/- 10
- thus conform to pharmacopeia.
Said Abdullahi, MSF. Home Insulin Management without refrigeration

17. Results- temperature monitoring
Periodic temperature monitoring for the charcoal coolers
Hottest and coolest months of the year
Varied between (min/max) [°C]
Said Abdullahi, MSF. Home Insulin Management without refrigeration

18. Limitations Diet Poor socio-economic status Illiteracy
Said Abdullahi, MSF. Home Insulin Management without refrigeration

19. Conclusion
Home-based insulin management is well accepted by patients- allows them to return to their normal activities.
HIM appears feasible in a complex humaniterian setting without refrigeration
Improved patient care, 44% improvement in HbA1c, no admission due to acute complication.
This model of care can be implemented in other MSF and non-MSF settings.
Said Abdullahi, MSF. Home Insulin Management without refrigeration

20. Acknowledgments Many thanks to:- MSF-CH field and co-ordination teams
OCG Medical Department and MOSU 
OCG innovation unit
UNIGE
Dagahaley Community and patients
We confirm we have permission to use images from participants included in this presentation
Said Abdullahi, MSF. Home Insulin Management without refrigeration