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									                                                 Leon Haiti Mission
                                                Treatment Guidelines
                                                       2009

INTRODUCTION

These are treatment guidelines for mission teams working in Leon, Haiti. The guidelines are not immutable or
comprehensive algorithms for treatment, but are guidelines to promote continuity and appropriateness of care. In
addition, the guidelines will help to orient new practitioners to working in Leon, and facilitate better planning of a rational
pharmaceutical cache to accompany the teams.

These treatment guidelines are dynamic, and will be modified over time. Improving our diagnostic capabilities, increasing
the availability of medications through our pharmacy cache and enhancing our knowledge of local health care resources
for referral and ongoing care will drive the modifications of these guidelines. It is expected that these guidelines will be
changed, expanded, and enhanced as they are used by the mission teams.

The goals of treatment in Leon are to respect culture, relieve suffering, promote health and do no harm. Care provided by
the mission teams must be integrated into the local system of health. Traditional healthcare must be respected. In
addition, practitioners are expected to practice within the scope of their U.S. professional licenses.

Careful consideration must be given to all chronic disease management. Initiation of chronic pharmacological therapy
should be done only when the practitioners have reasonable assurance that ongoing monitoring of care will be
accomplished. There is a nurse permanently assigned to the Leon dispensary, physicians at the Jeremie hospital and
village health workers through the Haitian Health Foundation that may be available to provide ongoing care. It is
imperative to determine if the patients can access these ongoing systems of care.

The treatment guidelines have several assumptions that must be understood:
   1.     Treatment must always be individualized. This is determined by the practitioner and the patient. The guidelines
          help to promote general continuity between providers and teams.




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   2.     The Pharmacy is staffed with either a Haitian Nurse or Pharmacist. Do not rely on these professionals to
          calculate doses. Be specific in your written orders, and if it is a unique situation, go to the pharmacy and
          personally explain you orders through a translator to ensure that it is dispensed correctly. For routine
          medications like Acetaminophen, Ibuprofen, etc, the pharmacy staff will dispense accordingly in a standard
          dosing.
   3.     Enteric parasites in Haiti are epidemic. This is presumed to be Ascariasis, but there is also Trichiuris and
          Necator. All patients seen at the Leon Dispensary for the first time during the mission will be provided treatment
          for these parasites. This medication will be dispensed by the triage staff automatically before the patient
          encounter. There is no need for the practitioner to write prescriptions for these medications. Pregnant women,
          infants under one year, and persons recently wormed through other national programs (schools) should not
          receive this treatment.
   4.     The guidelines are based upon syndromic diagnosis and treatment. There are very few definitive diagnostic
          tools in Western Haiti. When possible, we will pursue promoting better diagnostic confirmation, but this may be
          slow in development.
   5.     These guidelines are not meant to be comprehensive treatment plans or inclusive of all conditions you will
          experience in Haiti. These are the more common presenting ailments. Practitioners should be prepared to see
          a variety of unique medical conditions that are not experienced in the United States. Review of some of these
          “tropical” conditions prior to departure will be helpful. Dengue fever, yaws, polio, typhoid fever, filariasis,
          leishmaniasis and malaria are still present in Haiti.

REFERRALS

You can expect to see a variety of conditions for which surgical correction is the appropriate treatment. Untreated
hernias, skin disfigurements and cataracts are common. There may be surgical referral resources available for these
conditions, and possibly assistance through the Catholic Church to help pay for the surgery. Be discriminating about your
use of these referrals to ensure that these limited financial resources are used to care for the most needy. Consulting with
the local nurse and/or parish representatives can help you to make these decisions.

Referral resources in Western Haiti are fluid. A section of these guidelines describe these resources. This list will be
updated by each team as they learn of additional or changing health resources in Western Haiti. All referrals from the
Leon Medical Mission will be coordinated and tracked through a referral coordinator. There will be a designated referral



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coordinator for each mission team. If a person needs to be referred for any type of care, the practitioner will complete a
referral form and the patient and form will be given to the referral coordinator. The referral coordinator will then make
appropriate financial and transportation arrangements with the patient and/or family to get the necessary care. This will
involve providing the family with a small amount of money to pay for transportation and food, and a note from the St.
Paul’s Parish ensuring payment for the patient’s care. The practitioner should NOT attempt to get involved in these
arrangements or negotiations. The referral coordinators will work with locals to determine what is appropriate, and have a
much better understanding of the multiple factors that enter into these decisions. Generally a liaison from the parish will
be involved in the decisions. The referral coordinator will also track which patients have been referred, to whom, when
and for what condition.

HOSPITALIZATIONS

There is a small hospital in Jeremie where most referrals are sent. It is NOT like the hospitals in the US. It has electricity
intermittently. It can do surgery when there is electricity and supplies. It is staffed by local Haitian private physicians, and
Cuban physicians who do “national service” in Haiti. The Cuban physicians are very well trained, and often have sub-
specialization. Limitations on equipment and supplies, however, make it difficult for them to practice their specialties in
Jeremie.

Hospital care in Haiti, like many developing nations, is not full-service care. It is “pay as you go”. Supplies are purchased
as they are needed. If there isn’t money, there isn’t care. Patients must have a family member accompany them to do
bedside care and to cook meals. Without a family member, patients will not fair well in the hospital. Patients’ decisions to
be hospitalized or not will often depend upon the availability of a family member to stay with them at the hospital.

