Accredited Medicine Stores Training

Transcription

1 Accredited Medicine Stres Training Manual fr Dispensers May 2012 i

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3 CONTENTS Acrnyms... v Intrductin t the Accredited Medicine Stres Sellers Training Curse... 1 Mdule 1. INTRODUCTION TO MEDICINES MANAGEMENT... 3 Sessin 1. Backgrund t the AMS... 4 Sessin 2. Laws, Regulatins, and Ethics...10 Sessin 3. Basic Principles f Medicines Management r Medicines Handling...28 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use)...38 Sessin 5. Management Supprt and Quality f Medicines...60 MODULE 2: BASIC PRINCIPLES OF PATIENT MANAGEMENT Sessin 1. Intrductin t Patient Management...67 Sessin 2. First Aid...74 Sessin 3. Intrductin t Management f Fever, Pain and inflammatin...85 Sessin 4. Management f Malaria...92 Sessin 5. Management f Upper Respiratry Tract Infectins Sessin 6. Gastrintestinal Cnditins Sessin 7. Management f Anemia and Nutritinal Deficiencies Sessin 8. Management f Dermatlgical Cnditins Sessin 9: Management f Eye, Ear, Nse, and Thrat Infectins and Disrders MODULE 3: FAMILY, REPRODUCTIVE HEALTH, MATERNAL, AND CHILD HEALTH Sessin 1. Management f Diseases f the Reprductive System Sessin 2. Family Planning Sessin 3: Maternal and Child Health MODULE 4: COMMUNICATION SKILLS, HEALTH EDUCATION, AND PROMOTION IN AMS Sessin 1. Fundamentals f Cmmunicatin Skills Sessin 2. Cnsumer Rights Sessin 3: Health Educatin in the AMS Sessin 4. Cunseling and Referral References List f Tables Table 1. Levels f the Health System... 4 Table 2. Wrng Reasns t Prescribe Medicines Table 3. Cmmn Prescriptin Abbreviatins Table 4. Dsing fr AS/AQ (Fixed-Dse Cmbinatin) Table 5. Recmmended Dsage fr Du-Ctecxin Table 6. Dsage fr Quinine 300 mg Tablets r Quinine Syrup 100 mg/5 ml Table 7. Dsage f Paracetaml 500 mg Tablets r Syrup 120 mg/5 ml Table 8. Signs and What t D iii

4 Participant Manual AMS Dispensers Table 9. Fast Breathing Rates fr Children Table 10. Management f Diarrhea in Children 2 Mnths t 5 Years Table 11. Signs and Symptms f Vitamin Deficiencies Table 12. Signs and Symptms f Mineral Deficiencies Table 13. Cmmn Medicatins fr Nutritin Deficiencies Table 14. Summary: Management f Cmmn Ear Prblems in Children under Table 15. Cnsequences f the 4 Ts Table 16. Female Reprductive Cycle Table 17. Types f POCs Table 18. When t Initiate FP Methds Table 19. Immunizatin Chart List f Figures Figure 1. Typical medicine distributin system in Liberia... 6 Figure 2. Percentage f AMS antimalarial available at baseline... 8 Figure 3. Percentage f encunters with apprpriate malaria treatment... 8 Figure 4. Medicine management cycle Figure 5. The drug use prcess Figure 6. Transmissin f malaria Figure 7. Human respiratry tract Figure 8. Human GI tract Figure 9. Human geniturinary system Figure 10. Male reprductive rgans Figure 11. Female reprductive rgans Figure 12. Pregnancy decisin tree Figure 13. Decisin tree fr starting patients n COCs iv

5 ACRONYMS a.c. ADS AIDS AMS ANC AS/AQ b.d., b.i.d Cap. COC CPR DMPA DRABC ECP FB FEFO FP FSH FSHRF g GI GMP gt r gtts h.s. HIV i.m. i.v. Inj. IPR IUD kg L LAM LH LMHRA LRD mcg mg ml take medicine befre meals/fd accredited drug shp acquired immune deficiency syndrme accredited medicine stre antenatal care artesunate + amdiaquine twice a day capsule cmbined ral cntraceptive cardipulmnary resuscitatin dept medrxy prgesterne acetate (Dep Prvera) danger, respnse, airway, breathing, circulatin emergency cntraceptive pill freign bdy first expiry, first ut family planning fllicle-stimulating hrmne fllicle-stimulating hrmne releasing factr gram gastrintestinal Gd Manufacturing Practices drp (ne) r drps (mre than ne) at bed time human immundeficiency virus intramuscular intravenus injectin interpersnal relatinship intrauterine device kilgram liter lactatinal amenrrhea methd luteinizing hrmne Liberia Medicines and Health Prducts Regulatry Authrity Liberian dllar micrgram milligram milliliter v

6 Participant Manual AMS Dispensers MOH MSH NDA NGO nct. r ncte NSAID ccul r cculent int. ORS p.a.a. p.c. p.. p.r.n. PBL POC, POP q.i.d. RDT RH Rx SCJA SDSI SOP SP Stat. STD, STI t.d.s., t.i.d. t.s.p. Tab. TB URTI USD UTI WHO Ministry f Health Management Sciences fr Health Natinal Drug Authrity nngvernmental rganizatin at night nn-steridal anti-inflammatry drug eye intment intment ral rehydratin salt apply medicine t affected parts f the bdy take medicine after meals/fd take medicine by muth take medicine when required Pharmacy Bard f Liberia prgestin-nly cntraceptive, prgestin-nly pill fur times a day rapid diagnstic test reprductive health take sick child jb aid Sustainable Drug Seller Initiative standard perating prcedure sulfadxine-pyrimethamine take immediately sexually transmitted disease, sexually transmitted infectin three times a day teaspnful tablet tuberculsis upper respiratry tract infectin US dllar urinary tract infectin Wrld Health Organizatin vi

7 INTRODUCTION TO THE ACCREDITED MEDICINE STORES SELLERS TRAINING COURSE The accredited medicine stres (AMS) training prgram is fr medicine stre sellers t help them develp skills in the management f selected disease cnditins and medicines and t equip them with business skills s they can sustainably imprve access t a selected range f medicines thrugh these medicine stres. The training curse has been divided int fur mdules: Medicines management Patient management Family planning, reprductive health, and maternal and child health Cmmunicatin, health educatin, and prmtin It is expected that by the end f this curse, participants will have gained an understanding f the AMS cncept and will be equipped with the knwledge and skills necessary t perate an AMS prfitably within established standards while making significant cntributins in the cmmunity by availing quality medicines and managing cmmn diseases. Therefre, participants will becme cmpetent in the fllwing areas: Evaluating, managing, and referring patients Reading, interpreting, and labeling prescriptins Dispensing medicines Cmmunicating with patients and cunseling them n ptimal medicines use Prviding first aid Cmplying with regulatins and keeping required legal recrds Managing medicines inventry String medicines Demnstrating prfessinal cnduct and health-related ethics The curse lasts three weeks. T enhance learning, the training has been designed with presentatins, rle playing, grup wrk, and individual exercises. At the end f the training, participants are expected t pass exams; a certificate will be awarded nly t thse wh achieve passing marks. Participants Participants attending this curse are medicine sellers wh have attained a minimum f a nursing assistant curse and an rdinary-level certificate frm a high schl. Medicine stre wners wh are nt sellers and wuld like t attain business skills can attend the business skills training separate frm the dispensers training. 1

8 Participant Manual AMS Dispensers Resurces The training curse is adpted frm the Uganda accredited drug shps (ADS) and Tanzania accredited drug distributr utlets sellers training manuals [Ministry f Health, Natinal Drug Authrity (NDA) and Pharmaceutical Sciety f Uganda (PSU): Accredited Drug Shps Training Manual, Uganda, 2010; United Republic f Tanzania Ministry f Health and Scial Welfare, Tanzania Fd and Drugs Authrity. Accredited Drug Dispensing Outlet (ADDO) Dispensers Training Manual, first editin, 2007]. This manual als cntains a significant amunt f infrmatin n Liberian laws, regulatins, plicies, and guidelines in the diagnsis and management f cmmn diseases. 2

9 MODULE 1. INTRODUCTION TO MEDICINES MANAGEMENT Sessin 1. Backgrund f the AMS Sessin 2. Laws, Regulatins, and Ethics Sessin 3. Basic Principles f Medicines Management r Medicines Handling Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) Sessin 5. Management Supprt and Quality f Medicines 3

10 Sessin 1. Backgrund t the AMS Objectives 1) Outline the pharmaceutical sectr f Liberia 2) Understand the AMS cncept 3) Discuss the rle f AMS in service delivery Time 2:30 hurs The Pharmaceutical Sectr in Liberia Liberia is divided int 15 cunties and the public health care system is divided int the administrative structure described in the table belw. Table 1. Levels f the Health System Administrative structure Cuncil level Health structure Cmmunity Primary Cmmunity health wrkers District I Clinics and health centers Cunty health team/cunty health bard II Hspitals Natinal III Natinal referral In the public health care system, there is at least ne cunty referral hspital in each f the 15 cunties. There are several clinics and health centers in each f these cunties; ther types f hspitals can als be fund in sme f the cunties. The public pharmaceutical sectr fllws the same structure. Accrding t the Wrld Bank, gegraphical access t pharmaceutical services is limited t 49 percent f the ppulatin, i.e., the ppulatin living within 5 kilmeters (abut ne hur s walking distance). Rural cmmunities are particularly affected because health facilities are mstly lcated in twns and alng main rads. As a result, it is inevitable that the public pharmaceutical sectr is supprted by several privately wned pharmacies and medicine stres. The Gvernment f Liberia recgnizes the imprtance f the private sectr and is nw encuraging public-private partnership. The Sustainable Drug Seller Initiative (SDSI) prject is ne such attempt. The SDSI prject seeks t build capacity f private fr-prfit medicine dispensing utlets (medicine stres) t apprpriately manage the diseases that are mst prevalent in areas where these utlets are lcated. The prject als seeks t increase cllabratin between public and private health care prviders t encurage crss referral between the tw sectrs. Medicines play a majr rle in health care by saving lives, imprving health, and prmting trust and participatin in health services. The availability f medicines, the way they are handled, and the way they are used all influence the health f a cmmunity. The pharmaceutical sectr, 4

11 Mdule 1 Sessin 1. Backgrund t the AMS thrugh the Natinal Drug Plicy, aims t cntribute t the standard f health f the ppulatin f Liberia by ensuring that medicines are available, accessible, and affrdable at all times. In additin, the Gvernment f Liberia is interested in whether medicines are apprpriately handled s as t maintain their quality and ultimately whether they are used apprpriately. Medicine Supply System in Liberia A percentage f the natinal health budget is used fr prcurement and distributin f medicines. In Liberia, the medicine supply system is run by bth private and public sectr players. The majrity f the medicines and equipment fr the public sectr are btained frm the Natinal Drug Service, an autnmus gvernment agency charged with the prcurement, strage, and distributin f essential medicines and supplies t the public sectr. The Natinal Drug Service is als the majr surce fr medicines and health supplies fr nngvernmental and religius-based health facilities. Currently, there is n pharmaceutical manufacturer in Liberia. There are 2,939 public sectr health facilities, 300 private pharmacies, and ver 1000 drug shps frm which drugs may be dispensed. Of the private pharmacies and medicine stres in Liberia, nearly 80 percent are in Mntserrad Cunty. Limited r n access t pharmaceutical services thrugh registered pharmacies has led t a prliferatin f medicine stres in rural areas t cver the gap. Pharmacies are licensed t sell all classes f medicines while medicine stres are nly allwed t sell ver-the-cunter medicines. Hwever, the demand fr medicines in rural areas, cupled with the scarcity f pharmacies and the need t make businesses prfitable, has driven the medicine stres t sell all types f medicines and supplies, rather than restricting themselves t the classes fr which they have been apprved. This is further cmplicated by Liberia s lw capacity t regulate these stres. In additin, many medicine stres in Liberia are nt registered and therefre nt easily regulated r supervised. Because f the inadequate number f persnnel qualified in pharmaceutical management, mst f the persnnel manning the medicine stres d nt pssess the minimum skills required. The AMS mdel aims t imprve access t medicines in rural settings by building the capacity f medicine sellers t manage an extended range f quality medicines and apprpriately dispense them t the cmmunity while remaining prfitable. This manual, alng with the accmpanying training curriculum, is designed t equip AMS sellers and wners in pharmaceutical care delivery and prvide them with knwledge, skills, and attitudes regarding apprpriate medicines management. 5

12 Participant Manual AMS Dispensers Figure 1. Typical medicine distributin system in Liberia What is an AMS? An AMS is a dispensing utlet that deals in human medicines that is accredited after satisfying specific accreditatin requirements f the Pharmacy Bard f Liberia (PBL) and the Liberia Medicine and Health Prducts Regulatry Authrity (LMHRA)). Specific accreditatin requirements fr the AMS fcus n premises, persnnel, prducts, prcedures and all ther aspects f peratins f medicine dispensing utlet. These requirements make the AMS distinct frm ther medicine stres and thus, AMS is allwed t stck medicines and ther health related cmmdities beynd what is generally allwed by the laws gverning the sale f medicines in Liberia. This expanded medicines list was drafted t cver mst f the diseases mst prevalent in the cmmunities. An AMS is a special categry f class C medicine stre that is accredited by the PBL and allwed t stck medicines that are generally nt allwed t be stcked in an rdinary class C medicine stre. What Were the Steps in Develping the AMS Prject? A Natinal Steering Cmmittee was set up t guide activities f the SDSI prgram in Liberia. Frm the wrk f this cmmittee, the standards fr the AMS were develped and adapted. The LMHRA and PBL crdinated the AMS prject with technical and financial supprt frm Management Sciences fr Health (MSH). Medicine stres in Mntserrad Cunty were surveyed t identify cmmn challenges in prviding gd patient care. Frm this survey, a specific training prgram was develped. Staff frm medicine stres in Mntserrad Cunty was invited t meet with the AMS steering cmmittee fr sensitizatin t the standards f the AMS prject. 6

13 Mdule 1 Sessin 1. Backgrund t the AMS Medicine sellers and wners wuld be trained in business management, medicines management, and patient care. Inspectin, accreditatin, and supprt supervisins visits f medicine stres wuld be cnducted. A public awareness campaign will ensure that the public knws that AMSs are high-quality places t seek medicines in Mntserrad Cunty. The AMSs shall lead t better patient management, better quality f care, and generally imprved access t medicines in Mntserrad Cunty. In cllabratin with ther partners, the AMS prgram will be rlled ut t the ther 14 cunties in Liberia. Results f the AMS Baseline Assessment Study A baseline assessment was dne n behalf f SDSI by Pharmaceutical Systems Africa with a sub-grant frm MSH. The bjective f this exercise was t assess systems, perceptins, and practices f medicines stres and medicine stre clients t determine the extent t which the interventin will imprve health utcmes in Liberia. The baseline evaluatin exercise sught t cllect data in three main areas f medicine stre practice. Prduct price and availability Client perceptin f medicine stre practices Quality f services prvided in medicine stres Availability Mst f the tracer items were available in medicines stres in Mntserrad Cunty. 7

14 Participant Manual AMS Dispensers Availability f Antimalarials The chart belw shws the availability f antimalarials in medicine stres in Mntserrad Cunty. Figure 2. Percentage f AMS antimalarial available at baseline Quality f Antimalarial Dispensing The first-line medicine fr the management f uncmplicated malaria in Liberia is artesunate + amdiaquine (AS/AQ). The figure belw shws the percentage f clients presenting with malaria wh were managed with AS/AQ. Figure 3. Percentage f encunters with apprpriate malaria treatment 8

15 Mdule 1 Sessin 1. Backgrund t the AMS Quality f Dispensing Services Dispensing service indicatrs generally imprve after an AMS interventin; hwever, rm fr imprvement shuld be addressed in future training. In the baseline in Mntserrad Cunty, the percentage f mystery shpper encunters where the drug seller: Asked abut symptms f malaria and pneumnia were 35% and 29%, respectively Asked abut ther medicines the child tk fr malaria and pneumnia were 50% and 25%, respectively Gave instructins n dsing fr malaria and pneumnia medicines were abut 65% and 52%, respectively In additin, the percentage f mystery shppers wh were managed fr uncmplicated malaria with AS/AQ was abut 50%. Based n the standard treatment guidelines, ver 36% f medicine stre attendants did nt prvide the crrect medicatin fr the management f pneumnia. Fr malaria mystery shpping encunters, paracetaml was the medicine given mst frequently and fr the management f pneumnia, the majrity f medicines suggested were flu and cld medicines. These were fllwed by paracetaml and c-trimxazle. These results indicate the need fr imprvement in access and use f medicines in Mntserrad Cunty. The success f AMS depends n a number f factrs including: Strng supprt frm MOH, LMHRA, and PBL Strng cllabratin and cnsultatin with key stakehlders at every stage f implementatin Medicine sellers in Mntserrad Cunty being cmmitted t imprving the standards f the medicine stres and ffering better care t cmmunities 9

16 Sessin 2. Laws, Regulatins, and Ethics Objectives 1) Describe the required cde f ethics f an AMS seller 2) Discuss the laws gverning the AMS 3) Discuss the acceptable standards fr setting up an AMS Time 3-4 hurs Activity. Case Study: Ethics and Prfessinalism Mr. Kerkula wns a medicine stre in Mnrvia. He is fnd f drinking and bragging abut his academic success and abusing his cmmunity mates as failures. One day, Flm a cmmunity mate t Kerkula, cmes t the medicine stre cmplaining f stmach pain. Flm says that his wife and ne f his children have similar cmplaints. Kerkula tells him that he is suffering frm ulcers and gives him a dse f ciprflxacin fr tw days. Ciprflxacin was the nly medicine in tablet frm available at the medicine stre and the rest were ut f stck. Kerkula charges Flm LRD and tells him that this is the best treatment fr ulcers and by evening he will be fine. Flm pays prmptly because he is in such hrrible pain. A day later, Flm cmes back in wrse cnditin, this time unable t stand upright. The medicine seller gives him mre ciprflxacin and tells him t g back hme. Flm bjects and says he wants t be admitted. An argument erupts and Flm leaves the medicine stre a dejected man, vwing never t seek care frm any medicine stre ever again. 1) What ethical and prfessinal issues des the case bring ut? 2) Hw shuld Kerkula have cnducted himself? 3) Hw shuld Kerkula have dealt with Flm s case? Legal Requirements and Standards fr AMS Definitins Laws Laws are rules that gvern human cnduct and are binding n all persns within a given state r natin. Laws cmmand what is right and prhibit what is wrng. Laws are ften called acts r statutes. They are enacted in writing by a law-making bdy f a state r natin, such as the Senate and Huse f Representatives f the Natinal Legislature f Liberia. The acts r statutes are usually stated in general terms and their implementatin may require develpment f regulatins, guidelines, and plicies. 10

17 Mdule 1 Sessin 2. Laws, Regulatin, and Ethics Regulatins Regulatins are mre specific rules cntrlling r restricting a specific activity. They are made by the authrity respnsible fr the matters in questin, fr example, the Minister fr Health wh is respnsible fr matters f health and medical services. The Minister makes these regulatins after cnsultatin with the technical authritative bdy, agency, r grup f individuals wh are experts n the area r matter in questin, e.g., the Natinal Drug Service. These regulatins cme int frce n the date f their being adpted by the respnsible authrity selected by the legislature and given the pwer t prmulgate regulatins. An example f such regulatins is the LMHRA/PBL new standards and regulatins f Guidelines These are instructins n hw t implement r t enfrce the laws. They are nrmally drawn up, laid dwn, r issued by the gvernment, an authrity, r plicy-making bdy such as the LMHRA/PBL. The difference between guidelines and laws is based n hw they are enfrced. Vilatins f law are punishable by curts f law whereas vilatins f guidelines are punishable by withdrawal f certain rights and privileges ne nrmally enjys when adhering t the guidelines, e.g., withdrawal f the AMS accreditatin certificate. Plicy A plicy is a pint f reference r general understanding t guide r influence decisin making regarding lng-term actins, e.g., the natinal drug plicy n AMS. Drug Plicy A drug plicy is a statement indicating the bjectives and strategies t be undertaken t imprve the natinal pharmaceutical sectr t ensure availability, accessibility, and affrdability f drugs while emphasizing their quality and ratinal use. Regulatin f Medicines Regulatin f medicines and medicinal devices is a system f laws, regulatins, guidelines, and plicies that prvide a basis f legal and administrative cntrl ver the manufacture, distributin, marketing, and pst-marketing surveillance f these prducts. They prescribe and impse duties and respnsibilities f the different parties and intermediaries invlved in the prcesses that medicines and medicinal devices g thrugh, frm research and design t pstmarketing surveillance. Breach f such duties is enfrceable by regulatry authrities thrugh sanctins applied by administrative authrities r, ultimately, by the criminal curts. In relatin t AMS, there are specific regulatins regarding: What medicines can be prcured Where t prcure medicines Wh shuld handle medicines What dcumentatin must be kept 11

18 Participant Manual AMS Dispensers What Prducts Are Regulated? Any prduct that is presented fr diagnsing, treating, preventing, r alleviating disease r cmpensating fr an injury r handicap, including cntrl f cntraceptin, bth in humans and animals, is regulated by law. Grunds fr Regulating Medicines Increased number f individuals invlved in the manufacture and sale f medicines The increase in the number f peple invlved in the manufacture and sale f medicines at different levels created the need t regulate and cntrl activities at the different levels in rder t prtect the public. Patients dependence n health wrkers fr medicine advice Patients generally d nt select their wn medicines; they depend n the expert pinins f health wrkers. The health wrkers als depend n the distributrs wh als depend n the manufacturers. The quality f infrmatin that is generated by the manufacturer shuld be verifiable as it influences what will happen at the prceeding stages in the lifecycle f a medicine. This interdependence necessitates regulating activities that may affect the sale f medicine t the final cnsumer. Cnflict f interest Health wrkers als act as sellers f medicines. The ptential fr a cnflict f interest exists because f financial gains versus their prfessinal bligatins. Health wrkers may be mtivated t sell mre, rather than taking the welfare f the patient as the first pririty, e.g., giving an injectable medicine fr a cnditin where tablets wuld suffice. Pssibility f medicines causing harm Medicines are nt like any ther cmmdity f cmmerce; they are a scial cmmdity that is ptentially harmful t the individual using it r t the cmmunity, if nt used prperly. The cnsequence f misuse f medicines may be fatal, hence the need t put in place system that will mderate the design, manufacture, distributin, and use f medicines. Reasns fr Regulating Medicine T ensure that quality medicines are available t retailers and cnsumers T safeguard the welfare f the patient and the cmmunity T ensure that qualified persnnel are invlved in the handling f medicines T ensure that medicines are supplied and sld in suitable premises using suitable equipment 12

19 Mdule 1 Sessin 2. Laws, Regulatin, and Ethics Cntrl f AMSs and Class C Medicine Stres Classificatin f Medicines Fr purpses f effective management, medicines are classified int classes A, B, and C. Medicines are classified t avid misuse such as irratinal dispensing, abuse, ptential txicity, emergence f resistance, etc. The fllwing criteria are used t classify medicines as prescriptin nly. Medicine that is likely t present a danger, either directly r indirectly, even when used crrectly, e.g., diclfenac Medicine that is frequently abused r misused, e.g., narctics Cmpunds that are still under research Medicines administered by injectin All class A medicines and many class B medicines are prescriptin nly. By law, class C medicine stres are nly allwed t sell class C medicines, thse that are available withut a prescriptin. Licensing f Class C Medicine Stres The PBL regulatins allw a licensed persn t cnduct business r supply, in a retail setting, drugs ther than class A r class B. The regulatins als stipulate that licenses will be given t businesses in areas that are nt sufficiently served by existing retail pharmacies. Cnditins fr Licensing Class C Medicine Stres The persn t dispense medicines in said stre must be at least a high schl graduate and/r shuld have a medical backgrund, e.g., nurses, midwives, and must have received sme training in dispensing medicines. The applicant must receive certificatin frm the PBL. The premises where business is cnducted shuld satisfy the requirements set ut in the statute. The premises Must be permanent in nature Shall nt be shared with any ther business f a similar nature Shall be lcated within tw miles f an existing pharmacy The structure shuld be sufficient that medicines will be prtected frm adverse envirnmental cnditins, e.g., sunlight, rain. 13

20 Participant Manual AMS Dispensers Prper recrds f all transactins taking place in the shp must be kept and shuld be available fr inspectin by the Natinal Drug Authrity (NDA) r a plice fficer. Regulatin f the AMSs Befre an AMS is licensed, it must underg an accreditatin prcess that will include inspectin f the premises and training f medicine sellers. The accreditatin and issuance f an accreditatin certificate will be the respnsibility f the PBL. Cnditins fr Accreditatin f AMSs Fr an AMS t be accredited, the inspectrs must verify the fllwing cnditins are met: The wner and the persn perating the AMS are qualified fr the task. The persn must have undergne and passed the AMS accreditatin training prgram and received his/her certificate. The applicant must satisfy all the cnditins indicated fr licensing a class C medicine stre. Applicants will nt be supplied retail medicines utside f class C, althugh they may sell items frm the expanded medicines list apprved fr AMSs (see belw). Why is it Necessary t Accredit AMSs? Surveys have shwn that sme class C medicine stres are currently selling prescriptin medicines. In additin t being illegal, this practice has resulted in detrimental effects, such as the emergence f drug resistance. Apprpriate strage is nt assured as mst f the medicine stre peratrs hide the illegally sld medicines. Applicatin and Accreditatin Prcedure fr Medicine Stres Issuance f Applicatin Frms fr Accreditatin In the accreditatin prcess, all medicine stres shall submit their applicatins t the PBL. All applicatins shall be submitted and discussed in a timely manner at the PBL s regular meeting. Fllwing these discussins, the jint inspectin team f the PBL and the LMHRA shall jintly inspect the sites f the prpsed premises. The PBL and the LMHRA shall nt be under any bligatin t apprve an applicatin because f financial cmmitments made in respect t premises r fr any ther reasn. Apprval r rejectin f any premises by the PBL shall be n the basis f the reprt submitted by the jint inspectin team f PBL and LMHRA. Apprval by the PBL shall be valid fr a specific perid within which business is expected t cmmence. Pre-Inspectin Assessment and Inspectin f Premises There shall be a pre-inspectin assessment f all medicine stres that wish t becme AMSs t qualify the premises gegraphic lcatins. 14

21 Mdule 1 Sessin 2. Laws, Regulatin, and Ethics A jint PBL and LMHRA inspectin team shall cnduct a preliminary inspectin f stres that have applied fr accreditatin (annex 3). Inspectrs will identify deficiencies as per the expected standards f the AMS and will advise accrdingly. Medicine stres with nted deficiencies shall be re-inspected t ascertain whether crrective actins were taken. Fllwing the final inspectin, the PBL shall either issue a registratin frm t the wner r prvide advice n next ptins. Accreditatin Fllwing the final inspectin f the premises and issuance f the registratin frm, the inspectin reprt shall be reviewed and apprved during the PBL s regular mnthly meeting. The successful applicant will then be issued the accreditatin certificate which signifies that the requirements t perate an AMS have been fulfilled and that bth the wner and the dispenser have received the apprpriate training. Rutine Inspectins (Surce: Standards 2012, p. 15) Inspectin and Mnitring Levels (1) Inspectin and mnitring f AMSs shall be prvided jintly in partnership invlving the fllwing: a. PBL b. LMHRA natinal and znal levels c. Pharmacy Divisin/MOH Appintment f Inspectrs (2) All AMS inspectrs shall be appinted by the PBL r LMHRA. The persns shall undertake a special PBL/LMHRA training curse and receive peratinal tls such as IDs and an inspectin checklist. Limited Authrity (3) Decisin-making authrity shall principally rest with the central-level PBL r LMHRA. Fr the purpse f aviding abuse f pwer, all AMS inspectrs shall have limited decisin-making authrity. Accusatins and Cmplaints (4) Any accusatin related t inspectrs imprpriety r disagreement with inspectrs findings made by an utlet wner as well as cnsumer cmplaints assciated with medicine stre services shall be directed t the PBL Registrar r LMHRA Managing Directr. Inspectin (5) Upn visiting an AMS fr the purpse f inspectin, each inspectr in the team shall: 15

22 Participant Manual AMS Dispensers a. Prvide an fficial identificatin t the wner r dispenser b. Register himself/herself in the Inspectrs Register Bk prvided by the LMHRA/PBL t AMS upn accreditatin c. Upn cmpletin f inspectin, write all required infrmatin in the Inspectrs Register Bk and the wner r seller and all inspectrs in the team shall sign therein d. After the inspectin, prepare an inspectin reprt, cpies f which shall be submitted t the inspectrs immediate supervisry bdy AMS Expanded Medicines List AMSs can dispense medicines frm class C as well as frm the expanded medicines list belw. The expanded list takes int cnsideratin the prescribing levels in line with the natinal standard treatment guidelines. An effrt has als been made t ensure that the public has reasnable access t the mst essential (key) medicines needed t treat cmmn diseases fund in the cmmunity. The medicines n this list are identical t thse available at the clinic level, except fr injectable medicines. AMSs are nt allwed t stck, dispense, r administer injectable medicines. Apprved Medicines fr Accredited Medicine Stres (AMS) February 2013 Type f medicine Medicine name Strength (if applicable) Analgesics and ther nn-steridal antiinflammatries Antacids Anthelmintic Annusl suppsitries ASA (acetylsalicylic acid) Diclfenac sdium tablets Hydrcrtisne intment/cream Ibuprfen 200 mg Paracetaml (als knwn as acetaminphen)* Aluminum hydrxide Magnesium carbnate Magnesium trisilicate Milk f magnesia Sdium bicarbnate Albendazle Mebendazle 25 mg, 50 mg 0.5% r 1% (intment) 16

23 Mdule 1 Sessin 2. Laws, Regulatin, and Ethics Type f medicine Medicine name Strength (if applicable) Anti-allergics/ Antihistamines Anti-amebic Anti-asthmatics Antibacterial NOTE: Sales f the injectable frms f any medicine in AMSs are prhibited. Antidiarrheals Anti-emetics Cetirizine hydrchlride tablets Chlrpheniramine (Chlnnene, Chlrtrimetn, Piritn ) Cetirizine hydrchlride ral slutin Metrnidazle tablets and syrup nly Crmlyn sdium (nly) Amxicillin trihydrate capsules Amxicillin trihydrate ral suspensin Ampicillin 10 mg Chlramphenicl eye drps/intment 1% C-trimxazle suspensin C-trimxazle tablets Dxycycline capsules/tablets Erythrmycin ral suspensin Erythrmycin tablets 5 mg/5 ml 250 mg, 500 mg 125 mg/5 ml, 250 mg/ml 240 mg/5 ml in 100 ml bttle 480 mg 100 mg 125 mg/5 ml, 250 mg/5 ml 250 mg, 500 mg Metrnidazle tablets 200 mg, 250 mg, 400 mg Metrnidazle suspensin Nitrfurantin tablets Phenxymethyl penicillin suspensin Phenxymethyl penicillin tablets Silver sulfadiazine cream 200 mg/5 ml in 100 ml 50 mg, 100 mg 125 mg/5 ml 250 mg/5 ml in 100 ml 250 mg 10 mg Tetracycline eye drp/intment 1% Metrnidazle (tablet r syrup dsage frm) Oral rehydratin salt (ORS) Metclpramide Prmethazine syrup Anti-epileptic Phenytin tablets/capsules (sdium salt) 50 mg (tablet), 100 mg (capsule) Phenbarbital tablet Anti-fungal Cltrimazle cream 1% Gentian vilet, fr 1% slutin Grisefulvin tablets Ketcnazle tablets Nystatin ral suspensin Nystatin pessaries Nystatin skin intment Nystatin tablets 50 mg, 100 mg 25 g 500 mg, 100 mg 200 mg 100,000 IU/mL in 30 ml bttle 100,000 IU 100,000 IU/g 500,000 IU, 17

24 Participant Manual AMS Dispensers Type f medicine Medicine name Strength (if applicable) Antihemrrhidal Antimalarials NOTE: Injectable frms f antimalarials and pyrimethamine in a nn-cmbined frm are prhibited. Bland sthing preparatins (e.g. Annusl, yeast extract, r Preparatin H ) Artemether + lumefantrine tablets Artemether + amdiaquine tablets (AS/AQ) Quinine tablets (sulfate r bisulfate) 100,000 IU 20 mg mg 100 mg +270 mg 300 mg Antispasmdics Hyscine butyl brmide tablets 10 mg Cardivascular (antiarrhythmic drugs) Dermatlgical Prpranll tablets (hydrchlride) Benzic acid / salicylic acid preparatin (e.g., Whitfield intment) Benzyl benzate (emulsin/ltin) Calamine (e.g., ltin) Cltrimazle (intment r cream r pessaries) Crystal vilet (als gentian vilet G.V., /methyl vilet) Hydrgen perxide Pvidne idine Micnazle (intment, cream, r pessaries) Penicillin intment (skin) Sulfacetamide (preparatins) Sulfadiazine (intment r cream) Sulfur (intment r cream) Zinc xide and ther zinc preparatins 10 mg, 40 mg, 80 mg Diuretics Hydrchlrthiazide tablets 25 mg, 50 mg Hematinic Hney preparatins Menthl and vlatile ils (e.g., eucalyptl) Flic acid preparatins (single and cmbined frms) Oral irn preparatins (single and cmbined frms) Laxatives Bisacdyl tablets 5 mg Mechanical cntraceptives Nutritin supplements Castr il Magnesium hydrxide Magnesium sulfate (e.g., Andrew s Liver Salt ) Cndm Vitamin B cmplex preparatins Vitamin C Mineral preparatins Multivitamin preparatins (NOTE: except vitamin K) Neurbin frte 18

25 Mdule 1 Sessin 2. Laws, Regulatin, and Ethics Type f medicine Medicine name Strength (if applicable) Ophthalmic preparatins Zinc sulfate tablets Chlramphenicl (eye) drps and intment Sdium crmglycate (Optrex drps/intment) Sulfacetamide eye drps/intment Tetrahydrxline (Visine ) wash/drps 20 mg Oral cntraceptives Ethinylestradil + nvethisterne (0.03 mg) + (0.3 mg) Oral hygiene and tics Sexual stimulants r aphrdisiacs Therapeutic dressing materials Thrat preparatins Ethinylestradil + levnrgestrel Gargles/muth washes (e.g., Listerine ) Alchl ear wash Chlramphenicl ear drps Hydrgen perxide Ayuverdic preparatin (except thse with sterids) Nn-steridal aphrdisiacs Adhesive tape (r plasters) Antiseptics (r disinfectants,) including rubbing alchl 50% Bandages Cttn Surce: Standards 2012, p Gauze (cmpresses) Amylmetacresl, dichlrbenzyl alchl cntained lzenges (e.g., Strepsils ) (0.03 mg) + (0.15 mg) Standards fr Operating AMSs The standards fr perating AMSs have been develped t prvide a basis fr which services will be measured. A standard is a level f quality r a specified level f quality that will be measured. Services will be cnsidered t be f pr quality if they are perceived t fall belw the stipulated standard. Standards f Operatin (frm Standards 2012, p. 5 13) (a) Persnnel Accredited Medicine Stre Dispenser Basic Knwledge (1) A minimum qualificatin f a high schl diplma shall be required fr any persn intending t be trained as an AMS dispenser and/r prprietr. (2) In additin t requirement (1), every dispenser shall be required t successfully cmplete an AMS dispenser-training curse t be apprved by the LMHRA/PBL. The curse shall include but nt be limited t the fllwing: a. AMS guidelines, regulatins, and standards 19

26 Participant Manual AMS Dispensers b. Cde f ethics c. Cmmn medical illnesses in the cmmunity d. Basic medicine management and dispensing skills e. Cmmunicatin skills f. Recrd keeping and reprting The cntent and duratin f the dispenser-training curse shall be determined by the LMHRA/PBL. Dispenser Requirements (3) Every dispenser, while wrking in an AMS, shall bserve and maintain the fllwing standards: a. Keep a high standard f persnal hygiene b. Dress in a prfessinal manner that is, wearing a clean blue cat r dress c. Never wrk under the influence f alchl r illicit drugs d. Prminently display his/her dispensing certificate e. Wear a pht identificatin badge which identifies him/her as an AMS dispenser f. Be accuntable fr all activities cnducted therein g. Observe all regulatins pertaining t perating the AMS h. Observe prvisins cntained in the Natinal Medicine Plicy (NMP)/LMHRA Act 2010 and PBL Act i. Be f sund mind and in sund medical cnditin j. Cnduct him/herself in a manner that des nt cause prfessinal disrepute Cntract between Prprietr and Dispenser (4) Cmmitment letters shall be written and signed by the AMS dispensers, cmmitting t wrk with an AMS fr a specific perid f time. The letters will be endrsed by the AMS prprietr. Three mnths ntice shall be required if a dispenser is t resign frm a particular AMS. Prprietr s Requirements (5) Every wner f the AMS stre shall: a. Ensure that perating prcedures cmply with the AMS standards and the existing prvisins in the NMP/LMHRA Act 2010 and PBL Act b. Ensure the presence f a trained dispenser at the AMS at all times when the AMS is pen 20

27 Mdule 1 Sessin 2. Laws, Regulatin, and Ethics c. If he/she wrks in the capacity f dispenser, ensure that he/she has a valid AMS certificate d. Display accreditatin certificate prminently in the premises fr which the certificate is issued e. Ntify the PBL/LMHRA in writing within seven days when the AMS is permanently clsed; and upn receipt f such ntice, the LMHRA shall inspect the inventry and prvide advice fr prper dispsal f any inventry r medicatin f. Ntify the PBL/LMHRA in writing within seven days when an AMS is temprarily clsed and infrm f the anticipated date f re-pening; and in case the AMS is clsed fr ne year it shall be cnsidered as a new applicant g. Reprt immediately t the nearest plice statin and PBL/LMHRA ffices in the case f theft r any unexplained lss f medicines and recrds. Prprietr s Training Requirements (6) Every AMS prprietr shall be required t attend a training curse frmulated and apprved by the PBL/LMHRA; and such curse shall include but shall nt be limited t the fllwing: a. AMS guidelines, regulatins, and standards b. Cde f ethics c. Recrd keeping and reprting d. Basic business skills Cntinuing Educatin (7) All AMS dispensers shall be required t attend and cmplete cntinuing educatin t be rganized by PBL/LMHRA. The cntinuing educatin shall be mandatry and shall cnstitute a prerequisite fr annual license r permit and their renewal. (b) Premises Lcatin (8) Any persn wishing t perate an AMS shall: a. Clearly state the lcatin and address f his/her premises in the applicatin when applying fr registratin b. On the basis f lcal demand and need fr such service, lcate his/her business in an apprpriate lcatin t reduce unnecessary cngestin and prvide services t underserved cmmunities c. Priritize pening an AMS in a rural lcatin near dispensaries and health facilities d. Search fr a lcatin that is a minimum f 2 miles (3.2 km) frm any existing retail pharmacy and a distance f 500 ft. frm anther AMS; and if a new pharmacy is pened 21

28 Participant Manual AMS Dispensers within 2 miles frm the AMS, the AMS shall be given an pprtunity t upgrade t a pharmacy within 1 calendar year r frm the time a new retail pharmacy starts peratin in the lcatin e. Nt perate an AMS within the radius frm the Cathlic Hspital t Caldwell Junctin in the city f Mnrvia Premises Requirements (9) All AMS premises shall be required t meet minimum requirements as fllws: a. The premises shall be gegraphically and structurally permanent. b. They shall be rfed with materials which shall make the rf free frm leakages and with a leak-prf ceiling. c. They shall be well prtected frm entry f rdents, birds, vermin and pests. d. They shall have adequate space t carry ut the primary functins f strage, dispensing and sales. e. They shall have drs and windws which are well secured t prevent theft and unauthrized entry. f. They shall be fixed with glass cunters and the main dr shall include a glass panel fr safety. g. They shall prvide adequate ventilatin and lighting (fan, air-cnditiner, pen airways, etc.). h. They shall have surfaces/flrs with a smth finish that can be washed with disinfectants. i. They shall be painted with a washable white clr. j. They shall have adequate supply f sap, and clean and safe drinking water. k. They shall have facilities t wash hands which are clearly marked with a WASH HANDS sign. l. They shall have adequate tilet facilities in clean and gd wrking rder. m. They shall bserve general hygiene inside and utside the premises. n. They shall nt be shared with any medical clinic, veterinary surgery r any ther business f a similar nature.. They shall have a minimum flr length f 13 ft., flr width f 12 ft. and a minimum ceiling height f 9 ft. (10) The premises shall have the fllwing required signage: 22

29 Mdule 1 Sessin 2. Laws, Regulatin, and Ethics a. An fficially apprved identificatin lg, t differentiate it frm nn-amss (see AMS lgs in annex F) b. The name f the AMS and any ther authrized branding cnspicuusly displayed n the wall r stre bards, displayed after the final apprval f the premises by the PBL/LMHRA c. A NO SMOKING sign cnspicuusly placed t prhibit smking in the stre d. All certificates and registratin dcuments n display (c) Prduct Quality and Dispensing Prcedures Surce f Supply (11) Prducts shall meet the fllwing requirements: a. All health prducts sld by an AMS shall be registered by the LMHRA in accrdance with the LMHRA Act 2010 r ther written regulatins. b. The prducts shall be prcured frm a registered whlesaler r lcal manufacturer. c. AMSs shall nt sell expired prducts. All expired prducts shall be retrieved frm the sales area, warehuse areas, etc., and dispsed f by the LMHRA/PBL in cllabratin with ther relevant agencies. d. In additin t class C medicines and sme medical sundries (e.g., medicated sap, baby prducts, tthpaste and brushes), there shall be an apprved list f medicines t be sld by the AMSs. e. In additin t class C medicines, whlesalers shall sell prducts n the apprved medicines list t the AMSs. f. It shall be the respnsibility f the whlesalers t verify the credentials f an AMS prir t the sale f medicines prvided in the apprved medicines list. The whlesalers shall hnr rders frm the AMS nly when the stre presents a cpy f its accreditatin certificate. g. Whlesalers selling apprved medicines t AMSs shall be required t keep easily retrievable dcuments related t sales and shall als prvide t the AMS an invice/sales receipt fr all medicines sld t them. h. It shall be an ffense fr a whlesaler t sell any medicine n the apprved list t nn- AMSs, and als an ffense fr a whlesaler t sell t AMSs any medicine nt permitted fr sale in an AMS. Strage (12) All medicines shall be prperly labeled, packaged, and stred. 23

30 Participant Manual AMS Dispensers a. All pharmaceutical prducts held in inventry shall be stred in the manufacturer s riginal packaging and prperly labeled with the manufacturer s riginal label. b. Remval f labels frm cntainers is prhibited; remval renders the prduct unfit fr dispensing. c. Repackaging and relabeling f pharmaceutical prducts nt fr the purpse f immediate dispensing t clients is prhibited. d. Measures shall be taken t prtect pharmaceutical prducts frm heat, sunlight, misture, adverse temperatures, insects, rdents and cntaminatin. e. Damaged and/r expired medicines shall be recrded, sealed, quarantined and labeled with red ink with the statement Expired/damaged medicines Nt fr sale by the AMS dispenser. Dispensing Prcedure (13) Medicines shall be dispensed accrding t prper prcedures. a. Every AMS dispenser shall bear legal liability and prfessinal respnsibility fr the pharmaceutical prducts and services prvided under his/her care. b. Every AMS shall nly dispense pharmaceutical prducts registered by the LMHRA in accrdance with the NMP/LMHRA Act c. The dispenser shall nt dispense damaged, cunterfeit, substandard r expired medicines. d. The dispenser shall nt dispense r sell medicines t children less than 12 years. e. Every dispenser shall ensure that i. Prescriptin medicines are nly dispensed against a prescriptin ii. iii. iv. A full dse is dispensed Tablets and capsules are dispensed using an apprpriate device fr cunting and packaging A recrd f all medicines dispensed by him/her is maintained in a register apprved by the PBL/LMHRA v. Medicines are dispensed in accrdance with apprved regulatins 24

