The Interagency Emergency Health Kit 2006
Publication date: 2006
WHO/PSM/PAR/2006.4 Ecumenical Pharmaceutical Network International Organization for Migration United Nations Population Fund The Interagency Emergency Health Kit 2006 Medicines and medical devices for 10,000 people for approximately 3 months An interagency document The Interagency Emergency Health Kit 2006 ii First edition 1990 Reprinted 1992 Second edition 1998 Third edition 2006 Each agency collaborating in the distribution and use of the interagency emergency health kit will support the implementation of the interventions recommended in this booklet only in so far as they are consistent with the existing policy and mandate of that agency. © World Health Organization 2006 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: firstname.lastname@example.org). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: email@example.com). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization and the organizations listed on the title page do not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Acknowledgments iii Acknowledgments The following individuals and organizations contributed to the development of this revision and their advice and support are gratefully acknowledged. United Nations High Commissioner for Refugees (UNHCR): Nadine Ezard, Tsegereda Assebe, Nadine Cornier United Nations Childrenʹ Fund (UNICEF): Murtada Sesay, Monique Supiot, Hanne Bak Pedersen Joint United Nations Programme on HIV/AIDS (UNAIDS): Françoise Renaud‐Théry United Nations Population Fund (UNFPA): Wilma Doedens, Thidar Myint United Nations Development Programme/Inter‐Agency Procurement Services Office (UNDP/IAPSO): Jack Gottling World Bank: Yolanda Tayler, Juan Rovira International Committee of the Red Cross (ICRC): Stephanie Arsac‐Janvier International Federation of Red Cross and Red Crescent Societies (IFRC): Hakan Sandbladh, Birgitte Olsen, Adelheid Marschang International Office for Migration (IOM): Sajith Gunaratne, Daniel Grondin, Stéphanie Krause International Pharmaceutical Federation (FIP): Xuan Hao Chan, Satu Tainio WHO/Roll Back Malaria (RBM): Andrea Bosman, Charles Delacollette, Peter Olumese, Aafje Rietveld, Maryse Dugué, David Bell (WHO Regional Office for the Western Pacific) WHO/Contracting and Procurement Services (CPS): Françoise Mas, Paul Acriviadis WHO/Health Action in Crises (HAC): Elisabeth Pluut, Christine Chomilier WHO/Reproductive Health and Research: Margaret Usher‐Patel WHO/Making Pregnancy Safer (MPS): Rita Kabra WHO/Medicines Policy and Standards (PSM): Hans Hogerzeil, Marthe Everard, Sophie Logez, Shalini Jayasekar, Clive Ondari, Willem Scholten WHO/Child and Adolescent Health and Development (CAH): Olivier Fontaine, Shamim Qazi, Martin Weber WHO/Control of Neglected Tropical Diseases (NTD): Pamela Mbabazi, Michelle Gayer Médecins Sans Frontières: Myriam Henkens, Olivier Raemdonck, Christa Hook, Jean‐Marie Kindermans, Michel van Herp Save the Children (UK): Elizabeth Berryman John Snow, Inc. (JSI): Carolyn Hart, Paula Nersesian The Interagency Emergency Health Kit 2006 iv Ecumenical Pharmaceutical Network (EPN): Eva Ombaka Merlin: Elizabeth Berryman (previously with Save the Children, UK) International Dispensary Association (IDA): Connie van Marrewijk, Michiel de Goeje Missionpharma: Jens Rasmussen Centrale Humanitaire Médico‐Pharmaceutique (CHMP): Alasanne Ba Medical Export Group: Klaas‐Jan Koning Special thanks are due to Dr Robin Gray (WHO/PSM) who until his retirement was the focal point for coordinating the content updates of the last two emergency health kits. List of contents v Contents Acknowledgments .iii Introduction .1 Chapter 1. Essential medicines and medical devices in emergency situations.3 What is an emergency? .3 Principles behind the IEHK 2006.3 Composition of IEHK 2006.4 Referral system.5 Immunization and nutrition in emergency.5 Reproductive health .6 Malaria .7 HIV, AIDS, tuberculosis and leprosy.7 Procurement of IEHK 2006.7 Post‐emergency needs.7 Chapter 2: Selection of medicines and medical devices included in IEHK 2006.9 Selection of the medicines for IEHK 2006 .9 Medicines not included in IEHK 2006 .10 Selection of medical devices for IEHK 2006.10 Selection of equipment.11 Medical devices not included in IEHK 2006 .11 Major changes in content since the 1998 edition of the emergency health kit .12 Chapter 3: Content of IEHK 2006 .13 10 basic units ‐ for health care workers with limited training.13 One supplementary unit ‐ for physicians and senior health care workers.13 Basic unit (for 1,000 people for 3 months) .14 Supplementary unit (for 10,000 people for 3 months).16 Annex 1: Basic unit: treatment guidelines.23 Anaemia.23 Pain .24 Diarrhoea .24 Fever .27 Respiratory tract infections .28 Measles.28 ʺRed eyeʺ condition .28 Skin conditions.29 Sexually transmitted and urinary tract infections.29 Preventive care in pregnancy.29 Annex 2. Assessment and treatment of diarrhoea .31 A‐2.1 Assessment of diarrhoeal patients for dehydration.31 A‐2.2 Treatment of acute diarrhoea (without blood) .32 A‐2.3 Treatment Plan B: oral rehydration therapy for children with some dehydration.34 A‐2.4 Treatment Plan C: for patients with severe dehydration .37 The Interagency Emergency Health Kit 2006 vi Annex 3: Management of the child with cough or difficult breathing.39 A‐3.1 Assess the child.39 A‐3.2 Decide how to treat the child .39 A‐3.3 Child less than two months old .40 A‐3.4 Child two months to five years old.41 A‐3.5 Treatment instructions .42 Annex 4: Sample data collection forms.45 Annex 5: Sample health card .49 Annex 6. Guidelines for suppliers.51 Specifications for medicines and medical devices .51 Packaging.51 Packing list.52 Information slips.52 Annex 7. Other kits for emergency situations .55 Immunization.55 Nutrition .55 Reproductive health .56 Annex 8. Guidelines for Drug Donations .59 Selection of drugs .59 Quality assurance and shelf‐life .60 Presentation, packing and labelling .61 Information and management .62 Annex 9. Model Regulatory Aspects of Exportation and Importation of Controlled Substances .63 Introduction.63 Standard procedure for international transfer of narcotic and psychotropic substances.64 Procedure to be followed in disaster relief.64 Outline of standard agreement between supplier and control authorities of exporting countries.66 Shipment request/notification form for emergency supplies of controlled substances.68 Annex 10. References.71 Medicines.71 Medicine management.71 Communicable diseases.71 General public health .72 Child health .72 HIV and STIs .72 International travel and health .72 Malaria .72 Mental health.73 Nutrition .73 Reproductive health .73 Tuberculosis .73 Annex 11. Useful addresses.75 Partners .75 Suppliers .78 Feedback form .81 Introduction 1 Introduction The organizations and agencies of the United Nations system and international and nongovernmental organizations are called upon to respond to an increasing number of large‐ scale emergencies and disasters, many of which pose a serious threat to health. Much of the assistance provided in such situations is in the form of medicines and medical devices (renewable and equipment). During the 1980s, the World Health Organization (WHO) took up the question of how emergency response could be facilitated through effective emergency preparedness measures. The aim was to encourage the standardization of medicines and medical supplies needed in emergencies to permit a swift and effective response with medicines and medical devices using standard, pre‐packed kits that could be kept in readiness to meet priority health needs in disaster situations. The Interagency Emergency Health Kit 2006 (IEHK 2006) is the third edition of the WHO Emergency Health Kit which was the first such kit when it was launched in 1990. The second kit, ʺThe New Emergency Health Kit 98ʺ was revised and further harmonized by WHO in collaboration with a large number of international and nongovernmental agencies. This updated third edition takes into account the global HIV/AIDS epidemic, the increasing parasite resistance to commonly available antimalarials and the field experience of agencies using the emergency health kit. Over the years the concept of the emergency health kit has been adopted by many organizations and national authorities as a reliable, standardized, affordable, and quickly available source of the essential medicines and medical devices (renewable and equipment) urgently needed in a disaster situation. Its content is based on the health needs of 10,000 people for a period of three months. This document provides background information on the composition and use of the emergency health kit. Chapter 1 describes supply needs in emergency situations and is intended as a general introduction for health administrators and field officers. Chapter 2 explains the selection of medicines and medical devices ‐ renewable and equipment ‐ which are included in the kit and also provides more technical details intended for prescribers. Chapter 3 describes the composition of the kit, consisting of the basic and complementary units. The annexes provide more details on treatment guidelines, sample forms, a health card, guidelines for suppliers, other kits for emergency situations, guidelines for medicines donations, a standard procedure for importation of controlled medicines, references, and useful addresses. A feedback form is also included to report on experiences when using the emergency health kit and to encourage comments and recommendations on the contents of the kit from distributors and users for consideration when updating the contents. The Interagency Emergency Health Kit 2006 2 The WHO Department of Medicines Policy and Standards (formerly known as the Department of Essential Drugs and Medicines Policy) has coordinated the review process and has published this interagency document on behalf of all collaborating partners. Essential medicines and medical devices in emergency situations 3 Chapter 1. Essential medicines and medical devices in emergency situations What is an emergency? The term “emergency” is applied to various situations resulting from natural, political and economic disasters. The Interagency Emergency Health Kit 2006 (IEHK 2006) is designed to meet the initial primary health care needs of a displaced population without medical facilities, or a population with disrupted medical facilities in the immediate aftermath of a natural disaster or during an emergency. It must be emphasized that, although supplying medicines, medical devices (renewable and equipment) in standard pre‐packed kits is convenient early in an emergency, specific local needs must be assessed as soon as possible and further supplies must be ordered accordingly. Medicine and medical device needs in the context of an emergency situation The practical impact of many well‐meaning donations and support sent in emergencies has often been diminished because the supplies did not reflect real needs or because requirements were not adequately assessed. Often this resulted in donations of unsorted, unsuitable, inadequately labelled and expired medicines and other medical devices which could not all be used at the receiving end. The Interagency Guidelines for Drug Donations, revised in 1999, describe ʺgood donation practicesʺ and promote the principles necessary for improved quality medicine donations. More detailed information is provided in Annex 8. Morbidity patterns may vary considerably between emergencies. For example, in emergencies where malnutrition is common, morbidity rates may be very high. For this reason an estimate of medicine requirements can only be approximate, although certain predictions can be made based on previous experience. Principles behind the IEHK 2006 IEHK 2006 is designed principally to meet the first primary health care needs of a displaced population without medical facilities. Its content is a compromise and there will always be some items which do not completely meet requirements. An ideal kit can only be designed with an exact knowledge of the population characteristics, disease prevalence, morbidity patterns and level of training of those using the kit. The Interagency Emergency Health Kit 2006 4 IEHK 2006 consists of two different sets of medicines and medical devices, named a basic unit and a supplementary unit. To facilitate distribution to smaller health facilities on site, the quantities of medicines and medical devices in the basic unit have been divided into 10 identical units for 1,000 people each. Terminology Confusion has arisen over the words ʺkitʺ and ʺunitʺ. In this context, a kit refers to 10 basic units plus one supplementary unit as explained in Figure 1. Figure 1: Composition of IEHK 2006 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 } 10 x 1 basic unit for 10 x 1,000 people 10,000 } 1 supplementary unit for 1 x 10,000 people } Total: 1 emergency health kit for 10,000 people for 3 months Basic unit The basic unit contains essential medicines and medical devices for primary health care workers with limited training. It contains oral and topical medicines, none of which are injectable. Combination therapy for the treatment of uncomplicated falciparum malaria is provided unless there is a specific request not to include it in the kit. Standard treatment guidelines, based on symptoms, have been developed to help primary health care personnel use the medicines rationally and these can be found in Annexes 1 to 3. Two printed copies of this publication in English, French and Spanish are included in each basic unit. Additional printed copies can be obtained from the Department of Medicines Policy and Standards, WHO, Geneva, see Annex 10. Electronic copies can be downloaded from the web site: www.who.int/medicines/. Supplementary unit The supplementary unit contains medicines and medical devices for a population of 10,000 and is to be used only by professional health workers or physicians. It does not contain any medicines or devices from the basic unit and can therefore only be used when these are available as well. Modules for malaria and for patient post‐exposure prophylaxis (Patient PEP) are provided unless there is a specific request not to include them in the kit. The supplementary unit does not contain any medicines or medical devices from the basic units. The supplementary unit should only be used together with one or more basic units. Selection of medicines The selection of medicines in the kit has been based on treatment recommendations from technical units within WHO. A manual describing the standard treatment guidelines for Essential medicines and medical devices in emergency situations 5 target diseases was developed through collaboration between Médecins Sans Frontières (MSF) and WHO. Two copies of the manual in English, French and Spanish are included in each supplementary unit. Additional printed copies can be obtained from MSF, see Annex 11. Quantification of medicines The estimation of medicine requirements in the kit has been based on: 1. the average morbidity patterns among displaced populations; 2. the use of standard treatment guidelines; 3. figures provided by agencies with field experience. The quantities of medicines supplied will therefore only be adequate if prescribers follow the standard treatment guidelines. Referral system Health services can be decentralized by the use of basic health care clinics (the most peripheral level of health care) providing simple treatment using the basic units. Such decentralization will: (1) increase the access of the population to curative care; and (2) avoid overcrowding of referral facilities by treating common health problems at the most peripheral level. Standard treatment guidelines included in the kit will provide primary health care workers with information to enable them to take the right decision on treatment or referral, according to the symptoms. The first referral level should be staffed by professional health care workers, usually medical assistants or doctors, who will use medicines and medical devices from both the basic and supplementary units. It should be stressed here that the basic and supplementary units are not intended to enable these health care workers to treat rare diseases or major surgical cases. For such patients a second level of referral is needed, usually a district or general hospital. Such facilities are normally part of the national health system and referral procedures should be arranged with the local health authorities. Immunization and nutrition in emergency situations IEHK 2006 is not designed for immunization or nutritional programmes: kits covering immunization and nutritional requirements may be ordered after an assessment of needs (see Annex 7). Experience in emergencies involving displaced populations has shown that measles is one of the major causes of death among young children. The disease spreads rapidly in overcrowded conditions, and serious respiratory tract infections are frequent, particularly in malnourished children. The Interagency Emergency