How to manage non-communicable diseases (NCDs), such as diabetes, hypertension, and heart disease, in a shelter setting after flooding and displacement?

Managing Non-Communicable Diseases in Shelter Settings After Flooding

Displaced individuals with NCDs must have immediate access to their medications and medical supplies without interruption, as even brief treatment gaps can lead to life-threatening complications such as severe hypo/hyperglycemia in diabetes or hypertensive crises. 1

Immediate Priorities Upon Shelter Arrival

Medication Continuity and Access

• All patients with NCDs must continue their medications without any interruption upon entering the shelter, as gaps in treatment can precipitate acute decompensation 1
• Establish systems to ensure insulin administration is coordinated with meal timing to prevent dangerous hypo- and hyperglycemia 1
• Work with chain pharmacies that can refill medications based on prescription numbers alone, which is particularly useful when patients lack physical prescriptions 1
• Patients should ideally arrive with disaster kits containing glucose testing supplies, insulin in cool bags, syringes, glucose tabs/gels, and photocopies of medication lists 1

Early Medical Assessment

• All patients with diabetes should have capillary blood glucose (CBG) checked within 1-2 hours of shelter arrival 1
• Each person with NCDs requires a complete medical history and physical examination by a licensed prescriber in a timely manner 1
• Implement policies requiring staff notification of physicians for all CBG results outside specified ranges 1

Essential Shelter Infrastructure for NCD Management

Staffing and Training Requirements

• Shelter staff must be trained to recognize and treat hypo- and hyperglycemia 1
• Designated staff should be trained to administer glucagon for severe hypoglycemia 1
• Health care staff must have adequate knowledge and skills to direct NCD management and patient education 1

Supply and Equipment Access

• Patients and practitioners must have access to all classes of antidiabetic medications, equipment, and supplies without undue controls 1
• Ensure availability of glucose testing strips, lancets, meters, insulin storage with refrigeration, syringes, and emergency supplies 1
• Medical nutrition therapy (MNT) and diabetes self-management education (DSME) should be available 1

Specific Disease Management Protocols

Diabetes Management

• Monitor blood glucose frequently, with frequency determined by individual glycemic control and treatment regimens 1
• Coordinate insulin administration with meal schedules, accounting for potential emergency schedule changes or off-site transport 1
• Provide acetaminophen for fever management, as fever increases metabolic demands and can destabilize glucose control 1

Hypertension and Cardiovascular Disease

• Ensure access to essential medications including amlodipine, atenolol, enalapril, furosemide, hydralazine, hydrochlorothiazide, aspirin, and simvastatin for acute presentations 2
• Glyceryl trinitrate and heparin should be available for acute cardiac events 2

Chronic Respiratory Disease

• Stock beclomethasone, salbutamol, and prednisone for acute exacerbations 2

Critical Challenges and Mitigation Strategies

Infrastructure Resilience

• Public health service infrastructure damage severely jeopardizes access to NCD treatment and care, increasing risk of disease exacerbation or death 3
• Establish telemedicine capabilities to maintain specialist access when infrastructure is damaged 3
• Create treatment and care hubs after disasters for centralized NCD management 3
• Ensure evacuation centers have reliable power for medical equipment like insulin refrigerators and nebulizers 3

Information Systems

• Map people at risk by specific NCD type before disasters occur 3
• Establish mechanisms for sharing patient information between agencies and facilities 3
• Maintain accurate, easily accessible data on people with NCDs to allow adequate disaster preparation 3

Continuity of Care

• Establish clear referral pathways for complications requiring higher-level care 4
• Implement therapeutic patient education and patient self-management programs 4
• Engage community members in health promotion activities 4

Common Pitfalls to Avoid

• Never delay or interrupt NCD medications during shelter transitions - this is the most critical error that leads to preventable morbidity and mortality 1
• Do not wait for complete medical records before initiating treatment - use patient history and prescription numbers to restart medications 1
• Avoid inadequate monitoring of high-risk patients, particularly those with diabetes requiring insulin 1
• Do not assume younger adults are unaffected - NCDs affect all age groups in displaced populations 4
• Never deprioritize NCD care in favor of only acute/communicable disease management - NCDs generate the bulk of ill health and premature death globally 3

Ethical and Equity Considerations

• Individuals with NCDs are particularly vulnerable when health systems are disrupted, making this fundamentally an equity issue 5
• Apply the "do no harm" principle by ensuring treatment continuity rather than creating gaps 4
• Advocate for resource allocation specifically for NCDs, as financing shortfalls have slowed progress 6
• Recognize that the majority of NCD mortality occurs in low- and middle-income countries where disasters frequently occur 4