31 Mdule 1 Sessin 2. Laws, Regulatin, and Ethics Cunseling f Clients (14) Clients will be cunseled abut their medicines t ensure prper use. a. An AMS dispenser shall ensure that the client understands the infrmatin and advice given (including directins n the labels f dispensed prducts) well enugh t ensure safe and effective use f the medicine. b. Infrmatin fr medicines requiring particular instructins fr use must be clearly pinted ut t the clients befre they leave the AMS. c. Clients r their representatives must be warned t keep medicines well ut f reach f children. Dispensing Cntainers (15) Apprpriate cntainers will be used. a. All ral liquid preparatins must be dispensed in their riginal re-clsable cntainers. b. All cntainers fr medicines must be prtected frm and free f cntaminatin. c. The cntainers must be apprpriate fr bth the medicines dispensed and the users. Dispensing Labels (16) Apprpriate labels will be used. a. Labeling f dispensed medicines must be clear and legible. b. Dispensed medicines must bear the necessary cautinary and advisry labels. c. The label n the cntainer must indicate the name, strength, dsage and ttal quantity f the medicine sld. Hygiene (17) Prper hygiene will be bserved. a. N AMS dispenser shuld be allwed t wrk if he/she is suffering frm a cntagius disease, such as scabies, tuberculsis, etc. b. Dispensing must always be carried ut under cnditins which meet acceptable standards f hygiene, including high standards f persnal cleanliness. c. Use f bare hands fr cunting tablets and capsules is prhibited. 25

32 Participant Manual AMS Dispensers (d) Recrd Keeping and Dcumentatin Standards fr Recrd Keeping and Dcumentatin (18) Prper recrd keeping and dcumentatin shuld be fllwed: a. All invices and receipts fr apprved medicines shall be stred in the premises in an easily retrievable file fr nt less than tw years. b. A purchase recrd bk shall be kept, which shall minimally include: name f supplier; date f purchase; name and quantity f the medicine, manufacturer; batch number; and expiry date. c. All AMSs shall maintain, fr selected, apprved prescriptin medicines, a register bk, which shall minimally include: i. Name and age f the client fr which the prescriptin was written r prescriptin medicine dispensed ii. Name f medicine and quantity dispensed iii. Date n which the medicine was dispensed iv. Origin f the prescriptin d. There shall be a recrd fr expired prducts which shall be kept and maintained by the AMS dispenser and be ready fr inspectin by PBL/LMHRA. e. There shall be LMHRA adverse medicine reactin frms maintained in each AMS fr the purpse f recrding client medicine-related adverse reactins. f. Every AMS shall keep and maintain: i. A special file fr keeping all crrespndence related t medicines, guidelines frm the PBL, LMHRA and ther regulatry authrities ii. An inspectr s recrd bk fr the purpses f recrding all inspectins undertaken therein (e) Reference Materials Reference Bks (19) Each AMS shall have and maintain, fr easy reference, the fllwing reference bks: a. Accredited medicine stre apprved medicines list b. Accredited Medicine Stre Standards and Cde f Ethics c. Accredited medicine dispenser training manual d. Natinal Standard Treatment Guidelines e. Other recmmended references, including Essential Medicines List fr Liberia, relevant legislatin, and the Natinal Medicine Plicy 26

33 Mdule 1 Sessin 2. Laws, Regulatin, and Ethics (f) Offenses and Penalties (20) Any persn wh cntravenes any prvisins f these standards cmmits an ffense and shall be held liable. The vilatr may be subject t an administrative hearing r appear befre a curt f law and upn cnvictin shall be punished either by paying a prescribed fine r serving a prisn sentence r bth as specified under the LMHRA Act Example 1 Any AMS fund selling expired medicines r medicines nt n the apprved medicines list. Example 2 A persn wh illegally pens an AMS r medicine stre. Example 3 Like any ther business, an AMS shall be liable fr taxatin. Tax evasin may lead t clsure f the premises by law-enfrcing bdies and bring abut incnveniences t the AMS prprietr, dispenser, and the cmmunity served by the stre. Example 4 Purchase f medicines frm nn-licensed dealers: medicines frm unauthrized dealers are ften cunterfeit, s this practice is prhibited. Example 5 Dispensing t medicines purchased frm unauthrized dealers t clients may cause harm. Such vilatins f law are punishable n cnvictin by curts f law. It is therefre imprtant fr AMS prprietrs and dispensers t adhere strictly t the prvisins f the law, guidelines, and standards f peratins. Accredited Medicine Stre Cde f Ethics and Cnduct Hnesty and integrity Patient care Special relatinship with clients All AMS dispensers and prprietrs shall, in the curse f discharging their duties, act with hnesty and integrity. All AMS dispensers and prprietrs shall prvide their services in a caring and cmpassinate manner. The well-being f a patient shall be the center f AMS business practice, and therefre dispensers and prprietrs shall make sure that the needs f the patient are always given first pririty. AMS dispensers and prprietrs shall: Maintain a special relatinship with each client based n ethical agreement Uphld their mral bligatins in return fr the trust given t them by the cmmunity Respect the autnmy, individuality, and dignity f each client Acknwledge the right f clients t participate in decisins related t their 27

34 Participant Manual AMS Dispensers Cnfidentiality Quality f medical service Cllabratin with ther health prviders Respnsibility fr assuring and imprving cmpetence Illegal cnditins Health prmtin Cmmercial relatinships Surce: Standards 2012, p. 17 health Respect persnal, cultural, and religius differences and shall nt in any way practice any frm f discriminatin Every AMS dispenser and prprietr shall bserve the cnfidentiality f clients infrmatin acquired in the curse f practice and shall nt in any way disclse the infrmatin given except where authrized by the client r required by the law. AMS dispensers and prprietrs shall nt either cndne the dispensing, prmtin, r distributin f medicines r medical services that are nt f gd quality r participate in any prmtinal methds r campaigns that encurage the irratinal use f medicines r undermine the rle played by ther health care prviders. AMS dispensers and prprietrs shall be required t cllabrate with ther health care prviders t achieve the best pssible utcmes fr clients and t understand the rle f ther health care prviders and refer clients t them when it is apprpriate t d s. Each AMS service prvider shall assume respnsibility fr assuring and imprving his/her cmpetence and shall strive fr cntinuus imprvement f the quality f service and care he/she prvides. AMS prviders may ffer limited client advisry services but they shall nt, in any way, make diagnsis and/r prescribe any medicine. It shall be the duty f AMS wners t make sure that there are n cnditins r terms which prhibit the AMS dispensers and prprietrs frm practicing in accrdance with the prvisins f these regulatins. Each AMS service prvider shall advcate fr health prmtin at the individual, cmmunity and sciety levels and shall prmte the use f cst-effective therapies and ratinal medicine use. N cmmercial relatinship shall be permitted between health care practitiners and AMS prviders. Sessin 3. Basic Principles f Medicines Management r Medicines Handling Objectives 1) Discuss the basic principles f medicines management 2) Discuss the selectin prcesses 3) Discuss methds used t determine quantities t buy 4) Describe gd receiving, strage, and distributin principles Time 4-6 hurs Activity 1. Estimating Quantity t Buy by using the Cnsumptin Methd Estimate the quantity f dxycycline capsules needed fr the BetaMed drug shp Frm the dispensing lg, the cnsumptin in ne mnth was caps 28

35 Mdule 1 Sessin 3. Basic Principles f Medicines Management r Medicines Handling Each can f 1000 csts USD 7.00 Current stck is 150 capsules Calculate the quantity and cst f dxycycline t be rdered Activity 2. Grup Wrk What challenges d yu find at the different stages f the medicines management cycle up t distributin and hw can they be mitigated: When chsing which medicines t buy When purchasing medicines When string medicines When dispensing medicines What is Medicines Management? A system f prcesses and behavirs fr crdinating r supervising medicines handling, delivering services t patients, usage f medicines by patients, and delivering health care services t patients t ptimize the cntributin that medicines make in prducing desired patient utcmes. Medicines Management Cycle The medicines management cycle includes selectin, prcurement, distributin, and use. These activities are interlinked and reinfrced by apprpriate management supprt systems (i.e., tls), and are regulated by a legal and plicy framewrk. 29

36 Participant Manual AMS Dispensers Surce: Center fr Pharmaceutical Management Center fr PharmaceuticalManagement: Technical Framewrks, Appraches, and Results. Arlingtn, Virginia: Management Sciences fr Health. Figure 4. Medicine management cycle Selectin Selectin f medicines ensures that the medicines that are stcked in the utlet meet the health needs f the cmmunity. Selectin has been made easier by prducing an extended medicine list fr the AMS utlets. The items that the utlet will prcure are thse that are n the extended medicine list. Medicines n the extended medicines list were selected fllwing the baseline survey. The fllwing was the basis f the selectin. The medicines cver the mst prevalent diseases, ailments, and sicknesses in cmmunities arund the cuntry. The medicines can be adequately managed by the available cadre f staff, if well trained. The medicines are available at the health center in the public sectr that prvides the same level f health care and has cadres with the same level f training as the private sectr. The medicines are widely available in the cuntry and at relatively lw prices. On tp f the extended medicine list, AMSs will be allwed t stck all the class C medicines accrding t the Natinal Medicines Plicy f Uganda. Prcurement f Medicines 30

37 Mdule 1 Sessin 3. Basic Principles f Medicines Management r Medicines Handling Cnsumptin Methd This methd is based n hw much has been used in the past t estimate what will be needed in the near future. The assumptin is that there will nt be much change in the demand fr the medicines. The first step is t determine hw much was used ver a specific perid. The quantity cnsumed is easily btained by adding up the quantities f a specific prduct sld ver a specific time perid. This infrmatin shuld be easily fund in the dispensing lg which is used t recrd daily what has been sld. This figure is used t calculate the amunt needed ver a prcurement perid (perid ver which the stck is t be used). Deduct what is available in stck t get the actual quantity t buy. Example 5 packets f amxicillin were used ver the last mnth 1 packet is left in stck Stck is needed fr 1 mre mnth Quantity t purchase = 5-1 = 4 packets Determine the cst f 4 packets; each packet is UGX 20,000 4 packets = 4 UGX 20,000 = UGX 80,000 In cases where there is n cnsumptin data, estimates can be based n the number f cases f a disease seen in a perid. Prcedure t Estimate Needs n the Basis f Disease Patterns Identify the disease cnditin the medicine treats Estimate hw many patients are seen with this particular cnditin in a week Determine the dse, frequency, and duratin f treatment Estimate the quantity f medicine needed by multiplying the number f cases by the dse, frequency, and duratin Example: Estimating the Quantity f Adult ACT t Purchase The number f adult cases f uncmplicated malaria per week is 2 The dse is 4 tablets twice a day fr 3 days = tablets = 24 tablets 31

38 Participant Manual AMS Dispensers Number f tablets per day = 24 2 patients = 48 tablets Number f tablets per mnth (if frequency is a mnth) = 48 4 weeks = 192 tablets When Buying Medicines 1) Make a precise determinatin f the dsage frm, strength, and pack size f the prduct required 2) Find ut the prices f the different dsage frms and pack size required 3) Allcate funds fr each medicine item depending n: Pririty nature f the medicine and dsage frm Available finances It is imprtant t accurately estimate the quantity f medicine t be prcured t avid Overstcking which may lead t expiry f medicines and wastage Stck ut f medicines, which may lead t lss f trust, credibility, and cnfidence by the cmmunity Estimating the quantity f medicine t prcure is based n: Ppulatin the utlet serves Disease pattern Seasnal variatin in disease pattern, e.g., during the rainy seasn, there is increase in diarrheal diseases Rate cnsumptin f the medicine Frequency f prcurement Available space fr strage f medicine Distance t the pharmacy where the medicines are t be prcured Amunt f mney available Receiving and String Medicines Accrding t the results f the baseline survey, rders are dne by the drug shp wners r their agents physically ging t the pharmacy where the medicine is prcured. The drug shp wner r agent receives the supplies at the pharmacy and is respnsible fr transprting the cnsignment. 32

39 Mdule 1 Sessin 3. Basic Principles f Medicines Management r Medicines Handling Receiving Medicine When receiving medicines, make sure that the medicines received match the rder: Crss check t find ut if the dsage frm, strength, pack size, and quantity rdered match with what is required Check the prices Check the expiry dates Check fr quality, clr changes, and damages This exercise shuld take place at the pint medicines are received frm the supplier. Any discrepancies nted shuld immediately be cmmunicated t the supplier wh shuld crrect them. If the receiving is dne at the supplier s premises, the drug shp wner r agent takes the respnsibility f chsing the mde f transprt f the cnsignment t his r her premises. The transprt chsen shuld be apprpriate t ensure that medicines d nt deterirate during transit. It may happen that yu receive a drug withut a label r with an incrrect label. Never guess what it is! D nt use it; return it t the supplier. On reaching the drug shp, crss check again fr any damages that may have ccurred. Remve any damaged items frm the stck. Keep damages separately frm the medicines available fr sale. Ntify the PBL r LMHRA t request assistance with dispsing f these medicines. Determine/set the price at which the medicines will be sld. The fllwing factrs shuld be cnsidered in determining price: Purchase price Transprtatin charges Mark up t cver administrative and ther csts Strage f Medicines Medicines and related supplies are expensive and valuable. They need prper handling, therwise they may deterirate. If they deterirate, they may lse their ptency r may have the wrng effects n patients. Heat affects all medicines, especially liquids, intments, and suppsitries. Light-sensitive medicines, such as injectables, spil very quickly when expsed t light. Humidity can spil tablets and capsules because they can easily absrb water frm the atmsphere, making them sticky and causing them t deterirate. 33

40 Participant Manual AMS Dispensers Medicines require specially designed, secure, and clean premises t: Avid cntaminatin r deteriratin Avid disfiguratin f labels Maintain integrity f packaging and thereby guarantee quality and ptency f drugs during shelf life Prevent r reduce pilferage, theft, r lsses Prevent infestatin f pests and vermin Cnditins f the Premises The premises that are t huse the medicine utlet must be in gd cnditin, and all penings secured with grills r bars t prevent theft. The space shuld be large enugh t fit all the supplies and arranged t make the wrk flw easy. The premises shuld be lckable. It is best t put tw lcks (each with a different key) n the exit dr. Make nly a limited number f keys and stre these in a safe place. If the medicine utlet has a stre separate frm the dispensing area, access t the stre shuld be limited nly t staff members. Psitin the cunter such that the public cannt access the medicines n the shelves. The premises shuld prtect the medicine frm extreme cnditins f light, heat, and humidity that may affect the medicines and cause deteriratin. The standard fr perating an AMS utlet stipulates requirements fr the premises under which medicines shuld be sld. Maintaining the Premises Regularly inspect the physical structure f the premises and repair any damage t the rf, walls, dr, windws, and flrs. Cntrl the temperature in the stre by ensuring that: The premise has a well-maintained ceiling; if there is n ceiling, build ne. Ceilings shuld be as strng as pssible, but cardbard frm discarded bxes can be used temprarily. There is adequate air circulatin by pening drs and windws while the premises is pen t the public A fan is available, if pssible; keep it in gd wrking cnditin Cntrl the light in the stre by: Blcking direct light by using tinted glass windws 34

41 Mdule 1 Sessin 3. Basic Principles f Medicines Management r Medicines Handling Hanging curtains in the windws Cntrl humidity by: Preventing leaks r seepage thrugh the rf, drs, windws, and walls Allwing gd air circulatin Repairing leaks and water seepages as sn as they ccur Including sachets f desiccant in cntainers f tablets and capsules Nte: desiccants are nn-edible drying crystals that keep the insides f cntainers dry. DO NOT pen the desiccant sachet. Keep the sachet in the cntainer but d nt dispense it. Desiccants are txic if ingested. Keep the cntainer clsed except when dispensing the medicines. Keep the stre free f pests and vermin. Fd and sweet juice spills in the premises can attract rats, cckraches, ants, and wasps. Dark spts within the premises may be hiding spts fr pests. Pests can be avided by: Eating nly in a designated place n the premises and cleaning all fd and juice residue immediately Cleaning spills and remving brken cntainers immediately Clearing all bushes arund the premises Imprving lighting and arranging items neatly n shelves Aviding putting bxes directly n the flr Regularly mpping the flr and remving all unwanted bjects frm the premises Strage Envirnment The strage envirnment shuld prvide: Adequate temperature t avid deteriratin Sufficient lighting fr easy visibility; hwever, direct light n the medicines shuld be avided t prevent deteriratin Clean cnditins, e.g., the flrs and shelves shuld be dusted t avid cntaminatin Humidity cntrl t prevent cntaminatin and deteriratin Cld strage facilities fr medicines that require cld temperature Adequate shelving t ensure integrity f the stred drugs 35

42 Participant Manual AMS Dispensers Guidelines fr Arranging Medicines n Shelves In a clean and rganized medicine utlet, it is easy t lcate medicines and avid cntaminatin. Medicines are als likely t be in gd cnditin and ready t use. Shelves prvide an pprtunity t neatly arrange medicines and allw easy circulatin f air. Clean r dust the shelves befre placing medicines n them. Shelves shuld be strng, rbust, and easy t clean, preferably f steel r treated wd. Tp shelves: Stre dry medicines (tablets, capsules, ral rehydratin packets) in airtight cntainers. If the tp shelf is near the ceiling r ut f reach, use that shelf t stre items that are NOT sensitive t heat and NOT used regularly. Middle shelves: Stre liquids, including syrups and intments. DO NOT put dry medicines belw them. If liquids leak, the medicines belw may spil. Bttm shelves: Stre ther supplies, such as surgical items and cndms. Remember, DO NOT stre anything directly n the flr! Medicines shuld be arranged systematically in the fllwing way: Alphabetic rder by generic names f the medicines Pharmaclgical rder Dsage frm Or a cmbinatin f frmats Each dsage frm f a drug is arranged in separate and distinct areas. Sufficient empty space shuld demarcate ne medicine item r dsage frm frm anther. The mst recently received medicines shuld be placed behind ld stck n the shelf, except when new drugs have shrter expiratin dates. The medicine package shuld be placed such the name f the medicine is well displayed and easy t read. Heavy medicine packages shuld be placed n the lwer shelves and lighter nes n tp. Regularly dust the medicine cntainers and shelves. Dust cntaminates supplies and makes labels difficult t read. Fr increased safety and cnvenience, shelves shuld be labeled. The psitin where a specific drug is stred shuld carry that label in a prper and clear manner t avid cnfusin when taking medicines frm the shelves. It is mre efficient t always stre drugs in the same place. 36

43 Mdule 1 Sessin 3. Basic Principles f Medicines Management r Medicines Handling All drugs must have an expiry date. Always check yur new supplies fr expiry date. The new supplies may have a shrter expiry date than the ld stck. Thse that expire first shuld always be used first. This is called FEFO (first-expiry, first-ut) stcking, meaning that the first medicines t expire shuld be the first t be dispensed. Medicines shuld nt be used after its expiry date because: The drug is n lnger as effective This is very imprtant, especially with antibitics. Yu may nt be giving the patient enugh dse/strength; this may cause resistance t the antibitic. The drug may becme txic As sme drugs breakdwn, they frm txic substances, which gradually build up and becme harmful t the bdy. Recmmended strage cnditins relating t temperature, light, and misture shuld be fllwed as clsely as pssible t maintain prduct quality. Stck bttles must be kept clsed except when actually in use. A limited range f preparatins will be used with the greatest frequency, and these fast mvers can be placed in the mst accessible areas fr cnvenience in dispensing. Distributin At the medicine utlet, medicines are dispensed t patients mstly in respnse t a prescriptin written by a clinician wh has examined the patient and identified the prblem and the necessary medicines t heal r imprve the patient. Dispensing requires an understanding f the patients (wh may nt speak r understand the language f the dispenser) and practical skills in dispensing and recrd keeping. This will be tackled in detail in the curses that fllw. 37

44 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) Objectives 1) Describe the prcesses f gd prescribing and gd dispensing 2) Equip trainees with knwledge, skills, and attitudes t apprpriately cnduct the prescribing and dispensing prcess Time 4-6 hurs Activity. Dispensing Rle Play Divide int five grups In each grup, ne persn will present with a prescriptin while anther will dispense medicines As each grup enacts the scenari, the ther grups are making cmments n the quality f the dispensing Apprpriate use f drugs is ne essential element in achieving quality f health and medical care fr patients and the cmmunity. Quality f care is f cncern t practitiners. Actins r interventin prgrams t prmte the apprpriate use f drugs shuld be cntinuusly implemented and systematically incrprated as an integral part f the health care system. This sessin serves as an intrductin t the entire issue f prmting ratinal use f drugs in develping cuntries. The definitin f ratinal use will be discussed and cmmn examples f irratinal drug use will be highlighted. The sessin addresses the impacts and the underlying factrs f irratinal use f drugs. A series f examples will be presented. Definitin f Ratinal (Apprpriate) Drug Use Ratinal use f drugs requires that patients receive medicines apprpriate t their clinical needs, in dses that meet their wn individual requirements, fr an adequate perid f time, and at the lwest cst t them and their cmmunity (WHO 1985). 38

45 Mdule 1 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) Surce: MDS-3 Figure 5. The drug use prcess Apprpriate r ratinal use f medicines therefre requires that the medicine is prescribed fr a particular patient after prper diagnsis f a health prblem. The requirements fr ratinal use will be fulfilled if the prcess f prescribing and dispensing fllws the apprpriate steps: Define a patient s prblems (r diagnsis) Define effective and safe treatments (drugs and nn-drugs) Select apprpriate drugs, dsage, dsage frm, rute f administratin, frequency, and duratin Write a prescriptin Give patients adequate infrmatin Plan t fllw up n adherence and evaluate treatment respnses 39

46 Participant Manual AMS Dispensers The definitin implies that ratinal use f drugs, especially ratinal prescribing, shuld meet the fllwing criteria: Apprpriate indicatin. The decisin t prescribe drug(s) is entirely based n medical ratinale, and the drug therapy is an effective and safe treatment. Apprpriate drug. The selectin f drugs is based n efficacy, safety, suitability, and cst cnsideratins. Apprpriate patient. N cntraindicatins exist, the likelihd f adverse reactins is minimal, and the drug is acceptable t the patient. Apprpriate patient infrmatin. Patients are prvided with relevant, accurate, imprtant, and clear infrmatin regarding their cnditins and the medicatin(s) that are prescribed. Apprpriate evaluatin. The anticipated and unexpected effects f medicatins are apprpriately mnitred and interpreted. Unfrtunately, in the real wrld, prescribing patterns d nt always cnfrm t these criteria and can be classified as inapprpriate r irratinal prescribing. Irratinal prescribing may be regarded as pathlgical prescribing when the abve criteria are nt fulfilled. Cmmn patterns f irratinal prescribing may be manifested in the fllwing frms: The use f drugs when n drug therapy is indicated, e.g., antibitics fr viral upper respiratry tract infectins (URTIs) The use f the wrng drug fr a specific cnditin requiring drug therapy, e.g., tetracycline in childhd diarrhea requiring ral rehydratin salts (ORS) The use f drugs with dubtful r unprven efficacy, e.g., the use f antimtility agents in acute diarrhea The use f drugs f uncertain safety status, e.g., use f dipyrne (Baralgan, etc.) Failure t prvide available, safe, and effective drugs, e.g., failure t vaccinate against measles r tetanus r failure t prescribe ORS fr acute diarrhea The use f crrect drugs with incrrect administratin, dsages, and duratin, e.g., the use f IV metrnidazle when suppsitries r ral frmulatins wuld be apprpriate The use f unnecessarily expensive drugs, e.g., the use f a third generatin, bradspectrum antimicrbial when a first line, narrw spectrum agent is indicated 40

47 Mdule 1 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) Sme examples f cmmnly encuntered inapprpriate prescribing practices in many health care settings include: Overuse f antibitics and antidiarrheals fr nnspecific childhd diarrhea Indiscriminate use f injectins, e.g., in malaria treatment Multiple r ver-prescriptin Excessive use f antibitics fr treating minr respiratry tract infectins Multivitamins and tnics fr malnutritin Unnecessary use f expensive antihypertensives Factrs Underlying Irratinal Use f Drugs Many different factrs affect the irratinal use f drugs. In additin, different cultures view drugs in different ways, which can affect the way drugs are used. The majr frces can be categrized as thse deriving frm patients, prescribers, the wrkplace, the supply system including industry influences, regulatins, drug infrmatin and misinfrmatin, and cmbinatins f these factrs. All f these factrs are affected by changes in natinal and glbal practices. Fr example, the frequent use f injectins is declining in many African cuntries because f the fear f AIDS. In sme cuntries, hwever, the use f injectables remains high because f the false assumptin n the part f prescribers that injectins will imprve patient satisfactin and that they are always expected by the patient. Table 2. Wrng Reasns t Prescribe Medicines Patients Drug misinfrmatin Misleading beliefs Patient demands/expectatins Prescribers Lack f educatin and training Inapprpriate rle mdels Lack f bjective drug infrmatin Generalizatin f limited experience Misleading beliefs abut drugs efficacy Wrkplace Pressure t prescribe Lack f adequate lab capacity Insufficient resurces Drug supply system Unreliable suppliers Drug shrtages Expired drugs supplied Drug regulatin Nnessential drugs available Infrmal prescribers Lack f regulatin enfrcement Industry Prmtinal activities Misleading claims 41

48 Participant Manual AMS Dispensers Impact f Irratinal Use f Drugs The impacts f this irratinal use f drugs can be seen in many ways: Reductin in the quality f drug therapy leading t increased mrbidity and mrtality Waste f resurces leading t reduced availability f ther vital drugs and increased csts t the patient and cmmunity Increased risk f unwanted effects, such as adverse drug reactins and the emergence f drug resistance, e.g., malaria r multiple-drug resistant tuberculsis (TB) Psychscial impacts, such as when patients cme t believe that there is a pill fr every illness, which can cause an increased demand fr drugs What Infrmatin Shuld Be Given t Patients t Ensure Ratinal Use f Medicines? The dispenser shuld verbally give the patient additinal infrmatin t reinfrce the instructins written n the label. This shuld be in a language with which the patient is familiar. The infrmatin shuld including the fllwing: Hw ften t take the drug When t take the drug (e.g., befre r after meals) Hw lng the treatment is t last (e.g., why the entire curse f an antibitic treatment must be taken) Hw t take the drug (e.g., with water, chewing, r swallwing) Hw t stre the drug (e.g., avid heat, light, and dampness) Nt t share drugs with ther persns Keep drugs ut f the reach f children Cnsult in case the medicine causes undesirable effects r if there is n registered imprvement r the patient gets wrse Definitin f Dispensing Terms Adherence r cmpliance Adherence r patient cmpliance is a measure f the extent t which a patient fllws instructins n the use f a drug. These instructins shuld be given by the prescriber and the dispenser. The better a patient fllws the instructins, the higher the cmpliance. The results f the use f a medicine will be better when cmpliance is high. 42

49 Mdule 1 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) Brand r trade name It is the name f a pharmaceutical prduct given by the manufacturer. Medicines with the same active ingredient may have different brand r trade names, such as Panadl, Kamadl, and Cetaml, are brand names f medicines that cntain paracetaml as the active substance. Cntaminatin In pharmacy practice, the raw materials and finished prducts shuld nt cntain unwanted materials. Material that cntains any amunt f unwanted freign bdies is said t be cntaminated. Cntaminatin may be caused by the manufacturer, transprter, dispenser, r the user. Careful handling f materials and finished prducts with clean hands r equipment prevents cntaminatin. Curse f treatment Hw lng a medicine has t be taken fr cmplete treatment r management f the health prblem. Crss-cntaminatin Crss-cntaminatin ccurs when ne medicine in the pharmacy is cntaminated with anther ne during the dispensing prcess. The mst cmmn cause is frgetting t thrughly clean the equipment every time it has been in cntact with a different drug. Use f a single spn when dispensing different drugs is a majr surce f crss-cntaminatin. It may als happen if bare hands are used when cunting tablets r capsules. Dilutin This is the prcess whereby a cncentrated slutin is made weaker, usually befre use. Diluting medicines is mstly dne with purified water but ther liquids are als smetimes used. Disinfectants and antiseptic slutins, such as hydrgen perxide, very ften require dilutin. (Refer t the sectin n the dispensing prcess fr details n dilutin f hydrgen perxide.) Dispensing The prcess f issuing medicines t the patient. The prcess cvers all the activities invlved frm receiving the prescriptin t issuing the prescribed medicine t the patient. Dsage The amunt f medicine (i.e., dse) t be taken ver a given perid f time (e.g., per day, per week). Dsage frm Medicines are available in different frms tablets, capsules, injectins, pwders, syrups, slutins, intments, and creams. These frms are called dsage frms. Always read the label f a drug cntainer carefully t understand the right dsage frm. Dse 43

50 Participant Manual AMS Dispensers Amunt f the medicine t be administered at ne time. Expiry date The date fund n all medicines after which they are believed t have lst ptency (effectiveness). Sme medicines may becme txic due t deteriratin and presence f txic prducts. Never use medicines beynd their expiry date. Yu can avid having expired medicines at yur facility by maintaining an effective stck cntrl system and practicing FEFO t avid stck expiring n the shelf. Generic r nn-prprietary names The name given t a medicine that will be recgnized all ver the wrld. It remains the same regardless f which cmpany manufactures the medicine. Paracetaml is a generic name. Manufacturing date This is the date n which the medicine was manufactured. This date may be expressed in mnth and year f manufacturing. Prescriptin This is a written and signed rder frm an authrized r qualified prescriber t a dispenser. It cntains instructins t supply r dispense specified medicines t a specified patient. It shuld be clearly written fr easy reading and t prevent unnecessary mistakes in interpretatin. If a prescriptin is nt written clearly, check with the prescriber never guess! All class B drugs require a prescriptin fr dispensatin. Recnstitutin This is a prcess in which a specified amunt f water is added t a pwder frm f a drug. This methd is used when drugs are nt stable in water r in slutin. This means that the drug breaks dwn if left in water r in slutin fr a lnger perid f time. Fr this reasn, these medicines shuld nly be recnstituted just befre use. Such examples f the pwder frm f drugs include amxicillin (syrup) and Pen-V syrup. Vlume Vlume prvides infrmatin abut capacity. That is, the amunt f space that a material ccupies, fr example, the cntents f a bttle. The base unit fr vlume is the liter (L). In pharmacy practice, the fllwing units are cmmnly used t express vlume. Name Abbreviatin Equivalent t 1 liter L 1000 ml 1 milliliter ml L 44

51 Mdule 1 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) Water (ptable, purified, and water fr preparatin) Ptable water Drinking water, freshly drawn frm the public main water supply. If its quality is assured, it is suitable fr the preparatin f pharmaceutical prducts fr ral r external use. If the quality is nt assured, it must be biled and cled befre use. Mst f the dmestic ptable water available in Liberia is nt suitable fr direct preparatin f pharmaceutical prducts. Purified water Purified water is made frm ptable water by different prcesses including deinizatin, distillatin, r reverse smsis t make it purer. If it is nt freshly prepared, it needs t be biled and cled befre using in pharmaceutical prducts. Water fr preparatin May be either fresh, ptable water r purified water freshly biled and cled. Weight Ptable water, purified water, and water fr preparatin cannt be used t recnstitute injectins. Hw heavy a certain amunt f material is. In pharmacy practice, the base unit is the kilgram (kg). Other cmmn units f measure are listed in the table. Name Abbreviatin Equivalent t 1 kilgram kg 1,000 g 1 gram g 1,000 mg 1 milligram mg 1,000 mcg 1 micrgram mcg mg Dispensing Envirnment The dispensing envirnment must be clean, hygienic, tidy, and cnducive fr interactin between the patient and the medicine seller. A clean and hygienic envirnment will reduce chances f cntaminatin. A tidy envirnment will help prevent mistakes frm ccurring during dispensing. 45

52 Participant Manual AMS Dispensers An envirnment cnducive fr interactin will prmte patients understanding f instructins n hw t use medicines and sellers understanding f the patients prblems. The envirnment, in ttality, will prmte patient cnfidence in the medicine utlet. The ideal surrundings fr dispensing are: Quiet Adequate lighting Gd circulatin Clean Secure with n idlers The dispensing area shuld have: Enugh space s that wrk flws smthly Sitting facilities fr patients Enugh furniture fr staff Wrk surfaces that are easy t clean s that spills f liquid medicines and pwders can be wiped ff immediately Adequate equipment fr measuring liquids, cunting tablets, and packaging material The strage area shuld have: Enugh space t hld an adequate amunt f stck Shelves that are regularly cleaned Medicines that are neatly arranged and rutinely dusted The dispensing area shuld be neatly arranged t facilitate wrk flw. A daily drug use recrd shuld be kept in the dispensary. A dispensing table shuld be prvided. D nt vercrwd the dispensing table. Dcuments shuld be arranged in an rderly manner n the table. Clean tablet cunters after each use and place within easy reach n the table. Avid dispensing the wrng drugs by arranging drugs n the table in alphabetical rder s that the drug being dispensed is nt cnfused with anther. 46

53 Mdule 1 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) Always clse drug cntainers frm which drugs are nt being dispensed t prevent spillage r dispensing the wrng drug. Dispensing Persnnel The dispensing envirnment and the dispensing persnnel prvide the first impressin custmers have when they cme t the medicine utlet. The dispensing persn must: Be knwledgeable abut the medicines dispensed in regard t: Cmmn use Cmmn dse Precautins t be taken while using the drug Cmmn side effects Cmmn interactins with ther drugs r fd Strage needs Pssess gd calculatin and arithmetic skills Be able t assess the quality f preparatins Be accurate and hnest Be able t cmmunicate effectively with patients Exhibit prfessinalism at all times, whether serving custmers and patients r nt Shuld be clean and dressed in a way that depicts that he r she is a health wrker Organized Have cmmunicatin and leadership skills t be valuable t the cmmunity and t effectively interact with patients Prescriptin A prescriptin is a set f instructins written by a qualified prescriber t a dispenser fr a supply f medicines after cunseling the patient n hw t use the medicines. It is very imprtant that prescriptins are clearly written. The prescriptin shuld clearly state (using paracetaml as an example): The dsage frm f paracetaml tablets The strength f the paracetaml tablets 500 mg per tablet The number f days fr which the paracetaml tablets have been prescribed The number f times the tablets shuld be taken each day The number f paracetaml tablets t be taken each time 47

54 Participant Manual AMS Dispensers A prescriptin shuld have the fllwing: Name f the unit prescribing the medicatin Name f the patient and age (especially if a child) Date Prescriber s signature and name Instructins abut the prescribed drugs, including: Generic name and dsage frm Dse Frequency f administratin Duratin f treatment Any ther instructins cnsidered imprtant fr the patient t knw (e.g., hw t take the medicine in relatin t fd) Examples: One capsule every 8 hurs Take with r withut meals D nt use alchl as lng as yu are n medicatin Finish all drugs as directed fr success f treatment D nt drive a vehicle when using this drug Example f a Prperly Written Prescriptin St Paul River Health Centre Date: P.O. BOX 68 St Paul River, Mntserrad Name: Seep Jeane OPD NO. 340/09 Address: St Paul River Age: Adult Weight: 70 kg Rx 1. C-trimxazle tablets ii b.i.d. x 5/7 2. Paracetaml tablets ii tds x 3/7 Name f Prescriber/qualificatins Dr. Thmcellia Emanuel MD (UL) Signature Frequently Used Abbreviatins in Prescriptins The table belw lists sme regularly used abbreviatins and their meaning. Nevertheless, in sme cases, prescribers use lcal abbreviatins that are nt standard and that may nt be knwn t yu. In such cases, ask prescribers abut the meaning f different abbreviatins used in the prescriptin. D nt dispense if yu are nt sure f the meaning f the abbreviatin written in the prescriptin. 48

55 Mdule 1 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) Table 3. Cmmn Prescriptin Abbreviatins Abbreviatin a.c. b.d., b.i.d Cap. g.t. r g.t.t.s. h.s. i.m. Inj. i.v. nct. r ncte Occul r cculent int. p.a.a. p.c. p.. p.r.n. q.i.d. Rx Stat. Tab. t.d.s. t.i.d. t.s.p. Meaning Take medicine befre meals/fd Twice a day Capsule Drp (ne) r drps (mre than ne) At bed time Intramuscular Injectin Intravenus At night Eye intment Ointment Apply medicine t affected parts f the bdy Take medicine after meals/fd Take medicine by muth Take medicine when required Fur time a day Take Take immediately Tablet Three time a day Three time a day Teaspnful Basic Dispensing Prcedure If drugs are nt dispensed prperly t patients, all attempts t crrectly prescribe and select the best treatment can be useless. It is very imprtant t cncentrate while dispensing. Remember nt t carry ut mre than ne activity at the same time if yu d, yu are likely t cnfuse yurself r the patient. If yu pick up a prescriptin, cmplete the whle prcedure in filling that prescriptin befre yu start anything else. Keep the dispensing area and yurself clean, tidy, and rganized. An untidy, dirty, and unrganized dispensing area is the majr cause f cnfusin and pssible dispensing errrs. Dispensing Steps The cnsistent and repeated use f gd dispensing prcedure is very imprtant in ensuring that errrs are nticed and crrected at all stages f the dispensing prcess. The term dispensing prcess cvers all activities invlved, frm receiving the prescriptin t issuing the prescribed medicine t the patient. There are seven majr areas f activity. 49

56 Participant Manual AMS Dispensers 1) Receive and validate the prescriptin 2) Understand and interpret the prescriptin 3) Prepare items fr issue 4) Cst, label, and pack the medicines 5) Reread the prescriptin and check what has been packed 6) Recrd actin taken 7) Issue medicines t the patient with clear instructins and advice, checking the understanding f the patient Step 1. Receive and Validate the Prescriptin Upn receiving a prescriptin, the staff member respnsible shuld cnfirm the name f the patient. This is particularly imprtant because there is a pssible risk that staff r patients may mix up prescriptins. Crss-checking the name and identity f the patient must als be dne when issuing the drugs. Step 2. Understand and Interpret Prescriptin Interpreting a prescriptin must be dne by a staff member wh can: Read the prescriptin Crrectly interpret any abbreviatin used by the prescriber Cnfirm that the dses prescribed are in the nrmal range fr the patient (nting sex, weight, and age) Crrectly perfrm any calculatins f dses and issue the right quantity Identify any cmmn drug-drug interactins It is assumed that the prescriptin will be in written frm. If there is any dubt abut what is required by the prescriber, the prescriptin must be checked with the prescriber. Checking a prescriptin may save a life. Step 3. Preparing Items fr Issue Preparatin f items fr issue is the central part f the dispensing prcess, and it must include prcedures fr self-checking r cunter-checking t ensure quality. This part f the prcess begins nce the prescriptin is clearly understd and the quantity has been calculated. 1) Select stck cntainer and pack The cntainer label must be read at least twice during the dispensing prcess. When lking fr the crrect drug, read the label; never pick a drug by lking fr a particular clr label, a particular size f bttle r cntainer, r a particular shape r clr f the drug. This practice culd be very dangerus because many drugs and cntainers lk alike. In additin, the manufacturer may change the appearance f drugs and cntainers. Fr example, dxycycline capsules can be yellw r white, but all cntain the same drug. Read the generic name f the drug. This name always stays the same, whereas the trade/brand name changes, depending n the manufacturer. 50

57 Mdule 1 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) Yu shuld remember this rule when picking up a cntainer fr dispensing: As yu pick up a cntainer f any drug, read the label, take ut the required quantity, label the patient package, and pack the drugs. Befre yu return the cntainer t its place n the shelf, read the label again and refer t the package yu labeled. Befre handing the drug t the patient, read it again t ascertain yurself if it is crrect. D these steps every time yu pick up a cntainer; never assume that yu knw it all by heart! This prcedure ensures that the drug yu have taken and labeled is the same. 2) Check the expiry date and quality f the drug Once yu have fund the drug yu need, check the expiry date and the quality f the drug. When checking the expiry date, make sure that yu d nt cnfuse the expiry date with the date f manufacture, which may als be n the label. Never dispense expired drugs. When checking the quality f the drug, lk fr the fllwing: Tablets and capsules must nt be chipped, cracked, brken, r sticky. Check that the smell and clr have nt changed. If a liquid is being dispensed, check that the bttle is nt cracked r chipped. Check the clr and smell, and lk fr any unusual cludiness, crystals, freign particles in the liquid. When dispensing creams and intments, check that tubes are nt cracked r hardened. Check that large, pen tins d nt cntain any grwth and have nt changed in clr and smell. Cunt quantities f slid dsage frms frm stck cntainers. 3) Cunt slid dsage frms (mainly tablets and capsules) Yu may have nticed during yur daily dispensing wrk that a high prprtin f medicine yu dispense cnsists f tablets and capsules. Yu spend much f yur time cunting such medicines. Try t rganize this cunting activity in a systematic way. This makes yur jb easier, mre efficient and abve all ensures accuracy. Remember that re-packaging f large quantities f drugs ut frm their riginal cntainers may lead t deteriratin f drug quality due t expsure t misture and ther envirnmental cnditins. Pack drugs nly when yu have t dispense them t patients at that mment. Determine the number f tablets in each dse prescribed; multiply that by the frequency f taking the drug and the ttal duratin r number f days the drug is t be taken. Fr example: 51

58 Participant Manual AMS Dispensers Amxicillin capsules 500 mg tds 5/7 If each tin cntains 250 mg capsules f amxicillin, then dispense = 30 capsules 4) Dispensing slid dsage frms (mainly tablets and capsules) The simplest r (easiest) way is t use a clean spn. Never use yur hands fr cunting! Using hands is a bad dispensing practice that is very unhygienic and carries a high risk f multiple crss-cntaminatins and transfer f cmmunicable diseases, such as chlera and wrms, t patients. D yu remember hw many articles yu have tuched r hands yu have shaken? Can yur hands still be clean enugh t tuch ral prducts? Using a spn, simply take the medicine ut f the riginal cntainer and cunt the medicine n the spn withut tuching it. Empty the spn int the cntainer r bag fr the patient. Make sure that the spn is cleaned after every cunt t avid crss-cntaminatin. Keep several spns in the dispensing area fr that purpse. After cunting the tablets r capsules, put the remainder, if any, back int the cntainer. Check the label nce mre t see that yu have taken the crrect drug. Clse the cntainer well and put it back in its crrect place. 5) Dispensing liquid and semislid dsage frms Liquids and semislid dsage frms shuld be dispensing in the riginal packs. D nt measure any syrup, intment, r any ther frms f liquid and semislid medicines int any cntainer t be dispensed t the patient. The prcess f transferring liquids r semislids frm ne cntainer t anther may lead t crsscntaminatin. Such medicines shuld be sld in their riginal, primary packs. Hwever, when dispensing liquid dsage frms, it is imprtant t ensure that the pack has clearly graduated measures that patients r care takers can use t measure dses t be administered. If graduated measures are nt indicated, give clear instructins n what utensil(s) can be used t measure medicatins. Step 4. Cst, Label, and Package Medicines 1) Csting Determine the price f the medicines. Using the example abve, after determining the number f capsules t be dispensed, determine the ttal price f the medicine. If each can f 1000 capsules f amxicillin csts USD 44.00, then the ttal price fr 30 capsules is USD Cst all the medicines and let the patient knw the ttal price befre dispensing. 2) Labeling medicine 52

59 Mdule 1 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) Befre packing the drug, write the label. It is better t write the label befre cunting r measuring the drug. If mre than ne drug is being dispensed, write the label, pack the drug, and return the cntainer befre packing the next item. In this way, yu are less likely t mix up the drugs and write the wrng label. Labeling befre packing will als make it easier t write clearly, withut damaging r spilling the medicine. It is nt enugh just t tell the patient hw t take the drugs(s). By the time he reaches hme, he may have either frgtten the instructins r have mixed them up. It is very imprtant that written labels be attached t the drugs, in additin t prviding verbal instructins. Even if the patient cannt read, it is likely that anther member f the family will be able t help. What infrmatin shuld be fund n the label? Name f the patient Name f the drug Strength f the drug Quantity f the drug supplied Instructins n hw the drug is t be used Hw much t take each time Hw ften per day With r withut meals With plenty f fluids, etc. Date supplied Name and address f the health care facility medicine utlet Written labels must be neat and easy t read. The instructins must be clear s that the patient understands them. Always write instructins in full and avid abbreviatins, such as t.d.s. r 1 3 nly; instead, write take every 8 hurs n the label. 3) Packaging medicine After writing the label and measuring r cunting the crrect quantity f medicine, the medicine shuld be packed int an apprpriate cntainer. It is very imprtant that the crrect cntainer is chsen fr each drug, as this will ensure that the medicine is kept clean, dry, and free frm cntaminatin s that it remains effective. Packing material fr slid dsage frms (tablets/capsules) includes: Plastic dispensing bags Paper envelpes Small, sterilized bags (avid if pssible because they are expensive) Packing liquids and semislid dsage frms (mixtures, syrups, intments, creams, etc.): Liquids and semislids shuld be dispensed in their riginal r primary pack. 53

