Download Timmy Foundation Medical Protocols

Timmy Global Health Medical Protocols
Table of Contents
1. Medication Usage
2. Parasites
3. Malnutrition, Stunting, & Growth Charts
4. Chronic Disease
4.1 Hypertension
4.2 Diabetes
5. Parasite Therapy Quick Reference Guide
1
Using Medications on Timmy Brigades
Introduction:
During Timmy Global Health’s week-long brigades, medical providers will see a large
number of patients and prescribe a significant amount of medication. To ensure
consistent adherence to proper protocols as well as local norms, the below sets out
relevant procedures for the provision of medications to patients on brigades.
Protocols:
Formulary: Timmy Global Health supplies all of the medications using a formulary
(which can be found at the end of this document). Please review the formulary prior to
the trip so that you are familiar with the available medications. This medication list is
extensive and will cover all or most of the pathologies you will encounter during the
week. However, if there is a medication which is medically necessary and not on the
formulary, you may instruct the patient to purchase it at a pharmacy. While in almost all
cases patients do not need a formal prescription in order to purchase medication at a
pharmacy, you must still clearly write out the medication name and dosing instructions to
ensure that the patient receives the proper medicines from the pharmacist. Additionally,
prior to prescribing any medications for patient purchase, you must ask one of the local
medical providers or in-country Timmy Global Health staff if this medication is readily
available and affordable for the patients (as it does little good to prescribe a medication
that the patient will not be able to readily obtain.)
Access to medicine: As noted above, except for specific controlled substances, patients
do not need a prescription to obtain medications. Therefore, self-medication is a more
prominent concern than in the United States. Additionally, patients have been
conditioned to expect medication in response to any medical issue. As such the
expectation for receiving medication here is very high, even for conditions that do not
require medication. While it can be difficult when a patient is specifically requesting
medication, Timmy asks that you adhere to the same standards for dispensing medicines
that you would use in your practice at home. Specifically, Timmy policy is not to
dispense medication unless it is necessary. (Vitamins are an exception as all brigade
patients receive vitamins to compensate for potential dietary limitations) Given that
patients don’t need a prescription to purchase medicines, it is also important that you take
the time to explain why you are choosing not to prescribe medication so that the patients
don’t simply purchase it for themselves at the pharmacy. This is especially important
when it comes to antibiotics as they are widely overused in Guatemala (in fact, they are
even sold at the local markets). For treatment of cold symptoms, we have made an effort
to make available and use more natural treatments like saline drops, sprays and sinus
rinse kits when appropriate.
Antibiotic Resistance: As noted above, antibiotics are very often improperly used in
Guatemala. As such, antibiotic resistance is a problem and should be considered if it is
deemed necessary to dispense an antibiotic. Initially with the widespread use of
antibiotics, people used Tetracyclines as the first line medication. However, the
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pathogens developed resistance to this class of antibiotics and people changed to
Trimethoprim-sulfamethoxazole (Bactrim/Septra). Again, widespread resistance
developed and people are now buying Amoxicillin in pharmacies. Now there are several
examples of Amoxicillin-resistant pathogens (including a case of Group A Strep). While
this does not preclude us from using such medications, it is important to keep in mind
when choosing a specific antibiotic to administer (type of infection, previous antibiotic
exposure, etc.)
Breastfeeding: Many mothers here breastfeed their children for a significant amount of
time (up to three years of age and at times even longer.) Therefore, when prescribing
medication to a mother of young children, it is always important to ask if they are
breastfeeding as that may limit the choices of medications.
Vitamins: Vitamins will be distributed to all patients according to the following age
guidelines:
 Infants ages 0-2: Infant vitamins
 Males ages 2-14: Children vitamins
 Males ages 15 and older: Adult vitamins
 Females ages 2-14: Children’s vitamins
 Females ages 15-30: Prenatal vitamins
 Females ages 30-45: Determine whether patient is considering becoming
pregnant or breastfeeding; if so, give prenatal vitamins. If not, adult vitamins
 Females ages 45 and older: Adult vitamins
If a parent is accompanied by children who were not seen during the brigade, the children
may also be given vitamins. Like all other medication, vitamins should never be given
directly to children. Additionally, parents should be clearly instructed as to the dose (one
per day) and to keep the vitamins in a place where children can not access them to avoid
overdose. (Remember, they taste good so children seek them out!)