Team members are often given an opportunity to visit the hospital sometime during their mission. It often allows the team
members to see the type of hospital care provided to patients referred earlier in the week.

DIAGNOSTIC TESTING

There is very limited diagnostic testing available. Radiology is available at the hospital in Jeremie, but it obviously
depends upon the availability of electricity. Generally if a patient requires an x-ray of any type, they should be referred for
care to the hospital. The laboratory at the hospital also has limited capacity. In 2004 we started a mobile field laboratory



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that will be used by the teams. This lab is limited to urine analysis, pregnancy testing, hemoglobin, HIV, syphilis, malaria,
blood glucose, CBC, and chemistry. There is also a microscope at the clinic that can be used. Generally, however,
diagnosis is based upon syndromic assessment and the practitioner’s clinical acumen.


ELECTIVE CLINIC PROCEDURES

Many patients will present with conditions that would be easily corrected with a simple office procedure in the US.
Lipomas, nodules, polydactylia, and cysts are common. Performing elective procedures to remove or drain these
problems in Leon is not recommended. Limited sterile supplies, lack of a clean or sterile procedure area, and limited time
make these procedures difficult and risky. There may be a few situations where a procedure can be done quickly and
safely, but for the most part do not do elective procedures.

There are suturing and other wound care supplies at the clinic. Closure of simple lacerations is doable. More complex
wound management that may require deep debridment or tendon repair should not be attempted. Even though the
practitioner may have the skill, the environment and supplies do not adequately support these types of procedures.

EMERGENCIES

There will generally be one or two serious, emergency during your mission. In the past, these have included status
epilepticus, fractures, serious lacerations, acute CVAs, and car accidents. There will be limited supplies to handle these
situations. Practitioners need to be practical, sensitive and creative in determining the best management of these
emergencies. Generally, advanced cardiac life support measures, aside from supporting the airway, are not available.
The team may have a few emergency rescue medications, but these will be limited.


MEDICAL RECORDS

Whenever possible, documentation of patient encounters by team members will be done in the patients Leon Dispensary
medical chart. When the patient does not have an established record in Leon, a patient encounter form brought by the
teams will be used. Due to the large number of patients, encounter notes are brief. Ensure the notes contain the



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diagnosis (primary, secondary and tertiary if appropriate) and medications. The pharmacist will compute medication
dosages unless otherwise specified by the provider. Remember that these records will be used to collect the patient
encounter information needed for weekly reports to the Grand Anse Minister of Health, and will also be used to collect
data for the planning future missions.




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PHARMACETICAL DOSAGES

                Medication                                             Dosage
Abendazole                           Adults:400mg *1
                                     Peds: 1y.o. 100mg*1; 1-2y.o. 200mg *1, >2y.o. 400mg *1day
Albuterol Syrup                      Adult:2mg tid
                                     Peds:0.1 mg/kg/dose tid
Albuterol Inhaler                    Adult:2 puffs qid
                                     Peds:2 puffs qid
Amoxicillin                          Adult:250-500 mg tid
                                     Peds:40-80 mg/kg/day
Antacid (preferably Calcium based)   Adult: prn
                                     Peds: generally not indicated
ASA                                  Adult:325mg 1-2 qid
                                     Peds: not indicated
APAP                                 Adult:325mg 1-2 qid
                                     Peds:10-15mg/kg/dose qid
Benzyl Benzoate (scabicide)          Adult and Peds: apply once and leave on for 8 hours
Ceftriaxone                          Adult:250-1000 mg IM
                                     Peds:50mg/kg IM
Cephalexin                           Adult:250-500mg qid
                                     Peds:50 mg/kg/day qid
Chloroquine                          Adult:1gm po 1, 500mg in 6 hours, then 500mg qd2days
                                     Peds:10mg/kg*1, 5mg/kg in 6 hours, then 5mg/kg qd for 2 days
Cimetidine                           Adult:400mg bid
                                     Peds:20-40 mg/kg/day bid
Ciprofloxacin                        Adult:250-500mg bid
                                     Peds: contraindicated




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            Medication                                           Dosage
Diphenhydramine             Adult:25-50mg qid
                            Peds:1mg/kg/day qid
Doxycycline                 Adult:100mg bid
                            Peds: contraindicated
Docusate                    Adult: 100-250mg qd or bid
                            Peds:
                            6-12yo: 40-120mg/day
                            3-6yo: 20-60mg/day
                            <3yo: 10-40mg/day
Enalapril                   Adult: 5-20 mg daily
Erythromycin                Adult:250-500mg qid
                            Peds:40mg/kg/day (qid)
Erythromycin Ophthalmic     Adult: qid
Ointment/Drops              Peds: qid
Ferrous Sulfate             Adult: 325 mg tid
                            Peds: 5 mg/kg/day (tid)
Fluconazole                 Adult: 100mg (as indicated for the type of infection)
                            Peds: 3 mg/kg (as indicated for the type of infection)
Gentian Violet              Adult and Peds: apply qd
Griseofulvin                Adult: 330mg UM tab qd
                            Peds UM Tabs: 10mg/kg/day
                            Peds microsize susp: 20mg/kg/day
Hydrocortisone 1% Cream     Adults and Peds: tid
Hydrochlorothiazide         Adult: 12.5 – 50 mg
Ibuprofen                   Adult:400-600mg tid
                            Peds:5-10mg/kg/dose (q4h)
Ivermectin (6 mg tablets)   Adult: 200 mcg/kg taken once
                            Peds: 200 mcg/kg taken once
Ketoconazole                Adult: 200-400 mg qd




