For people living with diabetes in the developing world, a lack of electricity can hamper access to insulin. But a project in Kenya has shown that insulin can be maintained in hot climates without refrigeration. Researchers, calling it a breakthrough, are urging the World Health Organization to amend its guidelines.
For people living with diabetes in the developing world, getting daily life-sustaining doses of insulin has gone hand in hand with access to electricity.
Once a vial is opened, manufacturers recommend storing it in a refrigerator until it expires, which is usually after four weeks. But an estimated 470 million people around the world who don't have access to electricity and fridges for food and medicine, making it difficult to store insulin at home.
But now, a new program could help revolutionize treatments around the world.
It started at the Dadaab refugee camp in northern Kenya, where temperatures can reach up to 99 degrees Fahrenheit and many have no access to refrigeration. As a consequence, patients' lives have practically revolved around going to and from the hospital to receive insulin. Having diabetes could mean missing school, work, especially since the camp's curfew restricts when it's possible to make the trek.
When doctors working in the camp noticed more and more patients coming to the hospital with complications from their diabetes, they reached out to researchers at the University of Geneva and decided to monitor at-home insulin storage at the camp, which experienced much warmer temperatures than label recommendations.
Researchers replicated the camp's daily temperature, which ranged from 77 to 99 degrees Fahrenheit, in the lab, and tested the insulin's effectiveness. They also studied leftover insulin from vials that patients had used after storing them in their homes.
They discovered that even without refrigeration, insulin kept at the camp's tropical temperatures was safe to use for four weeks — a revelation that could be life-changing for diabetes patients around the world.
Following their investigation, the team adjusted the advice they were giving patients, teaching them how to self-inject, check their own blood sugar, and what danger symptoms to look out for. Most exciting of all, they showed patients how to store the insulin at home using a plastic container with a wet towel around it.
What followed was a dramatic drop in the number of diabetic patients coming to hospital with acute complications. They were able to go to work and school and "not spend all day seeking out healthcare to stay alive," said Philippa Boulle, from the Médecins Sans Frontières (MSF, also known as Doctors Without Borders).
Even though insulin can be damaged when it's stored at high temperatures, the researchers found that cooler temperatures overnight could keep the insulin safe.
"Every protein goes towards degradation when it's heated, but there are proteins that can go back when you cool them down again, and insulin seems to be one of them," Leonardo Scapozza, a professor at the University of Geneva's School of Pharmaceutical Sciences and one of the researchers who worked with doctors in the Dagahaley camp, told Insider.
At the moment, guidance says patients can store their insulin at an "'ambient temperature'," but Scapozza said "and hot settings" should be added for clarification. There only needs to be three words added to that: 'and hot settings', Scapozza says.
He said the findings could also be applied to high-income countries such as the US, for example, when natural disasters and storms that cut off power supplies.
The researchers have done further studies to test insulin in different climates, and are helping supporting refugees in their South Sudan setting to take insulin home, too.
Now, MSF is calling on pharmaceutical corporations to amend guidelines, and for the World Health Organization to endorse their findings.
While there have been many studies testing how stable insulin is at different temperatures, the oscillating temperature factor in this study is a "new twist," says Gojka Roglic, a medical officer at the WHO responsible for activities on diabetes management, told Insider.
WHO won't be making any recommendations based on this study alone, but Roglic said it will be included in a review of all research later this year.
Ali Bishar, who is in charge of MSF's insulin management program at the Dadaab refugee camp in Kenya, said education on diabetes and insulin is "paramount" to the program working.
"After they're trained, the patients have to pass a competency test. Then they're given their insulin and care is provided on and outside the wards," Bashar said, adding that the program, which started in 2015, has grown from 35 to 45 patients in the last six years.
However, insulin storage is only the start of managing diabetes in low-resource settings. Another major concern is how a poor diet can contribute to patients' symptoms.
"You have to have food when you inject insulin. In some settings, patients are fearful of the injection if they haven't had a meal that day," Boulle says.
Rahmo, who was in the first cohort of patients to start the MSF programme in 2015, told Insider that she has challenges with getting enough food and having a good diet., But regardless of her diet, Rahmo said her health has improved.
"Before this, I was confused about how to continue my life and if I'd survive," she told Insider through an interpreter. "Today, I'm very happy to control my diabetes at home."
Paul Odongo for MSF
Mohamed Hussein Bule, 27, a refugee from Somalia who works as a teacher at a primary school in Dagahaley, enrolled in the MSF program in 2015.
He was diagnosed with diabetes in 2014 after his weight plummeted from 150 pounds to 82 pounds, but since joining the program his weight is back up to about 143 pounds.
"I was supposed to pick up insulin at the hospital early in the morning to take home, then go to work. I was missing a lot of classes. Now, I take a vial in the morning and record my glucose, and continue with the program as my day continues," he said.
"I don't even feel like a patient with diabetes now. I'm very glad to be on the program."
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