Choosing medications: Medications should always be chosen according to what is best
for the patient. However, as in the US where you might choose a medication based on
cost considerations (for example depending on the insurance coverage of the patient),
cost and availability should be taken into account when deciding which medication to
use. Timmy Global Health works to acquire medications in the most economical manner
possible. However, there are specific medications that continue to be expensive and/or
difficult to obtain. Therefore, while these should always be used when medically
necessary, we ask that you consider whether another medication would be a suitable
substitute for the medicines listed below:
o Omeprazole/Lansoprazole—Symptoms of Gastritis/GERD are very
common here in Guatemala (largely due to diet). While PPIs are now
often used as the first-line treatment for Gastritis/GERD in the US, many
patients here have only mild symptoms and should be trialed on Calcium
Antacids and/or H2-antagonists prior to the initiation of PPIs (which are
expensive).
o GERD Packs—Similarly, GERD packs should be reserved for patients with
3
o
o
o
o
o
more severe symptoms of GERD and/or H Pylori infection. (GERD packs
consist of Omeprazole, Amoxicillin, and Clarithromycin)
Augmentin—While this antibiotic is frequently used in the US, it should be
reserved here for infections in which another antibiotic would not be
efficacious. The oral suspension form is particularly expensive.
Naproxen—Osteoarthritis is another diagnosis commonly seen here and
Naproxen is a good medication to use to control the pain. However, for
patients with only very mild, intermittent, or short-term symptoms,
Ibuprofen can often work just as well and is significantly less expensive.
Cephalexin Oral Suspension—This should be reserved for clinical situations
in which specific coverage is needed (e.g. Staph.) If Amoxicillin is as
appropriate a choice of antibiotic (and there is no worry of antibiotic
resistance), please use Amoxicillin instead.’
Prednisone taper—While this medication can be a good choice for patients
with severe inflammation, the instructions for proper usage are often
confusing and very diffiicult to follow, especially for an illiterate patient.
Therefore the medication should be reserved for only necessary clinical
situations. When used, the instructions must be clearly explained to the
patient (and family members when appropriate) and the patient should be
able to demonstrate clear understanding of the instructions before leaving
the pharmacy.
Permethrin: Scabies is a very common skin disease seen in the communities
in which we work. Permethrin is a well-known and effective treatment of
this disease. Unfortunately, it is also an expensive remedy. A less wellknown, but much more economical treatment is Ivermectin. Studies have
shown than two doses of Ivermectin given at least one week apart are an
effective treatment of scabies1. Therefore, for patients seen with classic
scabies, the treatment protocol is as follows:
 Children less than 15kg: Permthrin cream
 Children greater than 15kg and adults: 200 mcg/kg/dose x 2
doses given approximately 10 days apart.
 Ivermectin should be taken with food as significantly
increases drug penetration into epidermis
 Severe cases (crusted scabies) can require multiple doses of
Ivermectin and should be treated with Permethrin
concomitantly.1
 The same dose of Ivermectin (200 mcg/kg/dose x 2 doses
given one week apart for patients greater than 15kg) can be
used in the treatment of lice
Patients use of medication:
1
Bart J. Currie, F.R.A.C.P., and James S. McCarthy, F.R.A.C.P. Permethrin and Ivermectin for Scabies
N Engl J Med 2010; 362:717-725
4


Latino culture is largely centered on community and the sharing of what is
available. This pertains to resources, including medication. A medication that
gives symptom relief for one family member may very well be shared within the
extended family or with neighbors and friends. Medications that are NOT suitable
for familial use should be specified and cautioned. It is crucial to stress the
importance of completing a course of antibiotics as compliance seems to be low.
Also, details about which excess medications after treatment is complete should
be stored versus thrown out needs to be conveyed in the pharmacy.