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                Medication                                               Dosage
                                       Peds: 3.3-6.6 mg/kg/day
Mebendazole                            Adult:100mg bid for 3 days
                                       Peds:100mg bid for 3 days
Methyldopa                             Adult:250-500mg qd, bid, or tid
Metronidazole                          Adult:500mg tid
                                       Peds:30mg/kg/day (tid)
Miconazole Cream                       Adult and Peds: tid
Mineral Oil                            Adult: 15-45ml q hs
                                       Peds: (>6y.o.) 5-15ml q hs
Multivitamins                          Adult and Peds: one daily
Neosporin or Bacitracin Ointment (in   As directed
small dispensable packets)
Nystatin Suspension                    Adult and Peds:1 ml qid
Prenatal Vitamins                      Adult: qd
Polymixin B and Neosporin and          Adult and Peds:3 gtts qid
Hydrocortisone Ear Drops
Prednisone                             Adult: as prescribed
                                       Peds:2mg/kg/day for 4 days, then 1mg/kg/day for 4 days
Ranitidine                             Adult:150mg bid
                                       Peds:4-5mg/kg/day bid
TMP-SMX (single strength tabs)         Adult:2 tablets bid
                                       Peds:5mg TMP/kg bid or for suspension 0.5ml/kg bid




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WESTERN HAITI HEALTH RESOURCES FOR REFERRAL

There are several health resources in the Grand Anse Province of Western Haiti that all practitioners must be aware of in
order to coordinate care. Our mission is to augment the existing health system, NOT replace it. For many of the patients,
the mission teams are the only Western allopathic care they receive. When the teams are not in Haiti, the population
must rely upon the existing systems of care. It is important the mission teams know about these services and how to link
patients to these resources. Every year we learn more about available resources. This list will be expanded accordingly.
                    Organization                                                   Services
Haitian Health Foundation (284-6333)                 HIV Testing
(Headquarters in Jeremie, but have village health Diabetes
workers in many of the rural communities. This       Epilepsy
program does not have workers in Leon because Feeding Programs for Children
of the dispensary.)                                  High Risk Pregnancy and OB Residential Center
  Director: Dr. Betty Gebrian (American)             Acute Lower Respiratory Track Infection Treatment
  OB Residential Center:                             De-worming Programs
                                                     Vaccination
Jeremie Hospital                                                                          NAME
(There are local Haitian physicians that are in      Orthopedics         ______________________________________
private practice. There are also a group of          Internal Medicine ______________________________________
Cuban physicians that are assigned to the            OB-GYN              ______________________________________
hospital as an outreach activity of Cuba to help     Pediatrics         ______________________________________
other countries in the West Indies.)                 Ophthalmology        ______________________________________
PRED (Catholic Nuns in Leon)                         Traditional herbal healing
                                                     Health education services and community based programs
                                                     throughout the province.
Leon Dispensary                                      Immunizations
  Clinic Nurse: __________                           Prenatal care (Vitamin A and Tetanus)
  Pharmacy Tech: Robinson                            Nurse care with treatment by algorithms
  TB Program: Jean Claude                            Pharmacy (when medications are available)
Community Birth Attendants/Midwives                  Arrangements made privately with expectant mothers.
Gebeau (Jeremie)                                     Tuberculosis Care



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                                    Optometry and Ophthalmology care
CARE (Jeremie)                      Support program for families with members with HIV/AIDS
Missionaries of Charity (Jeremie)   This group runs an orphanage that also serves as a feeding and
Hospice                             support center for severely malnourished and Failure to Thrive
                                    children.
Port au Prince Hospitals            There are several hospitals and specialty services in Port au Prince
                                    that can be used. However, travel to and staying in Port au Prince is
                                    expensive and a significant hardship for the patient and their family.
Childspring International           Case management and transport of children needing care outside of
404-228-7770                        Haiti.
REB@childspringintl.org
www.childspringintl.org




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TREATMENT GUIDELINES

     Diagnosis             Syndrome                      Primary Treatment               Alternative Treatment
HEENT
Headache                  History               Peds: APAP                           Peds: Ibuprofen
                          R/O Infection
                          R/O Dental Caries     Adults: APAP                         Adults: Ibuprofen
                          R/O Vision Problem
Conjunctivitis            Red conjunctiva       Neonates: (assume gonorrhea)         Peds: Erythromycin (oral)
                          Purulence             Ceftriaxone and Erythromycin Oint
                          No eyeball pain                                            Adult: Erythromycin or
                          Vision OK             Peds and Adult: Erythromycin Oint.   Doxycycline (oral)
Conjunctivitis            Swollen conjunctiva   Peds: Erythromycin (oral and         Adults: Tetracycline (oral and
Inclusion (Trachoma)      Cobblestoned          ophthalmic ointment)                 ophthalmic ointment)
                           conjunctiva
                          Corneal Scarring      Adults: Erythromycin (oral and
                          Mainly adults and     ophthalmic ointment)
                           teens
Otitis Media              Ear pain              Peds and Adults: Amoxicillin         Peds: Ceftriaxone or TMP-
                          Diminished hearing                                         SMX
                          Red and/or dull TMs                                        Adults: TMP-SMX or
                                                                                      Erythromycin
Otitis Externa            Ear pain              Peds and Adults:                     Peds and Adults: Consider
                          Swollen EAC and       Polymixin/Neosporin/Hydrocortisone   adding oral Amoxicillin or
                           drainage              drops                                Erythromycin




