Role of Clinical Pharmacist in disaster management


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Role of Clinical Pharmacist in disaster management

  1. 1. 1 CONTENTS Introduction Major historical disasters Disasters in Pakistan Phases of Disaster Risks associated with Disaster Dengue Fever Earthquake Flood & water borne diseases Diarrhoea Malaria & its management Cholera Management of Disaster Educational & Awareness programs 1
  2. 2. 2Pharmacist’s role in disaster management INTRODUCTION• Disasters may be the consequence of human intent (terrorism), unintended results of humanactivity (industrial accidents), or natural occurrences.• More often, it is the interaction of human and environmental effects that result in increaseddevastation.• Unintended but contributing consequences of human activity have altered the environmentand increased our vulnerability.• Atmospheric changes increase the probability of a major disaster and altered ecosystems limitnatural defenses resulting in greater destruction.• Human effects on the environment increase both the probability for disasters and ourvulnerability.Types of DisastersVarious disasters like volcanic eruptions, fires, flood, Dengue fever, earthquake, landslides, andcyclones are natural hazards that kill thousands of people and destroy billions of dollars ofhabitat and property each year.• Asia tops the list of casualties due to natural disaster affecting very large areas and populationin the Indian subcontinent and south East Asia yearly. Disasters in PakistanThere was world’s largest migration of human beings in 14 august 1947. There was loss of manythousands of lives in refugee camps due to communicable diseases & other health relatedproblems.Pak-Iran Earthquake 2013On 16April 2013 at 3:44pm there was an earthquake of 7.9 richter scale intensity which causedhuge destruction of economy, infrastructure & life. More than 40 were died in Iran and samewere in Pakistan.Pakistan Floods 2010 So far 2000 people have died in recent floods in Pakistan and over 20 million affected.Pakistan has sought international help to cope with the catastrophe. The risk of water-bornedisease outbreaks increases in many areas.2007 CycloneAt least 730 people died as a result of flash floods triggered by Cyclone , which struck coastalareas in early July 2007. Some 350,000 people were displaced, 1.5 million affected and morethan two million livestock perished. 2
  3. 3. 32005 Kashmir Quake A 7.6-Richter scale quake struck the Kashmir region on the India-Pakistan border andparts of northwestern Pakistan on 8 October 2005. According to official figures, at least 73,000people were killed and more than 3.3 million made homeless.2000 Drought At least 1.2 million people in Balochistan were affected by drought, and over 100 died,mostly because of dehydration, according to the government. Millions of animals perished. Thedrought lasted over 10 months.1974 Hunza Earthquake A 6.2 Richter scale quake hit Kohistan and surrounding areas including parts of Swat,Hunza and Kashmir in northern Pakistan in 1974. About 5,300 people were killed, 17,000injured and 97,000 affected.1970 East Pakistan Cyclone The Bhola tropical cyclone struck the territory in 1970 was the deadliest tropical cycloneever recorded and is rated as one of the worst natural disasters in modern times. Up to 500,000lost their lives.1950 Floods Monsoon rain in 1950 killed an estimated 2,900 people across the country. PunjabProvince, including the city of Lahore, was among the worst hit when the River Ravi flooded.Over 100,000 homes were destroyed, leaving around 900,000 people homeless.1935 Quetta Quake: A 7.7 Richter scale earthquake virtually leveled the city of Quetta in the province ofBalochistan. About 60,000 people were killed in one of the deadliest earthquakes to hit SouthAsia. The epicenter was about 153km from Quetta. The Phases of a Disaster• There are 3 phases of the disaster response:– preevent planning.–responce to the event.– postevent restoration.• The aim of each phase is to optimize the response and reduce potential losses.Pre-event Phase:Planning and Prevention• The pre-event phase is defined by anticipation, planning, and training for potentialadversities.• We must continually rethink both the estimation of the risk and our response to it to ensure areliable response and we must expect setbacks and have contingency plans to counteract them. 3
