International Maritime Health, Vol. 68, No. 1, 2017

ORIGINAL PAPER

Identification of World Health Organisation ship’s medicine chest contents by Anatomical Therapeutic Chemical (ATC) classification codes

Seyed Khorsow Tayebati1, Giulio Nittari1, Syed Sarosh Mahdi, Nicholas Ioannidis2, Fabio Sibilio3, Francesco Amenta1, 3

1Telemedicine and Telepharmacy Centre University of Camerino, Camerino, Italy

2Ship Medical Ltd., Athens, Greece

3Research Department, International Radiomedical Centre (CIRM), Rome, Italy

Prof. Francesco Amenta, Centro Telemedicina e Telefarmacia, Università di Camerino, Via Madonna delle Carceri, 9, 62032 Camerino, Italy, e-mail: FAmenta@gmail.com

Paper presented at the Meeting “The Way Forward of Maritime Telemedicine” held in Rome on October 30–31, 2015 as an activity on the occasion of celebrations for the 80th anniversary of Centro Internazionale Radio Medico (CIRM).

Abstract

Background: Ships should carry mandatory given amounts of medicinal products and basic first aid items, collectively known as the ship’s medicine chest. Type and quantities of these products/items are suggested by the World Health Organisation (WHO) and regulated by individual flag states. In countries that lack national legislation, it is assumed that ships should follow WHO indications. An objective difficulty mainly involving vessels of international long-haul routes could be to recognise medicinal compounds obtained in other countries for replacing products used or expired. Language barrier may complicate, if not make it impossible to interpret the name of the medicinal product and/or of the active principle as indicated in a box printed in a completely different language. Handling of the ship’s pharmacy may be difficult in case of purchasing of drugs abroad due to language barriers. Medicinal products are identified by the international non-proprietary name of the active principle and/or by their chemical or invented (branded) names. This may make the identification of a medicinal product difficult, primarily if it is purchased abroad and the box and instructions are written in the language of the country where it is marketed. Therefore, there is a simpler classification system of the medicinal compounds the ATC (ATC: Anatomy, Therapeutic properties, Chemical, pharmacological properties). This paper has reviewed the list of medicinal products recommended by WHO and assigned to each one the ATC code as a solution to the problem of medicinal compounds organisation.

Materials and methods: Two researchers independently examined the list of medicinal compounds indicated in the third edition of the International Medical Guide for Ships and attributed to each compound the ATC code according to the 2013 Guidelines for ATC classification and Defined Daily Dose (DDD) assignment.

Results: The ATC code was attributed to the medicinal compounds indicated in the third edition of the International Medical Guide for Ships.

Conclusions: The availability of an objective system to identify medicinal products is required for ships, which will contribute in making the identification of items purchased simpler, making it easier to understand which drug seafarers need to be administer, and consequently reduce possible therapeutic mistakes.

(Int Marit Health 2017; 68, 1: 39–45)

Key words: ATC code, medicine chest, ship’s pharmacy, identification of medicinal compounds