60 Participant Manual AMS Dispensers Step 5. Re-Read the Prescriptin and Check What Has Been Packed After the medicines have been packed, check the prescriptin again t ensure that the medicines packed are exactly what have been prescribed in terms f the name, dsage frm, number f dses, frequency, and duratin. Step 6. Recrd Actin Taken Recrds f issues t patients are essential in an efficiently run medicine utlet. Such recrds can be used t verify the stcks dispensed, and they will be required t trace any prblems with medicines issued t patients. When the prescriptin is retained, the dispenser shuld sign it, file it, and enter the details int a recrd bk (prescriptin bk). When the prescriptin is returned t the patient, details f the medicines dispensed must be entered int a recrd bk (prescriptin/pisns bk) befre the items are issued t the patient. Enter the date, patients name and age, medicine name and strength, amunt issued by the prescriber, and dispenser s name. Step 7. Issue Medicine t Patient with Clear Instructins and Advice The medicine must be given t the named patient, r the patient s representative, with clear instructins and any apprpriate advice abut the medicine. The amunt f detailed advice that shuld be given abut pssible side effects varies frm patient t patient. Verbal advice is imprtant because bth illiteracy and pr labeling may be the cause f prblems. Apart frm emphasizing the dse, frequency, length f treatment, and rute f administratin, the pririty is t give the patient infrmatin that will maximize the effect f the treatment. Advice shuld therefre cncentrate n: When t take the medicine (particularly in relatin t fd and ther medicines) Hw t take the medicine (chewed, swallwed whle, taken with plenty f water) Hw t stre and care fr the medicine Warnings abut pssible side effects shuld be given with care. Cmmn but harmless side effects (nausea, mild diarrhea, urine changing clr) shuld be mentined t prevent a frightened patient frm stpping treatment. Every effrt shuld be made t cnfirm that the patient understands the instructins. Every patient must be treated with respect. The need fr cnfidentiality and privacy when explaining the use f sme types f medicine (e.g., suppsitries, pessaries) must be recgnized. It must be emphasized that the success f the treatment rests n the accuracy f the dispenser s cmmunicatin with the patient. Yu shuld understand that dispensing drugs and cunseling are sme f the mst imprtant aspects f the drug dispensing prcess. Yur task is t nt nly ensure that a patient receives medicatin, but als t ensure that the patient knws hw t use it prperly t achieve adequate results frm treatment. 54

61 Mdule 1 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) All the effrts that have been invested int pharmaceutical preparatins, frm the time f prductin thrugh all stages f buying and distributin, until the pint that prducts are dispensed will be wasted if the patient des nt use the prescribed medicatin in the crrect way. Yu have t ensure that the use f the medicine is explained t the patient in such a way that he r she fully understands hw t use it in the mst effective and prescribed manner. G thrugh the fllwing steps t ensure that the right patient is picking up the medicatin and the patient fllws instructins while using the medicine. Call the patient by ludly reading the name written n the prescriptin. This cnfirms that the right prescriptin is dispensed t the right patient. Fr each drug dispensed, verbally repeat the instructins n the label; prvide any additinal infrmatin specific fr each drug. NOTE: Always try t ask a female patient if she is pregnant r lactating, and check fr prper instructins t be given t pregnant wmen. Befre handing the medicines ver t the patient, cnfirm that the instructins are well understd. Yu may ask the patient t repeat the essential part f the explanatins. If they repeat yur instructins crrectly, yu will knw that they have understd. This exercise may take sme time, but it will cnsiderably increase cmpliance by the patient. D nt frget t give all the necessary infrmatin n hw t stre the drugs safely fr them t remain effective (e.g., sme drugs have t be stred in cl places, just like vaccines and insulin preparatins). Prvide warning t stre drugs away frm the reach f children. Useful Drug Infrmatin fr Patients Hw much is t be taken (dse)? Sme peple think that if they take mre tablets tgether, they will get better mre quickly. This culd be very dangerus. Yu must clearly explain exactly the amunt that the patient shuld take. Hw ften shuld it be taken (frequency)? It is imprtant t explain hw many times a day the dse shuld be taken and hw many hurs apart they shuld be taken. The dse taken shuld be spread evenly thrughut the day. Fr example, tw capsules t be taken every six hurs instead f tw capsules fur times a day (r 2 4). 55

62 Participant Manual AMS Dispensers Fr hw lng shuld it be take (duratin)? Sme patients nly take their medicines until they feel better. It might nt be serius if the treatment was fr a minr prblem, such as headache. Hwever, if the drug was fr treatment f high bld pressure r an infectin, such as bldy diarrhea, and the patient stps taking the drugs, he/she culd becme seriusly ill r the micrrganism might becme resistant t the drug. Always tell the patient hw many days r weeks he/she shuld take the medicines, and stress the imprtance f cmpleting the full curse f treatment. Why are they taking the drug (indicatin)? If the patient is tld the cnditin fr which the medicine has been given, they will be mre mtivated t take the medicine as they have been instructed. If a patient desn t knw why he/she has been tld t take a particular medicine, they are unlikely t take it crrectly r t finish the whle curse f treatment. While infrming the patient why she/he shuld take the medicines, bear in mind the need fr privacy. It will be embarrassing if a very private prblem is annunced penly t the rest f the patients in the cunseling rm. What ther infrmatin des the patient need t knw? Sme medicines wrk best if they are taken n an empty stmach, fr example, amxicillin taken at least half an hur befre meals is better absrbed. Antacids, e.g., magnesium trisilicate, wrk best if taken ne r tw hurs befre meals. Irn and aspirin tablets may cause gastric irritatin and shuld be taken with fd. Dxycycline shuld nt be taken tgether with antacids and irn tablets because they decrease dxycycline s effectiveness. Antacids and irn tablets shuld be taken after r during meals. Drugs with Alchl Alchl interacts with a number f drugs, s patients must be advised accrdingly. Fr example, alchl shuld nt be taken with metrnidazle, paracetaml, antihistamines, etc. Side Effects f Drugs The patient must be tld r warned abut the side effects f the drugs given. Fr example, antihistamines (e.g., chlrpheniramine) may cause drwsiness and patients shuld nt drive r perate machinery. Oral Cntraceptives When taken with ral cntraceptives, sme drugs, such as antibitics, render the ral cntraceptives less effective, and the patient may get pregnant. Always ask yur female patients if they are n ral cntraceptives and advise them accrdingly. 56

63 Mdule 1 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) Drug Strage by Patient Advise patients t keep their drugs ut f the reach f children. Sme brightly clred drugs are very attractive t children. Recnstitutin/Disslving Dry Pwders Hw t Recnstitute Dry Pwders Mst antibitics and antibacterial preparatins, such as amxicillin syrup, are supplied in bttles as dry pwders because they are nt stable in liquid frm. A specified amunt f purified water must be added immediately befre it is dispensed t the patient. The amunt t be added is usually indicated n the bttle r label. Sme manufacturers mark their bttles with the final level f the recnstituted vlume. The fllwing is the prcedure fr crrect recnstitutin f pwders: Disperse the dry pwder by first shaking it. This breaks up any pwder lumps in the bttle that wuld be difficult t disperse if water was added withut this step. If the vlume t be added is given n the label, measure that amunt; if nly a final vlume mark is given n the bttle, yu need nt measure any liquid. Nw add the water in small vlumes, shaking the bttle each time a prtin f water is added. D s until the pwder is hmgeneusly dispersed in the water. Finally, add the remaining water up t the final vlume pint r t finish the given vlume f liquid that yu were instructed t measure. The reasns water shuld be added in small prtins are: Dispersin f pwder is nt easy because a lt f gas is trapped in the bttle. If there is a lt f gas in the clsed bttle, it may even blw up during shaking. When nly the final marked vlume pint is given, adding water up t that level all at nce will result in excess water, thus diluting the syrup. Hw t Disslve Pwders In the treatment f diarrhea, ORS is frequently used. ORS is usually supplied in pre-packed sachets that cntain a mixture f salts and sugar, sufficient t make half r ne liter f ORS. When such sachets are dispensed t patients fr use at hme, give the fllwing instructins t ensure prper preparatin: Measure half r ne liter f clean, biled, and cled ptable water in a clean cntainer r pt. Tell yur patients that the vlume f ne tumpec mug r ne Nile special beer bttle equals half a liter r 500 ml. 57

64 Participant Manual AMS Dispensers Add the cntents f ne sachet int the water, stir until the liquid is clear and withut visible pwder particles. The pwder is nw disslved. Please nte that ORS slutins shuld be used within 24 hurs. If any f it remains, it shuld be discarded because lder slutins may have bacterial grwth due t presence f sugar. Prepare larger amunts f ORS nly if yu are sure that it will be used within 24 hurs. Diluting Hydrgen Perxide There are sme cncentrated liquid preparatins that may have t be diluted befre dispensing (cmmn fr antiseptics and disinfectants). Fr example, hydrgen perxide is ften diluted with purified water befre use as a disinfectant r antiseptic. The fllwing are the dilutin instructins fr hydrgen perxide. First Aid T arrest bleeding and disinfect wunds, dilute 1 part hydrgen perxide with 3 parts purified water; apply using a piece f cttn wl n the affected area T Remve a Dirty Dressing Dilute 1 part hydrgen perxide with 3 parts purified water; sak the dressing with the diluted slutin and leave it fr sme minutes befre remving the dressing Muth Wash and Dedrant Dilute ne tablespn t ne glass f water and gargle Recrd Keeping and Dcumentatin Medicine utlets are required t keep all invices and receipts fr nn-prescriptin and permitted prescriptin drugs fr at least tw years. This is imprtant because if dcumentatin is required fr a certain purpse, it can be easily retrieved. The shp shuld maintain a ledger f receipt and issue/dispensatin fr all permitted prescriptin drugs. The ledger shuld include: Date received and dispensed Name f patient, drug, and quantities dispensed Balance remaining This imprtant recrd will enable the medicine utlet t: Mnitr and establish prescriptin recrds f every permitted prescriptin drug and thereby avid stck-uts. 58

65 Mdule 1 Sessin 4. Apprpriate Medicines Use (Ratinal Drug Use) Identify patients that have been prescribed suspect medicatins, if adverse drug reactins ccur. Assist LMHRA inspectrs when cnducting their supervisin duties. Furthermre, the medicine utlet is required t keep and maintain a special file fr all crrespndences related t medicine directives and services frm regulatry authrities. 59

66 Sessin 5. Management Supprt and Quality f Medicines Objectives 1) Explain the basics f quality in medicines management 2) Explain causes f pr medicines quality 3) Recgnize signs f pr/bad quality medicines 4) Understand imprtance f maintaining medicines quality and stability 5) Discuss and internalize gd medicine strage practices 6) Discuss steps and prcedures fr quality assurance in a medicine utlet 7) Able t track drug expiries and damages Time hurs Management Supprt Efficient medicine management requires cmmitment f financial and human resurces t ensure that systems run smthly. Adequate funds shuld be available t ensure that medicines are prcured in apprpriate quantities and that quality systems are put in place and maintained. Adequately trained persnnel shuld be recruited and mtivated t manage the system and t effectively perfrm their tasks. Dcumentatin f activities, cllectin f relevant data, and generatin f reprts helps mnitr system perfrmance. Persnnel shuld be prvided with jb aids r standard perating prcedures (SOPs) fr perfrming critical activities in medicine management. Regulatin and Plicy Framewrk The regulatry framewrk under which medicines are sld has been discussed in previus mdules. It is, hwever, imprtant t emphasize that in regard t efficiency, regulatins and guidelines must be adhered t as tasks in the medicine management system are being perfrmed. Quality The supply f medicines f quality is a prerequisite fr effective delivery f health care. Withut assurance that medicines meet acceptable standards f quality, safety, and efficacy, health services will be cmprmised. It is critical that reliable systems are put in place t ensure that patients receive quality medicines. Drugs f pr quality nt nly have health cnsequences but als ecnmic cnsequences as mney is wasted in purchasing such prducts. At the same time, patients using pr-quality medicines will remain ill fr a lnger perid, delaying their engagement in prductive ecnmic activities, such as wrk. It is everybdy s rle, including the user, t ensure that medicines maintain their quality thrughut their shelf life r until they are used. 60

67 Mdule 1 Sessin 5. Management Supprt and Quality f Medicines The quality f medicines must be mnitred thrughut the life cycle f the medicine frm prduct develpment and manufacture thrugh transprtatin, distributin, and strage t dispensing and use f the medicine. A cnsiderable degree f care shuld be bserved at each stage as medicines mve thrugh their life cycle such that medicines made available t the public meet all quality requirements. Manufacturing As part f quality assurance, LMHRA must grant permissin, r manufacturing authrizatin, t whever intends t manufacture medicines in Liberia. This ensures that the medicines are manufactured: In apprpriate premises that meet standards stipulated by LMHRA By persnnel cmpetent fr the task f manufacturing By using machinery apprpriate fr the specific medicine Fllwing Gd Manufacturing Practices (GMP) The LMHRA regularly inspects medicine manufacturing plants t ensure cmpliance t the set standards. Distributin and Sale f Medicines Quality assurance during distributin and sale f medicines ensures that medicines d nt lse their quality and efficacy befre they reach the final cnsumer. T ensure this LMHRA perfrms the fllwing tasks. Registratin f Drugs Drug registratin ensures that all medicines sld n the Liberian market meet the required standards. Registratin starts with a thrugh inspectin f the manufacturing cmpany by the LMHRA. Once Liberia is satisfied that the cmpany meets all GMP requirements fr the manufacture f the particular medicine and after testing the prduct in its labratries, LMHRA will then add the medicine t its register. AMSs shuld: Sell nly medicines registered by LMHRA Buy medicines nly frm authrized surces (i.e., registered pharmacy whlesalers) Frm time t time, LMHRA inspects medicine utlets t ascertain that all the medicines sld are registered. It is an ffence if an utlet is fund with unregistered medicines. 61

68 Participant Manual AMS Dispensers Pssible Causes f Pr Drug Quality Pr Manufacturing Cnditins If medicines are nt manufactured accrding t GMPs, they are mst likely t be f pr quality. Manufacturers that have nt been inspected r nt apprved by the NDA are likely nt meeting all GMP requirements. Many cunterfeit medicines are manufactured under pr manufacturing cnditins. Cunterfeits are medicines that lk like registered medicines, but d nt cntain the right ingredients. AMSs shuld avid buying medicines frm unauthrized dealers t minimize the risk f buying cunterfeits. Pr Packaging Packing f drugs is imprtant at all levels. Althugh medicines are may be crrectly packed at the factry, medicines may be incrrectly packed when being sld t patients. Medicines inapprpriately packed may easily spil and lse their ptency. T avid this, medicines shuld be supplied in their riginal pack; if this is nt pssible, gd quality plastic bags shuld be used. Paper bags may be used, but are nt preferred. Ideally, AMSs shuld try t buy medicines that are packed in strips r blisters. Large cntainers f lse tablets are better suited fr hspitals. Pr Transprtatin and Strage Cnditins Apprpriate strage and transprt facilities must be available t prevent degradatin f the prduct by expsure t excessive misture, heat, r light during transprtatin r strage. AMS wners and sellers shuld be aware that medicines are sensitive and easily destryed Pr Knwledge f Persnnel Medicine utlet wners and sellers shuld be apprpriately trained in handling medicines. This prgram is intended t prvide that basic knwledge and understanding t all wners and sellers and t establish a cntinuing educatin system fr them t imprve the quality f bth medicines and services. Hw t Prevent Pr-Quality Drugs Preventing pr-quality drugs frm entering the market is the respnsibility f the NDA and everyne engaged in manufacturing, distributin, and prvisin f pharmaceutical services. Hw Can a Medicine Outlet Prevent Pr-Quality Medicines frm Reaching Patients? Adhering t laws, regulatins, plicies, and guidelines is the mst imprtant way t prevent pr-quality medicines frm reaching the market. It is imprtant as medicine sellers that we cmply with the regulatry framewrk discussed previusly. The fllwing guidelines shuld be fllwed: 62

69 Mdule 1 Sessin 5. Management Supprt and Quality f Medicines 1) Make sure the building where medicines are sld des nt allw expsure t misture, excessive heat and light, and vermin 2) Crss-check all new cnsignments f medicines fr any physical changes in the medicines 3) Rutinely crss-check medicines fr quality 4) Regularly clean the medicine utlet 5) Maintain neat and clean shelves; d nt keep medicines n the flr 6) Recrd all transactins t help track the surce f pr-quality medicines 7) Make sure medicines are adequately packed when dispensed t patients 8) Give patients infrmatin n hw t keep medicines at hme 9) Remve all expired and damaged medicines frm stck and cntact NDA fr their prper dispsal Sme Signs f Pr Drug Quality Medicines have particular prperties r characteristics such as clr, smell, viscsity, clearness, and shape. These are imprtant indicatrs f medicine quality that can be nted thrugh physical and visual examinatin. Sme attributes t lk fr include: Brken r ripped packaging Missing, incmplete, r unreadable labels Tablets r capsules that are/have: Disclred Sticky Crushed r crumbled An unusual smell Liquids that are/have: Disclred Sediment Cludy An unusual smell A brken seal n the bttle Cracks n the bttles Damp packaging 63

70 Participant Manual AMS Dispensers An expiry date must be indicated n the cntainer. This shuld nt be altered. Nne f the medicines n the shelves shuld have reached their expiry dates. Smetimes the physical characteristics f a prduct may change befre reaching the expiry date. Such medicines are nt fit fr human cnsumptin and shuld be remved frm stck. Keep all expired and damaged medicines separate frm medicines fr sale, preferably in a sealed bx. Infrm the nearest NDA inspectr and request infrmatin abut prper dispsal. Keep a recrd f all expired medicines. The fllwing shuld be recrded: Name f the medicine Dsage frm and strength Quantity Batch number Expiry date Jb Aids and SOPs Jb aids are devices r tls such as SOPs, instructin cards, wall charts, etc., that allw an individual t quickly access infrmatin needed t perfrm a particular task. An SOP is a set f written instructins that dcument a rutine r repetitive activity that an rganizatin fllws. SOPs give a step-by-step prcedure n hw t perfrm a particular task. Why SOPs? T prvide cnsistent quality; all prcesses undertaken during the prvisin f pharmaceutical services shuld be cnducted in a unifrm manner irrespective f when and wh is perfrming them T prvide predictable quality; whenever the prcesses are undertaken, the utcmes are expected and crrect T facilitate cmpliance with regulatins T facilitate n-the-jb training and rientatin f new emplyees Benefits f SOPs The fllwing benefits will accrue if SOPs are cnsistently and accurately used: Minimizatin f variatin and errrs Prmtin f quality services and medicines Prmtin f cmpliance t regulatins Reductin f wrk effrt Maximum efficiency and effectiveness frm the emplyees 64

71 Mdule 1 Sessin 5. Management Supprt and Quality f Medicines Easy delegatin f wrk and shift tasks List f SOPs Needed Receiving medicines String medicines Dispensing medicines Cunseling patients Physical cunting Cleaning and maintaining the utlet 65

72 MODULE 2: BASIC PRINCIPLES OF PATIENT MANAGEMENT Sessin 1. Intrductin t Patient Management Sessin 2. First Aid Sessin 3. Intrductin t Management f Fever, Pain and inflammatin Sessin 4. Management f Malaria Sessin 5. Management f Upper Respiratry Tract Infectins Sessin 6. Gastrintestinal Cnditins Sessin 7. Management f Anemia and Nutritinal Deficiencies Sessin 8. Management f Dermatlgical Cnditins Sessin 9. Management f Eye, Ear, Nse, and Thrat Infectins and Disrders 66

73 Sessin 1. Intrductin t Patient Management Objectives 1) Understand principles f patient assessment 2) Define health, disease, and sme pharmaceutical terminlgies used in patient management 3) Identify the different dsage frms and rutes f administratin 4) Recgnize cmmn drug reactins 5) Identify patients fr immediate referral r therwise 6) Understand the ethical issues surrunding patient management 7) Discuss the necessity and extent f treatment educatin Time 2 hurs Activity 1. Discussin There are a number f cultural beliefs abut the causes f diseases in Liberia. Mentin the varius ways that ur cultures perceive certain diseases and their causes. List factrs that an AMS shuld cnsider befre dispensing medicines. Give the ages in mnths/years fr the fllwing categries f patients: Nenate Infant Child Adults Elderly persn Activity 2. Rle Play a Patient Assessment In yur grups, perfrm a rle play n patient assessment; practice gd cmmunicatin skills between the patient and prescriber Patient 1 - uncmplicated malaria Patient 2 - malaria in pregnancy Patient 3 - child with bldy diarrhea Patient 4-17-year-ld by with a sexually transmitted disease As ne grup perfrms, the ther members listen and make ntes fr discussin in the plenary 67

74 Participant Manual AMS Dispensers Patient Assessment Patient assessment is the prcess thrugh which the health wrker btains infrmatin related t the patient, either frm the patient themselves, family members, care givers, r ther surces, and evaluates the infrmatin fr the purpse f deciding hw t manage the patient s prblem. It is very imprtant that the medicine seller assesses the patient s health, past medicatin histry, and scial issues and beliefs abut that cnditin. This prvides an pprtunity fr the medicine seller t adequately understand the patient s prblem. The fllwing infrmatin may be needed during patient assessment: Cmplaints/symptms frm the patient in his r her wn wrds Recent histry that pertains t thse symptms Past medical histry Medicatin histry, including cmpliance and adverse effects Allergies Scial and family histry, etc. The fllwing skills and attributes shuld be used during patient assessment: Listen actively Display empathy Be nn-judgmental Be kind If pssible, speak in a language the patient understands Cmmunicatin Medicine sellers need t be aware f the way peple in a particular lcality express their feelings, bth verbally and with bdy language. This imprtant as it will help bth the medicine seller and the patient understand each ther better. Steps t be Fllwed during Patient Assessment 1) Receive the patient curteusly and respectfully. This creates a fundatin fr an hnest and pen interactin between medicine seller and patient. 2) Take a histry abut the patient s cnditin. Ask the fllwing in this rder: What is the patient s main cmplaint/illness Hw lng has the patient had the illness r felt this way Has any treatment been received fr this cnditin; if medicines have been given, ask hw they were taken/swallwed Ask the patient abut any histry f drug allergies Depending n the cnditin, establish the family and scial histry 68

75 Mdule 2 Sessin 1. Intrductin t Patient Management Obtain ther useful infrmatin related t specific cnditins, fr example, use f msquit nets fr malaria patients, general sanitatin and hygiene fr diarrheal diseases, etc. The infrmatin btained frm the patient shuld be kept cnfidential t maintain trust and a gd relatinship. 3) Evaluate the acquired infrmatin and decide what t d fr the patient; treat the patient, give initial treatment and refer, r refer the patient right away 4) Explain t the patient abut their cnditin and the actin taken. If yu are treating the patient, educate the patient abut the treatment given. Factrs that Impact Patient Assessment Health Beliefs and Practices Patients usually cme fr health care with predetermined beliefs and preferences, which are influenced by their culture. Patterns f shared meanings, beliefs, and behavirs are learned and acquired by a grup f peple during the curse f histry. Culture reflects the whle human behavir including values, attitudes, and ways f relating t and cmmunicating with each ther. It als encmpasses an individual s cncepts f self, universe, time, and space as well as health, disease, and illness. Medicine sellers must keep in mind that patients will have varius views f health, illness, disease, and cure that are shaped by their particular culture and beliefs. One imprtant aspect that medicine sellers must keep in mind is what the patient believes causes disease and illness. Family Relatinships The family is the basic scial unit fr mst peple. Because the family is an integral part f mst peple s lives, it affects hw they view and, ultimately, hw they utilize health care services. When attending t patients, try t understand hw the family can help him r her t make recvery quick. Fr example, in many cases, patients may require bed rest r a special diet that the family must prvide. Administratin f Medicine Fr medicines t prduce the desired effects, they must be delivered t the site where actin is needed. It is imprtant t knw hw medicines wrk t prduce the desired effects. The medicine must be administered t the patient thrugh the apprpriate rute s that it will be absrbed int the bdy, distributed thrugh the bdy t reach the site f actin, metablized (brken dwn) by the bdy, and finally eliminated frm the bdy. 69

76 Participant Manual AMS Dispensers Factrs t Cnsider When Administering Medicines Befre administering medicine t the patient, take nte f the fllwing: Age Weight Time f administratin Frmulatin (pharmaceutical factrs) Rute f administratin Special cnditins f administratin, e.g., presence r absence f fd in the stmach Other factrs that need t be cnsidered include: Genetics f the patient, e.g., family histry f allergy Bilgical factrs, e.g., sex Rutes f Administratin There are several rutes by which the drugs reach the site f actin. Oral Rute By muth is the safest and mst cnvenient rute by which drugs are taken. Advantages Cnvenience Acceptability If the gastrintestinal (GI) tract is being treated, the drug is being placed at the site f actin Quick, e.g., sublingual, buccal Easy and uncmplicated, des nt need technical supervisin Disadvantages Gastric irritatin Erratic absrptin, depends n the status f the GI tract (with r withut fd, age, etc.) Destructin f drug in the GI tract befre absrptin Nt all drugs can be taken by muth Parenteral Rute This refers t administering medicine by injectin. The medicines, needles, and syringes shuld all be sterile. Als, the envirnment shuld be apprpriate. Advantages Rapid absrptin 70

77 Mdule 2 Sessin 1. Intrductin t Patient Management Useful in emergencies, when the patient is vmiting r uncnscius Preferred when the medical cnditin is severe and a fast therapeutic effect is needed t save life The medicine can be injected sub-cntinuusly (s.c.; under the skin), intramuscular (I.M.; int the muscle), intravenus (I.V.; in the vein), and ther rutes. Disadvantages (I.M. and I.V.) Rute is nt easy, needs technical expert t administer Painful If nt prperly dne, may cause serius damage t tissues r even paralysis Nt acceptable by children and sme adults High risk f infectin Rectal Rute Sme drugs are inserted int the rectum t fr either a systemic r lcal effect. Drugs usually used fr rectum insertin are in the frm f suppsitries r special slutins. Advantages Useful fr drugs that irritate the stmach, fr example, diclfenac, indmethacin Suitable fr vmiting patients, mtin sickness (travel sickness) Suitable fr patients wh have difficulty swallwing, are uncnscius, r are cnvulsing (e.g., use f rectal diazepam in a cnvulsing patient) Suitable fr patients that may nt be cperative (e.g., the mentally ill) Disadvantages Ptentially embarrassing t the patient Rectal inflammatin may ccur if the patient uses this rute very ften Absrptin can be unreliable, especially if rectum is full f feces Incrrect insertin may lead t pr absrptin Tpical Applicatin Medicines are applied directly t the skin, eyes, r ear t get either tpical r systemic effect. Yu shuld always take care that medicines that are meant fr tpical treatment are nt applied t pen wunds because it may be absrbed internally and cause serius prblems. Medicines cntaining sterid prducts fr tpical applicatin may be absrbed, especially when used n children. Advantages Prvides high, lcal cncentratin Easy t apply, self-treatment 71

78 Participant Manual AMS Dispensers Disadvantages Skin irritatin Drugs fr tpical use nly may be absrbed Uncertainty f absrptin fr drugs meant t prduce systemic effect Inhalatin Inhalatin is taking a drug thrugh the respiratry system by breathing in. This rute is very effective and fast. It is mstly used t effectively cntrl asthmatic attacks r ther serius prblems that need immediate interventin. Drugs administered primarily thrugh this methd are brnchdilatrs, such as Salbutaml, althugh ther drugs may be administered this way as well. Cmmn Definitins Dsage The ttal amunt f medicine given t a patient ver a perid f time t treat a particular cnditin Dse The amunt f medicine administered (swallwed, injected, applied n the skin, etc.) t a patient at a time Frmulatin Refers t hw the medicine is presented by the manufacturer fr use, e.g., tablet, capsule, intment, syrup, etc. Maximum dse The largest amunt f a medicine that can be given withut causing txic side effects Minimum dse The smallest amunt f medicine given that prduces the desired effect Side effects These are the effects f a medicine ther than thse that are intended. N drug is entirely free frm undesirable side effects. That is why it is imprtant make sure that the patient is taking the right dse and t ask that the patient immediately reprt any undesirable side effects. Undesirable side effects may influence hw the patient takes their medicines and therefre affect the treatment utcme. Therapeutic dse A dse between the minimum and the maximum dses that prduces the desired effect withut txic effects 72

79 Mdule 2 Sessin 1. Intrductin t Patient Management Txic dse An amunt f a given medicine that causes serius unwanted effects Sme Cmmn Side Effects f Medicines Abdminal Discmfrt Medicines that are taken rally usually cause stmach prblems that may be characterized by abdminal pain, feeling f a full stmach, diarrhea, nausea, and vmiting, amng thers. Medicines such as pain killers (diclfenac, Brufen, aspirin) and antibitics (erythrmycin) cmmnly cause abdminal discmfrt. Allergic Reactins t Drugs Allergy is an undesirable reactin specific fr sme drugs and sme individuals. Fr example, penicillin frmulatins (amxicillin, benzyl penicillin, Pen V) and sulfnamide frmulatins (ctrimxazle/septrin, sulfadxine-pyrimethamine (SP)/Fansidar) cmmnly cause very serius allergic reactins in sme individuals. Hwever, mst peple d nt get such reactins after taking these medicines. The first signs f such a reactin include; itching, skin rash/eruptin and if the medicine was taken rally swelling arund the muth. Anaphylaxis (Acute Hypersensitivity) Anaphylaxis is a life-threatening clinical respnse that appears within minutes after administratin f a medicine. Cmmn examples f medicines that cause anaphylaxis are penicillins, sulfnamides, vaccines, and bld prducts. Anaphylaxis is ne frm f very severe allergic reactin that may be caused by medicines, hwever, there may be ther causes, such as insect stings. Befre dispensing penicillin r sulfnamide frmulatins, it is very imprtant t ask the patient if he/she has ever had any reactin after using these medicines. Drwsiness Certain antihistamines may make patients feel sleepy and unable t remain alert. Examples f such medicines include chlrpheniramine and prmethazine. Many f the medicines used fr treatment f clds and allergies cntain antihistamines and therefre may cause drwsiness. Hwever, smetimes such medicines may be used t induce sleep. In such a case, drwsiness is nt a side effect, but the intended therapeutic effect. Other Cmmn Side Effects Other cmmn side effects include headache and phtsensitivity. 73

80 Sessin 2. First Aid Objectives 1) Understand the basic principles f first aid 2) Identify minr injuries and cmmn pisning 3) Be able t prvide first aid fr minr injuries and cmmn pisning Time hurs Activity 1 1. What des first aid mean? 2. Why may an AMS need first aid skills? 3. List emergency situatins in yur cmmunity that may require first aid. 4. What d yu d when faced with such emergencies? Objectives f First Aid 1. T preserve life 2. T prevent the illness r injury frm becming wrse 3. T prmte recvery Definitins Casualty The persn wh is injured r ill Emergency situatin A serius health situatin r ccurrence that happens unexpectedly and demands immediate medical actin First aid Emergency help given t an injured r suddenly ill persn using readily available materials First aider Anyne wh takes charge f an emergency situatin and gives first aid; a first aider als cmfrts (reassures) the casualty, family, and friends and ensures that the emergency scene is cleaned up and unsafe cnditins that may have caused the injury are crrected. 74

81 Mdule 2 Sessin 2. First Aid First aid and the law There are tw legal situatins under which ne can give first aid: Giving first aid as part f yur jb, e.g., health wrkers, a persn trained as a first aider, plice, fire brigade, Red Crss wrkers, etc. Yu have a legal duty t respnd t an emergency situatin at yur wrk place Yu have a duty t use reasnable skill and care based n yur level f training Giving first aid as a passer-by wh sees an emergency situatin and wishes t help an injured r ill persn. Yu shuld use reasnable skill and care based n yur level f training. Gd Samaritan A Gd Samaritan is a persn wh helps a persn in need when they have n legal duty t d s. Safety and first aid Giving first aid safely is the number ne rule. The first aider must ensure that his/her actins dn t put him/her r anyne else in danger. This necessitates that yu take time t lk fr any danger and assess the risks f the actins yu take. Preventing infectin: the first aider and casualty are always in clse cntact, thus infectin can pass frm ne persn t the ther. The first aider shuld be cautius f diseases caused by viruses and bacteria. These can be spread thrugh bld r in the air thrugh cughing r sneezing, e.g., TB, HIV, AIDS, and hepatitis B. Always use universal precautins t apply first aid t minimize the risk f transmissin f infectin. These include: Glves: use glves t prevent direct hand cntact between yu and the casualty, especially if yu might tuch bld, bdy fluids, pen wunds, r sres. Face masks r shields: use a face mask r shield when ding cardipulmnary resuscitatin (CPR). Fllw manufacturer s instructins n their use, care, and dispsal. Face masks shuld be used if yu suspect the patient has an airbrne cnditin, such as TB, cmmn cld, etc. Hand washing: wash hands with sap and running water immediately after any cntact with a casualty Steps in Incident Management 75

82 Participant Manual AMS Dispensers 1) Lk fr dangers t yurself then t the casualty. 2) Assess the situatin. 3) Find ut what happened and take precautins t avid a similar ccurrence. 4) If yu are at the incident scene, make the situatin safe by remving r reducing the cause. If the casualty has been brught t the medicines utlet, advise caretakers n hw t remve r reduce danger. 5) Assess casualties and decide n what actin t take as sn as pssible. 6) Give initial treatment; if the patient requires further attentin, refer t ther health facility r call in specialized assistance if the patient can t be mved. 7) After the incident, tidy up the treatment site and restck the first aid kit. Casualty Management and Initial Assessment 1) Actins Check fr dangers t yurself and the casualty Remve the dangers safely r mve the casualty if the danger cannt be remved 2) Respnse Check t see if the casualty is cnscius Ask questins, such as, are yu alright? Give a cmmand, such as, pen yur eyes Give a gentle shake 3) Airway Quickly check fr any bvius bstructin; the tngue may slip back and blck the airway Open the airway by lifting the chin while carefully tilting the head back 4) Breathing Check fr breathing by pening the airway and placing yur cheek just abve the casualty s muth and nse Lk at the chest and watch fr mvement Listen fr breathing Feel fr breath against yur cheek Check fr 10 secnds 76

83 Mdule 2 Sessin 2. First Aid 6) Decide what actin must be taken Send fr help if there is smebdy with yu If the casualty is uncnscius and breathing, put them in the recvery psitin immediately (teacher shuld demnstrate) If the casualty is uncnscius and nt breathing, start resuscitatin immediately (teacher shuld demnstrate) 7) Circulatin There are tw ways in which circulatin affects the way xygen mves arund the bdy: The heart may stp. Check fr the heartbeat by taking the pulse in the neck (cartid pulse) fr 10 secnds T find the pulse, place tw fingers in the grve between the vice bx and the large muscle in the neck and press dwn gently There may be bleeding. 8) The initial assessment and pririties can be remembered by the letters DRABC Danger Respnse Airway Breathing Circulatin Cnsider yur actins immediately. First Aid fr Sme Cmmn Cnditins Chking Signs Difficulty breathing r speaking Grasping at the neck Pinting at the muth and thrat Purple/red clr arund the face and neck Blueness t lips Aim: t remve bstructin and allw the casualty t breathe nrmally Actins 77

84 Participant Manual AMS Dispensers 1) First step backslaps Reassure the casualty Bend casualty frward with head lwer than the chest Encurage him/her t cugh Slap between the shulder blades up t 5 times (the frce f the slap shuld be mderate and nt cause further injury) See if yu can remve the bstructin 2) Secnd step abdminal thrusts; if backslaps are unsuccessful, try up t 5 abdminal thrusts Stand behind casualty Link yur hands belw the their rib cage Pull sharply, inwards and upwards If nt successful, call fr help Keep repeating the cycle f backslaps and abdminal thrusts until airway is clear r help arrives Fainting Signs Cllapse and lss f cnsciusness Pale r grey, cld, clammy skin Slw pulse, increases as casualty recvers Aim: imprve the bld supply t the brain and reassure the casualty Actins 1) Assess DRABC and treat any pririty cnditins 2) Lay the casualty dwn and gently raise and supprt the legs 3) Prvide a surce f fresh air if pssible 4) Reassure the casualty and keep nlkers away 5) When casualty recvers, sit him/her up slwly; if they feel faint again, lay them dwn 6) If the casualty des nt regain cnsciusness quickly, reassess DRABC, place in recvery psitin, and call fr medical help Shck Signs Pale r grey, cld, clammy skin Rapid pulse, becming weaker Fast, shallw breathing Feeling weak and dizzy Feeling sick, may vmit Feeling thirsty 78

85 Mdule 2 Sessin 2. First Aid Restless and anxius, may be aggressive Yawning r gasping fr air Level f cnsciusness will get lwer and may becme uncnscius Breathing may fail and the heart may stp Aims T treat any bvius cause Increase bld supply t the brain, heart, and lungs Get urgent medical help Actins 1) Assess DRABC and treat pririties 2) Lay casualty dwn, raise the legs gently 3) Keep casualty still and quiet, reassure 4) Lsen tight clthing arund the neck, chest, and waist 5) Keep warm 6) Call fr medical help 7) Keep checking breathing, pulse, and level f cnsciusness; may have t resuscitate and put in recvery psitin 8) Make ntes fr ambulance crew n yur findings and actins 9) DO NOT DO THE FOLLOWING D nt mve the casualty unless it is t escape frm danger D nt apply direct heat D nt leave the casualty alne D nt allw the casualty t eat, drink, r smke Wunds and Bleeding Aims Cntrl bld lss Treat fr shck Prevent infectin, e.g., tetanus Arrange fr transprt t nearest health facility Minr bleeding (small cut): 1) Encurage the wund t bleed fr a few minutes 2) Apply direct pressure fr 10 minutes 3) If dirty, clean it with an antiseptic, e.g., surgical spirit, hydrgen perxide, etc., and gently dry the area 4) Cver with sterile dressing (plaster r clean dressing) 5) Refer fr further medical attentin 79

86 Participant Manual AMS Dispensers Majr bleeding 1) Carefully expse the wund 2) Apply direct pressure t the wund 3) If there is an embedded bject, apply pressure arund the sides f the wund 4) Raise the limb 5) Lay casualty dwn 6) Use a clean pad r sterile dressing 7) Treat fr shck 8) Keep pressure n the wund fr ten minutes 9) When bleeding is cntrlled, apply a sterile dressing and bandage n tp f the riginal pad 10) If bld seeps thrugh the dressing, add anther dressing 11) Make a reprt and refer t the nearest health center with mre specialized facilities and health wrkers Nse Bleeds 1) Sit casualty dwn and ensure that their head is tipped frward 2) Instruct casualty t breathe thrugh their muth and t pinch the nse just belw the bridge fr 10 minutes 3) Instruct casualty nt t blw their nse r sniff 4) Release nse after 10 minutes; if still bleeding, pinch again fr 10 minutes 5) If nse bleed lasts ver 30 minutes, refer the casualty t a health center fr specialized care 6) Clean area with warm water nce bleeding has stpped 7) Advise casualty t rest fr a few hurs and avid blwing the nse r picking any clts Burns and Scalds Signs Superficial: redness, tenderness, and swelling Medium: redness, tenderness, swelling, and blistering Deep: pale and waxy, charred tissue Aims: stp the burning, relieve pain and swelling, and minimize risk f infectin Actins 1) DRABC 2) Fld injured area with cld running water r any harmless, cld fluid (d nt ver cl the casualty) 3) Gently remve any rings and watches that are arund the affected area 4) Lay casualty dwn and treat fr shck 5) Apply antiseptic cream (e.g., silver sulfadiazine) t the burn site and, where apprpriate, cver the area with a sterile dressing 6) Refer t a health center fr further management f mderate and severe burns 80

87 Mdule 2 Sessin 2. First Aid Fractures Fr fractures ther than fre and hind limb fractures, immediately refer the casualty fr specialized care. Only ffer advice t immbilize the pssible fracture site and give sme pain killers. Signs Recent fall r blw Sund f snapping frm the injury site Difficulty mving the limb Severe pain and tenderness ver the site f the injury Defrmity, swelling, r bruising Signs f shck, if injury is severe Aims Prevent mvement at the site f the injury Arrange transfer t medical aid while keeping the casualty cmfrtable Actins D an initial assessment Advise the casualty t keep still Treat any pririties frm the initial assessment If the injury is an upper limb, the casualty is prbably supprting the injured limb in a cmfrtable psitin If the injury is in a lwer limb, prvide supprt with yur hands abve and belw the injury Refer immediately fr further management Pisning Signs Burns r redness arund the muth and lips, frm drinking certain pisns Breath that smells like chemicals, such as gasline r paint thinner Burns, stains, and drs n the persn r their clthing r n furniture, the flr, rugs, r ther bjects in the surrunding area Empty medicatin bttles r scattered pills Vmiting, difficulty breathing, sleepiness, cnfusin, r ther unexpected signs Aims T maintain an pen airway, breathing, and circulatin Maintain r make safe an envirnment fr the casualty and yurself Obtain urgent medical aid Identify the pisn if pssible 81

88 Participant Manual AMS Dispensers Actins Inhaled pisns Remve casualty t pen air r pen windws If pssible, cut ff the surce f the pisn Make an initial assessment If casualty is breathing but uncnscius, place in recvery psitin and mnitr DRABC If casualty has stpped breathing, cmmence artificial ventilatin and chest cmpressins Refer fr further management in a health center Swallwed pisns Make initial assessment If casualty is uncnscius, put in recvery psitin and mnitr DRABC and be prepared t resuscitate If casualty is cnscius, place in recvery psitin and try t find ut what has been taken D nt induce vmiting If casualty has taken a crrsive pisn, give frequent sips f water r milk Use barrier t prtect yurself if resuscitatin is required Refer t mre specialized health center fr further management If casualty vmits, save a sample fr the medical team Identify cntainers that held pisn, if pssible, and give t medical team Skin cntact Make an initial assessment D nt tuch affected area with bare hands Wash away the pisn with large amunts f water; avid splashing nt yurself and int casualty s eyes, muth, r nse If chemical is causing burns, keep splashing with water fr at least 20 minutes D nt re-use same water Remve any clthing cntaminated by the pisn where pssible and if it is safe Try t preserve casualty s privacy, if pssible If casualty is uncnscius, place int recvery psitin and mnitr DRABC Be prepared t resuscitate; use barrier if face is cntaminated If n imprvement, refer t mre specialized health facility fr further management Injected pisns Make an initial assessment If casualty is uncnscius, put in recvery psitin and mnitr DRABC and be prepared t resuscitate Place in recvery psitin, even if casualty is cnscius; keep him/her calm and quiet and mnitr DRABC If pssible, identify injected syringes, needles, samples, r the substance itself 82

89 Mdule 2 Sessin 2. First Aid Refer t mre specialized health facility fr further management Animal Bites Aims: T cntrl bleeding, minimize risk f infectin t yurself and casualty, and btain medical attentin Actins 1) Make initial assessment 2) Flush superficial wunds with running water fr at least 5 minutes 3) Wash the wund with sap and water 4) When dry, cver with a sterile dressing 5) Advise casualty t seek further medical attentin and t check whether anti-tetanus and rabies injectins are required 6) Fr mre serius wunds, cntrl bleeding with direct pressure 7) Cver with sterile dressing and refer fr further medical attentin Insect Stings Aims: T relieve pain and btain medical aid, if required Actins Make initial assessment Carefully remve sting if visible; be careful nt t squeeze any pisn sac attached Apply cld cmpress t relieve pain and antihistamine creams t relive itching and swelling Advise casualty t seek further medical attentin if the pain and swelling dn t reduce in a day r s If sting ccurs in the muth, refer fr further medical attentin urgently, mnitr DRABC and reassure casualty while waiting If it is a swarm attack causing multiple stings, d nt apprach until it is safe Place casualty in the mst cmfrtable psitin Keep casualty quiet and reassure him/her Mnitr DRABC and be prepared t resuscitate Arrange urgent transfer t a specialized medical facility Snake Bites Aims: T reassure the casualty, prevent spread f the venm, get urgent medical aid Actins Little r lcalized swelling Wash the wund with sap and water if available Reassure casualty t reduce anxiety 83

