Clinical Guidelines and Treatment Manual (MSF, 1993, 319 p.) Appendix Disinfection and Sterilization of medical equipment and supplies Monthly epidemiological report List of essential drugs of WHO The New Emergency Health Kit - (WHO)

Clinical Guidelines and Treatment Manual (MSF, 1993, 319 p.)

Appendix

Disinfection and Sterilization of medical equipment and supplies

- Sterilization = elimination of all micro-organisms (viruses, microscopic fungi, bacteria, both vegetative and spore forms).

- Disinfection = elimination of most micro-organisms present on a surface or object.

- Decontamination = disinfection of object soiled by infectious material (pus, blood, excrete...).

General rules

All equipment or supplies:

- coming into contact with sterile parts of the body (injection equipment, surgical instruments, some dressings, catheters...).

- used for perfusion.
should be sterilized and kept sterile until utilization.

All reusable items, which do not correspond to the above definition, but which come into contact with mucus membranes, or get soiled with pus, blood, lymphatic or vaginal secretions, should be sterilized or subjected to a high level disinfection (effective among others against HIV and hepatitis B virus).

All soiled, non reusable equipment should be incinerated (warning: never recap needles after use = main cause of accidental needlestick).

To carry out proper sterilization is not always easy in the field conditions of isolated rural medical centers. It requires proper appliances (autoclave, hot air sterilizer), and an energy source.

In practice, one is often obliged to use alternative procedures which are not wholly satisfactory as they produce disinfection rather than sterilization (They are however compulsory if one cannot do better) (see following chapters).

Disinfection and sterilization of medical equipment is not enough to prevent iatrogenic infections (resulting from medical practice). It is obvious that basic hygienic and asepsis techniques ought to be applied: cleaning and disinfection of surfaces and premises, personal hygiene of the staff, aseptic handling of sterilized instruments...

Cleaning of reusable equipment

Soiled items and instruments should be carefully cleaned before being sterilized or subjected to a final disinfection.

The presence of organic matter could protect germs against the action of a disinfectant or sterilizing agent, or could react against it, rendering it ineffective.

INSTRUMENTS

Cleaning can be done either with water alone, with water and soap (or detergent), or with water and a compound of disinfectant/detergent.

Cleaning with a disinfectant chemical aims mainly to reduce the risks of contamination for the staff, but it does not eliminate them completely.

The staff in charge of instrument cleaning should be aware of the contamination risks (AIDS, hepatitis B), they should wear thick plastic or rubber gloves, and be careful when they handle sharp instruments.

After use and before cleaning, all instruments and items should be soaked in water to avoid deposits drying up. A disinfectant could be added for a first decontamination (chloramine 20 g/1, lysol 50 g/1).

Metallic instruments can be damaged if they are left in water too long (over several hours) or if the disinfectant concentration is too high.

Note

Needles and syringes for immunization should be soaked and cleaned with water alone, as traces of soap and disinfectant can inactivate vaccines.

After cleaning, instruments and items should be rinsed thoroughly with water and dried, then sterilized, boiled or disinfected (with a high level disinfectant) depending on their use and the local sterilizing facilities.

LINEN AND DRESSING

To decontaminate linen and dressings, one should wash them with an ordinary washing powder (ea. OMO) and boil them if possible (5 minutes).

If boiling is not possible, linen should be washed, rinsed and soaked for 30 minutes, in a 0.1 % chlorine solution (hypochlorite, bleach, chloramine), or 5 % lysol solution. It should then be rinsed abundantly and dried.

Theatre linen should be sterilized in an autoclave or ironed depending on local facilities.

Sterilization methods and alternatives

AUTOCLAVING

Sterilisation by steam under pressure in an autoclave.

Autoclaving is the most reliable sterilization method and the only one that allows effective sterilization of all medical equipment and supplies (especially linen and rubber). But relatively sophisticated appliances and energy source (electricity, kerosene or gas) are needed.

It is based on the same principle as a kitchen pressure cooker. Because water is heated in a closed container, temperatures above 100°C can be reached.

In the absence of air (air is purged at the beginning of sterilization), the temperature can be regulated by controlling the pressure.

According to the type of supply to be sterilized, sterilisation is carried out at 121°C (1 atmosphere over atmospheric pressure) or at 134°C (2 atm. over atmospheric pressure).

Table

Note:

- Do not forget to expell air (purge) while increasing the pressure (otherwise the temperature in the autoclave will not be sufficient).

- Drums or boxes holding objects to be sterilized must be open, never closed (unless fenestrated). The sliding windows in the special autoclave boxes should also be open during sterilization.

- Count the sterilizing time from the moment the required temperature or pressure is reached, not from the start of the heating phase.

DRY HEAT (IN HOT AIR STERILIZER OR OVEN - CALLED A POUPINEL IN FRENCH)

Sterilization by hot air (dry heat) at 160°C (320°F) for 2 hours or at 170°C (340°F) for 1 hour.

Reliable method provided it is carried out in a good electric appliance with working thermometer (an air circulation device is needed in large ovens).

This method is convenient for metal, heat resistant glass, and vaseline, but is not convenient for linen or gauze swabs. The oven method is quite simple but consumes more energy than an autoclave.

Ovens heated by charcoal fires or kerosene heaters are not reliable because they do not produce a sufficiently high temperature.

Time should be calculated from the moment the required temperature is reached (this is very important).

Notes

- Begin heating with the door open to expel any humidity (which could rust instruments).

- Do not exceed 170°C (could damage metallic instruments).

- It is better to place items in closed boxes. However, large boxes should be left halfopen to allow the material to more rapidly achieve the correct temperature.

BOILING

Boiling for 20 min (adding 5 minutes for 1000 altitude) provides high level disinfection, but not sterilization because it does not destroy bacterial spores (eg.: tetanus, gangrene).

Boiling is nevertheless essential when autoclaving or hot air sterilization are not possible. It is particulary useful for needles and syringes (it destroys HIV and hepatitis B virus).

After needles and syringes have been boiled, they should be kept dry and not left in the water (which can easily become recontaminated).

FLAMING

- In a flame: Effective if instruments are made red hot. This method should only be used in exceptional circumstances as it damages metal.

- With alcohol: Instruments are dipped in alcohol and set alight. This method is unreliable, expensive and in the long term damages instruments.

IRONING

Surgical drapes and gauzes can be ironed if an autoclave is either unavailable or too small to hold large operating drapes.

Iron on a table or bench covered with a sheet that has itself just been "sterilized" by ironing.

Dampen each item slightly with filtered boiled water.

The iron should be very hot and passed several times over each side of the linen/gauze.

However, if it is available, autodaving is always the preferred method.

IMMERSION IN "HIGH LEVEL" DISINFECTANTS

Immersion (of clean equipment) in the following disinfectant solutions destroys bacteria and virus including HIV and hepatitis B virus. The bacterial spores are generally not destroyed.

This process could be used as an alternative to sterilization when autoclaving or hot air sterilization are not possible.

Boiling however is always preferred. The effectiveness of chemical disinfection can always be impaired by dilution errors, by bad storage conditions, or by prolonged utilization of the same solution (solutions should be renewed at least once a day).

Chemical disinfection should never be recommended for syringes and needles.

Table

1. Hypochlorite solution (0.1 % or 1,000 ppm-1 ppm=1part per million=1mg/l- available chlorine) is prepared either from liquid bleach recently manufactured (< 3 months) or from calcium hypochlorite or from sodium dichloroisocyanurate (NaDCC, "Javel tablets", Javel solid, Stafilex, Actisan...), diluted according their respective available chlorine content.

Fresh liquid bleaches contain 3 to 15 % available chlorine (sometimes expressed in chlorometric degrees, 1° chlorom. = approx. 0.3 % available chlorine). Calcium hypochlorite contents from 30 to 70 % available chlorine. The NaDCC based tablets content generally 1.5 g available chlorine per tablet (1 tablet per litre = 1,500 ppm available chlorine).

NaDCC withstands heat much better than bleach and calcium hypochlorite.

2. As hypochlorite solutions are corrosive for metal, these solutions are convenient only for good quality stainless steel. The soaking should not exceed 1/2 hour and should be followed by thorough rinsing.

3. If instruments are used immediatly after soaking, it is not necessary to rinse the chloramine or the polyvidone iodine solution.

4. Ethanol and isopropylic alcohol (isopropanol) should be used at 70 % (70°) for the best effectiveness (more concentrated solutions are less effective). The prices, transportation and importation problems limit the use of these alcohols.

5. Immersion for several hours in aldehyde solutions, formaldehyde (formalin) and glutaraldehyde (Cidex), provides proper sterilization (destruction of all germs). These solutions however have many disadvantages: thorough rinsing compulsory (toxic residues), toxic vapours (formalin), high cost (glutaraldehyde).

Notes

- In order to obtain effective disinfection, eguipment must be cleaned before immersion in all these solutions...

- Aqueous solutions of cetrimide (Cetavlon), chlorhexidine (Hibitane), Savlon, HAC, Dettol and other common detergent and disinfectant solutions do not provide sufficient disinfection.

Soaking instruments in these solutions with the aim of "sterilization" should be avoided. This only provides an illusive feeling of safety and could in fact be a source of contamination.

STERILIZING GASES

- Ethylene oxide.

This method cannot be considered in field conditions because of its cost and of the special installation it requires (ethylene oxide is very toxic).

- Formol vapour (paraformaldehyde or trioxymethylene or "formol" tablets and Aldhylene)

Formol autoclaving also cannot be considered in the field. However formol vapour is often used for "makeshift" sterilization of instruments. The instruments are thoroughly cleaned and dried, then placed in a airtight container for at least 24 hours (minimum temperature of 20°C), either along with formol tablets 5 tablets for 1 litre container), or with formol alcoholic solution (Aldhylene) (1 ml for 1 litre container). Afterwards instruments are rinsed with sterile water. This is often impracticable, but it is absolutely compulsory if there is any visible deposit.