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     Diagnosis            Syndrome                    Primary Treatment             Alternative Treatment
Sinusitis                14 days duration     Peds and Adults: Amoxicillin      Peds and Adults: TMP-SMX
                         Purulent nasal
                          discharge
                         Facial pain
                         Headache
Allergic                 Rhinorrhea (clear)   Peds: Diphenhydramine             Peds: Claritin
Rhinoconjunctivitis      Sneezing
                         Conjunctival edema   Adults: Diphenhydramine           Adults: Claritin
                         Seasonal
Viral URI                Rhinorrhea           Peds: Oral rehydration            Peds and Adults: APAP and
                         Sneezing                                               Diphenhydramine
                         Coughing             Adults: Oral rehydration
                         Low grade fever
Acute Pharyngitis        Sore throat          Peds: Amoxicillin                 Peds and Adults:
                         Exudate                                                Erythromycin
                         Tonsil enlargement   Adults: Amoxicillin
                         Fever
Oral Moniliasis          White patches on     Peds: Nystatin                    Peds and Adults: Gentian
(Thrush)                  oral mucousa         Adults: Nystatin (consider HIV)   Violet of oral Ketoconazole
                         Primarily infants
RESPIRATORY SYSTEM
Bronchitis               Productive Cough     Peds: Bactrim                     Peds or Adults: TMP-SMX or
                         Fever                                                  Doxycycline in adults.
                         Bronchi that clear   Adult: Erythromycin/Doxycycline
                          with coughing




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     Diagnosis           Syndrome                       Primary Treatment             Alternative Treatment
Asthma                  Intermittent and      Peds: Albuterol Syrup               Adult and Peds:
                         reversible wheezing   Prednisone                          Subcutaneous Epinephrine if
                                               Hydration and Recheck in 3 days     severe
                                               Adults: Albuterol Inhaler
                                               Prednisone
                                               Hydrate and Recheck in 3 days       Treat for worms all cases.
Bronchiolitis           Less that 5 y.o.      Peds: Oral rehydration
                        Expiratory wheezing   Consider Albuterol Syrup
                        Single occurrence
Pertussis               Cough for over 2      Peds and Adults: Erythromycin for   Adults and Peds: TMP-SMX
                         weeks                 14 days                             bid for 14 days
                        Whooping cough
                        Afebrile
Pneumonia               Fever                 Neonate: Refer to hospital          Adult or Peds: Consider
                        Cough                 Peds: Bactrim                       Ceftriaxone if severe.
                        Tachypnea             Adult: Erythromycin                 Adults: Doxycycline or
                        Chest pain                                                Amoxicillin
Tuberculosis            Productive and        Adult and Peds: Refer to local TB
                         persistent cough      program
                        Fever/Night Sweats
                        Hemoptysis
CARDIOVASCULAR SYSTEM
Congestive Heart        Wet rales             Refer for hospitalization.
Failure                 Peripheral edema
                        Orthopnea/Dyspnea
Hypertension (mild      BP < 180/110          Adults: Low salt diet
and moderate)           BP > 140/90           Recheck BP with local provider




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     Diagnosis             Syndrome                         Primary Treatment                 Alternative Treatment
Hypertension              BP > 180/110            Adults: Low salt diet                   Enalapril 5-40 mg qd
(severe)                                           Treat only if patient can access
                                                   ongoing monitoring
                                                   Aldomet, HCTZ or Enalapril
                                                   Encourage follow-up
GASTROINTESTINAL SYSTEM
Intestinal Parasites      Asymptomatic            Peds: Abendazole                        Adult and Peds: Mebendazole
(pinworms,                Pruritis
Ascariasis,               Wheezing                Adult: Abendazole
hookworm)                 Worms seen              (all patients will receive worm meds)
“Acide”                   Intermittent            Adult or Peds: Calcium Antacid          Ginger
a.k.a. Dyspepsia           heartburn                                                       (ginger is used as a traditional
(mild and moderate)                                                                        treatment in Haiti)
“Acide”                   Daily epigastric pain   Peds and Adults: Ranitidine             Peds and Adults: Proton
Dyspepsia (severe)        One month or more                                               Pump Inhibitor if available
(Suspect PUD,              in duration
GERD, gastritis)          GI bleeding
                          Weight loss
Diarrhea (mild to         < 1 week duration       Infants: Continue breastfeeding.
moderate)                 < 10 dehydration        Supplement with ORS. Recheck the
                          Non-toxic               next day.
                          < 5 stools/day          Peds: ORS and recheck in 2-3 days
                          No blood in stool       Adult: ORS