90 Participant Manual AMS Dispensers Keep the casualty at rest, lying dwn with affected part level with his/her heart Get further medical attentin as sn as pssible If bite is n a limb, apply a pressure bandage t immbilize the area, apply a splint if necessary Severe lcalized swelling: refer immediately fr further medical attentin D NOT d the fllwing Cut the wund Apply suctin t the wund Use a turniquet r cnstricting bandage Apply r inject chemicals r medicines int the wund Use ice n the wund Nn-pisnus snake bites: treat the bite as any ther wund, hwever, casualty shuld be seen by medical aid If the casualty has any f the fllwing cnditins, refer immediately fr mre specialized care: heart attacks and angina, nn-breathing adult, adult with n heartbeat (needing CPR). 84

91 Sessin 3. Intrductin t Management f Fever, Pain and inflammatin Objectives 1) Understand fever and its causes 2) Appreciate the rle f the AMS in the management f fever 3) Recgnize fevers fr referral t a health facility Time 2 hurs What is Fever? Fever is a rise in the bdy s nrmal temperature. The average nrmal bdy temperature is 37 C. Fever is part f the bdy s defense mechanism. When ur bdies are fighting infectins, bdy temperature rises. Fever is the bdy s natural respnse t fighting germs. Fever may have several causes. If the cause f the fever is established, the patient shuld be apprpriately managed t eradicate the cause. Smetimes the cause f the fever may nt clearly manifest, making it difficult t establish the cause in the medicine utlet; in such a case, the patient must be referred fr further management. Hw t Determine Bdy Temperature Bdy temperature is usually measured in the armpit by a thermmeter being held there fr 5 t 8 minutes. Causes f Fever Bacterial infectins: tnsillitis, titis media, brnchitis, pneumnia, tetanus, urinary tract infectin (UTI), wunds, GI infectins Viral infectins: clds, flu, measles, mumps, chicken px, AIDS Medicatins Illicit drugs Heat illnesses In children 2 mnths t 5 years, the mst cmmn causes include malaria, measles, ear infectins, URTIs Signs and Symptms f Fever Signs and symptms f fever may be bvius r subtle; the yunger the child, the less bvius the symptms. 85

92 Participant Manual AMS Dispensers Infants Irritable Hard t please Tired Quiet Feels warm r ht Crying Rapid breathing Exhibits changes in sleeping r eating habits Elevated bdy temperature n the thermmeter Adults and Older Children Feels htter r clder than thers in the rm wh feel cmfrtable Bdy aches Headache Difficulty sleeping r sleeps mre Pr appetite Has shivers and chills when the fever is rising especially rapidly and sweats when the fever is drpping r breaking In Children 2 Mnths t 5 Years, Symptms Help Determine the Cause f Fever Fever by histry (feels ht r temperature 37.5 C r abve) indicates malaria Cludy crnea; deep, extensive muth ulcers; and pus draining frm eye r muth ulcers indicates measles Tender swelling behind the ear, pus draining frm the ear, and ear pain indicates an ear prblem Management The three gals f care fr a patient with fever are: Cntrl the temperature Prevent dehydratin, particularly if the patient is a child Mnitr fr serius r life-threatening illness The First Gal is t Cntrl Temperature Paracetaml/aspirin, diclfenac, and ibuprfen are used t reduce temperature. Fllw the dsage and frequency instructins printed n the label r refer t a credible reference r resurce. Remember t cntinue t give the medicatin ver at least 24 hurs r the fever will usually return. If fever persists, refer fr further management. 86

93 Mdule 2 Sessin 3. Intrductin t Management f Fever, Pain and inflammatin D nt use aspirin t treat fever in children, especially fr fever caused by chicken px. Aspirin has been linked t liver failure in sme children. Ibuprfen use is als questinable in patients with chickenpx. Use paracetaml in this case. When t Refer fr Further Medical Care Children and adult patients with fever shuld be referred under any f the circumstances listed belw. Child is yunger than 6 mnths f age since birth (regardless f prematurity) Fever cannt be cntrlled The child is r may becme dehydrated frm vmiting, diarrhea, r nt drinking (sunken eyes, dry diapers, tented skin, cannt be arused, etc.) Patient is getting wrse r new symptms have develped despite the treatment given Patient is having cnvulsins Child has a purple r red rash A change in cnsciusness ccurs r patient is hallucinating Child s breathing is shallw, rapid, r difficult Patient has cmplex medical prblems r takes prescriptin medicatins n a chrnic basis (medicatins rdered fr mre than tw weeks) Child with malaria has a stiff neck (indicates severe disease) Child has deep muth ulcers, a cludy crnea, r tender swelling behind the ears (indicates severe disease) Dsing Regimens fr Cmmnly Used Fever Medicines Paracetaml Presentatin 500 mg tablets 120 mg/5 ml syrup Indicatin Light t mderate pain Light t mderate fever Alternative t aspirin Dsages (fr Children and Adults) Children: ml every 8 hurs Adults: 500 mg 1000 mg every 6-8 hurs, maximum f 3 g/24 hurs Precautins Avid giving t patients with liver-kidney diseases 87

94 Participant Manual AMS Dispensers Avid giving t alchl addicts Side Effects Rare Vital Infrmatin fr the Patient Stre the drug away frm the reach f children If pain persists, g fr medical advice Ibuprfen Presentatin Tablets 200 mg and syrup 100 mg/5 ml Indicatins Pain and inflammatin in rheumatic disease, dysmenrrhea, fever, and pain in children Dsage (fr Adults and Children) Adults: mg every 6 t 8 hurs per day Children: 1-2 years, 2.5 ml every 6 t 8 hurs per day 3-7 years, 5 ml every 6 t 8 hurs per day 8-12 years, 10 ml every 6 t 8 hurs per day Precautins/Cntraindicatins Histry f GI diseases, hepatic and renal impairment, GI ulceratin r bleeding, histry f hypersensitivity t aspirin Side Effects GI discmfrt, nausea, diarrhea, ccasinal bleeding, and ulceratin Vital Infrmatin fr the Patient D nt use any ther nn-steridal anti-inflammatry drug (NSAID) while taking this drug; keep away frm children Diclfenac Presentatin Tablets 25 mg, 50 mg, 100 mg 88

95 Mdule 2 Sessin 3. Intrductin t Management f Fever, Pain and inflammatin Indicatins Severe pain and inflammatin in rheumatic disease, ther musculskeletal disrders, acute gut, and pstperative pain Dsage (fr Adults) Adults: 50 t 150 mg in 2-3 divided dses per day; ttal daily dse by any rute shuld nt exceed 150 mg Precautins See under previus NSAIDs abve. Side Effects As fr ther NSAIDs Vital Infrmatin t the Patient Take with fd r after meal with plenty f water Peple lder than 75 years are at mre risk f significant stmach prblems, such as ulcers, frm NSAIDs, especially if they have had previus ulcers. Elderly individuals als typically have higher risk factrs fr heart attack and strke. Supprtive Management fr Children with Fever The first gal is t lwer the fever. Advise the parent r guardian nt t verdress children indrs. Overdressing prevents the bdy frm cling. The mst practical slutin is t dress the child in a single layer f clthing, then cver the child with a sheet r light blanket. Advise the parent t give the child a spnge bath in warm water as this helps reduce the fever. Such a bath is usually nt needed but may mre quickly reduce the fever. Put the child in a few inches f warm water, and use a spnge r washclth t wet the skin f the bdy and arms and legs. The water itself des nt cl the child. The evapratin f the water ff the skin des, s d nt cver the child with wet twels, which wuld prevent evapratin. The secnd gal is t keep the child frm becming dehydrated. Humans lse extra water frm the skin and lungs during a fever. 89

96 Participant Manual AMS Dispensers Encurage the child t drink clear fluids such as juice r nn-carbnated drinks withut caffeine nt water. Water des nt cntain the necessary electrlytes and glucse. Other clear fluids such as ORS are available in medicine utlets. Tea shuld nt be given because it cntains caffeine, which increases urinary utput and may cntribute t dehydratin. Children shuld prduce light-clred urine at least every fur hurs if well hydrated. The third gal is t mnitr the child fr signs f serius r life-threatening illness. If bth the first and secnd gals are met and the patient still appears ill, a mre serius prblem may exist, and the patient shuld be referred fr mre specialized care. Preventin Preventin f illnesses that cause fever revlves arund persnal and husehld hygiene. Advise patients and their care takers t use these strategies t prevent the spread f viruses and bacteria: Wash yur hands with sap and water. Cver yur muth and nse when sneezing and cughing. Handle fd with clean hands. Prperly immunize yur child. Eat a healthy diet including fruits and vegetables. Get enugh sleep. What is Inflammatin? Inflammatin is a basic way in which the bdy reacts t infectin, irritatin, r ther injury. The key features f inflammatin are redness, warmth, swelling, and pain. What Is Pain? Pain is an unpleasant sensatin. Pain can be sharp r dull, burning r numbing, minr r majr, acute r chrnic. It can be a minr incnvenience r cmpletely disabling. Hw is Pain Diagnsed? There is n way t tell hw much pain a persn has. N test, device, r instrument can measure the intensity f pain. In mst cases, care prviders find that the best aid t diagnse pain is the patients wn descriptin f the type, duratin, and lcatin f pain, e.g. headache, backache, etc. Defining pain as sharp r dull, cnstant r intermittent, burning r aching may give the best clues as t the cause f pain. These descriptins are part f what is called the pain histry, taken by the health wrker during the assessment f a patient with pain. 90

97 Mdule 2 Sessin 3. Intrductin t Management f Fever, Pain and inflammatin Causes f Pain Arthritic cnditins characterized by jint pain in the legs and arms Back pain caused by nerve damage, degeneratin, and rupture f discs f the backbne Sprts injuries and ther trauma, such as sprains, strains, bruises, dislcatin, and fractures are always accmpanied by pain Burn pain is usually agnizing; smetimes healed patients have chrnic pain at the burn site Headaches that may be acute r chrnic; chrnic headaches include migraines, cluster, and tensin headaches arising frm stress r an underlying disease Muscle pain can range frm an aching muscle, spasm, r strain t severe spasticity that accmpanies paralysis Neurpathic pain results frm injury t nerves in any part f the bdy it is nrmally described as a ht, burning sensatin Hw are Pain and Inflammatin Treated? The gal f pain and inflammatin management is t imprve functin, enabling individuals t wrk, attend schl, r participate in ther day-t-day activities. And because the majr cncern f patients with pain and inflammatin is the pain assciated with the inflammatin, management fcuses mre n the pain. Patients and their care prviders have a number f ptins fr the treatment f pain and inflammatin; sme are mre effective than thers. Smetimes, relaxatin and nt thinking abut the pain r inflammatin may prvide relief. All pain medicatins relieve inflammatin. The effects f pain medicatin are different fr different peple. Als, the tlerance f pain varies greatly frm ne persn t anther. Fr this reasn, ne medicatin will nt be right fr everyne with the same injury. The right pain medicatin depends n the persn experiencing the pain, nt n the cnditin that is causing the pain. The fllwing medicines can be used in the management f pain: Paracetaml Ibuprfen Diclfenac Dsing Regimens fr Cmmnly Used Pain Relieving Medicines Medicines used in relieving pain are similar t thse used in management f fever. Refer t the sectin Dsing Regimens fr Cmmnly Used Fever Medicines n page 87 Supprtive Management Resting/sleeping is an adjunct t pain medicatin Exercise reduces stress which usually cntributes t pain Cunseling 91

98 Sessin 4. Management f Malaria Objectives 1) Understand the disease burden due t malaria in Liberia 2) Understand the causes, signs, and symptms f malaria in children and adults 3) Understand the Natinal Malaria Treatment Plicy fr uncmplicated malaria 4) Understand hw t prevent and cntrl malaria 5) T recgnize cmplicated/severe malaria, prvide apprpriate management, including referral Time 2.5 hurs Activity. Case Study: Malaria and Fever JK, a 5-year-ld by returned frm schl with a headache and felt warm t the tuch. Althugh he is usually quite a happy and active child, fr the past tw days, he has cmplained f feeling tired and he hasn t been hungry at meals. He was taken t a health center 2 where he infrmed the nurse that he had vmited nce and that his arms and legs are hurting. These symptms have wrsened as time has passed. JK s mther says that he desn t sleep under a msquit net and that he fears nurses because they administer painful injectins t yung children. He is the first-brn in a family f three. His 3-year-ld brther and 1-year-ld sister are fine back at hme. The health wrker cncludes that JK has uncmplicated malaria and suggests treatment fr him. Because sme f the medicines are nt available at the health center, JK s mther has t buy them frm a nearby AMS. While at the drug shp, she cmplains abut the ttal cst f the medicines and asks if it is kay t get a few dses tday and then cme back fr the rest later. Tasks 1) What signs and symptms des JK have that indicate the presence f malaria? 2) What are the pssible causes f JK s malaria? 3) What medicine alternatives are available fr treatment f uncmplicated malaria in this patient? 4) What infrmatin shuld be prvided t the patient/care taker t enhance adherence, ensure successful treatment, and minimize adverse effects? 5) What treatment, if any, wuld be apprpriate fr his brther and sister? 6) What advice d yu have fr JK s mther n hw t cntrl r prevent malaria? 7) Hw wuld yu slve JK s mther s dilemma n the ttal cst f medicines? 92

99 Mdule 2 Sessin 4. Management f Malaria Backgrund The public health gal f treatment is t reduce malaria transmissin t thers and prevent emergence and spread f drug resistance. Fr the individual, the gal is full and rapid recvery frm the malaria episde. In uncmplicated malaria, the bjective is t cure malaria and prevent prgressin t severe disease. The malaria cntrl plicy bjective is t ensure: Early diagnsis and prmpt, effective treatment f malaria That all malaria diagnses are supprted by parasitlgical diagnsis and, where feasible, rapid diagnstic tests (RDTs) Life Cycle f Malaria Malaria is an acute febrile illness caused by infectin with malaria parasites f the genus Plasmdium, the species being P. falciparum, P. vivax, P. vale, and P. malariae. Of these, P. falciparum is respnsible fr ver 95% f malaria episdes in Liberia and is the sle cause f severe malaria. Figure 6. Transmissin f malaria Hw is Malaria Diagnsed? Malaria presents with fever which is intermittent it cmes and ges many times. The bdy temperature may be nrmal during a clinical visit. A typical malaria attack has three phases: 93

100 Participant Manual AMS Dispensers The cld stage when the patient feels cld and shivers The ht stage when the patient feels ht The sweating stage, which is assciated with prfuse sweating and relief f symptms Fr prper treatment f malaria, it is imprtant t take a gd histry. Only then can the patient be adequately managed. Als check fr danger signs that require immediate actin. Checking fr danger signs is particularly imprtant in thse mst at risk f severe malaria children less than 5 years ld, nn-immune adults, and pregnant wmen. Ask the patient r caretaker and bserve fr the signs and symptms f malaria: What is the presenting cmplaint? Have there been r are there any danger signs nw? Lk fr signs and symptms f ther diseases Als establish when the illness began, hw it began, and if medicines have been taken, especially antimalarial medicines. If medicines have been taken, establish the type, dse, and duratin f treatment. Establish whether the medicines were nt vmited. Symptms f Uncmplicated Malaria Children under 5 years Fever (raised temperature detected by thermmeter r tuch) r a histry f fever Lss f appetite Weakness Lethargy Vmiting Older children and adults Fever (raised temperature detected by thermmeter r tuch) r a histry f fever Lss f appetite Nausea Vmiting Headache Jint pains Muscle aches Weakness Lethargy Signs f Uncmplicated Malaria Physical examinatin f patients shuld include taking the temperature and weighing the patient. Lk ut fr any f the fllwing signs: 94

101 Mdule 2 Sessin 4. Management f Malaria Raised temperature (abve 37.5 C par axilla) Mild anemia (mild pallr f palms and mucus membranes); ccurs cmmnly in children Dehydratin (dry muth, cated tngue, and sunken eyes); in adults, sunken eyes are usually a sign f severe dehydratin When Is It Necessary t Refer Patients fr Further Care? The fllwing are recgnized as danger signs f severe illness, and patients shuld be referred immediately fr further care: Cnvulsins r fits within the last tw days r at present Nt able t drink r breast-feed Vmiting everything Altered mental state (lethargy, drwsiness, uncnsciusness, r cnfusin) Prstratin r extreme weakness (unable t stand r sit withut supprt) Severe respiratry distress r difficulty breathing Severe anemia (severe pallr f palms and mucus membranes) Severe dehydratin (sunken eyes, cated tngue, lethargy, inability t drink) Lk carefully at the patient and answer the fllwing questins: a) Level f Cnsciusness Is the patient awake and attentive? Is the patient riented and interested in r aware f the surrundings? In yung children: Des the child lk at the mther r caretaker? Des the child fllw an bject mved in frnt f his/her eyes? Des the child react t lud nises? One r mre negative answers indicate reduced cnsciusness! b) Severe Anemia Lk at the tngue, the cnjunctivae, and the palms Are these parts very pale? If s, there is severe anemia! c) Dehydratin Is the muth dry? Are the eyes sunken? 95

102 Participant Manual AMS Dispensers Pinch the skin (f the abdmen in children r frehead in adults) between yur thumb and index finger and then suddenly let g; des the skin g back very slwly? If the answer t ne r mre f the abve questins is yes, then there is dehydratin! Remember t use weight and/r age t determine the right dse f antimalarial treatment especially fr yung children! General Principles fr Managing Uncmplicated Malaria Ensure early diagnsis and prmpt, effective treatment f malaria Ensure that all malaria diagnses are supprted by parasitlgical diagnsis, where feasible, necessitating the use f RDTs Always give a full curse f treatment the right number f tablets ver the right number f days Give the medicine rally unless the patient vmits repeatedly If symptms persist, but there are n danger signs, wait at least 48 hurs befre changing the treatment Malaria parasites may develp resistance against antimalarial medicines; this means that the medicine cannt cure the patient r, after initial imprvement, the symptms cme back within 14 days If a patient des nt respnd t the first-line medicine after tw days and n labratry facility is available, give the secnd-line medicine if there is n evidence f any ther cause f the fever. Treatment with AS/AQ Table 4. Dsing fr AS/AQ (Fixed-Dse Cmbinatin) Weight Age Tablet cntent Dsage 4.5 kg < 9 kg 2 t 11 mnths (infant) 25 mg AS mg AQ 1 tablet/day 3 days 9 kg < 18 kg 1 t 5 years (tddler) 50 mg AS mg AQ 1 tablet/day 3 days 18 kg < 36 kg 6 t 13 years (child) 100 mg AS mg AQ 1 tablet/day 3 days 36 kg t 14 years (adult) 100 mg AS mg AQ 2 tablets/day 3 days Surce: Natinal 2011 NB: Children with < 5 kg bdy weight and pregnant wmen in the first trimester shuld be given ral quinine at 30 mg/kg in tw r three divided dses (15 mg/kg b.i.d. r 10 mg/kg t.i.d. 7 days). 96

103 Mdule 2 Sessin 4. Management f Malaria Vital Patient Infrmatin Patients with malaria frequently lse their appetite. Patients shuld be encuraged t drink, preferably milk, and advised t start eating, preferably fatty fd, as sn as pssible. This imprves absrptin f AS/AQ. This medicine shuld nt be used in patients with a histry f reactins t amdiaquine (cmmnly knwn as camquine). Just like with all antimalarial medicines, patients shuld be advised t always cmplete the dse, even when they feel better. Side Effects Smetimes it is hard t tell the side effects f antimalarial medicines as they tend t be similar t the symptms f malaria. The mst cmmn side effects include sleeping disrders, headache, dizziness, abdminal pain, anrexia, diarrhea, vmiting, nausea, and skin rash. Mst f the side effects f this medicine are due t the amdiaquine cmpnent. The mst cmmn being visual disturbance, pigmentatin f the finger nails and skin, nausea, vmiting abdminal discmfrt, and general bdy weakness. Alternative First-Line Treatment with Artemether 20 mg + Lumefantrine 120 mg Artemether + lumefantrine cmbinatin treatment can be used as a first-line treatment fr uncmplicated malaria in situatins where AS/AQ is nt available. Alternative First-Line Treatment with Du-Ctecxin (Dihydrartemisinin 40 mg and Piperaquine 320 mg) Available in packs f 8 tablets Table 5. Recmmended Dsage fr Du-Ctecxin Over 16 years years 6-11 Day 1 3 tabs 2 tabs 1 1 / 2 tabs Day 2 3 tabs 2 tabs 1 1 / 2 tabs Day 3 2 tabs 2 tabs 1 tab Ttal 8 tabs 6 tabs 4 tabs Surce: Natinal

104 Participant Manual AMS Dispensers Vital Patient Infrmatin Du-Ctecxin is nt advised during the first trimester f pregnancy unless recmmended by a dctr. And a new curse f Du-Ctecxin treatment shuld nt be taken within fur weeks f finishing the first ne. Side Effects Few cases f side effects have been reprted, and mst f them were related abdminal disrders such as nausea, diarrhea, lss f appetite, and skin reactins, such as rash and itching. Other available cmbinatin treatments fr uncmplicated malaria are: artesunate + SP and artesunate + meflquine. It is imprtant fr medicine sellers t always read medicine inserts and labels t get mre detailed infrmatin regarding medicines. Treatment f Uncmplicated Malaria with Quinine Tablets (Secnd-Line Medicine) Quinine tablets are the secnd-line medicine fr the treatment f uncmplicated malaria. Secnd-line treatment shuld nly be given when the first-line medicine (AS/AQ) has failed r when it is cntraindicated. Quinine tablets (300 mg salt) are given as a dse f 10 mg/kg (up t a maximum f 600 mg) every 8 hurs fr 7 days. Table 6. Dsage fr Quinine 300 mg Tablets r Quinine Syrup 100 mg/5 ml Age grup Weight Dse (t be given every 8 hurs fr 7 days) 3 mnths up t 1 year 5 t 10 kg 75 mg ( 1 / 4 tab) r 5 ml syrup 1 t 5 years 10 t 18 kg 150 mg ( 1 / 2 tab) r 7.5 ml syrup 5 t 7 years 18 t 24 kg 225 mg ( 3 / 4 tab) r 10 ml syrup 7 t 10 years 24 t 30 kg 300 mg (1 tab) 10 t 13 years 30 t 40 kg 375 mg (1 1 / 4 tab) 13 t 15 years 40 t 50 kg 450 mg (1 1 / 2 tab) 15 years and abve Over 50 kg 600 mg (2 tabs) Surce: Natinal 2011 Supprtive Treatment and Cunseling fr Uncmplicated Malaria Gd management f uncmplicated malaria des nt cnsist f antimalarial treatment alne. It als shuld include the fllwing supprtive treatment: Antipyretic treatment Fluids and fd Cunseling 98

105 Mdule 2 Sessin 4. Management f Malaria Antipyretic Treatment If the fever is high (axillary temperature 38.5 C and abve), an antipyretic shuld be given. Children less than 8 years f age shuld nly receive paracetaml and lder children and adults can be given either paracetaml r aspirin. The dsage f paracetaml is 10 mg/kg bdy weight up t a maximum f 1000 mg in 8 hurs. Table 7. Dsage f Paracetaml 500 mg Tablets r Syrup 120 mg/5 ml Age grup Frm 2 mnths up t 3 years Dse (t be given every 8 hurs) 125 mg ( 1 / 4 tab) r 5 ml syrup 3 t 7 years 250 mg ( 1 / 2 tab) r 10 ml syrup 7 t 10 years 500 mg (1 tab) 10 t 15 years 750 mg (1 1 / 2 tabs) 15 years and abve 1000 mg (2 tabs) Surce: Natinal 2011 In additin t the antipyretic, undressing and spnging with lukewarm (tepid) water can be used t lwer the temperature. Fluid and Fd Patients with fever lse a lt f fluid thrugh sweating and respiratin. They shuld be encuraged t drink plenty f fluids t avid dehydratin! Althugh a sick persn shuld nt be frced t eat, care must be taken that the energy supply is sufficient. Light fds r fruit juices shuld be ffered frequently. Babies shuld cntinue t be breast-fed. Cunseling A patient can cmply with the treatment a lt better if he/she fully understands why and hw t take the treatment and what t expect during its curse. Therefre, yu shuld explain t the patient r the caretaker the fllwing: That the cause f the illness is malaria. The disease is characterized by fever and is transmitted by msquites. The crrect way t take the medicines. In rder t be ttally cured, the patient must take the full curse f treatment. Symptms may nt disappear immediately after taking the first dse. Imprvement may take up t tw days. The patient shuld cnsult a health wrker immediately if symptms wrsen r if they persist beynd tw days. The patient shuld take anther dse if he/she vmits the medicine within 30 minutes. 99

106 Participant Manual AMS Dispensers The patient shuld nt change treatment by himself/herself. Befre giving any medicatin, always ask abut a histry f reactins and avid medicines which caused serius reactins in the same patient. Make sure that the patient understands the illness and its treatment while at hme. Talk t the patient abut the preventin and cntrl f malaria, emphasizing the imprtance f sleeping under insecticide-treated nets. Preventin and Cntrl Malaria can be cntrlled by preventing msquites frm reaching and biting humans, reducing the ppulatin f msquites, and reducing the malaria parasite lad in the human ppulatin. Preventin f Cntact between Msquites and Humans The best way t prevent bites is t sleep under insecticide-treated msquit nets. Such nets create a physical barrier that prevents man-msquit cntact. They als repel and kill msquites. Putting mesh in windws, drs, and ventilatrs reduces the entry f msquites int huses. Drs and windws shuld als be clsed early in the evening. Residential huses shuld be built far away frm marshes and ther cllectins f stagnant water where msquites breed. Reductin f the Msquit Ppulatin Destructin f adult msquites Spraying f the internal walls f human dwellings with residual insecticides Use f insecticide-treated msquit nets Destructin f msquit larvae Intermittent cleaning and drying f water cntainers and intermittent crp irrigatin at least nce every 7 days ensures that msquites d nt have sufficient time t cmplete their breeding cycle. Putting chemicals, fish, r bacteria that kill larvae int stagnant water bdies (knwn as larviciding ) interrupts the msquit breeding cycle. Reductin f msquit breeding sites Peri-dmestic sanitatin, e.g., reducing breeding places arund the hme by prper dispsal f brken utensils and plastic bags, ld tires, and filling in hles in the grund Envirnmental management, e.g., cnstructing drainage channels fr strm water and rivers and drainage f stagnant water bdies Water management, e.g., prtectin f surces f water fr dmestic, agricultural, r industrial use 100

107 Mdule 2 Sessin 4. Management f Malaria Destructin f Malaria Parasites Early diagnsis and prmpt treatment f malaria cases (case management) Effective treatment reduces the length f mrbidity and the risk f mrtality. Thse wh are successfully treated als cease t serve as surces f malaria parasites. Preventive treatment Intermittent preventive treatment f pregnant wmen reduces the risk f pr pregnancy utcmes, e.g., maternal anemia, maternal death, abrtin, and lw birth-weight babies Chemprphylaxis fr special risk grups (e.g., peple with sickle cell, nn-immune visitrs, children prne t very frequent febrile cnvulsins) reduces the risk f mrbidity and mrtality. 101

108 Sessin 5. Management f Upper Respiratry Tract Infectins Objectives 1) Causes, signs, symptms, and clinical manifestatins f cmmn URTIs 2) Management f cmmn URTIs 3) Cmmn medicines used in treatment f URTIs 4) Patient infrmatin and cnditins fr referral Time 3 hurs Activity. Rle Playing Measuring Breathing Rates Wrk in pairs t measure each ther s breathing rates. Begin with slw breathing and then g n t fast breathing. Determine whether the breathing rate is nrmal r fast fr the respective ages. Age Rate 3 weeks 54 3 mnths 55 and 60 (60 is the rate recrded n the secnd measurement) 3 mnths 53 and 45 6 weeks 75 and 70 2 years 45 and 56 1 year 60 and

109 Mdule 2 Sessin 5. Management f Upper Respiratry Tract Infectins Surce: OpenStax Cllege. Organs and Structures f the Respiratry System [OpenStax-CNX Web site]. July 8, Available at: Figure 7. Human respiratry tract Definitin f Upper Respiratry Tract Infectin A URTI is an infectin by bacteria r viruses f the upper part f the respiratry system, which is abve the lungs. These infectins may affect the thrat (pharyngitis), naspharynx (naspharyngitis), sinuses (sinusitis), larynx (laryngitis), trachea (tracheitis), r brnchi (brnchitis). These infectins usually present as cld, sre thrat, flu, and cughs. Cmmn Cld A cmmn cld is an illness that may cure withut any specific treatment except supprtive management (symptmatic management). Cmmn cld is caused by any 1 f mre than 200 viruses. It prduces mild symptms lasting nly 5 10 days. It is different frm flu influenza, which can have severe symptms. 103

110 Participant Manual AMS Dispensers Mde f Transmissin f the Cmmn Cld The primary means f spreading a cld is by hand-t-hand cntact r frm cntaminated bjects such as dr knbs and telephnes tuched by an infected persn. The typical transmissin ccurs when a cld sufferer rubs his r her nse and then shrtly thereafter shakes hands with smene wh, in turn, tuches his r her wn nse r eyes. Symptms f the Cmmn Cld The mst cmmn cmplaints assciated with the cld are usually mild. Runny nse Sneezing Nasal and sinus blckage Headache Sre thrat Cugh When t Refer a Cld fr Medical Care If symptms becme severe r the patient develps the fllwing symptms, it may the flu virus, bacterial pneumnia, r anther illness that needs t be managed at a mre specialized health facility. Shaking, chills Prfuse sweating Muscle aches Nausea Vmiting High fever (greater than 39 C) Management f the Cmmn Cld Because the cmmn cld is viral, ANTIBIOTICS SHOULD NOT BE USED; antibitics kill bacteria, nt viruses. There is n cure (antiviral medicatin) that targets the 200 different causative viruses f the cmmn cld. Therefre, management f cmmn cld invlves several steps that alleviate the cld symptms. Pharmaclgical Management Pain and fever are treated as utlined in the sectin n management f pain, fever, and inflammatin. Nasal cngestin and cugh are managed by antihistamines and cugh preparatins. Preparatins cntaining pseudephedrine can be used t alleviate nasal cngestin. 104

111 Mdule 2 Sessin 5. Management f Upper Respiratry Tract Infectins Cugh suppressants act by blcking the cugh reflex. As a general rule, use a suppressant (cntains dextrmethrphan) fr a dry, hacking cugh. Expectrants are fr a cugh assciated with excessive mucus prductin, r phlegm (cntains guaifenesin). Lzenges and tpical sprays can prvide relief frm sre thrat pain. A warm saltwater gargle can relieve a scratchy thrat. There are many mixtures, syrups, tablets, and capsules that cmbine pain killers, antihistamines, and cugh medicines available ver the cunter. Medicine utlet sellers are encuraged t familiarize themselves with prducts available n the market by reading medicine packages and inserts. Avid giving t many medicines where ne frmulatin wuld suffice. Supprtive Management Drink plenty f fluids t help break up cngestin. Drinking water r juice will prevent dehydratin and keep the thrat mist. Drink at least 8-10 glasses f fluids daily. Cla, tea, and cffee are nt recmmended because they increase urine utput and hence decrease fluids in bdy system. Inhaled steam may ease cngestin and drippy nse. Hld yur head ver a pt f biling water and breathe thrugh yur nse. Be careful. If the steam burns yur nse, breathe in mre slwly. Preventin Wash hands frequently. Avid tuching the nse and eyes. D nt share utensils r twels at hme. Sre Thrat Sre thrats are usually defined by the anatmical site affected. Pharyngitis invlves pain and inflammatin f the pharynx, which is the area f the thrat directly behind the muth and sft palate. Tnsillitis invlves inflammatin f the tnsils, which are lcated n either side f the base f the tngue. Laryngitis invlves the larynx, which is the tp prtin f the windpipe (trachea). Laryngitis is pain and inflammatin f the larynx (ften assciated with a harse vice). Crup is a frm f laryngitis in children (it tends t be assciated with a seal bark-cugh and difficulty inhaling air). 105

112 Participant Manual AMS Dispensers Causes f Sre Thrat Infectin by viruses (ften the same viruses that cause clds and ther upper respiratry illnesses) r bacteria Chemicals (cigarette smke), injury (swallwing a fish bne), allergy r pstnasal drip, r, rarely, cancer (early cancer ften presents with painless symptms) Signs and Symptms f Sre Thrat Symptms f sre thrat thrughut the bdy include fever, headache, nausea, and malaise. These may be present with either a viral r bacterial infectin. Symptms specific t the thrat include pain with swallwing fr pharyngitis and a harse vice when laryngitis is present. Cld viruses tend t cause mre cughing and runny nse than bacteria. Other signs and symptms include: Pus n the surface f the tnsils (can happen with bacteria r viruses) Redness f the rpharynx (the pharynx viewed thugh the muth) Tender neck glands (inflamed lymph ndes) Drling r spitting (swallwing becmes t painful) Difficulty breathing (inhaling can be especially difficult when the passage thrugh the pharynx r larynx becmes t narrw fr a nrmal stream f air) Diagnsis Histry and physical examinatin based n abve signs and symptms are usually adequate. When t Refer a Patient with a Cugh fr Further Care When the patient has the fllwing symptms that pint t the pssibility f a bacterial infectin, seek mre advanced medical care. Severe sre thrat withut much f a cugh, swallwing hurts enugh that salivating ccurs Persistent fever ver 38 C Assciated headache, abdminal pain, r vmiting Difficulty in breathing, which may be a symptm f mre serius illness Dehydratin (dry muth, sunken eyes, severe weakness, r decreased urine utput); symptms f dehydratin in adults may be different frm symptms f dehydratin in children Pharmaclgical Management f Sre Thrat Thrat lzenges ften prve inadequate fr all but the mst minr cases. Gargling with salt water is smetimes helpful (try mixing table salt with warm water and gargling). 106

113 Mdule 2 Sessin 5. Management f Upper Respiratry Tract Infectins Althugh they may be rugh n the stmach, NSAIDs (aspirin, ibuprfen) are ften mre effective pain relievers than paracetaml. Supprtive Management Drinking enugh fluids is very imprtant. A fever can increase fluid requirements, and painful swallwing can decrease fluid intake. When it is hard t drink, it is imprtant t decrease yur bdy s requirements fr fluids by resting and lwering any fever. Pain treatment can help increase fluid intake. Antibitics Antibitics are nt helpful when a virus causes a sre thrat. Smetimes it is difficult t determine whether the cause is viral r bacterial, s antibitics may be given as a precautin. Antibitics are helpful in preventing rheumatic fever (an uncmmn but severe cmplicatin f a streptcccal infectin). Preventin Avid clse cntact with ill peple. Children shuld stay hme frm schl and day care during infectius perids. Cugh A cugh is an actin the bdy takes t get rid f substances that are irritating t the air passages, which carry the air yu breathe in frm the nse and muth t the lungs. A cugh ccurs when special cells alng the air passages get irritated and trigger a chain f events. One can chse t cugh (a vluntary prcess), r ne s bdy may cugh n its wn (an invluntary prcess). Causes f Cughs Acute cugh may be caused by infectius and nn-infectius agents. Infectius causes include viral URTIs (cmmn cld), sinus infectins, pneumnia, and whping cugh Nn-infectius causes include flares-up f the fllwing: chrnic brnchitis, emphysema, asthma, and envirnmental allergies 107

114 Participant Manual AMS Dispensers Chrnic cugh may be caused by the fllwing: Envirnmental substances, e.g., cigarette smke, dusts, pllen, particulate matter, industrial chemicals, pllutin, and lw envirnmental humidity Cmmn causes include asthma, emphysema, and chrnic brnchitis An ften verlked cause f chrnic cugh is gastresphageal reflux disease, which cmmnly manifests as heartburn; it ccurs when acid frm the stmach travels up the esphagus. This abnrmal cnditin can cause irritatin f the esphagus and larynx resulting in the reflex prductin f a cugh. Signs and Symptms f Cugh Althugh the signs f a cugh are self-explanatry, what differentiates the cause f a cugh is the assciated signs and symptms and whether it is acute r chrnic. Acute cughs are divided int infectius and nn-infectius causes. If the cugh is due t an infectin, the patient will have fever, chills, bdy aches, sre thrat, nausea, vmiting, headache, sinus pressure, runny nse, night sweats, and pstnasal drip. Sputum, r phlegm, smetimes indicates an infectin is present, but it is als seen in nninfectius causes. If the cugh is f a nn-infectius cause, signs and symptms include cughs that ccur when expsed t certain chemicals r irritants in the envirnment, cughs with wheezing, cughs that rutinely wrsen at certain lcatins r ding certain activities, r cughs that imprve with inhalers r allergy medicatins. Assessing Cugh in Children 2 Mnths t 5 Years Table 8. Signs and What t D Signs Classify as Treatment Any general danger sign r chest in-drawing r stridr in a calm child Severe pneumnia r very severe disease Give first dse f an apprpriate antibitic Give vitamin A Refer urgently t hspital Fast breathing Pneumnia Give an apprpriate antibitic fr 5 days Sthe the thrat and relieve the cugh with a safe remedy Give vitamin A Advise mther when t return immediately Fllw up in 2 days Cunsel and refer t check fr symptmatic HIV N signs f pneumnia r very severe disease N pneumnia, cugh, r cld If cughing mre than 30 days, refer fr assessment Sthe the thrat and relieve the cugh with a safe remedy Advise mther when t return immediately Fllw up in 5 days if nt imprving 108

115 Mdule 2 Sessin 5. Management f Upper Respiratry Tract Infectins Hw t Assess Breathing in Children Use a respiratry timer t determine the number f breaths per minute. Table 9. Fast Breathing Rates fr Children Child s age Child has fast breathing if the cunt is 0 t 7 days 60 r mre breaths per minute 2 mnths t 1 year Mre than 50 breaths per min 1 t 5 years Mre than 40 breaths per min Management f Cugh in Adults and Older Children The treatment f a cugh will depend largely n its severity and underlying cause. The treatment f an acute cugh is directed primarily at decreasing the cugh and related symptms in additin t treating the underlying cause. Symptmatic relief f cugh can be prvided by ver-the-cunter r prescriptin cugh remedies cugh mixtures and syrups. Antibitics are ften given if suspect a bacterial cause is suspected. It is imprtant that antibitics are given in apprpriate dses fr age in a sufficient quantity fr the apprpriate duratin f treatment. Cugh Cnditins that Necessitate Referral Cugh fails t get better after ther symptms g away r lessen Cugh that changes in character Trial therapy shws n signs f reducing the cugh Cughing up bld Cugh interferes with the activities f daily living r sleep cycles Shrtness f breath r difficulty breathing culd imply mre serius medical prblems Cugh that is caused by a chrnic cnditin; discuss what signs and symptms warrant seeking specialized care Elderly peple r peple with weakened immune systems wh develp a cugh and high fever Preventin Measures used in preventing cugh are similar t thse used in preventing cmmn cld Patients must be encuraged t cmplete the medicines given, particularly if antibitics are given. The medicine utlet seller shuld always give a full dse f antibitics. 109

116 Sessin 6. Gastrintestinal Cnditins Objectives 1) Describe the gastrintestinal system 2) Explain the causes, signs, symptms, and clinical manifestatins f cmmn gastrintestinal diseases and disrders 3) Explain the management f cmmn gastrintestinal disease and disrders 4) Describe what infrmatin patients need and cnditin fr referral Time hurs Activity 1. Diarrhea Case Study Jhn is a 35-year-ld man wh cmes t the AMS with a prescriptin frm a nearby clinic fr ctrimxazle tab 480 mg b.d. fr 5 days and magnesium suspensin 10 ml three times a day. The diagnsis n the prescriptin is fr gastrenteritis due t an infectin. Jhn cmplains that he has diarrhea and has nt been able t eat because he feels very bad. He als has nausea, vmiting, pain, and watery stl. He was well until tw days ag when he began t experience sme nausea that ccurred after taking a cld chapatti and tea at a nearby eating jint. He als tells yu that he has nt taken any medicine and he is nw feeling achy and warm. He has nt been able t eat slid fds r even small amunts f water withut thrwing up. Since yesterday, he has had seven liquid stls, but he has nt nticed any bld in the stl. Jhn is nt taking any medicines. He experienced itching and rash n his legs when he used c-trimxazle 10 years ag. Jhn is nt married. He des nt smke, but drinks lcal brew fr scial reasns; he claims that he des nt ver indulge in alchl. Questins 1) What are the pssible causes f Jhn s diarrhea? 2) What types f nn-drug therapy shuld be cnsidered fr this patient? 3) Was the crrect medicine and dse prescribed fr Jhn? Give reasns fr yur answer. If n, what steps wuld d yu take regarding the medicines prescribed fr Jhn? 4) What medicine alternatives are available fr treatment f diarrhea in this patient? 5) What infrmatin shuld be prvided t Jhn t ensure that he cmpletes the treatment? 6) Hw can Jhn prevent diarrhea in the future? Activity 2. Wrm Infestatin Case Study Maria, the mther f James, a 5-year-ld by in primary ne, cmes t the drug shp cncerned because her child keeps scratching himself in the buttcks and it is discmfrting. This has been ging n fr tw weeks and she is wndering if this is nrmal fr James r if it is an illness. 110

117 Mdule 2 Sessin 6. Gastrintestinal Cnditins On talking t Maria, she reveals that James des nt wash his hands befre settling dwn t eat. Als, during the just cncluded mang seasn, James ate manges every day withut washing them first. She als ntes that James had a skin reactin in the frm f blisters fur days ag, thugh it disappeared withut any treatment. Maria asks fr treatment fr this prblem and als asks abut hw she can prevent the same frm happening t James yung sister. Questins 1) What is James suffering frm? 2) What are the ther signs and symptms that James may present with? 3) What medicine, dse, schedule, and duratin are best fr James and why? 4) What infrmatin shuld be prvided t Maria t enhance adherence, ensure cmplete treatment, and minimize adverse effects? 5) What advice wuld yu prvide t James mther t prevent these cnditins frm happening t her children again? Surce: OpenStax Cllege. Overview f the Digestive System [OpenStax-CNX Web site]. June 4, Available at: Figure 8. Human GI tract 111

118 Participant Manual AMS Dispensers Diarrhea Diarrhea is the frequent passage (fur r mre times in 24 hurs) f lse, watery, sft stls plus blating, pressure, and cramps cmmnly referred t as gas. The mst significant cause f severe illness is lss f water caused by the diarrhea, which is ften accmpanied by vmiting. Fluids pass thrugh the bdy befre they can be absrbed in the intestine, which leads t dehydratin. Mst deaths frm diarrhea ccur in the very yung and the elderly, whse health may be put at risk frm a mderate amunt f dehydratin. Mre specific frms f diarrheal diseases include: Chrnic diarrhea in peple wh have had lse r liquid stl fr ver 2 weeks Acute enteritis which means inflammatin f the intestine Gastrenteritis is diarrhea assciated with nausea and vmiting Dysentery is diarrhea that cntains bld, pus, r mucus Causes f Diarrhea Viral infectins cause mst cases f diarrhea, usually mild-t-mderate symptms with frequent, watery bwel mvements, abdminal cramps, and lw-grade fevers. Diarrhea generally lasts frm three t seven days. Viral infectins are the cmmn cause f epidemics f diarrhea amng adults and schl age children. Bacterial infectins cause the mre serius cases f diarrhea. The mst cmmn surce f bacterial infectins is fd pisning. Bacterial infectins cause severe symptms with vmiting, fever, and severe abdminal cramps r abdminal pain. In mre serius cases, the stl may cntain mucus, pus, r bright red bld. Prtza infectins, e.g., amebiasis, giardiasis Malnutritin, e.g., kwashirkr Symptms f Diarrhea Watery, liquid stl: the stl may be any clr. The passage f red stl suggests intestinal bleeding and culd mean a mre severe infectin. The passage f thick, tarry, black stl suggests significant bleeding in the stmach r upper prtins f the intestine and is nt usually caused by acute infectins. Abdminal cramps: ccasinally, mild-t-mderate abdminal pain will be present. Severe abdminal pain is nt usually cmmn, but if present, suggests mre severe disease. Fever: a high fever is usually nt cmmn, but if present, suggests mre severe disease. Dehydratin: if nt well managed, diarrhea may lead t dehydratin, which is a sign f ptentially serius disease. Dehydrated adults may be very thirsty r appear t have dry muths. 112