There have been multiple reports of patients splitting chronic medications into
halves or even fourths to make them last longer despite the brigade ticket priority
given to patients on the chronic list. Always reassure patients on chronic
medications that we will be back in two months to provide a prescription refill
and remind them that the medication will not be effective unless taken daily and
at the proper dosage.
5
Protocol for Use of Anti-Parasite Medicine for Intestinal
Parasitic Infections on Timmy Brigades
Overview of epidemiology of Soil-Transmitted Helminth infections in
Guatemala
Parasitic infections are a significant problem in the developing world, including in
Guatemala. The soil-transmitted helminthiases--ascariasis, hookworm, and trichuriasis-are among the most prevalent infections worldwide and thus the central focus of this
protocol. The WHO recognizes that in Guatemala these infections are a significant issue
and require preventive chemotherapy treatment.i Given that school children tend to have
the highest disease burden and morbidity as a result of soil-transmitted heminth (STH)
infections, the treatment protocol focuses largely on the pediatric population.
Studies examining the prevalence of parasitic infections in children in Guatemala have
found a high prevalence of helminthiasis in children. Specifically, one such study in an
indigenous highland town found baseline helminth prevalences of Ascaris lumbricoides
of 91% and Trichuris trichiura of 82%.ii A separate study in a rural Guatemalan village
found the prevalences of the major helminths at 41% with Ascaris lumbricoides, 60%
with Trichuris trichiura and 50% with Necator americanus (Hookworm).iii While these
studies were not specific to the areas in which we work, they nonetheless indicate that the
common presence of STH infections represents a huge disease burden in Guatemala.
The approach to diagnosis and treatment of children with suspected STH infections is
difficult, especially as the large majority of patients are asymptomatic. Therefore, this
protocol is intended to provide a guideline for treating brigade patients according to
WHO standards.
Symptoms of common STH infections:
Ascaris Lumbricoides: The large majority of patients infected with this worm are
asymptomatic. Symptoms can occur with moderate to heavy worm burdens and affect
various organ systems. Transient pulmonary symptoms (including cough, dsypnea, and
wheezing,) can occur during the larval migration stage (1-2 weeks after infection.)
Gastrointestinal symptoms including abdominal pain, anorexia, nausea, and diarrhea have
been attributed to ascarisias, but are not specific. Malabsorption can lead to steatthorea
and micronutrient deficiencies. In severe cases, intestinal obstruction can occur.
Pancreatic and Hepatobiliary—migration of worms to the pancreatic and hepatobiliary
tracts can cause abdominal pain, cholecystitis, jaundice, and pancreatitis. Finally, heavy
infections have also been shown to be associated with impaired growth and cognitive
development in school children.iv
Trichiuris Trichiuria (Whipworm): The large majority of patients infected with this
worm are asymptomatic. Symptoms can occur with moderate to heavy worm burdens,
including loose stools (which may contain mucous and/or blood), rectal prolapse, and
impaired growth/cognition.v
6
Hookworm (Necator Americanus): Again the large majority of patients are
asymptomatic. Following skin penetration (mode of transmission for Hookworm),
patients may have pruritic rash at site of penetration. Gastrointestinal symptoms may
include abdominal pain (often midepigastric), vomiting, diarrhea, and flatulence. Finally
infection with hookworm may result in iron deficiency anemia secondary to blood loss. vi
3. Summary of WHO recommendations:
For countries that categorized as requiring preventive chemotherapy treatment for soil
transmitted helminthic infections, the WHO recommends the following therapy
guidelines:
Category
Prevalence of STH
infection among
school-aged
children
Action to be taken
High Risk
Community
>50%
Treat all school age
children (enrolled and
not-enrolled) twice
each year
Low Risk
Community
>20% and <50%
Treat all school age
children (enrolled and
not-enrolled) once
each year
Also treat:
 Preschool children
 Woman of
childbearing age
including pregnant
women in second
and third trimester,
lactating women,
 Adults at high risk in
certain occupations
(e.g. tea pickers and
miners)
Also treat:
 Preschool children
 Woman of
childbearing age
including pregnant
women in second
and third trimester,
lactating women
 Adults at high risk in
certain occupations
(e.g. tea pickers and
miners.)