  4. 4. 4• The primary objective of this phase of the disaster response is vulnerability reduction.• Long before the event, risks are identified and defined, preventative measures are attempted;and response plans are developed and practiced.• This phase revolves around a comprehensive risk assessment and measures of risk reduction,the basic concept behind disaster mitigation.• Simply put, preparation reduces both the likelihood and consequences of disasters.• The cornerstone of disaster preparation is an estimation of risk- It is not feasible to plan forevery contingency of every possible threat.• Pre-event planning must account for cost effectiveness and balance the allocation ofresources for improbable events versus the risks of not being prepared• Integration and Forming a Disaster Network.Event Phase:The Pharmaceutical Care Response• While the plans for the disaster response are detailed during the pre-event phase, they mustbe properly executed to achieve the goals of disaster mitigation.• Disasters may strike with little or no warning and cause damages that limit or prevent an aidresponse.• Despite adequate preparation, these events can easily overwhelm the healthcare system.• A well-developed and executed plan for the delivery of aid, sustenance, and pharmaceuticalcare may be the most useful tool to minimize losses and preserve lives.• The healthcare community must be familiar with local and federal disaster management plansas it will be called upon to be the first line of care during these situations.• The medical responsemay involve multiplesimultaneous threats.• However, while simultaneous events may occur it is more likely that one disaster will resultinsecondary events.• For example, the destruction of a hurricane may cause damage to an industrial plant or toxinstorage facility.Post event Phase: Restoration• Ongoing mitigation efforts must be continued even after resolution of the event and itsaftermath.• The recovery process needs to start immediately to restore normalcy and function as quicklyas possible.• In this phase, the affected community must be rebuilt and efforts made to reduce future risks. Risks associated with Disasters• Flooding, for example, is the most common type, and causes death in Asia.• Flooding may also cause disruption of water treatment and sanitation, resulting in exposureto infectious diseases.• Tornadoes, on the other hand, primarily cause traumatic injuries, and survivors may be mostlikely to suffer from fractures.• Trauma also occurs in earthquakes and tsunamis, although with a different profile.• In addition to fractures, crush injuries with rhabdomyolysis and compression syndromes mayoccur alongside dust inhalation injuries and heat or cold exposure injuries. 4
  5. 5. 5• For communicable diseases, the breakdown of sanitary barriers, crowding at shelters andother elements can enhance spread of disease in any population, although it is most likely andmost problematic in a community with previous endemicity.Management in different disasters under the supervision of Pharmacist are following: Dengue FeverDengue fever is a dangerous disease which is caused by a mosquito bite. Dengue fever iscurrently spreading very rapidly throughout the country. Its first occurrence was discovered in1994 in Karachi. Since then, it has been spreading all over the country rapidly. According to asurvey conducted by the World Health Organization, there were 4800 victims of Dengue Feverin 2006 and 50 deaths had occurred because of it. In Lahore, Dengue Fever hit the city in 2007.Since 2012, 5lakh people were affected by Dengue fever & 378 were died according to TimeNews Report. Today, it has spread to all the regions of the country.Dengue fever is a tropical disease. The question is how did this disease spread to Pakistan? InUSA, this disease first started spreading from the coastal regions in areas where stagnant waterwas found in imported goods. Dengue Fever spread in Karachi in the same way due to stagnantwater found in different imports. Goods are transported from Karachi to all parts of thecountry. This is how this disease spread to other regions of Pakistan.Dengue fever is caused by any one of four related viruses (DENV 1, DENV 2, DENV 3, andDENV4) transmitted by mosquitoes. Aedesaegypti mosquito is the most important vector(transmitter) of dengue viruses.Signs and symptomsDengue virus: Dengue virus can be Asymptomatic 80% with mild symptoms of fever &incubation period is 3-14 days. It has two types  dengue hemorrhagic fever (DHF) (Symptoms are bleeding, low level of platelets & plasma)  dengue shock syndrome (DSS). (Main feature is Low blood pressure)The principal symptoms of dengue fever (DF):High fever, severe headache, severe pain behind the eyes, joint pain, muscle and bone pain(hence the name "break bone fever"), rash & mild bleeding (e.g., nose or gums bleed, easybruising).Leukopenia (a decrease in white blood cells) is usually observed. Clinical features ofthe dengue rash include bright red petechiae (small skin hemorrhages) that typically appearfirst on the lower limbs and the chest. Eventually, the rash spreads to the rest of the body. 5
