GUIDELINES FOR

MEDICAL CLINICS IN FLOOD

AFFECTED AREAS

Dr. Shehla Baqi

Associate Professor in Infectious Diseases
Sindh Institute of Urology and
Transplantation

With

Recommendations for Immediate

Management of Infectious Diseases
in Flood Ravaged Areas

by

THE INFECTIOUS DISEASES SOCIETY OF PAKISTAN

Guidelines for Medical Clinics in Flood Affected Areas of Pakistan Page 1 of 18

ASSESS THE SITUATION
• Conduct an initial survey to see whether the area is not already served by another
medical team in order to avoid duplication of services and waste of resources.
• Co-ordination with local authorities may help to direct the medical team to underserved
areas.
• If the population to be served is mostly concentrated in one location within 1 kilometer
radius, a stationary clinic will be most effective.
• If the population to be served is scattered over wide areas, then it is best to have a
centrally located stationary clinic with mobile medical teams dispatched from the central
clinic on a daily basis.

ESTABLISHING A MEDICAL TEAM

If you estimate a daily patient load of 500 in a 12 hour day, you will need the following minimum
staff for the stationary clinic and the same number for the mobile clinic. (This number of patients
seems high for one day, but many of the diseases are skin conditions which require only a spot
diagnosis.)

• 3 doctors
• 1 pharmacist and 1 pharmacy helper. If there is no pharmacist available, and only a
dispenser or medical store keeper without formal training in pharmacy, then a fourth
doctor will be required to avoid medication errors.
• 1 nurse to take vital signs and weight and maintain IVs, dressings etc
• 1-2 non-medical volunteers who can be employed to document patient data, conduct
rapid surveys, language interpretation, help pharmacist etc.
• One of the 3 or 4 doctors, preferably with the most experience, should be appointed as
the Team Leader.

Orientation
The members of the team should meet before they are to leave for the affected areas for
orientation. Orientation for the new team should be the responsibility of and conducted by a
Team Leader who has already served in the camps and will comprise of the following:

• Introduction where all team members get to know each other. This has been shown to
greatly improve the efficiency and working of the team.

• Designate the team leaders.

• Describe the medical conditions most frequently encountered and their treatment. The
most common conditions seen are as follows:
o Anemia, even in males
o Conjunctivitis, probably of viral etiology.
o Diarrhoea, mostly watery and non-bloody.
o Dehydration
o Epigastric pain in the older patients.
o Febrile illness which could be malaria, typhoid or dengue.
o Malaria is mostly vivax.
o Malnutrition, often severe
o Pregnancy. Expect about 3 pregnant patients for every 100 that you see.
o Skin conditions such as scabies, tinea corporis, tinea capitis, lichen planus,
eczema, lice infestation, folliculitis and furunculosis.

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 o Upper respiratory infection.
o Lower respiratory tract infection is less frequent.
o Less commonly, you may get a case of asthma, or pick up a case of uncontrolled
hypertension or diabetes mellitus. Coughing patient may have TB or be a known
case of TB.

• Revise doses of medications that should be used with emphasis on pediatric dosing ( see
drug chart)

• Familiarize the team with the various brands of drugs and dosages that are on the
formulary. A sample of the drugs should be displayed at every orientation.

• Review policies that are being followed regarding dispensing of medications and duration
of treatment.
Duration of treatment in emergency situations should be the minimum effective for the
condition. Courses for greater than 1 week, in general, are not practical and can lead to
wastage of medications.

• Discuss policies regarding treating patients that are not from the flood affected areas that
may present to the clinic.
Essentially, no patient should be turned away.

• Discuss policies regarding dispensing of food items and water in addition to medications.
Food items should not be distributed since the focus of the Medical Clinic will not remain
the same. However, clean drinking water should be provided, atleast one 1.5 liter bottle
to each mother.

• Reinforce policy regarding dispensing of soap in addition to medications. Soap MUST be

provided to the patients, best dispensed as one bar of soap to each mother, written on
the prescription. Soap is essential since:
o Most of the diseases that we are treating at these camps are spread through lack
of hygiene.
o Prevention is better than cure.

