4.3 Patient management - Principles and organisation

4.3.1 Decentralised care

Early treatment of cases is a priority in order to reduce the case fatality rate, complications, and sequelae of measles.

Decentralised curative care and active case-finding make it possible to reduce the time between the onset of symptoms and the start of treatment. One study in a difficult-to-access area showed that before a decentralised care system (free care peripherally for uncomplicated cases and a referral system) was set up, children living more than 30 km from a hospital were three times more likely to die from measles [1]Citation 1.Gignoux E, Polonsky J, Ciglenecki I, et al. Risk factors for measles mortality and the importance of decentralized case management during an unusually large measles epidemic in eastern Democratic Republic of Congo in 2013. Arez AP, ed. PLOS ONE. 2018;13(3):e0194276. https://doi.org/10.1371/journal.pone.0194276 .
 

Treatment centres are distributed so that they cover the entire area affected by the outbreak. The chosen strategy should ensure that appropriate treatment is available at all levels. In some cases (where hospital referral is difficult or impossible), it may be necessary to open temporary inpatient units (in a public building, tents, etc.) for the duration of the outbreak.   

4.3.2 Referral system for severe cases

Ensure that an effective referral and counter-referral system is in place to transfer complicated cases to hospitalisation services. The transfer criteria and the treatment protocol prior to transfer must be clear and well-known. Transfer forms should be available in all peripheral centres, and the transfer must be recorded in the case register.

4.3.3 Free care

To guarantee access to care, treatment (for measles and related illnesses), patient transfer and hospitalisation absolutely must be free of charge. If needed, support for the referral hospital’s paediatric activities may be recommended.

4.3.4 Managing transmission risk

As soon as the first cases are identified or suspected, health care facilities should, without delaying the start of the treatment, take steps  to prevent transmission and isolate patients from triage to inpatients units.

Protection

Check the vaccination status (two doses) of the staff and caregivers and arrange for them to be vaccinated, if necessary.

Always prioritise the assignment of staff whose vaccination status (two doses) has been verified or whose history of measles infection can be confirmed and recommend that all staff in the vicinity of suspected or confirmed measles patients wear a respiratory protection mask (N95 or FFP2).

Clinics and health centres (outpatient treatment )

The measles transmission risk in health care facility waiting rooms can be high (overcrowding, small and poorly ventilated spaces, long wait times, etc.).

It is therefore necessary to:

• Triage patients: identify patients with measles symptoms (fever and rash) as soon as they arrive, and direct them to a designated waiting room/area where patients are spaced 2 m apart, if possible, to protect uninfected patients.
• Air out waiting rooms frequently and fully to replace the air contaminated by microdroplets expelled by infected patients.

Hospitals and temporary measles inpatient units

• Keep cases together and isolated throughout their hospital stay by using a different patient flow to that in the general hospital.
• For patient monitoring and care, provide:
  • A dedicated health care staff
  • Appropriate medical equipment
  • A unit for managing complicated measles cases that is up and running prior to opening (Appendix 8).

Advice to families

Advise any family members of patients with measles to avoid gathering places (e.g., schools and cultural or sporting events) for five days after the onset of symptoms. Although the risk that transmission within the household has already occurred is extremely high, ideally the vaccination status (two doses) of all family members should be checked and updated if necessary.

4.3.5 Care staff training and supervision

The training and supervision of staff are essential to the provision of quality healthcare.

Training

Assess knowledge and if necessary, hold training and refresher sessions:

• Initial training appropriate to job level, during which training documents, monitoring and treatment protocols, and treatment kits are distributed
• Continuing education during supervision visits

Supervision

Supervision visits are an opportunity to supply the centres, to reinforce epidemiological surveillance and to discuss complex clinical cases and any difficulties encountered.