Health Kit 2006 6 Measles vaccine administration should therefore be given a high priority, with all children between six months and five years old being immunized. Children immunized before nine months should be re‐immunized as soon after nine months as possible. All children in the target age group should be immunized, irrespective of history. Children with clinical measles should be treated promptly for complications, enrolled in a supplementary feeding programme and given appropriate doses of vitamin A. Reproductive health IEHK 2006 is not designed for reproductive health services: reproductive health kits for emergencies may be ordered after a basic assessment of needs (see Annex 7). A number of priority reproductive health interventions have been defined as essential for a displaced population during an emergency. The Minimum Initial Service Package for Reproductive Health (MISP) is a coordinated set of activities, including the provision of: emergency obstetric care to prevent excess neonatal and maternal morbidity and mortality; provisions to reduce HIV transmission; and activities to prevent and manage the consequences of sexual violence. Professional midwifery care is an essential service for which the necessary instruments and medicines are included in the kit. A small quantity of magnesium sulfate for severe pre‐ eclampsia and for eclampsia is included in the supplementary unit for use as a ʺholdingʺ measure prior to referral. The use of emergency contraception is a personal choice that can only be made by the woman herself. Women should be offered counselling on this method so as to reach an informed decision. A health worker who is willing to prescribe ECPs should always be available to prescribe them to rape survivors who wish to use them.1 In the context of patient post‐exposure prophylaxis (Patient PEP), a limited quantity of medicines for: (1) presumptive treatment of sexually transmitted infections, including N. gonorrhoea and C. trachomatis; for (2) prevention of transmission of human immunodeficiency virus (HIV); and (3) prevention of pregnancy (emergency contraception) for survivors/ victims of sexual assault (rape), is included in the kit. Supplies for routine and general treatment of sexually transmitted infections and contraception will have to be ordered separately according to need (see Annex 7). Comprehensive reproductive health services need to be integrated into the primary health care system as soon as possible and a referral system for obstetric emergencies must be made accessible to the population. It is also recommended that a qualified and experienced person be appointed as reproductive health coordinator. 1 Clinical management of rape survivors. Developing protocols for use with refugees and internally displaced persons. Revised edition. Geneva: World Health Organization; 2004. Essential medicines and medical devices in emergency situations 7 To assist the implementation of a reproductive health programme, the Inter‐Agency Working Group on Reproductive Health in Emergencies (IAWG) has designed a number of reproductive health kits for all levels of the health care system during an emergency (see Annex 7). The kits can be ordered through the United Nations Population Fund (UNFPA) IEHK 2006 will always be supplied with a Patient PEP module unless there is a specific request not to include these items at the time of ordering. Malaria In recent years, the pace of parasite resistance against the safest and least expensive antimalarials has been accelerating. A new approach to combat malaria is combination therapy. Artemether + lumefantrine is the first fixed‐dose antimalarial combination contain‐ ing an artemisinin derivative and is included in the kit for the treatment of malaria due to Plasmodium falciparum, including Plasmodium falciparum in areas with significant drug resistance. It is not recommended for prophylaxis and should not be used by women in the first trimester of their pregnancy, since safety in pregnancy has not yet been established. Rapid diagnostic tests (RDTs) are included in the malaria modules for the confirmation of suspected malaria cases. IEHK 2006 will always be supplied with malaria modules unless there is a specific request not to include these items at the time of ordering. HIV, AIDS, tuberculosis and leprosy IEHK 2006 does not include any medicines against communicable diseases such as HIV, AIDS, tuberculosis or leprosy. Supplies for prevention and/or treatment of these communicable diseases will have to be ordered separately after an assessment of needs. Procurement of IEHK 2006 Pharmaceutical suppliers who may supply the IEHK should ensure that (1) the content of the IEHK is updated according to the following kit and (2) manufacturers comply with the international guidelines for quality, packaging and labelling of medicines and medical devices. Pharmaceutical suppliers should follow the general instructions given in Annex 6. Some suppliers may have a permanent stock of IEHK ready for shipment within 24 hours. Post emergency needs IEHK 2006 is for use only in the early phase of an emergency. The kit is not designed and not recommended for re-supplying existing health care facilities. After the acute phase of an emergency is over and basic health needs have been covered by the basic and supplementary units, specific needs for further supplies and equipment should be assessed as soon as possible. The Interagency Emergency Health Kit 2006 8 Selection of medicines and medical devices included in IEHK 2006 9 Chapter 2. Selection of medicines and medical devices included in IEHK 2006 The contents of IEHK 2006 are based on epidemiological data, population profiles, disease patterns and certain assumptions based on experience gained in emergency situations. These assumptions are: ♦ The most peripheral level of the health care system will be staffed by health care workers with limited medical training, who will treat symptoms rather than diagnosed diseases using the basic units, and refer patients who need more specialized treatment to the next level. ♦ Half of the population is under 15 years of age. ♦ The average number of patients presenting themselves with the more common symptoms or diseases can be predicted. ♦ Standard treatment guidelines will be used to treat these symptoms or diseases. ♦ The rate of referral from the most peripheral to the next level of health services is 10%. ♦ The first referral level of health care is staffed by experienced nurses, midwives, medical assistants or physicians, with no or limited facilities for inpatient care. They will use the supplementary unit in conjunction with one or more basic units. ♦ If both the most peripheral and first referral health care facilities are within reasonable reach of the target population, every individual will, on average, visit such facilities four times per year for advice or treatment. The supplies in the kit therefore serve a population of 10,000 people for a period of approximately 3 months. Selection of medicines for IEHK 2006 Injectable medicines There are no injectable medicines in the basic unit as most common diseases in their uncomplicated form do not require injectable medicines. Any patient who needs an injection must be referred to the first referral level. Injectable medicines are provided in the supplementary unit and are intended for use by professional health care workers at first referral level. Antibiotics Infectious bacterial diseases are common at all levels of health care, including the most peripheral, and basic health care workers should therefore have the possibility to prescribe an antibiotic. However, many basic health care workers have not been trained to prescribe antibiotics in a rational way. Amoxicillin is the only antibiotic included in the basic unit, and The Interagency Emergency Health Kit 2006 10 this will enable the health care worker to concentrate on making the right decision between prescribing an antibiotic or not, rather than on choosing between several antibiotics. Amoxicillin is active against bacterial pneumonia and otitis media. The risk of increasing bacterial resistance must be reduced by rational prescribing practice. Medication for children Paediatric formulations included in the kit are paracetamol 100 mg tab, the fixed‐dose antimalarial combination artemether + lumefantrine 20 mg + 120 mg tab for the weight group 5‐14 kg, artemether injection 20 mg/ml, zinc sulfate 20 mg dispersible tab, ORS (oral rehydration salts) solution for children can be prepared with the sachets included in the kit. Syrups for children are not included because of their instability, their short shelf‐life after reconstitution and their volume and weight. Instead, for children, half or quarter adult tablets may be crushed and administered with a small volume of fluid or with food. Medicines not included in IEHK 2006 As indicated before, the kit includes neither the common vaccines nor any medicines against communicable diseases such as AIDS, tuberculosis2 or leprosy. No specific medicines are included for the treatment of sexually transmitted infections other than a small quantity as presumptive treatment of gonococcal infection, chlamydia and prevention of HIV infection in the context of post‐exposure prophylaxis. Supplies for regular contraception and condoms are not included in the kit. Selection of medical devices for IEHK 2006 Syringes, needles and safety boxes Unsafe injection leads to the risk of transmission of bloodborne pathogens including, hepatitis B, hepatitis C virus and HIV. Injection associated risks for patients and health workers should be limited by: ♦ limiting the number of injections; ♦ using disposable syringes and needles only; ♦ using safety boxes designed for the collection and incineration of used syringes, needles and lancets; ♦ strictly following the destruction procedures for disposable material. Only disposable syringes and needles are provided in the supplementary unit. Estimates of needs are based on the number of injectable medicines included in the supplementary unit, which are to be used in line with the treatment guidelines provided. 2 The general prerequisites for the establishment of a tuberculosis control programme for refugees and displaced persons are: 1) the emergency phase is over; 2) security in and stability of the camp or site is envisioned for at least six months; 3) basic needs of water, adequate food and sanitation are available; and 4) essential clinical services and medicines are available. Selection of medicines and medical devices included in IEHK 2006 11 Gloves Disposable protective gloves are provided in the basic unit and the supplementary unit to protect health workers against possible infection during dressings or handling of infected materials. Sterile disposable surgical gloves are supplied in the supplementary unit to be used for deliveries, sutures and minor surgery, all under medical supervision. Selection of equipment Sterilization A complete sterilization set is provided in the kit. The basic units contain two small drums each to be used as containers for sterile dressing materials. Two drums are included to allow sterilization of one while the other is being used. The supplementary unit contains one steam sterilizer, drums for steam sterilization, TST indicators, timer and kerosene stove. Dilution and storage of liquids The kit contains several plastic bottles to dilute and store liquids (e.g. chlorhexidine, benzyl benzoate and gentian violet solution). Water supply The kit contains several items to help provide clean water at the health facility. Each basic unit contains a collapsible water container and two plastic pails with bail. The supplementary unit contains a water filter with candles and tablets of sodium dichloroisocyanurate (NaDCC) to chlorinate the water. Medical devices not included in IEHK 2006 Resuscitation/major surgery The kit has been designed to meet the first primary health care needs of a displaced population without medical facilities, and for that reason no equipment for resuscitation or major surgery has been included. In situations of war, earthquakes or epidemics, specialized teams with medicines and medical devices will be required. IEHK 2006 does not contain equipment for resuscitation or major surgery. The Interagency Emergency Health Kit 2006 12 Major medicine and medical device changes since the 1998 edition of the emergency health kit Basic unit albendazole tab replaces mebendazole tab aluminium hydroxide + magnesium hydroxide tab replaces aluminium hydroxide tab amoxicillin tab replaces co-trimoxazole tab artemether + lumefantrine tab replaces chloroquine tab ibuprofen tab partially replaces acetylsalicylic acid tab paracetamol 500mg tab partially replaces acetylsalicylic acid tab rapid diagnostic tests for malaria are added thermometer clinical, digital replaces clinical mercury thermometer zinc sulfate dispersible tab is added Supplementary unit artemether inj is added atenolol tab is added ceftriaxone inj replaces chloramphenicol inj clotrimazole pessary replaces nystatin vaginal tablet cloxacillin tab is added doxycycline tab and amoxicillin tab replace chloramphenicol tab levonorgestrel tab replaces ethinylestradiol + levonorgestrel tab miconazole tab replaces nystatin tab miconazole cream replaces benzoic acid + salicylic acid ointment azithromycin tab is added as part of Patient PEP cefixime tab for gonococcal infection is added as part of Patient PEP zidovudine + lamivudine tab is added as part of Patient PEP disposable syringes and needles replace all sterilizable syringes and needles Content of IEHK 2006 13 Chapter 3. Content of IEHK 2006 IEHK 2006 consists of 10 basic units and one supplementary unit. 10 basic units - for health care workers with limited training Each basic unit contains medicines, medical devices renewable and equipment, for a population of 1,000 people for 3 months. To facilitate identification in an emergency, one green sticker should be placed on each parcel. The word “BASIC” should be printed on stickers for basic units. One basic unit contains: ♦ medicines ♦ medical devices, renewable ♦ medical devices, equipment ♦ module: malaria items (uncomplicated malaria)3 One supplementary unit - for physicians and senior health care workers A supplementary unit contains medicines, medical devices renewable and equipment for a population of 10,000 people for 3 months and is packed in cartons of a maximum weight of 50 kg. To be operational, the supplementary unit should be used together with at least one or more basic units. One supplementary unit contains: ♦ medicines ♦ essential infusions ♦ medical devices, renewable ♦ medical devices, equipment ♦ module: patient PEP3 ♦ module: malaria items3 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 } 10 x 1 basic unit for 10 x 1,000 people 10,000 } 1 supplementary unit for 1 x 10,000 people } Total: 1 emergency health kit for 10,000 people for 3 months One IEHK 2006 weighs approximately 1000 kg and occupies 4 m3 space. 3 These items are automatically provided unless a specific request is made not to include them in the kit. The Interagency Emergency Health Kit 2006 14 Basic unit (for 1,000 persons for 3 months) Items Unit Quantity Medicines albendazole, chewable tab 400mg tab 200 aluminium hydroxide + magnesium hydroxide, tab 400 mg + 400 mg4 tab 1,000 amoxicillin, tab 250 mg tab 3,000 benzyl benzoate, lotion 25%5 bottle, 1 litre 1 chlorhexidine gluconate, solution 5%6 bottle, 1 litre 1 ferrous sulfate + folic acid, tab 200 mg + 0.4 mg tab 2,000 gentian violet, powder 25 g 4 ibuprofen, scored tab 400 mg tab 2,000 ORS (oral rehydration salts)7 sachet for 1 litre 200 paracetamol, tab 100 mg tab 1,000 paracetamol, tab 500 mg tab 2,000 tetracycline, eye ointment 1% tube, 5 g 50 zinc sulfate, dispersible tab 20 mg8 tab 1,000 Malaria module (can be withheld from the order upon request) artemether + lumefantrine, tab 20 mg + 120 mg tab Weight group Treatments by weight 5-14 kg 6 x 1 tab box, 30 treatments 5 15-24 kg 6 x 2 tab box, 30 treatments 1 25-35 kg 6 x 3 tab box, 30 treatments 1 > 35 kg 6 x 4 tab box, 30 treatments 6 quinine sulfate, tab 300 mg tab 2,000 rapid diagnostic tests unit 800 lancet for blood sampling (sterile) unit 1,000 safety box for used lancets, 5 litres unit 2 4 WHO recommends aluminium hydroxide and magnesium hydroxide as single antacids. The Interagency Group agreed to include in the kit the combination of aluminium hydroxide + magnesium hydroxide tab. 5 WHO recommends benzyl benzoate, lotion 25%. The use of 90% concentration is not recommended. 6 WHO recommends chlorhexidine gluconate 5% solution. The use of 20% solution needs distilled water for dilution, otherwise precipitation may occur. Alternative: the combination of cetrimide 15% and chlorhexidine gluconate 1.5%. 7 The updated information about the ORS formulation is provided in the 2005 WHO Model List of Essential Medicines. 