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      Diagnosis       Syndrome                      Primary Treatment                Alternative Treatment
Diarrhea             > 1 week duration     Peds: ORS in clinic. Consider IV     Consider hospitalization it
(severe)             > 10% dehydration     hydration in clinic.                 toxic and continued hydration
                     > 5 stools/day        TMP-SMZ or Amoxicillin if            needed.
                     Blood and mucous in   bloody/mucoid stool
                      stools                                                     Consider adding
                     Febrile               Adult: ORS in clinic. Consider IV    Metronidazole.
                                            hydration.
                                            Cipro or TMP-SMZ if bloody/mucoid    Recheck next day in clinic.
                                            stools.
Constipation         < 1 BM per week       Peds and Adult: Mineral Oil          Peds and Adults: Colace
GENITOURINARY SYSTEM
Cystitis             Dysuria               Peds: Amoxicillin for 7-14 days      Peds: TMP-SMZ
                     Frequency/Urgency
                     Incontinence          Adult: TMP-SMZ                       Adult: Amoxicillin or
                                            Non-pregnant woman needs 3 days,     Doxycycline
                                            men and pregnant women need 7
                                            days. (Do not use TMP-SMZ within 2
                                            weeks of EDC in pregnant women.)
Pyelonephritis       Fever                 Peds: ORS and Amoxicillin            Peds and Adult: TMP-SMZ
                     Flank or abdominal                                         Consider Ceftriaxone if toxic
                      pain                  Adult: Cipro or Amoxicillin          or not able to take oral meds.
                     Dysuria                                                    Consider IV hydration in
                     Frequency/Urgency                                          clinic.




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     Diagnosis            Syndrome                        Primary Treatment                     Alternative Treatment
Vaginitis                Vaginal                Peds: Needs exam. Treat as
                          discomfort/pruritis    appropriate.
                         Discharge              Adult: Empiric treatment. Doing a           Adult: Nystatin or
                                                 vaginal exam in clinic is very difficult.   Clotrimazole Cream.
                                                 There is also no supportive lab.            Consider betadine douche or
                                                 Limit pelvic exams to suspected PID,        gentian violet if available
                                                 abnormal cervical bleeding, etc.)
                                                 Miconazole or Metronidazole
Gonorrhea/Chlamydia      Purulent urethral or   Adults: Cipro 500mg *1 and                  Adult: Ceftriaxone IM and
                          cervical discharge     Doxycycline for 14 days.                    Doxycycline for 14 days
                         Prostatitis with
                          discharge              Treat partners.
Prostatitis              Older men              Adult: Doxycycline for 7 days               Adult: Erythromycin for 7 days
                         +/- non-purulent
                          discharge
Pelvic Inflammatory      Lower abdominal or     Adult: Ceftriaxone IM and                   Adult: Ciprofloxin 1 gram - 1
Disease                   pelvic pain            Doxycycline and Metronidazole for           dose, then Doxycycline for 14
                         Tender cervical        14 days                                     days
                          movement               Treat partners
                         Not pregnant by LMP
Syphilis                 Painless chancre on    Adult: Benzathine Penicillin
                          genitalia
MUSCULOSKELETAL SYSTEM
Myalgias or              Vague, generalized     Adult and Peds: APAP                        Adult and Peds: Ibuprofen
Arthralgias (minor)       symptoms               (Rural Haitians live a physically
                         Minimal physical       demanding life with little automation.
                          findings               Muscle and joint pains are common
                         Non-disabling          complaints.)
Osteoarthritis           Painful joints         Adult and Peds: APAP                        Adult and Peds: Ibuprofen



                                                   Page 16 of 29
     Diagnosis       Syndrome                         Primary Treatment                 Alternative Treatment
                    Joint swelling or
                     disfigurement
Low Back Pain       History of injury        Adult and Peds: APAP                   Adult and Peds: Ibuprofen
                                              (Most rural Haitians are subsistence
                                              farmers that spend much time
                                              stooped over tending to their crops
                                              by hand. Low back pain is a
                                              common complaint.)
NEUROLOGICAL AND ENDOCRINE SYSTEM
Seizures            Generalized or focal     Adult and Peds: Refer to the local     Hysterical reactions and
                     shaking.                 Haitian Health Foundation Epilepsy     pseudoseizures are frequently
                    Intermittent             Program.                               misdiagnosed.
                    Recurring
Goiter              Symmetrical thyroid      Adults: Multivitamins                  Nontoxic goiters are common.
                     enlargement                                                     Treatment with long term
                    Non-tender                                                      iodine therapy is often
                    Not thyrotoxic                                                  unrealistic and not requested.
DERMATOLOGICAL SYSTEM
Impetigo            Multiple, crusted skin   Advise scrubbing daily and applying    Adult and Peds: Erythromycin
                     lesions                  Neosporin ointment.
                                              Adult and Peds: Amoxicillin
Scabies             Pruritis                 Adult and Peds: Ivermectin              (Pharmacy staff will explain
                    Generalized popular      Treat entire family                    the procedure for treatment.)
                     lesions with foci on     Wash linen and place in the sun for
                     hands, waist, axilla     24 hours.
                     and groin                Trim finger nails