  6. 6. 6Infants, younger children, and those with their first dengue infection typically have less severesymptoms than older children and adults.Four Different Stages of Dengue Fever In the first stage, an individual falls prey to severe fever. All the above mentioned signs and symptoms begin to appear. During the second stage of the disease, a patient’s skin, intestines and gums start bleeding while the above mentioned symptoms also prevail. The patient’s blood circulatory system is adversely affected in the third stage. In the fourth and final stage, the patient suffers from unbearable pain and ailments.Treatment & management:There is no specific medication or treatment for dengue fever. Supportive care is the onlyknown effective therapy. Adequate hydration and blood pressure control are essential inpatients with dengue fever. Analgesics (pain relievers) with acetaminophen & paracetamole should be used for fever control.Nonsteroidal anti-inflammatory medications (NSAIDs) such as aspirin and ibuprofen should not be used, as these agents may further hinder platelet function (elements needed for blood clotting) and hemorrhagic fever (DHF). Usually requires hospitalization. Supportive care by intravenous fluids and oxygen are typically administered increase the risk of bleeding. Preventory Measures: Don’t drop waste into drain Clear blocked drain if any Dengue mosquito live in clean water, so check flush tanks and if required Dispose empty cane, coconut shell, bottles, old tires etc Ensure no water is stagnant in pots Children attending morning school should be cautioned, when waiting for school bus as these mosquito usually at dawn and dusk Mosquitoes can be repelled by following sprays 1. Organo phosphate spray 2. Pyriethroid 3. N,N-diethyl-3-methylbenzamide (DEET)–mosquito repellent spray 6
  7. 7. 7Fever ComplicationsThe complications of dengue fever are usually associated with the more severe forms of denguefever, hemorrhagic and shock syndrome. The most serious complications, although infrequent,are as follows:  dehydration;  bleeding (hemorrhage);  low platelets;  low blood pressure (hypotension);  bradycardia;  liver damage;  neurological damage (seizures,encephalitis)  death.Psychological Management:• For each of these specific hazards, the psychosocial effects will create an additional area ofsignificant healthcare needs.• After any major disaster, an increased need for treatment of anxiety, posttraumatic stressdisorder, neuroses, and depression can be expected• Usage of drugs in these situation is unavoidable.• Reviewing the drug supply and dosage used in specific situation: diabetes, cardiac problems,pediatrics population etc.• Education for the residents on sanitation, nutrition, personal hygiene, life skills.• Prevention of respiratory tract infections• Prevention of diarrheal diseases• Educating on Women’s health issues.What can be done to overcome the problem?• Prepare the pharmacists with disaster management & train them.• At academic level introduce the disaster management into the syllabus.• Team work with other healthcare providers. EarthquakeAn earthquake is a sudden, rapid shaking of the ground caused by the breaking and shifting ofrock beneath the Earths surface. This shaking can cause buildings and bridges to collapse; 7
  8. 8. 8disrupt gas, electric, and phone service; and sometimes trigger landslides, avalanches, flashfloods, fires, and huge, destructive ocean waves (tsunamis). Earthquakes can occur at any timeof the year. Hazards associated with earthquakesWhen an earthquake occurs in a populated area, it may cause deaths and injuries and extensiveproperty damage. Ground movement during an earthquake is seldom the direct cause of deathor injury. Most earthquake-related injuries result from collapsing walls, flying glass, and fallingobjects as a result of the ground shaking, or people trying to move more than a few feet duringthe shaking. Much of the damage in earthquakes is predictable and preventable.Because earthquakes frequently affect populous urban areas with poor structural standards,they often result in high death rates and mass casualties with many traumatic injuries. Theseinjuries are highly mechanical and often multisystem, requiring intensive curative medical andsurgical care at a time when the local and regional medical response capacities have been atleast partly disrupted. Many patients surviving blunt and penetrating trauma and crush injurieshave subsequent complications that lead to additional morbidity and mortality.Earthquakes have caused over 780,000 deaths in the past decade alone, accounting for nearly60% of all disaster-related mortality, and in 2004, the tsunami crisis claimed over 200,000 lives. AftershocksAftershocks are smaller earthquakes that follow the main shock and can cause further damageto weakened buildings. After-shocks can occur in the first hours, days, weeks, or even monthsafter the quake. Be aware that some earthquakes are actually foreshocks, and a largerearthquake might occur. Pharmacist’s Role In EarthquakePharmacist can educate people to prevent from earthquake complications.  