119 Mdule 2 Sessin 6. Gastrintestinal Cnditins The skin f lder peple may appear t be lse. The elderly may als becme very sleepy r have behavir changes and cnfusin when dehydrated. Dehydrated infants and children may have sunken eyes and dry muths. They may appear very sleepy r may refuse t eat r drink frm a bttle. Investigatin Investigatin is mstly by clinical examinatin, hwever, specific diagnsis is based n stl examinatin. Supprtive Management f Diarrhea In mst cases, supprt treatment is sufficient in diarrheal management because diarrhea is almst always self-limiting. Hwever, if the cause is a bacterial r prtzan infectin, antibitics can be used. Adults Make sure the patient des nt becme dehydrated. Advise the patient t drink plenty f fluids. Avid milk because it will make the diarrhea wrse. Greasy and fatty fds shuld als be avided. Infants and children shuld be encuraged t eat bananas and rice. After the diarrhea stps, alchlic beverages and spicy fds shuld be avided fr at least tw days. Advice the patient t cntinue his r her usual activities if mildly ill with diarrhea, but t avid strenuus exercise until they feel better because strenuus exercise increases the risk f dehydratin. Children Dehydratin is a majr cncern. It pses significant prblems in very yung infants. Children shuld be drink slutins such as ORS frequently. These fluids als cntain necessary salts lst with diarrhea. Give zinc sulfate dispersible tablets t replace zinc lst in stl. Children with frequent stls, fever, r vmiting shuld stay hme until these symptms g away. In additin t allwing the child t rest and recver, this als helps prevent ther children frm becming ill. Because viruses cause mst cases f diarrhea, antibitics will nt wrk. Even the mre severe diarrhea caused by bacteria will usually g away in a few days withut antibitics. When t Refer Patients Unable t tlerate any fd r drink 113

120 Participant Manual AMS Dispensers Signs f dehydratin (e.g., fr children, sunken eyes and dry muth, appears very sleepy r may refuse t eat r drink frm a bttle) In cases f severe dehydratin, IV fluids are required, but these can nly be administered at a health center High fever; significant abdminal pain; very frequent, lse bwel mvements If the patient is elderly r has serius underlying medical prblems, particularly diabetes, heart, kidney, r liver disease, r HIV r AIDS If patient is a newbrn r an infant If symptms d nt imprve in 2-3 days r appear t becme wrse If the diarrhea appears t cntain bld (may be bright red r may lk like black, thick tar) If patient appears very sleepy r is acting unusual Oral Rehydratin Salt Presentatin ORS sachets with pwder fr preparatin f r 1 liter f ORS slutin (always read the label t find ut the right quantity f water t be added). Dsages fr Children and Adults Give rally; hw ften the patient takes it depends n the degree f dehydratin Precautins Severe dehydratin needs IV infusin D nt stp nrmal feeding, including breast feeding Vital Infrmatin t the Patient The cntents f ne sachet is disslved in 1 liter (half a liter equals ne beer bttle) The slutin shuld be used within 24 hurs Cver any leftver slutin tightly and stre in a cl place Zinc Sulfate Dispersible Tablets (ZINKID) Presentatin Each tablet cntains 20 mg f elemental zinc Dsage fr Children 2-6 mnths: ½ tablet per day fr 10 days 6 mnths-5 years: 1 tablet per day fr 10 days Precautins N particular precautins 114

121 Mdule 2 Sessin 6. Gastrintestinal Cnditins Vital Infrmatin Cntinue zinc supplement after diarrhea stps Preventin Adults and children shuld wash their hands after visiting the tilet Practice safe fd-handling; always wash hands befre and after handling fd Always eat fd when it is ready and still ht Utensils that cme in cntact with raw fd shuld be cleaned with sap and ht water Fruits and vegetables cnsumed raw shuld be thrughly rinsed in clean water Avid eating fds frm street vendrs Bil all water fr drinking In case f chlera, reprt t the health authrities s that the victim is islated Table 10. Management f Diarrhea in Children 2 Mnths t 5 Years Signs Classify As Treatment Lethargic r uncnscius Sunken eyes Nt able t drink r drinking prly Skin-pinch ges back very slwly Any 2 f the fllwing signs: Restlessness Sunken eyes Drinks eagerly, thirsty Skin-pinch ges back slwly Nt enugh signs t classify as sme r severe dehydratin Diarrhea present N dehydratin Severe dehydratin Sme dehydratin N dehydratin Severe persistent diarrhea Persistent diarrhea Refer URGENTLY t hspital, with mther giving frequent sips f ORS n the way Give fluid and fd fr sme dehydratin (plan B) Give zinc supplements Advise mther when t return immediately (in case f danger signs) Give fluid, zinc supplements, and fd, and treat diarrhea at hme Advise mther when t return immediately Treat dehydratin Refer t hspital Advise the mther n feeding a child wh has PERSISTENT diarrhea Give 3 dses f vitamin A and zinc fr 14 days Fllw up in 5 days Cunsel and refer t check fr symptmatic HIV N dehydratin Dysentery Give ral antibitic (metrnidazle) fr dysentery fr 5 days Give zinc supplements Fllw up in 2 days Surce: Gve

122 Participant Manual AMS Dispensers Cnditins Assciated with Diarrhea Gastrenteritis Gastrenteritis is a cnditin that causes irritatin and inflammatin f the stmach and intestines. The severity f infectius gastrenteritis depends n the immune system s ability t resist the infectin. Mst peple recver easily frm a shrt but with vmiting and diarrhea by drinking fluids and easing back int a nrmal diet. But fr thers, such as infants and the elderly, lss f bdily fluid with gastrenteritis can cause dehydratin, which is a life-threatening illness unless the cnditin is treated and fluids restred. Cmmn Symptms Lw grade fever t 37.7 C Nausea with r withut vmiting Mild-t-mderate diarrhea Painful abdminal cramps with blating Mre Serius Symptms Bld in vmit r stl Vmiting fr mre than 48 hurs Fever higher than 40 C Swllen abdmen r abdminal pain Dehydratin: weakness, dry skin, dry muth, and lack f sweat and tears Treatment Give ORS Vmiting can be treated using antiemetic medicines such as prmethazine Antibitics are used if bacterial causative rganisms are believed present; antibitics t be used are ciprflxacin r c-trimxazle, if ciprflxacin is cntraindicated; see the dsage belw Dysentery Dysentery is a serius frm f diarrhea accmpanied by passage f bld and mucus. It is due t infectin and inflammatin f the clnic mucus membranes, resulting in ulceratin. It is cmmnly caused by amebiasis (amebic dysentery) r shigellsis (bacillary dysentery). Amebic Dysentery This is a prtzal intestinal infectin caused by Entameba histlytica. The surce f the infectin is fecal matter cntaining the encysted frm f the parasite, and transmissin ccurs by ingestin f cntaminated fd r water. 116

123 Mdule 2 Sessin 6. Gastrintestinal Cnditins Symptms Symptms f amebiasis may be bserved at any time frm a few days t several years after infectin, althugh they ccur mst cmmnly during the first fur mnths. Onset may be sudden and symptms may vary in severity frm mild diarrhea t dysentery. The prblem may spread t ther rgans, such as the liver, causing liver, lung, r brain abscesses. The infectin reslves spntaneusly in sme individuals, but thers experience relapses ver several years. Treatment In additin t supprtive treatment, medicines such as metrnidazle can be given. Dsage is indicated belw. Giardiasis Giardiasis is a prtzal intestinal infectin caused by Giardia lamblia. The surce f the infectin is human feces cntaining the encysted (infective) frm f the parasite. Transmissin usually ccurs by ingestin f fd r water cntaminated with fecal matter, althugh direct transmissin frm persn t persn may take place. Symptms The incubatin perid is a few days t several weeks. Giardiasis may be acute r chrnic, and the severity f symptms may vary, frm asymptmatic t severe diarrhea with malabsrptin and weight lss. Abdminal pain, distensin, flatulence, and nausea may be experienced. Stls are usually yellw, frthy, and stinking. Treatment In additin t supprtive treatment, medicines such as metrnidazle can be given. Dsage is indicated belw. Bacillary Dysentery (Shigellsis) It is an acute disease invlving the large and small intestines, characterized with bldy mucid diarrhea. It is caused by shigella bacteria. Symptms Bldy mucid diarrhea, fever, nausea, vmiting, and abdminal cramps; the patient feels the need t defecate, but des nt prduct a significant amunt f feces. Treatment In additin t supprtive treatment, medicines such as ciprflxacin can be given. Dsage is indicated belw. 117

124 Participant Manual AMS Dispensers Chlera It is an acute infectin caused by the bacteria Vibri chlera that invlves the entire small bwel. It usually ccurs as an epidemic. Symptms Mild t severe painless, watery diarrhea (rice water stl); in sme cases vmiting, muscular cramps, dehydratin, and cllapse Treatment In additin t supprtive treatment, antibitics, such as dxycycline r ciprflxacin, can be given in adults. Children under the age f 8 shuld be given c-trimxazle r erythrmycin instead. Dsage is indicated belw. Drugs t Treat GI Cnditins Metrnidazle Presentatin Tablets 200 mg r 250 mg Suspensin 200 mg/5 ml Dsages fr Adults and Children Amebiasis Adults Over 12 years: mg every 8 hurs fr 5 t 10 days r 10 mg/kg bdy weight every 8 hurs fr the same perid Children 0 1 year: mg every 8 hurs fr 5 10 days 1 5 years: mg every 8 hurs fr the same perid 5 12 years: mg every 8 hurs fr the same perid Giardiasis Adults: Children: 2 g rally nce daily after fd fr 3 days 30 mg/kg bdy weight (maximum 1.2 g) nce daily fr 3 days Precautins/Cntraindicatins D nt give t chrnic alchl-dependent patients 118

125 Mdule 2 Sessin 6. Gastrintestinal Cnditins Avid use in pregnancy during the first 3 mnths D nt use the drug during breast feeding D nt use the drug fr mre than 10 cntinuus days Side Effects Headache, diarrhea, nausea, vmiting, and stmatitis Dark urine and smetimes leaves a metallic taste in the muth Makes the patient unable t tlerate alchl Vital Infrmatin fr the Patient D nt take any alchl r alchlic drink during the entire perid f treatment r immediately after treatment Take the whle dse, r the treatment may fail Take with fd Ciprflxacin Presentatin Tablets 500 mg r 250 mg Bacillary Dysentery and Bacterial Gastrenteritis Adults: 1 g single dse; avid in children and pregnancy; use c-trimxazle instead C-Trimxazle Presentatin Sulfamethxazle 400 mg and trimethprim 80 mg tablets; sulfamethxazle 200 mg/5 ml and trimethprim 40 mg/5 ml suspensin Dsages fr Adults and Children Chlera: 48 mg/kg bdy weight/24 hurs in tw divided dses fr 3 days Other infectins: depends n the type f infectin; usual dses are: Adults and ver 12 years: 960 mg every 12 hurs fr 5 t 7 days Children 6 mnths t 5 years: 240 mg/5 ml every 12 hurs 6-10 years: 480 mg/10 ml every 12 hurs Precautins/Cntraindicatins D nt use in patients: With knwn allergy t sulfnamide r trimethprim 119

126 Participant Manual AMS Dispensers Under the age f 6 mnths With serius liver/kidney diseases Wh are pregnant Use with cautin: During breast feeding In AIDS patients; they experience high incidences f serius reactins, particularly with higher dsages Mnitr bld cunt if treatment exceeds 14 days cntinuusly Vital Infrmatin t Patient Take a cmplete dse, therwise treatment may fail Suspensins shuld be shaken well immediately befre use Drink a lt f water, fluids during treatment Other GI Diseases Salmnella Infectins Salmnella infectins are caused by bacteria f the genus Salmnella which are gram-negative. They are respnsible fr typhid and paratyphid fever r, cllectively, enteric fever. Typhid Fever Typhid fever is caused by Salmnella typhi, which is endemic in many parts f Uganda, which has pr standards f sewage dispsal. S. typhi bacilli are excreted in feces and, t a lesser extent, urine and transmitted via cntaminated drinking water and fd. They can withstand freezing and drying and even remain viable fr lng perids n siled clthing r bedding. The nly reservir f infectin is man. Symptms Typhid fever is marked by phases f abut ne week s duratin. The initial phase starts with headache, fluctuating fever, and abdminal pain. Cnstipatin ccurs mre frequently than diarrhea in the early stages, althugh later, diarrhea becmes frequent. Other symptms may include lss f appetite, nn-prductive cugh, epistasis (nse bleeding), furred tngue, and muscular rash n the abdmen. In later stages, the fever may becme persistent, txemia may develp, and there culd be signs f mental deteriratin and eventually cmma. Final symptms include greenish diarrhea and melena (black tarry feces) and even perfratin f the intestine may result. The infectin may reslve; hwever, there can be relapses and, in a few cases, cmplicatins may be fatal. Paratyphid Fever It is caused by S. paratyphi A, B, r C. It is transmitted in a similar way t typhid fever. 120

127 Mdule 2 Sessin 6. Gastrintestinal Cnditins Symptms Paratyphid fever resembles typhid fever, but with a mre abrupt nset, milder symptms, and a shrter curse. Cmplicatins, relapses, and fatalities ccur less frequently. Treatment If typhid r paratyphid fever is suspected, refer patient fr further management. Gastritis This is an inflammatin f the gastric mucsa, which may be acute r chrnic. Acute Gastritis Acute gastritis may result frm irritatin due t drugs r alchl. Crrsive agents, irritatin, irradiatin, bacterial txins (e.g., staphylcccal), a bacterial infectin, (e.g., salmnella), trauma, r surgery may precipitate symptms. Symptms Acute gastritis is usually asymptmatic, but anrexia (lss f appetite fr fd), epigastric pain, nausea, and vmiting may fllw. Acute gastritis due t the ingestin f crrsive materials is characterized by severe chest pain, epigastric pain, hemrrhage, vmiting, shck, and perfratin may ccur. Chrnic Gastritis The causes f chrnic gastritis are nt clear, but are said t be autimmune diseases (e.g., thyrid disease), diabetes mellitus, and prlnged gastric irritatin. It is cmmnly assciated with peptic ulceratin, cancer f the stmach, and gastric surgery. Symptms Uncmplicated frms are usually asymptmatic althugh anrexia, epigastric pain, nausea, and vmiting may ccur. Treatment Gastritis is managed mainly by remval f the causative agent; in the case f acute gastritis, avidance f alchl and NSAIDs. In the case f chrnic gastritis, the resulting anemia can be treated with replacement therapy. If it is due t bacterial infectin, an apprpriate antibacterial r antibitic may be used. Magnesium trisilicate, which can be purchased ver the cunter, neutralizes stmach acid and is used t treat gastric and dudenal ulcers, gastritis, and heartburn. Presentatin Mstly tablets f 500 mg r mixture f slutin 121

128 Participant Manual AMS Dispensers Dsage One t tw chewable tablets r ml f the mixture shuld be taken every 4-6 hurs, n r after meals and at bed time. Precautins Avid when patient is vmiting r has kidney prblems. Side Effects May cause mild diarrhea Vital Infrmatin t the Patient Mre effective if the tablets are chewed, nt swallwed; fr the mixture, shake the bttle well each time befre taking a dse. Irritable Bwel Syndrme Irritable bwel syndrme is a chrnic mtility disrder f the cln with n demnstrable cause. Symptms It is characterized by recurrent episdes (attacks) f abdminal discmfrt, pain, and altered bwel habit. The pain may be clicky r cntinuus; a dull ache is cmmnly related t fd intake. It may be relieved by defecatin r n the passage f flatus. There may be alternating diarrhea and cnstipatin; the feces may be described as marbles, pellets, r rabbit drppings, and mucus r ther lesins may als be present. Other symptms include abdminal distensin and flatulence (presence f excess gas in the stmach). Treatment Reassure the patient by explaining the nature f the prblem. Treatment may cnsist f advising the patient t eat fds with a high fiber-cntent, like vegetables. Cnstipatin Cnstipatin is an increased difficulty and reduced frequency f bwel evacuatin, and may be acute r chrnic. Nrmal frequency f defecatin varies frm three times per day t nce every three days. Simple chrnic cnstipatin can be due t dietary fiber r pr bwel training. Acute cnstipatin implies a sudden change in bwel habit. There are several ther causes f cnstipatin. Cnstipatin may be a side effect f drug administratin and laxative abuse. Therefre, befre advising yur patient t use any unnatural laxatives, enquire abut the histry and duratin f the prblem; advise the patient t use natural fiber r bulk-frming fds t slve the prblem. Treatment 122

129 Mdule 2 Sessin 6. Gastrintestinal Cnditins Mst cases f cnstipatin can be successfully treated by dietary measures alne. Lng-term cnstipatin shuld be treated by increasing the intake f bulk-frming prducts such as fds with a lt f rughage and by drinking plenty f water; if symptms persist, refer fr further management. Peptic Ulcers In the digestive system, an ulcer is an area where tissue has been destryed by gastric juices and stmach acid. Peptic ulcer disease is a general term fr ulcers that ccur in the stmach r dudenum (upper part f the small intestines). This breakdwn causes a gnawing r burning pain in the upper middle part f the belly (abdmen). Cause f Peptic Ulcers Peptic ulcers ccur when hydrchlric acid and the enzyme pepsin vercme the defense mechanisms f the G tract and cause ersin in the mucsal wall. Sme peple are naturally mre prne than thers t develp peptic ulcers. Hwever, lifestyle factrs als play a rle in the develpment f peptic ulcers. They weaken the prtective mucsal barrier f the stmach, which increases the chances f getting an ulcer and slws healing f existing ulcers. Sme f the lifestyle factrs include: Use f aspirin, NSAIDs (such as ibuprfen, diclfenac, and naprxen), and newer antiinflammatry medicatins Excessive use f alchl Physical (severe injuries r burns, majr surgery) r emtinal stress Excessive use f caffeine Cigarette smking Radiatin therapy used t treat diseases such as cancer Symptms f Peptic Ulcer Disease The mst cmmn symptm f peptic ulcers by far is abdminal pain. The pain is usually in the upper middle part f the abdmen, abve the belly buttn (navel) and belw the breastbne. The pain can feel like burning r gnawing, and it may g thrugh t the back. Pain ften cmes several hurs after a meal when the stmach is empty. The pain is ften wrse at night and early mrning. It can last anywhere frm a few minutes t several hurs. The pain may be relieved by fd, antacids, r vmiting. Other symptms f peptic ulcers include: Nausea Vmiting Lss f appetite Lss f weight 123

130 Participant Manual AMS Dispensers Treatment f Peptic Ulcers Always refer patients that yu suspect are suffering frm peptic ulcers. Hwever, ver the cunter anti-acid medicines, such as magnesium trisilicate, Relcer gel, Alcid, may be given as a first treatment. Supprtive Management Dn t smke and avid cffee and alchl. These habits increase gastric acid prductin and weaken the mucsal barrier f the GI tract, thus prmting ulcer frmatin and slwing ulcer healing. Dn t take aspirin r NSAIDs. Paracetaml is a gd substitute fr sme cnditins. If symptms are mild, try an antacid. N particular diet is helpful fr peple with peptic ulcers. Cmmn Wrm Infestatins Wrm infestatin is smetimes referred t as helminthic infestatin. Mst wrms are hsted in the GI tract, thugh few may invade specific rgans utside the GI tract. Mst infestatin is a result f ingestin f fd and drink that is cntaminated with wrms at any stage f develpment. Others, such as hk wrms and filarial wrms, enter the human hst thrugh the skin. These wrms are parasites t the human bdy in that they depend n their hst fr survival. When these wrms reach large numbers in the human bdy, they interfere with the nrmal functining f the hst systems and rgans, causing physilgical prblems and disease f the hst. Infestatins are classified based n the type f wrm with characteristic symptms fr each type. Ascariasis Infectin by Ascaris lubricides, the intestinal rundwrm, is the mst cmmn wrm infectin in humans. Ascaris eggs are fund in the sil. Infectin ccurs when a persn accidently ingests (swallws) infective ascaris eggs. Once in the stmach, larvae (immature wrms) hatch frm the eggs. The larvae are carried thrugh the lungs, then t the thrat where they are then swallwed. Once swallwed, they reach the intestines and develp int adult wrms. Adult female wrms can grw ver 12 inches (4.8 cm) in length. Adult male wrms are smaller. Adult female wrms lay eggs that are then passed in feces; this cycle takes tw t three mnths. Adult wrms can live ne t tw years. Infectin ccurs wrldwide. It is mst cmmn where sanitatin and hygiene are pr. Children are infected mre ften than adults. 124

131 Mdule 2 Sessin 6. Gastrintestinal Cnditins Dmestic animals can be infested with ascaris; ccasinally infestatin ccurs in humans when waste prducts frm these animals are used as manure and humans pick it up frm cntaminated sil. Signs and Symptms Infestatin is ften silent. But if smene is heavily infected, they may have abdminal pain. While the immature wrms migrate thrugh the lungs, they may cugh and have difficulty breathing. And if smene has a very heavy wrm infectin in the intestines, the intestines may becme blcked. Chrnic ascaris infectin can stunt the grwth f children. Pinwrms (Enterbius vermicularis) Any individual may develp a case f pinwrms. The infectin ccurs mst frequently in schl children between 5 t 10 years f age. Pinwrm infectins ccur in all sciecnmic grups; hwever, human-t-human spread is favred by clse, crwded living cnditins. Spread amng family members is cmmn. Animals d nt harbr pinwrms; humans are the nly natural hst fr this parasite. Signs and Symptms The mst cmmn symptm f pinwrms is an itchy rectal area. Symptms are wrse at night when the female wrms are mst active and crawl ut f the anus t depsit their eggs. Thread Wrms (Strngylides stercralis) The infectin is usually asymptmatic, but patients may have vague symptms, such as abdminal pain, nausea, flatulence, vmiting, acute fatty diarrhea, epigastric pain, and weight lss. Heavier infectins are mre likely t prduce strnger symptms. Adult Strngylides stercralis live in the gut and prduce larva that penetrate the gut wall and invade the tissues, resulting int aut-infectins. Hk Wrm (Ancylstmiasis) Hkwrm disease is caused by infectin f the small intestine with Ancylstma dudenale r Necatr americanus. It is ne f the majr clinical causes f anemia in many cmmunities. The majrity f patients are asymptmatic. A patient shuld be advised t take ferrus sulfate if anemic. Tape Wrms (Cestde Infectins) A persn gets tapewrms by eating raw r undercked beef infected with Cystricercus bvis, the larval stage f Taenia saginata (beef tapewrm) r uncked fd cntaining prk tapewrm. Mst tapewrm infectins are symptmless and the mst cmmn way f presentatin is the appearance f segments in the stl. There may be mild epigastric discmfrt, nausea, weight lss, and diarrhea. Chrnic wrm infectin may result in anemia, allergic reactins, and fatigue. Diagnsis 125

132 Participant Manual AMS Dispensers Diagnsis is primarily clinical n the basis f signs and symptms. Where pssible, stl may be examined. T Prevent Wrm Infestatins Avid cntacting sil that may be cntaminated with human r dmestic animal feces. D nt defecate utdrs. Dispse f human excreta in a pit latrine. Wash hands with sap and water befre handling fd. Wash, peel, r ck all raw vegetables and fruits befre eating. Avid scratching the anal regin. Avid biting the fingernails. Keep fingernails shrt and clean. Wash all bedding and pajamas regularly. Be sure yur child changes underwear daily. Avid eating half-cked fd. Treatment f Wrm Infestatin Mst cmmnly used medicines in wrk infestatins include mebendazle and albendazle. These medicines are effective and appear t have few side effects. Additinal stl exams are dne 1 t 2 weeks after therapy; if the infectin is still present, treatment is repeated. Drugs t Treat Wrms Mebendazle Presentatin Tablet 100 mg; suspensin 100 mg/5 ml Indicatin Treatment f rund wrms, pinwrms, hkwrms, threadwrms, and tapewrms Dse fr Adults and Children Over 2 Years 100 mg every twelve hurs fr 3 cnsecutive days r 500 mg single dse Side Effects Rare; hypersensitivity reactins, abdminal pain Precautins Nt indicated during the first 3 mnths f pregnancy 126

133 Mdule 2 Sessin 6. Gastrintestinal Cnditins Nt indicated fr children under tw years Vital Advice t Patient Take a full dse, therwise treatment may fail. It is better t chew the tablets befre they are swallwed with sufficient water. Albendazle Presentatin Tablet 200 mg, 400 mg; suspensin 400 mg/10 ml Dse fr Adults and Children Over 2 years: 400 mg single dse Hwever, in severe infectins, 400 mg every 12 hurs fr 3 days, which can be repeated after 3 weeks if necessary. Cntraindicatins Nt fr pregnant r lactating mthers Use nn-hrmnal cntraceptin during treatment and fr ne mnth after treatment Side Effects GI disturbances, headache, dizziness Vital Infrmatin t the Patient Wman shuld nt take ral cntraceptives during treatment Chew the tablet(s) and swallw with enugh water Avid driving r perating machinery if feeling dizzy Always cunsel patients n hw t prevent getting infected r spreading the infectin t thers. There are ther wrm infestatins, such as schistmiasis r bilharzias, but these are nrmally handled by mre specialized health facilities. 127

134 Sessin 7. Management f Anemia and Nutritinal Deficiencies Objectives 1. Understand the manifestatin and causes f anemia 2. Understand key features f severe anemia 3. Understand the apprpriate management f all frms f anemia 4. Understand nutritin diseases in children, their management, and preventin Time hurs Activity. Case Study in Nutritin Precius, a 19-year-ld mther f tw children cmes t ask fr advice n prper nutritin fr her children. She says her first brn has gradually develped bleeding gums and wunds that take lng t heal. Questins 1) Advise the mther n a balanced diet 2) Outline the benefits f eating green vegetables and fruits Anemia This is a cnditin caused by inadequate bld hemglbin levels. Causes f Anemia Lss f bld r increased break dwn f bld cells Irn deficiency due t malaria, malnutritin, r acute r chrnic bld lss, e.g., hemrrhage, trauma, hkwrm infestatin, pregnancy, abrtin, heavy menstrual lss Vitamin deficiency/malabsrptin as in flic acid and vitamin B 12 deficiencies Bld disrders, e.g., leukemia Cngenital disrders, e.g., sickle cell anemia Chrnic infectins, e.g., TB, AIDS (especially in adults), schistsmiasis Clinical Features Tiredness Headache, dizziness, palpitatins Swelling f bdy r feet Pallr f palms and mucus membranes (tngue, eye) Breathlessness Pr appetite Heart failure 128

135 Mdule 2 Sessin 7. Management f Anemia and Nutritinal Deficiencies In Children Severe wasting Edema f bth feet Palmr pallr Differential Diagnsis It is imprtant t rule ut the fllwing cnditins which may manifest with similar symptms. Cnditins which cause heart failure Cnditins which cause general bdy weakness Management f Anemia Irn deficiency anemia: ferrus sulfate 200 mg every 12 hurs with fd fr 3 mnths t replenish irn stres Children: 2 t 4 mnths r 4 t 6 kg: 30 mg elemental irn 4 mnths t 3 years r 6 t 14 kg: 60 mg elemental irn 3 t 5 years r 14 t 19 kg: 90 mg elemental irn Starting at the age f 1 year, children shuld receive a 400 mg dse f albendazle every 6 mnths t prevent wrms. The mther shuld be cunseled t feed the child fds rich in irn, e.g., green leafy vegetables, liver, etc. The child shuld be fllwed up after 5 days. Pregnant wmen shuld be given ferrus sulfate + flic acid tablets. Preventin Imprve nutritin by giving fds rich in irn and vitamins, e.g., vegetables, fruits, meat, liver Get prmpt and effective treatment f infectins and infestatins, especially malaria, hkwrm, and respiratry infectins Nutritin A balanced diet is a meal cntaining all the necessary nutrients in the crrect quantities fr nrmal grwth and maintenance f health and general well-being. Essential Cmpnents Energy surces (carbhydrates): unrefined glucse, rice, sweet ptates, yams, cassava Bdy building (prteins): meat, chicken, fish, milk, eggs, liver, beans, peas, sya prridge, grundnuts, simsim Fats: milk, cking ils, meat 129

136 Participant Manual AMS Dispensers Vitamins and minerals: these are needed in small amunts but are vital t well-being; fds rich in these nutrients include: Vegetables: cabbage, spinach, Irish ptates; these fds shuld nt be vercked r the nutritinal value is lst Fruits : manges, pineapples, fenne (jackfruit), avcad, passin fruit, tmates Milk, meat, and carrts are rich in vitamin A and minerals such as irn and calcium Cnditins That Can Lead t Deficiency Insufficient intake: malnutritin, under nurished; unbalanced diet; alchlism; pr appetite; chrnic diseases Reduced absrptin: parasitic infectins (hkwrms, malaria, bilharzia), advanced age (the elderly), alchlism, smking Increased requirements: increased physical activity, grwth, infectin, and healing time after sickness, pregnancy, and lactatin Signs and Symptms It is difficult t detect slight r even severe vitamin and mineral deficiencies. Vague symptms can include fatigue, tiredness, weakness, lss f appetite, and lwered resistance t certain infectins. Prtein r energy deficiencies (kwashirkr, marasmus) are caused by reduced cnsumptin f prtein and high-energy fds. Thse with kwashirkr r marasmus present with wasting, stunting (children lking yunger than their real age), muscle wasting (especially at the buttcks), bniness, edema f bth feet, misery, pr attitude (apathy), irritability, pr appetite, thinning and brwn hair, wise ld-man facial appearance, severe pallr f palms and sles, and dehydratin. Management Advise the mther r caretaker n prper feeding Check fr ther diseases (malaria, diarrhea) Give fds rich in prteins especially sya meal, grundnuts, milk Give children multivitamin syrup t imprve appetite Check immunizatin status fr children under 5 years and refer if needed Grwth Prmtin and Mnitring Review charts prvided in class n grwth prmtin and mnitring t assess if a child is under weight. There are new grwth curves fr males and females. The lack f imprtant vitamins and minerals (listed in the tables belw) in children s diet can severely affect their grwth. If any f these symptms are apparent, advise the parent and treat accrdingly. 130

137 Mdule 2 Sessin 7. Management f Anemia and Nutritinal Deficiencies Review the chart prvided in class n immunizatin f children under 5. Natinal plicy and schedule fr children under five years f age Supplementatin f pst-partum mthers within 2 mnths f delivery Table 11. Signs and Symptms f Vitamin Deficiencies Vitamin Symptms f deficiency Treatment A Dry skin (rugh and thickened; tad like) and mucus membranes Bulging eyes Night blindness Blurred visin Give vitamin A supplements Eat fds rich in vitamin A (e.g., milk, carrts, vegetables, avcad) D Bw legs Give vitamin D supplements Get enugh early mrning sunlight Eat fds rich in vitamin D (e.g., vegetables, milk, meat, eggs) K Tendency t bleed Give multivitamin supplements Advise increase in meaty fds and vegetables B 1 B 2 B 3 B 6 pyridxine B 12 C Weak appetite Nerve prblems, especially in alchlics (e.g., itching, back pain, shaking) Muth sres Pain when lking at light Uncntrlled tearing Itching eyes Weak visin Skin flaking and itching Diarrhea Cnfusin Hyperirritability Depressin Nerve prblems Muth sres and peeling Diarrhea Cnstipatin Stmach ache Pernicius anemia Delayed wund healing, Muth wunds Brittle bnes and teeth Bleeding gums, lse teeth Anemia Give vitamin B cmplex supplements Advise n nutritin Give vitamin B cmplex supplements Advise n nutritin Treat anemia Give vitamin C supplements Advise n nutritin Flic acid Anemia Treat as anemia; give irn + flic acid + vitamin B supplements 131

138 Participant Manual AMS Dispensers Table 12. Signs and Symptms f Mineral Deficiencies Mineral Symptms f Deficiency Treatment Ptassium Calcium Magnesium Sdium Zinc Irn Dizziness Muscle weakness Cnfusin Bne abnrmalities Weak teeth Bne pains Weak nails Psychiatric abnrmalities Muscle cramps General weakness Excessive sweat Dizziness Cnfusin Muscle cramps Delayed wund healing Reductin in taste, smell Grwth abnrmalities Anemia Restlessness Tiredness Pallr Feed ptassium rich fds, e.g., bananas, citrus fruits Milk, calcium supplement Milk Cmmn salt, ORS Milk As fr anemia Patient Cunseling Advise n adequate feeding and balanced diet and ensure that they have understd. Ask mther/caregiver what fds child eats, hw ften, fluids, fruit and vegetable intake, hw large are the servings, breastfeeding habits. Mnitr respnse t treatment, e.g., rutine weighing, level f appetite, lss f edema, sensry and emtinal changes, n lnger withdrawn; in general, reslutin f symptms is a gd sign. Advise n prmpt and prper management f infectins and infestatins (malaria, wrms). Give vitamin A t children with measles, chrnic respiratry infectins, and persistent diarrhea and t lactating mthers. Ask if child has had vitamin A in the last 6 mnths; if nt, give. Check dewrming; ask if patient has been dewrmed, especially children in the last 3 mnths; if nt give mebendazle. 132

139 Mdule 2 Sessin 7. Management f Anemia and Nutritinal Deficiencies Cnditins fr Referral Severe deficiencies which have resulted in assciated disease; decide n the basis f the severity f the symptms listed abve Identify and refer patients at high risk f malnutritin and deficiencies; fr example, pregnant wmen, smkers, alchlics, the elderly, peple trying t lse weight, grwing children wh are very wasted, persns with r recvering frm ther diseases, and peple chrnically using medicatins. Table 13. Cmmn Medicatins fr Nutritin Deficiencies Name Dse Cmmn preparatins Irn, ferrus sulfate Adults: tablets 200 mg three times a day FEFOL, Ferr B, Vitaglbin, ferrus sulfate tablets (these preparatins may cause GI disturbance) Flic acid Single daily dse fr 14 days < 5 years, 2.5 mg > 5 years, 5 mg Vitamin A Give 3 dses (days 1, 2, 14) < 6 mnths, IU 6-12 mnths, IU > 12 mnths, IU Flic acid tablet Vitamin A caps Vitamin C 100 mg rally every 8 hurs, max. 4 g Vitamin C caps Multivitamin preparatins Calcium Vitamin B cmplex Rinavit syrup Calcium lactate tabs Vitamin B cmplex tabs 133

140 Sessin 8. Management f Dermatlgical Cnditins Objectives 1) Understand cmmnly ccurring dermatlgical cnditins and their management 2) Identify cases fr referral Time 2.5 hurs Activity. Case Study n Dermatlgical Cnditins Sam, a 15-year-ld by, cmes t yur accredited shp t buy betamethasne cream. He says his yunger brther has cins in the head and a neighbr recmmended that cream fr him. Yu ask him if he shares bathing spnges, basins, and twels with his yung brther, t which he says yes. On clse bservatin f his hands, yu realize he has rund patches f disclred skin. Tasks 1) Wuld yu dispense the cream t Sam? Give reasns fr yur answer. 2) What cnditin are Sam and his brther suffering frm? Give reasns fr yur answer. 3) What are the pssible causes f the cnditin? 4) What medicine alternatives are available fr t treat Sam and his brther? 5) What infrmatin shuld be prvided t ensure that he cmpletes the treatment? 6) What advice d yu have fr Sam n hw t cntrl r prevent the abve cnditin? Skin Diseases The skin is the first line f defense against infectins t the bdy. When the integrity f the skin is disrupted, the bdy is expsed t infectins. Several factrs may disrupt the integrity f the skin. Althugh many f these are external t the bdy, in sme instances, changes n the skin may be a sign f a bigger prblem in the bdy. Generalized skin prblems that cver a large part f the bdy and lcalized skin prblems that the medicine seller may nt recgnize shuld be prmptly referred fr specialized attentin. Bils A bil is a lcalized bacterial infectin deep in the skin; it is als referred t as a skin abscess. A bil generally starts as a reddened, tender area. Over time, the area becmes firm, hard, and tender. Eventually, the center f the abscess sftens and becmes filled with infectin-fighting white bld cells that the bdy sends frm the bldstream t eradicate the infectin. This cllectin f white bld cells, bacteria, and prteins is knwn as pus. Finally, the pus frms a 134

141 Mdule 2 Sessin 8. Management f Dermatlgical Cnditins head which can be surgically pened r spntaneusly drain ut thrugh the surface f the skin. Clinical Features There may be ne r mre acute, tender, painful swellings at the site f infectin. The site f the bil may feel ht, and be accmpanied by an inflamed lymph nde and smetimes fever. Management The primary treatment fr mst bils is heat applicatin, usually with ht saks r ht packs. Heat applicatin increases the circulatin t the area and allws the bdy t better fight ff the infectin. Advise the patient t apply ht saks and t take paracetaml t relieve pain. D nt incise the bil because the infectin may spread t ther areas; immediately refer patients with accmpanying fever and generalized lymph nde inflammatin. Ringwrm (Tinea) Ringwrm is a fungal infectin that ccurs n the surface f the skin. It is characterized by rund spts that may ccur n any part f the skin such as head, feet, back, face, etc. Ringwrm causes a scaly, crusted rash that may itch. Depending n the lcatin, types f ringwrm infectins are: Tinea barbea: Ringwrm f the bearded area f the face and neck, with swelling and marked crusting, ften with itching, smetimes causing the hair t break ff. Tinea capitis: Ringwrm f the scalp cmmnly affects children, mstly in late childhd r adlescence. This cnditin may spread in schls. Tinea capitis appears as scalp scaling that is assciated with bald spts. Tinea crpris: When fungus affects the skin f the bdy, it ften prduces the rund spts f classic ringwrm. Smetimes, these spts have an active uter brder as they slwly grw and advance. Tinea criris: Tinea f the grin ( jck itch ) tends t have a reddish-brwn clr and t extend frm the flds f the grin dwn nt ne r bth thighs. Tinea faciei: Ringwrm n the face, except in the area f the beard. On the face, ringwrm is rarely ring-shaped. Characteristically, it causes red, scaly patches with indistinct edges. Tinea manus: Ringwrm invlving the hands, particularly the palms and the spaces between the fingers. It typically causes thickening (hyperkeratsis) f these areas, ften n nly ne hand. Tinea pedis: Athlete s ft may cause scaling and inflammatin in the te webs. 135

142 Participant Manual AMS Dispensers Tinea unguium: Fungus can make the fingernails and, mre ften, the tenails yellw, thick, and crumbly, ften referred t as fungal nails. Management All types f ringwrm infectins can be treated tpically with cltrimazle cream, Whitsfield s intment, r sulfur intment, which shuld be applied twice a day n the affected part after bathing. If the infectin des nt respnd t tpical preparatins, refer fr specialized attentin. Preventin Minimizing sweat and misture and imprving persnal hygiene can help prevent fungal infectins. Scabies Scabies is a cntagius skin disease assciated with severe itch. It is caused by a parasitic mite that is transmitted thrugh persnal cntact. Clinical Features The main clinical features are itching initially between the fingers r n the buttcks r genitals r ther bdy flding that may latter becme generalized. If nt well managed, infected areas may be infected by bacteria that may lead t ther cmplicatins, such as rheumatic fever and glmerulnephritis. Management Advise patient t wash the bdy thrughly and apply benzyl benzate every 12 hurs; avid cntact with the eyes Give antihistamines such as chlrpheniramine t relieve itching Treat all clse cntacts, especially children in the same husehld, with benzyl benzate Wash clthing and bedding and leave in the sun t dry In cases where secndary bacterial infectin are characterized by septic sres, refer fr specialized attentin Advise that the itch may cntinue fr several weeks Prurig-Papular Itching Rash This presents as an itching rash with small papules and scratch marks and dark spts with pale centers. Treatment Apply calamine ltin 136

143 Mdule 2 Sessin 8. Management f Dermatlgical Cnditins Give antihistamine by muth, e.g., cetrizine If n imprvement, use hydrcrtisne 1% This rash can be an early sign f HIV, and patients shuld be referred t a health facility fr cunseling and assessment fr HIV. Chicken Px Appears as vesicles ver the bdy; the vesicles appear prgressively ver days and frm scabs after they rupture Treat itching with calamine ltin and give antihistamine by muth; if nt imprved, use hydrcrtisne 1% Refer urgently if pneumnia r jaundice appear Herpes Zster Herpes zster, als knwn as shingles, is due t the resurgence f the varicella zster virus, which als causes chickenpx. Severe burning pain precedes a rash which is vesicular and almst always unilateral, althugh it des nt crss the midline. In uncmplicated cases, the rash disappears in 24 weeks; in the hemrrhagic necrtizing frm, (HIV related) scarring ften remains. Amng HIV-psitive individuals, it is a clinical stage 2 defining disease Management Give analgesic (see pain management) Diclfenac may be helpful in the acute phase Apply tpical calamine ltin Refer health facility fr management Nappy Rash It is a reddish, yellw skin rash in areas cvered by a baby s nappy, such as buttcks, external genitalia, thighs, and lwer abdmen, caused by persistent dampness f wet nappies that leads t irritatin f the skin. Management Advise parent t change the child s nappy mre frequently Apply calamine ltin twice a day If the rash persists r becmes wrse, refer fr further management 137

144 Participant Manual AMS Dispensers Allergic Reactins Skin Allergy/Urticaria An acute, sub-acute, r chrnic inflammatin f the skin caused by cntact with a multitude f agents that induce allergic reactins Clinical Features Skin inflammatin characterized by redness, itching, and edema Management Try t establish the cause and remve it Apply calamine ltin 15% twice a day Give pain killers such as paracetaml t relieve pain Treatment Chlrpheniramine Adults: Children: 4 mg every 8 hurs 2 mg per dse (frequency t be determined by physician) Prmethazine Adults: Children: 25 mg nce a day r every 12 hurs 6.25 mg-12.5 mg nce a day r every 12 hurs Cetrizine Adults and children ver 6 years: Children 2-6 years: 10 mg nce a day 5 mg nce a day Nte: children under 12 years shuld be given the syrup frm f the medicine Eczema Signs Appears as wet, zing sres r excruciated thick patches. It is cmmnly fund in children. Management Sak sres with clean water t remve crusts (n sap) where present Dry skin gently Shrt-term use f tpical sterid, e.g., hydrcrtisne t treat itching 138

145 Mdule 2 Sessin 8. Management f Dermatlgical Cnditins Fixed Drug Reactins Reactins t medicatins such as penicillins (amxicillin), cephalsprins (cephalexin), and sulfur drugs (c-trimxazle) Signs Usually presents as generalized, red, and widespread with small bumps r blisters r ne r mre dark skin areas Management Stp medicatins Give ral antihistamines If peeling rash, refer Stevens Jhnsn Syndrme Stevens Jhnsn Syndrme is a severe reactin t c-trimxazle r nevirapine invlving the skin as well as the eyes and muth; might cause difficulty breathing. Management Stp medicatin and refer immediately Wunds A wund is an injury t the skin that expses tissue beneath the skin. The injury be due t an bject cutting thrugh the skin, burns due t chemicals r heat, r may be the result f an infectin. Because wunds break the bdy s first line f defense, badly managed wunds may get infected, leading t cmplicatins such sepsis, tetanus, etc. Management Large wunds and wund that have lasted fr several weeks are mre likely t be infected and may expse patients t cmplicatins and shuld be referred immediately fr a specialist s attentin. Minr, particularly fresh, nes can be managed by applying antiseptics, such as idine tincture, and antibitic creams, such as silver sulfadiazine cream, t prevent infectin. 139

