 Hello everyone. I'm going to present to you an implementation of home-based insulin management without refrigeration in the Gahle refugee camp in Kenya. This is a follow-up implementation of insulin stability study which was done sometimes in 2014 with field ambient temperature. So we had to do the actual implementation of the program. So a bit background of the Gahle camp. The Gahle camp is one of the five camps in the WFUG complex, the world largest refugee camp. It's situated in northern Kenya and it has been in existence since 1991 after the civil war in Somalia. The camp is a home to over 69,000 FUGis, majority of being Somali origin. MSF Swiss started this operation in March 2009 with primary healthcare and in the months of August the same year I did the secondary healthcare with a hundred bed capacity hospital with 24-hour operational theater and emergency room. As of the end of 2016 we had 810 NCD patients on follow-up which comprises about 1.2% of the camp population. NCD clinics integrated in primary healthcare while the insulin-dependent diabetic patients come to the hospital emergency room for daily injection of the insulin in the morning and the evening which was quite hectic for them. The camp has a high security which makes even accessibility more difficult and MSF is the only medical organization in the camp. So why did we do the we did we implement this program? Due to the increasing number of patients requiring insulin, the distance and insecurity in the camp hindered this patient to come for the insulin dose especially in the evening which led to uncontrolled hypoglycemia and frequent admission to the hospital. So the aim of the study was to assess feasibility of home-based insulin management in a complex humanitarian settings without refrigeration and to improve access to insulin and adherence to insulin to prevent acute complications and also decongest the emergency room because patients have to come every day in the morning and the evening for insulin injection and also to reduce hospital admission and overall to improve patient outcome. So we did a descriptive study where we retrospectively analyzed routine program data. So after we have faced this problem in the field we requested the OCG medical team to look into best ways we can deliver insulin to these patients and in 2014 study to test insulin stability in field temperatures were done with collaboration of University of Geneva. Then the results showed that various insulin which were tested at field temperatures remained stable after a period of time with temperatures in the field. So these findings informed the implementation of home-based insulin management. After that we had to sensitize the community, inform them that now you can be given insulin and manage yourself at home without refrigeration. Then we conducted, we developed SOPs on implementation of this program. So eligibility criteria for joining home insulin management was all diabetic patients who are using insulin are eligible as long they were willing to inject insulin themselves, check their blood sugar and willing to be admitted for insulin optimization and vocation and come for follow-up, be able to read and write the numbers or the caretakers can do so and process sufficient manual dexterity since motor skills was required for injection and sugar testing. So patients who met this criteria were admitted into the hospital in a small group of four to five for five days for initial medical assessment and education which included blood sugar monitoring, insulin dose adjustment, baseline investigation and education on insulin, what's insulin, how to store, what's the diabetes and complication of diabetes. So and after completing five days of hospitalization before we discharge patients we did a competency checklist to be sure that the patient understood everything we taught them and then some of the parameters we checked was if the patient could recognize signs and symptoms of hypoglycemia or hypoglycemia and if they know how to react, what to do if they feel those symptoms, if they can store insulin well, they can have the technique of injecting insulin, dose withdrawal and sick day rules. So the ones who completed this satisfied the checklist were given a list of kits which included a container for storage of insulin and injection and monitoring equipment like glucometers and sugar strips and the patients were happy to go home and self-manage themselves in the blocks. So this is a locally made charcoal cooler, it's used for storage of insulin, they wet it twice in a day, it has some charcoal inside which is when it's wet with aeration it releases some vapor so it cools the insulin to temperatures which is good for the insulin storage. So this is locally made in the camp. So results, yeah all 24 patients who were eligible for the study were enrolled and successfully completed induction course, the five days training and the age range between one year and 65 with a mean of 20 and nearly half of the cohort were below 18 years and 41.7% of them being female. So during the year we had eight new admissions who joined the program and six exit, five relocation and one death of unrelated course, 83.3% of the cohort were type one patients and 25% of the cohort had comorbidity of either hypertension and organ damage and time since diagnosis range between one month and 12 years. So patient outcome, HPONC is a test to measure patient diabetic control, the lower the readings the better the results. So this test was done at enrollment and every three months, the HPONC at enrollment range between seven to 14. So the target we set for the patient was anything below 8.5, it's a good target for our setup. So at enrollment we had 7.0 to 14 with a mean of 10.4 and at 12 months, 18 patients for whom we had data, the HPONC still range between seven to 14 with a mean of 10.2. But this an overall improvement of 44.4% of the initial cohort had improved their HPONC as compared to the first one at enrollment. So this is our HPONC analyzer, it's available at our point of care, it can also do microalbinuria. So in terms of ER and hospital admission, decongestion, diabetic-related hospital admission dropped from 93 in the months of June to November 2015 to 15 in November, in June to November 2016, that's after we enrolled the program, which transferred to about 83.7 reduction in hospital admission. Same for the ER consultation, it has dropped from 543 in the months of June to November 2015 to 109 in the months of July to November 2016 with a 79.7 reduction in ER consultation, which really decongested the emergency room. So after storage and usage period of insulin patients returned the residual insulin to the clinic, we sent for potency analysis to University of Geneva. We sent 32 samples, which were analyzed and the time period of this insulin strain in the patient's home range between 12 and 31 days. So all samples tested were within the target plus or minus 100%, which conformed to the pharmacopoeia of the drug. So we also did temperature monitoring of the cooler charcoal periodically just to make sure that we don't expose insulin to higher temperatures and we did during the hottest period of the year and the coolest period of the year. And temperatures varied between 23.5 to 37, which was within the acceptable range of insulin stability. So challenges we faced was food insecurity in the camp, which made patient management particularly challenging with reduction of general food distribution to about 50% in 2016. And some partner agencies like WFP, they are not sensitive to this class of refugees or beneficiaries, especially with diabetic-friendly food. Poor socioeconomic status and high literacy level among the patient and caretaker made difficult to adjust insulin doses and change regimen. So to wrap up, home insulin management is accepted by all patients. Since it allowed them to return to their normal activities, school-going children had the chance to go back to school. And home insulin management appears feasible in a complex humanitarian setting without refrigeration. And it really improved patient care. 44% of the patients improved the HPONC. We had no admission due to acute complications of diabetes. And this model can be implemented in other MSF and non-MSF settings. In fact, it's now been used in South Sudan. And finally to thank MSF CH Field Staff Coordination, OCG Medical Department and Innovation Unit and University of Geneva for doing analysis of our insulin potency. Thank you.