Introduction


These Clinical guidelines should be viewed as an aid in prescribing treatment. They do not go into detail on public health measures like immunisation and nutrition programmes, or hygiene and sanitation procedures, for managing the health of a population; these are covered in other publications. They do, however, talk about preventive measures – such as vaccines – that patients can be offered to protect them from disease.

Objective

These guidelines’ primary objective is to cure an individual patient of his disease, and to minimise the impact of that disease on both the patient and those around him (the risk of transmission, for example).

But well-organised, carefully-followed treatments for high priority pathologies – such as infectious diseases – also reduce mortality in the population. And if enough patients are treated for endemic diseases like tuberculosis, transmission will be reduced.

Strategy

Curative activities should focus on priority targets, in terms of both diseases and particularly vulnerable populations. All prescribers should be familiar with the epidemiological situation around the medical facilities in which they practice (epidemic and endemic diseases, the frequency of traumatic injuries, etc.), and with the demographics of the population they serve (proportion of children under five and pregnant women, as they are more vulnerable).

The treatment protocols and drugs that are used must be adapted to the epidemiological circumstances; that is the aim of both this publication and Essential drugs - practical guidelines. These two sets of guidelines use a narrow list of drugs based on the World Health Organization’s (WHO) model list of essential medicines. Health ministries may, however, have their own national list of essential drugs and treatment protocols that must be followed.

Resources

The quality of prescribing relies on prescribers (health workers, physician’s assistants, nurses, midwives and physicians) being properly trained. It will vary depending on the region and on the level of both their training and the medical facility in which they work (health post, health centre or hospital). As that level must often be evaluated to ensure that training is adequate, this publication and the Essential drugs factsheets can be used as a foundation.

The drugs are chosen based on:
– Their efficacy and tolerance (few adverse effects);
– Their ease of administration, duration of action, number of daily doses and ease of adherence;
– Their stability at room temperature, availability, and cost.

The WHO model list of essential medicines is the basic tool for this selection, which should be fine-tuned to the epidemiological profile of the region, the skills of the medical staff and the possibility of referral to a higher-level medical facility.

The most important basic rule for a prescribing programme is standardised treatment protocols. These is essential to the overall effectiveness of the treatments offered, health care staff training and programme continuity during staff turnover.

The protocols in these guidelines were written according to the following principles:
– All drugs are designated by their international non-proprietary name (INN).
– Selection is based on clinical and epidemiological reasoning, and on scientific evidence that can be discussed and agreed upon by users.
– Selection facilitates treatment adherence: the shortest possible treatment with the fewest daily doses; single dose treatments always given preference; the fewest possible drugs prescribed. When efficacy is comparable, the oral route is preferred to reduce the risk of contamination by injectables.

Consultation

Try to provide enough prescribers for the expected number of patients, so that each patient gets at least 20 to 30 minutes per consultation.

The consultation area for diagnosis and treatment should be carefully arranged to ensure privacy during the interview and patient comfort.

The quality and outcome of the treatment depends on more than just the protocol. Treatment adherence relies on the quality of the trust relationship established by the prescriber and the respect he shows the patient.

The prescriber must know the local habits – for example, whether it is customary to have gender-separate consultations, or if there is a rule that the examination must be done by a prescriber of the same gender as the patient.

It is often necessary to use an interpreter, and interpreters should be trained in systematically questioning the patient regarding his complaints and history. Like the rest of the health care staff, interpreters must be aware that they are also bound by the rules of confidentiality.

Diagnosis rests primarily – and sometimes exclusively – on the clinical findings; hence the importance of taking a careful history of the complaint and symptoms and doing a complete, systematic exam. The data should be copied into the health record, admission note or register so that the patient’s progress can be monitored.

Diagnostic aids

The equipment for ancillary testing depends on the level of the facility where the treatment takes place.

When there is no laboratory available, either for outpatient or inpatient care, rapid diagnostic tests may be made available (for malaria, HIV, hepatitis B and C, etc.).
A laboratory must be set up for certain diseases, such as tuberculosis, trypanosomiasis and visceral leishmaniasis.

Medical imaging (X-rays and ultrasound) may be nonexistent. In that case, patients who cannot be diagnosed without imaging should be referred (trauma patients, in particular).