146 Sessin 9: Management f Eye, Ear, Nse, and Thrat Infectins and Disrders Objectives 1) Understand the varius diseases f the eye, ear nse and thrat and hw they manifest 2) Understand pre-referral care and cnditins that shuld be referred t a higher level Time hurs Activity. Eye stye Weah, a 19-year-ld man, cmes t yur drug shp and presents with a cmplaint f a swllen left eye. On clse examinatin, yu realize Weah has a swelling n the lwer skin just belw the eye. He explains that this is nt the first time this has happened, and he usually applies eye drps r tetracycline eye intment. Questins 1) Explain t Weah the ptential cause f a stye. 2) Cunsel him n the right medicine t use and prvide infrmatin t ensure prper use and adherence. 3) Hw shuld Weah prevent future prblems f the same nature? Eye Cnditins Sme eye cnditins are shrt-lived and can successfully be managed at the AMS. Hwever, many f them need t be referred fr specialized attentin as they can be a sign f serius cmplicatins that may easily lead t permanent eye damage r even lss f visin. It is highly recmmended that when drug sellers encunter eye cnditins they prvide first aid and refer the patient fr further medical attentin. Eye Cnditins That Can Be Managed by Drug sellers Freign Bdy (FB) in the Eye Causes Slids (dust, insects, metal r wd particles) and liquids (splashes f irritating fluids) 140

147 Mdule 2 Sessin 9. Management f Eye, Ear, Nse, and Thrat Infectins and Disrders Clinical Features May be severe pain, tears, r redness; FB may be visible Differential Diagnsis Other injury r trauma Management (All Patients) Make a thin finger f mistened cttn wl, mve the eyelid ut f the way, and gently remve the FB If this fails, refer t an eye specialist Fr irritating fluids in the eye, wash the eye with plenty f clean water r saline; if the crnea is damaged, apply tetracycline eye intment, cver the eye, and refer t an eye specialist Stye (Hrdelum) A stye is a lcalized infectin f the hair fllicle f the eyelids caused by bacteria called Staphylcccus aureus. Signs and Symptms Itching in the early stages, swelling, pain, tenderness, pus frmatin; the stye may burst spntaneusly Management Usually the stye will heal spntaneusly; avid rubbing the eye as this might spread the infectin Apply a warm/ht cmpress t the eye Apply tetracycline eye intment 1% 2-4 times daily Remve the eye lash when it is lse Preventin Remve any lse eyelashes Gd persnal hygiene Cnditins that Need t be Recgnized and Referred Cataracts Opacity f the lens inside the eye; by far the cmmnest cause f blindness in Uganda 141

148 Participant Manual AMS Dispensers Cause Old age, trauma, genetics, severe dehydratin in childhd Signs and Symptms Reduced visin Pupil is nt the nrmal black clr, but is grey, white, brwn, r reddish Cnditin is nt painful unless caused by trauma Eye is nt red unless cnditin is caused by trauma Management (Adults and Children) D nt give any medicines. Explain t the patient that the cnditin is very treatable and refer t a cataract surgery center (hspital). Preventin Give early treatment fr childhd diarrhea and vmiting t prevent severe dehydratin Wear prtective gggles when hammering, sawing, chpping, grinding, etc. Cautin children abut playing with sticks and the risk f eye injuries Cnjunctivitis Causes Infectin (bacterial r viral) r trauma (chemicals, FBs), smke, dust, allergies Clinical Features Watery discharge (virus r chemicals) Pus discharge (bacteria) Crnea is clear and des nt stain with flurescein Visual acuity is nrmal Redness (usually bth eyes, but may start/be wrse in ne, usually reddest at uter edge f the eye) Swelling Itching may be present Management Adults and children: apply tetracycline eye intment 1% HCl r chlramphenicl eye intment 1% fr 7 days; refer t a higher health center 142

149 Mdule 2 Sessin 9. Management f Eye, Ear, Nse, and Thrat Infectins and Disrders Cautin D nt use sterid preparatins unless sure f the diagnsis because sterids may mask infectins. Preventin Persnal hygiene; daily face washing Wear prtective gggles when using dangerus chemicals, hammering, sawing, chpping, grinding Warn children playing with sticks abut the risk f eye injuries Avid irritants and allergens Keratitis Inflammatin f the crnea Cause Infectin (bacterial, viral, r fungal, leading t crneal ulceratin) r trauma (chemical, FBs) Clinical Features Same as fr cnjunctivitis except that the crnea is nt clear and visin is nt clear Cnditin is ften in nly ne eye The eye is painful Management Adults and children: apply tetracycline eye intment 1% Explain the seriusness f the cnditin t the patient Refer t a qualified eye health wrker Preventin Wear prtective gggles when hammering, sawing, chpping, grinding, etc. Warn children playing with sticks abut the risk f eye injuries Ophthalmia f the Newbrn Purulent discharge frm the eyes in babies <1 mnth Causes Infectins, usually frm mther s birth canal r pr hygiene f the persn caring fr the newbrn; bacterial, e.g., Gnccci, chlamydial 143

150 Participant Manual AMS Dispensers Clinical Features Reddening f ne r bth eyes Swelling f the eye lids Purulent discharge Excessive prductin f tears (lacrimatin) If nt treated early, will result in scar frmatin r perfratin f the crnea, either f which will lead t blindness Preventin and Prphylaxis Gd antenatal care (ANC) with screening and treatment f the mther fr genital r UTIs Clean delivery; prphylactic treatment f all nenates Management Apply tetracycline eye intment 1% twice daily, carefully clean away any purulent discharge as required, and refer fr further management Trachma A chrnic infectin f the uter eye caused by Chlamydia trachmatis, a type f bacterium Signs and Symptms Early stages: reddening f the eye, itching, fllicles (grain-like grwth) n the cnjunctiva Later stages: scar frmatin n the eyelids causing the upper eyelid t turn inwards and causing the eyelashes t scratch the crnea; scarring f the crnea leading t blindness Management Adults and children: Apply tetracycline eye intment 1% twice daily and refer fr further management Preventin Gd persnal hygiene, regular face washing; clean deliveries Xerphthalmia Dryness f the part f the eye ball expsed t air and light; due t vitamin A deficiency Clinical Features Starts with night blindness, fllwed by dryness f the cnjunctiva and crnea; eventually the crnea melts away, the eye perfrates, and ttal blindness ccurs 144

151 Mdule 2 Sessin 9. Management f Eye, Ear, Nse, and Thrat Infectins and Disrders Management Vitamin A supplements Preventin Gd, balanced diet, especially fr children, wmen, lng-term hspital in-patients, barding schl students, etc. Ear Cnditins Ear cnditins may be an indicatin f a serius and cmplicated cnditin that may easily result in deafness. It is imprtant that when a medicine seller recgnizes an ear cnditin, the patient must be referred t a specialist. It is highly recmmended that when drug sellers encunter cases with ear cnditins, they prvide first aid and refer the patients fr further attentin. FB in the Ear Causes Children may insert FBs in their ears as they play, typically insects (e.g., flies, cckraches, ants), seeds, beads Adults: usually insects, cttn buds Occasinally the FB may penetrate adjacent parts and ldge in the ear Signs and Symptms Blckage, FB may be visible Nise in the ear Hearing lss Bleeding r discharge frm the ear, if attempts have been made t remve the FB Management These are nrmally mechanically remved using special equipment. Because such equipment may nt be present at the medicine utlet, the patient must be referred t a specialist. Attempts t remve the FB at the medicine utlet may lead t eardrum perfratin that may lead t deafness. Otitis Media (Middle Ear Infectin) May r may nt present with pus effusin 145

152 Participant Manual AMS Dispensers Cause Blckage f the eustachian tube by adenids, infectin in the tube, thick mucid fluid, tumrs, unreslved acute titis media, viral r bacterial infectin (e.g., Streptcccus pneumniae, H. influenzae); cmmnly fllws an acute infectin f the upper respiratry tract The cnditin is cnsidered chrnic if it lasts mre than tw weeks. Clinical Features Primarily hearing impairment, which ften fluctuates, i.e., the patient smetimes can hear, smetimes can t Presence f nn-purulent fluid in middle ear Buzzing nise in ears/head Retracted r bulging ear drum Lss f usual clr f ear drum r dullness Acute nset f pain in the ear, redness, fever, pus discharge Bulging f the eardrum Management Give an antibitic ear drp, e.g. chlramphenicl ear drp Give amxicillin 500 mg every 8 hurs fr five days; fr children: 15 mg/kg per dse Give paracetaml 1 g every 8 hurs and as indicated abve in children Refer t ear, nse, and thrat specialist in cases f titis media with n pus r titis media with pus lasting fr mre than 7 days Review after 5 days; if eardrum is still red, repeat the abve curse Preventin Health educatin, e.g., advising patients n recgnizing the discharge f titis media (believed by sme t be milk in the ear ) Early diagnsis and treatment f titis media and URTI Otitis Externa (Infectin f the Outside Ear) Infectin f the external ear canal which may be lcalized r generalized (diffuse) Causes Bacterial, fungal, viral infectins Clinical Features Pain, tenderness n pulling the pinna (external ear) Itching Swelling 146

153 Mdule 2 Sessin 9. Management f Eye, Ear, Nse, and Thrat Infectins and Disrders Pus discharge Investigatin Gd histry and physical examinatin are imprtant in making a diagnsis. If discharge is white r black, it is fungal; if discharge is yellw, it is bacterial. Management Thrughly clean external ear canal Apply antibitic drps, e.g., chlramphenicl 1% ear drps, 2 drps int the affected ear every 8 hurs fr 14 days Paracetaml 1 g every 8 hurs and as indicated abve in children If fungal infectin is suspected, apply gentian vilet 1% 2 r 3 times daily; cntinue until discharge dries up Amxicillin 500 mg every 8 hurs fr seven days, child: 15 mg/kg per dse Refer t ear, nse, and thrat specialist if cnditin des nt imprve r is severe Wax in the Ear An accumulatin f wax in the external ear Cause Excessive and/r thick wax prductin, small and/r hairy ear canal Clinical Features Blcked ears, buzzing sund, smetimes mild pain Management in Adults and Children Wax in the ear is nrmal and usually cmes ut naturally frm time t time. If it accumulates t frm a wax plug and causes a prblem fr the patient: Sften the wax by inserting drps f vegetable il r glycerin int the ear 3 times a day fr a few days; after this, the wax may fall ut n its wn Refer t the health center where the ear may be cleaned Advise the patient nt t pke anything int the ear in an attempt t clean it, as this may damage the eardrum Mastiditis Inflammatin f the mastid bne behind the ear 147

154 Participant Manual AMS Dispensers Causes Usually a cmplicatin f a middle ear infectin with pus Clinical Features Pain r tender swelling felt ver the mastid bne, with r withut pus discharge frm the ear, fever Management Apply chlramphenicl ear drps, give pain killers, and refer t a hspital urgently Table 14. Summary: Management f Cmmn Ear Prblems in Children under 5 Signs r symptms Classify as Management Tender swelling behind the ear Mastiditis Treat with chlramphenicl ear drps and paracetaml fr pain Refer immediately Pus is seen draining frm the ear and discharge is reprted fr less than 14 days Ear pain Pus is seen draining frm the ear and discharge is reprted fr 14 days r mre Acute ear infectin Chrnic ear infectin Treat with chlramphenicl ear drps and paracetaml fr pain Dry ear by wicking Advise t check fr HIV infectin Fllw up in 5 days Treat with chlramphenicl ear drps Dry ear by wicking Advise t check fr HIV infectin Fllw up in 5 days Nasal Cnditins Nse Bleeding Bleeding frm the nstrils may be arterial r venus. Nse bleeding may be a symptm f a serius disease. Causes Nse-picking, trauma, infectins f the nse, tumrs, high bld pressure, bleeding disrders, pertussis, sickle-cell trait/disease, kidney failure, r it may be genetic Clinical Features Bleeding frm the nse; n examinatin, the site f bleeding may be seen Signs and symptms f shck, if bleeding is severe 148

155 Mdule 2 Sessin 9. Management f Eye, Ear, Nse, and Thrat Infectins and Disrders General Management Sit the patient up (if patient nt in shck) Instruct patient t pinch the nse between the finger and the thumb fr 15 minutes, breath thrugh the muth, and spit ut any bld Manage as indicated in the curse n first aid If bleeding has nt stpped in 5-10 minutes, refer t hspital fr further management Preventin Avid picking the nse Treat/cntrl predispsing cnditins Nasal Allergy An abnrmal reactin f the nasal tissues t certain allergens that tends t start in childhd, althugh it may start at adlescence. It may be hereditary r may be predispsed by infectins. Causes Changes in humidity and temperature, dust mites, certain fds and medicines, and infectin Clinical Features Often present in schl-age children, smetimes preceded r fllwed by eczema r asthma Sneezing in spasms Prfuse watery nasal discharge Nasal bstructin, variable in intensity and may alternate frm side t side Pstnasal drip (mucus dripping frm the back f the nse) Management Avid precipitating factrs (mst imprtant) Give antihistamines, e.g., chlrphenamine 4 mg every 12 hurs when necessary Reassure and refer if n imprvement D nt use vascnstrictr nasal drps, e.g., ephedrine and xylmetazline because (especially with repeated r prlnged use) they cause rebund cngestin and alter the nasal envirnment making structures hardened Sinusitis (Acute) Inflammatin f air sinuses f the skull 149

156 Participant Manual AMS Dispensers Causes Allergies, FBs in the nse, dental fcal infectin, viruses (rhinvirus) ften as a cmplicatin f URTI, r bacteria, e.g., Streptcccus pneumniae, Haemphilus influenzae, Streptcccus pygenes Clinical Features Thrbbing headache abve the eyes, sinus tenderness Discharge frm nstrils and int the thrat; clear when due t viruses, yellw (purulent) when due t bacteria Nasal blckage (smetimes) Management Give pain killers and give supprtive management as in cmmn cld Refer if symptms persist r if becme severe Other nse cnditins such as adenid disease and atrphic rhinitis shuld be referred fr specialized attentin. 150

157 MODULE 3: FAMILY, REPRODUCTIVE HEALTH, MATERNAL, AND CHILD HEALTH Sessin 1. Management f Diseases f the Reprductive System Sessin 2. Family Planning Sessin 3. Maternal and Child Health 151

158 Sessin 1. Management f Diseases f the Reprductive System Objectives 1) Describe the cmmn prblems related t RH 2) Discuss AMS management f sme f the RH prblems 3) Identify RH prblems that AMS refer t a health facility Time 4-6 hurs Activity 1. Case Study: UTIs Prince, a 35-year-ld married man cmes t yur AMS with a prescriptin frm a nearby clinic fr metrnidazle tab 400 mg t.d.s. fr five days and diclfenac tab 50 mg t.d.s. fr three days. The diagnsis n the prescriptin is fr a UTI. On interactin with Prince, he infrms yu that he experiences a burning pain during urinatin and that his frequency f urinatin has increased. He says that smetimes the urine is cludy and ful smelling. This has lasted three days and the symptms are getting wrse. Prince admits t having mre than ne sexual partner, but is wrried abut what t tell his wife wh he has nt seen in fur weeks. He als cnfesses that his latest partner had an unusual vaginal discharge. On further discussin, Prince reveals that he des nt use cndms during his sexual encunters. Tasks 1) Was the crrect medicine and dse prescribed fr Prince? Give reasns fr yur answer. If n, what steps wuld yu take regarding the medicines prescribed fr Prince? 2) What medicine alternatives are available fr treating Prince s cnditin? 3) What infrmatin shuld be prvided t Prince t ensure adherence and successful therapy and minimize adverse effects? 4) What advice d yu have fr Prince n hw t prevent this cnditin? 5) Hw shuld Prince s partners be handled in the abve case? Review f the Geniturinary System The geniturinary system refers t structures that urine passes thrugh befre being eliminated frm the bdy as shwn in the diagram. 152

159 Mdule 3 Sessin 1. Management f Diseases f the Reprductive System Surce: OpenStax Cllege. Hmestasis and Osmregulatin [OpenStax-CNX Web site]. April 8, Available at: Figure 9. Human geniturinary system Urinary Tract Infectins A UTI is an infectin invlving the kidneys, ureters, bladder, r urethra. As a rule, the farther up in the urinary tract the infectin is lcated, the mre serius it is. The upper urinary tract is cmpsed f the kidneys and ureters. Infectin in the upper urinary tract generally affects the kidneys (pyelnephritis). The lwer urinary tract cnsists f the bladder and the urethra. Infectin in the lwer urinary tract can affect the urethra (urethritis) r the bladder (cystitis). UTIs are usually referred t as simple r cmplicated. Simple infectins ccur in healthy urinary tracts and d nt spread t ther parts f the bdy. They usually g away readily with treatment. Cmplicated infectins are caused by anatmic abnrmalities, spread t ther parts f the bdy, r are resistant t many antibitics. They are mre difficult t cure. UTI is much mre cmmn in adults than in children, but abut 1-2% f children d get UTIs. UTIs in children are mre likely t be serius than thse in adults and shuld nt be ignred. These infectins are much mre cmmn in girls and wmen than in bys and men yunger than 50 years. The reasn fr this is nt well understd, but sexual activity may be partially respnsible in sexually active wmen. 153

160 Participant Manual AMS Dispensers Causes f UTIs Urine is nrmally sterile. An infectin ccurs when bacteria get int the urine and begin t grw. The infectin usually starts at the pening f the urethra where the urine leaves the bdy and mves upward int the urinary tract. The cmmnest cause is Escherichia cli, bacteria that nrmally live in the bwel (cln) and arund the anus. These bacteria can mve frm the area arund the anus t the pening f the urethra. The tw mst cmmn causes f this are pr hygiene and sexual intercurse. Usually, the act f emptying the bladder (urinating) flushes the bacteria ut f the urethra. If there are t many bacteria, urinating may nt stp their spread. The bacteria can travel up the urethra t the bladder, where they can grw and cause an infectin. The infectin can spread further as the bacteria mve up frm the bladder via the ureters. If they reach the kidney, they can cause a kidney infectin (pyelnephritis), which can becme a very serius cnditin if nt treated prmptly. Symptms Lwer UTI (cystitis): The lining f the urethra and bladder becmes inflamed and irritated. Dysuria: Pain r burning during urinatin Frequency: Mre frequent urinatin (r waking up at night t urinate) Urgency: Sensatin f nt being able t hld urine Hesitancy: Sensatin f nt being able t urinate easily r cmpletely (r feeling that yu have t urinate but nly a few drps f urine cme ut) Cludy, bad smelling, r bldy urine Lwer abdminal pain Mild fever (less than 39 C), chills, and just nt feeling well (malaise) Althugh mst peple have symptms with a UTI, sme d nt. Which UTI Symptms Necessitate Referral? If a patient has symptms f a lwer UTI and any f the fllwing, they may have a UTI that invlves the kidneys and therefre needs t be referred: Vmiting and inability t keep dwn clear fluids r medicatin Nt better after taking antibitics fr tw days Pregnancy; an unrecgnized infectin can cause miscarriage r ther pregnancy cmplicatins Diabetes r anther disease that affects the immune system (fr example, AIDS) 154

161 Mdule 3 Sessin 1. Management f Diseases f the Reprductive System Infants, children, and elderly peple with any f the signs and symptms shuld be referred t a health center IV r hspital. Fever, lethargy, and pr appetite may be signs f smething mre serius. UTIs have the ptential t make these vulnerable peple very ill. Als, patients with an upper UTI (pyelnephritis) shuld be referred immediately. Symptms develp rapidly and may r may nt include the symptms fr a lwer UTI. Fairly high fever (higher than 38 C) Shaking, chills Nausea Vmiting Flank pain, pain in the back r side, usually n nly ne side at abut waist level In newbrns, infants, children, and elderly peple, the classic symptms f a UTI may nt be present. Other symptms may indicate UTI. Newbrns: Fever r lw bdy temperature, pr feeding, jaundice Infants: Vmiting, diarrhea, fever, pr feeding, nt thriving Children: Irritability, eating prly, unexplained fever that desn t g away, lss f bwel cntrl, lse bwels, change in urinatin pattern Elderly peple: Fever r lw bdy temperature, pr appetite, lethargy, change in mental status UTIs shuld always be referred fr further management. Supprtive Treatment Take a pain-relieving medicatin. Use a ht-water bttle t ease pain. Avid cffee, alchl, and spicy fds, all f which irritate the bladder. Avid smking. Smking irritates the bladder and is knwn t cause bladder cancer. Ensure adequate intake f fluid (ral r IV) t irrigate the bladder and dilute bacterial cncentratins. Ensure peri-anal hygiene. Ensure regular cmplete emptying f the bladder and/r duble viding (additinal attempt t empty bladder after initial urine flw ceases). Finish all antibitic medicatin even if the patient is feeling better befre the medicatin is gne. Pharmaclgical Treatment The usual treatment fr bth simple and cmplicated UTIs is antibitics. The type f antibitic and duratin f treatment depend n the circumstances. In an therwise healthy yung female, a three-day curse f antibitics is usually enugh. Sme prviders prefer a seven-day curse t be sure f getting rid f the infectin. Occasinally, a single dse f a pwerful antibitic is used. 155

162 Participant Manual AMS Dispensers Adult males with a UTI require 7 t 14 days f antibitics. If the prstate is als infected (prstatitis), fur weeks f antibitic treatment may be required. Adult females with ptential fr r early invlvement f the kidneys, urinary tract abnrmalities, r diabetes are usually given a five- t seven-day curse f antibitics. Sdium Bicarbnate Slutin 5% Disslve 5 g in 100 ml water and drink twice daily; will make the urine alkaline and may help relieve symptms in mild cases. C-trimxazle Adults: Children: 960 mg twice daily fr days 24 mg/kg, twice daily fr days Amxicillin Adults: Children: 500 mg every 8 hurs fr days 15 mg/kg every 8 hurs fr days If pr respnse r recurrent infectins, d nt cntinue t treat blindly ; refer t mre specialized health center fr investigatin f culture and sensitivity and further management. Preventin Wmen and girls shuld wipe frm frnt t back (nt back t frnt) after ging t the bathrm. This helps prevent bacteria frm the anus entering the urethra. Empty the bladder regularly and cmpletely, especially after sexual intercurse. Drink plenty f fluids. Imprve persnal/genital hygiene. Avid sharing bathing basins, twels, sap, etc. Sexually Transmitted Diseases Sexually transmitted diseases (STDs) are spread thrugh sexual intercurse and mstly affect sex rgans r the muth; the infectin can als be spread thrugh cntact with bld during sexual activity. STDs are amng the mst cmmn infectius diseases in Uganda. Fr effective management f these cnditins, a syndrmic apprach is used where medicine is given fr all the suspected causative rganisms depending n the symptms. STDs affect men and wmen f all ages and backgrunds. STDs have becme mre cmmn, partly because yung peple are becming sexually active at a yunger age and have multiple partners. 156

163 Mdule 3 Sessin 1. Management f Diseases f the Reprductive System Frequently, STDs cause n symptms, especially in wmen. Hwever, they remain infective t their sexual partners. Health prblems frm STDs tend t be mre severe fr wmen than fr men. Sme STDs can cause pelvic infectins that may lead t scarring f the reprductive rgans, which can result in an ectpic pregnancy (a pregnancy utside the uterus) and infertility fr wmen. STDs can be passed frm a mther t her baby befre, during, r immediately after birth. Because the methd f becming infected is similar with all STDs, a persn can easily pick up mre than ne infectin at a time. Experts believe that having an STD that is nt AIDS increases ne s risk fr becming infected with AIDS. Take Special Care with STD Patients Smetimes peple with STDs are t embarrassed r frightened t ask fr help r infrmatin. Hwever, mst STDs are easy t treat. The sner a persn seeks treatment and warns sexual partners abut the disease, the less likely the disease will d permanent damage, be spread t thers, r be passed t a baby. Once a diagnsis f an STD has been made, the patient shuld: Seek treatment t stp the spread f the disease. Be encuraged t ntify sexual cntacts and urge them t have a check-up. Take all f the prescribed medicatin. Smetimes, fllw-up visits and tests are imprtant. Cnsult a health wrker with any specific needs and questins. Avid sexual activity while being treated fr an STD. Urethral Discharge Syndrme (Males) Causes A number f diseases, usually spread by sexual intercurse, prduce similar manifestatins in the male and may be difficult t distinguish clinically: Gnrrhea: caused by the bacterium Neisseria gnrrhea Trichmniasis: caused by the prtzan Trichmnas vaginalis Nn-gncccal urethritis: caused by virus-like bacteria Mycplasma and Chlamydia trachmatis; C. trachmatis is mst cmmn cause f bacterial STDs; transmitted thrugh ral and anal sexual cntact 157

164 Participant Manual AMS Dispensers Clinical Features Patients cmplain f mucus r pus appearing at the tip f the penis r staining underwear Burning pain n passing urine (dysuria) Examinatin may shw a scanty r prfuse discharge Treatment f Patients and Partners Ciprflxacin 500 mg single dse plus dxycycline 100 mg every 12 hurs fr 7 days If the partner is pregnant, give erythrmycin 500 mg every 6 hurs fr 7 days plus ctrimxazle 2.4 g (5 tabs) every 12 hurs fr 3 days. If discharge still persists, refer fr specialist management. Lwer Abdminal Pain Syndrme (Female)/Pelvic Inflammatry Disease (PID) Syndrme Causes Infectin f the uterus, tubes, and varies by N. gnrrhea, Chlamydia, and anaerbes Investigatin Take histry, check if perid verdue If pssible, examine the patient manually fr pregnancy, bleeding, recent delivery, r abrtin Check fr severe pain, vmiting, r rebund tenderness Treatment If any f the abve signs and symptms are fund, refer quickly fr further management. If nne f the abve signs and symptms are fund, give: Ciprflxacin 500 mg every 12 hurs fr 3 days Plus dxycycline 100 mg every 12 hurs fr 10 days Plus metrnidazle 400 mg every 12 hurs fr 10 days If there is an IUCD, remve it 2-4 days after cmmencing treatment. If n imprvement within 7 days, refer fr specialist management. 158

165 Mdule 3 Sessin 1. Management f Diseases f the Reprductive System Abnrmal Vaginal Discharge Syndrme An abnrmal vaginal discharge is ften the first evidence f genital infectin, althugh the absence f an abnrmal vaginal discharge des nt mean absence f infectin. Causes Can be a variety and ften mixture f rganisms Bacterial vaginsis Clinical Features In all cases: abnrmal increase f vaginal discharge; nrmal discharge is small in quantity and white t clrless Gnrrhea prduces a thin mucid, slightly yellw pus discharge with n smell Trichmniasis causes a greenish-yellw discharge with small bubbles and a fishy smell and itching f the vulva Candida albicans causes a very itchy, thick, white discharge like sur milk Mycplasma and chlamydia may cause a nn-itchy, thin, clrless discharge Ectpic pregnancy and infertility are the mst serius cmplicatins Treatment If there is lwer abdminal tenderness with itching, reddening, r tenderness, treat as lwer abdminal pain syndrme and give: Ciprflxacin 500 mg every 12 hurs fr 3 days Plus dxycycline 100 mg every 12 hurs fr 10 days Plus metrnidazle 400 mg every 12 hurs fr 10 days If there is n lwer abdminal tenderness but there is itching, erythema, r excriatins, insert ne nystatin pessary 100,000 IU int the vagina at night fr 14 days r insert ne cltrimazle pessary 500 mg single dse at night fr 1 night plus metrnidazle 2 g single dse. If Pregnant Give erythrmycin 500 mg every 6 hurs fr 7 days plus c-trimxazle 2.4g (5 tabs) every 12 hurs fr 3 days D nt give c-trimxazle in the first trimester r after 36 weeks Pstpne giving metrnidazle until after the first trimester D nt give ciprflxacin r dxycycline Children (7-day curse) C-trimxazle 24 mg/kg every 12 hurs r erythrmycin 12.5 mg/kg every 6 hurs plus metrnidazle 12.5 mg/kg every 8 hurs If n imprvement within 7 days, refer fr specialist management. 159

166 Participant Manual AMS Dispensers Antibitic treatment is initiated upn prescriptin frm a health facility.if discharge still persists, infrm the patient t g t a higher facility fr specialist management. N lwer abdminal tenderness and n itching, erythema, r excriatins: Ciprflxacin 500 mg stat Plus dxycycline 100 mg every 12 hurs fr 7 days Plus metrnidazle 2 g single dse Preventin The best way t prevent STDs is t avid sexual cntact with thers. If peple decide t becme sexually active, they can reduce the risk f develping an STD in these ways: Cunsel the patient n risk reductin, e.g., practice safe sex by using cndms, remaining faithful t ne sexual partner, persnal hygiene, aviding anal intercurse, r abstaining r delaying sexual relatins as lng as pssible. Encurage t crrectly and cnsistently use a male latex cndm. Have regular checkups. Avid having sex during menstruatin; HIV is passed mre easily at this time. 160

167 Sessin 2. Family Planning Objectives 1) Identify and cunsel thse at risk n different family planning methds. 2) Explain types and categries f all family planning methds in Liberia t enable clients t make vluntary and infrmed chices. 3) Screen, initiate, and instruct clients n taking ral pills and using cndms. 4) Cunsel and refer clients fr cntraceptive methds nt available at the medicine stre 5) Recgnize and refer clients with cntraceptive-related side effects and cmplicatins. 6) Give health educatin abut STIs (very imprtant), e.g., including symptms f STDs. Prvide specific educatin n the need fr early reprting and cmpliance with treatment 7) Ensure ntificatin and treatment f sexual partners 8) If necessary and pssible, schedule return visits Time 8-10 hurs Rle Play Scenari 1 A 31-year-ld wman wh gave birth 7 weeks ag has cme t yur drug shp t buy a syrup fr her baby. She wants t delay anther pregnancy fr at least 2 years. She asks yu t assist her. She is breast-feeding her baby, but during the day when she is at wrk in the market, her mther-in-law gives the baby milk frmula. Hw can yu help her? Scenari 2 Mrs. Cecilia, wh is 19-years ld and living with her husband, develped high bld pressure when she was pregnant, but it returned t nrmal after a nrmal delivery f her baby girl 3 mnths ag. She is exclusively breast-feeding and has cme t buy paracetaml syrup at yur drug shp n her way back hme frm the MCH clinic where she had her baby immunized. She wants t have anther baby within tw years and has n knwledge abut family planning (FP) services. Hw can yu help her? Scenari 3 Princess Jhnsn is an 18-year-ld wh cmes t yur accredited shp fr a pregnancy test because a cndm had brken during intercurse the night befre. Her last menstrual perid was 13 days ag and was nrmal. She always has a mnthly menstrual cycle. She is extremely nervus abut pregnancy because she still stays in her father s huse. She states there have been n ther acts f unprtected intercurse since her last menstrual perid. She did take ral cntraceptives briefly in the past but discntinued use due t weight gain and md swings. 161

168 Participant Manual AMS Dispensers Hw can yu help her? Rle and Tasks f the Drug Seller in Delivering Selected FP Methds 1) Educate and cunsel clients n ral pills and cndms Identify and cunsel thse at risk n different FP methds. Plan, cnduct, and evaluate individual and grup educatinal and cunseling sessins fr FP. Give clear infrmatin abut all FP methds t enable clients t make vluntary, infrmed chices. 2) Manage clients n ral pills and cndms Apply knwledge f reprductive anatmy and physilgy t client cunseling fr ral pills and cndms. Initiate use f ral pills and cndms n the basis f clients infrmed chices, medical and scial histry, and checklist assessment. Instruct clients n use f ral pills and cndms. Cunsel and refer clients fr cntraceptive methds nt available at the medicine stre. Crrectly prescribe and dispense ral pills and cndms. Refer clients with cntraceptive-related side effects and cmplicatins t trained health wrkers. 3) Manage FP services in the drug shp Prvide ral FP methds and cndm services as an integral part f ther drug sales. Prcure and maintain stcks f ral pills and cndms in the drug shp. Maintain accurate recrds f FP services and submit drug shp FP service returns/reprts t the apprpriate authrity. Use data frm mnthly reprts t mnitr and evaluate FP integratin int drug shp activities. High-Risk Cncept in Family Planning/Reprductive Health Service Delivery A high-risk client in FP/reprductive health (RH) is ne whse life and that f her baby/baby-tcme are threatened by pregnancy. Fr example: Yung mthers under 20-years ld: Children brn t yung mthers and thse brn after a shrt birth-interval are subject t much higher mrtality rates than thse brn t lder mthers and after lnger birth intervals. All sexually active males and females are at risk f cntracting STI/HIV; behavirs that put the individual r cuple at risk include practicing unprtected sex, having mre than ne sexual partner, r having sex with an infected persn withut prtectin. Certain wmen and/r their unbrn babies are likely t have prblems during pregnancy and child birth and after delivery. The service prvider needs t pay special attentin t them. 162

169 Mdule 3 Sessin 2. Family Planning Table 15. Cnsequences f the 4 Ts Cncept Cnsequences t the mther Cnsequences t the baby T early: Having a pregnancy befre 20 years f age T sn: Having a pregnancy within an interval f less than 2 years T many: Having mre than fur pregnancies T late: Having a pregnancy after 35 years f age Difficult delivery because f an immature birth passage Pregnancy-induced hypertensin, which creates risks fr mther and baby (e.g., assisted deliveries that may result in birth injuries) Unwanted pregnancies, resulting in abrtin and pst-abrtin cmplicatins Lack f rest and time t replace lst bld, weak, and anemic; maternal depletin syndrme Repeated child birth can t lead t: Antepartum/pstpartum hemrrhage in the successive pregnancies Malpsitins, leading t assisted deliveries At the age f 35, pelvic bnes begin t harden, making it difficult t give way fr the baby t be brn; mther is likely t have bstructed/ difficult delivery, caesarean sectin Unwanted, prly cared fr, illnesses, and neglect Abandned r thrwn away Premature birth with lw chance f survival Lw birth weight Insufficient time t breast-feed, baby will have lwered immunity, diarrhea Lack f care and lve Premature deliveries, small even at full term Cmpetitin f children fr parental lve and care may lead t inadequacies amng sme f the children Baby may be brn with prblems such as cngenital handicaps r prematurely r small fr dates. What is Family Planning? It is abut deciding when t have children A cuple r an individual decides: When t start and when t stp having children Hw many children t have Hw ften t have children 163

170 Participant Manual AMS Dispensers Male Reprductive System Surce: OpenStax Cllege. Human Reprductin [OpenStax-CNX Web site]. June 28, Available at: Figure 10. Male reprductive rgans Penis The part f man s bdy that depsits the man s seeds int the vagina and als the rgan fr urinatin. The cndm is wrn ver the penis. Urethra This is a single tube apprximately 15 cm running frm the bladder thrugh the penis and is a passage fr urine and als fr seminal fluid. Vas deferens Tw tubes that carry sperm frm the testicles t the penis. This is the site fr vasectmy; these tubes are tied and cut s that they can n lnger carry the man s seeds frm the testicles t the penis. 164

171 Mdule 3 Sessin 2. Family Planning Vasectmy des nt affect sperm prductin; the testes cntinue t prduce sperm, but after maturing, they degenerate and are absrbed int the bdy. Seminal vesicles These tw accessry glands lie psterir t and at the base f the bladder and secrete the liquid prtin f the semen, which cntributes t the viability f the sperm. Mature sperm are stred here until they are ejaculated during sexual intercurse r passed during wet dreams. The seminal vesicles cntinue t prduce semen even after vasectmy. This infrmatin helps t dispel the myth that a man will cntinue t ejaculate, but the ejaculatin will have n sperm. Testes Tw balls inside the scrtum; they prduce sperm and sex hrmnes and stre sperm. The mature sperm can live abut 3-5 days in a wman s genitals after ejaculatin. Epididymis These are tw cmma-shaped ciled tubes abut 5-6 meters r 20-feet lng ciled n tp f each f the testes. It stres sperm fr abut 10 days until they mature. But, if after 4 weeks, the sperm are nt passed t the vas deferens, they are absrbed int the bdy. Prstate gland One f the accessry glands that secretes a fluid that helps sperm mve and neutralizes the acidity in the penile urethra and the vagina. Cwper s glands Tw accessry glands abut the size f peas, lying beneath the prstate; they prduce semen and an alkaline secretin that prtects sperm against the acid secretins f the male urethra and vagina. After the remval f the prstate gland, the Cwper s glands cntinue t secrete alkaline fluid. Scrtum It is a sac that cntains and prtects the testes. It regulates the temperature f the testes which is critical fr their nrmal functin. 165

172 Participant Manual AMS Dispensers Female Reprductive System Surce: OpenStax Cllege. Human Reprductin [OpenStax-CNX Web site]. June 28, Available at: Figure 11. Female reprductive rgans Vagina This is the passage frm utside f the female bdy t the uterus. It is the utlet fr menstrual flw, entry fr the penis during sexual intercurse, and passage fr a baby at birth. This is where the female cndm is applied and can be fund here if it slips ff during intercurse. Threads fr intrauterine device (IUD) device can be felt in the vagina. Cervix This is the muth f the uterus (wmb). It allws the menstrual bld t cme ut frm the uterus and sperm t enter the uterus frm the vagina. It dilates and permits the birth f a baby frm the uterus. Uterus The uterus is a muscular, pear-shaped rgan where the baby grws and is nurished until ready t be brn. Every mnth, the wmb prepares itself fr a baby by making a thick lining. If there is n baby, the wmb thrws away the lining, that is, mnthly bleeding riginates here. The baby grws in the wmb during pregnancy. Fallpian Tubes Tw tubes cnnecting the varies t the wmb. One egg travels alng the tube frm the vary t the wmb every mnth and if it meets the man s seeds, then they jin t start making a baby. 166

173 Mdule 3 Sessin 2. Family Planning In a tubal ligatin, the fallpian tubes are tied and cut s that the passage is blcked, and the wman s egg and male seed cannt meet t make a baby. Ovaries Tw sacks n each side f the wmb cntaining 300, ,000 egg cells at birth. One egg (vum) matures and is released int the fallpian tube every mnth. Ovaries secrete female hrmnes, estrgen and prgesterne, which change a girl int a wman at puberty and cntinue t secrete female hrmnes after puberty. When a wman is using hrmnal FP, the eggs d nt mature and are nt released frm the varies. Therefre, there is n unin f the female egg and the male seeds t make a baby. Menstrual Cycle When a girl is brn, she has thusands f egg cells, r va in her tw varies. Each egg is the size f ne grain f sand. The tiny dts in the tw varies are the eggs. Each mnth, ne egg ripens and leaves the varies; this is vulatin. The egg is picked up by the brad end f the fallpian tube and starts mving tward the uterus. At the same time, the uterus starts getting ready fr the egg by thickening its inner lining. An egg can grw int a baby nly if it meets a sperm cell frm a male. If the sperm and egg meet, a wman becmes pregnant. The fertilized egg attaches t the thick lining f the uterus. This lining nurishes and supprts the baby until birth. If the egg is nt fertilized by a sperm, the lining is nt needed and it breaks dwn. The lining, tissue, and the egg flw ut f the uterus thrugh the vagina and leave the bdy; this is menstruatin. Menstruatin ccurs apprximately 14 days after vulatin, if the egg is nt fertilized. Menstrual perids may last 2-8 days; the average menstrual perid lasts 4-6 days. The menstrual cycle ccurs abut every mnth until a wman ges thrugh menpause. It als stps during pregnancy and starts again after the baby is brn. The menstrual cycle starts frm day 1 f menstruatin and cntinues t the day befre the first day f the next menstruatin. On average, it is usually 28 days in duratin, but may vary frm 21 t 35 days r mre. It cnsists f the menstrual phase, the estrgen (prliferative) phase, and the prgesterne (secretry) phase. Menstruatin (als called perids because they ccur every mnth) marks the nset f sexual maturity in girls. Menstruatin is the peridic shedding f bld and tissue frm the female reprductive rgan called the uterus. Beginning t menstruate means a girl is capable f becming pregnant and having a baby. Phases f the Menstrual Cycle and Clinical Applicatins Hrmnes are natural chemicals carried in the bld stream that influence hw glands and rgans wrk. Lw levels f hrmnes give feedback messages t the brain t release hrmnes I and II at apprpriate intervals which make the anterir pituitary lbe release fllicle-stimulating hrmne (FSH) r luteinizing hrmne (LH), depending n the gnadtrpin-releasing hrmne. 167

174 Participant Manual AMS Dispensers Table 16. Female Reprductive Cycle Phase Menstrual phase, days 1-7 Changes that take place Ovaries: Crpus luteum (shell that vum has been released frm) shrivels and dies; levels f prgesterne and estrgen drp. Uterus: Inner lining f uterus is shed. Cervix: Bld flws frm the cervix and is visible externally (the menstrual perid). Hypthalamus: Receives message t release FSH releasing factr (FSHRF). Estrgen (prliferative) phase, apprximately days 7-14 Prgesterne (secretary) phase, apprximately days Clinical applicatins: The uterus is nt ready fr pregnancy during this perid; therefre, it is safe t start clients n FP methds n days 1-7 as the chances f pregnancy are extremely lw in the majrity f wmen. Anterir pituitary lbe: Releases FSH t the varies due t presence f FSHRF Ovaries: FSH stimulates/activates the varian fllicles (eggs) t grw and as they d s, high levels f estrgen and sme prgesterne are released. Uterus: Estrgen starts re-grwth f inner lining f the uterus, which becmes thick and firm. Cervix: Estrgen makes cervical mucus thin, clear, and stretchy t assist entry and t nurish sperm. High levels f ne hrmne send a message back t the brain and anther hrmne is released. At varies: Eggs begin t grw faster; ne matures and is released frm the vary int the fallpian tube. This mature egg is ready fr fertilizatin. This prcess is called vulatin. A mature egg is released frm a shell which is a yellw bdy r crpus luteum, which releases high levels f prgesterne and estrgen. Uterus: Prgesterne makes the lining f the wmb thicker and richer in bld supply, ready fr implantatin. Cervix: Mucus becmes dryer and stickier, plugging the cervix and blcking the passage f sperm. If n pregnancy ccurs, the yellw bdy (crpus luteum) shrinks and levels f estrgen and prgesterne drp. The inner lining f the wmb begins t shrink and shed, starting a new cycle. If pregnancy ccurs, the yellw bdy cntinues t prduce prgesterne and estrgen until the placenta takes ver. Clinical applicatins Prgestin in FP methds alters the cervical mucus making it thick and nt easy fr sperm t pass. Hence, the quick (24 hurs) prtectin against pregnancy by Dep Prvera, prgestin-nly pills (POPs), and Nrplant. The fact that vulatin ccurs befre menstruatin explains the risk f pregnancy befre menses in pst-abrtin and pstpartum wmen, and unnticed pregnancy in wmen with lactatin amenrrhea. Just as the lwering f hrmnes causes shedding f the inner lining f the wmb if a wman frgets t take three r mre pills, she gets withdrawal (lwering f hrmnes) bleeding. Methds that cntain high levels f prgestin with n withdrawal, such as Dep Prvera r Nrplant, switch ff FSH and LH and therefre cause amenrrhea with prlnged use. Emergency cntraceptive pills (ECPs) prevent fertilizatin. 168

175 Mdule 3 Sessin 2. Family Planning Types f FP Methds Available in Liberia Hrmnal cntraceptive methds Oral pills: cmbined ral cntraceptives (COCs; L-feminal, Micrgynn, and Pill Plan) and POPs (Overette and Micrval) Injectables (dept medrxy prgesterne acetate [DMPA/Dep Prvera]) and implants (Nrplant, Jadelle, and Implann IUDs, such as the cpper T380A Barrier methds, such as female and male cndms Natural FP: lactatinal amenrrhea methd (LAM), fertility awareness methds, mn beads Permanent methds: tubal ligatin and vasectmy Cmbined Oral Cntraceptives COCs prevent pregnancy by suppressing vulatin and thickening the cervical mucus, thus making sperm entry difficult. COCs cntain tw hrmnes, namely, artificial estrgen and prgestin. They are taken rally and daily t prevent pregnancy. COCs are very effective when used prperly; abut 3 in 1,000 wmen (0.3%) wh use COCs crrectly and cnsistently get pregnant in the first year f use. L-feminal and Micrgynn are fund in the public sectr health facilities whereas Dufem (Pilplan) is fund in the private sectr. COCs d nt prvide prtect against STIs, including HIV. Advantages and Nn-Cntraceptive Benefits f COCs Cause perids t be regular and predictable Reduces menstrual bld lss which prevents anemia Reduces painful perids, where pain is nt caused by infectin Can be used as an emergency cntraceptin Are very effective if taken crrectly Are easily reversible Are safe fr mst wmen Are independent f citus Disadvantages and Cmmn Side Effects f COCs Must be taken daily Requires regular and dependable supply Reduces breast milk, especially in the first six mnths after delivery Minr side effects cmmn in first three mnths may include sptting, amenrrhea, nausea, breast tenderness, headaches, weight gain, depressin, and acne 169