Pick "safe places". A safe place could be under a sturdy table or desk or against an interior wall away from windows and bookcases, or tall furniture that could fall on you. The shorter the distance to move to safety, the less likely you will be injured. Injury statistics show that people moving as little as 10 feet during an earthquakes shaking are most likely to be injured.  Practice drop, cover, and hold-on in each safe place. Drop under a sturdy desk or table and hold on to one leg of the table or desk. Protect your eyes by keeping your head down. Practice these actions so that they become an automatic response.  Practice drop, cover, and hold-on at least twice a year. Frequent practice will help reinforce safe behavior. When an earthquake or other disaster occurs, many people hesitate, trying to remember what they are supposed to do. Responding quickly and automatically may help protect you from injury.  Wait in your safe place until the shaking stops, then check to see if you are hurt. You will be better able to help others if you take care of yourself first, then check the people around you. Move carefully and watch out for things that have fallen or broken, creating hazards. Be ready for aftershocks. 8
  9. 9. 9  If you must leave a building after the shaking stops, use the stairs, not the elevator. Earthquakes can cause fire alarms and fire sprinklers to go off. You will not be certain whether there is a real threat of fire. As a precaution, use the stairs.  If youre outside in an earthquake, stay outside. Move away from buildings, trees, streetlights, and power lines. Crouch down and cover your head. Many injuries occur within 10 feet of the entrance to buildings. Bricks, roofing, and other materials can fall from buildings, injuring persons nearby. Trees, streetlights, and power lines may also fall, causing damage or injury.  Inform workers of the plan. Everyone in your workplace should know what to do if an earthquake occurs.  Get training. Take a first aid class from your local Red Cross chapter. Get training on how to use a fire extinguisher. Keep your training current. Training will help you to keep calm and know what to do when an earthquake occurs.  Discuss earthquakes with workers. Everyone should know what to do. Discussing earthquakes ahead of time helps reduce fear and anxiety and lets everyone know how to respond. Flood & Water borne diseasesIntroductionThe epic flood of 2010 has taken hundreds of lives and devastated tens of thousands of homes.Millions of people have been displaced and the landscape remains ravaged. An onslaught ofinfectious diseases is expected to further add to morbidity and mortality. Massive dislocationof a population may lead to an increase in disease transmission. Populations may move intoareas where pathogens exist, to which the immigrants have no specific immunity. Evacuation tocamps following mass migration or loss of housing is particularly dangerous from an infectiousdisease perspective. Refugee camps tend to combine high population density and poor sanitaryconditions , a perfect prescription for fecal -oral , airborne droplet and skin infections bycontact of disease pathogens. Environmental changes result in fresh invasion by animals andvectors. Well-meaning groups or individuals are trying to help prevent and treat diseases butthe efforts are in isolation and uncoordinated. Under uncontrolled conditions medicines,antimicrobials especially tend to be given away without understanding the basics or principlesof their rational use. The Infectious Diseases Society of Pakistan (IDSP) has collectively writtenthese recommendations in consultation with WHO guidelines while keeping in view endemicityof diseases in our local population, cost effectiveness of preventive and treatment modalities,and practicality of drug dispensation.Diagnoses in calamity situations are at best presumptive under circumstances where laboratoryconfirmation is nonexistent; judgments must be made on clinical grounds while over treatmentshould be considered erroneous as much as under treatment or negligence. At the same time 9