Users should be cautious during manipulation as vapors are toxic and highly irritative.

This method is not suitable for linen or gauze swabs as they absorb formaldehyde, which is toxic and necroses skin and mucus membranes.

This method is not totally reliable and has many disadvantages. It should be abandoned. If it is used an effective disinfection method against HIV (AIDS virus) (eg. boiling) should always be carried out before hand.

Equipment and metbods recommended

DISPENSARIES

Recommended equipment

- 1 small autoclave pressure cooker type (volume 15 to 20 litres)
- 1 powerful kerosene stove (or electric hot-plate)
- 1 metal mesh basket
- Appropriate fenestrated containers (drums)

Recommended methods

- Instruments, syringes, glass, rubber, plastic, gauze swabs, small drapes: autoclave.

- Large drapes, gowns: wash with soap powder, boil if possible, then "sterilize" by ironing.

MOBILE TEAMS

Recommended equipment

If possible same equipment as for dispensaries.

Otherwise:

- 1 container for boiling
- Chloramine T or Polyvidone iodine (Betadine)

Recommended methods

As for dispensaries if possible.

Otherwise:

- Metal instruments: boiling (best), otherwise sodium dichloroisocyanurate (NaDCC) or chloramine T or polyvidone iodine (exceptionally, after boiling and drying, instruments may be kept with formol tablet or Aldhylene until utilization)

- Needles, syringes: boiling

- Swabs: use disposable supplies

HOSPITALS WITH SURGICAL FACILITIES

Recommended equipment
Same equipment as for dispensaries and:

- 1 large autoclave (interior dimensions about 40 x 60 cm), operating with electricity, gas or kerosene according to local conditions.

- 2 mesh baskets

- Several fenestrated drums (number according to activity)

- Several fenestrated instrument boxes
If electric current is available continuously for at least 3 hours per day:

- 1 electric hot air sterilizer

Recommended methods

- Metal instruments, glass: hot air sterilizer if good electric apparatus available, other-wise autoclave

- Swabs, linen (gowns, drapes): large autoclave

- Rubber, plastic items, syringes: small or large autoclave (at 121°)

Directions for use of an autolcave

Figure

1. Body of the autoclave

2. Mesh basket to contain packages to be sterilized

3. Metal base to support basket, drums above water

4. Drain tap

5. Lid, usually with a rubber seal and bolt-type catches

6. Tap or valve to allow purging of air during heating phase

7. Pressure valve: regulates the pressure by allowing excess vapour to escape

8. Safety valve

9. Pressure gauge

Note

In small autoclave, pressure cooker type, there is no purging tape, one uses the valve for purging.

The safety valve should not be manipulated during autoclaving (it will function only in case of excessive pressure rise).

Pressure gauge shows a pressure scale and sometimes a temperature scale. Pressure could be indicated in different manners.

One may consider that 1 bar = 1 kg/cm2 = 1 atmosphere = 15 psi

Temperature could be indicated in °C ou °F (135°C = 275°F; 121°C = 250°F).

OPERATION

1. Put the require quantity of water in the autoclave before each sterilization (dry heating could damage the autoclave): the level is usually marked or the quantity indicated by the manufacturer. If possible use distilled water or filtered rain water.

2. Place the objects to be sterilized in the mesh basket or onto the support, leaving enough room for vapour to circulate freely. The sliding "windows" on drums or containers must be open. Do not overload the autoclave.

3. Close the lid by tightening the bolds in diametrically opposite pairs (as the wheel nuts of a vehicle).

4. With the purging tap or valve open, begin to heat.

5. When a continuous jet of vapour is coming out of this tap/valve, close it.

6. Allow the pressure to rise to 0.5 atm, then open the purge tap/valve for 10 seconds to purge air, then close it.

7. Repeat this purge at about 0.7 atm, then again at about 0.9 atm.After this, al1 air should have been expelled from the autoclave and only steam will remain.

8. When desired operating pressure (and thus temperature) is obtained, sterilization begins. Start to time it then, not before.

The pressure valve regulates the pressure inside the autoclave allowing excess steam escape. There may be two interchangeable valves or positions to operate at either 1 or 2 atm.. If a lot of steam is being expelled, heat source should be lowered slightly.

9. After the required duration of sterilization, shut off the heat source.

10. Evacuate water and steam:

- For large autoclaves: through drain tap (to be connected outside).

- For pressure cooker type autoclaves: evacuate the steam by opening the purge valve. Once pressure drops to zero, open the lid, lift out the basket, pour out the water then replace the basket.

11. Allow to cool with the lid slightly open. Residual heat helps dry the sterilized items (the danger of contamination by ambient air is minimal).

12. Once items are dry, close the sliding windows on drums.

Note

If the autoclave is equiped with a drying system, follow the manufacturer's recommendations starting from paragraph 9.

PRESSURE OR TEMPERATURE AND DURATION REQUIREMENTS

Table

OPERATION VERIFICATION

- The stove should be powerfull enough to obtain a minimum rise of pressure of 1 atmosphere (1 bar or 1 kg/cm2 or 15 Psi).

- If possible, use sterilization autoclave tests, for example, 3M Autoclave Tape should turn black, brown is insufficient).

Warning, do not confuse test tape for hot air sterilizers with that for autoclaves. They are very similar but not interchangeable.

Place tests (eg. strip of tape) in the middle of the load into the boxes or drums to ensure that sterilization (temperature, steam, duration) is completed.

PACKAGING OF ITEMS FOR STERILIZATION

- Packaging of items: either

· without package if items are to be used immediatly,
· fenestrated drums or boxes,
· heavy duty paper: wrapping paper, kraft paper or news paper (2 layers),
· closely-woven linen (2 layers),
· mixed (1 layer of paper, 1 layer of linen).

Paper plus linen is advisable if item is to be stored several weeks (because more resistant than paper alone and best barrier for germs than linen alone).

- Fenestrated containers should be equiped with a filter (a layer of heavy duty paper see above) accross the windows within the container or around the load to be sterilized so as to filter air during the drying phase after auto-craving. The paper should be checked and renewed regularly.

- If the autoclave is not equiped with a drying system, drying up of items inside boxes and drums is often unsastifactory. It is easier when the items are packed with paper or linen.

- Packed items should be placed vertically in the autoclave basket (not lying flat).

- Small packages and small drums are preferable to large ones.

- Needles and syringes: separate plunger and barrel of syringes and stick needles onto a gauze swab.

- Swabs and drapes should not be compressed inside boxes or drums.

Monthly epidemiological report

The goal of this report is to facilitate and standardize data collection for epidemiological surveys. It should record the monthly activities of the program and help in constructing the three-month and yearly reports. This form is a frame work for data collection, it should be adapted to the specific program.

Identification

Country:	Month:
Place or site:	Year:

Population

MONTHLY REPORT

Source:

Total of previous month:

Arrivals:		+	-Departures:
Births:		+	-Deaths:
				Monthly report
	+ Subtotal:		- Subtotal:

Average population= (total of previous months + monthly total)/2

AGE DISTRIBUTION

Source:
Methodology of data collection:	Survey	Census
Date of data collection:

	Male	Female	0-4 years	5-14 years	15-44 years	>=45 years	Total
%							100%
Number

Medical staff

The "title" (diploma, qualification) of each member of the medical staff should be indexed in the table below:

Table

Mortality

The data collection should be carried out by the administration in charge of the civilian status in order to obtain the most representative date (counting death that occured outside of health structures).

The personnel in charge of death records (political authorities, administrative, religious...) should be trained. This training consists of describing the most frequent pathologies and how to create a new file. One is only concerned with the primary cause of death.

Source of data collection:

Table:

Table

Morbidity

Record of new cases diagnosed.

Table

Rules for morbidity data collection

- The information is collected at the O.P.D. by physicians, nurses, medical auxiliaries; the medical staff will be supervised to make sure that definitions are respected.

- Only the new cases are recorded: patients consulting again for the same reason, in the same month, will be recorded at the index "reconsultation".

- The diagnosis is the one mentioned at the consultation (only one diagnosis per patient).

Definition of the table index

- Fever is defined as temperature > 38°C (axilla).

- Upper respiratory tract infections: any nose ear throat infection (N.E.T.) (sinusitis, cold, otitis, pharyngitis, laryngitis...).

- Lower respiratory tract infections: any infectious episode below the larynx (bronchitis, pneumonia, bronchiolitis...).

- Malaria: any fever (complicated or not), related to malaria (specify the definition: clinical or proven by microscopic examiniation).

- Measles: fever, + rhinopharyngitis, + conjunctivitis, + one of the two following signs:

· koplick's spots
· skin eruption

- Eye infection: unilateral or bilateral conjunctival inflammation or infection of any other part of the eye: conjunctivitis, trachoma, keratitis...

- Diarrhea: any episode with more than 3 watery stools per day.

· watery: is an estimation frequency of viral and choleriform diarrhea.

· bloody: estimates the frequency of entero-invasive diarrhea (bacillary and amoebic dysenteria).

- Cutaneous infection: any cutaneous infection due to a bacterial (impetigo, pyodermitis, abscess), viral (zone, herpes...), mycosal (ring worm...) or parasitic (scabies) infection.

- Sexually transmitted disease: genital infections, ulcerative or discharging (vaginitis, urethritis), apparently related to sexual contamination.

- Obstructive jaundice: yellow conjunctivitis, discolored stools, discolored urine and associated signs. It estimates the frequency of hepatitis.

- Urinary tract infections: burning on micturition associated with pollakiuria, whether there is fever, lumbar pain or not.

- Tuberculosis: the new cases begin their treatment during the month of diagnosis (bacteriological positive Ziehl's colouration for the pulmonary TB).

