| Clinical guidelines - Diagnostic and treatment manual |
In a health program adapted to the needs of a developing country, the curative care is an important component. Initially however, more important measures have to be implemented to provide the foundations for all programs aimed at improving the health of a community. These measures are related to:
- maternal and child health,
- health education,
- health workers training,
- community awareness and participation.
These measures should interact and complement the curative care component of the health program.
At the individual level
The objective is to cure the patient and to minimize or prevent the consequences of illness (eg. transmission).
At the community level
The objectives are to reduce the mortality and morbidity attributable to the common severe illnesses in the community.
For a few infectious endemic diseases
Curative care can reduce transmission of certain diseases (e.g. TB, leprosy, trypanosomiasis, bilharzia) provided a high proportion of the infected community is treated.
In developing countries there are enormous needs and limited resources. The resources should be aimed at the diseases, amenable to effective treatment in the field, which are causing high mortality and morbidity (priority diseases).
Priority diseases can vary from one geographical region to another, but a standard epidemiological profile remains. In order to get an accurate profile an initial assessment is necessary. It should be qualitative (descriptive), and if possible, quantitative (incidence, morbidity and mortality rates). This evaluation will characterise the most common diseases (e.g. diarrhoea, acute respiratory infections...) and will identify the exposed and high risk groups in the population (e.g. children < 5 years, pregnant women...). These diseases and high risk groups should be the targets of the program. This does not mean that curative care should be limited to these diseases and groups of people, but rather that the resources, particularly at the primary health care level, should be targeted at these groups.
In some instances (e.g. displaced or isolated persons) a complete evaluation is necessary. In other instances, such as a rehabilitation program or a study to reinforce an existing program, the Ministry of Health (MOH) may already have qualitative or quantitative data available and only a partial evaluation may be necessary.
The health care program can be defined and carried out as soon as priorities have been defined, and health policy and local resources identified (e.g. essential drug list, MOH management protocols, medical personnel and their training and the medical structure).
This manual, "Essential drugs - practical guidelines" and "Principales conduites a tenir en dispensaire" are additional tools to help evaluate, define and establish a health care program (e.g. management protocols, training, guidelines...).
In certain situations (e.g. displaced populations, refugees), a program has to be created, whereas in others, an existing program is evaluated so it can be improved.
Infrastructure and medical staff
Health centers, dispensaries, medical centers and hospitals are run by personnel with different skills and different levels of competence (e.g. community health workers (C.H.W.), medical auxiliaries, nurses, midwifes and doctors).
The evaluation should clarify their technical level. In refugee camps, most of the staff will have no previous training.
Selection of medicines depends on the targets and needs identified in the epidemiological profile. However, are other restraints: cost, stability, administration route, duration of treatment and whether single or multiple drug doses are required.
The W.H.O. list of essential drugs (appendix 3), is the basic framework for establishing an essential drug list. A drug list should be defined in accordance with objectives, target diseases, epidemiological profile, medical staff competence and whether it is possible to refer severe cases. The quantitative and qualitative drug lists of the Emergency Health Kit (for 10.000 persons for 3 months) recommended by the W.H.O. and Medecins sans Frontieres are given as an example in appendix 4.
Drugs are listed under their Intemational Nonproprietary (generic) Names: INN.
These protocols are the foundation stone of any curative health program and should be standardised in order to have an effective impact on the target diseases.
The therapeutic protocols should:
- Give clear accurate instructions.
- Include the therapeutic uses and dosages of drugs, and the duration of treatment.
- Choose the most effective drug with least side effects.
- Be supported by epidemiological and clinical data and should be discussed and agreed by the users.
- Be practical, simple, understandable and adapted to the field.
- Encourage the training and retraining of medical staff.
- Encourage the organization of medical infrastructure (e.g. pharmacy, management...).
- Be periodically re-evaluated.
- Always use the national recommendations of the country.
The therapeutic protocols should be adapted to the skill and knowledge of the medical staff. They should cover: drug prescription, curative and preventive measures, cases which should be notified (e.g. epidemic threats: cholera, typhoid), and the grounds for referral to a superior level hospital.
