Guidelines for Medical Clinics in Flood Affected Areas

I stumbled across this briliant document prepared by Dr. Shehla Baqi and her associates, they been doing outstanding flood relief in the region from the start and have drafted this document which can truly serve as a survival guide to managing and running a medical camp in the flood affected region of Pakistan.  I must thank the Dr. Shahla, the Infections disease society of Pakistan and the various co-authors for taking the time to prepare this amazing document and be willing to share it publicly for the greater good. The original document in DOC, PDF & TXT format can be downloaded from Scribd under a Creative Commons, Attribution-NonCommercial license

GUIDELINES FOR MEDICAL CLINICS IN FLOOD AFFECTED AREAS

Dr. Shehla Baqi
Associate Professor in Infectious Diseases
Sindh Institute of Urology and Transplantation

with Recommendations for Immediate Management of Infectious Diseases in Flood Ravaged Areas by The Infectious Diseases Society of Pakistan

Assess the Situation

• Conduct an initial survey to see whether the area is not already served by another medical team in order to avoid duplication of services and waste of resources.
• Co-ordination with local authorities may help to direct the medical team to underserved areas.
• If the population to be served is mostly concentrated in one location within 1 kilometer radius, a stationary clinic will be most effective.
• If the population to be served is scattered over wide areas, then it is best to have a centrally located stationary clinic with mobile medical teams dispatched from the central clinic on a daily basis.

Establishing a Medical Team

If you estimate a daily patient load of 500 in a 12 hour day, you will need the following minimum staff for the stationary clinic and the same number for the mobile clinic. (This number of patients seems high for one day, but many of the diseases are skin conditions which require only a spot diagnosis.)

• 3 doctors
• 1 pharmacist and 1 pharmacy helper.  If there is no pharmacist available, and only a dispenser or medical store keeper without formal training in pharmacy, then a fourth doctor will be required to avoid medication errors.
• 1 nurse to take vital signs and weight and maintain IVs, dressings etc
• 1-2 non-medical volunteers who can be employed to document patient data, conduct rapid surveys, language interpretation, help pharmacist etc.
• One of the 3 or 4 doctors, preferably with the most experience, should be appointed as the Team Leader.

Orientation

The members of the team should meet before they are to leave for the affected areas for orientation.  Orientation for the new team should be the responsibility of and conducted by a Team Leader who has already served in the camps and will comprise of the following:

• Introduction where all team members get to know each other.  This has been shown to greatly improve the efficiency and working of the team.
• Designate the team leaders.
• Describe the medical conditions most frequently encountered and their treatment.  The most common conditions seen are as follows:

• • Anemia, even in males
  • Conjunctivitis, probably of viral etiology.
  • Diarrhoea, mostly watery and non-bloody.
  • Dehydration
  • Epigastric pain in the older patients.
  • Febrile illness which could be malaria, typhoid or dengue.
  • Malaria is mostly vivax.
  • Malnutrition, often severe
  • Pregnancy.  Expect about 3 pregnant patients for every 100 that you see.
  • Skin conditions such as scabies, tinea corporis, tinea capitis, lichen planus, eczema, lice infestation, folliculitis and furunculosis.
  • Upper respiratory infection.
  • Lower respiratory tract infection is less frequent.
  • Less commonly, you may get a case of asthma, or pick up a case of uncontrolled hypertension or diabetes mellitus. Coughing patient may have TB or be a known case of TB.

• Revise doses of medications that should be used with emphasis on pediatric dosing ( see drug chart)
• Familiarize the team with the various brands of drugs and dosages that are on the formulary. A sample of the drugs should be displayed at every orientation.
• Review policies that are being followed regarding dispensing of medications and duration of treatment.

Duration of treatment in emergency situations should be the minimum effective for the condition. Courses for greater than 1 week, in general, are not practical and can lead to wastage of medications.

• Discuss policies regarding treating patients that are not from the flood affected areas that may present to the clinic.

Essentially, no patient should be turned away.

• Discuss policies regarding dispensing of food items and water in addition to medications.