An initial visit to all health care facilities in the affected area is indispensable as soon as supply is set up. It allows the supervisor to:

• Verify that health care staff are getting accurate information (about the case definition, data collection, treatment protocols, free care and referral criteria) and that they understand it
• Define a supply strategy with the staff
• Inform the authorities and the public about how the outbreak is evolving
• Other visits are then scheduled to answer practical questions, monitor inventory management and record keeping, and assess the quality of care

4.3.6 Supplying treatment facilities

Estimating the number of treatments needed

Drug and medical supply needs are estimated based on the expected number of cases, the number of facilities to be provisioned, and the existing stocks (Appendix 9). Allow for a reserve supply.

The expected number of cases is estimated based on the average cumulative attack rate seen in previous outbreaks or on observations of other outbreaks. An examination of outbreaks over the past twenty years aCitation a.MSF internal reports  has shown that the cumulative attack rate over the entire course of an outbreak can vary widely, from 100 to more than 3,000 cases per 100,000 (or from 0.1% to 3%). An initial needs estimate based on an attack rate of 500 cases per 100,000 seems reasonable.

Example: A city of 300,000 people with 400 cases reported over the past five weeks

The proportion of patients requiring hospitalisation will vary between 10 and 20% of cases, depending on the context (access to care, etc.).

In this example, it is assumed that 15% of patients will require hospitalisation, and so the number of “complicated case” treatments needed is: 1,375 x 0.15 = 206.

The initial estimate at the start of the outbreak permits an order for the first few weeks. Depending on the course of the outbreak, vaccination activities and inventories, further orders may be needed.

A standard treatment protocol permits ordering based on the list of selected items and drugs.
 

Treatment kits

All outpatient and inpatient treatment facilities, at both the national and local level, are supplied in the form of kits for the duration of the outbreak. This simplifies the transport and management of stocks, reduces the risk of shortages and ensures patient access to the full treatment.

There are two types of kits (Appendix 10):

• The 10-treatment "uncomplicated case" kit for clinics and health centres
• The 20-treatment “complicated case” kit for hospitals and temporary inpatient units

To save time and allow a focus on other activities (e.g. support and exchanges with staff) during visits, the kits are prepared in advance at the central storehouse and then distributed to health care facilities. If necessary, one of the team’s medical staff can hire and train day workers to prepare the kits.

Supply planning

This is defined according to:

• The epidemiological data (number of cases, shape of the epidemic curve, and case fatality rate)
• The accessibility of treatment facilities: distance, travel time, road conditions, and security
• Staff supervision needs
• The available resources: vehicles, public/private transportation, and fuel
• The availability of qualified personnel to supply the facilities and supervise patient treatment

There are several possible options:

• Mobile teams supervise and supply the health centres and collect data
• Health centre staff collect supplies directly from the central pharmacy and bring their weekly data
• A combination of the two

Support and supply can be fine-tuned using rapid means of communication (telephone and radio).

Kit distribution strategy

The goal here is to ensure that each facility has treatments available at all times throughout the outbreak (Appendix 11).

1) Initial coverage of the zone

As soon as an outbreak is confirmed, kits are sent as quickly as possible to all health care facilities in the area in question. They are distributed, in the following order of priority, to:

• Hospitals and temporary measles inpatient units (complicated case kit)
• The health care facilities reporting the largest number of cases, and particularly those with the highest case fatality rate (uncomplicated case kit)
• All health centres that report cases
• Health centres that have yet to report any cases: pre-position a 10-treatment “uncomplicated case” kit

Standardised case definitions, admission criteria, treatment protocols (Appendix 13) and weekly epidemiological data collection forms are distributed at the same time to all the facilities being supplied.

2) Subsequent supply

Supply then continues to all facilities according to the number of reported cases, the theoretical number of treatments in stock, and the case fatality rate. The period for which treatments will be supplied is defined as a function of the workload and the logistical resources available (Appendix 11).

Note:

• Do not give all of the treatment kits at once, but rather for a specific period
• Avoid dispersal: treatments may be allocated unnecessarily to centres that are not treating cases, to the detriment of centres that are treating a lot of cases and on which resources should be concentrated
• When the outbreak is over, continue to distribute treatment kits for a few weeks after the vaccination campaign to ensure treatment of the last few cases