8 In addition to ORS for the treatment of acute diarrhoea in children. Content of IEHK 2006 15 Items Unit Quantity Medical devices, renewable bandage, elastic, 7.5 cm x 5 m, roll unit 20 bandage, gauze, 8 cm x 4 m, roll unit 200 compress, gauze, 10 cm x 10 cm, non-sterile unit 500 cotton wool, 500 g, roll, non-sterile unit 2 gloves, examination, latex, medium, disposable unit 100 soap, toilet, bar, approximately 110 g, wrapped unit 10 tape, adhesive, zinc oxide, 2.5 cm x 5 m unit 30 Stationery book, exercise, A4 size, 100 pages, hard cover9 unit 4 envelope, plastic, 10 cm x 15 cm unit 2,000 health card10 unit 500 pad, note, plain, A6 size, 100 sheets unit 10 pen, ball-point, blue unit 12 plastic bag, for health card, 11 cm x 25 cm, snap-lock fastening unit 500 Treatment guidelines for basic unit users11 - IEHK2006, English version unit 2 - IEHK2006, French version unit 2 - IEHK2006, Spanish version unit 2 Medical devices, equipment basin, kidney, stainless steel, 825 ml unit 1 bottle, plastic, 1L, with screw cap unit 3 bottle, plastic, 250 ml, wash bottle unit 1 bowl, stainless steel, 180 ml unit 1 brush, hand, scrubbing, plastic unit 2 drum, sterilizing, approximately 150 mm x 150 mm unit 2 forceps, artery, Kocher, 140 mm, straight unit 2 pail, with bail, handle, polyethylene, 10L or 15L unit 2 scissors, Deaver, 140 mm, straight, sharp/blunt unit 2 surgical instruments, dressing set12 unit 2 thermometer, clinical, digital, 32-43 Celsius unit 5 tray, dressing, stainless steel, 300 mm x 200 mm x 30 mm unit 1 water container, PVC/PE, collapsible, 10L or 15L unit 1 9 It is recommended that one exercise book be used for recording daily medicine dispensing and another for daily basic morbidity data, see Annex 4. 10 For a sample health card, see Annex 5. 11 For standard treatment guidelines, see Annexes 1, 2 and 3. 12 Surgical instruments, dressing set (3 instruments + box): • 1 forceps, artery, Kocher, 140 mm, straight • 1 forceps, dressing, standard, 155 mm, straight • 1 scissors, Deaver, 140 mm, straight, sharp/blunt • 1 tray, instruments, stainless steel, 225 mm x 125 mm x 50 mm, with cover. The Interagency Emergency Health Kit 2006 16 Supplementary unit (for 10,000 people for 3 months) Items Unit Quantity Medicines Anaesthetics ketamine, inj 50 mg/ml 10 ml/vial 25 lidocaine, inj 1%13 20 ml/vial 50 Analgesics14 morphine, inj 10 mg/ml15 1ml/ampoule 50 Recall from basic unit ibuprofen, tab 400 mg (10 x 2,000) 20,000 paracetamol, tab 100 (10 x 1000) 10,000 paracetamol, tab 500 mg (10 x 2,000) 20,000 Antiallergics hydrocortisone, powder for inj 100 mg vial 50 prednisolone, tab 5 mg tab 100 epinephrine (adrenaline) see “respiratory tract” Antidotes calcium gluconate, inj 100mg/ml16 10 ml/ampoule 4 naloxone, inj 0.4 mg/ml 17 1 ml/ampoule 20 Anticonvulsants/antiepileptics diazepam, inj 5 mg/ml 2 ml/ampoule 200 magnesium sulfate, inj 500 mg/ml 10 ml/ampoule 40 phenobarbital, tab 100 mg tab 500 Anti-infective medicines benzathine benzylpenicillin, inj 2.4 million IU/vial (long-acting penicillin) vial 50 benzylpenicillin, inj 5 million IU/vial18 vial 250 ceftriaxone, inj 1 g vial 800 cloxacillin, caps 500 mg19 caps 1,000 clotrimazole, pessary 500 mg pessary 100 doxycycline, tab 100 mg tab 3,000 metronidazole, tab 500 mg tab 2,000 13 20 ml vials are preferred, although 50 ml vials may be used as an alternative. 14 Alternative injectable analgesics, such as pentazocine and tramadol, are not recommended by WHO. It is however recognized that these may be practical alternatives to morphine in situations where opioids cannot be sent. 15 See Annex 9 for more details. 16 For use as an antidote to magnesium sulfate overdose in case of severe respiratory depression or arrest. 17 Naloxone is an opioid antagonist given intravenously for the treatment of morphine overdose and to reverse the effects of therapeutic doses of morphine. 18 Benzylpenicillin inj 5 million UI/vial is provided for diseases requiring high dosage treatment. The vials are not intended for multiple use because of concerns over contamination. 19 Alternative: cloxacillin tablet 250 mg and doubling the quantity is acceptable. Content of IEHK 2006 17 Items Unit Quantity miconazole, muco-adhesive tab 10mg20 tab 350 procaine benzylpenicillin, inj 3-4 million IU/vial21 vial 200 Recall from basic unit: albendazole, tab 400 mg (10 x 200) 2,000 amoxicillin, tab 250 mg (10 x 3,000) 30,000 Malaria module (can be withheld from the order upon request) artemether, inj 20 mg/ml22 1ml/ampoule 200 artemether, inj 80 mg/ml 22 1ml/ampoule 72 quinine dihydrochloride, inj 300 mg/ml23 2 ml/ampoule 100 Recall from basic unit: malaria module artemether + lumefantrine, tab 20 mg+120 mg (10 x 6,120 tab) 61,200 quinine sulfate, tab 300 mg (10 x 2,000) 20,000 rapid diagnostic tests (10 x 800) 8,000 lancet for blood sampling (sterile) (10 x 1000) 10,000 safety box for used lancets, 5 litres (10 x 2) 20 Medicines affecting the blood folic acid, tab 5 mg tab 1,000 Recall from basic unit: ferrous sulfate + folic acid, tab 200 mg + 0.4 mg (10 x 2,000) 20,000 Cardiovascular medicines atenolol, tab 50 mg tab 1,000 hydralazine, powder for inj 20 mg24 ampoule 20 methyldopa, tab 250 mg25 tab 1,000 Dermatological medicines polyvidone iodine, solution 10% bottle, 200 ml 10 silver sulfadiazine, cream 1% tube, 50 g 30 miconazole, cream 2% tube, 30 g 25 Recall from basic unit: benzyl benzoate, lotion 25% (10 x 1L) 10 gentian violet, powder 25 g (10 x 4) 40 tetracycline, eye ointment 1% (10 x 50) 500 20 WHO recommends nystatin, tablet, lozenge and pessary as an antifungal agent. The interagency group agreed to include in the kit miconazole muco-adhesive tablets as they are more agreeable for patients than oral nystatin. 21 The combination of procaine benzylpenicillin 3 million IU and benzylpenicillin 1 million IU (procaine penicillin fortified) is used in many countries and may be included as an alternative. 22 Alternative: artesunate, 60 mg for inj., 300, and 5 ml of glucose 5% or NaCl 0.9% inj, 300, is acceptable. Before using, inject the added 1 ml sodium bicarbonate 5% injection solution into the artesunate vial, dissolve and then add 5 ml of glucose 5% or NaCl 0.9% inj. Tuberculin syringe, disposable, 1 ml, sterile, 200, needs to be included too for administration purposes. 23 Intravenous injection of quinine must always be diluted in glucose 5%, bag 500 ml. 24 For the acute management of severe pregnancy-induced hypertension only. 25 For the management of pregnancy-induced hypertension only. The Interagency Emergency Health Kit 2006 18 Items Unit Quantity Disinfectants and antiseptics sodium dichloroisocyanurate (NaDCC), tab 1.67 g26 tab 1,200 Recall from basic unit: chlorhexidine, solution 5% (10 x 1L) 10 Diuretics furosemide, inj 10 mg/ml 2 ml/ampoule 20 hydrochlorothiazide, tab 25 mg tab 200 Gastrointestinal medicines promethazine, tab 25 mg tab 500 promethazine, inj 25 mg/ml 2 ml/ampoule 50 atropine, inj 1 mg/ml 1 ml/ampoule 50 Recall from basic unit: aluminium hydroxide + magnesium hydroxide, tab 400 mg + 400 mg (10 x 1,000) 10,000 Oxytocics oxytocin, inj 10 IU/ml27 1 ml/ampoule 200 Psychotherapeutic medicines chlorpromazine, inj 25 mg/ml 2 ml/ampoule 20 Respiratory tract, medicines acting on salbutamol, tab 4 mg tab 1,000 epinephrine (adrenaline), inj 1 mg/ml 1 ml/ampoule 50 Solutions correcting water, electrolyte and acid-base disturbances28 compound solution of sodium lactate (Ringer's lactate), inj solution, with IV giving set and needle 500 ml bag 200 glucose 5%, inj solution, with IV giving set and needle29 500 ml bag 100 glucose 50%, inj solution (hypertonic) 50 ml/vial 20 water for injection 10 ml/plastic vial 2,000 Recall from basic unit: oral rehydration salts, sachets (10 x 200) 2,000 Vitamins retinol (vitamin A), caps 200,000 IU caps 4,000 ascorbic acid, tab 250 mg tab 4,000 26 Each effervescent tablet containing 1.67g of NaDCC releases 1g of available chlorine when dissolved in water. 27 For prevention and treatment of postpartum haemorrhage. 28 Because of the weight, the quantity of infusions included in the kit is minimal. 29 Glucose 5%, bag 500 ml, for administration of quinine by infusion. Content of IEHK 2006 19 Items Unit Quantity Patient PEP module, 50 treatments (can be withheld from the order upon request) azithromycin, tab 250 mg30 tab 200 cefixime, tab 200 mg31 tab 100 pregnancy test unit 50 levonorgestrel, tab 1.50 mg32 tab 50 zidovudine (AZT) + lamivudine (3TC), tab 300 mg +150 mg33 tab 3,000 Guidelines WHO Model Formulary (latest edition), English version unit 2 MSF Essential Drugs, practical guide (latest edition) - English version unit 2 - French version unit 2 - Spanish version unit 2 MSF Clinical Guidelines, diagnostic and treatment manual (latest edition) - English version unit 2 - French version unit 2 - Spanish version unit 2 Medical devices, renewable cannula, IV short, 18G (1.3 x 45 mm), sterile, disposable unit 100 cannula, IV short, 22G (0.8 x 25 mm), sterile, disposable unit 50 cannula, IV short, 24G (0.7 x 19 mm), sterile, disposable unit 50 needle, disposable, 19G (1.1 x 40 mm), sterile34 unit 2,000 needle, disposable, 21G (0.8 x 40 mm), sterile unit 1,500 needle, disposable, 23G (0.6 x 25 mm), sterile unit 1,500 needle, disposable, 25G (0.5 x 16 mm), sterile unit 100 needle, scalp vein, 21G (0.8 x 19 mm), sterile, disposable unit 100 needle, scalp vein, 25G (0.5 x 19 mm), sterile, disposable unit 300 needle, spinal, 20G (0.9 x 90 mm), sterile, disposable unit 25 needle, spinal, 22G (0.7 x 40 mm), sterile, disposable unit 25 syringe, disposable, 20 ml, sterile35 unit 100 syringe, disposable, 10 ml, sterile unit 600 syringe, disposable, 5 ml, sterile unit 2,000 syringe, disposable, 2 ml, sterile unit 700 syringe, disposable, 1 ml, sterile36 unit 200 30 For presumptive treatment of sexually transmitted infections (Clamydia infection) by sexual assault (rape). Alternative: azithromycin tab 500 mg and halving the quantity is acceptable. 31 For presumptive treatment of sexually transmitted infections (Gonococcal infection) by sexual assault (rape). It may be used in pregnancy. 32 For women who seek help within 72 hours of rape and wish to use emergency contraception to prevent pregnancy, they should take one tablet of levonorgestrel 1.50 mg. Alternative: levonorgestrel 0.75 mg tablets and doubling the quantity is acceptable. 33 For presumptive treatment to reduce the chances of HIV infection by sexual assault (rape) and by needle stick. 34 Included mainly for reconstitution purposes. 35 Included for the administration of magnesium sulfate only. 36 Included for the administration of artemether in children only. The Interagency Emergency Health Kit 2006 20 Items Unit Quantity safety box for used syringes/needles, 5 litres37 unit 50 syringe, feeding, 50 ml, conical tip, sterile38 unit 10 syringe, feeding, 50 ml, Luer tip, sterile38 unit 10 tube, aspirating/feeding, CH16, L125 cm, conical tip, sterile, disposable unit 10 tube, feeding, CH08, L40 cm, Luer tip, sterile, disposable unit 50 tube, feeding, CH05, L40 cm, Luer tip, sterile, disposable unit 20 catheter, Foley, CH12, sterile, disposable unit 10 catheter, Foley, CH14, sterile, disposable unit 5 catheter, Foley, CH18, sterile, disposable unit 5 bag, urine, collecting, 2000 ml unit 10 gloves, examination, latex, large, disposable unit 100 gloves, examination, latex, medium, disposable unit 100 gloves, examination, latex, small, disposable unit 100 gloves, surgical, 6.5, sterile, disposable, pair unit 50 gloves, surgical, 7.5, sterile, disposable, pair unit 150 gloves, surgical, 8.5, sterile, disposable, pair unit 50 compress, gauze, 10 cm x 10 cm, sterile unit 1,000 gauze, roll, 90 cm x 100 m, non-sterile39 unit 3 razor blade, double-edged, disposable (for use with razor, see p.21) unit 100 scalpel blade, No. 22, sterile, disposable unit 100 suture, absorbable, synthetic, braided DEC2 (3/0), curved needle 3/8 circle, 26 mm, triangular point unit 144 tape umbilical, 3 mm x 50 m, non-sterile unit 2 tongue depressor, wooden, disposable unit 500 indicator, TST (Time, Steam, Temperature) control spot unit 300 indicator, TST (Time, Steam, Temperature) control strip unit 100 masking tape, 2 cm x 50 m40 roll 1 Recall from basic unit: Medical devices, renewable bandage, elastic, 7.5 cm x 5 m, roll (10 x 20) 200 bandage, gauze, 8 cm x 4 m, roll (10 x 200) 2,000 compress, gauze, 10 cm x 10 cm, non-sterile (10 x 500) 5,000 cotton wool, 500 g, roll, non-sterile (10 x 2) 20 gloves, examination, latex, medium, disposable (10 x 100) 1000 soap, toilet, bar, approximately 110 g, wrapped (10 x 10) 100 tape, adhesive, zinc oxide, 2.5 cm x 5 m (10 x 30) 300 Stationery book, exercise, A4 size, 100 pages, hard cover (10 x 4) 40 envelope, plastic, 10 cm x 15 cm (10 x 2,000) 20,000 health card (10 x 500) 5,000 pad, note, plain, A6 size, 100 sheet (10 x 10) 100 pen, ball-point, blue (10 x 12) 120 plastic bag, for health card, 11 cm x 25 cm, snap-lock fastening (10 x 500) 5,000 37 WHO/UNICEF standard E10/IC2: boxes should be prominently marked. 38 Alternative: the two types of feeding syringes 50 ml may be replaced by, syringe, feeding, 60 ml, with Luer and conical connector, unit, 20. 39 Alternative: gauze, roll, 60 cm x 100 m, non-sterile. 40 To secure small paper parcels of instruments for sterilization allowing contents and date to be written. Content of IEHK 2006 21 Items Unit Quantity Medical devices, equipment apron, protection, plastic, reusable41 unit 2 drawsheet, plastic, 90 cm x 180 cm unit 2 brush, hand, scrubbing, plastic unit 2 towel, Huck, 430 mm x 500 mm unit 2 stethoscope, binaural, complete unit 4 sphygmomanometer, (adult), aneroid unit 4 stethoscope, fetal, Pinard unit 1 otoscope set, cased42 unit 2 spare battery R6 alkaline AA size, 1.5 V (for otoscope) unit 12 scale, electronic, mother-and-child, 150 kg x 100 g unit 1 scale, (only) infant spring, 25 kg x 100 g unit 3 weighing trousers for scale infant spring, set of 5 unit 3 razor, safety, metal, 3 piece43 unit 2 tape measure, vinyl-coated, 1.5 m unit 5 tape measure, arm circumference, MUAC (mid-upper arm circumference) unit 50 tourniquet, latex rubber, 75 cm44 unit 2 thermometer, clinical, digital, 32-43 Celsius unit 10 sterilizer, steam, approximately 21 L or 24 L unit 1 stove, kerosene, single-burner, pressure unit 1 timer, 60 minutes unit 1 basin, kidney, stainless steel, 825 ml unit 2 bowl, stainless steel, 180 ml unit 2 drum, sterilizing, approximately 150 mm x 150 mm unit 2 forceps, artery, Kocher, 140 mm, straight unit 2 scissors, Deaver, 140 mm, straight, sharp/blunt unit 2 tray, dressing, stainless steel, 300 mm x 200 mm x 30 mm unit 1 surgical instruments, suture set45 unit 2 surgical instruments, dressing set46 unit 5 filter, drinking, candle, 10-80 L per day unit 3 41 Alternative: apron, protection, plastic disposable, unit, 100, may be supplied. 42 Spare bulb must be included within the otoscope set. 43 Alternative: razor, safety, disposable, unit, 100, may be supplied. 44 Alternative: tourniquet with Velcro, unit, 2, may be supplied. 45 One suture set should be reserved for repair of postpartum vaginal tears. Abscess/suture set (7 instruments + box) • 1 forceps, artery, Halsted-mosquito, 125 mm curved • 1 forceps, artery, Kocher, 140 mm, straight • 1 forceps, tissue, standard, 145 mm, straight • 1 needle holder, Mayo-Hegar, 180 mm, straight • 1 probe, double-ended, 145 mm • 1 scalpel handle, No. 4 • 1 scissors, Deaver, 140 mm, curved, sharp/blunt • 1 tray, instruments, stainless steel, 225 mm x 125 mm x 50 mm, with cover. 