Protocols should be adapted to:
1) The skill and knowledge of the medical staff
A doctor is trained in terms of diseases and syndromes (e.g. pneumonia, liver abscess) whereas a Community Health Worker (CHW) is trained in terms of symptoms (e.g. cough, fever). These two approaches are presented in Chapter 2 "Respiratory Diseases", with an introduction of the WHO program on respiratory conditions which is founded on a symptomatic approach.
2) The cultural milieu and environment
For example, if it is the custom to treat children with diarrhea with rice water, or for children with fevers to remain clothed, do not reprimand their parents.
3) The pharmaceutical supplies and local dosages of drugs
Dosages are often different between countries (e.g. chloroquine 100 mg or 150 mg tablets).
4) The improvement of patient treatment and compliance
It is recommended that prescribed treatments are short (< 5 days) and, if possible, in single or twice daily doses. "Stat dose" treatments, although less effective pharmacologically, do not rely on patient compliance (e.g. treat amoebiasis with a single dose of 8 metronidazole tablets (tab 250 mg) instead of a 7 day course). For the same reasons, the prescription should be limited to a maximum of 2 prescribed drugs. Injections should be avoided to reduce HIV transmission or B hepatitis.
Protocols should avoid classical mistakes like recommending the boiling of water when energy resources (e.g. wood) are limited.
Recommendations and examples of therapeutic protocols can be found in:
- The protocols from the "New Emergency Health Kit" (CHW level) to target diseases (see appendix 4).
- The clinical and treatment sections of this manual.
These methods depend on the structure of the organization and on the technical expertise of the staff. Staff expertise directly influences protocol formulation and drug list contents.
As a rule, diagnosis is based on the clinical examination and basic laboratory investigations (as it is defined in WHO).
The principles here described are for trained medical staff. The approach for the CHW is similar but simpler.
Quality history taking and clinical examination is vital. If poor, the process from syndrome etiology to diagnosis will likewise be poor, and the treatment inappropriate. It is important to master a technique of clinical assessment that is methodical, complete and rapid. A method is all the more necessary because in field conditions the laboratory support may be rudimentary and the practitioner may have to communicate with the patient via an interpreter.
The following examination framework should be adapted to conditions. It emphasizes the advantages of a methodical approach.
CIRCUMSTANCES OF THE EXAMINATION
- Routine, as in a MCH clinic for prenatal women and well babies. The emphasis of the examination will depend upon local circumstances eg prevalence of anemia, malnutrition.
- With respect to a complaint, the commonest of which tend to be pain, fever, cough, diarrhea, fatigue...
APPROACH TO HISTORY AND PHYSICAL EXAMINATION
- A methodical approach is vital. This will save time and reduce omissions.
- An interpreter will usually be necessary. He/she must have received prior training and there must be good rapport between the clinician and the interpreter. Eventually, a good interpreter takes a very active role in the clinical process and becomes far more than a simple translator. Choosing an interpreter requires thought; the person must be acceptable to the community and appropriate for the specific role (eg a woman for obstetrics and gynaecology).
- Learning the local words for major symptoms and diseases will allow the clinician to check that an interpreter, unfamilar to him or her (such as a relative), is giving an accurate rendition of the patient's complaints.
FRAMEWORK OF A CLINICAL ASSESSMENT
· history of the present illness
· the circumstances
· past history, family history
· current medications, allergies
The patient should be undressed if possible.
· General appearance: nutrition (weight and height of children), hydration, temperature, pallor; does the patient look sick ?
· Examination by systems: respiratory, cardiovascular, etc. This part of the examination in particular should be rigorously methodical.
- Laboratory Tests: if necessary.
- Diagnosis: This is a synthesis of all information gathered from the history, physical examination and laboratory tests. A diagnosis should be etiological but may of necessity be only symptomatic.
· etiological, ie treating the cause. This may have to await the results of laboratory results;
· advice to the patient, whether or not a treatment is given.
- All important clinical data should be recorded, either on a card or in a family health booklet. Especially note positive and significant negative clinical signs, laboratory results, and treatment given (generic name, dose, duration).
