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 is the only way to shorten the time between the onset of symptoms and the start of treatment. The chosen strategy should ensure that appropriate treatment is available at all levels.

Treatment centres are distributed so that they cover the entire area affected by the outbreak. 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

There must be an efficient referral system in place for transferring complicated cases to inpatient departments.

Everyone should be familiar with the transfer criteria and treatment protocol prior to transfer. Transfer forms should be available in all peripheral centres, and the transfer should be noted in the measles case register.

4.3.3 Free care

To guarantee access to care, treatment, patient transfer and hospitalisation absolutely must be free of charge.

4.3.4 Patient isolation

As soon as the first cases are identified, area health care facilities should take transmission prevention and patient isolation measures.

Clinics and health centres (outpatient treatment)

Advise parents to avoid gathering places (e.g., schools, cultural or sporting events, etc.).

There is significant measles transmission in health care facilities waiting rooms, where a lot of people are gathered in often small, poorly-ventilated areas. It is therefore necessary
to:
– identify patients with measles symptoms (fever and rash) as soon as they arrive, and send them to a special waiting room/area 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.
– Provide health care staff and all the necessary medical supplies for managing the cases.

The functioning of the measles unit is established before it opens (Appendix 8).

4.3.5 Care staff training and supervision

Caregiver training and supervision are essential.

Training

Assess knowledge and if necessary hold training and refresher sessions:
– basic training by personnel level, during which training documents, 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 indispensible as soon as supply is set up. It allows the supervisor to:
– provide the staff with clear, accurate information (case definition, data collection, protocol, free care, referral criteria, and answers to medical questions) and verify that it is understood;
– define a supply strategy with the staff;
– inform the authorities and the public.

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. A study ofseven outbreaks between 2002 and 20081 shows a cumulative attack rate for the duration of the outbreak somewhere between 300 and 1,400 cases per 100,000 (or between 0.3 and 1.4%). An initial estimate based on an attack rate of 500 to 750 cases per 100,000 seems reasonable.

Example: Matadi (DRC), population 300,000

At-risk population300,000
Estimated number of cases (attack rate 500/100,000)1,500
Subtract the number of reported cases to date– 400
Estimated number of new cases through the end of the outbreak1,100
Add a 25% reserve275
TOTAL treatments needed1,375

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 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 care facilities and collect data.
– Health staff collect supplies directly from the central pharmacy and bring their weekly data.
– A combination of the two.

Using rapid means of communication (telephone and radio) enables contact for fine-tuning support and supply.

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;
– the health care facilities reporting the largest number of cases, and particularly those with the highest case fatality rate;
– all health centres that report cases;
– health care facilities that have not yet reported any cases: pre-position a 10-treatment “uncomplicated case" kit.

Standardized 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 given 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 following the vaccination campaign to ensure treatment of the last few cases.



Footnotes
Ref Notes
1 MSF internal reports