- Meningitis: any meningeal syndrome with fever, diagnosed by a physician.

- Trauma and burns: any consultation related to trauma (fight, fall, burn, wound...).

- Others: tetanus, poliomyelitis, diphtheria, whooping cough, typhus, leprosy, trypanosomiasis... adapt according to the situation. Each of these supplementary itemps will have to be defined by the team and the definition will be added to the one above.

List of essential drugs of WHO

(7th list, 1992)

1. Anaesthetics

1.1 GENERAL ANAESTHETICS AND OXYGEN
Diazepam (lb, 2) Ether, anaesthetic (2) Halothane (2) Ketamine (2)
Nitrous oxide (2) Oxygen Thiopental (2)

1.2 LOCAL ANAESTHETICS
Bupivacaine (2,9) Lidocaine

1.3 PREOPERATIVE MEDICATION
Atropine, Chloral hydrate, Diazepam (lb) Morphine (la)
Promethazine

2 Analgesics, antipyretics, non-steroidal anti-inflammatory drugs and drugs used to beat gout

2.1 NON-OPIOIDS
Acetylsalicylic acid, Allopurinol (4) Colchicine (7) Ibuprofen,
Indometacin, Paracetamol

2.2 OPIOID ANALGESICS
Codeine (1a)Morphine (l a)Pethidine (A) (la, 4)

3. Antiallergics and drugs used in anaphylaxis
Chlorphenamine, Dexamethasone, Epinephrine.Hydrocortisone,
Prednisolone

4. Antidotes and other substances used in poisonings

4.1 GENERAL
Charcoal, activated Ipecacuanha

4.2 SPECIFIC
Atropine,Deferoxamine, Dimercaprol (2) Methionine Methylthioninium chloride (methylene blue), Naloxone Penicillamine (2) Potassium ferric hexacyanoferrate (II) 2H2O (Prussian blue), Sodium calcium edetate (2) Sodium nitrite, Sodium thiosulfate

5. Antiepileptics
Carbamazepine, Diazepam (lb)Ethosuximide, Phenobarbital (lb)Phenytoin, Valproic acid (7)

6. Anti-infective drugs

6.1 ANTHELMINTHICS

6.1.1 Intestinal anthelminthics
Levamisole (8) Mebendazole, Niclosamide, Piperazine, Praziquantel, Pyrantel, Tiabendazole

6.1.2 Specific anthelminthics
Albendazole

6.1.3 Antifilarials
Diethylcarbamazine, Ivermectin, Suramin sodium (2, 7)

6.1.4 Antischistosomals
Metrifonate, Oxamniquine, Praziquantel

6.2 ANTIBACTERIALS

6.2.1 Penicillins
Amoxicillin (4) Ampicillie (4) Benzathine Benzyl penicillin (5) Benzylpenicillin, Cloxacillin Phenoxymethyl penicillin, Piperacillin, Procaine Benzylpenicillin

6.2.2 Other antibacterials
Chloramphenicol (7) Ciprofloxacin (B) Clindamycin (B) Doxycycline (B) (5, 6) Erythromycin, Gentamicin (2, 4, 7) Metronidazole, Nitrofurantoin (B) (4, 7) Spectinomycin (8) Sulfadimidine (4)
Sulfamethoxazole + trimethoprim (4) Tetracycline, Trimethoprim (B)

6.2.3 Antileprosy drugs
Clofazimine, Dapsone, Rifampicin

6.2.4 Antituberculosis drugs
Ethambutol (4) Isoniazid,Pyrazinamide, Rifampicin, Rifampicin + isoniazid, Streptomycin (4) Thioacetazone + isorniazid (A) (7)

6.3 ANTIFUNGAL DRUGS
Amphotericin B(4) Flucytosine (B) (4, 8)Griseofulvin

6.3 ANTIFUNGAL DRUGS
Ketoconazole (2)Nystatin

6.4 ANTIPROTOZOAL DRUGS

6.4.1 Antiamoebic and antigiardiasis drugs Chloroquine (B) Diloxanide, Metronidazole

6.4.2 Antileishmaniasis drugs Meglumine antimoniate,Pentamidine (5)

6.4.3 Antimalarial drugs a) For curative treatment, Chloroquine,Mefloquine (B),Primaquine,Quinine, Tetracycline (B), Sulfadoxine + pyrimethamine (B) b) For prophylaxis, Chloroquine,Mefloquine (B),Proguanil

6.4.4 Antitrypanosomal drugs a) African trypanosomiasis,Eflornithine (C),Melarsoprol (5),Pentamidine (5),Suramin sodium b) American trypanosomiasis Benzonidazole (7),Nifurtimox (2, 8)

6.5 INSECT REPELLENTS
Diethyltoluamide

7. Antimigraine drugs

7.1 FOR TREATMENT OF ACUTE ATTACK
Acetylsalicylic acid,Ergotamine (7),Paracetamol

7.2 FOR PROPHYLAXIS
Propanolol

8. Antineoplastic and immunosuppressant drugs

8.1 IMMUNOSUPPRESSANT DRUG
Azathioprine (2) Cidosporin (2)

8.2 CYTOTOXIC DRUGS
Bleomycin (2), Cisplatin (2), Cydophosphamide (2), Cytarabine (2), Dacarbazine (2), Dactinomycin (2), Doxorubici (2), Etoposide (2), Fluorouracil (2), Mercaptopurine (2), Methotrexate (2), Procarbazine, Vinblastine (2), Vincristine (2)

8.3 HORMONES AND ANTIHORMONES
Dexamethasone, Ethinylestradiol, PrednisoloneTamoxifen

9. Antiparkisonism drug.
Biperiden, Levodopa + Carbidopa (5, 6)

10. Drugs afecting the blood

10.1 ANTIANAEMIA DRUGS
Ferrous salt, Ferrous salt + Folic acid,Folic acid (2),Hydroxocobalamin (2), Iron dextran (B) (5)

10.2 DRUGS AFFECTING COAGULATION
Desmopressin (8), Heparin, Phytomenadione, Protamine sulfate, Warfarin (2, 6)

11. Blood products and plasma substitutes

11.1 PLASMA SUBSTITUTES
Dextran 70, Polygeline

11.2 PLASMA FRACTIONS FOR SPECIFIC USES
Albumin human (2, 8),Factor VIII concentrate(C) (2, 8) Factor IX complex concentrate (C) (2, 8)

12. Cardiovascular drugs

12.1 ANTIANGINAL DRUGS
Atenolol (B),Glyceryl trinitrate,Isosorbide dinitrate,Nifedipine,Propranolol

12.2 ANTIDYSRHYTHMIC DRUGS
Atenolol (B),Lidocaine,Procainamide (B),Propranolol,Quinidine (A),Verapamil (8)

12.3 ANTIHYPERTENSIVE DRUGS
Atenolol (B),Captopril (B),Hydralazine,Hydrochlorothiazide,Methyldopa (B) (7),Nifedipine,Sodium nitroprusside(C) (2, 8),Propranolol,Reserpine (A)

12.4 CARDIAC GLYCOSIDES
Digitoxin (B) (6) Digoxin (4)

12.5 DRUGS USED IN VASCULAR SHOCK
Dopamine

12.6 ANTITHROMBOTIC DRUGS
Acetylsalicylic acid, Streptokinase (C)

13. Dermatological drugs

13.1 ANTIFUNGAL DRUGS (TOPICAL)
Benzoic acid + salicylic acid,Miconazole, Nystatin, Sodium thiosulfate, Selenium sulfide (C)

13.2 ANTI-INFECTIVE DRUGS
Methylrosanilinium chloride (gentian violet), Mupirocin, Neomycin
+ Q Bacitracin, Silver sulfadiazine

13.3 ANTI-INFLAMMATORY AND ANTIPRURITIC DRUGS
Betamethasone (3) Calamine lotion, Hydrocortisone

13.4 ASTRINGENT DRUGS
Aluminium diacetate

13.5 KERATOPLASTIC AND KERATOLYTIC DRUGS
Salicylic acid,Dithranol, Fluorouracil, Coal tar, Benzoyl peroxide, Podophyllum resin (7)

13.6 SCABICIDES AND PEDICULICIDES
Benzyl benzoate, Permethrin

13.7 ULTRAVIOLET-BLOCKING AGENTS
Benzophenones, sun protection factor 15 (C) p-aminobenzoic acid, sun protection factor 15 (C), Zinc oxide (C)

14. Diagnostic agents

14.1 OPHTHALMIC DRUGS
Fluorescein, Tropicamide

14.2 RADIOCONTRAST MEDIA
Amidotrizoate, Barium sulfate, Iopanoic acid, Meglumine iotroxate (C), Propyliodone

15. Disinfectants and antiseptics

15.1 ANTISEPTICS
Chlorhexidine, Hydrogen peroxide, Iodine

15.2 DISINFECTANTS
Calcium hypochlorite, Glutaral

16. Diuretics
Amiloride (4, 7, 8), Furosemide, Hydrochlorothiazide, Mannitol (C), Spironolactone (C)

17. Gastrointestinal drugs

17.1 ANTACIDS AND OTHER ANTIULCER DRUGS
Cimetidine, Aluminium hydroxide, Magnesium hydroxide

17.2 ANTIEMETIC DRUGS
Metoclopramide, Promethazine

17.3 ANTIHAEMORRHOIDAL DRUGS
Local anaesthetic, astringent and antiinflammatory drug

17.4 ANTI-INFLAMMATORY DRUGS
Hydrocortisone, Sulfasalazine (2)

17.5 ANTISPASMODIC DRUGS
Atropine

17.6 CATHARTIC DRUGS
Senna

17.7 DRUGS USED IN DIARRHEA

17.7.1 Oral rehydration
Oral rehydration salts (for glucose-electrolyte solution):
Sodium chloride 3.5 g/1, Potassium chloride 1.5 g/1, Trisodiurn citrate dihydrate 2.9 g/1, Glucose 20 g/1