From: Preventive chemotherapy in human helminthiasis, Coordinating use of anthelminthic drugs in control
interventions: A manual for health professionals and programme managers (World Health Organization, Geneva) 2006
Timmy Protocol for Use of Anti-Parasitic Medication
Based on prevalence data on STH infections in the communities we serve in Guatemala
and WHO recommendations, we have adopted the following protocol for treatment:
i. All children who have not received antiparasitics in past 6 months should be
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treated. Note—it is important to ask several different ways if patient has been
recently treated including last visit to MD, if received anti-parasitic at school,
explanation of fear of resistance and then ask again, etc
ii. Treatment must be clearly documented on intake form; be sure to explain to
parents that they should take note of when the patient received treatment to
avoid retreatment in next few months
iii. A patient who recently received treatment and has symptoms suspicious
of parasitic infection should be sent for stool sample
iv. While the WHO recommends treatment of pregnant women in the 2nd and 3rd
trimesters, Albendazole and Mebendazole are not recommended for use during
pregnancy and breastfeeding. Therefore asymptomatic pregnant and lactating
women are not treated; any such woman who is symptomatic should be
referred to an OB for further evaluation
v. Adults with symptoms suggestive of helminthic infection should be considered
for stool testing vs anti-parasitic medication, decided on a case-by-case basis.
Treatment regimen
Albendazole 200mg PO x 1 dose for children aged 12-23 months;
400mg PO x 1 dose for children >2 year of age and adults
Or
Mebendazole 500mg PO single dose for children >1 year of age and adults
(alternative treatment regimen is 100mg PO BID x 3 days)
Protozoal Intestinal Infections:
Protozoal intestinal infections, especially Entamoeba and Giardia Lamblia are also very
common infections in Guatemala. A study on the prevalence of gastrointestinal parasites
among school children in the Palajunoj Valley of Guatemala (outside of Xela) found
16.1% of children were infected with Entaemoba histolytica and 10.9%% with Giardia.vii
Entamoeba histolytica can cause intestinal amebiasis, although the large majority of
patients are asymptomatic. Acute symptoms of amebiasis include diarrhea, abdominal
pain, and bloody stools. Entaemoba dispar is another cause of intestinal amebiasis,
including in Ecuador. Patients suspected of having symptomatic intestinal amebiasis
should be sent for stool samples or empirically treated as follows:
Children
Metronidazole 35-50mg/kg/day divided TID 7-10 days
Adults:
Metronidazole 500mg PO TID x 7-10 days
8
Giardia Lamblia is another protozoal infection that can cause intestinal symptoms.
Approximately 55-65% of patients are asymptomatic. Acute giardiasis presents with
symptoms including watery diarrhea, abdominal cramping and bloating, flatulence, and
nausea. Chronic giardiasis can present with loose stools, weight loss, lactose intolerance,
and growth retardationviii. Infection with Giardia Lamblia should be considered in any
patient with these symptoms. Patients can be sent for stool samples or given empiric
treatment as follows:
Children
Metronidazole 15mg/kg/day divided TID x 5-7 days (max 250mg/dose)
Adults:
Metronidazole 250mg PO TID x 5-7 days
Treatment of any patient should be accompanied with education regarding water source,
hand-washing, etc to avoid re-contamination.
______________________________________________________________________________________
Preventive chemotherapy in human helminthiasis, Coordinating use of anthelminthic drugs in control
interventions: A manual for health professionals and programme managers (World Health Organization,
Geneva) 2006
II
Watkins WE, Pollit E. Effect of removing Ascaris on the growth of Guatemalan schoolchildren.
Pediatrics 1996 Jun; 97(6 Pt 1):871-6.