46 Dressing set (3 instruments + box) • 1 forceps, artery, Kocher, 140 mm, straight • 1 forceps, dressing, standard, 155 mm, straight • 1 scissors, Deaver, 140 mm, straight, sharp/blunt • 1 tray, instruments, stainless steel, 225 mm x 125 mm x 50 mm, with cover. The Interagency Emergency Health Kit 2006 22 Items Unit Quantity Recall from basic unit: Medical devices, equipment basin, kidney, stainless steel, 825 ml (10 x 1) 10 bowl, stainless steel, 180 ml (10 x 1) 10 drum, sterilizing, approximately 150 mm x 150 mm (10 x 2) 20 forceps, artery, Kocher,140 mm, straight (10 x 2) 20 scissors, Deaver,140 mm, straight, sharp/blunt (10 x 2) 20 thermometer, clinical, digital 32-43 Celsius (10 x 5) 50 tray, dressing, stainless steel, 300 mm x 200 mm x 30 mm (10 x 1) 10 surgical instruments, dressing set (10 x 2) 20 Basic unit: treatment guidelines 23 Annex 1: Basic unit: treatment guidelines These treatment guidelines are intended to give simple guidance for primary health care workers using basic units. In these guidelines, five age groups have been distinguished, except for the treatment of diarrhoea with oral rehydration fluid where six age and weight categories are used. When dosage is shown as ʺ1 tab x 2ʺ, one tablet should be taken in the morning and one before bedtime. When dosage is shown as ʺ2 tab x 3ʺ, two tablets should be taken in the morning, two tablets should be taken in the middle of the day and two tablets before bedtime. The treatment guidelines contain the following diagnostic/symptom groups: ♦ anaemia ♦ pain ♦ diarrhoea (see detailed diagnosis and treatment schedules in Annex 2a, b and c) ♦ fever ♦ respiratory tract infections (see detailed diagnosis and treatment schedules in Annex 3) ♦ measles ♦ ʺred eyeʺ condition ♦ skin conditions ♦ sexually transmitted and urinary tract infections ♦ preventive care in pregnancy ♦ worms. Anaemia Weight 0 - <4 kg 4 - <8 kg 8 - <15 kg 15 - <35 kg ≥35 kg Age Diagnosis/ Symptom 0 -<2 mths 2 mths - <1 yr 1 - <5 yrs 5 - <15 yrs ≥15 yrs Severe anaemia (oedema, dizziness, shortness of breath) REFER Moderate anaemia (pallor and tiredness) REFER ferrous sulfate + folic acid 1 tab daily, for at least 2 months ferrous sulfate + folic acid 2 tab daily, for at least 2 months ferrous sulfate + folic acid 3 tab daily, for at least 2 months ferrous sulfate + folic acid 3 tab daily, for at least 2 months The Interagency Emergency Health Kit 2006 24 Pain Weight 0 - <4 kg 4 - <8 kg 8 - <15 kg 15 - <35 kg ≥35 kg Age Diagnosis/ Symptom 0 -<2 mths 2 mths - <1 yr 1 - <5 yrs 5 - <15 yrs ≥15 yrs Pain (headache, joint pain, toothache) paracetamol tab 100 mg ½ - 1 tab x 4 paracetamol tab 100 mg 1 - 2 tab x 4 or ibuprofen tab 400 mg ½ tab x 4 paracetamol tab 500 mg 1 tab x 4 or ibuprofen tab 400 mg 1 tab x 4 paracetamol tab 500 mg 2 tab x 4 or ibuprofen tab 400 mg 2 tab x 4 Stomach pain REFER Al + Mg hydroxide tab ½ tab x 3 for 3 days Al + Mg hydroxide tab 1 tab x 3 for 3 days Diarrhoea Weight 0 - < 5 kg 5 - 7.9 kg 8 - 10.9 kg 11 - 15.9 kg 16 - 29.9 kg >30 kg Age* Diagnosis/ Symptom <4 mths 4 - 11 mths 12 - 23 mths 2 - 4 yrs 5 - 14 yrs ≥15 yrs Quantity of ORS 200-400 ml 400-600 ml 600-800 ml 800 ml-1.2 L 1.2 - 2.2 L 2.2 - 4 L Diarrhoea with no dehydration Treatment Plan A (see Annex 2) Give more fluids than usual to prevent dehydration and zinc sulfate 20 mg dispersible tab and continue to feed. Advise that the patient returns to the health worker in case of frequent stools, increased thirst, sunken eyes, fever or when the patient does not eat or drink normally, or does not get better within three days, or develops blood in the stool or repeated vomiting. Diarrhoea with some dehydration Treatment Plan B (see Annex 2) Approximate amount of ORS solution to give in the first 4 hours. In addition, give zinc sulfate 20 mg dispersible tab as soon as the child is able to eat. Diarrhoea with severe dehydration Treatment Plan C (see Annex 2) REFER patient for nasogastric tube and/or IV treatment. Diarrhoea lasting more than two weeks or in malnourished or poor condition patient Give ORS according to dehydration stage and zinc sulfate 20 mg dispersible tab and REFER. Bloody diarrhoea (check the presence of blood in stools) Give ORS according to dehydration stage and zinc sulfate 20 mg dispersible tab and REFER. * Use the patientʹs age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the patient’s weight in kg by 75. All children should be given supplemental zinc (20 mg) daily for 10 - 14 days. Basic unit: treatment guidelines 25 Confirmed malaria diagnosis In low malaria transmission areas Parasite-based diagnosis47 for all patients of all age groups before treatment is started. In high malaria transmission areas Parasite-based diagnosis47 for all adult patients, including pregnant women, and children > 5 years before treatment is started. For children < 5 years, fever or history of fever or evidence of high temperature (feeling hot or temp. > 37.5C), to be treated on the basis of having had a clinical diagnosis of malaria before treatment is started. Performing the test Things to remember when using a rapid diagnostic test (RDT): • prior instruction in the use and interpretation of the particular product is vital; • a management plan for results must be in place; • blood-safety precautions should be followed; • product instructions should be strictly followed; • RDT should be discarded if the envelope is punctured or badly damaged; • test envelope should be opened only when it has reached ambient temperature, and the RDT used immediately after opening; • result should be read within the time specified by the manufacturer; • RDT cannot be re-used if preparation is delayed after opening the envelope, humidity can damage the RDT. 47 By microscopy or RDTs. The Interagency Emergency Health Kit 2006 26 Figure 2: Sample decision chart for treatment of malaria based on the results of a malaria rapid diagnostic test Derived from model in National Treatment Guidelines for Malaria (2002), Ministry of Health, Kingdom of Cambodia. Suspected cases (clinical criteria) RDT/Microscopy Positive Negative Falciparum Non-falciparum High suspicion of malaria Treatment protocol Treat while excluding other illnesses Uncomplicated malaria Severe malaria Treatment protocol Treatment protocol Look for other illness Review/Refer Suspected cases (clinical criteria) RDT/Microscopy Positive Negative Falciparum Non-falciparum High suspicion of malaria Treatment protocol Treat while excluding other illnesses Uncomplicated malaria Severe malaria Treatment protocol Treatment protocol Look for other illness Review/Refer Basic unit: treatment guidelines 27 Fever Weight 0 - <10 kg 10 - <15 kg 15 - <25 kg 25 - <35 kg ≥35 kg Age Diagnosis/ Symptom 0 -<1 yr 1 - <5 yrs 5 - <10 yrs 10 - <15 yrs ≥15 yrs Fever in malnourished or poor condition patient or when in doubt REFER Fever with chills in confirmed uncomplicated malaria REFER artemether/ lumefantrine tab 20mg A+120mg L 1 tab at once, followed by 5 doses of 1 tab after 8h, 24h, 36h, 48h and 60 hours artemether/ lumefantrine tab 20mg A+120mg L 2 tab at once, followed by 5 doses of 2 tab after 8h, 24h, 36h, 48h and 60 hours artemether/ lumefantrine tab 20mg A+120mg L 3 tab at once, followed by 5 doses of 3 tab after 8h, 24h, 36h, 48h and 60 hours artemether/ lumefantrine tab 20mg A+120mg L 4 tab at once, followed by 5 doses of 4 tab after 8h, 24h, 36h, 48h and 60 hours Pregnant women: Fever with chills in confirmed uncomplicated malaria quinine sulfate tab 300 mg 2 tab x 3, for 3 days Fever with cough REFER See respiratory tract infections below. Fever (unspecified) REFER paracetamol tab 100 mg 1-2 tab x 4, for 1 to 3 days paracetamol tab 100 mg 2-3 tab x 4, for 1 to 3 days or ibuprofen tab 400 mg ½ tab x 4, for 1 to 3 days paracetamol tab 500 mg 1 tab x 4, for 1 to 3 days or ibuprofen tab 400 mg 1 tab x 4, for 1 to 3 days paracetamol tab 500 mg 2 tab x 4, for 3 days or ibuprofen tab 400 mg 2 tab x 4, for 1 to 3 days The Interagency Emergency Health Kit 2006 28 Respiratory tract infections Weight 0 - <4 kg 4 - <8 kg 8 - <15 kg 15 - <35 kg ≥35 kg Age Diagnosis/ Symptom 0 -<2 mths 2 mths - <1 yr 1 - <5 yrs 5 - <15 yrs ≥15 yrs Severe pneumonia Annex 3 Give the first dose of amoxicillin (see pneumonia) and REFER. Pneumonia Annex 3 REFER amoxicillin tab 250 mg ½ - 1 tab x 2, for 5 days amoxicillin tab 250 mg 1- 1½ tab x 2, for 5 days amoxicillin tab 250 mg 1½ -2 tab x 2, for 5 days amoxicillin tab 250 mg 4 tab x 2, for 5 days Reassess after 2 days; continue (breast) feeding, give fluids, clear the nose; return if breathing becomes faster or more difficult, or not able to drink or when the condition deteriorates. No pneumonia: cough or cold Annex 3 REFER Paracetamol48 tab 100 mg ½ tab x 4, for 1 to 3 days paracetamol tab 100 mg 1 tab x 4, for 1 to 3 days or ibuprofen tab 400 mg ½tab x 3, for 1 to 3 days paracetamol tab 500 mg 1 tab x 4, for 1 to 3 days or ibuprofen tab 400 mg 1 tab x 3, for 1 to 3 days paracetamol tab 500 mg 2 tab x 4, for 1 to 3 days or ibuprofen tab 400 mg 2 tab x 3, for 1 to 3 days Supportive therapy; continue (breast) feeding, give fluids, clear the nose; return if breathing becomes faster or more difficult, or not able to drink or when the condition deteriorates. Prolonged cough (30 days) REFER Acute ear pain and/or ear discharge for less than 2 weeks REFER amoxicillin tab 250 mg ½ - 1 tab x 2, for 5 days amoxicillin tab 250 mg 1- 1½ tab x 2, for 5 days amoxicillin tab 250 mg 1½ -2 tab x 2, for 5 days amoxicillin tab 250 mg 4 tab x 2, for 5 days Ear discharge for more than 2 weeks, no pain or fever Clean the ear once daily by syringe without needle using lukewarm clean water. Repeat until the water comes out clean. Dry repeatedly with clean piece of cloth. Measles Weight 0 - <4 kg 4 - <8 kg 8 - <15 kg 15 - <35 kg ≥35 kg Age Diagnosis Symptom 0 -<2 mths 2 mths - <1 yr 1 - <5 yrs 5 - <15 yrs ≥15 yrs Measles Treat respiratory tract disease according to symptoms. Treat conjunctivitis as “Red eyes”. Treat diarrhoea according to symptoms. Continue (breast) feeding, give retinol (vitamin A). "Red eye" condition Red eyes (conjunctivitis) Apply tetracycline eye ointment 3 times a day for 7 days. If not improved after 3 days or if in doubt, REFER. 48 If fever is present. Basic unit: treatment guidelines 29 Skin conditions Wounds: extensive, deep or on face REFER Wounds: limited and superficial Clean with clean water and soap or diluted chlorhexidine solution.49 Gently apply gentian violet solution50 once a day. Severe burns (on face or extensive) Treat as for mild burns and REFER. Mild moderate burns Immerse immediately in cold water, or use a cold wet cloth. Continue until pain eases then treat as wounds. Severe bacterial infection (with fever) REFER Mild bacterial infection Clean with clean water and soap or diluted chlorhexidine solution.49 If not improved after 10 days refer. Fungal infections Apply gentian violet solution50 once a day for 5 days. Infected scabies Bacterial infection: clean with clean water and soap or diluted chlorhexidine solution.49 Apply gentian violet solution50 twice a day. When infection is cured: Apply diluted benzyl benzoate51 once a day for 3 days. Apply non diluted benzyl benzoate 25% once a day for 3 days. Non-infected scabies Apply diluted benzyl benzoate51 once a day for 3 days. Apply non diluted benzyl benzoate 25% once a day for 3 days. Sexually transmitted and urinary tract infections Suspicion of sexually transmitted or urinary tract infection REFER Suspicion of sexual violence REFER Preventive care in pregnancy Weight 0 - <4 kg 4 - <8 kg 8 - <15 kg 15 - <35 kg ≥35 kg Age Diagnosis/ Symptom 0 -<2 mths 2 mths - <1 yr 1 - <5 yrs 5 - <15 yrs ≥15 yrs Anaemia for treatment see under anaemia ferrous sulfate + folic acid 1 tab daily, throughout pregnancy Hookworm in endemic areas: albendazole can be safely given in the second and third trimesters of pregnancy albendazole chewable tab 400 mg, 1 tab once 49 Chlorhexidine 5% must always be diluted before use: 20 ml in 1L of water. Take the 1L plastic bottle supplied with the kit; put 20 ml of chlorhexidine solution into the bottle using the 10 ml syringe supplied and fill up the bottle with boiled or clean water. Alternative: chlorhexidine 1.5% + cetrimide 15% solution should be used in the same dilution. 50 Gentian violet 0.5% concentration = 1 teaspoon of gentian violet powder/1L of boiled/clean water. Shake well, or use warm water to dissolve all powder. 51 Dilute by mixing ½L benzyl benzoate 25% solution with ½L clean water in the 1L plastic bottle supplied with the kit. The Interagency Emergency Health Kit 2006 30 Worms Weight 0 - <4 kg 4 - <8 kg 8 - <15 kg 15 - <35 kg ≥35 kg Age Diagnosis/ Symptom 0 -<2 mths 2 mths - <1 yr 1 - <5 yrs 5 - <15 yrs ≥15 yrs Roundworm Pinworm Threadworm Hookworm Hookworm in pregnant women: see above albendazole tab 400 mg ½ -1 tab once albendazole tab 400 mg 1 tab once albendazole tab 400 mg 1 tab once Assessment and treatment of diarrhoea 31 Annex 2. Assessment and treatment of diarrhoea52 A-2.1 Assessment of diarrhoeal patients for dehydration Table 1: Assessment of diarrhoea patients for dehydration A B C 1. Look at: Conditiona Eyesb Thirst Well, alert Normal Drinks normally, not thirsty Restless, irritable Sunken Thirsty, drinks eagerly Lethargic or unconscious Sunken Drinks poorly or not able to drink 2. Feel: Skin pinchc Goes back quickly Goes back slowly Goes back very slowly 3. Decide: The patient has no signs of dehydration If the patient has two or more signs in B, there is some dehydration If the patient has two or more signs in C, there is severe dehydration 4. Treat: Use Treatment Plan A Weigh the patient, if possible, and use Treatment Plan B Weigh the patient and use Treatment Plan C Urgently a Being lethargic and sleepy are not the same. A lethargic child is not simply asleep: the child's mental state is dull and the child cannot be fully awakened; the child may appear to be drifting into unconsciousness. b In some infants and children the eyes normally appear somewhat sunken. It is helpful to ask the mother if the child’s eyes are normal or more sunken than usual. c The skin pinch is less useful in infants or children with marasmus or kwashiorkor or in obese children. 52 Department of Child and Adolescent Health and Development. The treatment of diarrhoea - a manual for physicians and other senior health workers. Geneva: World Health Organization; 2005. The Interagency Emergency Health Kit 2006 32 A-2.2 Treatment of acute diarrhoea (without blood) Treatment Plan A to treat diarrhoea at home Use this plan to teach the mother how to: ♦ prevent dehydration at home by giving the child more fluid than usual; ♦ prevent malnutrition by continuing to feed the child, and why these actions are important; ♦ recognize signs indicating that the child should be taken to a health worker. The four rules of Treatment Plan A: Rule 1: Give the child more fluids than usual, to prevent dehydration ♦ Use recommended home fluids. These include: ORS solution, salted drinks (e.g. salted rice water or a salted yogurt drink), vegetable or chicken soup with salt, and plain clean water. ♦ Avoid fluids that do not contain salt, such as: plain water, water in which a cereal has been cooked (e.g. unsalted rice water), unsalted soup, yoghurt drinks without salt, green coconut water, weak tea (unsweetened), unsweetened fresh fruit juice. Other fluids to avoid are those with stimulant, diuretic or purgative effects, for example: coffee, some medicinal teas or infusions. ♦ Be aware of fluids that are potentially dangerous and should be avoided during diarrhoea. Especially important are drinks sweetened with sugar, which can cause osmotic diarrhoea and hypernatraemia. Some examples are: commercial carbonated beverages, commercial fruit juices, sweetened tea. ♦ Use ORS solution for children as described in the box below. (Note: if the child is under 6 months and not yet taking solid food, give ORS solution or water.) Give as much as the child or adult wants until diarrhoea stops. Use the amounts shown below for ORS as a guide. Describe and show the amount to be given after each stool is passed, using a local measure. Age Amount of ORS to be given after each loose stool Amount of ORS to provide for use at home ≤ 24 months 50-100 ml 500 ml/day 2 - 10 years 100-200 ml 1L/day ≥10 years as much as wanted 2L/day Show the mother how to mix ORS and show her how to give ORS. ♦ Give a teaspoonful every 1‐2 minutes for a child under 2 years. ♦ Give frequent sips from a cup for older children. Assessment and treatment of diarrhoea 33 ♦ If the child vomits, wait 10 minutes. Then give the solution more slowly (for example, a spoonful every 2‐3 minutes). ♦ If diarrhoea continues after the ORS packets are used up, tell the mother to give other fluids as described in the first rule above or return for more ORS. Rule 2: Give supplemental zinc sulfate 20 mg tab to the child, every day for 10 to 14 days Zinc sulfate can be given as dispersible tablets. By giving zinc sulfate as soon as diarrhoea starts, the duration and severity of the episode as well as the risk of dehydration will be reduced. By continuing zinc sulfate supplementation for 10 to 14 days, the zinc lost during diarrhoea is fully replaced and the risk of the child having new episodes of diarrhoea in the following 2 to 3 months is reduced. Rule 3: Continue to feed the child, to prevent malnutrition ♦ Breastfeeding should always be continued. ♦ The infantʹs usual diet should be continued during diarrhoea and increased afterwards; ♦ Food should never be withheld and the childʹs usual food should not be diluted; ♦ Most children with watery diarrhoea regain their appetite after dehydration is corrected; ♦ Milk: • Infants of any age who are breastfed should be allowed to breast‐feed as often and as long as they want. Infants will often breastfeed more than usual, encourage this; • Infants who are not breastfed, should be given their usual milk feed (formula) at least every three hours, if possible by cup. • Infants below 6 months of age who take breast milk and other foods should receive increased breastfeeding. As the child recovers and the supply and the supply of breast milk increases, other foods should be decreased. • A child who is at least 6 months old or is already taking soft foods should be given cereals, vegetables and other foods, in addition to milk. If the child is over 6 months and such foods are not yet being given, they should be started during the diarrhoea episode or soon after it stops. • Recommended food should be culturally acceptable, readily available. Milk should be mixed with a cereal and if possible, 1 ‐ 2 teaspoonfuls of vegetable oil should be added to each serving of cereal. If available, meat, fish or egg should be given. • Foods