  10. 10. 10wastage of precious resources should be minimized. A balance between need and delivery isessential for optimum success in health care.The term "waterborne disease" is reserved largely for infections that predominantly aretransmitted through contact with or consumption of infected water. Trivially, many infectionsmight be transmitted by microbes or parasites that accidentally, possibly as a result ofexceptional circumstances, had got into water, but the fact that there might be an occasionalfreak infection need not mean that it is useful to categorise the resulting disease as"waterborne". Nor is it common practice to refer diseases such as malaria as "waterborne" justbecause mosquitoes have aquatic phases in their life cycles, or because treating the water theyinhabit happens to be an effective strategy in control of the mosquitoes that are the vectors.Microorganisms causing diseases that characteristically are waterborne, prominently includeprotozoa and bacteria, many of which are intestinal parasites, or invade the tissues orcirculatory system through walls of the digestive tract. Various other waterborne diseases arecaused by viruses. Some most common diseases in related to flood outcome are as following. DIARRHOEADiarrhoea is defined as an increased frequency of bowel evacuation, with the passage ofabnormally soft or watery faeces. The basis of treatment is electrolyte and fluid replacement; inaddition, antidiarrhoeals are useful in adults and older children.Symptoms:Some sufferers may pass slightly watery stools and have brief episodes of stomachache, whileothers may pass very watery stools and have more severe stomach cramping. The mostcommon symptoms include: Abdominal cramps  Abdominal pain  Vomiting  Nausea  Temperature (fever)  Headache  Loss of appetite  Fatigue  Loose, watery stools  Bloating  Blood in stool EtiologyAll Waterborne diseases are caused by pathogenic microorganisms that most commonly aretransmitted in contaminated fresh water that is most common in case of flood . According to 10
  11. 11. 11the World Health Organization, such disease account for an estimated 4.1% of the total globalburden of disease, and cause about 1.8 million human deaths annually. The World HealthOrganization estimates that 88% of that burden is attributable to unsafe water supply, lowsanitation and poor hygiene which is usually an outcome of flood.The etiology of diarrhoea depends upon its cause.Acute gastroenteritis, the most common cause of diarrhoea in all age groups, is usually viral inorigin. Commonly implicated viruses are the rotavirusthe Norwalk virus and the Norwalk-like virus.Rotaviruses are the most common cause of diarrhoea in children under the age of 2.Bacterial causes, for example:Shigella and Salmonella species are invasive, penetrating the mucosa of the small intestinenormally a result of eating contaminated food or drink such as in flood. Role of PharmacistHe should provide suitable home fluids immediately upon onset of diarrhoea in a child  Treat dehydration with ORS solution (or with an intravenous electrolyte solution in cases of severe dehydration)  Emphasize continued feeding or increased breast- feeding during, and increased feeding after the diarrhoeal episode  Use antibiotics only when appropriate, i.e. in the presence of bloody diarrhoea or shigellosis, and abstain from administering anti-diarrheal drugs ManagementOral rehydration therapy:The risk of dehydration from diarrhoea is greatest in babies, and rehydration therapy isconsidered to be the standard treatment for acute diarrhoea in babies and young children. Oralrehydration sachets may be used with antidiarrhoeals in older children and adults. Rehydrationmay still be initiated even if referral to the doctor is advised.Other therapy:Loperamide: Loperamide is an effective antidiarrhoeal treatment for use in older children andadults. When recommending loperamide the pharmacist should remind patients to drink plentyof extra fluids. Oral rehydration sachets may be recommended. Loperamide may not berecommended for use in children under 12 years.Kaolin: Kaolin has been used as a traditional remedy for diarrhoea for many years. Its use wasjustified on the theoretical grounds that it would absorb water in the GI tract and would absorbtoxins and bacteria onto its surface, thus removing them from the gut. 11
  12. 12. 12 Malaria & its Managementa mosquito-borne infectious disease of humans and other animals caused by Plasmodium. Itbegins with a bite from an infected female Anopheles mosquito, which introduces theplasmodium through saliva into the circulatory system. In the blood, it travels to the liver tomature and reproduce. Malaria causes symptoms that typically include fever and headache,which in severe cases can progress to coma or death. The disease is widespreadin tropical and subtropical regions in a broad band around the equator, including much of Sub-Saharan Africa, Asia, and the Americas. Malaria is prevalent in tropical and subtropical regionsbecause flood, rainfall, warm temperatures, and stagnant waters provide habitats idealfor mosquito larvae.The World Health Organization has