7.3 Drug supply and management

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    7.3.1 Supply

    The medical stock must always be sufficient to guarantee continuous care, including in the event of a sudden influx of patients and/or supply difficulties. Ringer lactate (RL), catheters and infusion sets, and oral rehydration salts (ORS) are the most important articles as they are essential to the treatment of cases. A shortage of these articles could result in an increased case fatality rate.

     

    Supplies are provided in kits a Citation a. For the contents of the 001 Cholera Kit, 625 treatments, MSF, see the MSF kit catalogue. The 001 Cholera Kit can be divided into smaller kits for a given number of patients (10, 20, 50, etc.) in order to supply small facilities that are linked to a CTC or to pre-position treatments in areas at risk, including during on-site investigations.  . Cholera kits do not contain all articles; certain articles need to be ordered apart.

    7.3.2 Calculation of treatment needs

    Using one of the examples given in Chapter 2 (Box 2.1 and Table 2.1), in a refugee camp, 1500 cases are expected over the course of the outbreak. Of these 1500 patients, 75% (1125 patients) will receive oral treatment only and 25% (375 patients) will receive IV + oral treatment. A 50 bed CTC is set up.

    First order for the CTC

    An initial order for treatment supplies is made to the central store. It includes treatment supplies for all patients (no/some/severe dehydration), including for facilities such as ORPs that are linked to the CTC.

     

    Decide how long the initial stock will need to last (1 or 2 weeks) and add a buffer stock (20-25%). This buffer stock must be maintained throughout the outbreak.

     

    In the example of the refugee camp, 20% of cases are expected during the peak week of the outbreak. To simplify ordering and have sufficient stock, without being excessive, use the following rules of thumb:
    – If the order is to cover 1 week, order sufficient supplies to cover one quarter of patients expected during the peak week (i.e. 5% of total expected patients).
    – If the order is to cover 2 weeks, order sufficient supplies to cover half the patients expected during the peak week (i.e. 10% of total expected patients).

     

    It is estimated that the following quantity (rounded) of supplies will be needed for e.g. 2 weeks:

     

     

    For expected cases

    Buffer stock (20%)

    Total

    Sachets of ORS

    1500

    300

    2000 sachets of ORS

    Litres of RL

    400

    80

    500 litres of RL

    Infusion sets

    200

    40

    250 infusion sets

    Catheters

    150

    30

    200 catheters

    Doxycycline

    300

    60

    400 tablets

    Zinc sulfate

    300

    60

    400 tablets

     

    This calculation is based on the following standards: 10 litres of ORS per patient, 10 litres of RL per patient with severe dehydration, 1 infusion set for 2 litres of RL, 1 catheter for 3 litres of RL b Citation b. Or alternatively, 3 catheters per patient, which is almost equivalent.  , one antibiotic therapy per patient with some or severe dehydration and pregnant women (in total, around 60% of patients), one blister of zinc sulfate per child under 5 (20% of patients).

     

    For example for 10% of 1500 expected cases i.e. 150 patients:
    150 patients x 10 litres of ORS = 1500 sachets
    150 patients, of which 25% on IV treatment i.e. 38 patients x 10 litres of RL = 380 litres of RL rounded to 400.
    Do not forget to add the buffer stock.

     

    Notes:
    – Part of the ORS sachets are for on-site patient treatment, the others are to give to patients on discharge to finish treatment at home and/or treat family members that develop symptoms.
    – For orders and stock, count RL in litres not in bags or pouches.
    – It is not necessary to have as many infusion sets and catheters as litres of RL. Always have 2 sizes of adult catheters and 2 sizes of child catheters.
    – Antibiotics (depending on the antibiotic sensitivity test and national protocol):
    • doxycycline: 3 tab of 100 mg/patient
    • azithromycin: 4 tab of 250 mg/patient + oral suspension for children < 5 years (20%)
    • ciprofloxacin: 4 tab of 250 mg/patient
    – Zinc sulfate: one blister of 10 tablets per child < 5 years

    Subsequent orders

    For subsequent orders, others elements need to be taken into account e.g. an increase or decrease in the number of cases per week depending on the evolution of the outbreak and consumptions.

    7.3.3 CTC pharmacy management

    Range of articles

    The range of articles used should be limited and focused on:
    – The treatment of dehydration, and
    – The main complications related to cholera treatment (hypokalaemia, fluid overload).
    Nevertheless treatment for some of the most common comorbidities (e.g. malaria, respiratory infections) must be available. These articles must be ordered in addition to the kits.

     

    Note: IV potassium is a dangerous drug and must be used in one presentation only (volume and concentration) in the CTC. Recommended presentation is 10 ml-ampoule containing 10% potassium chloride (13.4 mmol/ampoule).

    Organisation of stock

    Articles are classed by category, to be found easier:
    – Oral drugs: antibiotics, zinc sulfate, potassium chloride syrup, etc.
    – Specific drugs, in small quantities, for the treatment of complications (e.g. injectable potassium, furosemide, glucose).
    Ampoules of injectable potassium must be stored in a specific place away from water for injection, or any other drugs that look similar.
    – Medical materials (infusion materials, sharp containers, etc.).
    – Boxes of ORS, RL, kits and modules.

     

    Drugs and medical materials are put away on shelves as quickly as possible, and boxes of ORS, RL and kits on palettes. This organization makes visual evaluation of available stock easier and protects materials from deterioration.

    Drug storage

    ORS powder and dispersible zinc tablets are extremely sensitive to humidity.
    ORS can be used as long as it remains a white powder. Humidity transforms it into a compact, tinted, insoluble mass. In this condition it is unfit for consumption and must be discarded, even if it has not reached its expiry date.

    7.3.4 Stock management in treatment wards

    Each ward (or each tent) has a limited stock of essentials items (ORS/RL, basic drugs) sufficient for 12 or 24 hours, depending on the setup and activity (1 or 2 deliveries to the ward/24 hours).

     

    This stock is managed by the nurse, with the help of the pharmacy manager, and under the supervision of the CTC coordinator or the healthcare supervisor that checks wards’ stocks several times a day.

    7.3.5 ORS management in treatment wards

    Oral rehydration solution must be available at all times for patients. This implies appointing staff specifically responsible for ORS management: preparation and elimination if applicable (ORS only keeps for 24 hours).

     

    Depending on the context (size, resources, organization), staff in charge of ORS must be supervised either by the pharmacy manager (if ORS preparation is centralised for the entire CTC) or by the unit’s nurse (if ORS is prepared in each unit by the nurse auxiliary).

     

    Footnotes
    • (a)For the contents of the 001 Cholera Kit, 625 treatments, MSF, see the MSF kit catalogue. The 001 Cholera Kit can be divided into smaller kits for a given number of patients (10, 20, 50, etc.) in order to supply small facilities that are linked to a CTC or to pre-position treatments in areas at risk, including during on-site investigations.
    • (b)Or alternatively, 3 catheters per patient, which is almost equivalent.