17.7.2 Antidiarrheal (symptomatic) drugs
Codeine (la)

18. Hormones, other endocrine drugs and contraceptives

18.1 ADRENAL HORMONES AND SYNTHETIC SUBSTITUTES
Dexamethasone, Fludrocortisone (C), Hydrocortisone, Prednisolone

18.2 ANDROGENS
Testosterone (C)

18.3 CONTRACEPTIVES
Depot medroxyprogesterone acetate (B) (7, 8), Ethinylestradiol + levonorgestrel, Ethinylestradiol + Norethisterone, Norethisterone (B), Norethisterone enantate (B) (7, 8)

18.4 ESTROGENS
Ethinylestradiol

18.5 INSULINS AND OTHER ANTIDIABETIC AGENTS
Insulin injection (soluble), Intermediate-acting insulin, Tolbutamide

18.6 OVULATION INDUCERS
Clomifene (C) (2, 8)

18.7 PROGESTOGENS
Norethisterone

18.8 THYROID HORMONES AND ANTITHYROID DRUGS
Levothyroxine, Potassium iodide, Propylthiouracile

19. Immunologicals

19.1 DIAGNOSTIC AGENTS
Tuberculin, purified protein derivative (PPD)

19.2 SERA AND IMMUNOGLOBULINS
Anti-D immunoglobulin (human), Antiscorpion sera Antitetanus immuno globulin (human), Antivenom sera, Diphtheria antitoxin Immunoglobulin human normal (2), Rabies immunoglobulin

19.3 VACCINES

19.3.1 For universal immunization
BCG vaccine (dried)
Diphtheria-pertussistetanus vaccine, Diphtheria-tetanus vaccine, Measles-mumps-rubella vaccine, Measles vaccine, Poliomyelitis vaccine(inactivated), Poliomyelitis vaccine(live attenuated), Tetanus vaccine

19.3.2 For specific groups of individuals
Hepatitis B vaccine, Influenza vaccine, Meningococcal vaccine, Rabies vaccine,Rubella vaccine, Typhoid vaccine, Yellow fever vaccine

20. Muscle relaxants (peripherally acting) and cholinesterase inhibitors
Gallamine (2), Neostigmine, Pyridostigmine (B) (2, 8), Suxamethonium (2), Vecuronium bromide (C)

21. Ophthalmological preparations

21.1 ANTI-INFECTIVE AGENTS
Gentamicin, Idoxuridine, Silver nitrate, Tetracycline

21.2 ANTI-INFLAMMATORY AGENTS
Prednisolone

21.3 LOCAL ANAESTHETICS
Tetracaine

21.4 MYOTICS AND ANTIGLAUCOMA DRUGS
Aeetazolamide, Pilocarpine, Timolol

21.5 MYDRIATICS
Atropin Epinephrine (A)

22 Oxytocics and antioxytocics

22.1 OXYTOCICS
Ergometrine, Oxytocin

22.2 ANTIOXYTOCICS
Salbutamol (2)

23. Peritoneal dialysis solution
Intraperitoneal dialysis solution (of appropriate composition)

24. Psychotberapeutic drugs
Amitriptyline, Chlorpromazine, Diazepam (lb), Fluphenazine (5), Haloperidol, Lithium carbonate (2, 4)

25. Drugs acting on the respiratory tract

25.1 ANTIASTHMATIC DRUGS
Cromoglicic acid (B), Aminophylline (2), Beclometasone, Ephedrine (A), Epinephrine, Salbutamol

25.2 ANTITUSSIVES
Codeine (la)

26. Solutions correcting water, electrolyte and acid-base disturbances

26.1 ORAL REHYDRATION
Oral rehydration salts (for glucose-elecrolyte solution)
Potassium chloride

26.2 PARENTERAL
Compound solution of sodium lactate, Glucose, Glucose with sodium chloride, Potassium chloride (2) Sodium chloride, Sodium hydrogen carbonate

26.3 MISCELLANEOUS
Water for injection

27. Vitamins and minerals
Ascorbic acid (C), Calcium gluconate (C) (2, 8), Ergocalciferol, Iodine, Nicotinamide, Pyridoxine, Retinol, Riboflavin, Sodium fluoride (8), Thiamine

Many drugs included in the list are preceded by a square symbol to indicate that they represent an example of a therapeutic group and that various drugs could serve as alternatives. Numbers in parentheses following the drug names indicate:

(1) Drugs subject to international control under: a) the Single Convention on Narcotic Drugs (1961), b) the Convention on Psychotropic Substances (1971), or c) the Convention on Illicit
Traffic in Narcotic Drugs and Psychotropic Substances (1988).

(2) Specific expertise, diagnostic precision or special equipment required for proper use.

(3) Greater potency or efficacy.

(4) In renal insufficiency, contraindicated or dosage adjustments necessary.

(5) To improve compliance.

(6) Special pharmacokinetic properties.

(7) Adverse effects diminish benefit/risk ratio.

(8) Limited indications or narrow spectrum of activity.

(9) For epidural anaesthesia.

Letters in parentheses after the drug names indicate the reasons for the inclusion of complementary drugs:

(A) When drugs in the main list cannot be made available.

(B) When drugs in the main list are known to be ineffective or inappropriate for a given individual.

(C) For use in rare disorders or in exceptional circumstances.

The New Emergency Health Kit - (WHO)

Lists of drugs and medical supplies for a population of 10,000 persons for approximately 3 months

Introduction

In recent years the various organizations and agencies of the United Nations system have been called upon to respond to an increasing number of large-scale emergencies and disasters, many of which pose a serious threat to health. Much of the assistance provided in such situations by donor agencies, governments, voluntary organizations and others is in the form of drugs and medical supplies. But the practical impact of this aid is often diminished because requests do not reflect the real needs or because these have not been adequately assessed. This can result in donations of unsorted, unsuitable and unintelligibly labelled drugs, or the provision of products which have passed their expiry date. Such problems are often compounded by delays in delivery and customs clearance.

The World Health Organization, which is the directing and coordinating authority for international health work within the United Nations system, took up the question of how emergency response could be facilitated. After several years of study, field testing and modifications, standard lists of essential drugs and medical supplies for use in an emergency were developed. The aim was to encourage the standardization of drugs and medical supplies used in an emergency to permit a swift and effective response with supplies that meet priority health needs. A further goal was to promote disaster preparedness since such standardization means that kits of essential items can be kept in readiness to meet urgent requirements.

The WHO Emergency Health Kit, which resulted from this work, was originally developed in collaboration with the Office of the United Nations High Commissioner for Refugees (UNHCR) and the London School of Hygiene and Tropical Medicine. It has now been revised in collaboration between the Action Programme on Essential Drugs (WHO, Geneva), the Emergency Preparedness and Response Unit (WHO, Geneva), the unit of Pharmaceuticals (WHO, Geneva), the Office of the United Nations High Commissioner for Refugees, UNICEF, Medecins Sans Frontieres, the League of Red Goss and Red Crescent Societies (Geneva), the Christian Medical Commission of the World Council of Churches and the International Committee of the Red Cross. A review of the experience of previous users of the kit, prepared by the London School of Hygiene and Tropical Medicine, as well as field experience of UNICEF and Medecins Sans Frontieres, were also considered during the revision. Major suppliers of the kit were consulted on the specifications of its contents.

The kit has now been adopted by many organizations and national authorities as a reliable, standardized, inexpensive, appropriate and quickly available source of the essential drugs and health equipment urgently needed in a disaster situation. Its contents are calculated to meet the needs of a population of 10,000 persons for three months. It has been renamed the: "New Emergency Health Kit" because of the number and diversity of United Nations agencies and other bodies which have adopted this list of drugs and medical supplies for their emergency operations and which participated in its revision.

This booklet provides background information on the development of the kit, a description of its contents, comments on the selection of items, treatment guidelines for prescribers and some useful checklists for suppliers and prescribers.

Chapter 1 (Essential drugs and supplies in emergency situations) is intended as a general introduction for health administrators and field officers.

Chapter 2 (Comments on the selection of drugs, medical supplies and equipment included in the kit) contains more technical details and is intended for prescribers.

Publication of this document was made possible by financial contributions received from the United Nations High Commissioner for Refugees, the Government of the Netherlands, the WHO Emergency Preparedness and Response Unit and the WHO Action Programme on Essential Drugs.

Chapter 1: Essential drugs and supli'es in Emergency situations

What is an Emergency ?

The term "emergency" is applied to various situations resulting from natural, political and economic disasters. The New Emergency Health Kit is not intended for the acute phase of epidemics, war, earthquake, floods, etc. but is designed to meet the needs of a population with disrupted medical facilities in the second phase of a natural or other disaster, or a displaced population without medical facilities. It has also been used in countries with acute shortages of drugs due to economic reasons.

It must be emphasized that, although supplying drugs and medical supplies in the standard kits is convenient in the second phase of an emergency, specific local requirements need to be assessed as soon as possible and further supplies must be ordered accordingly.

Qunantification of drug requirements

Morbidity patterns (the relative frequency of different illnesses) may vary considerably between emergencies. For example, in emergencies where malnutrition is common morbidity rates may be very high. For this reason an estimation of drug requirements from a distance can only be approximate, although certain predictions can be made based on past experience. For the present kit estimates have been based on the average morbidity patterns and the use of standard treatment guidelines. The quantities of drugs supplied will therefore only be adequate if prescribers follow these guidelines (given in Annexes 1-3).