                                                Page 17 of 29
     Diagnosis           Syndrome                          Primary Treatment                  Alternative Treatment
Pediculosis (lice)      Nits in the hair         Adult and Peds: Benzyl Benzoate for      Adult and Peds: Gamma
                        Scalp itching            12 hours.                                Benzene or Permethrins (if
                        Adult arthropod seen     Treat entire family                      available)
                                                  Wash linen and place in the sun for
                                                  24 hours.
                                                  Trim finger nails
Eczema                  Dry, scaly patches of    Peds and Adults: Hydrocortisone 1%       Severe: Prednisone (oral)
                         skin
                        Atopic areas affected
Tinea                   Raised, scaly            Adult and Peds: Miconazole Cream         Adult and Peds: Griseofulvin
 Capitis                 annular lesions with     Ketoconazole, Fluconazole of             (oral) for the severe capitis
 Corporis                central clearing         Griseofulvin                             infections. Ketoconazole if
 Cruris                                                                                    available.
Tinea versicolor        Hypopigmented            Ketoconazole (one dose)
                         patches of skin
Pruritis                Generalized itching      Adult and Peds: Diphenhydramine          Adult and Peds: Hydrating
                         without rash                                                      lotion if available
MISCELLANEOUS CONDITIONS
Malaria                 Periodic fevers, often   Peds and Adult: Chloroquine
                         in the PM                (Haitians are often familiar with this
                        Headache                 disease and will tell you they have
                        Myalgias                 “Malaria”. For some, it can be a
                        No localizing signs      recurring problem.)
Anemia                  Pale conjunctiva and     Peds and Adults: Ferrous sulfate         (need to treat for worms)
                         nail beds                and Abendazole
Animal Bite             History of bite          Clean and Debride                        Peds and Adult: Cipro or
                        Open or infected         Peds: Cephalexin                         Ceftriaxone if severe
                         wound                    Adult: Doxycycline                       infection.




                                                    Page 18 of 29
      Diagnosis       Syndrome                        Primary Treatment                   Alternative Treatment
Infected Wound       Dirty wound           Clean and debride.                       Peds and Adult: Erythromycin
                     Purulence             Tetanus immunoglobulin (250-500IU        (Sterile technique is very
                     Redness/Indurations   IM) (if available)                       difficult to accomplish at the
                                            Tetanus toxoid (if available)            clinic. There is a single sink
                                            Adult and Peds: Cephalexin               with running water.)
Malnutrition         Wasting               This is a common complaint in Haiti,     Peds and Adult: Multivitamins
                     Growth retardation    and unfortunately there is little that   (It is a poor substitute for the
                     Edema                 can be done. There is a feeding          real need, FOOD!) Referral to
                     Kwashikor syndrome    program for children with the Haitian    the Sisters of Charity or HHF
                                            Health Foundation in Jeremie, but it     for the severely
                                            is for the severely malnourished.        malnourished.)
Immunizations        Well Child Care       This is done by the HHF or the nurse     Make sure children you see
                                            at the Leon Dispensary. There is a       are plugged into some system
                                            cold chain supported through             of vaccination.
                                            UNICEF.
Family Planning      Health Maintenance    This is done through HHF.                Refer to the clinic staff for
                                            Remember this is a predominantly         ongoing care
                                            Catholic society, so respect the
                                            health beliefs on family planning.
Pregnancy            Health Maintenance    Prenatal Vitamins and Iron               Same day referral to the
                                            Refer all newly identified pregnant      dispensary nurse.
                                            clients to the dispensary nurse. She
                                            will ensure the client gets into the
                                            usual system of prenatal care and
                                            monitoring.
Insomnia             History               Common complaint. Relieving
                                            chronic pain syndromes may help.
                                            Diphenhydramine for severe cases.




                                              Page 19 of 29
     Diagnosis          Syndrome                Primary Treatment               Alternative Treatment
Refractive Vision      History         Teams will often bring generic      If specialized refraction is
Problems               R/O Cataracts   reading glasses for distribution.   needed, refer to Gebeau.




                                          Page 20 of 29
                                                   Laboratory Testing
Leon Haiti Mission Laboratory User Guide
February 2009
Page 1 of 6
Leon Haiti Clinic ¤ Laboratory User Guide
February 2009
This document is an overview of the laboratory services available at the Leon Clinic.
We plan on offering all tests and services described in this document. However, due to the
sometimes unpredictable nature of travel to Haiti, certain tests may not be available due to
equipment damage in shipping or supply transport issues. Upon setup in Leon, the team laboratory
technologist will let everyone know the availability of the various tests.
Requesting Laboratory Tests
1. The triage area and all provider stations will have a supply of Laboratory Request
Forms (Appendix A), urine cups, and marking pens.
2. To order lab tests, fill in the top section of the form with the patient information and
check the boxes for the tests requested. The lab will fill in the box for “Lab Number”
3. If urine tests are ordered, the translator or provider should label the container with the
patient’s name and instruct the patient on collecting the urine.
4. Requestors should always send the lab request form and dossier to the lab with the
patient. Always keep the dossier and request form together. This helps to avoid
confusion with paperwork.
5. To help improve patient flow, triage staff may order tests (with the exception of malaria
antigen) based on initial patient presentation in the triage area.
6. Once testing is complete, the laboratory will return the completed request form and
dossier to the provider.
7. If you are referring a patient to another facility, please let the lab worker know so a
duplicate copy of the results can be made to send with the patient.
Test Utilization
1. Based on test utilization from past missions, we forecast the amount of laboratory
supplies we bring on each trip.
2. We are working with limited resources that need to last for two weeks. Please consider