• Emphasize that the Medical Clinic should not function as a Drug Distribution Center.
Clinic should be a Treatment Center which means that you need to conduct a problem
oriented history and examination, make a diagnosis and then prescribe medications
together with counseling regarding hygiene and the correct way to take the medications
prescribed.

• Encouraging the team members to counsel patients at every opportunity regarding

hygiene.

• Discuss protocol regarding patient referral to a hospital.

• Personal protection for the team members.

o Mosquito repellants and spraying of clinic areas is the most practical intervention
o Malaria prophylaxis with doxycycline 100mg PO once daily started 2 days before,
during and for 4 weeks after working in the area (not in children <8 and
pregnancy). This will cover both vivax and falciparum but requires daily doses.

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 For vivax alone, chloroquine tablets are effective, 2 tabs of chloroquine
phosphate 500mg (300mg base) once a week starting one week before travel,
then during the stay and then continued for 4 weeks after return.
o Masks to use when examining a coughing patient or one with measles.
o Alcohol handrub with 70% alcohol, one bottle for each physician.
o Soap and water for handwashing if soiling of hands occurs.
o Disposable gloves.

SETTING UP THE CLINICS

a. Stationary Clinics
One can utilize an existing building or use tents. The clinic will need:
• Area for patient consultation and examination. There should be a screen available that
can be used for examinations that need to be conducted privately.
• Pharmacy
• Sick Room for patients to receive IV hydration, wound dressing, minor surgery.

b. Mobile Clinics
To maximize efficiency of the mobile clinics, essential steps to follow are:
• Find an area, some distance from the center of the camp, where you can set down a few
chairs for the doctors and patients, and folding tables. If no shade available, keep a large
umbrella in your mobile van. You can examine patients inside a large ambulance as well.
Trying to create a level of comfort for the medical staff is important in maintaining
efficiency.

• Appoint one person for crowd control who can be firm and knows the language. Allow
one patient at a time.

• Nurse should triage the patient, and make sure that the sickest patients are seen before
the others.

• Nurse should document the name, age, sex, and some vital signs (if indicated) on a pre-
printed paper, which the patient then brings to the doctor. Record the temperature if
there is complain of fever. Take the blood pressure if dehydrated or patient gives a
history of hypertension. Obtaining vital signs for all patients is not practical. Weigh all
children who appear to be less than 35kg. Check blood sugar if patient gives a history of
diabetes. The nurse should counsel patients regarding hygiene at every opportunity.
Document immunization and nutritional status of children if you are interested to collect
this information.

• Doctor should examine the patient, and then send him/her to the pharmacy with the
prescription written on the paper that nurse has already filled with patient information.

• Doctors must write the prescription clearly, giving exact dosages e.g the mg/kg strength
of syrups, then the tsf required, in case of the pediatric patients, e.g amoxicillin-
clavulanate 156mg/5ml 1 tsf TDS for 5 days. The dosing needs to be explained to the
patient. Hygiene should be discussed, even if it is briefly.

PROMOTING EFFICIENCY OF THE MOBILE PHARMACY

Crowd control is the first step to maintain efficient dispensing of drugs.

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 • The back of the van/ambulance can be converted into the pharmacy. It is helpful if the
prescription is received at one window and medication dispensed from the next window
on the side, rather than from an open van door. The small windows allow lines to be
formed and maintains order.

• A volunteer who assists in receiving the prescription and finding the medications and
handing them to the pharmacist is essential, since the biggest crowds gather at the
pharmacy window, especially if more than 1 doctor is working at a time.

• Medications should be stored in order and divided into labeled areas such as analgesics,
antibiotics, GI drugs with ORS packets, cough and cold preparations, skin lotions and
creams, vitamins and supplements.

• Avoid syrups in your formulary since they are bulky and can get spoilt in the heat. Only
use syrups for very small children. Cough syrups are rarely of much use and their stock
should be limited.