Contents of the kit

The New Emergency Health Kit consists of two different sets of drugs and medical supplies, named a BASIC UNIT and a SUPPLEMENTARY UNIT (The previous version of three lists: A-basic drugs; B-supplementary drugs; C-medical supplies and requirement for basic supplementary lists). To facilitate distribution to smaller health facilities on site, the quantities of drugs and medical supplies in the basic unit have been divided into ten identical units for 1,000 persons each.

Table

The BASIC UNIT contains drugs, medical supplies and some essential equipment for primary health care workers with limited training. It contains twelve drugs, none of which are injectable. Simple treatment guidelines, based on symptoms, have been developed to help the training of personnel in the proper use of the drugs. Copies of these treatment guidelines, an example of which is printed in Annexes 1-3, should be be included in each unit. Additional copies can be obtained from the Action Programme on Essential Drugs, WHO, Geneva, and from UNICEF Copenhagen (see Annex 7 for addresses).

The SUPPLEMENTARY UNIT contains drugs and medical supplies for a population of 10,000 and is to be used only by professional health workers or physicians. It does not contain any drugs or supplies from the basic units and can therefore only be used when these are available as well.

The selection and quantification of drugs for the basic and supplementary units have been based on recommendations for standard treatment regimens from technical units within WHO. A manual describing the standard treatment regimens for target diseases, developed in collaboration between Medecins sans Frontieres and WHO, is available from Medecins sans Frontieres at cost price and is to be included in each supplementary unit.

To facilitate identification in an emergency, one green sticker (international color code for medical items) should be placed on each parcel. The word "BASIC" should be printed on stickers for basic units.

Referral system

Health services can be decentralized by the use of basic health care clinics (the most peripheral level of health care) providing simple treatment using the basic units. Such a decentralization will: 1) increase the access of the population to curative care; and 2) avoid overcrowding of referral facilities by solving all common health problems at the most peripheral level. Basic treatment protocols have been drawn up to allow these health workers to take the right decision on treatment or referral, according to the symptoms (see Annexes 1-3).

The first referral level should be staffed by professional health workers, usually medical assistants or doctors, who will use drugs, supplies and equipment from both the basic and the supplementary units. It should be stressed here that the basic and supplementary units have not been intended to enable these health workers to treat rare diseases or major surgical cases. For such patients a second level of referral is needed, usually a district or general hospital. Such facilities are normally part of the national health system and referral procedures are arranged with the local health authorities.

Procurement of the kit

The New Emergency Health Kit can be provided from a number of major pharmaceutical suppliers, some of which will have a permanent stock of kits ready for shipment within 48 hours. It may however be desirable to secure procurement at the regional level to reduce the cost of shipping. The procuring agency should ensure that manufacturers comply with the guidelines for quality, packaging and labelling of drugs (see Annexe 6).

It is important to note that many drugs in the kit can be considered as examples of a therapeutic group, and that other drugs can often serve as alternatives. This should be taken into consideration when drugs are selected at the national level, since the choice of drugs may then be influenced by whether equivalent products are immediately available from local sources, and their comparative cost and quality. National authorities may wish to stockpile the same or equivalent drugs and supplies as part of their emergency preparedness programme. The kit can also serve as a useful baseline supply list of essential drugs for primary health care.

Donor guidelines

Whatever the source of drugs, it is very important that:

- No drugs should be sent from a donor country without a specific request, or without prior clearance by the receiving country;

- No drugs should be sent that are not on the List of Essential Drugs of the receiving country, or, if such a national list is not available, on the WHO Model List of Essential Drugs;

- No drugs should arrive with a future life (before expiry date) of less than one year;

- Labelling of the drugs should be in the appropriate language(s) and should at least contain the generic name, strength, name of manufacturer and expiry date (see Annexe 6);

- Labelling on the outside package should contain the same information, plus the total quantity of drugs in the package.

Immunization in emergency

Experience in past emergencies involving displacements of populations has shown measles to be one of the major causes of death among younger children. The disease spreads rapidly in overcrowded conditions, and serious respiratory tract infections are frequent, particularly in malnourished children. An adequate supply of essential drugs may reduce the mortality rate, but measles can be prevented by immunization. A measles immunization programme should therefore be given high priority in the early phase of an emergency. The WHO Expanded Programme on Immunization (EPI), UNICEF, the Office of the High Commissioner for Refugees (UNHCR) and OXFAM have collaborated in the development of the Emergency Immunization Kit, which may be used to set up an emergency immunization programme against measles. This kit contains cold chain and injection equipment for 5,000 immunizations and may be ordered from OXFAM. Vaccines are not included.

Post emergency needs

After the acute phase of an emergency is over and basic health needs have been covered by the basic and supplementary units, specific needs for further supplies should be assessed as soon as possible. In most cases this will necessitate a quick description and, if possible, quantification of the morbidity profile. It should characterise the most common diseases and should identify the exposed and high risk groups in the population (e.g. children below 5 years of age and pregnant women). These high risk groups should be the first target of the continuing health care programme. Any other factors that may influence requirements should also be taken into account, ea. the demographic pattern of the community, the physical condition of the individuals, seasonal variations of morbidity and mortality, the impact of improved public health measures, the local availability of drugs and other supplies, drug resistance, usual medical practice in the country, capabilities of the health workers and the effectiveness of the referral system.

Much time and money may be saved by adapting re-order forms to the specific needs of the situation and by standardizing re-order procedures for all locations and health teams, regardless of whether supplies are available locally or must be ordered from abroad.

Chapter 2: Comments on the selection of drugs, medical supplies and equipment included in the kit

The composition of the New Emergency Health Kit is based on epidemiological data, population profiles, disease patterns and certain assumptions bome out by emergency experience. These assumptions are:

- The most peripheral level of the health care system will be staffed by health workers with only limited medical training, who will treat symptoms rather than diagnosed diseases and who will refer to the next level those patients who need more specialized treatment.

- Half of the population is 0-14 years of age.

- The average number of patients presenting themselves with the more common symptoms or diseases can be predicted.

- Standardized schedules will be used to treat these symptoms or diseases.

- The rate of referral from the basic to the next level is 10 %.

- The first referral level of health care is staffed by experienced medical assistants or medical doctors, with no or very limited facilities for inpatient care.

- If both the basic and first referral health care facilities are within reasonable reach of the target population, every individual will, on average, visit such facilities four times per year for advice or treatment. As a consequence the supplies in the kit, which are sufficient for approximately 10,000 outpatient consultations, will serve a population of 10,000 people for a period of approximately three months.

Selection of the drugs

Injectable drugs

There are no injectable drugs in the basic unit. Basic health workers with little training have usually not been taught to prescribe injections, neither are they trained to administer them. Moreover, the most common diseases in their uncomplicated form do not generally require an injectable drug. Any patient who needs an injection must be referred to the first referral level.

Antibiotics

Infectious bacterial diseases are common at all levels of health care, including the most peripheral, and basic health workers should therefore have the possiblity to prescribe an antibiotic. However, many basic health workers have not been trained to prescribe antibiotics in a rational way. Cotrimoxazole is the only antibiotic included in the basic unit, and this will enable the health worker to concentrate on taking the right decision between prescribing an antibiotic or not, rather than on the choice between several antibiotics. Cotrimoxazole has been selected because it is active against the most common bacteria found in the field, especially S. pneumoniae and H. influenzae for acute respiratory infections. It is also stable under tropical conditions, needs to be taken only twice daily and its side-effects (exfoliative dermatitis or bone marrow depression) are uncommon. In addition to this it is less expensive than other antibiotics. The risk of increasing bacterial resistance must be reduced by rational prescribing practice.

Drugs not included in the kit

The kit includes neither the common vaccines nor any drugs against communicable diseases such as tuberculosis or leprosy. The vaccines needed and any plans for an expanded programme on immunization should be discussed with the national authorities as soon as possible; the same applies for programmes to combat communicable diseases. In general no special programme should be initiated unless there is sufficient guarantee for its continuation over a longer period.

In addition, drugs in the kit do not cover some specific health problems occurring in certain geographical areas, e.g. specific resistant malaria strains.

Selection of renewable supplies

Syringes and needles

Considering the risk of direct contamination with hepatitis and AIDS during handling, needles are dangerous items. The health risk for the staff should be limited by the following means:

· Limiting the number of injections;
· Using disposable needles only;
· Strictly following the destruction procedures for disposable material.

It is less dangerous to handle syringes than needles. For this reason a system with resterilisable nylon syringes and disposable needles has been chosen for the supplementary unit. However, in the very first stage, when sterilization procedures are not yet established, some provision will be necessary for giving injections by means of fully disposable materials. A small number of disposable syringes are therefore provided in the supplementary unit and their destruction should be supervised by the person in charge.

Gloves

Disposable protective gloves are provided in the basic unit to protect health workers against possible infection during dressings or handling of infected materials. In any case a dressing should be applied or changed with the instruments provided in the kit. Surgical gloves, which should be resterilizable, are supplied in the supplementary unit. They are to be used for deliveries, sutures and minor surgery, all under medical supervision.

Selection of equipment

Resuscitation / Surgical instruments

The kit has been designed for general medicine under primitive conditions, and for that reason no equipment for resuscitation or major surgery has been included. In situations of war, earthquakes or epidemics, specialised teams with medical equipment and supplies will be required.

Sterilization

A complete sterilization set is provided in the kit. The basic units contain two small drums each for sterile dressing materials. Two drums are included to enable the alternate sterilization of one at the first referral level while the other is being used in the peripheral facility. The supplementary unit contains a kerosene stove and two pressure sterilizers, a small one for sterilizing 2 ml and 5 ml syringes, and a larger one for the small drums with dressing materials and the instrument sets.

Dilution and storage of liquids

The kit contains several plastic bottles and a few large disposable syringes which are needed to dilute and store liquids (e.g. benzyl benzoate, chlorhexidine and gentian violet solution).