Food items should not be distributed since the focus of the Medical Clinic will not remain the same. However, clean drinking water should be provided, atleast one 1.5 liter bottle to each mother.

• Reinforce policy regarding dispensing of soap in addition to medications. Soap MUST be provided to the patients, best dispensed as one bar of soap to each mother, written on the prescription. Soap is essential since:
  • Most of the diseases that we are treating at these camps are spread through lack of hygiene.
  • Prevention is better than cure.

• Emphasize that the Medical Clinic should not function as a Drug Distribution Center.

Clinic should be a Treatment Center which means that you need to conduct a problem oriented history and examination, make a diagnosis and then prescribe medications together with counseling regarding hygiene and the correct way to take the medications prescribed.

• Encouraging the team members to counsel patients at every opportunity regarding hygiene.
• Discuss protocol regarding patient referral to a hospital.
• Personal protection for the team members.

• • Mosquito repellants and spraying of clinic areas is the most practical intervention
  • Malaria prophylaxis with doxycycline 100mg PO once daily started 2 days before, during and for 4 weeks after working in the area (not in children <8 and pregnancy).  This will cover both vivax and falciparum but requires daily doses.

For vivax alone, chloroquine tablets are effective, 2 tabs of chloroquine phosphate 500mg (300mg base) once a week starting one week before travel, then during the stay and then continued for 4 weeks after return.

• • Masks to use when examining a coughing patient or one with measles.
  • Alcohol handrub with 70% alcohol, one bottle for each physician.
  • Soap and water for handwashing if soiling of hands occurs.
  • Disposable gloves.

Setting up the Clinics

a. Stationary Clinics

One can utilize an existing building or use tents.  The clinic will need:

• Area for patient consultation and examination.  There should be a screen available that can be used for examinations that need to be conducted privately.
• Pharmacy
• Sick Room for patients to receive IV hydration, wound dressing, minor surgery.

b. Mobile Clinics

To maximize efficiency of the mobile clinics, essential steps to follow are:

• Find an area, some distance from the center of the camp, where you can set down a few chairs for the doctors and patients, and folding tables.  If no shade available, keep a large umbrella in your mobile van. You can examine patients inside a large ambulance as well. Trying to create a level of comfort for the medical staff is important in maintaining efficiency.
• Appoint one person for crowd control who can be firm and knows the language.  Allow one patient at a time.
• Nurse should triage the patient, and make sure that the sickest patients are seen before the others.
• Nurse should document the name, age, sex, and some vital signs (if indicated) on a pre-printed paper, which the patient then brings to the doctor.  Record the temperature if there is complain of fever.  Take the blood pressure if dehydrated or patient gives a history of hypertension.  Obtaining vital signs for all patients is not practical.  Weigh all children who appear to be less than 35kg.  Check blood sugar if patient gives a history of diabetes. The nurse should counsel patients regarding hygiene at every opportunity.  Document immunization and nutritional status of children if you are interested to collect this information.
• Doctor should examine the patient, and then send him/her to the pharmacy with the prescription written on the paper that nurse has already filled with patient information.
• Doctors must write the prescription clearly, giving exact dosages e.g the mg/kg strength of syrups, then the tsf required, in case of the pediatric patients, e.g  amoxicillin-clavulanate 156mg/5ml 1 tsf TDS for 5 days.  The dosing needs to be explained to the patient.  Hygiene should be discussed, even if it is briefly.

Promoting Efficiency of the Mobile Pharmacy

Crowd control is the first step to maintain efficient dispensing of drugs.