Introduction

The provision of good quality medical care for people on board seagoing vessels still represents a challenge for medicine as the majority of vessels do not have a doctor or adequately trained paramedic personnel on board. On the other hand, ships are at sea for days or weeks before they can reach a port. In this situation, the best possibility for treating diseases or injuries is to provide medical advices via telecommunication systems, to guarantee adequate training of personnel with the responsibility of health care on board and to have an adequate supply of medicinal products and medication items [1, 2]. Medicines and medical equipment available on board of a ship constitute the so-called “medicine chest”. Although, at present, in larger ships the medicine chest is no longer a chest, but rather a small pharmacy with a variety of medicinal products and medical devices, the name has remained in memory of the box containing some of the therapeutic aids of the past, that was kept on board, centuries ago by the captain, paramedics or physicians. The United States of America were probably the first country to mandate in 1790, that every American flag vessel over 150 tons with a crew of ten should to carry a medicine chest [3]. In the nineteenth century, probably in relation to the significant increase in maritime traffic, various states began to regulate the matter of hygiene on board ships. Some countries started to prescribe the presence of a medicine chest on ships. International regulations were introduced with the international health conference held in Paris at the end of 1851 [4]. This meeting lead to an agreement in force of which the contracting states undertook to check the hygienic condition of the vessels, the food ration, the health of the crew, and the presence of the “chest for medicinal products” with, attached, instructions for their use [4]. In a global world and taking into account that shipping is per se an international activity, the best solution is to approach the problem of the provision of the medical chest with a global view and commence efforts for the harmonisation of the contents of the ship pharmacy as much as possible. Ships should carry compulsorily given amounts of medicinal products and medication items. Type and quantities of these products/items are established by flag state regulations. The first attempt to address the problem of providing international ships with a minimum supply of medicinal products and medication items come from the World Health Organisation (WHO). In collaboration with the International Labour Office (ILO) WHO published in 1967, the first edition of the International Medical Guide for Ships with a final appendix in which the minimum provision of medicinal products required to be on board of all the world’s ships was indicated. This list was updated in 1988 with the second edition of the International Medical Guide for Ships [5] and in 2008, with the third and last edition of the same book [6, 7]. Lacking national regulations, it is assumed that ships should follow WHO indications. Besides the discussion on the quality and quantity of medicines and medication items should be available on board ships [8], another practical problem especially for vessels involved in international long-haul routes could be to recognise medicinal products obtained in other countries for replacing products utilised or expired. Language barrier may complicate, if not make it impossible to interpret the name of the medicinal product and/or of the active principle as indicated in a box printed, in a completely different language. This is due to lack of a precise indication system to recognise the same pharmaceutical product in any part of the world. This is why the best solution of this problem could be the use, for the contents of ship medical chest, an accurate indication system such as the ATC code (The Anatomical Therapeutic Chemical Classification System) [9, 10]. The ATC is a classification system of drugs maintained by the Nordic Council on Medicine and WHO/WHO Collaborating Centre for Drug Statistics Methodology of Uppsala (Sweden) [9]. In the ATC system drugs are divided into several groups according to the target organ, the mechanism of action and chemical and therapeutic characteristics [11]. In this work we have attributed the ATC code to the medicinal products of the WHO list for making identification and storage of products irrespective of the country where they were obtained, simpler and efficient.

Materials and methods

The ATC classification system is based on the principle that each pharmaceutical product is associated with a single code. The drugs, therefore, must be classified according to their main therapeutic use. In the ATC system the drugs are divided into different groups according to the target organ, the mechanism of action and chemical and therapeutic characteristics [11]. Each main group is divided into five hierarchical levels as detailed in Table 1.

Table 1. The five hierarchical levels of the ATC classification system

Level

Groups

Characteristic

I

The ANATOMIC GROUP

Characterised by a letter of the alphabet

II

GROUP THERAPY

Characterised by a 2-digit number

III

SUB THERAPEUTIC

Characterised by a letter of the alphabet

IV

SUB CHEMICAL/THERAPEUTIC

Characterised by a letter of the alphabet

V

SUB CHEMICAL

Characterised by a 2-digit number specific to each chemical

Based on the target organ of a therapeutic action, the ATC Anatomical Main Group is divided into 14 “Anatomical Main Groups” each indicated by a letter identifying the apparatus or system of organs on which the drug exerts its therapeutic action according to alphabetical order. The categories are listed in Table 2.

Table 2. Categories further dividing the ATC Anatomical Main Group based on the therapeutic action on the target organ

A

Alimentary tract and metabolism

B

Blood and blood-forming organs

C

Cardiovascular system

D

Dermatological

G

Genito-urinary system and sex hormones

H

Hormonal preparations, excluding sex hormones

J

Anti-infectives for systemic use

L

The antineoplastic and immunomodulating agents

M

Musculoskeletal system

N

Nervous system

P

Antiparasitic, insecticides and repellents

R

Respiratory system

S

Sensory organs

V

Various

Two researchers independently (first analysis team) examined the list of medicinal compounds indicated in the third edition of the International Medical Guide for Ships [6] and attributed to each compound the ATC code according to the 2013 Guidelines for ATC classification and Defined Daily Dose (DDD) assignment [11] and the centralised human medicinal product by ATC code of the European Union [12]. A drug, however, can be used for two or more therapeutic indications of equal importance and this leads to different alternatives for its classification. A drug may also be provided in two or more dosages or pharmaceutical forms for different therapeutic uses: the actual therapeutic use in such cases will determine the classification. Preparations that cannot be unequivocally classified in a particular group are coded to a level IV with the letter X. For the classification of such ambiguous cases, two researchers (second analysis team), were involved in the evaluation and allocation of ATC code and in consensus with the first two researchers, and based on the actual main therapeutic use, they were assigned a proper ATC code.