rich in potassium, such as bananas, green coconut water and fresh fruit juice are beneficial; − offer the child food every three or four hours (six times a day); − after the diarrhoea stops, continue to give the same energy‐rich food, and give one more meal than usual each day for at least two weeks. The Interagency Emergency Health Kit 2006 34 Rule 4: Take the child to a health worker if there are signs of dehydration or other problems The mother should take her child to a health worker if the child: ♦ Starts to pass many watery stools ♦ Vomits repeatedly ♦ Becomes very thirsty ♦ Is eating or drinking very poorly ♦ Develops a fever ♦ Has blood in the stool; or ♦ Does not get better in three days‐ Treatment Plan B: oral rehydration therapy for children with some dehydration Table 2: Guidelines for treating children and adults with some dehydration Approximate amount of ORS solution to give in the first 4 hours Age* <4 mths 4-11 mths 12-23mths 2-4 years 5-14 years ≥15 years Weight < 5 kg 5-7.9 kg 8-10.9 kg 11-15.9 kg 16-29.9 kg ≥30 kg Quantity 200-400 ml 400-600 ml 600-800 ml 800 ml-1.2 L 1.2-2 L 2.2-4 L In local measure Use the patient's age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the patient’s weight in kg by 75. • If the patient wants more ORS than shown, give more. • Encourage the mother to continue breastfeeding her child. NOTE: during the initial stages of therapy, while still dehydrated, adults can consume up to 750 ml per hour, if necessary, and children up to 20 ml per kg body weight per hour. How to give ORS solution ♦ Teach a family member to prepare and give ORS solution. ♦ Use a clean spoon or cup to give ORS solution to infants and young children. Feeding bottles should not be used. ♦ Use droppers or syringes to put small amounts of ORS solution into mouths of babies. ♦ Children under 2 years of age, should get a teaspoonful every 1‐2 minutes; older children (and adults) may take frequent sips directly from a cup. ♦ Check from time to time to see if there are problems. ♦ If the child vomits, wait 5‐10 minutes and then start giving ORS again, but more slowly, for example, a spoonful every 2‐3 minutes. Assessment and treatment of diarrhoea 35 ♦ If the child’s eyelids become puffy, stop the ORS and give plain water or breast milk. Give ORS according to Plan A when the puffiness is gone. Monitoring the progress of oral rehydration therapy ♦ Check the child frequently during rehydration. ♦ Ensure that ORS solution is being taken satisfactorily and the signs of dehydration are not worsening. ♦ After four hours, reassess the child fully following the guidelines in Table 1 and decide what treatment to give. ♦ If signs of severe dehydration have appeared, shift to Treatment Plan C. ♦ If signs indicating some dehydration are still present, repeat Treatment Plan B. At the same time offer food, milk and other fluids as described in Treatment Plan A, and continue to reassess the child frequently. ♦ If there are no signs of dehydration, the child should be considered fully rehydrated. When rehydration is complete: skin pinch is normal; thirst has subsided; urine is passed; child becomes quiet, is no longer irritable and often falls asleep. ♦ Teach the mother how to treat her child at home with ORS solution and food following Treatment Plan A. Give her enough ORS packets for 2 days. ♦ Also teach her the signs that mean she should bring her child back to see a health worker. If oral rehydration therapy must be interrupted If the mother and child must leave before the rehydration with ORS solution is completed: ♦ Show her how much ORS to give to finish the 4‐hour treatment at home. ♦ Give her enough ORS packets to complete the four hour treatment and to continue oral rehydration for two more days, as shown in Treatment Plan B. ♦ Show her how to prepare ORS solution. ♦ Teach her the four rules in Treatment Plan A for treating her child at home. When oral rehydration fails ♦ If signs of dehydration persist or reappear, refer the child. Giving zinc sulfate ♦ Begin to give supplemental zinc sulfate tablets, as in Treatment Plan A, as soon as the child is able to eat following the initial four hour rehydration period. Giving food ♦ Except for breast milk, food should not be given during the initial four‐hour rehydration period. The Interagency Emergency Health Kit 2006 36 ♦ Children continued on Treatment Plan B longer than four hours should be given some food every 3‐4 hours as described in Treatment Plan A. ♦ All children older than 6 months should be given some food before being sent home. This helps to emphasize to mothers the importance of continued feeding during diarrhoea. Assessment and treatment of diarrhoea 37 Treatment Plan C: for patients with severe dehydration Follow the arrows. If the answer is “yes” go across. If “no” go down. Can you give intravenous (IV) fluids immediately? Yes ⎬ Start IV fluids immediately. If the patient can drink, give ORS by mouth while the drip is set up. Give 100 ml/kg Ringer’s Lactate Solution (or if not available normal saline), divided as follows: Age First give 30ml/kg in: Then give 70ml/kg in: Infants (under 12 months) 1 hour* 5 hours Older 30 minutes* 2 ½ hours No * Repeat once if radial pulse is still very weak or non‐detectable. ♦ Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip more rapidly. ♦ Also give ORS (about 5 ml/kg/hour) as soon as the patient can drink: usually after 2-4 hours (infants) or 1-2 hours (older patients). ♦ After 6 hours (infants) or 3 hours (older patients), evaluate the patient using the assessment chart. Then choose the appropriate Plan (A, B or C) to continue treatment. Is IV treatment available nearby (within 30 minutes)? Yes ⎬ ♦ Send the patient immediately for IV treatment. ♦ If the patient can drink, provide the mother with ORS solution and show her how to give it during the trip to receive IV treatment. No Are you trained to use a naso-gastric tube (NG) for rehydration? Yes ⎬ ♦ Start rehydration by tube with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120ml/kg). ♦ Reassess the patient every 1-2 hours: • if there is repeated vomiting or increased abdominal distension, give the fluid more slowly. • if hydration is not improved after 3 hours, send the patient for IV therapy. No ♦ After 6 hours, reassess the patient and choose the appropriate treatment plan. Can the patient drink? Yes ⎬ ♦ Start rehydration by mouth with ORS solution, giving 20 ml/kg/hour for 6 hours (total of 120 ml/kg). ♦ Reassess the patient every 1-2 hours: • if there is repeated vomiting, give the fluid more slowly-if hydration is not improved after 3 hours, send the patient for IV therapy. No ♦ After 6 hours, reassess the patient and choose the appropriate treatment plan. Urgent: send the patient for IV or NG treatment. NB: If possible, observe the patient for at least six hours after rehydration to be sure the mother can maintain hydration giving ORS solution by mouth. If the patient is over two years old and there is cholera in your area, give an appropriate oral antibiotic after the patient is alert. The Interagency Emergency Health Kit 2006 38 Management of the child with cough or difficult breathing 39 Annex 3. Management of the child with cough or difficult breathing A-3.1 Assess the child Ask • How old is the child? • Is the child coughing? For how long? • Is the child able to drink (for children age 2 months up to 5 years)? • Has the young infant stopped feeding well (for children less than 2 months)? • Has the child had fever? For how long? • Has the child had convulsions? Look and listen (the child must be calm) • Count the breaths in a minute. • Look for chest indrawing. • Look and listen for stridor. • Look and listen for wheeze. Is it recurrent? • See if the child is abnormally sleepy, or difficult to wake. • Feel for fever, or low body temperature (or measure temperature). • Look for severe undernutrition. A-3.2 Decide how to treat the child The child aged less than two months: � see Annex 3.3 The child aged two months up to five years: • who is not wheezing � see Annex 3.4 • who is wheezing � Refer Treatment instructions � see Annex 3.5 • give an antibiotic • advise mother to give home care • treatment of fever. The Interagency Emergency Health Kit 2006 40 A-3.3 Child less than two months old No fast breathing (LESS than 60 a minute) Fast breathing (60 per minute or MORE) Not able to drink Convulsions and or Abnormally sleepy or difficult to wake Stridor in calm child Signs: No severe chest indrawing Severe chest indrawing Wheezing Or Fever or low body temperature No pneumonia - cough or cold Severe pneumonia Very severe disease Classify as: Advise mother to give following home care: keep infant warm Refer URGENTLY to hospital Refer URGENTLY to hospital Breastfeed frequently Clear nose if it interferes with feeding Give first dose of an antibiotic Give first dose of an antibiotic Treatment: Advise mother to return quickly if: Illness worsens Breathing is difficult Breathing becomes fast Feeding becomes a problem Keep infant warm (If referral is not feasible, treat with an antibiotic and follow closely) Keep infant warm (If referral is not feasible, treat with an antibiotic and follow closely) Management of the child with cough or difficult breathing 41 A-3.4 Child two months to five years old Signs: No chest indrawing and No fast breathing (less than 50 per minute if child 2‐12 months of age or 40 per minute if child 1‐5 years) No chest indrawing and Fast breathing (50 per minute or MORE if child 2‐12 months of age or 40 per minute if child 1‐5 years) Chest indrawing Not able to drink Convulsions Abnormally sleepy or difficult to wake Stridor in calm child or Severe undernutrition Classify as: No pneumonia: cough or cold Pneumonia Severe pneumonia Very severe disease If coughing more than 30 days, refer for assessment Advise mother to give home care Refer URGENTLY to hospital Refer URGENTLY to hospital Treat‐ ment: Assess and treat ear problem or sore throat if present Give an antibiotic Give first dose of antibiotics Give first dose of antibiotics Assess and treat other problems Treat fever if present Treat fever if present Treat fever if present Advise mother to give home care Treat fever if present Advise mother to return in 2 days for reassessment, or if the child is getting worse (If referral is not possible, treat with an antibiotic and follow closely) If cerebral malaria is possible, give an antimalarial medicine È Reassess in 2 days a child who is taking an antibiotic for pneumonia Signs: Improving Less fever Eating better Breathing slower The same Worse Not able to drink Has chest indrawing Has other danger signs Treatment: Finish 5 days of antibiotics Change antibiotic or Refer Refer URGENTLY to hospital The Interagency Emergency Health Kit 2006 42 A-3.5 Treatment instructions A-3.5.1 Give an antibiotic • Give first dose of antibiotic in the clinic. • Instruct mother on how to give the antibiotic for five days at home (or to return to clinic for daily procaine‐penicillin injection). Amoxicillin tab 250 mg Age or (Weight) Twice daily for 5 days < 2 mths (< 6 kg)* ¼ tab 2 - 12 mths (6-9 kg) ½ tab 12 mths - 5 yrs (10-19 kg) 1 tab * Give oral antibiotic for five days at home if referral is not feasible. A-3.5.2 Advise mother to give home care (for child age 2 months up to 5 years) • Feed the child − feed the child during illness − increase feeding during illness − clear the nose if it interferes with feeding • Increase fluids − offer the child extra to drink − increase breastfeeding − soothe the throat and relieve cough with a safe remedy • Most important: for the child classified as having no pneumonia, cough or cold, watch for the following signs and return quickly if they occur: − breathing becomes difficult − breathing becomes fast − child not able to drink − child becomes sicker } This child may have pneumonia Management of the child with cough or difficult breathing 43 A-3.5.3 Treat Fever (see also page 27) Malaria is not confirmed: Give paracetamol, see table below. Fever is high: (> 39°C) Parasite-based diagnosis53 for all patients of all age groups Malaria is confirmed: Give artemether/lumefantrine treatment see Fever on page 27(or follow national malaria treatment recommendations) Malaria is not confirmed: Advise the mother to give more fluids. In low malaria transmission areas Fever is not high: (38-39°C) Parasite-based diagnosis53 for all patients of all age groups Malaria is confirmed: Give artemether/lumefantrine treatment see Fever on page 27 (or follow national malaria treatment recommendations) Malaria is not confirmed: Give paracetamol, see table below. Parasite based diagnosis53 for all adult patients and children > 5 years Malaria is confirmed: Give artemether/lumefantrine treatment see Fever on page 27 (or follow national malaria treatment recommendations) In high malaria transmission areas All cases of fever For children < 5 years, to be treated on the basis of a clinical diagnosis of malaria Give artemether/lumefantrine treatment see Fever on page 27 (or follow national malaria treatment recommendations) Fever alone is not a reason to give an antibiotic, except in a young infant (age less than 2 months). Give first dose of an antibiotic and Refer URGENTLY to hospital. PARACETAMOL Every six hours, for 1 to 3 days Age or Weight 100 mg tab 500 mg tab 3 - 12 mths (6-<10 kg) ½ - 1 1- < 5 yrs (10-<15 kg) 1 - 2 5 - < 10 yrs (15-<25 kg) 2 - 3 ½ 10-<15 yrs (25-<35 kg) 1 53 By microscopy or by RDTs The Interagency Emergency Health Kit 2006 44 Sample data collection forms 45 Annex 4: Sample data collection forms Daily morbidity data Location: Clinic: Date: Children Children five years under 5 years old and older, and adults Total Diarrhoea with blood Diarrhoea without blood Fever Confirmed malaria Malnutrition Measles Meningitis Severe acute respiratory infections/pneumonia Sexually transmitted infections Others Totals Number of cases referred to other services: Other information: The Interagency Emergency Health Kit 2006 46 Weekly mortality statistics Location: Total population: Week: Cause of death Children under 5 years Children 5 years and older, and adults Total Male Female Male Female Male Female ARI54/pneumonia Diarrhoea Diarrhoea with blood Fever Confirmed malaria Malnutrition Maternal deaths Measles Meningitis Others Totals Other information 54 ARI = Acute Respiratory Infection Sample data collection forms 47 Daily medicine consumption form Date: Location: Item/medicine Quantities dispensed* Total 1. albendazole 400 mg chewable tab 2. aluminium hydroxide 400 mg + magnesium hydroxide 400 mg tab 3. amoxicillin 250 mg tab 4. artemether + lumefantrine, 20 mg + 120 mg tab 6 x 1 tab 6 x 2 tab 6 x 3 tab 6 x 4 tab 5. benzyl benzoate 25%, lotion 6. chlorhexidine 5%, solution 7. ferrous sulfate + folic acid 200 mg + 0.4 mg tab 8. gentian violet, powder 9. ibuprofen 400 mg scored tab 10. ORS, sachets 11. paracetamol 100 mg tab 12. paracetamol 500 mg tab 13. tetracycline 1% eye ointment 14. quinine sulfate 300 mg tab 15. zinc sulfate 20 mg dispersible tab * For example: 10 + 30 + 20… The Interagency Emergency Health Kit 2006 48 Sample health card 49 Annex 5. Sample health card HEALTH CARD Card No. Carte No. CARTE DE SANTE Date of registration Date d’enregistrement Site Lieu Section/House No. Section /Habitation No. Date of arrival at site Date dʹarrivée sur le lieu Family name Nom de famille Given names Prénoms Date of birth or age Date de naissance ou âge Or Ou Years Ans Sex Sexe M/F Name commonly known by Nom d’usage habituel Mother’s name Nom de la mère Father’s name Nom du père Height Taille CM Weight Poids KG Percentage weight/height Pourcentage poids/taille Feeding programme Programme d’alimentation Immunization Measles Rougeole Date 1 2 BCG Date Others Autres C H I L D R E N E N F A N T S Immunization Polio Date DPT Polio Date DTC Polio 1 2 3 Pregnant Enceinte Yes/No Oui/Non No. of pregnancies No. de grossesses No. of children No. d’enfants Lactating Allaitante Yes/no Oui/Non Tetanus Tétanos Date 1 2 3 4 5 W O M E N F E M M E S Feeding programme Programme d’alimentation C O M M E N T S O B S E R V A T I O N S General (Family circumstances, living conditions etc.) Générales (Circonstances familiales, condition de vie, etc.) Health (Brief history, present condition) Médicales (Résumé de l’état actuel) The Interagency Emergency Health Kit 2006 50 DATE CONDITION (Signs/symptoms/diagnosis) ETAT (Signes/symptômes/diagnostic) TREATMENT (Medication/dose time) TRAITEMENT (Médication/durée de la dose) COURSES (Medication due/given) APPLICATION (Médication requise/effectuée) OBSERVATIONS (Change in condition) NAME OF HEALTH WORKER OBSERVATIONS (Changement d’état) NOM DE L’AGENT DE SANTE Guidelines for suppliers 51 Annex 6. Guidelines for suppliers Specifications for medicines and medical devices 1. Medicines, and medical devices ‐ renewable and equipment ‐ in the kit should comply with specifications given in UNICEF web catalogue where items specifications are updated on line, at: http://www.supply.unicef.dk/Catalogue/ 2. Suppliers should purchase as much as possible from manufacturers which are pre‐ qualified by WHO. The list of pre‐qualified manufacturers and products can be found on http://mednet3.who.int/prequal/ 3. Medicines, and medical devices ‐ renewable and equipment ‐ in the kit should comply with specifications and advice given in Interagency Guidelines for drug donations. Revised 1999. World Health Organization Geneva (WHO/EDM/PAR/99.4). 