ABOUT THESE GUIDELINES The Burmese Border Clinical Guidelines are specifically designed to assist medics and health workers practising along the Thailand-Myanmar border. These 2016 guidelines are an adaptation and update of the 2007 Burmese Border Clinical Guidelines (BBG) which was produced in conjunction with a number of organisations on the Thai-Myanmar border. The updated has been completed using resources such as Médecins Sans Frontières (MSF) 2013 ‘Clinical Guidelines Diagnosis and Treatment Manual,’ and other international treatment guidelines and medical literature from the World Health Organisation (WHO) and Non-Government Organisations (NGOs). These guidelines have been updated and approved by physicians working at Shoklo Malaria Research Unit (SMRU). Mae Tao clinic kindly contributed their pharmacy handbook which has been created using MSF 2013 ‘Clinical Guidelines Diagnosis and Treatment Manual,’ and the ‘British National Formulary’ (BNF) 2014. In addition, some parts of the ‘Mae Tao Clinic 2015 Chronic Guidelines’ are included. There may be minor discrepancies between the pharmacy handbook and the guidelines due to slightly different practices. Please follow local protocols for your organisation if available. Specific guidelines for malaria, obstetrics and paediatrics/neonates exist so most duplicated information has been removed from this guideline to avoid conflicting advice. For information regarding these topics, please see separate guidelines. Where possible each chapter follows the following format: EMERGENCY CONDITIONS, DEFINITION, CAUSES, SIGNS AND SYMPTOMS, DIAGNOSIS, TREATMENT and PREVENTION. The information within each chapter may not be an extensive list but the most relevant aspects for clinics on the border are included. The guidelines are written in simple English to allow for understanding, and the language has been checked and approved by medics at SMRU clinics. SMRU gives permission for the reproduction and translation of these guidelines for use by other health organisations on the border. These guidelines are recommendations only, SMRU and Mae Tao clinic cannot be held responsible for the use of these guidelines by other organisations. SMRU CONTRIBUTORS Dr Lauren Chalmers Dr Edyta Kolakowska Dr Patty Salisbury (Co-ordinator and Editor) Dr Esther Schutte Prof Rose McGready Dr Aung Pyae Phyo Dr Henrike Elsinga Dr Sein Sein Thi Dr Alice Whittaker Dr Lei Lei Swe Dr Thaw Dr Aye Min Dr Margreet Trip Dr Verena Carrara Dr Cindy Chu Dr Mellie Gilder Tyrosvoutis Dr Zainab Oseni Dr Daphne Voorend Dr Nay Win Tun Medics at SMRU sites (MKT, MLA and WPA) for proof reading the understanding of the language. SPECIAL CONTRIBUTORS: Mae Tao Clinic who kindly donated the medications section and their chronic guidelines for comparison. Dr Frank Green (MTC) heavily involved in updating the Eye Disease Chapter. Dr Lily Stanley (SMRU) for her emergency teaching material Dr Rangsun Sitthichai for assistance with the mental health chapters. Maria Bovill (TBC) for help with the nutrition chapter. FINANCIAL ASSISTANCE The printing of the guidelines for the organisations involved in the production was very kindly funded by Malaria Dokters. The production and distribution was supervised by Lauren Chalmers. Contributors to the original BBG 2007 are outlined below: • Aide Medicale Internationale (AMI) • American Refugee Committee (ARC) • International Rescue Committee (IRC) • Malteser International (MI) • Medecins Sans Frontieres – France (MSF) • Mae Tao Clinic • Shoklo Malaria Research Unit (SMRU) • Thailand Burma Border Consortium (TBBC) • United Nations High Commissioner for Refugees (UNHCR) HOW TO USE THESE GUIDELINES These guidelines should not replace clinical decision-making, but should help confirm a diagnosis when you already have an idea of the patient’s disease. These guidelines have been adapted for use in the context of SMRU clinics on the Thai-Myanmar border, and therefore may not be fully appropriate for use elsewhere. The treatment options help you to choose a therapy according to the severity of the disease and the age of the patient. Treatment schedules mentioned in this book are just one way to cure a patient; keep in mind that other therapies (suggested by other guidelines or new health workers) could also be used to treat your patient. 1. Read the TEXT for information about the disease. This tells you which signs and symptoms you should expect, which tests you can use to make a diagnosis, which complications or signs of severity to look for, which treatment to use and how to prevent the disease. 