Home-based insulin management in Dagaheley refugee camp, Kenya
Abdijabar Adan, Said Abdullahi Hassan, Bashir Abdiweli, Djamila Rakhmatbekova, Susanna Cristofani, Iza Ciglenecki, *Philippa Boulle
Médecins Sans Frontières (MSF), Geneva, Switzerland
*
Introduction
MSF has been providing health care services in Dagahaley refugee camp, Kenya, since 2009. With no home refrigeration, patients requiring insulin received biphasic insulin twice daily at the emergency department of the MSF hospital, but irregular attendance resulted in poor glycaemic control. In 2014, we conducted a study to test insulin stability at Dagahaley field temperatures, and showed that various formulations of insulin remained viable in the absence of refrigeration. Our findings informed implementation, in November 2015, of a home insulin management (HIM) programme, intended to improve patient care and reduce admissions due to complications, thereby reducing admissions to the emergency room. Patients and their caretakers were admitted to hospital for a 5-day induction course. During admission they received health education, baseline investigations and a patient/caretaker competency assessment. Upon discharge, patients were given kits containing a cooling container and injecting and monitoring equipment. We conducted follow-up consultations at patients’ homes and in the clinic.
Methods
We retrospectively analysed routine programme data.
Ethics
This research fulfilled the exemption criteria set by the MSF ERB for a posteriori analyses of routinely collected clinical data and thus did not require MSF ERB review. It was conducted with permission from Micaela Serafini, Operational Centre Geneva, MSF.
Results
All 24 eligible patients were enrolled in the HIM programme, and all successfully completed the induction course. Patients ranged in age from 1 to 65 years (mean 20.4 years, SD13.38), with 11 patients <18 and 10 (41.7%) female. Time since diagnosis ranged from 1 month to 9 years (mean 4.65 years, SD2.95). HbA1cs at enrolment ranged from 6.7 to 14.0% (49.7-129.5 mmol/mol) (median 10.5, IQR 8.9-11.1). Of 16 patients for whom 12-month data were available, HbA1cs ranged from 7.0 to 14.0% (53.0-129.5 mmol/mol) (median 10.2, IQR 9.6-11.4). The median change in HbA1c was a small increase of 0.7%, (IQR -0.65 – 2.55). During follow-up, there were no admissions due to diabetic ketoacidosis, and diabetes-related hospital admissions dropped from 93 (mean 15.5 monthly) in June-November 2015, to 15 (mean 2.7 monthly) in June-November 2016. One patient died of an unrelated reason (burns) and five patients were repatriated to Somalia. Eight new patients were enrolled in 2016.
Conclusion
HIM is well accepted by patients in Dagahaley and allowed them to return to their normal activities. Insufficient diet made patient management particularly challenging, and HbA1c levels remain high in some patients, putting them at increased risk of chronic complications of diabetes. Nevertheless, we observed decreased admissions due to acute complications. This pilot demonstrates the feasibility of home insulin management in a challenging humanitarian setting and in the absence of refrigeration, and may be applicable in similar contexts elsewhere.
Conflicts of interest
None declared.