                                                          Page 21 of 29
this and avoid over ordering tests.
3. Typically we have a very generous supply of hemoglobin cuvettes, glucose strips, urine
dipsticks, and HIV tests. Tests with more limited availability include malaria antigen
tests and chemistry panels.
4. Please do not be offended if the lab worker comes to see you and discuss over-ordering
certain tests. We want to make sure we have sufficient resources to test patients that
really need it.
5. Based on patient presentation or other test results, the lab may add on tests to your
original request. (Example: Adding on an HIV test when a positive syphilis result is
obtained.)
6. Please feel free to come and consult the laboratory worker about tests that may be
useful for a specific patient or if you have any questions about results.
Outreach Testing
1. Outreach testing is very basic and consists of hemoglobin, urinalysis, glucose, and HIV
screening.
2. Patients who are HIV positive on outreach are referred back to the main clinic for
additional testing.
Leon Haiti Mission Laboratory User Guide
February 2009
Page 2 of 6
Prenatal Screening
1. Please ask all pregnant women if they have been tested during their current pregnancy.
2. Prenatal services are available at the Haitian Health Foundation (HHF) in Jeremie.
Women may have been tested at HHF and we do not need to repeat testing if it has been
already completed.
3. If a woman has not been tested, the standard prenatal tests which should be ordered are:
a. Hemoglobin
b. Glucose
c. HIV antibodies
d. Syphilis
e. Urinalysis
Leon Haiti Mission Laboratory User Guide




                                                             Page 22 of 29
February 2009
Page 3 of 6
Test Specific Information
Hemoglobin
1. Primary methodology: Modified azidemethemoglobin (Hemocue)
2. Testing guidelines
a. Clinical signs of anemia.
NOTE: The presentations of significant anemia are often atypical or extreme. Do
not get fooled by patient appearance.
b. Children between 6 months to 5 years
c. Women of child bearing years.
3. Local reference ranges (Source: Clinic data collected in Leon since 2004)
a. Adult males: 7.0-16.3 g/dL
b. Adult females: 7.9-14.7 g/dL
4. Repeat analysis
a. 5 g/dL is typically the decision point for transfusion in the local area. Because of
this we repeat and verify hemoglobin results that are less than 5.
5. Referral for Transfusions
a. When patients are referred to the hospital for a transfusion, they will need to bring
friends and relatives that are able to donate for them as banked blood is generally
not available.
b. Blood component therapy (packed RBCs, platelet concentrate, plasma products) is
not available in Jeremie. Whole blood is generally the only product that is
available.
Glucose
1. Methodology: Glucose Dehydrogenase/electrochemical sensing (Precision XTra)
Urine Pregnancy Test
1. Methodology: Lateral flow/strip immunoassay (Signify hCG Urine)
Malaria Antigen
1. Methodology: Whole blood immunochromatographic test (Binax NOW)
2. Test utilization




                                                              Page 23 of 29
a. Many patients present with symptoms of malaria. We do not have enough tests to
test everyone who thinks they have malaria. Your interpreter can assist by asking
questions to help clarify the diagnosis.
3. Testing guidelines
a. Patients brought into the clinic unconscious or with a recent history of seizures
b. Patients with a fever of >38.5C with no assignable cause
c. Patients with a hemoglobin of <6g/dL
d. Patients with recent history of headache, chills, and very high fevers that recur every
few hours to few days
4. Because this is a malaria antigen test, patients may remain positive with this test for a few
days after completion of treatment due to the detection of residual antigen
Syphilis
1. Methodology: Immunochromatographic test for detection of antibodies to T. pallidum
(Determine Syphilis TP)
Leon Haiti Mission Laboratory User Guide
February 2009
Page 4 of 6
NOTE: This is a treponemal specific antibody assay. This is different from the nontreponemal
based tests (like RPR) commonly used in the US.
2. Testing guidelines
a. Patients with clinical symptoms of primary, secondary or tertiary syphilis infection.
b. Syphilis is more common in Haiti than you may think, so have a low index of
suspicion.
c. Patients with other STD symptoms.
d. Patients desiring testing. (There is usually a good reason they are asking even
though we may not fully appreciate the significance.)
e. Patients who are HIV positive (HIV and syphilis often are found together)
f. As part of prenatal screening
g. Babies with failure to thrive
3. Additional Information
a. Very common in Grand Anse province (7-12% positive). Patients with all stages of
syphilis have been seen in Leon.



                                                              Page 24 of 29
b. Stages of syphilis
i. Primary syphilis
1. Painless chancre (ulcer) at site of inoculation
2. Chancre heals within 3 to 6 weeks; dissemination of organism occurs
during this stage
ii. Secondary syphilis
1. Occurs 2 to 24 weeks later; symptoms appear when organisms reach
a sufficient number
2. Symptoms
3. Fever, weight loss, malaise, loss of appetite
4. Skin rash
iii. Tertiary syphilis
1. Tissue destructive phase; Occurs 10 to 25 years after initial infection
2. Symptoms
3. Central nervous system disease
4. Cardiovascular abnormalities
5. Eye disease
6. Granuloma-like lesions (gummas) in any organ
iv. Congenital syphilis
1. Big problem in Haiti
2. Testing of pregnant women very important
3. At any stage of the disease, women who become pregnant can
transmit syphilis to the baby via the placenta resulting in
miscarriages, stillbirths, or neonatal infection
4. Symptoms
a. Failure of baby to thrive
b. Rashes
c. Congenital pneumonia
d. Watery discharge from nose
c. Yaws vs. Venereal Syphilis
Leon Haiti Mission Laboratory User Guide