III
Anderson TJ, Zizza CA, Leche GM, Scott ME, Solomons NW. The distribution of intestinal helminth
infections in a rural village in Guatemala. Mem Inst Oswaldo Cruz. 1993 Jan-Mar;88(1):53-65.
iv
http://www.uptodate.com/online/content/topic.do?topicKey=parasite/11831&selectedTitle=1%7E29&sou
rce=search_result
v
http://www.uptodate.com/online/content/topic.do?topicKey=parasite/17013&selectedTitle=1%7E15&sour
ce=search_result
vi
http://www.uptodate.com/online/content/topic.do?topicKey=parasite/6485&selectedTitle=1%7E32&sour
ce=search_result
vii
Cook DM, Swanson RC, Eggett DL, Booth GM. A retrospective analysis of prevalence of
gastrointestinal parasites among school children in the Palajunoj Valley of Guatemala. J Health Popul
Nutr. Feb 2009;27(1):31-40
viii
http://books.google.com/books?id=VbjFQiz8aR0C&pg=RA1-PA1331&lpg=RA1PA1331&dq=giardia+guatemala&source=bl&ots=CDo2rOckLj&sig=iXWtoTzBKOIP97Ljhi0JytGpdE8&
hl=en&ei=6hu2TLG4C4K0lQee6aDyBQ&sa=X&oi=book_result&ct=result&resnum=1&ved=0CBEQ6A
EwADgK#v=onepage&q=giardia%20guatemala&f=false
9
Malnutrition, Stunting, and Use of Growth Charts
Introduction
Malnutrition is a very serious problem for children in Guatemala. In fact, the country has the highest
levels of chronic malnutrition in the Western Hemisphere. According to UNICEF, 24% of Guatemalan
children under the age of 5 are underweight (low weight-for-age) and 54% of children age 5 and under
are stunted (low height-for age), which is tied with East Timor for third highest in the world, behind
only Afghanistan and Yemen.2
In addition to its most acute physical effects, malnutrition has a significant impact on a child’s health
and cognitive development. It is estimated that malnutrition is responsible for 44 to 60 percent of
deaths from measles, malaria, pneumonia and diarrhea.3 Furthermore, malnutrition significantly affects
brain development, school performance and economic potential.
Growth Charts:
Given the profound effects of malnutrition on a child’s physical, mental, and cognitive health, it is vital
that child’s nutritional status should be clearly documented at all medical visits. The best form for
documenting this nutritional status is a growth chart. When determining the height and weight
percentiles in developing countries, questions often arise as to which growth charts are most suitable.
Many think country specific growth charts are the best measurement, however, in under-resourced
nations the use of country specific data masks the degree of malnutrition and does not account for a
child’s full growth potential. In other words, a growth chart should provide more generalized and
objective standards for how a child should grow if given the necessary nutrition. As such, the WHO’s
updated growth standards, released in 2006, used growth data from 6 countries and “reiterate[d] the
fact that child populations grow similarly across the world’s major regions when their needs for health
and care are met.”4 Similarly, growth charts from the Centers for Disease Control (CDC) in the United
States provide objective standards for growth given with proper nutrition.
This universal growth potential is true even in countries such as Guatemala, where many people think
that prevalence of short stature is genetic. In reality, many studies have refuted this genetics centered
belief. For example, a study by the World Bank found that Mayans in southern Mexico are taller than
those over the border in Guatemala5. Concluding that those in Mexico have the same genetics but
different access to nutrition resulting in taller physical stature. Another study that compared Mayan
children in Guatemala and with Mayan children in the US found those that had immigrated to the US
were better nourished and significantly taller.6
Thus, as illustrated above, the use of growth charts based on established grown norms are the most
appropriate for children in Guatemala. The World Health Organization (WHO) and CDC growth charts
are the two most commonly used. There is a notable difference between the two organizations’ charts
from the ages of 0 to 2: at this age the WHO charts reflect a focus breastfeeding, while CDC charts
reflect a higher reliance on bottle-feeding. When plotting an identical height or weight on both charts
2
http://www.feedthefuture.gov/documents/FTF_2010_Implementation_Plan_Guatemala.pdf
http://www.dcp2.org/pubs/DCP/28/Section/3991
4
http://www.who.int/childgrowth/faqs/how_different/en/index.html
5
http://pulitzercenter.org/articles/malnutrition-guatemala-national-shame
6
Bogin B, Loucky J. Plasticity, political economy, and physical
growth status of Guatemala Maya children living in the United
States. Am J Phys Anthropol 1997; 102: 17–32.