Results

The ATC codes of medicines prescribed by WHO to be made available on board ships are shown divided for therapeutic classes. Table 3 summarises the ATC code for anti-inflammatory, anti-viral, anti-malarial drugs, antibiotic and anti-fungal agents. Table 4 indicates the ATC code for anti-allergic and anti-shock, cardiovascular and nervous system agents.

Table 3. ATC codes for anti-inflammatory, anti-viral, anti-malarial drugs, antibiotic and anti-fungal agents

Generic name

Therapeutic group

Possible trade names

Dosage form

ATC CODE V

Anti-inflammatory drugs

Acetylsalicylic acid

Analgesic, anti-inflammatory

Aspirin, Aspro

Tablet 300 mg

N02BA01

Ibuprofen

Anti-inflammatory, antirheumatic non steroids

Advil, Actifen, Genpril, Haltran, Medipren, Brufen

Coated tablet 400 mg

M01AE01

Paracetamol

Acetaminophen

Anti-fever and antalgic

Tylenol, Panadol

Tablet 500 mg

N02BE01

Hydrocortisone 1% cream

Anti-inflammatory and anti-allergic

NA

Cream

D07AA02

Prednisone

Corticosteroids for systemic use

Prednisolone

Tablet 25 mg

H02AB07

Anti-viral drugs

Aciclovir

Antiviral

Zovirax, Acyclovir

Tablet 400 mg

J05AB01

Zidovudine plus Lamivudine

Antiviral (HIV)

Combivir

Tablet 300 mg + 150 mg

J05AR01

Anti-malarial drugs

Artemether

Anti-malarial

Larither

Ampoule 1 mL = 80 mg

P01BE02

Artemether + Lumefantrine

Anti-malarial

Riamet

Tablets 2 mg + 120 mg

P01BF01

Antibiotic and anti-fungal agents

Amoxicillin + clavulanate

Antibiotic

Augmentin, co-amoxyclav

Tablet 875 mg/125 mg

J01CR02

Azithromycin

Antibiotic

Zithromax

Tablet 500 mg

J01FA10

Ceftriaxone

Antibiotic

Rocephin

Ampoule 1 g powder for injection (dissolve in water for injection)

J01DD04

Ciprofloxacin

Antibiotic

Ciproxin, Cipro

Tablet 250 mg

J01MA02

Mebendazole

Anthelmintic, remedy for intestinal worms

Vermox

Tablet 100 mg

P02CA01

Metronidazole

Antiprotozoal

Flagyl

Tablet 500 mg

P01AB01

Miconazole 2% cream

Antifungal

Daktarin, Dermacure, Monistat

Cream

A01AB09

Tetracycline 1% ointment

Antibiotic

NA

Ointment

S01AA09

Doxycycline

Antibiotic with broad-spectrum antibacterial activity

Neo-Dagracycline, Unidox, Vibra-S, Vibramycine, Doryx

Tablet 100 mg

J01AA01

NA – not available

Table 4. ATC codes for anti-allergic and anti-shock, cardiovascular and nervous system agents