• The back of the van/ambulance can be converted into the pharmacy.  It is helpful if the prescription is received at one window and medication dispensed from the next window on the side, rather than from an open van door.  The small windows allow lines to be formed and maintains order.
• A volunteer who assists in receiving the prescription and finding the medications and handing them to the pharmacist is essential, since the biggest crowds gather at the pharmacy window, especially if more than 1 doctor is working at a time.
• Medications should be stored in order and divided into labeled areas such as analgesics, antibiotics, GI drugs with ORS packets, cough and cold preparations, skin lotions and creams, vitamins and supplements.
• Avoid syrups in your formulary since they are bulky and can get spoilt in the heat.  Only use syrups for very small children.  Cough syrups are rarely of much use and their stock should be limited.
• It may be helpful to make pre-packaged doses in some cases e.g

Pregnancy Package

• 1 bottle of Folic Acid of 100 tablets, 1 tablet daily
• 60 ferrous tablets, 1 tablet BD
• 1 pack of 30 multivitamins, 1 tablet daily

Adult GI Package in cases of bloody diarrhoea

• Flagyl for 5 days
• Ciproxin BD for 3 days

Analgesic packages of 10-12 paracetemol tabs

• ORS should be prepared in clean water and provided to patients.  If that is not possible, give a bottle of clean water with sachet of ORS.If medication requires mixing with water, the pharmacist should mix the medication with the exact amount of clean water before dispensing it.
• Make sure that we provide spoons or medication cups since it is pointless to direct a patient to take 1 tsf three times a day if they do not have a teaspoon.
• For families who have more than 1 patient, pharmacy needs to keep paper bags for separate prescriptions, so that the family does not mix up the medications.

REMEMBER, OUR GOAL IS NOT DRUG DISTRIBUTION. IT IS TO PROVIDE MEDICAL CARE.

• Prescriptions can be saved by the pharmacy for data collection.  On the other hand, it may be valuable for the patient to have a record of his treatment in case of follow-up visit by ourselves or from another medical team. If the patient is given the prescription to keep, patient data will need to be documented in a separate register.
• Data collection is essential to gauge the needs of the camps and whether outbreaks are occurring.

RECOMMENDATIONS FOR IMMEDIATE MANAGEMENT OF INFECTIOUS DISEASES IN FLOOD RAVAGED AREAS

by Infectious Diseases Society of Pakistan

Drs. Naseem Salahuddin, Faisal Mahmood, Farheen Ali, Shehla Baqi, Faisal Sultan, Anita Zaidi, Asad Ali, Ejaz A. Khan, Altaf Ahmed, Fatima Noman

1. Hygiene and Clean Water

• Soap for hand washing and bathing should be provided as a priority item, and personal hygiene stressed and practiced as much as possible.
• Wash cloth
• Write a prescription for soap for the mother of the family, one per family.
• Purification of drinking water: Chlorination with PUR sachet is a cheap, effective and easily accessible way of purifying water, 1 sachet will disinfect 10 liters of water.
• Provide 10 liter capacity bucket, a mug and 1 meter white mulmul cloth
• Provide laundry soap

2. General Diarrhoea Treatment

• Educate regarding rehydration
• Continue breast-feeding for infants who are breast-fed
• Regular ORS. Low osmolarity ORS such as pedialyte is not recommended as it may cause hyponatremia in cholera.
• IV Fluids (0.9 NS and Ringer lactate drips) for severe dehydration.  If shock: 0.9%NS10ml/kg bolus then ringer lactate 90ml/kg over 4 hours (in children). If no shock, Ringers lactate 100ml/kg over 4 hours(in children)
• Syrup zinc for 10 days in children under 5 years with diarrhoea
• Anti diarrheal: not recommended because of risk of toxic mega-colon
• Ciprofloxacin for bloody diarrhea when we are suspecting bacillary dysentery. It should also be given for severe acute watery diarrhea with dehydration where we may be dealing with cholera. Also give ciprofloxacin for child less than 6 months old with diarrhoea, fever and toxicity.
• Give metronidazole if suspecting amoebic dysentery.
• Do not use metronidazole and ciprofloxacin as general antidiarrhoeal drugs.

3.  Acute Respiratory Infections

Most acute respiratory infections are viral and self limiting and do not need antibiotic therapy. Supportive care may be given. If you suspect pneumonia then antibiotics must be given.

1. Pneumonia in Adults: Levofloxacin
2. Pneumonia in Children: Amoxicillin

4.  Eye Infections

Mostly secondary to viral infection, hence no specific treatment is required.