2. DRUG DOSAGES are written in the text for specific conditions but more information such as contraindications and side effects can be found in the Pharmacy Handbook at the end of the BBG. If the dosage is not written in the text then please refer to the Pharmacy Handbook. Make sure you aware of the contra-indications and warnings for each medicine. Abbreviations used mg = Milligram IV = intravenous g = Gram PR = per rectum kg = Kilogram PV = per vagina ml = Millilitre SC = subcutaneous L = Litre STAT = single dose IU = International Units OD = one time a day MIU = Million International Units BID = 2 times a day/ 12 hourly cm = Centimetre TID = 3 times a day/ 8 hourly m = Metre QID = 4 times a day/ 6 hourly sec = Second Mmol/l = Millimole per litre min = Minute Mg/dl = Milligrams per decilitre d = Day < = Less than yr = Year < = Less than or equal to X = Times = = Equal to / = Per > = More than Tab = Tablet > = More than or equal to PO = oral IM = intramuscular Note: 1cc = 1ml Example: ‘2 tabs TID x 5d’ means ‘2 tablets taken 8 hourly over a period of 5 days’ AFB = Acid Fast Bacilli LRTI = Lower Respiratory Tract Infection Acquired Immuno Deficiency MS = Malaria Smear AIDS = Syndrome NSS = Normal Saline Solution ANC = Ante Natal Care OPD = Out-Patient Department ARI = Acute Respiratory Infection ORS = Oral Rehydration Salts BC = Blood Culture PR = Pulse Rate BP = Blood Pressure R/L = Ringers Lactate CBC = Complete Blood Count RR = Respiratory Rate CRP = C - Reactive Protein SBP = Systolic Blood Pressure D5W = Dextrose 5% and Saline/Water SFP = Supplementary Feeding Program D10W = Dextrose 10% and Saline/Water SpO2 = Oxygen Saturations DBP = Diastolic Blood Pressure TB = Tuberculosis ESR = Erythrocyte Sedimentation Rate TFP = Therapeutic Feeding Program e.g. = For example URTI = Upper Respiratory Tract Infection Hb = Haemoglobin UTI = Urinary Tract Infection Hct = Haematocrit VCT = Voluntary Counselling and Testing HIV = Human Immuno-deficiency Virus IPD = In-Patient Department CONTENTS ABOUT THESE GUIDELINES ......................................................................................................................................... 3 HOW TO USE THESE GUIDELINES............................................................................................................................... 4 CHAPTER 1: APPROACHING PATIENTS ....................................................................................................................... 1 1.1 GENERAL APPROACH TO PATIENTS .......................................................................................................... 1 1.2 DANGER SIGNS ........................................................................................................................................... 3 1.3 PREVENTATIVE CARE................................................................................................................................... 3 1.4 FOLLOW UP CARE ....................................................................................................................................... 3 CHAPTER 2: UNIVERSAL PRECAUTIONS .................................................................................................................... 5 2.1 HANDWASHING ........................................................................................................................................... 5 2.2 PROTECTIVE CLOTHING ............................................................................................................................. 5 2.3 ISOLATION .................................................................................................................................................... 6 2.4 SHARPS ........................................................................................................................................................ 6 2.5 CLEANING ROUTINE .................................................................................................................................... 6 2.6 LAB STAFF .................................................................................................................................................... 6 CHAPTER 3: POST EXPOSURE PROPHYLAXIS ........................................................................................................... 7 3.1 GENERAL INFORMATION ........................................................................................................................... 7 3.2 POST EXPOSURE PROPHYLAXIS (PEP) TREATMENT ................................................................................ 8 3.2.1 PEP FOR HUMAN IMMUNODEFICIENCY VIRUS (HIV) ................................................................. 8 3.2.2 PEP FOR HEPATITIS ....................................................................................................................... 9 3.3 FOLLOW UP FOR ALL EXPOSED PERSONS .............................................................................................