Role of the laboratory
A basic medical laboratory of the type described by WHO can play an important role. Nevertheless, there are special constraints upon the operation of a laboratory, which should not be underestimated. There are staff constraints (necessity of trained and competent technicians), logistic constraints (supply of reagents and other equipment), time constraints (a minimum of time is necessary for each examination) and quality constraints. If attention is not paid to the above considerations, the laboratory will loose its accuracy and therefore its useful purpose.
Two levels of examination should be considered:
- Stool exams direct and stained with Lugol's iodine solution, for parasites (ova, cysts, protozoa...).
- Blood slides: thick and thin smears (for malaria, trypanosomiasis, filiariasis, relapsing fever, screening for leucocytes): GIEMSA stain.
- Hemoglobin (Lovibond method).
- Urine exam:
· urine analysis: dipsticks for glucose and proteins.
- Sputum exam: Ziehl - Nielsen stain.
- Urethral and vaginal swabs: slides for gonococcus and trichomonas.
- CSF exam
Certain more complex examinations may be provided according to the specific program.
A laboratory can be used in two complementary ways:
- Clinically: examinations can be requested for individual patients according to the clinical picture. The aim will be to assist the practitioner in:
· diagnosis orientation (e.g. leucocytosis in blood count);
· etiological diagnosis (e.g. stool exam for parasites, malaria smear...).
- Epidemiologically: the aim will be to construct or to validate clinical and therapeutic protocols. One can investigate a sample of patients presenting with a particular clinical picture (symptoms and syndromes) specify the etiology of that clinical picture and thus arrive at an appropriate standardized therapeutic management protocol.
· Fever and chills: are they due to malaria ? Rather than being obliged to perform blood slides on every febrile patient, choose at random 100 patients presenting with these symptoms and investigate them. If a significant proportion of the blood slides are positive, such cases can henceforth be presumed to be malaria and treated according to an appropriate protocol.
· Bloody or mucusy diarrhea with no fever: the same approach can be used to determine if this clinical presentation is synonymous with amoebiasis and/or another intestinal parasite.
· This epidemiological method of using a laboratory is especially appropriate in responding to priority needs. It can be used in emergency or "normal" conditions. Bibliographical references n° 2 and 19 give two examples for malaria, one in a refugee camp, another one in Malawi.
Training or retraining of medical staff should be directed at program objectives and means (e.g. target diseases, list of essential drugs, management protocols) and should take into consideration the technical level of the staff (to be evaluated). The training program should be defined according to local needs.
Community awareness and participation
It is necessary for curative care to cover the whole population and target diseases. Coverage should be as wide as possible.
For many reasons (e.g. ignorance, different cultural perception), a large proportion of severely ill patients may present late or may pass through the system without being cured. Coverage can be improved by increasing awareness, improving health education, encouraging the exchange of information at all levels and by improving the quality of care.
Consider how to efficiently and effectively manage available resources. Figure 2 gives an example of organization of an out-patient department.
The evaluation of the common diseases and their effects on the community directly influence the nature of a program.
Program evaluation should be performed at the following levels:
- Level of functioning
Activity assessment, quantity of drugs used, prescription management, correct use of protocols, pharmacy management (orders, reports and stock keeping), all of this information should be used as indicators in program management. The morbidity rate at the dispensary level and its analysis is a useful epidemiological observation. Target disease variation in the community can be followed according to time, place, and population concerned (eg.: morbidity survey, appendix 2).
- Level of coverage
The aim is to determine what proportion of all patients affected by target diseases are reached by the program. Good coverage is an essential factor. The evaluation should be done on a representative sample of a target population (see below).
- Level of community impact
This aspect is difficult to evaluate. The evaluation relates to the objectives and should be expressed in terms of a decrease in morbidity and/or mortality. A mortality survey of a community can be conducted over a defined period of time. If the total population is known, a mortality rate can be determined.
Sample protocols for community surveys are available and have been used for evaluations (e.g. WHO, diarrheal disease program, but they require much organization and need to be repeated to give evidence of a trend).