If symptoms persist more than 3 days or purulent discharge then use topical antibiotic eye drops such as:

1. Chloramphenicol eye drops

In mobile clinics, and even in the stationary clinics, there may not be an opportunity to follow up the patient.  Therefore, in practice, it is best to give antibiotic eye drops in the first patient encounter, if there is conjunctivitis, although we suspect that it is probably viral in nature.

If symptoms persist for more than 2 wks, give oral erythromycin 12.5 mg/kg qid x 14 days for trachoma.

5. Vector Control

1. Insect repellants may be used.
2. Permethrin impregnated bed nets, if practical

6. Skin Infections

• Scabies
  • Local application of Benzyl benzoate OR
  • Permethrin 5% cream.
  • Provide treatment for the entire family.
  • Council regarding washing of clothes and linen if conditions allow.

• Impetigo, cellulitis, boils, folliculitis, furunclosis
  • Cloxacillin for 7 days or
  • Cephradine for 7 days or
  • Amoxicillin clavulanate for 7 days
  • Local antiseptics: Pyodine, Gentian violet

• Tinea corporis
  • Clotrimazole cream

• Tinea capitis
  • Topical treatment is ineffective.
  • Terbinafine tablets for 2-4 weeks. Impractical to treat in emergency conditions.

• Eczema and lichen planus
  • steroid skin cream

7. Typhoid

1. Cefixime PO for 10 days
2. Typhoid (if not responding to cefixime) then IV Ceftriaxone

8. Meningitis

1. Ceftriaxone IV

9. Malaria

1. Artemether/lumefantrine : for suspected P falciparum or P vivax
2. Chloroquine only if proven vivax species

10. Deworming

1. Albendazole single dose or mebendazole for 3 days.

11. Tuberculosis

Patients already on anti TB treatment should be referred to TB Centers. New suspected cases of TB should be referred to tertiary care hospitals.

12. Snake bite

First Aid

R=Reassurance: 70% of snake bites are from non-venomous species.  Only 50% of venomous species actually envenomate
I=Immobilize in same way as a fractured limb using bandage or cloth.  Do not apply compression.
G.H= Get to Hospital Immediately
T=Tell the doctor of any symptoms

13. Vaccines

For pediatric age group: EPI vaccines should be continued, especially for measles.
For adults, no injectable vaccination  is recommended in the current phase of this emergency for the following reasons:

1. Most vaccines require 2 or more injections to be effective. It would be logistically difficult to attain this goal
2. It is not possible to maintain cold chain in flood affected areas
3. Re-use of needles and syringes is likely to occur in majority of cases, further compounding the already high incidences of Hepatitis B and C

14. Personal Protection

Gloves and masks should be provided in large quantities. Hand hygiene between patients

15. Laboratory

Rapid malaria detection tests are easy to perform and cost effective for diagnosis of malaria and its species. A positive test will help rule out dengue and typhoid fever and allow proper malaria surveillance. This is the only test we recommend for the mobile clinics.

Table 1.  Indications and Uses of Drugs in Flood Relief

(Estimated quantities to stock for a single day at a camp serving 500 patients with varying diagnoses. However, the requirement for drugs can vary from camp to camp and from day to day)