4. Suppliers should contact WHO/Procurement Services (Annex 11) for the latest specifications of Rapid Diagnostic Tests (RDTs), and information on the most appropriate tests for use in different regions (see also http://www.who.int/malaria/docs). Packaging 1. The tablets or capsules should be packed in sealed waterproof containers with replaceable lids, protecting the contents from light and humidity. 2. There will be ʺno objectionʺ against blister packaging provided it will be waterproof and protecting the contents from light and humidity where applicable. 3. Liquids should be packed in unbreakable leak‐proof bottles or containers. 4. Containers for all pharmaceutical preparations must conform to the latest edition of internationally recognized pharmacopoeial standards. 5. Ampoules must either have break‐off necks, or sufficient files must be provided. 6. Each basic unit should be packed in one carton with the malaria module packed separately. The supplementary unit must be packed in cartons of a maximum weight of 50 kg each. 7. Medicines, infusions, renewable medical devices and medical devices, and other equipment should all be packed in separate cartons, with corresponding labels. The cartons should preferably have two handles attached. The Interagency Emergency Health Kit 2006 52 8. Each carton must be marked with labels permitting identification and classification of each carton within the kit. The word “BASIC” must be printed on each label for the basic unit. Packing list Each consignment must be accompanied by a list of contents, stating the total number of cartons and for each carton, the following should be clearly specified: 1. name of each product; 2. batch number of each product; 3. quantity of each product; and 4. expiry date of each product, especially for pharmaceutical products. Information slips Each basic unit carton and a number of the supplementary unit cartons should contain an information slip in, at least, three languages (English, French, Spanish) which reads as follows: English ʺThe Interagency Emergency Health Kit 2006 is primarily intended for displaced populations without medical facilities; it may also be used for initial supply of primary health care facilities where the normal system of provision has broken down. It is not intended as a re‐supply kit and, if used as such, may result in the accumulation of items and medicines which are not needed. It is recognized that some of the medicines, medical devices contained in the kit may not be appropriate for all cultures and countries. This is inevitable as it is a standardized emergency kit, designed for worldwide use, which is prepacked and kept ready for immediate dispatch. The kit is not designed for immunization programmes, cholera, meningitis or specific epidemics such as those caused by Ebola virus, SARS and avian flu virus.” French << Le Kit Sanitaire d’Urgence Inter‐institutions 2006 est principalement destiné aux populations déplacées n’ayant pas accès à un système de soins médicaux. Il peut également être utilisé pour donner des soins de santé primaires, partout où le système habituel nʹest plus fonctionnel. Il ne doit en aucun cas servir de réapprovisionnement car cela pourrait entraîner une accumulation inappropriée de matériel médical et de médicaments. Dans la mesure où ce kit est standardisé, destiné à être utilisé dans le monde entier et préconditionné afin dʹêtre distribué immédiatement en cas de nécessité, Guidelines for suppliers 53 il est inévitable qu’une partie du matériel médical et des médicaments qu’il contient ne conviennent pas à tous les pays et à toutes les cultures. Ce kit n’est ni conçu pour les programmes de vaccination, choléra, méningite, ni pour des épidémies spécifiques comme celles dues au virus Ebola, SARS et le virus de la grippe aviaire. >> Spanish << El botiquín médico de emergencia interorganismos 2006 está destinado principalmente a las poblaciones desplazadas carentes de servicios médicos; podrá utilizarse también para la prestación inicial de servicios de atención primaria de salud donde el sistema normal de prestación esté paralizado. No tiene por objeto reabastecer el botiquín, pues si se utiliza con este fin ello puede dar lugar a que se acumulen artículos y medicamentos innecesarios. Se reconoce que algunos de los suministros y medicamentos contenidos en el botiquín pueden no ser apropiados en todos los contextos culturales y países. Esto es inevitable, ya que se trata de un botiquín estándar de emergencia destinado para su uso en todo el mundo, preempaquetado y listo para su envío inmediato. El botiquín no está destinado a los programas de inmunización ni a combatir el cólera, la meningitis o epidemias particulares como la provocada por el virus de Ébola, SRAS y la gripe aviar. >> The Interagency Emergency Health Kit 2006 54 Other kits for emergency situations 55 Annex 7. Other kits for emergency situations The following additional kits covering immunization, nutrition and reproductive health may be provided after assessment of needs. Please see Annex 11 for the addresses of Médecins Sans Frontières (MSF), OXFAM, and the United Nations Population Fund (UNFPA). Immunization Immunization kit for 10,000 immunizations by 5 teams The kit may be used for mass immunization campaigns for epidemic prevention or control (measles, meningitis and yellow fever, etc.) It is composed of cold chain, logistic and medical devices divided into 7 modules, including a generator, refrigeration, cold chain transport and equipment, logistics, stationery, and medical device renewable items. Vaccines must be ordered separately. MSF code: KMEDKIMM3‐ Nutrition Nutrition kits OXFAM and MSF have developed kits for nutritional support. The nutritional kits contain the necessary equipment to set up a nutritional programme. The MSF anthropometric kit is different from the one from Oxfam (Kit 1). The other kits developed both by Oxfam and MSF have different codes but are comparable. The nutrition kits will be packed and labelled by Oxfam. Survey kits for measuring weight and height of children This kit contains equipment for measuring weight and height of children to assess nutritional status and materials needed for nutritional surveys by two teams. OXFAM anthropometric kit ‐ Kit 1 MSF anthropometric kit code: KMEDKNUT4M‐ Registration kits These kits contain material needed for registering children and record keeping for nutritional programmes. OXFAM registration kit for supplementary feeding (wet) ‐ Kit 2A MSF registration kit for supplementary wet feeding, 250 beneficiaries code: KMEDMNUT61‐ OXFAM registration kit for supplementary feeding (dry) ‐ Kit 3A MSF registration kit for supplementary dry feeding, 500 beneficiaries code: KMEDMNUT71‐ The Interagency Emergency Health Kit 2006 56 OXFAM registration kit for therapeutic feeding‐ Kit 4A MSF registration kit for therapeutic feeding, 100 severely malnourished children code: KMEDMNUT51‐ Supplementary feeding (wet) kit Designed for 250 people, moderately malnourished children or other vulnerable groups and includes feeding and cooking equipment. Recent guidelines discourage the use of wet supplementary feeding programmes but do recommend that they are only implemented when populations have limited access to fuel and water, where security conditions place people at risk when taking rations home, or for groups who are in need of additional food but are unable to cook for themselves. OXFAM Supplementary Feeding (wet) ‐ Kit 2 MSF Nutrition, supplementary wet feeding, 250 beneficiaries code: KMEDMNUT62‐ Supplementary feeding (dry) kit Designed for 500 people, moderately malnourished children or other vulnerable groups and includes equipment for mixing and distributing food. It is not intended for general food distribution of an entire population in need of food aid. OXFAM Supplementary Feeding (dry) ‐ Kit 3 MSF Nutrition, supplementary dry feeding, 500 beneficiaries code: KMEDMNUT72‐ Therapeutic feeding kit Designed for therapeutic feeding of 100 severely malnourished children. The kit should only be used by trained staff who are able to recognize and respond to the main health problems associated with severe malnutrition. There should be access to medical care as the kit contains no medicines. OXFAM Therapeutic Feeding ‐ Kit 4 MSF Therapeutic Feeding, 100 severely malnourished children code: KMEDMNUT52‐ Reproductive health Interagency reproductive health kits for crisis situations The reproductive health kits prepared by UNFPA provide the supplies needed to implement basic reproductive health services during the early phase of a crisis. The RH kits are designed for a varying population for 3 months There are 12 kits divided into three blocks: Block 1: Six kits for use at the community and primary health care level for a population of 10,000 people for 3 months. They contain mostly disposable medical devices and equipment. Kit 0 ‐ Administration kit To facilitate administration and training activities. Kit 1 ‐ Condoms kit 120 gross (17,280) male condoms with 400 safe sex leaflets; 3.8 gross (540) female condoms with 25 use leaflets. Other kits for emergency situations 57 Kit 2 ‐ Clean delivery kit 200 individual packets containing items and pictorial instruction sheet for home delivery plus material for traditional birth attendants. Kit 3 ‐ Rape treatment kit Management of the immediate consequences of sexual violence with appropriate medicines and supplies: basic treatment after a rape and PEP treatment for HIV (including treatment for children). Kit 4 ‐ Oral and injectable contraception To respond to womenʹs needs for hormonal contraception. Kit 5 ‐ Treatment of sexually transmitted infections To diagnose and treat STIs in people presenting with complaints. Block 2: Five kits for use at primary health care and referral hospital levels, designed for a population of 30,000 people for 3 months Kit 6 ‐ Clinical delivery kit To perform normal deliveries, repair episiotomies and perineal tears under local anesthetics and stabilize women with obstetric complications (eclampsia and haemorrhage) before transfer to a referral unit, for trained personnel, midwives, nurses with midwifery skills and medical doctors. Kit 7 ‐ Intra‐uterine device kit To place IUDs either as contraception or as emergency contraception, and to remove IUDs and provide preventive antibiotic treatment, for trained personnel. Kit 8 ‐ Management of miscarriage and complications of abortion To treat the complications arising from miscarriage and unsafe abortion, including sepsis, incomplete evacuation and bleeding, for trained personnel. Kit 9 ‐ Suture of tears vaginal/cervical and vaginal examination kit To allow vaginal examination and suturing of cervical and vaginal tears, for trained personnel, midwives, physicians, nurses with midwifery skills. Kit 10 ‐ Vacuum extraction delivery kit To assist in vaginal delivery by using manual vacuum extraction method to deliver the newborn. Block 3: Two kits designed for referral surgical/obstetric level for 150,000 people for 3 months. Kit 11 ‐ Referral level kit for reproductive health (part A+B) Medical devices, renewable and equipment and medicines for use at the referral level for caesarian sections, resuscitation of mothers and babies, treatment of complications of sexually transmitted infections, and complications of pregnancy and delivery. Kit 12 ‐Blood transfusion kit To perform safe blood transfusion after testing for HIV, syphilis and hepatitis B and C. The Interagency Emergency Health Kit 2006 58 Guidelines for Drug Donations 59 Annex 8. Guidelines for Drug Donations55 Selection of drugs 1. All drug donations should be based on an expressed need and be relevant to the disease pattern in the recipient country. Drugs should not be sent without prior consent by the recipient. Justification and explanation This provision stresses the point that it is the prime responsibility of the recipients to specify their needs. It is intended to prevent unsolicited donations, and donations which arrive unannounced and unwanted. It also empowers the recipients to refuse unwanted gifts. Possible exceptions In acute emergencies the need for prior consent by the recipient may be waived, provided the drugs are amongst those from the WHO Model List of Essential Drugs that are included in the UN list of emergency relief items recommended for use in acute emergencies (http://www.iapso.org/pdf/erc_vol2.pdf). 2. All donated drugs or their generic equivalents should be approved for use in the recipient country and appear on the national list of essential drugs, or, if a national list is not available, on the WHO Model List of Essential Drugs, unless specifically requested otherwise by the recipient. Justification and explanation This provision is intended to ensure that drug donations comply with national drug policies and essential drugs programmes. It aims at maximizing the positive impact of the donation, and prevents the donation of drugs which are unnecessary and/or unknown in the recipient country. Possible exceptions An exception can be made for drugs needed in sudden outbreaks of uncommon or newly emerging diseases, since such drugs may not be approved for use in the recipient country. 3. The presentation, strength and formulation of donated drugs should, as much as possible, be similar to those of drugs commonly used in the recipient country. Justification and explanation Most staff working at different health care levels in the recipient country have been trained to use a certain formulation and dosage schedule and cannot constantly change their treatment practices. Moreover, they often have insufficient training in performing the necessary dosage calculations required for such changes. 55 Reprinted from: Interagency guidelines for drug donations. Revised 1999. Geneva: World Health Organization; WHO/EDM/PAR 99.4. The Interagency Emergency Health Kit 2006 60 Quality assurance and shelf-life 4. All donated drugs should be obtained from a reliable source and comply with quality standards in both donor and recipient country. The WHO Certification Scheme on the Quality of Pharmaceutical Products Moving in International Commerce should be used. Justification and explanation This provision prevents double standards: drugs of unacceptable quality in the donor country should not be donated to other countries. Donated drugs should be authorized for sale in the country of origin, and manufactured in accordance with international standards of Good Manufacturing Practice (GMP). Possible exceptions In acute emergencies the use of the WHO Certification Scheme may not be practical. However, if it is not used, a justification should be given by the donor. When donors provide funds to purchase drugs from local producers, those which comply with national standards should not be excluded on the sole grounds that they do not meet quality standards of the donor country. 5. No drugs should be donated that have been issued to patients and then returned to a pharmacy or elsewhere, or were given to health professionals as free samples. Justification and explanation Patients return unused drugs to a pharmacy to ensure their safe disposal; the same applies to drug samples that have been received by health workers. In most countries it is not allowed to issue such drugs to other patients, because their quality cannot be guaranteed. For this reason returned drugs should not be donated either. In addition to quality issues, returned drugs are very difficult to manage at the receiving end because of broken packages and the small quantities involved. 