• It may be helpful to make pre-packaged doses in some cases e.g

Pregnancy Package
1 bottle of Folic Acid of 100 tablets, 1 tablet daily
60 ferrous tablets, 1 tablet BD
1 pack of 30 multivitamins, 1 tablet daily

Adult GI Package in cases of bloody diarrhoea

Flagyl for 5 days
Ciproxin BD for 3 days

Analgesic packages of 10-12 paracetemol tabs

• ORS should be prepared in clean water and provided to patients. If that is not possible,
give a bottle of clean water with sachet of ORS.

• If medication requires mixing with water, the pharmacist should mix the medication with
the exact amount of clean water before dispensing it.

• Make sure that we provide spoons or medication cups since it is pointless to direct a
patient to take 1 tsf three times a day if they do not have a teaspoon.

• For families who have more than 1 patient, pharmacy needs to keep paper bags for
separate prescriptions, so that the family does not mix up the medications.

REMEMBER, OUR GOAL IS NOT DRUG DISTRIBUTION.

IT IS TO PROVIDE MEDICAL CARE.

• Prescriptions can be saved by the pharmacy for data collection. On the other hand, it
may be valuable for the patient to have a record of his treatment in case of follow-up visit
by ourselves or from another medical team. If the patient is given the prescription to
keep, patient data will need to be documented in a separate register.

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 • Data collection is essential to gauge the needs of the camps and whether outbreaks are
occurring.

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 RECOMMENDATIONS FOR
IMMEDIATE MANAGEMENT OF
INFECTIOUS DISEASES IN
FLOOD RAVAGED AREAS

INFECTIOUS DISEASES SOCIETY OF PAKISTAN

Drs. Naseem Salahuddin, Faisal Mahmood,

Farheen Ali, Shehla Baqi, Faisal Sultan,
Anita Zaidi, Asad Ali, Ejaz A. Khan,
Altaf Ahmed, Fatima Noman

Guidelines for Medical Clinics in Flood Affected Areas of Pakistan Page 7 of 18

1. Hygiene and Clean Water
• Soap for hand washing and bathing should be provided as a priority item, and personal
hygiene stressed and practiced as much as possible.
• Wash cloth
• Write a prescription for soap for the mother of the family, one per family.
• Purification of drinking water: Chlorination with PUR sachet is a cheap, effective and
easily accessible way of purifying water, 1 sachet will disinfect 10 liters of water.
• Provide 10 liter capacity bucket, a mug and 1 meter white mulmul cloth
• Provide laundry soap

2. General Diarrhoea Treatment

• Educate regarding rehydration
• Continue breast-feeding for infants who are breast-fed
• Regular ORS. Low osmolarity ORS such as pedialyte is not recommended as it may
cause hyponatremia in cholera.
• IV Fluids (0.9 NS and Ringer lactate drips) for severe dehydration. If shock:
0.9%NS10ml/kg bolus then ringer lactate 90ml/kg over 4 hours (in children). If no shock,
Ringers lactate 100ml/kg over 4 hours(in children)
• Syrup zinc for 10 days in children under 5 years with diarrhoea
• Anti diarrheal: not recommended because of risk of toxic mega-colon
• Ciprofloxacin for bloody diarrhea when we are suspecting bacillary dysentery. It should
also be given for severe acute watery diarrhea with dehydration where we may be
dealing with cholera. Also give ciprofloxacin for child less than 6 months old with
diarrhoea, fever and toxicity.
• Give metronidazole if suspecting amoebic dysentery.
• Do not use metronidazole and ciprofloxacin as general antidiarrhoeal drugs.

3. Acute Respiratory Infections

Most acute respiratory infections are viral and self limiting and do not need antibiotic therapy.
Supportive care may be given
If you suspect pneumonia then antibiotics must be given.
a. Pneumonia in Adults: Levofloxacin
b. Pneumonia in Children: Amoxicillin

4. Eye Infections
Mostly secondary to viral infection, hence no specific treatment is required.
If symptoms persist more than 3 days or purulent discharge then use topical antibiotic eye drops
such as:
a. Chloramphenicol eye drops
In mobile clinics, and even in the stationary clinics, there may not be an opportunity to follow up
the patient. Therefore, in practice, it is best to give antibiotic eye drops in the first patient
encounter, if there is conjunctivitis, although we suspect that it is probably viral in nature.