176 Participant Manual AMS Dispensers Wmen Wh Can Use COCs All wmen f reprductive age wh wish t can use COCs, including wmen with: Anemia, but the basic prblem causing anemia must be evaluated and treated Painful perids nt caused by infectin Irregular cycles Histry f ectpic pregnancies Bld pressure less than 160/100 mm Hg Unexplained vaginal bleeding Thyrid disease Benign breast disease STIs, including HIV and AIDS Wmen Wh Shuld Nt Use COCs Thse wh are pregnant Have cmplicatins r side effects that a service prvider is nt capable f handling Mthers wh have been breast feeding less than six mnths Wmen with: Heart disease High bld pressure Diabetes Headache with blurred visin Yellw clring f the eyes Wmen wh smke cigarettes and are ver 35 Wmen taking ther drugs fr cnditins such as TB, epilepsy Wmen wh are absent minded r mentally retarded Signs f Prblems that Require Urgent Medical Attentin Severe headaches with blurred visin Severe cnstant pain in the chest with difficulty in breathing Acute abdminal pain Pain in the calf muscle Eyes r skin becme unusually yellw Prgestin-Only Cntraceptives (POPs, Injectables, and Implants) POPs are effective fr seven days, and the effectiveness is maintained by swallwing every day at the same time. Injectables are effective within 48 hurs; specifically fr DMPA, effectiveness will last 12 weeks. Prviders are als reminded that the effectiveness f injectables and implants depends n giving the injectin fllwing the crrect prcedure and fllwing infectin preventin prtcls. 170

177 Mdule 3 Sessin 2. Family Planning Implants The new implants (Jadelle and Implann) are different frm the Nrplant implants. Nrplant was effective within 48 hurs and was used fr 5 years, whereas the new nes are effective fr 3 years. Effectiveness depends n prper insertin under the skin (subdermally). The side effects are temprary and stp (usually within three mnths) when the bdy gets used t the implant. All cntraceptives that cntain nly prgestin are referred t as prgestin-nly cntraceptives (POCs). In Liberia, the majr types f POCs available include ral pills, injectable, and implants. All POCs prevent pregnancy in tw ways by thickening the cervical mucus within 24 hurs making it difficult fr sperm t enter the uterus and/r inhibiting vulatin. Table 17. Types f POCs Type f POC Name Descriptin Oral pills POP The ne fund in the health units in Liberia is Overette. Injectable DMPA The cmmn name is Dep Prvera, marketed as Injecta Plan. It is fund in public sectr health facilities. Implants Implann A single rd (capsule) prvides cntraceptive prtectin fr 3 years Jadelle Cnsists f tw rds (capsules) Prgestin-Only Pills Effectiveness POPs are mst effective when taken at the same time every day. A delay f nly three hurs may result in pregnancy if the wman has unprtected sexual intercurse in that time. Fr breast-feeding wmen, POPs are very effective when taken crrectly because breastfeeding itself prvides much prtectin against pregnancy. A pregnancy may ccur in 1 f every 100 wmen in the first year f use. POPs are als very effective when used crrectly and cnsistently in bth breast-feeding and nn-breast-feeding wmen. A pregnancy may ccur in 1 f every 200 wmen in the first year f use. Advantages and Nn-Cntraceptive Benefits Very effective if taken crrectly Can be very effective during breast-feeding, if started six weeks after delivery Des nt suppress lactatin N estrgenic side effects Easy habit t establish; because ne pill f the same clr is taken every day with n break, it is easy t make it a habit 171

178 Participant Manual AMS Dispensers Suitable fr thse with hypertensin, cardiac, r sickle cell disease Des nt increase bld cltting Cmmn Side Effects and Disadvantages Wmen wh are nt breast-feeding may have: Sptting r bleeding between perids Amenrrhea Mild headache Breast tenderness An increased risk f pregnancy, if the pill is taken even a few hurs late Des nt prtect against STIs r HIV Dep Prvera (DMPA) Very effective; a pregnancy may ccur in 1 f every 33.3 wmen when injectins are given regularly, every 12 weeks. Advantages and Nn-Cntraceptive Benefits Des nt suppress lactatin Client nly has t remember the return date fr subsequent injectins, i.e., it is private, n ne needs t knw that the wman is n it Can be used at any age N estrgen side effects May reduce the frequency f epileptic and sickle cells crises Disadvantages and Cmmn Side Effects Changes in menstrual bleeding: sptting (mst cmmn at first), amenrrhea (nrmal after first year f use), heavy bleeding (rare) Weight gain Delayed return f fertility, have t wait abut fur mnths lnger t get pregnant after stpping use Mild headaches Breast tenderness Lss f libid Mdiness Nausea Acne r hair lss Requires injectin every three mnths Des nt prtect against STIs r HIV Implants There are tw types f implants in Uganda, i.e., Implann and Jadelle. 172

179 Mdule 3 Sessin 2. Family Planning Effectiveness Implants are very effective, nly 1 pregnancy per 1000 wmen ccurs in the first year f use. Pregnancy rates have been slightly higher amng wmen weighing mre than 70 kg. Advantages and Nn-Cntraceptive Benefits Very effective even in heavier wmen Effective within 24 hurs after insertin N delay in return t fertility after remval Lng acting; needs replacement after three years N repeated clinic visits required Helps t prevent irn deficiency, anemia, and ectpic pregnancy Makes sickle cell crises less frequent and less painful N effect n breast milk N estrgen side effects Little r n pain frm anesthesia injectin Cmmn Side Effects and Disadvantages Changes in menstrual bleeding: sptting, heavy bleeding (rare), r amenrrhea Minr surgical prcedure required fr insertin and remval Discmfrt in the arm after insertin Des nt prtect against STIs including HIV and AIDS Weight gain Headaches Dizziness Breast tenderness Mdiness Nausea Acne, skin rash Change in appetite Hair lss r mre hair grwth n the face Client cannt start r stp using an implant n her wn; the capsules must be inserted and remved by a specially trained health care prvider Wmen with the Fllwing Cnditins Can Use POCs Pst abrtin (anytime) Breast feeding mthers; can be started after six weeks pstpartum Sickle cell disease Diabetes, withut evidence f hypertensin r histry f a heart attack Smkers Hypertensin with bld pressure nt higher than 140/100 Headaches, including migraines Cngenital heart disease Unexplained vaginal bleeding (althugh evaluatin shuld be dne as sn as pssible t 173

180 Participant Manual AMS Dispensers rule ut underlying malignancy), except fr DMPA and implants Cervical, endmetrial, r varian cancer (awaiting definitive treatment) Thse underging treatment with the antibitic grisefulvin Thse underging treatment with antiretrvirals, althugh effectiveness f the POC may be reduced Wmen Wh Cannt Use POCs Breast-feeding less than six weeks pstpartum Pregnant mthers (althugh there is n harm t wmen r the fetus if POCs are accidentally used during pregnancy) Under treatment fr current breast cancer r have a histry f breast cancer Under treatment fr epilepsy with phenytin r TB with rifampicin Current deep venus thrmbsis Active viral hepatitis Severe cirrhsis r liver tumrs Signs f Prblems that Need Urgent Medical Attentin Repeated severe headaches that start r becme wrse while client is n POCs Missed r delayed menstrual perid after several mnths f regular menses Severe lwer abdminal pain, which maybe a sign f ectpic pregnancy Very heavy vaginal bleeding, twice as much r twice as lng as usual Client shuld reprt back t the clinic if any f the fllwing ccur at the injectin r insertin site: Pus Prlnged pain Bad smell Feels ht t the tuch Redness Bleeding Specifically fr implants, if the capsule cmes ut r skin r eyes becme unusually yellw IUDs The IUD is a plastic and cpper device that is inserted in the uterine cavity t prevent pregnancy. In Liberia, the cpper T 380A is the mst cmmn IUD used. It is T-shaped, with cpper n its stem and arms. It has a shelf-life f 10 years and an intrauterine life f 12 years. Mechanism f Actin f IUD Cpper-bearing IUDs like the cpper T 380A act primarily by preventing fertilizatin. Cpper ins emitted frm the IUD decrease sperm mtility and functin by altering the uterine and tubal 174

181 Mdule 3 Sessin 2. Family Planning fluid envirnment which means that sperm rarely reach the fallpian tubes and are unable t fertilize the vum. Effectiveness f IUD Cpper T 380A IUDs are 96-99% effective. Hwever, their effectiveness depends n the skillfully the service prvider places the device during insertin. Advantages f IUDs (Cpper T 380A) Easily reversible Lng-term cntraceptin N hrmnal-related side effects Minimal attentin needed; the user needs t check that the IUD is still in place (by checking n the strings) and uses pads during menstrual perids Can be inserted immediately after delivery up t 48 hurs r six weeks after delivery Safe fr mst wmen Only ne fllw-up visit after insertin is required unless a client has prblems Mre ecnmical than ther methds Private N interactins with medicatins a wman may use Disadvantages and Side Effects f IUDs Mild cramps during the first few days (3-5) after insertin May experience lnger and heavier menses in the first three mnths after insertin Increased nrmal vaginal discharge in first three mnths after insertin Sptting between menstrual perids Increased menstrual cramps Expsure t injectin during insertin and remval Are service prvider dependent May be partially r cmpletely expelled frm the uterus Des nt prtect against endmetrial r varian cancer Prtectin against STIs/HIV/AIDS IUDs d nt ffer prtectin against STIs nr HIV. If a client is at a risk f STIs, there is an increased risk f PID and subsequent infertility if an IUD is inserted. Wmen Wh Can Use an IUD Wmen f reprductive age wh prefer a nnhrmnal, highly reliable methd f cntraceptin that des nt require daily attentin Wmen and cuples wh have reached their desired family size and d nt want underg sterilizatin Wmen wh have truble with crrect and cnsistent use f ther cntraceptive methds (e.g., remembering t take pills n time, negtiating cndm use with a partner) 175

182 Participant Manual AMS Dispensers Wmen at lw risk f STIs The IUD can be used withut restrictins r generally used by wmen f any age and parity wh may als have the fllwing cnditins. Breastfeeding Current r histry f cardivascular disease r strke Headaches, including migraine Wmen Wh Shuld Nt Use an IUD The IUD is nt generally recmmended r is cntraindicated fr wmen with the fllwing: Pregnancy Distrted uterine cavity incmpatible with IUD insertin (including uterine fibrids) Unexplained vaginal bleeding (befre evaluatin) Cervical, endmetrial, r varian cancer Current PID High individual likelihd f expsure t gnrrhea and chlamydia Signs f Prblems that Warrant Immediate Return t the Clinic Severe lwer abdminal pain Pain during intercurse Fever Ful-smelling vaginal discharge Missed perids Missing strings Prlnged vaginal bleeding Sptting Permanent Methds f Cntraceptin Vasectmy is a permanent methd f cntraceptin in which the tubes (vas deferens) thrugh which sperm travel frm the testes t the penis are tied and cut s that sperm can n lnger enter the semen that is ejaculated. Tubal ligatin is a permanent methd f cntraceptin whereby bth fallpian tubes are tied and cut using a mdern peratin (Mini-Lap) s that the vum cannt travel thrugh them t meet the sperm and be fertilized. These methds are cnsidered vluntary because the decisin is made by an individual r cuple after receiving prper cunseling and withut any bias r influence frm anyne else. 176

183 Mdule 3 Sessin 2. Family Planning Vasectmy Vasectmy is % effective. Hwever, effectiveness is nt immediate; it usually takes at least 20 ejaculatins t clear sperm frm the seminal vesicles. Cndms r anther cntraceptive methd shuld be used until then. The surest way t cnfirm sterility is t bring a sample f semen t a clinic t determine whether it still cntains sperm after at least 20 ejaculatins. Advantages and Nn-Cntraceptive Benefits Permanent Surgery is relatively fast (usually less than 30 minutes) Very apprpriate fr cuples wh already have the number f children they want Requires nly a single prcedure and therefre is inexpensive in the lng term Prcedures are very safe, and majr cmplicatins are rare Des nt require hspitalizatin Des nt interrupt lve-making Disadvantages and Side Effects f Vasectmy Cnsidered irreversible May cause pain and skin disclratin in area f incisin (treatable) May cause swelling and disclratin f the scrtum (treatable) Sexual relatins must cease until tw r three days after the prcedure and can resume nly if there is n discmfrt A cndm r anther methd needs be used fr the next 20 ejaculatins Prtectin Against STI/HIV Infectin frm Vasectmy Vasectmy ffers n prtectin against STIs and HIV. Men Wh Can Have a Vasectmy In general, the majrity f men wh want vasectmy can have a safe and effective prcedure in a rutine setting, prvided they have been cunseled. They shuld als be able t give infrmed, written cnsent. Men wh may cnsider sterilizatin include thse: Wh are certain that they have achieved their desired family size Wh want a highly effective, permanent cntraceptive methd Whse wives face unacceptable risk in pregnancy Men Wh Shuld Nt Have a Vasectmy There are n medical cnditins that wuld abslutely restrict a man s eligibility fr vasectmy. Sme cnditins and circumstances indicate that the prcedure shuld be delayed r that certain precautins be taken. 177

184 Participant Manual AMS Dispensers Lcal infectins (scrtal skin infectin) Current STI Systemic infectin r gastrenteritis Men r cuples wh are nt certain that they have cmpleted their family size Men making the decisin because f scial prblems Men r cuple wh d nt understand that vasectmy is permanent Signs f Prblems frm Vasectmy Warranting Immediate Return t Clinic Bleeding at the incisin site r internally Infectin at the incisin site r internally Injury t abdminal rgans Bld clts in scrtum Tubal Ligatin Tubal ligatin is a permanent methd f cntraceptin whereby bth fallpian tubes are tied and cut using a mdern peratin (Mini-Lap) s that the vum cannt travel thrugh t meet the sperm and be fertilized. The prcedure can be btained at any public r private hspital r ther health facility. Effectiveness The prcedure is mre than 99% effective. Less than 1 wman in 100 may becme pregnant within tw years. Advantages Private Permanent Very apprpriate fr cuples wh already have the number f children they want Requires nly a single prcedure and therefre is inexpensive in the lng term Prcedures are very safe and majr cmplicatins are rare Disadvantages and Side Effects Once it has been dne, it cannt be reversed Needs cuple cnsent Minr cmplicatins, such as slight bleeding and wund infectin, ccur in less than 5% f cases Prtectin Against STI/HIV Infectin frm Tubal Ligatin Tubal ligatin ffers n prtectin against STI/HIV. 178

185 Mdule 3 Sessin 2. Family Planning Wmen Wh Can Have Tubal Ligatin Wmen wh may cnsider tubal ligatin include: Thse wh are certain that they have achieved their desired family size Thse wh want a highly effective, permanent methd f cntraceptin Thse fr whm pregnancy presents an unacceptable risk such as Wmen wh have had fur r mre previus caesarean sectins Wmen with medical cnditins Cuples r wmen wh understand and vluntarily give infrmed cnsent fr the prcedure Wmen Wh Shuld Nt Have Tubal Ligatin N medical cnditin abslutely restricts a wman s suitability fr tubal ligatin. Hwever, tubal ligatin shuld be delayed in case f: Pregnancy Pstpartum (between day seven and six weeks) High bld pressure, prlnged rupture f membranes (24 hurs r mre), infectin, bleeding befre r sn after delivery Cmplicated abrtin (infectin, hemrrhage) Current bld clts in the veins Current ischemic heart disease Unexplained vaginal bleeding (befre evaluatin) Current PID r purulent cervicitis Current gall bladder disease Acute respiratry disease Severe anemia Acute respiratry disease Abdminal skin infectin Wmen r cuples wh are nt certain f their desired family size Wmen requesting tubal ligatin because f scial prblems Timing Within the first seven days after childbirth (if she made vluntary, infrmed chice in advance) Six weeks r mre after childbirth Immediately after an abrtin (if she made vluntary, infrmed chice in advance) Any ther time, prvided pregnancy is ruled ut (but nt between seven days and six weeks pstpartum) During caesarean sectin Signs f Prblems frm Tubal Ligatin Warranting Immediate Return t the Clinic Severe bleeding at the incisin site r internally Infectin at the incisin site r internally Injury t abdminal rgans 179

186 Participant Manual AMS Dispensers Cndms (Male and Female) A cndm is a thin rubber sheath wrn n an erect penis (by men) r inserted int the vagina (by wmen) t prevent the male ejaculate frm mixing with the female vaginal secretin. A cndm serves a dual purpse. It prtects the wman frm pregnancy by preventing entry f sperm int the vagina. It als prtects bth the male and female frm cntracting STI/HIV because it prvides a barrier that prevents male and female fluids frm meeting during sexual intercurse. If used crrectly, cndms keep sperm and any disease rganisms in the semen ut f the vagina and likewise they als stp any disease rganisms in the vagina frm entering the penis. Effectiveness It is very imprtant t use the cndm crrectly and cnsistently t be highly effective. When used crrectly every time, nly 3 pregnancies may ccur per 100 wmen in the first year f use (1 in every 33). When nt used cnsistently and crrectly every time, 14 pregnancies may ccur per 100 wmen in the first year f use (1 in every 7). Advantages and Nn-Cntraceptive Benefits Prevents STIs, including HIV and AIDS, and pregnancy when used crrectly with every act f sexual intercurse Can be used alne r with anther FP methd as dual methds Helps prevent cnditins caused by STI s, e.g., PID, infertility in bth men and wmen, and pssibly cancer f the cervix Safe, n hrmnal side effects Offers ccasinal cntraceptin with n daily upkeep Invlves men in taking respnsibility fr cntraceptin and fr preventin f STIs Increases sexual enjyment because there is n wrry abut STIs r pregnancy Helps men with premature ejaculatin maintain an erectin Easy t btain, sld in many places including vending machines Can be used immediately after childbirth Disadvantages and Cmmn Side Effects Deterirates (lses structural integrity) quickly if strage is pr 180

187 Mdule 3 Sessin 2. Family Planning Slipping ff, tearing, and spillage f sperm can ccur, especially amng inexperienced users and users with inadequate vaginal lubricatin Cuple must take time t put the cndm n the erect penis befre sex User must be highly mtivated t use crrectly and cnsistently A man s cperatin is required fr a wman t prtect herself frm pregnancy and disease May embarrass sme peple t buy, ask partner t use, put n, take ff, and thrw away Latex cndms may cause itching in thse wh are allergic t rubber; sme peple may be allergic t the lubricant in sme brands Wh Can Use Cndms? Cndms can be used by any man r wman regardless f his r her health status. Peple wh may want t cnsider cndm use include: Men wishing t participate mre actively in FP Cuples wh have sexual intercurse infrequently Peple in casual sexual relatinships where pregnancy is nt desired Cuples needing a back-up methd while waiting fr anther cntraceptive methd t becme effective r when the wman has frgtten t take the pill Cuples wh need a temprary methd while waiting t receive anther cntraceptive methd Thse wh are at increased risk f STIs (e.g., when ne r bth partners have ther partners) Cuples where ne r bth partners are HIV psitive Wh Shuld Nt Use Cndms Men r wmen wh have an allergy t rubber Men wh are unwilling t use cndms cnsistently and crrectly Men wh cannt maintain an erectin when using a cndm Signs f Prblems that Require Urgent Medical Attentin Severe reactin t the rubber r the lubricant in sme brands f cndms 181

188 Participant Manual AMS Dispensers Natural FP with LAM LAM is a cntraceptive methd that relies n the cnditin f lactatinal infertility, which results frm specific breast-feeding patterns. There are three criteria and cre parameters that must be met t use LAM. 1. Wman s menses have nt returned. 2. Wman exclusively breast-feeds an infant. 3. Infant is less than 6 mnths ld. If any ne f the three criteria changes, a cmplementary cntraceptive must be started immediately. Hwever, nce the menses have resumed, lactatin will n lnger prtect a wman frm pregnancy. Six mnths after delivery, the chance that vulatin will ccur befre the first menstruatin significantly increases, even in a fully lactating amenrrheic (wh has nt seen menstruatin) wman. Any factr that causes a decrease in suckling can result in the return f vulatin and decreased milk prductin. These factrs include use f supplemental feeding, reductin in number f breast-feeds r increasingly lng intervals between breast-feeds, maternal stress, and maternal/child illness. As the time after delivery increases, as supplemental feeding is intrduced and suckling decreases, r when the feeding pattern is changed, prlactin levels will diminish, leading t varian fllicle develpment, vulatin, and menses. Effectiveness Effectiveness is 97-98% in the first six mnths pst-partum if the client is still amenrrheic and exclusively breast-feeding (n mre than 4 hurs between feeds in the day and 6 hurs at night with n supplementary baby fd). Advantages and Nn-Cntraceptive Benefits Very effective cntraceptive methd particularly during the first six mnths in exclusively breast-feeding wmen befre the return f menses Requires n medical r chemical substances Available and cnvenient Prtects baby against diarrhea and ther infectius diseases by prviding antibdies and by aviding expsure t cntaminated milk Prvides imprtant nutrients t the baby Prmtes bnding with the mther Disadvantages and Side Effects Effectiveness decreases: 182

189 Mdule 3 Sessin 2. Family Planning After six mnths Once the mther s menses have returned Once the baby starts n fds ther than breast milk If vulatin precedes a perid and therefre client culd becme pregnant befre having a perid Prtectin Against STI/HIV Infectin N prtectin against STI/HIV. Reasns t Initiate Client n Anther FP Methd Wman s menses have resumed Mther cannt breast-feed exclusively Baby cannt suckle well fr any reasn (e.g., illness) It is six mnths since delivery Mther is supplementing baby s feed Mther desires anther methd Screening Clients fr and Initiating Them n Oral Pills A drug shp peratr needs t screen FP clients s as t: Rule ut cntraindicatins and precautins t FP methd use Determine eligibility fr methd f chice, accrding t WHO criteria (WHO 2009) Ensure that the client is nt pregnant befre beginning t use any methd f cntraceptin What is Invlved in Screening Clients fr FP? A drug shp peratr will use the Checklist fr Screening Clients Wh Want t Initiate Cmbined Oral Cntraceptives t ask questins t ensure that the client des nt have any medical cnditins that may prevent her frm taking ral pills. Anther checklist Hw t be reasnably sure a client is nt pregnant shuld be used t exclude pregnancy. Initiating Clients n Oral Pills Hrmnal FP methds and IUDs are initiated after prper screening and yu are reasnably sure a client is nt pregnant. T easily apply the WHO eligibility criteria, (WHO 2009) the Ministry f Health has develped simple checklists. The checklists are based n WHO guidance and are designed t identify medical cnditins and high-risk behavirs that wuld prevent use f sme cntraceptive methds. 183

190 Participant Manual AMS Dispensers Table 18. When t Initiate FP Methds COCs POPs Cndms LAM Any time in the cycle nce certain the client is nt pregnant After 6 mnths pstpartum with LAM and pregnancy ruled ut Changing frm Dep Prvera r POP, even if having n perids 1 week after abrtin (first trimester)* 2 weeks pst-abrtin (secnd trimester) r pst-delivery and nt breast-feeding Any time in the cycle nce certain the client is nt pregnant Pstpartum perid with LAM if client nt pregnant At 6-8 weeks pstpartum Changing frm Dep Prvera r COC Immediately pstpartum r pst-abrtin Any time f the cycle As back up when: Starting COC Missing pills Drug interactin *When methd is started befre vulatin ccurs, it increases prtectin against pregnancy by suppressing/preventing vulatin. Immediately pstpartum Any time befre first 4 weeks pstpartum Ways t be Reasnably Sure a Wman is Nt Pregnant The Ministry f Health has develped a simple checklist fr use by FP prviders t help nnmenstruating clients safely initiate their methd f chice. The checklist is based n criteria endrsed by WHO t determine with reasnable certainty whether a wman is pregnant. The tl is very effective and can be used by any health care prvider wh needs t determine if a wman is pregnant. Pregnancy Checklist: Hw t be Reasnably Sure a Client is nt Pregnant Ask the client these six questins. If the client answers yes t any questin, stp and fllw the instructins. NO NO Did yu have a baby less than 6 mnths ag, are yu fully r nearly fully breast-feeding, and have yu had n menstrual perid since then? Have yu abstained frm sexual intercurse since yur last menstrual perid r delivery? YES YES NO Have yu had a baby in the last 4 weeks? YES NO Did yur last menstrual perid start within the past 7 days? YES NO Have yu had a miscarriage r abrtin within the last 7 days? YES NO Have yu been using a reliable methd f cntraceptin cnsistently and crrectly? YES If the client answered NO t all f the questins, pregnancy cannt be ruled ut. Client shuld await menses r use a pregnancy test. If the client answered YES t at least ne f the questins and she is free f signs and symptms f pregnancy, prvide client with desired methd. Figure 12. Pregnancy decisin tree 184

191 Mdule 3 Sessin 2. Family Planning Checklist fr Screening Clients Wh Want t Initiate COCs T determine if the client is medically eligible fr COCs, ask questins 1-9. If the client answers yes t any questin, stp and fllw the instructins after questin 9. NO 1. Are yu currently breastfeeding a baby under 6 mnths f age? YES NO 2. D yu smke cigarettes and are ver 35 years f age? YES NO 3. D yu have severe repeated headaches, ften n ne side, and/r pulsating, causing nausea, and which are made wrse by light, nise, r mvement? NO 4. D yu have serius liver disease r jaundice (yellw skin r eyes)? YES NO NO NO 5. Have yu ever had a strke, bld clt in yur legs r lungs, r heart attack? 6. D yu regularly take any medicine fr tuberculsis (TB) r seizures (fits)? 7. Have yu ever been tld yu have breast cancer r d yu have an abnrmal breast lump? NO 8. Have yu ever been tld yu have high bld pressure? YES NO 9. Have yu ever been tld yu have diabetes (high sugar in yur bld)? YES YES YES YES YES If the client answered NO t all f the questins 1-9, the client can use COCs. Ensure that yu ask questins t be reasnably sure that she is nt pregnant. If the client answered YES t any f the questins 1-7, she is nt a gd candidate fr COCs. Cunsel abut ther available methds r refer. If the client answered YES t questins 8 r 9, COCs cannt be initiated withut further evaluatin. Evaluate r refer as apprpriate, and give cndms t use in the meantime. Figure 13. Decisin tree fr starting patients n COCs Instructins t Clients n Taking Birth Cntrl Pills (COCs and POPs) Start taking yur first pill n days 1 t 7 f yur menstrual cycle. Take yur pills daily at the same time, preferably at bed time. This will help yu remember t take the pills and prevent any discmfrt such as nausea. D nt miss r skip taking the pill any day. If yu start taking pills after day 5 f yur cycle, yu need t use anther methd, such as cndms, r abstain frm sex fr ne week. 185

192 Participant Manual AMS Dispensers Taking the pill fr 7 days is enugh t suppress fllicular develpment (i.e., prtect yu frm pregnancy). Use cndms in additin t the pill if yu think there is any chance that yu r yur partner are at risk f expsure t STIs, including HIV. Yu will have yur perid when yu are taking the brwn pills. D nt stp taking the pills. Cntinue swallwing them. When yu finish ne packet, start n a new packet. Stre the pills and all ther medicines in a dry place and ut f reach f children. Return t the drug shp fr mre pills befre yu have finished yur last pack f pills. Nte: It is recmmended t give three cycles f COCs t clients at the initial visit. Instructins t Clients When They Miss Taking Pills (Including POPs) If yu miss ne white pill, take it as sn as yu remember, then cntinue t take ne daily until yu finish that packet. If yu miss taking the white pill tw r mre days in a rw, start taking them as sn as yu remember and cntinue ding s until yu finish the packet. Hwever, use cndms and/r jelly r abstain frm sexual intercurse until yu have taken ne white pill each day fr 7 days in a rw. A wman must take hrmne pills fr 7 days cntinuusly in rder t prevent vulatin reliably. If yu miss taking the brwn pill, d nt wrry. Skip the missed brwn pill, but cntinue t take the rest f the brwn pills until the end f the packet. If yu keep frgetting t take pills, yu may need t use anther methd that is easier fr yu t use. Yu shuld return t the drug shp r g t the health facility fr cunseling n anther methd. Minr Side Effects Nausea, headaches, r sptting; if these last mre than three mnths, the client shuld cme back t the drug shp. What t Tell the Client If They have Diarrhea r Vmiting If yu have severe diarrhea r vmiting fr any reasn, yur pills may nt be wrking as well as they ught t. Therefre, if yu have severe diarrhea r vmiting, yu shuld use cndms r abstain frm sexual intercurse until yu are well and have taken the white pills fr 7 days after the vmiting and diarrhea stp. (This als applies t POPs.) 186

193 Mdule 3 Sessin 2. Family Planning What t Tell the Client If They Are Taking Other Drugs If yu are taking medicines, specifically rifampicin, grisefulvin, r anticnvulsants such as phenytin, carbamezapine, barbiturates, and primadne, the pill may nt wrk as well as is ught t, and yu shuld use cndms r jelly fr the time yu are taking the medicines and fr 7 days after yu have finished taking them. (This als applies t POPs). Tell the Client t Return Urgently t the Clinic if They Have Any f These Signs Severe abdminal r chest pain r shrtness f breath Severe headaches Sight prblems such as blurred visin r lss f visin Severe leg pain n the calf r thigh Pills and Medical Care Bring the pill packets with yu n each return visit. Mentin that yu are taking the pill (COCs) any time yu visit a health prvider r dctr, because certain medicines may interfere with the effectiveness f COCs. Tell the prvider if yu are n anti-tb treatment, antibitics, r antiretrvirals. (This als applies t POPs.) Instructins fr Clients n Hw t Use Cndms Check cndm packet t ensure that the packet is intact and there are n hles. Check cndm packet fr the expiry date t make sure that the cndm is still gd t use. If the cndm has expired, thrw it away and get a newer ne. Open the cndm packet carefully and take the cndm ut. Squeeze the tip f the cndm t remve the air; this will create space at the tip f the cndm. This will be the space fr the semen. Rll the cndm nt the erect penis up t the hairline befre it cmes int cntact with any f the wman s private parts. Immediately after the man ejaculates and while he is still hard, he shuld withdraw his penis frm the vagina while hlding the cndm n. This stps the semen frm spilling ut. Remve the cndm frm the penis carefully, making sure the semen des nt spill. A new cndm shuld be used fr each new act f sexual intercurse. Wrap the used cndm in a piece f paper and thrw it in a pit latrine r burn it. Hw t Keep Unused Cndms Keep cndms in a cl, dry place away frm the sun, insects, and rdents. Keep cndms where children cannt reach them. 187

194 Participant Manual AMS Dispensers Hw t Make the Cndm Mre Effective Cndms are mre effective if the wman uses faming tablets r jelly when the man uses the cndm. Never use a petrleum-based lubricant (such as Vaseline) with cndms because it can cause cndms t break. Instructins fr Clients n LAM Allw the client t ask questins at intervals and answer her questins factually. Fr LAM t wrk effectively, yu shuld: Breast-feed yur baby n bth breasts n demand at least 10 times during the day and night D nt give any slid fds r liquids t the baby ther than breast milk NB: Supplementary feeding makes the baby suckle less and breast-feeding will n lnger be effective as a cntraceptive methd. LAM will n lnger be an effective methd when: The baby fr any reasn des nt breastfeed exclusively Menstrual perids have resumed There are ther FP methds such as IUDs, cndms, Dep Prvera, implants, POPs, and spermicides that yu can use while breast-feeding. These methds d nt decrease breast milk. Yu will need t use anther cntraceptive methd when the baby cannt breast-feed exclusively fr any reasn, such as: Yu begin t wrk When yu r the baby are very ill When yu are nt prducing enugh breast milk When yur menstrual perids resume When the baby is being given slid fds r ther liquids Use cndms in additin t LAM if yu think there is any chance that yu r yur partner(s) are at risk fr STIs, including HIV. Guidelines n Dse/Quantity t be Given at the Initial Visit The Ministry f Health has apprved tw evidence-based strategies n initiatin f FP t imprve uptake f ral cntraceptives. 1) Prviding ral cntraceptives in advance is an imprtant strategy fr clients wh want t initiate use f ral cntraceptives but are nt able t rule ut pregnancy and are nt 188

195 Mdule 3 Sessin 2. Family Planning currently menstruating. Althugh such a client must wait fr menses t begin her first pack f pills, she des nt need t return t the drug shp at menses t receive her supply. As a prvider, yu may give her the pills t take hme with her t begin swallwing when she gets her menses. 2) Prvide mre than ne packs f pills during the initial and return visits. The number f packs prvided in advance depends upn the available supply. If supplies allw, WHO recmmends prviding up t a ne-year supply (13 packs) f pills fr new and returning COC users. Restricting the number f pill packs given t a client may result in discntinuatin f the methd when the wman is nt able t cme back fr resupply and may increase her risk fr pregnancy. Nte: The abve guidelines may nt be applicable in drug shps because mst clients can nly take the number f cycles they are able t buy. Cnducting Rutine Fllw-Up Visits fr FP COCs/POPs Ask hw the client is ding with the methd and whether she is satisfied. Ask if she has any questins r anything t discuss. Ask especially if she is cncerned abut bleeding changes. Give her any infrmatin r help that she needs. Ask if she ften has prblems remembering t take a pill every day. If s, discuss ways t remember, review what t d in case she misses the pill, and/r cunsel her fr anther methd. Ask a lng-term client if she has had any new health prblems since her last visit. Address prblems as apprpriate. Fr any new health prblem that may require switching the methd, cunsel the client. Ask a lng-term client abut majr life changes that may affect her needs, particularly plans fr having children and STI/HIV risk. Fllw-up as needed. LAM A wman can switch t anther methd anytime she wants while using LAM. If she still meets all three LAM criteria, it is reasnably certain she is nt pregnant. She can start a new methd with n need fr a pregnancy test, examinatins, r evaluatin. T cntinue preventing pregnancy, a wman must switch t anther methd as sn as any ne f the three LAM criteria n lnger applies. Help the wman chse a new methd befre she needs it. If she will cntinue t breastfeed, she can chse frm several hrmnal r nn-hrmnal methds, depending n hw much time has passed since childbirth. 189

196 Participant Manual AMS Dispensers Emphasize that all clients shuld cme back t yu r g the nearest health facility as sn as they ntice any prblem r cncerns at any time. WHO Instructins n Missed Pills In 2004, WHO simplified recmmendatins t wmen wh miss pills (WHO 2004). Cunseling COC clients by using the new missed pill instructins may help decrease failure rates. The new recmmendatins state: A wman wh misses any number f hrmnal pills shuld take a hrmnal pill as sn as pssible and then cntinue taking ne pill each day. A wman wh misses three r mre hrmnal pills in a rw needs t take an additinal step. She shuld use cndms r abstain frm sex until she has taken hrmnal pills fr seven days in a rw. A wman must take hrmnal pills fr seven days cntinuusly in rder t prevent vulatin reliably. Fr all cmplaints n bleeding n FP methds, refer the client t trained health prviders. 190

197 Sessin 3: Maternal and Child Health Objectives 1) Prvide care fr mthers, new brn, infants, and children 2) Identify danger signs in mthers and children that require referral Time 3-4 hurs Services fr Pregnant Mthers and Mthers f Children An AMS seller shuld ffer the fllwing services t pregnant mthers and mthers f children under 5 years: Assessment, identificatin, and treatment f illnesses Advice n when and where t access ANC and pst-natal checks (health centers II, III, and IV and hspitals) General advice n hw t care fr newbrns and children up t three years Assessment f newbrn babies fr any danger signs and referral t a health facility Advice n the use f msquit nets Advice n immunizatin f children under five years and administratin f dewrmers and vitamin A Assessment and advice n nutritin fr children under five years Referral f children and mthers wh are HIV psitive t health facility fr care The Integrated Management f Childhd Illnesses was designed t build n health facilities management f diarrhea, malaria, and pneumnia in children under five years. These guidelines are intended t ease the management f cases and have been used in public health facilities and at the cmmunity level and will nw be extended t AMSs. AMSs shuld manage the selected cases in the best interests f patients and in accrdance with regulatins. Cmplicated cases and cases invlving children under tw mnths f age shuld be referred. Steps in the Case Management Prcess When a child is brught t the AMS, the seller must always g thrugh the fllwing steps as indicated in the Sick Child Jb Aid (SCJA). 191

198 Participant Manual AMS Dispensers 1) Assess and classify the sick child (2 mths-5 years) r infant (1 week t 2 mnths) 2) Identify treatment 3) Treat the child 4) Cunsel the mther Charts are available and used accrding t age grup (refer t SCJA). Steps in the Assessment Prcess Assess the child s age and determine the chart t use. 1) Ask the mther abut the child s prblem 2) Check fr general danger signs 3) Ask the mther abut the fur main symptms: Cugh r difficult breathing Diarrhea Fever Ear prblems When a main symptm is present g thrugh the fllwing steps: 1) Assess the child further fr signs related t the main symptm 2) Classify the illness accrding t the signs that are present r absent 3) Check fr signs f malnutritin, anemia, and classify the nutritinal status 4) Check the immunizatin status and determine if the child needs immunizatin tday (refer if needed) 5) Check the vitamin A supplementatin status in children aged 6 mnths r mre and decide if the child needs supplementatin tday 6) Check the de-wrming status in children aged 1 year r mre and decide if the child needs de-wrming tday 7) Assess any ther prblems Treatment After assessing the child, the next step is t identify treatment. Patients wh need urgent referral shuld be given pre-referral treatment and cunseling tgether with a referral nte. 192

199 Mdule 3 Sessin 3. Maternal and Child Health When Offering Treatment t a Child Always teach the mther t cntinue giving treatment at hme. The drug seller shuld be able t crrectly determine the apprpriate ral drugs and dsages fr a sick child and t give ral drugs (including antibitics, antimalarials, vitamin A, etc.) while teaching the mther hw and when t give ral drugs at hme. Observe the child and assess fr the presence f lcal infectins (such as eyes, ears, muth ulcers, sre thrat, and cugh), prvide treatment, and teach the mther hw t give treatments (refer t SCJA pages 10-12) at hme. Always check if the mther understands the instructins by asking her t repeat them. Prevent lw bld-sugar in children by encuraging the care giver t feed the child ften with sweet sugar fds. Treat different classificatins f dehydratin, and teach the mther abut extra fluid t give at hme (refer t SCJA page 15 plans A and B) Refer children fr immunizatin, if needed All prcedures shuld be accmpanied with infrmatin and cunseling. Examples f accmpanying infrmatin include: Feeding When t return fr fllw-up visits; teach the care giver abut signs that indicate the need t return immediately fr further care Refer t the recmmendatins n Fd, Fluid, and When t Return n the chart titled Cunsel the Mther (refer t SCJA pages 22-26) When cmmunicating with the mther, fcus n: Giving relevant advice Using gd cmmunicatin skills (establish rapprt, be respectful, greet warmly, shw empathy, listen actively, maintain cnfidentiality) Using a Mther s Card as a cmmunicatin tl The Cunsel chart describes hw t: Assess the child s feeding Identify feeding prblems Cunsel the mther abut feeding prblems Advise the mther t increase fluid during illness Additinal advice t the mther (SCJA page 28) 193

200 Participant Manual AMS Dispensers Examples f Gd Assessment Skills Asking the mther questins abut frequency f feeds, the type f fds the child eats mst, etc. Listening carefully t the mther s answers s that yu can make yur advice relevant t her child. Active listening invlves ndding and lking int the eyes f the mther. Maintain gd psture when cmmunicating. Praising the mther fr apprpriate practices and advising her abut any practices that need t be changed. Using simple language that the mther can understand. Asking checking questins t ensure that the mther knws hw t care fr her child at hme. Fllw-Up Visits t the AMS Advise the caregiver n the dates when the child shuld return fr fllw-up. Althugh nt all children shuld, sme sick children need t return t the AMS fr fllw-up. At a fllw-up visit, treatments given are ften different frm the first treatments. Children wh have returned immediately t the clinic because they became sicker shuld be assessed as if this was their initial visit t ascertain if the right assessment was dne. When cnducting fllw-up, assess signs in the fllw-up bx fr the previus classificatin. Select new treatment n the basis f the child s signs. Fr any new prblems, assess and classify them as if it is an initial visit. Ask the mther abut the child s prblem. Children wh return repeatedly with chrnic prblems that d nt respnd t treatment shuld be referred t hspital. These include children with AIDS wh may have persistent diarrhea r repeated episdes f pneumnia. Als refer children wh cme fr fllw-up with several prblems and are getting wrse, thse wh may need secnd-line treatment, and thse fr whm it is nt clear what t d. Antenatal Care Visits These are visits t the health facility that a mther makes during her pregnancy t help ensure that her and her unbrn child are healthy and grwing well. 194

201 Mdule 3 Sessin 3. Maternal and Child Health What t Tell Pregnant Mthers abut ANC Visits The AMS seller shuld always tell a pregnant wman when t begin her visits and hw many she shuld have. It is recmmended that each pregnant wman has at least fur ANC visits during a pregnancy. The first visit shuld be dne when the mther misses at least tw menstrual perids. Additinal visits shuld be dne at least three r mre times as advised by the health wrker. At the health facility, the pregnant wman will be given medicines t prevent malaria and lss f bld and vaccines against tetanus. During ANC visits, urine tests will be dne t check fr sugar diabetes and kidney disease. High-risk pregnancies can be easily identified and managed t avid dangers. Mthers will be cunseled and tested t prevent transmissin f HIV t their unbrn babies while treating any STDs that may be present t ensure a healthy pregnancy. At each encunter with a pregnant wman, the AMS shuld lk fr the fllwing danger signs fr referral: Breaking f water befre expected time Excessive vaginal bleeding High temperature Severe headache r dizziness Swllen feet, hands, and face Fits r cnvulsins Paleness r fatigue Baby has stpped mving Advise pregnant wmen n hw t care fr newbrn babies as fllws: Dry baby immediately, cut the crd, and wrap the baby in dry clthes t keep it warm Place baby t breast-feed Check fr danger signs at least every hur fr the first 6 hurs Breast-feed exclusively, at least 8 times a day fr the first 6 mnths Maintain direct cntact with the baby; sleep in the same bed and wrap in dry, warm clthing t keep baby warm Clean the crd with warm, clean water and leave it dry and expsed Take the baby fr immunizatin n schedule Every persn wh tuches the baby shuld carry ut hygienic practices; wash hands with sap and water befre tuching the baby and after every visit t the latrine Danger Signs Advise the caregiver n the fllwing signs that need immediate attentin at a health facility: Difficulty in breathing Weakness Fever Failure t breast-feed well Reddened area surrunding the crd, with discharge 195

202 Participant Manual AMS Dispensers Cnvulsins Vmiting everything Immunizatin Why Immunize? Immunizatin is a way f prtecting a persn against certain diseases by building up the bdy s defenses. When Shuld Children be Immunized? Table 19. Immunizatin Chart Vaccine Prtects against Hw it is given At birth BCG TB Upper right arm Pli 0 Pli Muth drps At 6 weeks Pli 1 Pli Muth drps DPT + HEP B + Hib 1 Diphtheria/tetanus/whping cugh/hepatitis B/ H. influenzae type B Upper left thigh At 10 weeks Pli 2 Pli Muth drps DPT + HEP B + Hib 2 Diphtheria/tetanus/whping cugh/hepatitis B/ H. influenzae type B Upper left thigh At 14 weeks Pli 3 Pli Muth drps DPT + HEP B + Hib 3 Diphtheria/tetanus/whping cugh/hepatitis B/ H. influenzae type B Upper left thigh At 9 mnths Measles Measles Upper left arm Children shuld be taken fr immunizatin even if the schedule is missed. In additin t immunizatins, a child shuld receive vitamin A supplementatin every 6 mnths starting at 6 mnths. Management f Yung Infants Yung infants have special characteristics that must be cnsidered when classifying their illness: They can becme sick and die very quickly frm serius bacterial infectins. 196