3
10
after infancy, the percentile differences are clinically insignificant, especially for the purposes of
nutrition assessment and growth monitoring done during and between the brigades7. Given that
breastfeeding is the ideal source of nutrition and primary source of feeding for babies in Guatemala,
Timmy Global Health’s policy is to use WHO growth charts for children ages 0-2 and CDC growth
charts for children ages 2-18 (WHO growth charts are limited after the age of 5 and utilizing CDC
growth charts for all children older than age 2 allows us to reduce the number of different charts used
for each patient8).
Protocol:
 All children ages 0-18 seen on the brigade will receive a growth chart for their chart as follows:
- Children age 0-2: WHO growth chart
- Children ages 2-18: CDC growth chart
 Weight for age and Height for age must be plotted for all children. When appropriate, weight for
height and/or BMI should also be plotted. The growth chart should then be used as a pictorial tool to
discuss the child’s nutritional status with the parent(s).
- Note: It is important to accurately document a child’s age, including not just number
of years old, but months as well. (e.g. a child that turned 7 last month needs to be
differentiated from a child that is 7 years and 8 months old.)
 Any child that is below the third percentile for weight and/or height is considered chronic and
should receive regular follow up. Dietary interventions should also be discussed at length with the
family (see separate “Dietary Intervention” sheet).
Note: Diets mostly consist of rice and potatoes in the rural areas of the country as
well as the indigenous populations of the metropolitan areas. This is partly cultural
but largely due to financial strain and the large difference in cost between starches
and proteins/vegetables/fruits. A child reporting low appetite may not have much food
being offered in the home. It is important to address the issues of food availability in
the home delicately with the parent before encouraging the child to generally eat
more.
 In Guatemala, any child age 5 or younger that is undernourished should be considered for referral
to the malnutrition program in Xela. (Speak with Dr Sullivan for more details.)
7
http://www.cdc.gov/mmwr/pdf/rr/rr5909.pdf
The CDC growth chart measures height and weight from age 2 until age 20, whereas the WHO has a
separate chart for ages 2 to 5 and then additional charts for older children (with weight for age charts
only until age 10.)
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8
Evaluating and Treating Chronic Diseases on Timmy Brigades
Introduction: Chronic diseases, including cardiovascular diseases and diabetes, are becoming an
increasing cause of morbidity and mortality in Guatemala. This is due largely to changes in diet
(increased saturated fat, refined foods, and sugar) and lifestyle (urbanization, sedentary lifestyle.) This
western influence has reached many of the rural communities as well and we are encountering chronic
diseases there not seen previously. This protocol will focus on two of the diseases most commonly
encountered—hypertension and diabetes.
Diagnosing and/or managing a patient with a chronic disease on a medical brigade is challenging for
several reasons, including:
o
o
o
o
The patient is unknown to the medical provider
The patient is being evaluated at only one point in time
The medical history is often uncertain and/or unreliable
Follow up is uncertain (and will often not be done by the same medical provider who sees the patient
during the brigade)
Timmy Global Health has several strategies in place to help deal with these challenges, including:
o Partnering with a local organization that has an established clinic and a regular presence in the
communities
o Employing a full time US physician and providing a stipend to a local Guatemalan doctor, both of whom
assist with follow up between brigades.
o Sending medical brigades every 2-3 months to the same communities to the patients can be followed
closely.
These strategies allow the brigades to adhere closely to established standards in terms of evaluating and
managing chronic diseases. These specific protocols for hypertension and diabetes are discussed
below.
Hypertension
Review of Classification of Hypertension:
Classification of Blood Pressure (BP)
Category
SBP mmHg
DBP mmHg
Normal
<120
<80
and
Prehypertension
120-139
80-89
or
Hypertension, Stage 1
140-159
90-99
or
Hypertension, Stage 2
>160
>100
or
http://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf
Protocol for Evaluation and Treatment of Hypertension
1. A patient suspected of having Hypertension (HTN) should be treated according to the
WHO guidelines below (with modifications described subsequently.)