estimated that in 2010, there were 219 million documentedcases of malaria. That year, between 0.6-1.2 million people died from the disease (roughly2000–3000 per day). The actual number of deaths is not known with certainty, as accurate datais unavailable in many rural areas, and many cases are undocumented. Malaria is commonlyassociated with poverty and may also be a major hindrance to economic development.Signs & symptoms:The signs and symptoms of malaria typically begin 8–25 days following infection. Initialmanifestations of the disease common to all malaria species—are similar to flu-like symptoms.These may include headache, fever, shivering, arthralgia (joint pain), vomiting, hemolyticanemia, jaundice, retinal damage and convulsions.The classic symptom of malaria is paroxysm—a cyclical occurrence of sudden coldness followedby rigor and then fever and sweating.ComplicationsAcute respiratory distress syndrome (ARDS) may develop.Renal failure is a feature of blackwater fever, where hemoglobin from lysedred blood cells leaksinto the urine.Infection with P. falciparum may result in cerebral malaria, a form of severe malaria thatinvolves encephalopathy. Splenomegaly, severe headache, hepatomegaly, hypoglycemia, andhemoglobinuria with renal failure may occur.Malaria in pregnant women is an important cause of stillbirths, infant mortality and low birthweight. 12
  13. 13. 13CauseMalaria parasites belong to the genus Plasmodium. In humans, malaria is causedby P. falciparum, P. malariae, P. ovale, P. vivax and P. knowlesi (very rare). Among thoseinfected, P. falciparum is the most common species identified (~75%) followedby P. vivax (~20%).Life cycleIn the life cycle of Plasmodium, a female Anopheles mosquito transmits a motile infective form(called the sporozoite) to a vertebrate host such as a human, thus acting as atransmission vector. A sporozoite travels through the blood vessels to liver cells (hepatocytes),where it reproduces asexually (tissue schizogony), producing thousands of merozoites. Theseinfect new red blood cells and initiate a series of asexual multiplication cycles (bloodschizogony) that produce 8 to 24 new infective merozoites, at which point the cells burst andthe infective cycle begins anew. Other merozoites develop into immature gametes, orgametocytes. When a fertilised mosquito bites an infected person, gametocytes are taken upwith the blood and mature in the mosquito gut. The male and female gametocytes fuse andform zygotes, which develop into new sporozoites. The sporozoites migrate to theinsects salivary glands, ready to infect a new vertebrate host. The sporozoites are injected intothe skin, alongside saliva, when the mosquito takes a subsequent blood meal. Malaria parasitescan also be transmitted by blood transfusions, although this is rare.Recurrent malariaSymptoms of malaria can reappear after varying symptom-free periods. Depending upon thecause, recurrence can be classified as either recrudescence, relapse, or reinfection.Recrudescence is when symptoms return after a symptom-free period. It is caused by parasitessurviving in the blood as a result of inadequate or ineffective treatment. Relapse is whensymptoms reappear after the parasites have been eliminated from blood but persist asdormant hypnozoites in liver cells. Reinfection means the parasite that caused the pastinfection was eliminated from the body but a new parasite was introduced. Reinfection cannotreadily be distinguished from recrudescence, although recurrence of infection within twoweeks of treatment for the initial infection is typically attributed to treatment failure.DiagnosisMalaria is usually diagnosed by the microscopic examination of blood films or by antigen-based rapid diagnostic tests (RDT). Microscopy is the most commonly used method to detectthe malarial parasite. Despite its widespread usage, diagnosis by microscopy suffers from two 13
  14. 14. 14main drawbacks: many settings are not equipped to perform the test, and the accuracy of theresults depends on both the skill of the person examining the blood film and the levels of theparasite in the blood. The sensitivity of blood films ranges from 75–90% in optimum conditions,to as low as 50%. Commercially available RDTs are often more accurate than blood films atpredicting the presence of malaria parasites, but they are widely variable in diagnosticsensitivity.PreventionMethods used to prevent malaria include medications, mosquito elimination and theprevention of bites. The presence of malaria in an area requires a combination of high humanpopulation density, high mosquito population density and high rates of transmission fromhumans to mosquitoes and from mosquitoes to humans. If any of these is lowered sufficiently,the parasite will eventually disappear from that