203 Mdule 3 Sessin 3. Maternal and Child Health They frequently have nly general signs e.g. few mvements, fever, r lw bdy temperature Mild chest in drawing is nrmal because their chest wall is sft Yung infants (newbrn t 2 mnths) shuld be referred t a health facility Infants with the fllwing danger signs must always be referred t a health facility: Cugh fr 14 days r mre Diarrhea fr mre than 7 days Bld in stl Cnvulsins Nt able t eat r drink Vmiting everything the child eats Sucking in f the stmach when breathing Very sleepy child r uncnscius T thin a child Presence f edema Rle Play: Receiving a Care Giver AMS Seller: Hell. Welcme. Please cme in. Mrs. Theresa: Hell. My sn is sick. He has been sick since last night. Can yu please take a lk at him? AMS Seller: Certainly. I am glad that yu brught yur sn right away. Please seat dwn here. Let me ask yu a few questins t find ut what is wrng. I als need t get sme infrmatin frm yu. First, what is yur sn s name? [Sit clse t Mrs. Theresa and lk at her in a cncerned, supprtive way. Use a recrding frm t recrd the infrmatin yu get frm the answers t yur questins.] Mrs. Theresa: His name is Chris. C-H-R-I-S AMS Seller: Hw ld is Chris? Mrs. Kat: He is 12 weeks ld. AMS Seller: And what is yur name? Mrs. Theresa: My name is Theresa. AMS Seller: Mrs. Theresa, where d yu live? Mrs. Theresa: We live near Fish Market Crner. 197

204 Participant Manual AMS Dispensers AMS Seller: Thank yu, Mrs. Theresa. I hpe we can help Chris feel better. Let me ask yu sme questins t find ut hw he is feeling. Des Chris have a cugh? And if s, hw lng has he had a cugh? Mrs. Theresa: Yes. He has been cughing since the market day, Sunday. AMS Seller: S he has been cughing fr 3 days. Has he had any diarrhea? Mrs. Theresa: N. He des nt have diarrhea. AMS Seller: Has he had any fever r ht bdy? Mrs. Theresa: N. He has nt had fever. AMS Seller: D yu have any ther cncern abut Chris that yu wuld like t talk abut tday? Mrs. Theresa: N. I am mstly wrried abut his cugh. AMS Seller: I can see that yu are. It is gd that yu brught Chris t see me. I will take a clser lk at Chris. Annex. Cnditins That Can be Managed at the AMS The fllwing cnditins may be diagnsed and managed by a trained AMS after prper examinatin and diagnsis. In case the AMS is uncertain abut the diagnsis, the patient shuld be referred t the nearest health facility. 1) Uncmplicated malaria 2) URTIs a. Cughs lasting less than 30 days b. Nn-severe pneumnia (with danger signs, chest in-drawing, r stridr in calm child) 1) Diarrhea and dysentery, except severe diarrhea r severe dehydratin 2) Ear infectins, except in cases f tender swelling behind the ear (mastiditis) 3) Anemia and malnutritin, except fr severe cases as defined in this manual 4) Minr skin cnditins, such as bils, ring wrm, scabies, chicken px, nappy rash, and minr cuts 5) Eye cnditins, including FBs and styes The AMS shuld als ffer the fllwing services t their clients: Rutine dewrming, especially fr children under 5 years Checking immunizatin status fr children under 5 years FP, cndms, and ral cntraceptives Advice n the need fr FP and FP methds Advice n newbrn care Advice n prper nutritin and care fr children 198

205 MODULE 4: COMMUNICATION SKILLS, HEALTH EDUCATION, AND PROMOTION IN AMS Sessin 1. Fundamentals f Cmmunicatin Skills Sessin 2. Cnsumer Rights Sessin 3. Health Educatin in AMS Sessin 4. Cunseling and Referral 199

206 Sessin 1. Fundamentals f Cmmunicatin Skills The wrk f AMS dispensers invlves interactin with custmers n a daily basis. Gd cmmunicatin skills are the fundatin f dispensing wrk and this translates int bth increased custmer satisfactin and sales revenue. Mre imprtantly, gd cmmunicatin skills are critical fr hw infrmatin and health educatin abut diseases and recmmended treatment is passed n t custmers. The dispenser s unique psitin in ne-n-ne cmmunicatin culd prfundly influence a custmer s beliefs and help change practices. Behavir change is very difficult, but is essential t prmting ratinal drug use. Objectives 1) Establish/strengthen and maintain psitive interpersnal relatinships with cnsumers, the wner f the AMS, and clleagues. 2) Identify elements f IPRs and list situatins/behavirs r actins that indicate bth psitive r negative IPR and their effects n AMS service. 3) Demnstrate the ability t use verbal and nn-verbal cmmunicatin/ipr skills during the fllwing interactins: Dispenser/cnsumer Dispenser/wner Dispenser/clleague Dispenser/inspectr f AMS service Time 4-6 hurs Establishing and Maintaining Interpersnal Relatinships in AMS Services Why Discuss r Learn abut IPR in AMS Services Interpersnal relatinships (IPRs) is ne f several factrs that influence the quality f a service; cnsumers r clients are attracted t r discntinue a service where they feel IPRs are negative. Many satisfied cnsumers help AMS services grw. Dispensers interact with their peers in their wn r referral sites/services, with the AMS wners, cnsumers, supervisrs, and the cmmunity at large. Each persn likes t be treated well by thers and satisfactin is necessary fr an AMS t grw. Psitive IPRs cntribute t jb satisfactin and uninterrupted service and t meeting expectatins f cnsumers, dispensers, and wners in yur area Sme Benefits f Establishing and Maintaining Psitive IPR in AMS Services Between Dispenser and Cnsumers Cnsumers trust and listen t dispensers during cmmunicatin n drugs r relevant illnesses. 200

207 Mdule 4 Sessin 1. Fundamentals f Cmmunicatin Skills Thrugh apprpriate use f IPR (cmmunicatin r facilitatin) skills, the dispenser cllects adequate infrmatin frm the cnsumer t guide the care he/she prvides. Cnsumers feel their needs and rights are addressed by dispensers. Openness and transparency prevail, even in cases f shrtages r expiratin f drugs and ther challenges in the AMS service. Dispenser/Owner A gd wrking atmsphere prmtes: Openness and transparency Cnsideratin f the needs f the dispenser r wner withut reducing the quality f service Ging ut f the way t prvide extrardinary service when needed, but maintaining the gals r plans made fr enhancing quality service Dispensers and wners are clear abut each ther s rles and respnsibilities in rdinary circumstances and emergencies. Dispenser/Inspectr Dispensers are cperative during inspectrs visits and in relatin t fllw-up activities after the visit. Dispensers view inspectrs visits as an pprtunity fr learning r prblem slving. Inspectrs use the pprtunity t prvide supprtive supervisin (ppsite f checking wrngs ). Clarity f rles f inspectrs is achieved. Dispenser/Clleague Cnsumers trust and listen t the dispensers during cmmunicatin n drugs r relevant illnesses. The team apprach t handling prblems ccurs, e.g., when new drugs enter the market. Sharing f interesting prfessinal activities may ccur. Cnsumers that are referred are likely t receive apprpriate service. Dispenser/Cmmunity at Large Cmmunity advertises services fr the AMS and prviders. 201

208 Participant Manual AMS Dispensers Cmmunity cnsiders the AMS as ne f the services it must supprt. Cmmunity helps t easily establish the service r slve prblems. IPRs in AMS Services The skills that are necessary fr establishing r maintaining IPRs are als knwn as cmmunicatin r facilitatin skills. Sme f these skills are verbal and thers are identified as nnverbal r bdy language. Verbal and Nnverbal Cmmunicatin IPR Skills/Actins Verbal Skills Use I rather than yu statements. Fr example, say I understand yu t say r I was cnfused when yu said ; d nt say yu did nt explain well r yu cnfuse me. Use encuraging wrds, such as Tell me mre, g n, aha, and yes. Respnd t nnverbal cmmunicatin f the persn talking with yu. Fr example, when he/she shws cnfusin, ask Have yu any questins r is there smething we have discussed s far that I need t clarify? Paraphrase r summarize what yu have heard. Ask pen-ended questins by using what, when, and hw. Further, use clsed questins t start an idea, but fllw it with pen-ended questins. When applicable, tell the ther persn that the discussin is being recrded. Nnverbal Cmmunicatin Skills Listen actively. Signs f listening actively include: Ensuring culturally acceptable eye cntact Aviding lking at yur watch r a clck Aviding interrupting when the ther is speaking Ensuring n interruptins f any kind frm third persns r phnes Shw yu care and want t help r slve the prblem if applicable. Say I am srry as needed. Use an apprpriate tne f vice. Be respectful regardless f gender, age, race, r creed. Smile and shake yur head t shw yu are listening r agreeing with his/her pint. 202

209 Mdule 4 Sessin 1. Fundamentals f Cmmunicatin Skills Put aside yur persnal feelings abut a subject, e.g., d nt shw yu are disgusted with a particular idea r practice f the persn yu are talking with. Prvide cnfidentiality and privacy. Cnfidentiality is when the cnsumers persnal infrmatin (written r spken) is nt shared with ther peple r expsed s that an unauthrized persn can read it. Privacy can be prvided by: Being in a place where thers cannt see (visual privacy) Talking sftly enugh t be heard nly by the persn cncerned (auditry privacy) Demnstrate prfessinalism in dress and hw yu maintain and pack yur drugs fr cnsumers. Be sber. Be creative in enabling a quick but effective service and reduce lng queues (lining up f cnsumers waiting t be served). Shw acceptance, even if yur attitude differs frm the cnsumer r ther persn. Practice Using Verbal and Nnverbal Cmmunicatin Skills Rle Play Guides Objective: T demnstrate ability t use IPR skills In grups f three, each persn will act as: Sender (the ne speaking) Receiver (the ne being spken t) Observer (the ne listening and making ntes while tw are discussing) Everyne shuld use as many verbal and nnverbal cmmunicatin skills as yu can. Each rund shuld take nly 10 minutes: 3 minutes: agree n subject 5 minutes: sender and receiver talk (in the first rund, dispenser and cnsumer; secnd rund, dispenser and clleague; third rund, dispenser and wner) 2 minutes: share immediate feelings f sender and receiver abut the exercise (say ne t three wrds nly t shw hw yu feel (I felt..) 5 minutes: bservers prvide feedback n strengths and limitatins bserved n use f IPR skills Examples f subjects (chse any f these fr ne rund nly; use any ther subject related t wrking in the AMS): Cnsumer has stmach ache after taking aspirin Dispenser s clleague gave medicatin which was inadequate fr a full curse 203

210 Participant Manual AMS Dispensers Dispenser is justifying his/her request t the wner t attend the next fur-week AMS training r seminar Other subject f yur chice fr the same pairs (dispenser/custmer, dispenser/clleague and dispenser/wner). 204

211 Sessin 2. Cnsumer Rights Cnsumers rights are an essential aspect f the quality f services prvided by an AMS, and it is imprtant that AMS wners and dispensers becme acquainted with the basic elements f cnsumer rights. This sessin will intrduce cnsumer rights. Objectives 1) Identify key cnsumers rights as they apply t the AMS health service 2) Demnstrate the ability t make a referral that the cnsumer is likely t fllw 3) Uphld cnsumers rights during interactins with them and thrugh maintenance f the AMS envirnment Time 2 hurs 1.0. Intrductin Applying Cnsumers Rights during AMS Service Delivery (Adapted frm IPPF 1993) One way f prviding quality AMS services is t ensure that the rights f cnsumers are applied by the dispensers and wners in the AMS. Each member cntributes t the ttal service. Cnsumers shuld be educated abut these rights apprpriately in rder t enhance their participatin in the AMS services Cnsumer Rights Ten cnsumers (clients) rights have been identified based n research cnducted by the Internatinal Planned Parenthd Federatin (IPPF) in early 1990s. These are briefly explained belw. (A pster explaining each f these rights can be prepared and psted fr yur and the cnsumers reference) Infrmatin Cnsumers have the right t clear, up-t-date infrmatin. Cnsumers have the right t infrmatin that is relevant t their needs and t nt be verladed Chice Chice is facilitated by facts. Fr example, the dispenser explains the crrect use f drugs, side effects, actins the custmer shuld take if side effects ccur, and the help that the dispenser can prvide if any f these prblems shuld happen. The dispenser helps the cnsumer t chse the actins he/she wishes t take after prviding the facts. The dispenser des nt cerce r frce the cnsumer in any way. 205

212 Participant Manual AMS Dispensers 2.3. Access Cnsumers shuld have access t infrmatin, educatin, and cunseling abut drugs and cmmn illnesses, regardless f the cnsumers sex, age, sciecnmic status, creed, religius affiliatin, marital status, r lcatin. Dispensers are bligated t prvide and discuss this infrmatin with cnsumers upn request Safety In an AMS, the safety f the cnsumer is maintained r achieved by ensuring that the cnsumer: Understands the crrect dsage and side effects and hw t manage them Is given unexpired drugs that have been prperly stred t maintain their efficacy Clearly understands thse drugs that interact negatively with the nes he/she is taking Obtains relevant infrmatin fr emergencies that may ccur as result f taking r having medicatin 2.5. Privacy The cnsumer is prvided with auditry privacy if pssible and visual privacy in terms f being seen by third persns during cunseling, educatin, and purchase f drugs Cnfidentiality AMS dispensers ensure that any persnal infrmatin is nt shared with anyne else, even a parent r guardian, in the case f yuth. This includes recrded infrmatin as well as any infrmatin the cnsumer prvides verbally Dignity Cnsumers are treated r served with curtesy by the dispenser and ther staff. Cnsideratin and attentiveness is prvided, regardless f sex, age, creed, marital status, sciecnmic status, and ther factrs stated earlier under access Cmfrt Cnsumers shuld be made t feel cmfrtable when receiving services. Fr example, cnsumers are prvided with a shaded area and seating if they have t wait and are spken t in a way that des nt embarrass them Cntinuity Cnsumers are prvided with services in a way that encurages them t return t the AMS and even recmmend that thers chse that AMS. These services include prviding clear instructins n taking medicatins, reasns fr the way they are taken, and any precautins. The AMS may make a full curse f medicatin available n special credit Opinin Cnsumers are given the pprtunity t express their views n the services ffered during purchases, cunseling, r educatin. 206

213 Mdule 4 Sessin 2. Cnsumer Rights In sme cases, a suggestin bx may be placed in the AMS. The bx shuld be placed where all cnsumers can see and reach it. The dispenser r wner encurages cnsumers t put their suggestins r cncerns in the bx. Once a mnth, the cmments are read and analyzed and actins taken t imprve the service. When pssible, the cnsumers are thanked fr the cmments and tld hw they have been used. Case Study: Applying Cnsumers Rights during AMS Service Stry f Tarmay Yekele at the Gd Health (GH) Drug Shp Tarmay Yekelle is the 16-year-ld mther f Tabl a three-mnth ld by. She has a sixth grade educatin. Tarmay came frm Pp Beach village, abut ne hur s walk t GH. She arrived at the shp with her baby n her back, lking tired. Her dctr had prescribed the fllwing: Ferslate, 200 mg b.d. Flic acid, 1 tablet daily On arrival at GH, Tarmay fund that Frd the dispenser was busy receiving new stck f supplies frm Mnrvia. He greeted Tarmay and asked her t wait until he finished receiving and string the supplies. This task tk ne hur. When Frd went t pack the prescriptin, he fund that there were n ferslate tablets; nly flic acid tablets were available. S Frd gave Tarmay thse tablets and said take as instructed by yur dctr. He then wrte the name f the tablets, the dsage, and directins n a pill packet. There were n marked bxes at GH. Tarmay went hme and started taking flic acid tablets every secnd day t make them last lnger. Purpse f the Stry 1) T identify which cnsumers rights were applied and thse that were nt during Tarmay s visit 2. T suggest actins/guidance thrugh educatin r cunseling that Frd shuld have prvided t Tarmay, given the details abut her in the stry Instructins 1) Read the stry 2) Based n the cntent f the stry: a) List the cnsumers rights that Frd upheld b) Suggest tw r three actins that reflect uphlding the cnsumer s rights by a health prvider/dispenser 3) Present yur grup wrk t the class 207

214 Sessin 3: Health Educatin in the AMS Health educatin is a cntinuing prcess f infrming peple hw t achieve and maintain gd health; f mtivating them t d s; and f prmting envirnmental and lifestyle changes t facilitate their bjective. Objectives 1) Cnduct health educatin n illnesses and symptms fr which the cnsumer is purchasing drug(s). 2) Cnduct ne-t-ne health educatin sessins n drugs used and cmmn illnesses encuntered in the AMS s service delivery. 3) Identify the cnsumers health educatin needs as part f the health educatin prcess. List factrs that can be a barrier t meeting cnsumer needs. 4) Use recrds n recmmended services fr develping cnsumer educatin messages. Time 3 hurs Cnducting Health Educatin as Part f AMS Services Health Educatin The prcess f prviding infrmatin s that the cnsumer can: Crrectly and cnsistently use r relate the actins f medicatins t his/her sickness r prblem Cnvince his cntact (in case f STD/HIV/AIDS) t seek medical help Health educatin that is successful changes the behavir f the cnsumer. Teaching This is the prcess f helping anther persn learn a new knwledge r skill. In the AMS cntext, teaching will be cnsidered similar t health educatin and explaining written instructins abut drugs r illnesses. Reality-based teaching is needed by cnsumers, as it can be immediately used r applied and meets their needs at that particular time. Otherwise, if the cnsumer des nt see the value f the teaching, he/she will nt listen and may cme away with miscnceptins. Learning in Health Service/AMS Setting This is the result f an effective health educatinal r cunseling sessin. The cnsumer practices and shares with thers the ideas he/she btained frm the AMS service prvider r frm the infrmatin distributed r psted at the AMS. 208

215 Mdule 4 Sessin 3. Health Educatin in the AMS Effective Cmmunicatin The cnditin that is reached by fllwing the guidelines and principles f cmmunicatin and the crrect and apprpriate use f verbal and nnverbal cmmunicatin skills while uphlding cnsumers rights. Principles f effective cmmunicatin include but are nt limited t: Prviding a cmfrtable setting with few distractins Fcusing n the listeners /cnsumers needs, interests, and health status Being brief and aviding verlad f infrmatin Using wrds that are familiar t the listener/cnsumer Using a tw-way cmmunicatin style (listening as well as speaking and allwing the cnsumer t talk during the discussin) Reasns fr Imprving Cnsumer Health Educatin as Part f AMS Services 1) Increased self-prescriptin and hme care Cnsumers expsure t general medical infrmatin has cntributed t their ability t self-treat and t reduce the number f visits t health facilities. Unfrtunately many under-treat themselves, thus leading t resistance t drugs. Sme cnsumers share ne curse f medicatin, apparently t save mney r time fr medical care. But they d nt return t receive the rest f their medicatin. 2) Multiple service prviders r caretakers fr ne patient/cnsumer Hurried r n explanatin f the medicine r health cnditin is prvided. Assumptin that the next prvider will have r the previus prvider already has explained t cnsumer the crrect use f medicine and actin n the symptm. Sme dispensers/prviders in the multiple caregiver grup have inadequate r n technical backgrund t help cnsumers use drugs crrectly. 3) Team apprach t care In a team apprach t service delivery, every prvider r care taker has a special rle t play. If it is nt played, the care f the cnsumer is negatively affected, and sme f the patient s rights may nt be upheld (e.g., safety, infrmatin, cntinuity). Imprtant fr lng-term results fr cnsumers health 4) A legal respnsibility and a way f adhering t the Cde f Ethics 5) Less cnfusin abut medicatins Because drugs ften have mre than ne trade name, it helps reassure cnsumers f similarity with ther medicatins they have been taking. 209

216 Participant Manual AMS Dispensers 6) Cmpetitive business envirnment An AMS prvider wh prvides clear health educatin gains the respect f cnsumers. Happy cnsumers will spread the reputatin f the AMS, bringing in mre cnsumers. 7) Integrated health services When a dispenser explains a health cnditin t a cnsumer in an AMS, the dispenser is participating in integrated health services. Guide fr Establishing a Gd Relatinship between Cnsumer and Dispenser This relatinship may als be referred t as the prvider/cnsumer relatinship. This relatinship, which incrprates psitive IPR skills, is als crucial t health educatin and cunseling cnsumers. Cnsumers are nt interested in learning frm a dispenser r ther health prvider if they d nt feel that dispensers care. Guide fr Establishing and Maintaining Trust f Cnsumers Shw respect Treat the persn as unique and wrthwhile. Build trust Be cnsistent in the way yu deal with the cnsumer r care fr him/her. Act with integrity t help the cnsumer develp cnfidence in yu and yur abilities Accept the cnsumer Shw the cnsumer that yu accept him/her as he/she is and shw that he/she can be pen and feel safe with yu. Demnstrate caring Shw the cnsumer yur interest and cncern fr him/her and their prblems. Be sincere Make sure that what yu say and d during interactin with the cnsumer sends the right message t the cnsumer. Be an advcate fr yur cnsumers; be cnsumer riented in what yu d Advcate fr cnsumers rights wherever and whenever pssible. Teach cnsumers the 10 cnsumer rights; when apprpriate, ensure these rights are applied during their care at the AMS. 210

217 Mdule 4 Sessin 3. Health Educatin in the AMS Avid making assumptins; btain facts Understand yurself Ensure that yur persnal beliefs and values d nt interfere with cnsumer care. Recgnize that yu and cnsumers are likely t have differences f values, perceptins, r views n particular subjects r practices. Take a psitive stand abut hw yu will bjectively handle specific care that is a challenge t yur beliefs. Fr example, prvide STI treatment and cunseling t an adlescent and uphld his/her right t privacy, cnfidentiality, respect, and access, even if yu wuld prefer nt t prvide the service. Or help a cnsumer wh is nt gd at reading by explaining the facts with visuals r read t them until they understand and can repeat the infrmatin back t yu. D nt frce them t read if they dn t want t. Cntinually self-evaluate yur wrk and make imprvements as needed. Establish psitive IPR, always. Chse a variety f teaching methds that yu can use cmfrtably t btain psitive results. Establish and maintain a nn-judgmental attitude abut cnsumers. Make health educatin smething that gives yu jb satisfactin. Other Cmmunicatin Skills Als be sure t acknwledge and reassure cnsumers. Allw silences. This allws time fr cnsumers t think abut what they have been tld, what has been discussed, and what needs t be discussed further. Sme Cnsumers Health Educatin Needs Assessing cnsumers needs is the first step in health educatin; sme needs are described belw. These may cntribute r be barriers t the health educatin that the dispenser prvides. Cnsumers health educatin needs in an AMS setting must be assessed quickly by: Observing cnsumers and listening frm the mment they arrive Asking questins Cnferring with escrts r guardians Once the cnsumer s needs are identified the dispenser and cnsumer shuld agree n the utcmes f the health educatin r what the cnsumer wishes t achieve r learn befre returning hme. During imprmptu health educatin, sme f the steps f assessing cnsumer needs may be mitted r bserved ver time. 211

218 Participant Manual AMS Dispensers Language Language can be a prblem, especially fr freigners, the lder generatin, r thse frm rural areas. Supprt Systems A cnsumer may need help with their care. Fr example, fr hmeless cnsumers, the dispenser shuld find ut wh will help the cnsumer take their medicatin. That persn shuld be invlved when medicatin is dispensed. Health Expectatins The cnsumer may have expectatins f health r results f taking a particular drug that differ frm the dispenser. Hence, it is imprtant t find ut this infrmatin frm the cnsumer when necessary. Fr example, if the cnsumer is bstinate abut taking a particular drug r fllwing a particular apprach f drug taking. The dispenser will need t use cunseling skills t help the cnsumer make decisins that will cntribute t effective care by the AMS and the dctrs treating him/her. Mre will be cvered in the cunseling sessin n unslicited service r difficult mments. Learning Needs The dispenser asks the cnsumer what he/she already knws r asks if the cnsumer has any questins r cncerns. Miscnceptins culd be identified as learning needs. Learning Readiness As part f the health educatin r cunseling sessin, the dispenser r health wrker shuld assess readiness fr learning. If the client is very sick, he/she is nt ready fr lng health educatin. Give the client the pririty infrmatin they need nw, and at an agreed upn later time, arrange fr detailed health educatin. Difficulty in Seeing Mdify yur teaching n drug use. Difficulty in Hearing Use written material fr them t read r t be helped t read. Lack f Family Invlvement Talk t the family, the cnsumer alne, r with peple the cnsumer respects. Lw Literacy Skills 212

219 Mdule 4 Sessin 3. Health Educatin in the AMS Teach essential infrmatin nly, ne step at a time Have the cnsumer repeat the infrmatin discussed Be creative in explaining pints Use simple, cnsistent language Barriers t Meeting Cnsumer Needs The fllwing are als factrs that can interfere with learning (frm health educatin and cunseling) r cmpliance abut drugs and illnesses. On the Part f the Prvider/Dispenser Ignrance abut the imprtance f health educatin Inadequate technical cmpetence Time management prblems Religius affiliatin r beliefs (smetimes) Lack f resurces t d the jb Inadequate r n supprtive supervisin Ignrance abut where t refer On the Part f the Cnsumer Extent f trust in health service/ams Miscnceptins and rumrs Pain, fears abut his/her cnditin Embarrassment and shyness t penly state the prblem Lives t far frm the AMS On the Part f the Cmmunity at Large Tabs and ther cultural r gender riented practices (e.g., laws that d nt allw men and wmen t be tgether in the same meeting) Reluctance n the part f adults t discuss reprductive and sexual health issues with yunger generatins (e.g., birth cntrl, sexually transmitted diseases) Beliefs in certain traditinal medicines given t cnsumers, despite mdern care Cnducting Imprmptu Health Educatin during Sale f Medicines by Using the GATHER Apprach GATHER is ne way t remember the prcess that the cunselr/ams service prvider must g thrugh t help a cnsumer make decisins and gd chices. 213

220 Participant Manual AMS Dispensers The prcess f GATHER requires the use f verbal and nnverbal cmmunicatin skills t ensure that it is allws the cnsumer t participate. G Stands fr Greet and create an atmsphere fr free and tw-way infrmatin flw between the cnsumer and the AMS service prvider. Give the cnsumer yur full attentin. Assume cnfidentiality and privacy, if pssible. Offer seating if pssible. This part is als referred t as creating rapprt. A Stands fr Ask the cnsumer questins t ascertain what they already knw abut the drug r health prblem, r find ut the real prblem behind a situatin that the client is presenting. In sme situatins, such as FP r a specific prblem, this stage f GATHER can be used t find ut the cnsumers cncerns, health, r life gal. T Stands fr Tell/tactfully explain the drug r health cnditin. This part f GATHER helps the cnsumer btain crrect infrmatin (facts) and thus dispel miscnceptins he/she may have. Depending n needs identified in the previus tw steps, deal with what seems t be the client s primary cncerns, then ffer chices f services that can be prvided that are related t the same needs r prvide a referral. H Stands fr Help the cnsumer t make a decisin based n the cunseling sessin/discussin that has taken place s far: The cunselr summarizes imprtant ideas f the cunseling sessin that will help the cnsumer make an infrmed decisin. He/she des nt give advice r his pinin f what the cnsumer shuld d. E Stands fr Explain fully, r in a build-n manner (t what cnsumer already knws): Hw t use the relevant drug Facts that are related t what the cnsumer feels is imprtant fr him/her t address Facts that the cnsumer must remember befre leaving the AMS/health prviders Encurage questins and answer them penly and fully Check that the cnsumer understands. The dispenser then gives the drug r related supplies fr which he/she has paid r will pay accrding t an agreement yu have with him/her. R Stands fr infrmatin prvided in rder t help the cnsumer Return t the AMS/health prviders: As per rutine/usual practice In an emergency When the cnsumer has cncerns, r needs t be reminded abut facts. 214

221 Mdule 4 Sessin 3. Health Educatin in the AMS GATHER Script The fllwing is a script that prviders may use as a guide when talking t custmers. Greet Welcme Make the cnsumer cmfrtable; prvide privacy Ask fr and quickly review the prescriptin r verbal request Ask and praise Tell/explain Assess cnsumer s knwledge and feelings abut the drug Praise cnsumer and build n cnsumer s knwledge Explain t cnsumer abut the drug Dse, hw t take it Side effects Cntraindicatins, if relevant Hw t manage cmplicatins, side effects, and emergencies caused by taking the medicine Drug interactins with ther drugs, fds, and alchl Specific r unique instructins, e.g., strage, dispsal f cntainer(s), hw t pen the cntainer, and stre fr safety f children Using the insert, if applicable Allw questins and answer fully using facts Refer t apprpriate health facility; be clear with cnsumer abut why they are being referred Help Ask cnsumer t repeat infrmatin discussed; he/she can use the facilitatr s materials and visuals, if applicable Ask cnsumers hw he/she will use the infrmatin learned frm the sessin Ask if yu can discuss a matter that is cincidental t using the prescribed drug Explain If the cnsumer is ready, prvide health educatin and cunseling Give the curse f drugs Encurage cnsumer t vice any cncerns Respnd apprpriately 215

222 Participant Manual AMS Dispensers Return Invite cnsumer t return whenever he/she needs infrmatin r t purchase mre medicines Thank and bid him/her farewell Apprach t Health Educatin fr Selected Cmmn Illnesses The dispenser shuld prvide the fllwing infrmatin n selected illnesses t educate cnsumers. Diarrhea and Vmiting Main danger is extreme lss f bdy fluids and electrlytes Cautin the cnsumer t avid giving r taking anti-diarrhea medicines What t d: give ORS r plenty f fluids in small amunts until the patient is passing urine as usual If a breast-feeding baby has diarrhea, the mther shuld cntinue t breast-feed Refer t a health facility if diarrhea r vmiting becmes wrse Signs f Seriusness and Wrsening f the Cnditin Being very weak, restlessness, and even lsing cnsciusness Sunken eyes Difficulty drinking r drinking as a very thirsty persn Skin ver the lwer abdmen recedes very slwly after lifting it Stl is bld-stained Diarrhea is accmpanied by high fever (ver 37.5 C) Chrnic Prblems f the Elderly Heartburn Heartburn is the backflw f stmach cntents past the end f the fd canal (esphagus). It ccurs because the muscles that clse the fd canal (lwer esphageal sphincter) are weak due t incmpetence r ther prblems. Symptms Acid feeling Blated, full feeling after eating even a small amunt f fd Even after swallwing, the sensatin f fd remaining stuck 216

223 Mdule 4 Sessin 3. Health Educatin in the AMS Simple Treatment and Management Antacids Eat small amunts f fd mre frequently than usual Reduce predispsing factrs, such besity, tbacc use, and fdstuffs that upset the stmach Infertility Infertility is the inability t cnceive in at least ne year f marriage in a situatin where the cuple has lived tgether (primary infertility) r the inability t cnceive again after having had a pregnancy (secndary infertility). Management Bth husband and wife have t be checked r investigated Prevent it by: Early treatment f infectins in the rgans respnsible (men and wmen) Infectin cntrl where wmen deliver Treat accrding t results f investigatin Respiratry Infectins Symptms Blcked r stuffed nse May have a cugh r nse bleed Fever Sre thrat Headaches A child may als have diarrhea Lss f appetite Management Symptmatic treatment, e.g., use f anti-fever tablets accrding t age Give plenty f fluids Refer t health facility if nt imprving r if fever is higher than 37.5 C STI (Sexually Transmitted Infectins) STIs are categrized as ulcerative r nn-ulcerative. Fr simplicity, fur types f symptms are described: 217

224 Participant Manual AMS Dispensers Vaginal, cervical, r urethral discharge (men and wmen) Lwer abdminal pain (wmen) Ulcer in private parts (genital ulcer disease) Ulcer disease (men and wmen), e.g., multiple blisters n sex rgans Management f STIs Get medical care at a health facility. Abstain frm sex r use a cndm, if apprpriate, until treatment is ver. Get the cntact(s)/sex partners t receive treatment cnfidentially (n need t make it publicly knwn with whm he/she is having sex). Use verbal and nnverbal cmmunicatin cunseling skills t help partner accept that they need t g fr treatment. 4 C s in supprting the management f STIs Cunseling T help slve STI-related prblems T emphasize the imprtance f the ther C s Cmpliance t Treatment Explain the imprtance f cmpliance in preventing future resistance t medicatins Explain the imprtance f returning t the health service as requested by the health prvider, even if feeling well Cndms Give cndms t cnsumer if abstinence is nt an ptin he/she can use Demnstrate the use f cndms Ensure cnsumer that they can return if necessary Cntact Treatment Get the cntact(s)/sex partners t receive treatment cnfidentially (n need t make it publicly knwn with whm he/she is having sex). Preventing Future Occurrences Discuss safe sex practices that the cnsumer can accept and fllw Prvide cmmunity educatin r help distribute leaflets frm the Ministry f Health n STIs Teach that an STI-infected persn can be withut symptms, but can still infect thers 218

225 Mdule 4 Sessin 3. Health Educatin in the AMS Case Studies/Situatins fr Health Educatin Simulatins The time fr cnducting each health educatin sessin is 10 minutes. Fr each f the three simulatins belw (tpical, ral, and injectable drugs), fllw these instructins: Plan and cnduct health educatin with the cnsumer Fllw guidelines fr imprmptu health educatin n drugs, as applicable Tpical Drugs (Drug fr Skin Disease) Mama Flrence has been suffering frm sreness between her tes. Her dctr prescribed tw tubes f anti-fungal cream. She cmes t yur AMS t buy nly ne tube. Oral Drugs Baba Tit has cme t buy SP fr malaria treatment. But n arrival, he tells yu that he really wants t understand the many prblems which SP causes befre buying and using it. He still has a fever f mre than 37.5 C. Parenteral/Injectable Drugs Esther is a 16-year-ld girl wh has an abscess n her nail. She has cme t purchase a curse f injectable, brad-spectrum antibitic. She mentins t yu that she really fears getting injectins. New FP Practice Mama Peace is the village chairpersn. She has heard that in yur shp yu cnduct health educatin sessins with cnsumers. Nw she has cme t discuss with yu a rumr that ECPs hurt the unbrn child and cause abrtin. Instructins Hld an imprmptu health educatin sessin with Mama Peace t explain: Hw ECPs are used Why ECPs d nt hurt unbrn children and cause abrtin 219

226 Participant Manual AMS Dispensers Guide fr Explaining ECPs by Using GATHER Greet Create rapprt and establish an atmsphere fr free-flwing infrmatin. Greet in a culturally accepted way Prvide privacy and cnfidentiality Prvide seating Use verbal and nnverbal cmmunicatin skills thrughut the sessin Ask and praise Find ut the cnsumers knwledge r what he/she has heard abut ECPs Praise fr cming in t talk and fr any crrect infrmatin that the cnsumer has Tell/explain Explain ECPs in a way that builds int the knwledge and ideas that the cnsumer already has Which pills are used as ECPs; shw them t the cnsumer When they shuld be used t ensure that they wrk Effectiveness Advantages Disadvantages Why they shuld nt be used as regular FP Check the cnsumer s understanding n ECPs Ask the cnsumer what is clear and nt clear Allw the cnsumer t ask questins Add any infrmatin that has been mitted and crrect any mistaken infrmatin Help Ask the cnsumer hw the infrmatin discussed will be used Help the cnsumer select ne type f ECP Explain Review imprtant pints f using the selected pills Issue the pills Return Give an pen invitatin t start FP r discuss cncerns Thank the cnsumer and bid them farewell 220

227 Sessin 4. Cunseling and Referral Objectives 1) Apply GATHER (in previus sessin), CLEARS, r SOLER appraches in cunseling cnsumers t help them make decisins n drugs r ther pharmaceuticals available in the expanded list f the AMS. 2) Make referrals that cnsumers are likely t fllw. Time 2 hurs Guide fr Effective Referral Ensure that the cnsumer: Has understd the reasn fr the referral Can repeat t yu the imprtance ging t the referral as sn as pssible, e.g., fr effectiveness f the medicine prescribed r t ensure early management f an emerging prblem identified during purchase f the medicine Knws that yu are available any time fr any questins abut the referral; tell her/him hw t find yu r what t d after wrking hurs Give a written referral with: Name f cnsumer Date f referral Reasn fr referral When t g and, if pssible, t whm If applicable, what medicatin has already been sld t the cnsumer Yur name, signature, AMS name, and AMS address in writing r n a rubber stamp Hw t Make Cunseling Effective Use verbal and nnverbal skills apprpriately. The acrnyms CLEARS and SOLER can help yu remember these skills. 221

228 Participant Manual AMS Dispensers CLEARS Verbal Skills Clarify by using pen-ended r prbing questins Listen actively; d nt interrupt the cnsumer when he/she is talking Eye cntact made in a culturally acceptable manner; d nt lk at yur watch Accurately reflect and fcus the discussin in line with cnsumers needs Repeat r paraphrase Summarize and ensure cmmn understanding f the discussin SOLER Nnverbal Skills Smiling and/r ndding at the cnsumer Open and nn-judgmental facial expressin Leaning tward the cnsumer Eye cntact made in a culturally acceptable manner Relaxed and friendly Other Aspects f Effective Cunseling Uphld the cnsumers rights. Maintain up-t-date knwledge s as t prvide accurate infrmatin. Ensure that the cunseling sessin addresses cnsumers pririty needs. Avid prviding unnecessary infrmatin (t avid infrmatin verlad ). Respect cnsumers cultural, religius, and ther persnal beliefs. Hwever, remember that sme f these beliefs have the ptential t interfere with the use f prescribed medicatins. Clients shuld be cunseled t help them drp their beliefs, at least temprarily during the use f a particular curse f treatment. Other beliefs are harmless and can just be ignred. Changing Behavir Acknwledge that changing behavir takes time, depending n what stage f the behaviral change prcess the individual cnsumer is at. There are five stages f behaviral change. The cnsumer has n plan t change, r appears indifferent r unaware f the need t change. What t D Offer yurself fr cunseling any time the cnsumer wishes t return. Thank the cnsumer fr cming; if pssible, prvide a leaflet n the subjects r illnesses that were discussed. 222

229 Mdule 4 Sessin 4. Cunseling and Referral The cnsumer is aware f the need t change, but has n specific plans t d s. What t d Praise the cnsumer fr being aware that change is needed. Use verbal and nnverbal cmmunicatin skills t help the cnsumer make plans even after leaving the AMS. Offer an pen invitatin fr further discussin; issue a leaflet, if available. The cnsumer is ready fr actin, has cnsulted with friends r their partner, and has established persnal gals t change behavir, but has nt yet made an actin plan t achieve the gals. What t d Cunsel the cnsumer using GATHER. Offer an pen invitatin fr further discussin. The cnsumer is at the actin stage. The cnsumer has begun t change, the change is new, and the cnsumer alne r with a partner is trying ut ways f reaching the gal. What t d Cunsel him/her using GATHER. Offer an invitatin fr further discussin. The cnsumer cnsistently demnstrates the changed behavir, and the change is sustained. Fr example, the cnsumer fully cmplies with taking a full curse f any prescribed drug. What t d Praise the cnsumer and ask them t share with their peers, friends, etc., the benefits f fully cmplying with instructins fr taking medicatins. If pssible, invlve the cnsumer in relevant cmmunity educatin activities, if applicable. Situatins fr Practicing Cunseling Skills Slicited Services Sarah received a prescriptin fr a full curse f amxicillin 250 mg. She wants t purchase half f the capsules because she cannt affrd the price tday. In additin, she says that she received capsules f a similar clr six mnths ag and sme were left ver. Her daughter Rehema referred her t yu t help her use antibitics crrectly. Instructins: Cunsel Sarah t help her effectively use drugs prescribed t her. Mr. Bea Jnes was given Panadl tablets at the hspital fr pain in his knees. They wrked well. He came t purchase the same tablets. When yu gave him paracetaml, he became wrried and said he prefers t g back t his dctr fr Panadl. 223

230 Participant Manual AMS Dispensers Instructins: Cunsel Mr. Bea Jnes and help him t be cnfident in using paracetaml r Panadl tablets. Miss Mnique received a prescriptin fr a curse f ral Flagyl. She has cme t purchase the tablets. Hwever, she tells yu that she is wrried abut taking these pills because her friend wh tk the same type f pills tld her that they are very strng and make ne weak. Instructins: Cunsel Miss Mnique and help dispel her wrries abut Flagyl and use it crrectly. Mr. Krma reprts t yur AMS lking very frustrated because, he was prescribed Indcid three weeks ag, but it has been ut f stck in all the medicine stres. Yur AMS has ibuprfen 200 mg pills. Instructins: Cunsel Mr. Krma n the use f ibuprfen, its similarity t Indcid; help him use ibuprfen cnfidently and crrectly as an alternative t Indcid. Mrs. Sasha has cme t purchase an antifungal fr her child s scalp. Sifa has ringwrm. The MCH aid referred her t yur AMS fr the drug. Mrs. Sasha has used Fungistat (micnazle cream BP 2% w/w) befre and believes it is the best medicine, but yu have a substitute that wrks as well. Mrs. Sasha has difficulty in catching instructins, accrding t the nte frm the MCH aid nurse. Instructins: Cunsel Mrs. Sasha s that she crrectly uses the anti-fungal cream yu have in stck n her child s scalp. Als address the fact that she has difficulty with instructins. Unslicited Services As yu are talking t Mrs. Walter wh has cme t purchase dxycycline tablets, she infrms yu that this is the third time within six mnths that she has had a vaginal discharge that requires this drug. Instructins: In additin t ensuring that she uses dxycycline crrectly, cunsel her t help her address the prblem f having three buts f vaginal discharge within six mnths. Mr. and Mrs. Wilsn have cme t yur AMS t purchase ORS fr their seven- mnth ld baby. During discussin with Mr. and Mrs. Wilsn, yu hear them say that they will try weaning the baby because breast milk seems t disagree with his stmach. Instructins: Help Mr. and Mrs. Wilsn use ORS crrectly, and cunsel Mrs. Wilsn t cntinue t breast-feed their baby. Mr. Livingstne has been prescribed SP fr malaria. His wife whispers t yu that, althugh they will purchase SP, Mr. Livingstne will prbably nt take it because a friend with medical training advised them t avid taking SP, since it has very serius side effects. Mr. Livingstne is a literate blind man. His wife wrks daily and returns late in the evening. Instructins: Cunsel Mr. and Mrs. Livingstne t help the man cmply with the SP curse f treatment. 224

231 Mdule 4 Sessin 4. Cunseling and Referral Miss Cecilia, a yung lady 16 years ld, reprts t yu that she had an unexpected baby six weeks ag. She has cme t purchase prper medicine t stp a bad-smelling vaginal discharge. Her parents are yur best friends. She asks yu nt t reveal t anyne that she came t buy the medicine. Instructins: Cunsel Miss Cecilia t help her btain and cmply with apprpriate treatment fr her prblem. Als include infrmatin that will help her maintain her child s and her health, based n the brief infrmatin she shared with yu. 225

232 REFERENCES Accredited Drug Dispensing Outlet (ADDO) Dispensers Training Manual. First editin. United Republic f Tanzania Ministry f Health and Scial Welfare, Tanzania Fd and Drugs Authrity Accredited Drug Shps Training Manual. Ministry f Health, Natinal Drug Authrity and Pharmaceutical Sciety f Uganda Gve, S. Integrated Management f Childhd Illness by Outpatient Health Wrkers: Technical Basis and Overview. Bulletin f the Wrld Health Organizatin 1997;75(suppl 1):7-24. MDS-3: Managing Access t Medicines and Health Technlgies. Management Sciences fr Health Sterling, Va. Kumarian Press; page Medical Eligibility Criteria fr Cntraceptive Use. 4th ed. WHO. 2009; Natinal Therapeutic Guidelines fr Liberia and Essentials Medicines List. Ministry f Health and Scial Welfare, Republic f Liberia. 2011; The Ratinal Use f Drugs: Reprt f the Cnference f Experts, Nairbi, Nvember Wrld Health Organizatin; Selected Practice Recmmendatins fr Cntraceptive Use. 2nd ed. WHO Department f Reprductive Health and Research, Geneva. 2004; Standards fr Accredited Medicine Stres. Liberia Medicines and Health Prducts Regulatry Authrity and The Pharmacy Bard f Liberia. April 2012; pages 5 13, 15, 17, and (annex A). 226

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