6. After arrival in the recipient country all donated drugs should have a remaining shelf- life of at least one year. An exception may be made for direct donations to specific health facilities, provided that: the responsible professional at the receiving end acknowledges that (s)he is aware of the shelf-life; and that the quantity and remaining shelf-life allow for proper administration prior to expiration. In all cases it is important that the date of arrival and the expiry dates of the drugs be communicated to the recipient well in advance. Justification and explanation In many recipient countries, and especially under emergency situations, there are logistic problems. Very often the regular drug distribution system has limited possibilities for immediate distribution. Regular distribution through different storage levels (e.g. central store, provincial store, district hospital) may take six to nine months. This provision especially prevents the donation of drugs just before their expiry, as in most cases such drugs would only reach the patient after expiry. It is important that the recipient official responsible for acceptance of the donation is fully aware of the quantities of drugs being donated, as overstocking may lead to wastage. The argument that short‐dated products can be donated in the case of acute emergencies, because they will be used rapidly, is incorrect. In emergency situations the systems for reception, storage and distribution of drugs are very often disrupted and overloaded, and many donated drugs tend to accumulate. Guidelines for Drug Donations 61 Additional exception Besides the possible exception for direct donations mentioned above, an exception should be made for drugs with a total shelf‐life of less than two years, in which case at least one‐third of the shelf‐life should remain. Presentation, packing and labelling 7. All drugs should be labelled in a language that is easily understood by health professionals in the recipient country; the label on each individual container should at least contain the International Nonproprietary Name (INN) or generic name, batch number, dosage form, strength, name of manufacturer, quantity in the container, storage conditions and expiry date. Justification and explanation All donated drugs, including those under brand name, should be labelled also with their INN or the official generic name. Most training programmes are based on the use of generic names. Receiving drugs under different and often unknown brand names and without the INN is confusing for health workers and can even be dangerous for patients. In the case of injections, the route of administration should be indicated. 8. As much as possible, donated drugs should be presented in larger quantity units and hospital packs. Justification and explanation Large quantity packs are cheaper, less bulky to transport and conform better to public sector supply systems in most developing countries. This provision also prevents the donation of drugs in sample packages, which are impractical to manage. In precarious situations, the donations of paediatric syrups and mixtures may be inappropriate because of logistical problems and their potential misuse. 9. All drug donations should be packed in accordance with international shipping regulations, and be accompanied by a detailed packing list which specifies the contents of each numbered carton by INN, dosage form, quantity, batch number, expiry date, volume, weight and any special storage conditions. The weight per carton should not exceed 50 kilograms. Drugs should not be mixed with other supplies in the same carton. Justification and explanation This provision is intended to facilitate the administration, storage and distribution of donations in emergency situations, as the identification and management of unmarked boxes with mixed drugs is very time‐ and labour‐intensive. This provision specifically discourages donations of small quantities of mixed drugs. The maximum weight of 50 kilograms ensures that each carton can be handled without special equipment. The Interagency Emergency Health Kit 2006 62 Information and management 10. Recipients should be informed of all drug donations that are being considered, prepared or actually under way. Justification and explanation Many drug donations arrive unannounced. Detailed advance information on all drug donations is essential to enable the recipient to plan for the receipt of the donation and to coordinate the donation with other sources of supply. The information should at least include: the type and quantities of donated drugs including their International Nonproprietary Name (INN) or generic name, strength, dosage form, manufacturer and expiry date; reference to earlier correspondence (for example, the letter of consent by the recipient); the expected date of arrival and port of entry; and the identity and contact address of the donor. 11. In the recipient country the declared value of a drug donation should be based upon the wholesale price of its generic equivalent in the recipient country, or, if such information is not available, on the wholesale world-market price for its generic equivalent. Justification and explanation This provision is needed solely to prevent drug donations being valued in the recipient country according to the retail price of the product in the donor country. This may lead to elevated overhead costs for import tax, port clearance and handling in the recipient country. It may also result in a corresponding decrease in the public sector drug budget in the recipient country. Possible exception In the case of patented drugs (for which there is no generic equivalent) the wholesale price of the nearest therapeutic equivalent could be taken as a reference. 12. Costs of international and local transport, warehousing, port clearance and appropriate storage and handling should be paid by the donor agency, unless specifically agreed otherwise with the recipient in advance. Justification and explanation This provision prevents the recipient from being forced to spend effort and money on the clearance and transport of unannounced consignments of unwanted items, and also enables the recipient to review the list of donated items at an early stage. Model regulatory aspects of exportation and importation of controlled substances 63 Annex 9. Model Regulatory Aspects of Exportation and Importation of Controlled Substances Introduction Organizations involved in the provision of medical supplies in emergency situations are often faced with serious difficulties in providing narcotic and psychotropic medicines because of the regulatory requirements concerning their exportation and importation. The lack of these medicines results in additional human suffering by depriving those in need of adequate pain relief and sedation. This makes these medicines an essential part of medical supply in emergency situations. The Basic Unit of the Interagency Emergency Health Kit 2006 does not contain any substances that are regarded as narcotics or psychotropics, so they are not under international control and will not require additional formalities for international transport. However, the Supplementary Unit contains several substances under international control, and other substances in it are under discussion for future control. Also, certain countries have additional national regulations for medicines not under international control. Substances from the Kit under international control are morphine injection 10mg/ml, 1 ml-ampoule; diazepam injection 5mg/ml, 2 ml-ampoule and phenobarbital tablets 100mg. Morphine requires import and export licences in any case. For the two other substances this may vary with the country. Some countries have brought additional substances under their national regulations. This could be the case in some countries for ketamine injection 50mg/ml 10 ml-vial, promethazine tablets 25 mg, promethazine injection 25 mg/ml, 2ml-ampoule and chlorpromazine injection 25mg/ml, 2ml- ampoule. At present there is an assessment going on, in order to decide whether ketamine needs to be brought under international control. There are three international treaties that control narcotic and psychotropic substances: • UN Single Convention on Narcotic Drugs (1961, amended by protocol of 1972) • UN Convention on Psychotropic Substances (1971) • UN Convention against the Illicit Traffic in Narcotic Drugs and Psychotropic Substances (1988). These treaties are quite complex and it would go too far to go into details here. For the really interested, their texts can be found at the website of the International Narcotics Control Board (INCB) (www.incb.org). The Interagency Emergency Health Kit 2006 64 Those who need to consult the most recent lists of scheduled substances can find them at this website too. Standard procedure for international transfer of narcotic and psychotropic substances The international transportation of narcotic medicines and psychotropic substances is ʺexportation” from one country and ʺimportationʺ to the other one. This requires an export authorization from the authorities of the sending country as well as an import authorization from the authorities of the receiving country. The export authorization is granted only after the issue of the import authorization. As such, the import/export authorization system makes the quick international transportation of controlled medicines to sites of emergencies virtually impossible. In addition, countries have to estimate their narcotic drug consumption in advance and send the estimates to the INCB. Only after the INCB has received an estimate for a substance from a receiving country, the sending country will grant an application for an export authorization. It will be clear that the rigorous application of the estimate system can further complicate the procedure, especially in situations of suddenly risen demands. This procedure takes too long to meet the acute need for relief in emergency situations ‐from several weeks up to many months. This will be even more true when the control authorities in the receiving country are struck themselves by the disaster. Procedure to be followed in disaster relief Model guidelines were prepared to enable adequate procurement of controlled substances in disaster relief. The procedures would allow suppliers to ship controlled medicines internationally in emergency situations at the request of recognized agencies providing humanitarian assistance without prior export/import authorizations. The defined procedures are acceptable to the control authorities and the INCB. The INCB has advised control authorities that emergency humanitarian deliveries are considered as being consumed in the exporting country. This makes that no additional estimate has to be sent by the authorities of the receiving country. (As the sent amounts are usually relatively small in comparison to the domestic use of the sending country, in most cases the existing estimation is large enough to comprise the amount sent, and hence, the sending country has no additional estimations to submit to the INCB either.) The INCB recommends to limit control obligations in emergency situations to the authorities of exporting countries.56 56 This principle was endorsed by the UN Commission on Narcotic Drugs in 1995, and was further reinforced by its resolution entitled “Timely provision of controlled medicines for emergency care” adopted at the 39th session in 1996. This and a similar resolution adopted by the 49th session of the World Health Assembly requested WHO to prepare model guidelines to assist national authorities with simplified regulatory procedures for this purpose, in consultation with the relevant UN bodies and interested governments. (Model Guidelines for the International Provision of Controlled Medicines for Emergency Medical Care, WHO/PSA/96.17). Model regulatory aspects of exportation and importation of controlled substances 65 Who should do what? The operator57 should make a written request for emergency supplies of controlled substances to the supplier58, using the attached model form. The operator is responsible for: ♦ selection of suppliers;59 ♦ information provided on the form; ♦ actual handling of controlled medicines at the receiving end or adequate delivery to the reliable recipient; ♦ reporting to the control authorities of the receiving country (whenever they are available) as soon as possible; ♦ reporting to the control authorities of the receiving country on unused quantities, if any, when the operator is the end‐user or to arrange for the end‐user to do so; ♦ reporting to the control authorities of the exporting country through the supplier, with copy to the INCB, any problems encountered in the working of emergency deliveries. Before responding to the request from the operator, the supplier should be convinced that the nature of the emergency justifies the application of the simplified procedure without export/import authorizations. The supplier is also responsible for: ♦ submitting immediately a copy of the shipment request to the control authorities of the exporting country; ♦ submitting an annual report on emergency deliveries and quantities of medicines involved as well as their destinations, with copy to the INCB; ♦ reporting to the control authorities of the exporting country, with copy to the INCB, any problems encountered in the working of emergency deliveries. The control authorities of the exporting country should inform their counterpart in the receiving country (whenever they are available) of the emergency deliveries. 57 Operators: organizations engaged in the provision of humanitarian assistance in health matters recognized by the control authorities of exporting countries. 58 Suppliers: supplier of medicines for humanitarian assistance at the request of an operator (either a separate entity or a department of an operator). 59 Suppliers should be limited to those recognized by the control authorities of exporting countries. They should at least have: • adequate experience as a supplier of good quality emergency medical supplies; • managerial capability to assess the appropriateness of requests for the simplified procedure from operators; • adequate level of stock and a responsible pharmacist; • sufficient knowledge about the relevant international conventions; • standard agreement with the control authorities of exporting countries (see attached document with outlines for the agreement). The Interagency Emergency Health Kit 2006 66 The control authorities of the receiving country have the right to refuse the importation of such deliveries. Outline of standard agreement between supplier and control authorities of exporting countries60 The standard agreement should at least cover: 1. Criteria for acceptance of shipment requests from operators (a model form is attached at the end). The criteria for immediate acceptance of shipment requests from operators should at least specify the essential information to be furnished to the supplier concerning: a. credibility of the requesting operator A pre‐determined list of credible operators ought to be prepared. A credible operator should (i) be an established organization; (ii) have adequate experience for international provision of humanitarian medical assistance; (iii) have responsible medical management (medical doctor(s) or pharmacist(s)); and (iv) appropriate logistic support. b. nature of the emergency and the urgency of the request A statement to the supplier on the nature of the emergency by the operator, or if appropriate, by a UN agency. c. availability of control authorities in the receiving country. d. diversion prevention mechanism after delivery Indicate if the requesting operator itself is the user of the supplies. If not, the name and organization of the person responsible for receipt and internal distribution of the supplies should be indicated. As far as possible, the recipients in the receiving country should be identified. 2. Timing and mode of reporting to the control authorities and the INCB When control authorities are available in the receiving country, they should be notified as soon as possible by the control authorities of the exporting country and the operator of a consignment of the emergency delivery, while their import authorization may not have to be required under the circumstances of an emergency situation. Suppliers should inform the control authorities of the exporting country of each emergency shipment being made in response to a request from an operator so that the control authorities can intervene if necessary. Suppliers should submit to the control authorities of the exporting country an annual report on emergency deliveries and quantities of medicines involved as well as their destinations in duplicate, so that one copy can be forwarded to the INCB. 60 When an operator is also a supplier, the agreement will be between the operator and the control authorities. Model regulatory aspects of exportation and importation of controlled substances 67 Suppliers, or operators through the suppliers, should inform the control authorities of the exporting countries, with copy to the INCB, of any problems encountered in the working of emergency deliveries. 3. Other relevant matters As appropriate, the agreement may include provisions on other relevant matters such as inspection and guidance by the control authorities. Although the quantities involved would be rather small, it may touch upon estimated/assessed requirements based on the principle that the medicines provided should be regarded as having been “consumed” in the exporting country. The Interagency Emergency Health Kit 2006 68 Shipment request/notification form for emergency supplies of controlled substances Operator: Name: . Address: . Name of the responsible medical director/pharmacist: . Title: . Phone No. . Fax No. . Requests the supplier:61 Name: . Address: . Responsible pharmacist: . Phone No. . Fax No. . For an emergency shipment62 of the following medicine(s) containing controlled substances: Name of product (in INN/generic name) and dosage form, amount of active ingredient per unit dose, number of dosage units in words and figures Narcotic medicines as defined in the 1961 Convention (e.g. morphine, pethidine, fentanyl) [e.g.morphine injection 1 ml ampoule; morphine sulfate corresponding to 10 mg of morphine base per ml; two hundred (200) ampoules] . . . . Psychotropic substances as defined in the 1971 Convention (e.g. buprenorphine, pentazocine, diazepam, phenobarbital) . . . . Others (nationally controlled in the exporting country, if applicable) . . 