area,. However, unless the parasite iseliminated from the whole world, it could become re-established if conditions revert to acombination that favours the parasites reproduction. I. For individual protection, the most effective chemical insect repellents as DEET and picaridin. II. Insecticide-treated mosquito nets (ITNs) and indoor residual spraying (IRS) have been shown to be highly effective vector control. III. Education can also inform people to cover over areas of stagnant, still water, such as water tanks that are ideal breeding grounds for the parasite and mosquito, thus cutting down the risk of the transmission between people.ManagementThe treatment of malaria depends on the severity of the disease. The most effective strategyfor P. falciparum infection is the use ofartemisinins in combination with other antimalarials(known as artemisinin-combination therapy, or ACT).Artemether (Availability: 80 mg/ml Inj)Arteether (Availability: 150mg/2 ml injection)Fansidar can be used both prophylacticaly & for treatment of malaria & many others. CholeraCholera is an intestinal infection caused byVibrio cholerae . Cholera can be endemic, epidemic,or pandemic. cholera is transmitted by the fecal-oral route. In the United States and otherdeveloped countries, because of advanced water and sanitation systems, cholera is not a majorthreat but in Pakistan due to flood it is common. 14
  15. 15. 15Historical backgroundThe discovery of the cholera organism is credited to German bacteriologist Robert Koch, whoindependently identified V cholerae in 1883 during an outbreak in Egypt.EtiologyCertain environmental and host factors appear to play a role in the spread of V cholerae.Environmental factorsV cholerae is a saltwater organism, and its primary habitat is the marine ecosystem where itlives in association with plankton.Cholera has 2 main reservoirs, humans and water.Primary infection in humans is incidentally acquired. Risk of primary infection is facilitated byseasonal increases in the number of organisms,Secondary transmission occurs through fecal-oral spread of the organism through person-to-person contact or through contaminated water and food.Host factorsMalnutrition increases susceptibility to cholera.Infection rates of household contacts of cholera patients range from 20-50%.Clinical presentationAfter a 24- to 48-hour incubation period, symptoms begin with the sudden onset of waterydiarrhea often followed by vomiting. The patient may experience abdominal cramps.An estimated 5% of infected patients will develop cholera gravis, i.e, severe watery diarrhea,vomiting, and dehydration. patients with cholera have frequent and often uncontrolled bowelmovements. The characteristic cholera stool is an opaque white liquid that is not malodorousand often is described as having a “rice water” appearance.VomitingVomiting, although a prominent manifestation, may not always be present. Early in the courseof the disease, vomiting is caused by decreased gastric and intestinal motility; later in thecourse of the disease it is more likely to result from acidemia.Dehydration:If untreated, the diarrhea and vomiting lead to isotonic dehydration, which canlead to acute tubular necrosis and renal failure. In patients with severe disease, vascularcollapse, shock, and death may ensue. Dehydration can within hours after the onsetsymptoms. Sensorium Eyes Thirst Skin Pinch DecisionAbnormally sleepy Sunken Drinks poorly Goes back very If the patient has 2 or more of or lethargic or not at all slowly (>2 sec) these signs, severe dehydration is present Patient has no Sunken Drinks eagerly Goes back If the patient has 2 or dehydration slowly (< 2 sec) more signs, some dehydration is present Well, alert Normal Drinks Goes back normally, not quickly 15
  16. 16. 16 thirstyTreatment and managementRehydration is the first priority in the treatment of cholera. Rehydration is accomplished in 2phases: rehydration and maintenance.The goal of the rehydration phase is to restore normal hydration status, which should take nomore than 4 hours. Set the rate of intravenous infusion in severely dehydrated patients at 50-100 mL/kg/hr. Lactated Ringer solution is preferred over isotonic sodium chloride solutionbecause saline does not correct metabolic acidosisThe goal of the maintenance phase is to maintain normal hydration status by replacing ongoinglosses. The oral route is preferred, and the use of oral rehydration solution (ORS) at a rateof 500-1000 mL/hr is recommended.Composition of ORSchloride – 65 mmol/LPotassium – 20 mmol/LBicarbonate – 30 mmol/LGlucose – 111 mmol/LAntibiotic TreatmentAntibiotic treatment is indicated for severely dehydrated patients who are older than 2years.this treatment should start after the patient has been rehydrated and vomiting hasstopped.Antibiotic Single Dose (PO)Doxycycline† 7 mg/kg; not to exceed 300 mg/dose‡Trimethoprim Not evaluatedSulfamethoxazoleCiprofloxacin§ 30 mg/kg; not to exceed 1 g/dose‡Ampicillin Not evaluated Management of Disaster• Disasters impact our health, community, and economy, they devastate the environment andsignificantly disrupt our daily life.• The fundamental goals of disaster mitigation are to understand and define the threat, limitour vulnerabilities, prevent the occurrence when possible, and minimize the effects and losseswhen they arise.• Aids from all over the world reached the site with millions of USD in term of medication 16