Water supply

The kit contains several items to help provide for clean water at the health facility. Each basic unit contains a 20 litre foldable jerrycan and a plastic bucket. The supplementary unit contains a water filter with candles and 2.5 kg of chloramine powder to chlorinate the water.

Chapter 3: Composition of the New Emergency Health Kit

The New Emergency Health Kit consists of ten basic units and one supplementary unit.

10 basic units (for basic health workers) for a population of 10,000 persons for 3 months (1 basic unit for 1,000 persons for 3 months). The unit contains drugs, renewable supplies and basic equipment packed in one carton.

1 supplementary unit (for physicians and senior health workers), for a population of 10,000 people for 3 months. One supplementary unit contains:

- drugs (approximately 130 kg)
- essential infusions (approximately 180 kg)
- renewable supplies (approximately 60 kg)
- equipment (approximately 40 kg)

NB: The supplementary unit does not contain any drugs and medical supplies from the basic unit. To be operational, the supplementary unit should be used together with ten basic units.

Table

Basic unit (for 1,000 persons for 3 months)

Drugs

Acetylsalicylic acid, tab 300 mg.............................................................tab 3,000

Aluminium hydroxyde, tab 500 mg..........................................................tab 1,000

1) Benzyl benzoate, lotion 25 %...........................................................bottle 1 litre 1

2) Chlorhexidine (5%).........................................................................bottle 1 litre 1

Chloroquine, tab 150 mg base................................................................tab 2,000

Ferrous Sulfate + Folic Acid, tab 200 + 0.25 mg......................................tab 2,000

Gentian Violet, powder ..........................................................................25 g 4

Mebendazole, tab 100 mg ......................................................................tab 500

ORS (Oral Rehydration Salts) .............................................................. sachet for 1 litre 200

Paracetamol, tab 100 mg.......................................................................tab 1,000

Sulfamethoxazole + Trimetoprim, tab 400 + 80mg (cotrimoxazole) ............... tab 2,000

Tetracycline eye ointment 1 %............................................................... tube 5 g 50

Renewable supplies
Absorbent cotton wool
................................................................ kg 1 Adhesive tape 2.5 cm x 5 m.......................................................... roll 30 Bar of soap (100-200 g)............................................................... bar 10 Elastic bandage (crepe) 7.5 cm x 10 m
...............................................unit 20Gauze bandage 7.5 cm x 10 m,.........................................................roll 100Gauze compress 10 x 10 cm, 12 ply, nonsterile....................................... unit 500Ballpen, blue or black..............................................................
.unit 10Exercise book A4
...................................................................
.unit 43) Health card + plastic sachet......................................................unit 500Small plastic bag for drugs..........................................................unit 2,000Notepad
A6.................................................................
..........unit 10Thermometer (oral/rectal) Celsius /
Fahrenheit...................................... unit 6Protective glove, nonsterile, disposable............................................ unit
1004) Treatment guidelines for basic list.............................................. unit 2

Equipment
Nail brush, plastic, autoclavable................................................... unit 2Bucket, plastic, approx. 20 litres...................................................unit 1Gallipot, stainless steel, 100 ml....................................................unit 1

1) According to WHO recommendations Benzyl henzoate solution 25 % concentration is being supplied. The use of 90 % concentration is not recommended.

2) Chlorhexidine 20 % needs distilled water for dilution, otherwise precipitation may occur. 5 % solution is WHO standard. Alternatives include the combination of chlorhexidine 1.5 % and cetrimide 15 %.

3) For a sample health card, see Annex 4.

4) For sample treatment guidelines, see Annexes 1, 2 and 3.
Kidney dish, stainless steel, approx. 26 x 14 cm.................................... unit 11) Dressing set (3 instruments + box)............................................... unit 2Dressing tray, stainless steel, approx. 30 x 15 x 3 cm.............................. unit 1Drum for compresses approx. 15 cm H, 0 14 cm........................................ unit 2 Foldable jerrycan, 20 litres........................................................ unit 1Forceps Kocher, no teeth, 12-14 cm.................................................. unit 2Plastic bottle, 1 litre
.............................................................unit 3Syringe Luer, disposable, 10 ml..................................................... unit 1Plastic bottle, 125 ml.............................................................. unit 1Scissors straight/blunt, 12-14 cm....................................................unit 2

1) Dressing set (3 instruments + box):

· 1 stainless steel box approx. 17 x 7 x 3 cm
· 1 pair surgical scissors, sharp/blunt, 12-14 cm
· 1 Kocher forceps, no teeth, straight, 12-14 cm
· 1 dissecting forceps, no teeth, 12-14 cm

Supplementary unit (for 10,000 persons for 3 months)

Drugs

Anaesthesics
Ketamine, inj. 50 mg/ml........................................................10 ml/vial 251) Lidocaine. inj.
1%..........................................................20 ml/vial 50

Analgesics
2) Pentazocine, inj. 30 mg/ml............................................. 1 ml / ampoule 503) Probenecid, tab 500 mg
............................................................tab 500Recall from basic unit:Acetyl salicyclic acid, tab 300 mg.......................................... (10 x 3,000) 30,000Paracetamol, tab 100 mg
................................................... (10 x 1,000J) 10,000

Anti-allergics
Dexamethasone, inj. 4 mg/ml
...................................................1 ml / amp 50Prednisolone, tab 5 mg............................................................... tab 100Epinephrine (adrenaline), see "respiratory tract"
Anti-epileptics
Diazepam, inj. 5 mg/ml.................................................... 2 ml / ampoule 200Phenobarbital, tab 50 mg
.............................................................tab 1,000

Anti-infective drugs
4) Ampicillin, tab 250 mg
........................................................... tab 2,0004) Ampicillin, inj. 500 mg /vial
................................................... vial 200Benzathine benzylpenicillin, inj. 2.4 MIU / vial.................................... vial 50Chloramphenicol, caps 250 mg........................................................ caps 2,000Chloramphenicol, inj. 1 g / vial.................................................... vial 500Metronidazole, tab 250 mg............................................................ tab 2,0005) Nystatin, non-coated tablet
..........................................100,000 IU / tab 2,000Phenoxymethylpenicillin, tab 250 mg
..................................................tab 4,0006) Procain benzylpenicillin, inj. 3-4 MU / vial
.................................... vial 1,000

1) 20 ml vials are preferred, although 50 ml vials may be used as an alternative.

2) Because of narcotic drugs regulation, pentazocine has been chosen as an alternative to morphine or pethidine.

3) To be used with penicillin in the treatment of gonorrhoea.

4) Ampicillin tablets and injections to be used only in neonates and pregnant women.

5) For the treatment of oral candidiasis.

6) The combination of procaine benzylpenicillin 3 MU and benzylpenicillin 1 MU (procaine penicillin fortified) is used in many countries and may be included as an alternative.

1) Quinine, inj. 300 mg/ml
................................................... 2 ml / amp 100Quinine sulfate, tab 300 mg
..........................................................tab 3
,0002) Sulfadoxine + pyrimethamine, tab 500 mg + 25 mg
.................................. tab 303) Tetracycline, caps or tab 250 mg
..........................................caps or tab 2,000
Recall from basic unit
Mebendazole, tab 100 mg
...................................................... (10 x 500) 5,000Cotrimoxazole, tab 400 + 80 mg
..............................................(10 x 2,000) 20,000Chloroquine, tab 150 mg..................................................... (10 x
2,000) 20

Blood, drugs affecting the

Folic acid, tab 1 mg........................................................... 5,000

Recall from basic unit:
Ferrous sulfate + Folic acid, tab 200 + 0.25 mg............................. (10 x 2,000) 20,000

Cardiovascular drugs
4) Methyldopa, tab
250................................................................ tab 500Hydralazine, inj.:20 mg/ml
..................................................1 ml / amp 20

Dermatological
5) Polyvidone iodine 10 %, sol., 500 ml
...........................................bottle 4
Zinc oxyde 10 % ointement..........................................................
.....kg 2Benzoic acid 6 % + salicylic acid 3 % ointment........................................ kg 1
Recall from basic unit:
Tetracycline eye ointment, 1 %
.................................................(10 x 50) 500Gentian violet, powder 25 g..................................................... (10 x 4) 40Benzyl benzoate, lotion 25 %, litre............................................. (10 x 1)
10

Diuretics
Furosemide, inj. 10 mg/ml..................................................... 2 ml / amp 20Furosemide, tab 40 mg
............................................................... tab 200
Gastro-intestinal drugs
Promethazine, tab 25 mg
..............................................................tab 500Promethazine, inj. 25 mg/ml................................................... 2 ml / amp 50.Atropine, inj. 1 mg/ml
........................................................1 ml / amp 50.

Recall from basic unit:
Aluminium hydroxyde, tab 500 mg...............................................(10 x 1,000)
10,000

1) For the treatment of cerebral and resistant malaria cases.
Intravenous injection of quinine must always be diluted in 500 ml glucose 5 %.

2) For the treatment of resistant malaria strains (check national protocols).

3) For the treatment of cholera and chlamydia infections.

4) For the treatment of hypertension in pregnancy.

5) Polyvidone iodine has been chosen because the use of iodine tincture in hot climates may result in toxic concentrations of iodine by partial evaporation of the alcohol.