Drug	Indication	Doses	Quantity for a camp where 500 patients may be expected
Albendazole 400mg tablet	Worm infestation	400mg single dose.  If less than 1 year, then 200mg single dose.	50 tabs
Amoxicillin 250mg and 500mg tablets and syrup 125mg/5ml Syrup 250mg/5ml	Respiratory or otitis media in children only. However, amoxicillin is the drug of choice for streptococcal sore throat in both children and adults.	2 months-12 months: 125mg three times a day 1 year to 5 years: 250mg three times a day 5 years to 14 years: 50mg/kg/day in 3 doses Adult: 1.5gm/day in 3 divided doses All for 7 days max	500 of 250mg tabs 500 of 500mg tabs 50 of 125mg syp 50 of 250mg syp
Amoxicillin-clavulanate 375mg (250mg Amoxicillin) tabs 625mg (500mg Amoxicillin) Syrup 156mg/5ml (contains 125mg of amoxicillin) Syrup 312.5mg (contains 250mg of amoxicillin)	Respiratory or ENT infection or bacterial skin infection	Calculate according to the amoxicillin component same as above.	300 of 375mg tabs 300 of 625mg tabs 50 156mg syp 50 312.5mg syp
Artemether 20mg and Lumefantrine 120mg combination	Malaria.  Use for children less than 35kg that are able to take tablets	5-14kg    1 tab BD  15-24kg 2 tabs BD 25-34kg 3 tabs BD >35kg    4 tabs BD All given for 3 days. (The second dose should be 8 hours after the first dose, then BD dosing on the second and third day.)	400 tabs
Artemether 40 and Lumefantrine 240mg (DS preparation)	Malaria.  Use the DS preparation for all adults above 35kg	>35kg 2 tabs BD for 3 days. (The second dose should be 8 hours after the first dose, then BD dosing on the second and third day.)	400 tabs
Drug	Indication	Doses	Quantity for a camp where 500 patients may be expected
Artemether 15mg and Lumefantrine 90mg suspension	Malaria. Use the suspension for children who cannot take tablets	4mg/kg/day of Artemether given as a single dose for 3 days e,g a 5 kg child requires 7ml once a day for 3 days	50 bottles
Chloroquine 150mg base (250mg tab)	Vivax malaria	Adult: 4 tabs stat, then 2 tabs 6 hours later, then 2 tabs once a day for 2nd and 3rd day. Child: 10mg.kg once daily for 2 days and 5mg/kg on 3rd day	100 tabs (stock more if the data shows that most cases are of vivax malaria)
Ceftriaxone	Typhoid, meningitis	1gm twice a day. 2gm twice a day if meningitis Child: 50-75mg/kg/24hours in 1-2 doses. 100mg/kg/day in 2 doses if meningitis	10 vials
Cefixime 400mg tabs Cefixime syrup 200mg/5ml	Typhoid	Adult: 400mg BD for 10 days Child: 16mg/kg/day in a single dose for 10 days	200 tabs 20 bottles
Cephradine 500mg tabs Cephradine syrup 250mg/5ml	Skin and soft tissue bacterial infections	Adult: 250mg every 6 hours or 500mg every 12 hours Children 25-50mg/kg/day in 2-3 doses Give for 5-7 days	250 tabs 25 bottles
Ciprofloxacin 500mg tablets 250mg tablets Syrup 125mg/5ml	Urinary tract infection Bloody diarrhoea Cholera	Adult: 500mg BD for 5-7 days for UTI; 3 days for diarrhoea Child: 20-30mg/kg/24 hours divided into 2 doses e.g 10kg child needs 1 tsf of 125mg/5ml BD for 3 days for diarrhoea	300 of 500mg tabs 200 of 250mg tabs 50 bottles of syrup
Cloxacillin 250mg tabs Syrup 125mg/5ml	Skin bacterial infection	Adults: 1-2 tablets every 6 hours for 5-7 days Child:50-100mg/kg/day divided into 4 doses for 7 days	300 tabs 30 bottles
Drug	Indication	Doses	Quantity for a camp where 500 patients may be expected
Cough syrup	cough	1-2 tsf  three times a day	50
Domperidone 10mg tabs Suspension 1mg/ml	Nausea and vomiting	1-2 tabs before meals and at bedtime Child: 2-5-5ml/10kg Max for 2 days	100 tabs 10 bottles
Ferrous sulfate tablets Iron syrup	Anemia and antenatal care.  Include in pregnancy package.	1 tablet BD for 1 month	5-10,000 tabs 50 bottles of iron syrup