61 If the operator is exporting directly from its emergency stock, it should be considered as a supplier. 62 Emergency deliveries do not affect the estimate of the recipient country since they have already been accounted for in the estimate of the exporting country. Model regulatory aspects of exportation and importation of controlled substances 69 To the following recipient (whichever applicable): Country of final recipient: . Responsible person for receipt: . Name: . Organization/Agency:. Address: . Phone No. . . Fax No. . For use by/delivery to: Location: . Organization/Agency . . . . . Consignee (If different from above e.g. transit in a third country): Name: . Organization/Agency . Address: . Phone No. . . Fax No. . Nature of the emergency (Brief description of the emergency motivating the request): . . . Availability of, and action taken to contact the control authorities in the receiving country: . . I certify that the above information is true and correct. My Organization will: ♦ Take responsibility for receipt, storage, delivery to the recipient/end‐user, or use for emergency care (strike out what is not applicable) of the above controlled medicines; ♦ Report the importation of the above controlled medicines as soon as possible to the control authorities (if available) of the receiving country; ♦ Report the quantities of unused controlled medicines, if any, to the control authorities of the receiving country (if available), or arrange for the end‐user to do so (strike out what is not applicable). Title: .Date: . Location: . . (Signature) The Interagency Emergency Health Kit 2006 70 References 71 Annex 10. References The books and documents referenced below may be obtained (some are priced others are free of charge) from the respective organizations ‐ contact details are provided in Annex 11 or can be found on the organizationsʹ websites. Medicines WHO. Electronic Essential Medicines Library and WHO Model Formulary URL: http://mednet3.who.int/EMLib/wmf.aspx WHO. WHO Model List of Essential Medicines. http://www.who.int/medicines/publications/essentialmedicines/en/index.html Medicine management UNHCR. UNHCR Drug Management Manual 2006. Policies, Guidelines, UNHCR List of Essential Drugs. UNHCR, Geneva, 2006 http://www.unhcr.org/cgi‐bin/texis/vtx/publ/opendoc.pdf?tbl=PUBL&id=43cf66132 John Snow, Inc./DELIVER. Logistics Handbook: A Practical Guide for Supply Chain Managers in Family Planning and Health Programs. 2004 http://portalprd1.jsi.com/portal/page?_pageid=93,3144386,93_3144425&_dad=portal&_schema=PORT AL John Snow, Inc./DELIVER in collaboration with WHO. Guidelines for the Storage of Essential Medicines and Other Health. Arlington, VA: John Snow, Inc./DELIVER; 2003. http://portalprd1.jsi.com/portal/page?_pageid=93,3144386,93_3144425&_dad=portal&_schema=PORT AL Communicable diseases WHO. Communicable Disease Control in Emergencies ‐ A Field Manual. WHO/CDS/2005.27. ISBN 92 4 154616 6 http://bookorders.who.int/bookorders/anglais/home1.jsp?sesslan=1ʺ WHO. Guidelines for the control of shigellosis, including epidemics due to Shigella dysenteriae type 1. World Health Organization, Geneva 2005. (ISBN 92 4 159233 0) http://whqlibdoc.who.int/publications/2005/9241592330.pdf WHO/Department of Child and Adolescent Health and Development. The treatment of diarrhoea ‐ A manual for physicians and other senior health workers. World Health Organization, Geneva, 2005. (ISBN 92 4 159318 0) http://www.who.int/child‐adolescent‐ health/New_Publications/CHILD_HEALTH/ISBN_92_4_159318_0.pdf The Interagency Emergency Health Kit 2006 72 WHO. Environmental health in emergency situation. A practical guide. Control of communicable diseases and prevention of epidemics. World Health Organization, Geneva, 2002. http://www.who.int/water_sanitation_health/hygiene/emergencies/em2002chap11.pdf General public health MSF. Refugee health: an approach to emergency situations. London: Macmillan; 1997. ISBN 0‐333‐ 72210‐8 http://www.msf.org/source/refbooks/msf_docs/en/Refugee_Health/RH1.pdf WHO. Environmental health in emergencies and disasters: a practical guide. Geneva: World Health Organization; 2003. ISBN 92 4 154 541 0 http://www.who.int/water_sanitation_health/emergencies/emergencies2002/en/index.html UNHCR. Water manual for refugee situations. Geneva: Office of the United Nations High Commissioner for Refugees; 1992 Child health WHO. Child health in emergencies. 2003 http://www.who.int/child‐adolescent‐health/publications/pubemergencies.htm WHO. Report of consultative Meeting to Review Evidence and Research Priorities in the Management of Acute Respiratory Infections (ARI). Geneva 29 September ‐ 1 October 2003. WHO/FCH/CAH/04.2. http://www.who.int/child‐adolescent‐ health/New_Publications/CHILD_HEALTH/WHO_FCH_CAH_04.2.pdf WHO. Technical updates of the guidelines on the Integrated Management of Childhood Illness (IMCI). Evidence and recommendations for further adaptations. World Health Organization, Geneva 2005. http://www.who.int/child‐adolescent‐health/New_Publications/IMCI/ISBN_92_4_159348_2.pdf HIV and STIs IASC. Guidelines for HIV interventions in emergency settings. Inter‐Agency standing committee . Geneva: Joint United Nations Programme on HIV/AIDS; 2003. WHO. Guidelines for the management of sexually transmitted infections. Geneva: World Health Organization; 2003. ISBN 92 4 1546263. URL: http://www.who.int/reproductive‐health/publications/rhr_01_10_mngt_stis/ International travel and health WHO. Internal travel and health. Geneva: World Health Organization; 2005. ISBN 92 4 1580364 http://www.who.int/ith/en/ Malaria WHO. Guidelines for the treatment of malaria. Geneva: World Health Organization; 2006. ISBN 92 4 154694 8. WHO/HTM/MAL/2006.1108. http://www.who.int/malaria/docs/TreatmentGuidelines2006.pdf References 73 WHO. Malaria control in complex emergencies. An Interagency field handbook. Geneva: World Health organization; 2005. ISBN 92 4 159389 X. WHO/HTM/MAL/2005.1107 http://www.who.int/malaria/docs/ce_interagencyfhbook.pdf Mental health WHO. Tool: Rapid Assessment of Mental Health Needs of Refugees, Displaced and other Populations affected by Conflict and Post‐Conflict Situations. Geneva: World Health Organization; 2001. MNH/MHP/99.4 rev.1 http://www.who.int/hac/techguidance/pht/7405.pdf Nutrition WHO. Guiding principles for feeding infants and young children during emergencies. Geneva World Health Organization; 2004.ISBN 92 4 154606 9. http://whqlibdoc.who.int/hq/2004/9241546069.pdf Reproductive health UNFPA. Inter‐agency reproductive health kits for crisis situations, 3rd edition. Draft April 2005. WHO/UNHCR. Clinical management of survivors of rape. Developing protocols for use with refugees and internally displaced persons. Revised edition. Geneva, World Health Organization; 2005. Eng: ISBN 92 4 159263 X. FR: ISBN 92 4 259263 3 http://www.who.int/reproductive‐ health/publications/clinical_mngt_survivors_of_rape/clinical_mngt_survivors_of_rape.pdf UNHCR. Sexual and gender‐based violence against refugees, returnees, and internally displaced persons: guidelines for prevention and response. Geneva: Office of the United Nations High Commissioner for Refugees; May 2003. URL:http://www.unhcr.ch/cgi‐ bin/texis/vtx/protect/opendoc.pdf?tbl=PROTECTION&id=3f696bcc4 UNFPA. Reproductive Health for Communities in Crisis. UNFPA Emergency Response, 2001 http://www.unfpa.org/upload/lib_pub_file/78_filename_crisis_eng.pdf UNFPA/UNHCR/WHO. Reproductive health in refugee situations: an interagency field manual: Geneva: Office of the United Nations High Commissioner for Refugees; 1999 http://www.unfpa.org/emergencies/manual/ Tuberculosis WHO. TB/HIV a clinical manual 2004. Geneva: World Health Organization; 2004. 2nd edition. WHO/HTM/TB/2004.329. URL: http://www.who.int/tb/publications/who_htm_tb_2004_329/en/index.html WHO. Treatment of tuberculosis: guidelines for national programmes. 3rd.edition. Geneva: World Health Organization; 2003. WHO/CDC/TB/03.313 URL: http://whqlibdoc.who.int/hq/2003/WHO_CDS_TB_2003.313.pdf WHO/UNHCR. Tuberculosis Control in Refugee Situations: an Interagency Field Manual. Geneva: World Health Organization; 1997. WHO/TB/97.221 http://whqlibdoc.who.int/hq/1997/WHO_TB_97.221.pdf The Interagency Emergency Health Kit 2006 74 Useful addresses 75 Annex 11. Useful addresses Partners Ecumenical Pharmaceutical Network Community Initiatives Support Services International P.O. Box 73860 Nairobi Kenya Tel: +254 20 444 4832/5020 Fax: +254 20 444 5095/444 0306 E‐mail: firstname.lastname@example.org, http://www.epnetwork.org/ International Committee of the Red Cross 19 Avenue de la Paix CH‐1202 Geneva Switzerland Tel. +41 22 734 6001 Fax: +41 22 733 2057 E‐mail: www.icrc.org http://www.icrc.org International Federation of Red Cross and Red Crescent Societies 17 Chemin des Crêt Petit Saconnex P.O. Box 372 CH‐1211 Geneva Switzerland Tel: +41 22 730 4222 Fax: +41 22 733 0395 E‐mail: email@example.com http://www.ifrc.org International Organization for Migration 17 route des Morillons P.O. Box 71 CH‐1211 Geneva 19 Switzerland Tel: +41 22 717 9111 Fax: +41 22 7986150 E‐mail: firstname.lastname@example.org http://www.iom.int The Interagency Emergency Health Kit 2006 76 John Snow, Inc. JSI Logistics Services 1616 N Fort Myer Drive, 11th floor Arlington VA 22209 United States of America Tel: +1 703 528 7474 Fax: +1 703 528 7480 E‐mail: email@example.com http://www.jsi.com or http://www.deliver.jsi.com Médecins Sans Frontières Belgium Office 94 rue Dupré B‐1090 Brussels Belgium Tel: +32 2 474 7474 Fax: +32 2 474 7575 E‐mail: firstname.lastname@example.org http://www.msf.be/ Merlin 207, Old Street, 12th floor London EC1V 9NR United Kingdom Tel: +44 20 7014 1600 Fax: +44 20 7014 1601 E‐mail: www.merlin.org.uk http://www.merlin.org.uk OXFAM Oxfam House John Smith Drive Cowley Oxford OX4 2JY United Kingdom Tel: +44 1865 473 727 E‐mail: http://www.oxfam.org.uk/contact http://www.oxfam.org.uk United Nations Children’s Fund UNICEF House 3 United Nations Plaza New York, New York 10017 United States of America Tel: +1 212 326 7000 Fax: +1 212 887 7465 E‐mail: www.unicef.org http://www.unicef.org Useful addresses 77 United Nations High Commissioner for Refugees Case Postale 2500 CH‐1211 Geneva 2 Dépot Switzerland Tel: +41 22 739 8111 Fax: +41 22 731 9546 E‐mail: http://www.unhcr.org http://www.unhcr.org World Council of Churches Christian Medical Commission, Churches’ Action for Health 150 Route de Ferney P.O. Box 2100 CH‐1211 Geneva 2 Switzerland Tel: +41 22 791 6111 Fax: +41 22 791 0361 E‐mail: koa@wcc‐col.org; http://www.wcc‐coe.org United Nations Population Fund UNFPA/HRU 11 Chemin des Anémones CH‐1219 Geneva Switzerland Tel: +41 22 917 8315 Fax: +41 22 919 8016 E‐mail: email@example.com/ Website: www.unfpa.org World Health Organization 20, Avenue Appia CH‐1211 Geneva 27 Switzerland Tel: +41 22 791 2111 Fax: +41 22 791 3111 E‐mail: firstname.lastname@example.org Website: www.who.int The Interagency Emergency Health Kit 2006 78 Suppliers Centrale Humanitaire Médico‐pharmaceutique 4 voie militaire des Gravanges F‐63100 Clermont‐Ferrand France Tel: +33 4 73982481 Fax: +33 4 73982480 E‐mail: email@example.com http://www.chmp.org International Dispensary Association Foundation Slocherweg 35 1027 AA Amsterdam PO Box 37098 NL‐1030 AB Amsterdam The Netherlands Tel: +31 20 403 3051 Fax: +31 20 403 1854 E‐mail:firstname.lastname@example.org http://www.idafoundation.org Missionpharma Vassingeroedvej 9 3540 Lynge Denmark Tel.: +45 4816 3200 Fax: +45 4816 3248 E‐mail: email@example.com http://www.missionpharma.com MSF ‐ Supply Preenakker 20 B‐1785 Merchtem Belgium Tel.: +32 52 2610 00 Fax: +32 52 2610 04 E‐mail: office‐firstname.lastname@example.org http://www.msfsupply.be Medical Export Group Papland 16 P.O. Box 598 4200 AN Gorichem The Netherlands Tel: +31 20 403 3051 Fax: +31 20 403 1854 E‐mail: email@example.com http://www.meg.nl Useful addresses 79 United Nations Children’s Fund ‐ Supply Division UNICEF Plads Freeport DK‐2100 Copenhagen Æ, Denmark Tel: +45 35 37 35 27 Fax: +45 35 26 94 21 E‐mail: firstname.lastname@example.org http://www.unicef.org/supply UNFPA Nordic Office Procurement services Midtermolen 3 DK‐2100 Copenhagen Denmark Tel: +45 35 467 000 Fax: +45 35 467 018 E‐mail: email@example.com http://nordic.unfpa.org/ World Health Organization Procurement Services 20, Avenue Appia CH‐1211 Geneva 27 Switzerland Tel: +41 22 791 2111 Fax: +41 22 791 0746 http://www.who.int/ United Nations Development Programme Interagency Procurement Services Office Midtermolen 3 P.O. Box 2530 DK‐2100 Copenhagen Ø Denmark Tel: +45 35 46 7000 Fax: +45 35 46 7001 E‐mail: firstname.lastname@example.org www.iapso.org/ The Interagency Emergency Health Kit 2006 80 Feedback form 81 Feedback form The purpose of this form is to seek your opinion about the contents of the Interagency Emergency Health Kit 2006. Any remarks, suggestions or recommendations you may have are welcomed. We will use your written feedback about the kit during the next revision of its contents which is planned for 2008. Your input will be acknowledged. Please send your feedback either by post to WHO, Department of Medicines Policy and Standards, 20 Avenue Appia, CH‐1211 Geneva 27, Switzerland; or by fax: +41 22 791 4167 or e‐mail: email@example.com Feedback on the Interagency Emergency Health Kit 2006 Emergency situation Please describe briefly the situation in which you used the Interagency Emergency Health Kit 2006. Date/period and year: ………………………………………………………………. Country: ………………………………………………………………. Kind of emergency situation: ………………………………………………………………. …………………………………………………………………………………………………………… Your qualification and position: ………………………………………………………………. …………………………………………………………………………………………………………… I. Content of the basic unit Selected medicines 1. Are the contents of the basic unit appropriate for the needs of the displaced population in terms of the selected medicines? Yes No If no, which medicines are inappropriate?: If no, which medicines are missing?: Selected renewable medical supplies 2. Are the contents of the basic unit appropriate for the needs of the displaced population in terms of the selected renewable medical supplies? Yes No If no, which renewable medical supplies are inappropriate?: If no, which renewable medical supplies are missing?: Selected health equipment 3. Are the contents of the basic unit appropriate for the needs of the displaced population in terms of the selected health equipment? Yes No If no, which health equipment is inappropriate?: If no, which health equipment is missing?: The Interagency Emergency Health Kit 2006 82 II. Content of the supplementary unit Selected medicines 4. Are the contents of the supplementary unit appropriate for the needs of the displaced population in terms of the selected medicines? Yes No If no, which medicines are inappropriate?: If no, which medicines are missing?: Selected renewable medical supplies 5. Are the contents of the supplementary unit appropriate for the needs of the displaced population in terms of selected renewable medical supplies? Yes No If no, which renewable medical supplies are inappropriate?: If no, which renewable medical supplies are missing?: Selected health equipment 6. Are the contents of the supplementary unit appropriate for the needs of the displaced population in terms of selected health equipment? Yes No If no, which health equipment is inappropriate?: If no, which health equipment is missing?: III. Information 7. Does the booklet IEHK 2006 provide appropriate information and instructions to understand the emergency health kitʹs guiding principles? Yes No If no, why not? 8. Does the booklet IEHK 2006 provide appropriate treatment guidelines for the use of the contents of basic units? Yes No If no, why not? 9. Are all sections of the booklet IEHK 2006 relevant? Yes No If no, what would you take out?: If no, what would you like to see included?: 10. Are all annexes of the booklet IEHK 2006 relevant? Yes No If no, what would you take out?: If no, what would you like to see included?: 11. Was there any technically inaccurate or incomplete information? Yes No If yes, what?: 12. What are your 3 suggestions to improve the contents of the kit and the booklet IEHK 2006 for the next update? 1. 2. 3. 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The Supplies Information Database (SID) is an online reference library with more than 2000 records on the status of reproductive health supplies. The library includes studies, assessments and other publications dating back to 1986, many of which are no longer available even in their country of origin. Explore the database here.