Oxtocics
Ergometrine maleate, inj. 0.2 mg/ml..............................................1 ml/amp
200
Psychotherapeutic drugs
Chlorpromazine, inj. 25 mg/ml................................................. 2 ml / amp 20. Respiratory tract, drugs acting on
Aminophylline, tab
100mg.............................................................. tab 1,000Aminophylline, inj. 25 mg/ml
.................................................10 ml / amp 50Epinephrine (adrenaline), inj. 1 mg/ml
....................................... 1 ml / amp 50
Solutions correcting water, electrolyte and acid-base disturbances(because of the weight, the quantity of infusion included in the kit is minimal. Look for local supply, once in the field.)
Compound solution of sodium lactate (Ringer's Lactate),inj. sol., with giving set and needle....................................... 500 ml / bag 200Glucose, inj. sol. 5 %, with giving set and needle...........................500 ml / bag 100(for dilution of quinine/injection)Glucose, inj. sol. 50
%.................................................... 50 ml / vial 20Water for injection
................................................ 10 ml / plastic vial 2,000

Recall from basic unit:
ORS (Oral Rehydration Salts)
................................................. (10 x 200)
2,000

Vitamins
Retinol (Vitamin A), caps 200,000
IU................................................ caps 4,000Ascorbic acid, tab 250 mg
........................................................... tab 4,000

Renewable supplies
Scalp vein infusion set, disposable, 25G (í0.5 mm).................................. unit 300Scalp vein infusion set, disposable, 21G (í0.8 mm).................................. unit 100IV placement canula, disposable, 18G (í1.7 mm)...................................... unit 15IV placement canula, disposable, 22G (í0.9 mm)...................................... unit 15Needle Luer IV, disposable, 19G (í1.1 mm x 38 mm)................................... unit 1,000Needle Luer IM, disposable, 21G (í0.8 mm x 40 mm)................................... unit 2,000Needle Luer SC, disposable, 25G (í0.5 mm x 16 mm)................................... unit 100Spinal needle, disposable, 20G (64 mm - í0.9 mm)
....................................unit 30Spinal needle, disposable, 23G (64 mm - í0.7 mm).................................... unit 30Syringe Luer resterilisable, nylon, 2 ml............................................ unit 20Syringe Luer resterilisable, nylon, 5 ml............................................ unit 100Syringe Luer resterilisable, nylon, 10 ml........................................... unit 40Syringe Luer, disposable, 2 ml
..................................................... unit 400Syringe Luer, disposable, 5 ml
..................................................... unit 500Syringe Luer, disposable, 10 ml
.................................................... unit 200Syringe conic connector (for feeding), 60 ml
........................................unit 20Feeding tube, CH5 (premature baby), disposable...................................... unit 10Feeding tube, CH8, disposable....................................................... unit 50Feeding tube, CH16, disposable...................................................... unit 10Urinary catheter (Foley), n°12, disposable.......................................... unit 10Urinary catheter (Foley), n°14, disposable.......................................... unit 5Urinary catheter (Foley), n°18, disposable
..........................................unit 5Surgical gloves sterile and resterilisable n°6.5.................................... pair 50Surgical gloves sterile and resterilisable n°7.5
....................................pair 150Surgical gloves sterile and resterilisable n°8.5
....................................pair 50
Recall from basic unit:
Protective glove, non sterile, disposable............................... (100 units x 10) 1,000
Sterilization test tape (for autoclave).............................................. rol 2Chloramine, tabs or powder............................................................ kg 2,5Thermometer (oral/rectal) dual Celsius /
Fahrenheit................................ unit 10Spare bulb for otoscope...........................................................
. unit 2Batteries R6 alkaline AA size (for otoscope)........................................ unit 6
Recall from basic unit:Thermometer (oral/rectal) celsius
/fahrenheit............................. (6 units x 10) 60Ballpen, blue or black................................................... (10 units x 10) 100Exercise book A4
......................................................... (4 units x 10) 40Health card + plastic sachet
........................................... (500 units x 10)
5,000Small plastic baa for drugs
.......................................... (2,000 units x 10)
20,000Notepad A6
...............................................................(10 units x 10) 100
Urine collecting bag with valve, 2000 ml............................................ unit 10Finger stall 2 fingers, disposable.................................................. unit 300

Suture, synthetic absorbable, braided, size DEC.2 (000) withcutting needle curved 3/8, 20 mm triangular......................................... unit 24
Suture, synthetic absorbable, braided, size DEC.3 (00) withcutting needle curved 3/8, 30 mm triangular......................................... unit 36Surgical blade (surgical knives) n°22 for handle n°4
............................... unit 50Razor blade..............................................................
.......... unit 100Tongue depressor (wooden), disposable.............................................. unit 100Gauze roll 90 m x 0.90 m........................................................... roll 1,000

Recall from basic unit: Absorbent cotton wool........................................................ (1 kg x 10) 10Adhesive tape 2.5 cm x 5 m............................................... (30 rolls x 10) 300Bar of soap (100-200 g/bar)
.............................................. (10 bars x 10) 100Elastic bandage (crepe) 7.5 cm x 10 m
....................................(20 units x 10) 200Ganze bandage 7.5 cm x 10 m
.............................................(100 rolls x 10)
1,000Gauze compress 10 x 10 cm, 12 ply, nonsterile........................... (500 units x 10) 5,000

Equipment
Clinical stethoscope, dual cup...................................................... unit 2Obstetrical stethoscope (metal)
.................................................... unit 1Sphygmomanometer
(adult)............................................................ unit 1Razor non disposable
................................................................uni t 2Scale for adult
...................................................................
..unit 1Scale hanging 25 kg x 100 g (Salter type) + 3 trousers
............................. unit 3 Tape measure............................................................
............ unit 5Drum for compresses, h:15 cm, D14 cm............................................... unit 2
Recall from basic unit:Drum for compresses, approx. h:15 cm, 014 cm............................. (2 units x 10) 20
Otoscope + disposable set of pediatric speculums.................................... unit 1Tourniquet
...................................................................
...... unit 2Dressing tray, stainless steel, approx. 30 x 15 x 3 cm.............................. unit 1Kidney dish, stainless steel, approx. 26 x 14 crn
.................................. unit 1Scissors straight/blunt, 12-14 cm................................................... unit 2Forceps Kocher no teeth, 12-14 cm
...................................................unit 2
Recall from basic unit:Kidney dish, stainless steel, approx. 26 x 14 cm
...........................(1 unit x 10) 10Gallipot, stainless steel, 100 ml
......................................... (1 unit x 10) 10Dressing tray, stainless steel, approx. 30 x 15 x 3 an..................... (1 unit x 10) 10Scissors straight/blunt, 12-14 cm
........................................ (2 units x 10) 20Forceps Kocher, no teeth, 12-14 cm........................................ (2 units x 10) 20
1) Abcess/suture set (7 instruments + box)........................................ unit 22) Dressing set (3 instruments + box)............................................... unit 5
Recall from basic unit:
Dressing set (3 instruments + box)
....................................... (2 units x 10) 20
Pressure sterilizer, 7.5 litres (type: Prestige 7506, double rack,ref. UNIPAC 01.571.00)
............................................................. unit 1Additional rack Public Health Care 2ml/5ml, ref.Prestige 7531
...................... unit 2Pressure sterilizer, 20-40 litres with basket (type UNIPAC
01.560.00)............... unit 1Kerosene stove, single burner (type UNIPAC 01.700.00)
.............................. unit 2Water filter with candles, 10-20 litres (type UNIPAC 56.199.02)
.................... unit 3Nail brush, plastic, autoclavable
.................................................. unit 2

Recall from basic unit:
Plastic bottle, 1
1itre................................................... (3 units x 10) 30Syringe Luer, disposable, 10 ml............................................ (1 unit x 10) 10Plastic bottle, 125 ml
.....................................................(1 unit x 10) 10Nail brush, plastic nutoclavable
..........................................(2 units x 10) 20Bucket, plastic, approx. 20 litres
........................................ (1 unit x 10) 10Foldable jerrycan, 20 litres............................................... (1 unit x 10) 10
Portable weight / height chart (UNICEF/SCF) (UNIPAC 01.455.70)
..................... unit 1
Clinical guidelines - diagnostic and treatment manual
................................... 1Guide clinique et therapeutique......................................................
.... 1Guia clinica y terapeutica
.............................................................. 1

(Avaible at cost price from Medecins Sans Frontiers)

Annex 1

Basic unit: treatment guidelines

These treatment guidelines are intended to give simple guidance for the training of primary health care workers using the basic unit. In the dosage guidelines, five age groups have been distinguished. When dosage is shown as 1 tab. x 2, one tablet should be taken in the morning and one before bedtime. When dosage is shown as 2 tab. x 3, two tablets should be taken in the morning, two should be taken in the middle of the day and two before bedtime.

The treatment guidelines contain the following diagnosis/symptom groups:

- Anemia
- Pain
- Diarrhoea: see detailed diagnosis and treatment schedules in Annex 2 a-c.
- Fever
- Respiratory tract infections: see detailed diagnosis and treatment schedules in Annex 3.
- Measles
- Eye
- Skin conditions
- Urinary tract infections
- Sexually transmitted disease
- Preventive care in pregnancy
- Worms

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Annex 2

Evaluation and treatment of diarrhoea

Assessment of diarrhoea patients for dehydration Annex 2a

Annex 2a

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Annex 2b

Treatment plan A to treat dirrhoea at home

Use this plan to teacb the mother to:

· Continue to treat at home her child's current episode of diarrhoea.

· Give early treatment for future episodes of diarrhoea.

Explain the tbree rules for treating diarrhoea at home

1. GIVE THE CHILD MORE FLUIDS THAN USUAL TO PREVENT DEHYDRATION:

· Use a recommended home fluid, such as a cereal gruel. If this is not possible, give plain water.

· Use ORS solution for children described in the box overleaf.

· Give as much of these fluids as the child will take. Use the amounts shown below for ORS as a guide.

· Continue giving these fluids until the diarrhoea stops.

2. GIVE THE CHILD PLENTY OF FOOD TO PREVENT UNDERNUTRITION:

· Continue to breast-feed frequently.

· If the child is not breast-fed, give the usual milk. If the child is less than 6 months old and not yet taking solid food, dilute milk of formula with an equal amount of water for 2 days.

· If the child is 6 months or older, or already taking solid food:

- Also give cereal or another starchy food mixed, if possible, with pulses, vegetables, and meat of fish. Add 1 or 2 teaspoonfuls of vegetable oil to each serving.