If symptoms persist for more than 2 wks, give oral erythromycin 12.5 mg/kg qid x 14 days for
trachoma.

5. Vector Control
a. Insect repellants may be used.
b. Permethrin impregnated bed nets, if practical

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6. Skin Infections
• Scabies
a. Local application of Benzyl benzoate OR
b. Permethrin 5% cream.
c. Provide treatment for the entire family.
d. Council regarding washing of clothes and linen if conditions allow.

• Impetigo, cellulitis, boils, folliculitis, furunclosis

a. Cloxacillin for 7 days or

b. Cephradine for 7 days or
b. Amoxicillin clavulanate for 7 days
c. Local antiseptics: Pyodine, Gentian violet

• Tinea corporis
a. Clotrimazole cream

• Tinea capitis
Topical treatment is ineffective.
a. Terbinafine tablets for 2-4 weeks. Impractical to treat in emergency conditions.

• Eczema and lichen planus

a. steroid skin cream

7. Typhoid
a. Cefixime PO for 10 days
b. Typhoid (if not responding to cefixime) then IV Ceftriaxone

8. Meningitis
a. Ceftriaxone IV

9. Malaria
a. Artemether/lumefantrine : for suspected P falciparum or P vivax
b. Chloroquine only if proven vivax species

10. Deworming
a. Albendazole single dose or mebendazole for 3 days.

11. Tuberculosis
Patients already on anti TB treatment should be referred to TB Centers. New suspected cases of
TB should be referred to tertiary care hospitals.

12. Snake bite

First Aid
R=Reassurance: 70% of snake bites are from non-venomous species. Only 50% of
venomous species actually envenomate
I=Immobilize in same way as a fractured limb using bandage or cloth. Do not apply
compression.
G.H= Get to Hospital Immediately
T=Tell the doctor of any symptoms

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13. Vaccines
For pediatric age group: EPI vaccines should be continued, especially for measles.
For adults, no injectable vaccination is recommended in the current phase of this emergency for
the following reasons:
a. Most vaccines require 2 or more injections to be effective. It would be logistically difficult to
attain this goal
b. It is not possible to maintain cold chain in flood affected areas
c. Re-use of needles and syringes is likely to occur in majority of cases, further compounding
the already high incidences of Hepatitis B and C

14. Personal Protection

Gloves and masks should be provided in large quantities.
Hand hygiene between patients

15. Laboratory
Rapid malaria detection tests are easy to perform and cost effective for diagnosis of
malaria and its species. A positive test will help rule out dengue and typhoid
fever and allow proper malaria surveillance. This is the only test we recommend for the mobile
clinics.

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Table 1. Indications and Uses of Drugs in Flood Relief
(Estimated quantities to stock for a single day at a camp serving 500 patients
with varying diagnoses. However, the requirement for drugs can vary from camp
to camp and from day to day)

Drug Indication Doses Quantity for a

camp where 500
patients may be
expected
Albendazole 400mg tablet Worm infestation 400mg single dose. 50 tabs
If less than 1 year,
then 200mg single
dose.
Amoxicillin 250mg and Respiratory or otitis 2 months-12 months: 500 of 250mg tabs
500mg tablets and syrup media in children 125mg three times a 500 of 500mg tabs
125mg/5ml only. However, day 50 of 125mg syp
Syrup 250mg/5ml amoxicillin is the 1 year to 5 years: 50 of 250mg syp
drug of choice for 250mg three times a
streptococcal sore day
throat in both 5 years to 14 years:
children and adults. 50mg/kg/day in 3
doses
Adult: 1.5gm/day in 3
divided doses
All for 7 days max
Amoxicillin-clavulanate Respiratory or ENT Calculate according 300 of 375mg tabs
375mg (250mg infection or bacterial to the amoxicillin 300 of 625mg tabs
Amoxicillin) tabs skin infection component same as 50 156mg syp
625mg (500mg above. 50 312.5mg syp
Amoxicillin)
Syrup 156mg/5ml
(contains 125mg of
amoxicillin)
Syrup 312.5mg (contains
250mg of amoxicillin)
Artemether 20mg and Malaria. Use for 5-14kg 1 tab BD 400 tabs
Lumefantrine 120mg children less than 15-24kg 2 tabs BD
combination 35kg that are able to 25-34kg 3 tabs BD
take tablets >35kg 4 tabs BD
All given for 3 days.
(The second dose
should be 8 hours
after the first dose,
then BD dosing on
the second and third
day.)
Artemether 40 and Malaria. Use the DS >35kg 2 tabs BD for 400 tabs
Lumefantrine 240mg (DS preparation for all 3 days. (The second
preparation) adults above 35kg dose should be 8
hours after the first