2. Any patient with pre-HTN, HTN, or risk factors should be clearly flagged and the need
for follow up at the next brigade clearly indicated.
3. Any patient with severe and/or symptomatic HTN, after being started on treatment, must
be followed up by a medical provider within one week (Pop Wuj Clinic when possible
or the local Centro de Salud). This must be explained clearly to both the patient and
community leader and a plan put in place during the patient encounter.
12
http://www.who.int/bulletin/volumes/88/6/08-062364/en/
13
Modifications to above Protocol:
 Patients with age < 40 and SBP>140 should be screened for causes of secondary hypertension.
Depending on individual case (and degree of suspicion for secondary HTN causes,) the decision
should be made to either refer for further workup or perform trial of lifestyle modifications and
follow up at next mobile clinic/brigade. This decision process should be clearly documented.
 For patients with SBP>180 or SBP 140-179 and co-existing disease should be started on
treatment according to the above protocol and followed up within 1-2 weeks. These patients
should be discussed with Dr Sullivan or Dr Christian to ensure a proper follow up plan has been
established.
 In a patient with severe/symptomatic HTN, consider administering fast-acting treatment to lower
the BP to an acceptable level (while closely monitoring the patient), initiating treatment, and
arranging for close follow up following discussion with the in-country medical professionals.
 The timing of follow up visits (i.e. Visit 1, Visit 2, Visit 3 referred to in the protocol) will be
determined by the mobile clinic and brigade schedule (e.g. Visit 2 may occur at 2-3 months,
rather than 4 months.)
Management of Existing HTN:
Whenever possible, patients who are well controlled on a treatment regimen should be
continued on this regimen (i.e. medications should not be switched due to provider preference.) If a
medication change is felt necessary, this must be clearly explained on the patient chart. The need for
patient follow up should also be clearly indicated.
While HCTZ is the drug of choice for initiation of treatment for HTN, drug regimens should be
modified according to co-existing conditions (e.g. ACE Inhibitor for diabetic patient, Beta Blocker
and/or ACE I if history of MI.)
Diabetes: Preliminary Draft
Review of Diagnosis of Diabetes:
American Diabetes Association Criteria for the Diagnosis of Diabetes
A1C ≥6.5%. The test should be performed in a laboratory using a method that is NGSP certified
and standardized to the DCCT assay.*
OR
2. FPG ≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*
OR
3. Two-hour plasma glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT. The test should be
performed as described by the World Health Organization, using a glucose load containing the
equivalent of 75 g anhydrous glucose dissolved in water.*
OR
4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma
glucose ≥200 mg/dl (11.1 mmol/l).
*In the absence of unequivocal hyperglycemia, criteria 1–3 should be confirmed by repeat testing.
http://care.diabetesjournals.org/content/33/Supplement_1/S62.full.pdf#page=1&view=FitH
1.
14
Notes on above criteria:
 Hemoglobin A1C and 2-hour OGTT are not readily available on the brigades and therefore,
except in specific instances, a fasting glucose is the preferred method.

On brigades, finger stick glucose (a.k.a. whole blood glucose) is used in place of plasma
glucose.
Screening for Diabetes:
ADA Criteria for testing for diabetes in asymptomatic adult individuals
1 Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and have
. additional risk factors:
o physical inactivity
o first-degree relative with diabetes
o members of a high-risk ethnic population (e.g., African American, Latino, Native
American, Asian American, Pacific Islander)
o women who delivered a baby weighing >9 lb or were diagnosed with GDM
o hypertension (≥140/90 mmHg or on therapy for hypertension)
o HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 mg/dl
(2.82 mmol/l)
o women with polycystic ovary syndrome
o A1C ≥5.7%, IGT, or IFG on previous testing
o other clinical conditions associated with insulin resistance (e.g., severe obesity,
acanthosis nigricans)
o history of CVD
2 In the absence of the above criteria, testing diabetes should begin at age 45 years
.