                                                              Page 25 of 29
February 2009
Page 5 of 6
i. Possible that some patients were exposed to Yaws (T. pallidum subsp.
pertenue) rather than syphilis (T. pallidum subsp. pallidum)
ii. Yaws is transmitted when open wounds come in contact with an infected
lesion
iii. Age group: Children
iv. Presentation: skin nodules, papules, ulcers
v. Not possible to differentiate syphilis from yaws serologically
Complete Blood Counts
1. Methodology: Centrifugation with fluorescent cell staining (QBC Autoread Plus)
Chemistry Testing
1. Methodology: Direct Ion Selective Electrode (ISE) and electrochemical detection (iSTAT)
2. Analytes: Sodium, potassium, chloride, CO2, urea nitrogen, creatinine, glucose, ionized
calcium, hemoglobin and hematocrit.
Urinalysis
1. Methodology: Multistix 10SG
2. Analytes: Glucose, bilirubin, ketones, pH, specific gravity, blood, protein, urobilinogen,
nitrite, and leukocyte esterase.
Leon Haiti Mission Laboratory User Guide
February 2009
Page 6 of 6
HIV Testing
1. Methodologies:
a. Lateral Flow Immunoassays
i. Oraquick HIV-1/HIV-2 Antibody Test (Primary Test)
ii. Determine HIV-1/HIV-2 Antibody Test (Alternate Test)
2. Testing guidelines
a. HIV is more common in Haiti than you may think, so have a low index of suspicion.
Furthermore, there are treatment and behavioral adaptations that can support the
individual and family. Knowledge of infection is important.
b. Patients with other STD symptoms.




                                                            Page 26 of 29
c. Patients with unexplainable weight loss and clinically apparent weakness.
d. Patients with unusual infections that may be opportunistic.
e. Patients desiring testing. (There is usually a good reason they are asking even
though we may not fully appreciate the significance.)
f. Patients with syphilis (HIV and syphilis often are found together)
g. Children who are not thriving (also consider testing their mothers)
h. As part of prenatal screening
3. Pre-Test Counseling
a. Testing should only be performed after patient has received pre-test counseling from
local Haitian nurse, experienced translator or provider.
b. Please check the box on the laboratory request once pre-test counseling has been
performed.
4. Algorithm
a. Patient screened with the primary test.
b. If the primary test is non-reactive, the result is reported as “Negative”.
c. If reactive results are obtained with the primary test, a second test is done using
another type of test from a different manufacturer.
d. If results from both tests are reactive, the result is reported as “Positive. Result
verified using a second, different HIV test.”
5. Positive HIV referrals
a. Pregnant HIV positive patients are referred to the Haitian Health Foundation for
management
b. Other HIV positive patients are referred to the hospital for further testing and
follow-up
6. Testing of Infants
a. HIV antibody tests cannot be reliably used for confirmatory diagnosis of HIV in
infants as the interpretation of positive HIV antibody testing is complicated by the
fact that maternal HIV antibody can persist for 18 months (although it usually clears
by 9-12 months).
b. HIV RNA testing is preferred for infant diagnosis. HIV RNA testing may not be
accessible or consistently available in Haiti.



                                                            Page 27 of 29
c. Antibody-negative results suggest that infants are unexposed and or uninfected,
however if the infant is breastfeeding the risk of acquiring HIV continues
throughout the entire breastfeeding period.
Haiti 2009
Patient Name __________________________________ Gender M F Age ____________
Provider Name _________________________________
. Hemoglobin _________ g/dL
. Glucose _________ mg/dL
. Urine Pregnancy Result _____________
. Syphilis Result _____________
(Detects antibody to T. pallidum antigen)
. Malaria Antigen Result _____________
(Detects P. falciparum, P. malaria, P. ovale, and P. vivax antigens)
. HIV Abs. Result _____________
(Detects antibodies to both HIV-1 and HIV-2)
. HIV pretest counseling done
Tested by ______________
Date ______________
Lab Number
. iSTAT Panel
Result Units Reference Range
Sodium ___________ mmol/L 138 – 146
Potassium ___________ mmol/L 3.5 – 4.9
Chloride ___________ mmol/L 98 – 109
Ionized Calcium ___________ mmol/L 1.12 – 1.32
Carbon Dioxide ___________ mmol/L 24 – 29
Glucose ___________ mg/dL 70 – 105
Urea Nitrogen ___________ mg/dL 8 – 26
Creatinine ___________ mg/dL 0.6 – 1.3
Hematocrit ___________ % 39 – 48 (Male)
36 – 45 (Female)
Hemoglobin ___________ g/dL 13 – 16 (Male)




                                                                       Page 28 of 29
12 – 15 (Female)
Anion Gap (calc.) mmol/L 10 – 20
. Urinalysis
Result
Color __________
Appearance __________
Glucose __________
Bilirubin __________
Ketones __________
Specific Gravity__________
Blood __________
pH __________
Protein __________
Urobilinogen __________
Nitrite __________
Leukocyte Est. __________
. Complete Blood Count
Result Units Reference Range
Hematocrit ___________ % 39 – 48 (Male)
36 – 45 (Female)
Hemoglobin ___________ g/dL 13 – 16 (Male)
12 – 15 (Female)
Platelets ___________ x 109/L 140 – 440
WBC ___________ x 109/L 4.3 – 10.0
Granulocytes ___________ %
Lymph/Mono ___________ %
Granulocytes ___________ x 109/L 1.8 – 7.2
Lymph/Mono ___________ x 109/L 1.7 – 4.9
Lab User Guide
Appendix A




                                             Page 29 of 29

								
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