- Give fresh fruit juice or mashed banana to provide potassium.

- Give freshly prepared foods. Cook and mash or grind food well.

- Encourage the child to eat: offer food at least 6 times a day.

- Give the same foods after diarrhoea stops, and give an extra meal each day for two weeks.

3. TAKE THE CHILD TO THE HEALTH WORKER IF THE CHILD DOES NOT GET BETTER IN 3 DAYS OR DEVELOPS ANY OF THE FOLLOWING:

· Many watery stools
· Repeated vomiting
· Marked thirst
· Eating or drinking poorly
· Fever
· Blood in the stool

Children sbould be given ORS solutions at bome, if:

· They have been on Treatment Plan B or C.
· They cannot return to the health worker if the diarrhoea gets worse.
· It is national policy to give ORS to all children who see a health worker for diarrhoea.

IF THE CHILD WILL BE GIVEN ORS SOLUTION AT HOME, SHOW THE MOTHER HOW MUCH ORS TO GIVE AFTER EACH LOOSE STOOL AND GIVE HER ENOUGH PACKETS FOR 2 DAYS:

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· Describe and show the amount to be given after each stool using a local measure.

Show the mother bow to mix ORS.
Show her how to give ORS:

· Give a teaspoonful every 1-2 minutes for a child under 2 years.

· Give frequent sips from a cup for an older child.

· If the child vomits, wait 10 minutes. Then give the solution more slowly (for example, a spoonful every 2-3 minutes).

· If diarrhoea continues after the ORS packets are used up, tell the mother to give other fluids as described in the first rule above or return for more ORS.

Annex 2c

Treatment plan B to treat dehydration

APPROXIMATE AMOUNT OF ORS SOLUTION TO GIVE IN THE FIRST 4 HOURS:

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· If the child wants more ORS than shown, give more.

· Encourage the mother to continue breast-feeding.

· For infants under 6 months who are not breast-fed, also give 100-200 ml clean water during this period.

OBSERVE THE CHILD CAREFULLY AND HELP THE MOTHER GIVE ORS SOLUTION:

- Show her how much solution to give her child.

- Show her how to give it- a teaspoonful every 1-2 minutes for a child under 2 years, frequent sips from a cup for an older child.

- Check from time to time to see if there are problems.

- If the child vomits, wait 10 minutes and then continue giving ORS, but more slowly, for example, a spoonful every 2-3 minutes.

- If the child's eyelids become puffy, stop ORS and give plain water or breast milk. Give ORS according to Plan A when the puffiness is gone.

AFTER 4 HOURS, REASSESS THE CHILD USING THE ASSESSMENT CHART. THEN SELECT PLAN A, B OR C TO CONTINUE TREATMENT.

· If there are no signs of dehydration, shift to Plan A. When dehydration has been corrected, the child usually passes urine and may also be tired and fall asleep.

· If signs indicating some dehydration are still present, repeat Plan B, but start to offer food, milk and juice as described in Plan A.

· If signs indicating severe dehydration have appeared, shift to Plan C.

IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT PLAN B:

· Show her how much ORS to give to finish the 4-hour treatment at home.

· Give her enough ORS packets to complete rehydation, and for 2 more days as shown in Plan A.

· Show her how to prepare ORS solution.

· Explain to her the three rules in Plan A for treating her child at home:

- to give ORS or other fluids until diarrhoea stops;
- to feed the child;
- to bring the child back to the health worker, if necessary.

Annex 2d

Treatment plan C to treat severe dehydration quickly

Fallow the arrows. If the answer is "yes", go across. If "no", go down.

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Notes:

· If possible, observe the patient at least 6 hours after rehydration to be sure the mother can maintain hydration giving ORS solution by mouth.

· If the patient is above 2 years and there is cholera in your area, give an appropriate oral antibiotic after the patient is alert.

Annex 3

Management of the child with cough or difficutt breathing

· Assess the child

Ask:

-How old is the child ?
-Is the child coughing ? For how long ?
-Is the child able to drink ? (for children age 2 months up to 5 years)
-Has the child stopped feeding well ? (for children less than 2 months)
-Has the child had fever ? For how long ?
-Has the child had convulsions ?

Look and listen (the child must be calm).

- Count the breaths in one minute.
- Look for chest indrawing.
- Look and listen for stridor.
- Look and listen for wheeze. Is it recurrent ?
- See if the child is abnormally sleepy, or difficult to wake.
- Feel for fever, or low body temperature (or measure temperature).
- Look for severe undernutrition.

· Decide how to treat the child

-The child aged less than two months see Annex 3a
-The child aged two months up to five years see Annex 3b
- who is not wheezing
- who is wheezing

-Treatment instructions
- Give an antibiotic
- Advise mother to give home care see Annex 3c
- Treatment of fever

Annex 3a

The child aged less than two months

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Annex 3b

The child aged two months to five years

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Annex 3c

Treatment instructions

· Give an antibiotic

- Give first dose of antibiotic in clinic.

- Instruct mother on how to give the antibiotic for five days at home (or to retum to clinic for daily procaine penicillin injection).

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- Advise mother to give home care

· Feed the child.

- Feed the child during illness.
- Increase feeding after illness.
- Clear the nose if it interferes with feeding

· Increase fluids.

- Offer the child extra to drink.
- Increase breastfeeding.

· Soothe the throat and relieve the cough with a safe remedy.

· More important: in the child classified as having "No pneumonia: cough or cold", watch for the following signs and return quickly if they occur:

- Breathing becomes difficult.
- Breathing becomes fast.
- Child is not able to drink.
- Child becomes sicker.

This child my have pneumonia

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Annex 4

Table

Annex 5

Table

Annex 6

Guidelines for suppliers

Quality

1. The quality of the drugs must comply with internationally recognized pharmaco poeial standards.

2. At the time of shipment the product shall have at least two thirds of its shelf life.

3. Tablets should preferably be divisible and carry characteristic symbols for easy identification.

4. Drugs should be procured only from those manufacturers able to produce documents meeting the regulations of the WHO Certification Scheme on the Quality of Pharmaceutical Products Moving in International Commerce.

Labelling

1. Labelling should be in English and preferably one other official language of WHO.

2. All labels should display at least the following information: International nonproprietary name (INN) of the active ingredient(s).

· Dosage form.

· Quantity of active ingredient(s) in the dosage form (e.g., tablet, ampoule) and the number of units per package.

· Batch number.

· Date of manufacture.

· Expiry date (in clear language, not in code).

· Pharmacopoeial standard (e.g. BP, USP...).

· Instructions for storage.

· Name and address of the manufacturer.

3. A printed label on each ampoule should contain the following:

· INN of the active ingredient(s).
· Quantity of the active ingredient.
· Batch number.
· Name of the manufacturer.
· Expiry date.

The full label should again appear on the collective package.

4. Directions for use, warnings and precautions may be given in leaflets (package inserts). However, such leaflets should be considered as a supplement to labelling and not as an altemative.

5. For articles requiring reconstitution prior to use (e.g. powders for injection) a suitable beyond-use time for the constituted product should be indicated.

Example of label:

Figure

Packaging

1. Tablets and capsules should be packed in sealed waterproof containers with replaceable lid, protecting the contents against light and humidity.

2. Liquids should be packed in unbreakable leak-proof bottles or containers.

3. Containers for all pharmaceutical preparations must conform to the latest edition of internationally recognized pharmacopoeial standards.

4. Ampoules must either have break-off necks, or sufficient files must be provided.

5. Each Basic Unit should be packed in one carton. The Supplementary Unit must be packed in cartons of max. 50 kg. The cartons should preferably have two handles attached. Drugs, renewable supplies, infusions and equipment should all be packed in separate cartons, with corresponding labels.

6. Each carton must be marked with a green label (the international colour code for medical supplies in emergency situations). The word "BASIC" must be printed on each green label for the basic unit.

Packing list

Each consignment must be accompanied by a list of contents, stating the number of cartons and the type and quantity of drugs and other supplies in each carton.

Annex 7

Useful addresses

World Health Organization, Avenue Appia, CH-1211 Geneva-27, Switzerland. Telephone 41.22.7912111; telex 27821; telefax 41.22.7910746

United Nations High Commissioner for Refugees, Palais des Nations, CH-1211 Geneva-10, Switzerland. Telephone 41.22.7398111; telex 27492; telefax (general) 41.22.7319546; telefax (supplies) 7310776

UNICEF (UNIPAC), Arhusgade 129, Freeport, DK 2100, Copenhagen, Denmark. Telephone 45.31.262444; telex 19813; telefax 45.31.269421 OXFAM, 274 Branbury Road, Oxford OX2 7DZ, United Kingdom. Telephone 44.865.56777; telex 83610; telefax 44.865.57612 Medecins Sans Frontieres, 8 Rue Saint-Sabin, 75011 Paris, France. Telephone 33.1.40212929; telex 214360; telefax 33.1.48066868

International Committee of the Red Cross, 17 Avenue de la Paix, CH-1202 Geneva, Switzerland. Telephone 41.22.7346001; telex 22269; telefax 41.22.7332057

League of Red Cross and Red Crescent Societies, P.O.Box 372, CH-1211 Geneva-19, Switzerland. Telephone 41.22.7345580; telex 22555; telefax 41.22.7330395

Christian Medical Commission of the World Council of Churches, P.O.Box 66, CH-1211 Geneva-20, Switzerland. Telephone 41.22.7916111; telex 23423; telefax 41.22.791.03.61

London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom. Telephone 44.1.6368636; telex 8953474; telefax 44.1.4365389

International Dispensary Association, P.O.Box 3098, 1003 AB Amsterdam, The Netherlands. Telephone 31.2903.3051; telex 13566; telefax 31.2903.1854