  17. 17. 17• Doctor, nurses, Pharmacist & other volunteers.• But where is the pharmacists?He can play role inDrugs – a lot of almost expired or expired drugsPharmacotherapychoiceof drugs for specificconditionsPharmacokineticsNot even focus due to lack of expertise.• Many healthcare providers mainly doctors and nurses contributed significantly during thecatastrophe.• Unfortunately the role of pharmacist remains unclear, So far the involvement of pharmacistsin this issue seems to be almost none• Contribution of pharmacist’s expertise should be there, as in most disasters, drugs are beingused regularly and the counseling during such event almost not exist.Pharmacy system during disaster:• Pharmacy service set up during the event usually consists of:• Mobile pharmacy and temporary pharmacy related services.• Distribution of drugs and related medical care.• Educate the community on health, hygiene, and wellbeing.• Mental health assessment and community characteristic.• Quality of therapy would be increased with intervention from pharmacists.Limited Ability of Health Care System to Respond• During disasters, the demand for healthcare will rapidly increase and likely exceed thecapacity the local community.• At the same time, there will be loss of infrastructure further limiting the ability to meet thisincreased demand.• Healthcare providers are, in themselves, a limited resource and there is a shortage of doctors,pharmacists and nurses, especially in critical care.During disasters, especially in emerginginfectious diseases, healthcare workers (HCW) may be disproportionately affected.• Disasters both increase the demand for healthcare and limit our ability to provide it.• The effect on the infrastructure reduces the medical response and increases our susceptibilityto future events. Educational & Awareness programsFor the management of natural as well as disasters relating to human activities, pharmacist canplay very critical role. Directly or indirectly all the disasters are result of human deeds & hisactivities.  Pharmacist should arrange seminars & awareness programs to prevent many such incidents. He can educate people to stop frequent cutting of plants & forests for industries and housing facilities and he should encourage people to grow more trees & thus by forestation pollution can be easily controlled. Forestation can overcome the increased level of global warming gases e.g carbon dioxide and thus its outcome will be decrease in green house effect and global warming and the most common cause of flood would also be minimized. 17
  18. 18. 18  Due to global warming there is fluctuation in the temperature of almost all the regions in biosphere and there is chance for the insects & other pathogens to colonize the areas where these pathogens were not present in past. Pharmacist should acknowledge this issue to the authorities. He should also highlight these issues globally to prevent our global village from disasters.  Pharmacist should also highlight the risks associated with the use of Chloroflorocarbons (CFC) as refrigerants.  Pharmacist should aware the people to adopt healthy lifestyle & to control over pollution specially radiation pollution as occurred during tsunami in Japan & causing Nuclear power station damage and thus affecting a massive life in the region. Pharmacist should aware people and authorities about the risks associated with Nuclear power as source of energy because waste management is very low and it can ruin the whole world.Conclusion• Recent events have reminded us that disasters, both natural and manmade, can and willoccur, often with little or no warning.• There exists a real threat and pharmacists must be prepared to provide a competent responseand mitigate potential losses.• Previous events and the threat of future disasters reinforce the fundamental need forpharmacists preparedness- Disasters are inevitable, predictable, and expected; we must beready to face them. REFERENCES  Federal Emergency Management Agency (FEMA)  World Confideration for Physical management  Clinical Pharmacy & Therapeutics by Roger Walker.  Pharmaceutical practice by A.J Winfield  Web Search 18