3 If results are normal, testing should be repeated at least at 3-year intervals, with consideration of
. more frequent testing depending on initial results and risk status.
*At-risk BMI may be lower in some ethnic groups.
http://care.diabetesjournals.org/content/33/Supplement_1/S11/T4.expansion.html
Modifications of above criteria for brigades:

Using the criteria above, the patient population served by the brigades is considered a high risk
ethnicity (based on the definition of Latino.) However, these screening criteria apply largely to
patients living in the United States and does not necessarily mean that all patients of the noted
ethnicities are at high risk. For example, patients in the community of Xeabaj in Guatemala have
very little exposure to the western diet and lifestyle that has played a major role in the increased
incidence of diabetes. Therefore the decision to screen patients should be based on the presence of
other risk factors as well.

Measurements of cholesterol, triglycerides, and HgB A1c are not readily available for patients
and should be considered only in very specific cases.

For the purposes of this brigade, the following patients should be screened with a fasting finger
stick glucose (or random finger stick glucose when fasting is not possible):
o Known history of diabetes
o Symptoms suggestive of diabetes
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o A BMI>25 and one of the following:
 A strong family history of diabetes
 HTN
 History of CVD
 Severe obesity and/or acanthosis nigracans
 History of GDM and/or an infant with birthweight > 9lbs
Treatment of Diabetes:
New Diagnosis:
o Most patients with suspected or newly diagnosed diabetes may be initially counseled on lifestyle
modifications and followed up at the next brigade. This includes patients who have a first-time
fasting blood glucose level of >126 (remember two readings are needed to confirm diagnosis).
o The exception to the above is patients that are severely hyperglycemic and/or symptomatic.
These patients should be started on oral hypoglycemic agents that day and close follow up
should be arranged.
o A patient who is being seen for a repeat finger stick glucose level that has persistent
hyperglycemia (therefore meeting the criteria for diagnosis outlined above) should also be
started on oral hypoglycemic agents as well (again with close follow up arranged).
o Metformin is the initial treatment of choice. Should a patient require a sulfonylurea, symptoms of
hypoglycemia should be clearly discussed with the patient and very close follow up for blood
glucose monitoring arranged.
Chronic treatment:
A patient with a known history of diabetes should be followed closely at every brigade and maintained
on a treatment regimen to maximize glycemic control. Diet and exercise modification should also be
discussed at every brigade. If changes are made to the patient’s previous regimen, this must be clearly
documented in the patient’s chart.
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5. Parasite Therapy Quick Reference Guide
De-worming Protocol
Albendazole Dosing
200mg PO x 1 dose for children aged 12-23 months;
400mg PO x 1 dose for children >2 year of age and adults
Mebendazole Dosing
500mg PO single dose for children >1 year of age and adults
(alternative treatment regimen is 100mg PO BID x 3 days)
Please Note:
1. Children over the age of 1 should be empirically treated every six months. (Prior to
giving medicine, it is important to ensure the patient has not received treatment in the
past six months, either during a previous Timmy brigade or from another source (school,
another medical professional, etc.))
2. Symptomatic adults should be considered for treatment (vs stool testing)
3. Patients who are pregnant or breastfeeding do not receive de-worming treatment.
4. Patients under the age of 1 do not receive de-worming treatment.
5. For very young children, the tablet should be crushed prior to administration
Protozoal Intestinal Infections
*Due to the fairly indistinguishable symptoms of Entamoeba and Giardia Lamblia and
the difficulty of stool testing, we will defer to the higher dose of Metronidazole when
either is suspected in the absence of test results.
Entamoeba
Children
Metronidazole 35-50mg/kg/day divided TID 7-10 days (max 500mg/dose)
Adults:
Metronidazole 500mg PO TID x 7-10 days
Giardia Lamblia
Children
Metronidazole 15mg/kg/day divided TID x 5-7 days (max 250mg/dose)
Adults:
Metronidazole 250mg PO TID x 5-7 days
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