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 dose, then BD dosing
on the second and
third day.)

Drug Indication Doses Quantity for a

camp where 500
patients may be
expected
Artemether 15mg and Malaria. Use the 4mg/kg/day of 50 bottles
Lumefantrine 90mg suspension for Artemether given as
suspension children who cannot a single dose for 3
take tablets days e,g a 5 kg child
requires 7ml once a
day for 3 days

Chloroquine 150mg base Vivax malaria Adult: 4 tabs stat, 100 tabs (stock more
(250mg tab) then 2 tabs 6 hours if the data shows
later, then 2 tabs that most cases are
once a day for 2nd of vivax malaria)
and 3rd day.
Child: 10mg.kg once
daily for 2 days and
5mg/kg on 3rd day
Ceftriaxone Typhoid, meningitis 1gm twice a day. 10 vials
2gm twice a day if
meningitis
Child: 50-
75mg/kg/24hours in
1-2 doses.
100mg/kg/day in 2
doses if meningitis
Cefixime 400mg tabs Typhoid Adult: 400mg BD for 200 tabs
Cefixime syrup 10 days 20 bottles
200mg/5ml Child: 16mg/kg/day
in a single dose for
10 days
Cephradine 500mg tabs Skin and soft tissue Adult: 250mg every 6 250 tabs
Cephradine syrup bacterial infections hours or 500mg 25 bottles
250mg/5ml every 12 hours
Children 25-
50mg/kg/day in 2-3
doses
Give for 5-7 days
Ciprofloxacin Urinary tract infection Adult: 500mg BD for 300 of 500mg tabs
500mg tablets Bloody diarrhoea 5-7 days for UTI; 3 200 of 250mg tabs
250mg tablets Cholera days for diarrhoea 50 bottles of syrup
Syrup 125mg/5ml Child: 20-30mg/kg/24
hours divided into 2
doses e.g 10kg child
needs 1 tsf of
125mg/5ml BD for 3

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 days for diarrhoea
Cloxacillin 250mg tabs Skin bacterial Adults: 1-2 tablets 300 tabs
Syrup 125mg/5ml infection every 6 hours for 5-7 30 bottles
days
Child:50-
100mg/kg/day
divided into 4 doses
for 7 days
Drug Indication Doses Quantity for a
camp where 500
patients may be
expected
Cough syrup cough 1-2 tsf three times a 50
day
Domperidone 10mg tabs Nausea and vomiting 1-2 tabs before 100 tabs
Suspension 1mg/ml meals and at bedtime 10 bottles
Child: 2-5-5ml/10kg
Max for 2 days
Ferrous sulfate tablets Anemia and 1 tablet BD for 1 5-10,000 tabs
Iron syrup antenatal care. month 50 bottles of iron
Include in pregnancy syrup
package.
Folic acid 5mg Antenatal care. 1 tablet daily 20 bottles of 100
100 tabs in one bottle Include in pregnancy tabs each
package.
Hyoscine butylbromide Gastrointestinal and 1 tab three times a 50
genitourinary day. Max 2 days
spasms treatment
Levofloxacin 750mg tabs Adult pneumonia 1 tab once a day for 40 tabs
5 days
Mebendazole Worm infestation, 100mg twice daily for 200 tabs
severe malnutrition 3 days
Metronidazole 400mg Amoebiasis, Adult: 400mg three 500 tabs
tabs giardiasis times per day for 5 50 bottles
Suspension 200mg/5ml days
Child: 30mg/kg/day
once daily for 3 days
for giardiasis.
45mg/kg/day in 3
divided doses for
amoebiasis for 5
days
Multivitamins tablets 30 in 50 packs of 30 tabs
one pack 50 syrups
Multivitamin syrup