Folic acid 5mg 100 tabs in one bottle	Antenatal care.  Include in pregnancy package.	1 tablet daily	20 bottles of 100 tabs each
Hyoscine butylbromide	Gastrointestinal and genitourinary spasms	1 tab three times a day.  Max 2 days treatment	50
Levofloxacin 750mg tabs	Adult pneumonia	1 tab once a day for 5 days	40 tabs
Mebendazole	Worm infestation, severe malnutrition	100mg twice daily for 3 days	200 tabs
Metronidazole 400mg tabs Suspension 200mg/5ml	Amoebiasis, giardiasis	Adult: 400mg three times per day for 5 days Child: 30mg/kg/day once daily for 3 days for giardiasis. 45mg/kg/day in 3 divided doses for amoebiasis for 5 days	500 tabs 50 bottles
Multivitamins tablets 30 in one pack Multivitamin syrup			50 packs of 30 tabs 50 syrups
Omeprazole	20mg capsules	Once daily in the morning for maximum 7 days	210 capsules
Oral Rehydration Salts	Prevention and treatment of dehydration	1 sachet in 1 liter of clean water: give 2 sachets per patient	500 sachets
Paracetemol 500mg tablets Syrup 120mg/5ml	Fever and pain	Adult 3gm daily in 3-4 divided doses Child: 15mg/kg per dose not more than 4 times a day e.g 8kg child requires 1 tsf every 6 hours	1000 tabs 150 bottles
Drug	Indication	Doses	Quantity for a camp where 500 patients may be expected
Pheniramine maleate tablets 25mg tabs 15mg/5ml	Allergic conditions	Adult: 1 tab 2-3times a day 1-3 years ½ tsf 4-12 years 1 tsf Three times a day.  Max for 3 days	100 tabs 25 bottles
Salbutomol 4mg tabs Syrup 2mg/5ml	asthma	Adult: 6-12mg/day in 3 divided doses 2-6 years ½-1 tsf 6-12 years 1 tsf Three times a day for max 5 days	50 tabs 10 bottles
Sulfadiazine silver 1% cream	Burns and infected leg ulcers	Apply once daily and cover with sterile compresses	10 tubes
Zinc sulfate 20mg/5ml	Diarrhoea in children<5	<6months 10mg, >6months 20mg once daily for 10 days	100 bottles
Benzyl benzoate 25% lotion	Scabies	After bath, apply from neck down.  Repeat application after 24hours for 3 consecutive days and then wash off the next day	100 bottles
Permethrim 5% cream	Scabies	Apply once from neck down and wash out after 12-24 hours.	1000 tubes
Calamine 15% lotion	Itching skin conditions	2-4 applications per day	50
Gentian violet	Antifungal and for oozing dermatosis	2 applicatiosn a day until lesions disappear	50
Pyodine 10% solution	Antiseptic and disinfectant		20
Ringers lactate	Severe dehydration	<1yr: 30ml/hg first hour; 70ml/kg within 5 hours >1 year: 30ml/kg in first 30 minutes; 70ml/kg in 3 hours	20
Tramadol hydrochloride, 50mg/ml, 2ml ampule	Severe acute pain (fracture, trauma)	Child >6m: 2mg/kg injection every 6 hours Adult: 50-100mg injection every 6 hours, max 600mg/day	10 ampules
Drug	Indication	Doses	Quantity for a camp where 500 patients may be expected
Atenolol 50mg tabs	Uncontrolled hypertension	1 tablet once a day for max 7 days.  Refer to hospital for longterm care	50
Antisnake venom.  There are 2 preparations: a. Liquid (NIH) more effective for Pakistan but requires cold chain and refrigeration b. Lyophilized (Indian) in powder form, only keep cool	Snake bite if evidence of coagulopathy or neurotoxicity	If type of snake not known, 8 vials of Indian or 4 vials of NIH can be used for initial dose.  Refer to hospital	4 vials NIH 8 vials Indian
Antirabies vaccine	Dogbite	Wash and flush wound with soap and clean water for 15 minutes and apply antiseptic.  Inject 1 dose of any cell culture vaccine IM into deltoid. Refer to hospital for further management.	2 doses
Diazepam 5mg/ml, 2ml ampule	seizures	Child 0.5mg/kg rectally or 0.2mg/kg by slow IV injection Adult: 10mg rectally or by slow IV injection.	10 ampules
Dextrose, 10%	Hypoglycemia due to severe dehydration	5ml/kg by very slow IV injection over 5 minutes or by infusion	2
SOAP (any brand)	1-2 for each family		300
Purification Tablets			2000