7.3 Drug supply and management

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 kits1 . 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 RL2 , 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
Ref Notes
1

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.

2

Or alternatively, 3 catheters per patient, which is almost equivalent.