Omeprazole 20mg capsules Once daily in the 210 capsules

morning for
maximum 7 days

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Oral Rehydration Salts Prevention and 1 sachet in 1 liter of 500 sachets
treatment of clean water: give 2
dehydration sachets per patient
Paracetemol 500mg Fever and pain Adult 3gm daily in 3- 1000 tabs
tablets 4 divided doses 150 bottles
Syrup 120mg/5ml Child: 15mg/kg per
dose not more than 4
times a day e.g 8kg
child requires 1 tsf
every 6 hours

Drug Indication Doses Quantity for a

camp where 500
patients may be
expected
Pheniramine maleate Allergic conditions Adult: 1 tab 2-3times 100 tabs
tablets 25mg tabs a day 25 bottles
15mg/5ml 1-3 years ½ tsf
4-12 years 1 tsf
Three times a day.
Max for 3 days
Salbutomol 4mg tabs asthma Adult: 6-12mg/day in 50 tabs
Syrup 2mg/5ml 3 divided doses 10 bottles
2-6 years ½-1 tsf
6-12 years 1 tsf
Three times a day for
max 5 days
Sulfadiazine silver 1% Burns and infected Apply once daily and 10 tubes
cream leg ulcers cover with sterile
compresses
Zinc sulfate 20mg/5ml Diarrhoea in <6months 10mg, 100 bottles
children<5 >6months 20mg
once daily for 10
days
Benzyl benzoate 25% Scabies After bath, apply from 100 bottles
lotion neck down. Repeat
application after
24hours for 3
consecutive days
and then wash off the
next day
Permethrim 5% cream Scabies Apply once from 1000 tubes
neck down and wash
out after 12-24 hours.
Calamine 15% lotion Itching skin 2-4 applications per 50
conditions day

Gentian violet Antifungal and for 2 applicatiosn a day 50

oozing dermatosis until lesions
disappear

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Pyodine 10% solution Antiseptic and
disinfectant
Ringers lactate Severe dehydration
Tramadol hydrochloride, Severe acute pain
50mg/ml, 2ml ampule (fracture, trauma)
20
<1yr: 30ml/hg first 20
hour; 70ml/kg within
5 hours
>1 year: 30ml/kg in
first 30 minutes;
70ml/kg in 3 hours
Child >6m: 2mg/kg 10 ampules
injection every 6
hours
Adult: 50-100mg
injection every 6
hours, max
600mg/day

Drug Indication Doses Quantity for a

camp where 500
patients may be
expected
Atenolol 50mg tabs Uncontrolled 1 tablet once a day 50
hypertension for max 7 days.
Refer to hospital for
longterm care
Antisnake venom. There Snake bite if If type of snake not 4 vials NIH
are 2 preparations: evidence of known, 8 vials of 8 vials Indian
a. Liquid (NIH) more coagulopathy or Indian or 4 vials of
effective for Pakistan but neurotoxicity NIH can be used for
requires cold chain and initial dose. Refer to
refrigeration hospital
b. Lyophilized (Indian) in
powder form, only keep
cool
Antirabies vaccine Dogbite Wash and flush 2 doses
wound with soap and
clean water for 15
minutes and apply
antiseptic. Inject 1
dose of any cell
culture vaccine IM
into deltoid. Refer to
hospital for further
management.
Diazepam 5mg/ml, 2ml seizures Child 0.5mg/kg 10 ampules
ampule rectally or 0.2mg/kg
by slow IV injection
Adult: 10mg rectally
or by slow IV
injection.

Dextrose, 10% Hypoglycemia due to 5ml/kg by very slow 2

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 severe dehydration IV injection over 5
minutes or by
infusion
SOAP (any brand) 1-2 for each family 300
Purification Tablets 2000

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