Generic name

Therapeutic group

Possible trade names

Dosage form

ATC CODE V

Anti-allergic and anti-shock agents

Cetirizine

Anti-histaminic, anti-allergic

Zyrtec

Tablet 10 mg

R06AE07

Dexamethasone

Anti-allergic, anti-asthmatic, anti-anaphylactic shock

Decadron

Ampoule 4 mg/mL

H02AB02

Salbutamol

Anti-asthma, anti-chronic bronchitis, anti-emphysema

Albuterol, Ventolin, Proventil

Inhaler 0.1 mg/dose with volume spacer

R03AC02

Cardiovascular agents

Adrenaline

Cardiac stimulants, anti-anaphylactic shock, anti-asthma

Epinephrine, Adrenaline 1:1000

Ampoule 1 mL = 1 mg

C01CA24

Isosorbide dinitrate

Anti-angina and anti-cardiac failure

Cedocard, Isordil

Tablet 5 mg

C01DA08

Metoprolol

Anti-hypertension; anti-atrial fibrillation

Selokeen, Lopresor, Toprol XL, Betaloc

Tablet 100 mg

C07AB02

Nervous system agents

Diazepam

Anxiolytic

Valium

Tablet 5 mg

N05BA01

Midazolam

Anxiolytic

Hypnovel

Ampoule 1 mL = 5 mg

N05CD08

Haloperidol

Antipsychotic

Haldol

Ampoule 1 mL = 5 mg

N05AD01

Table 5 lists the ATC codes for gastrointestinal, local anaesthetic, main analgesic, anti-haemorrhagic, anti-muscarinic, diuretic and hyperglycaemising agents recommended by WHO to be carried on board ships. The ATC codes of other drugs are indicated in Table 6.

Table 5. ATC codes for gastrointestinal, local anaesthetic, main analgesic, anti-haemorrhagic, anti-muscarinic, diuretic and hyperglycaemising agents

Generic name

Therapeutic group

Possible trade names

Dosage form

ATC CODE V

Gastrointestinal agents

Ondansetron

Anti-vomiting, anti-seasickness

Zofran

Tablet 4 mg

A04AA01

Sodium chloride 0.9% infusion

Liquid replacement

NaCl 0.9%, saline solution

Plastic bottle, 1 L

A12CA01

Loperamide

Antidiarrheal

Imodium, Diacure

Tablet 2 mg

A07DA03

Oral rehydration salt

Anti-dehydration in diarrhoea

Repolyte, Gastrolyte, Dioralyte

Sachets of powder for reconstitution

A07CA

Omeprazole

Anti-peptic ulcer, anti-gastro-oesophageal, reflux

Losec, Prilosec

Tablet 20 mg

A02BC01

Docusate with Senna (or equivalent)

Anti-constipation

Coloxyl

Tablet 50 mg + 8 mg

A06AG10

Local anaesthetic agents

Amethocaine 0.5% eye drops

Local anaesthetic

Tetracaine

Single-use vial 1 mL

S01HA03

Lignocaine 1% (without adrenaline)

Local anaesthetic

Xylocaine, Lidocaine

Ampoule 5 mL

N01BB02

Main analgesic agents

Morphine (injectable)

Opioid analgesic (treatment severe pain)

NA

Ampoule 1 mL = 10 mg

N02AA01

Morphine (oral)

Opioid Analgesic (treatment of moderate to severe pain)

NA

Liquid 1 mg/mL

N02AA01

Naloxone

Antidote for opiate

Narcan

Ampoule 1 mL = 0.4 mg

V03AB15

Anti-haemorrhagic agents

Misoprostol

Prevent postpartum haemorrhage

Cytotec

Tablet 200 mg

A02BB01

Vitamin K

Anti-bleeding caused by the use of warfarin

Konakion, Phytomenadione

Ampoule 1 mL = 10 mg

B02BA01

Anti-muscarinic agents

Atropine

Ophthalmologicals, mydriathics and cycloplegics

NA

Ampoule 1.2 mg/mL

S01FA01

Diuretic agents

Frusemide

Diuretic

Lasix, Furosemide

Ampoule 4 mL = 40 mg

C03CA01

Hyperglycaemising agents

Glucagon, ready to use

Glycogenolytic (used in severe hypoglycaemic crisis)

Glucagen

Ampoule 1 mg

H04AA01

NA – not available

Table 6. ATC codes for other (minor) agents not listed in Tables 3–5

Generic name

Therapeutic group (E.U.)

Possible trade names

Dosage form

ATC CODE V

Ethanol 70%, hand cleanser gel

Disinfectant (alternative hand washing)

NA

Gel

D08AX08

Ethanol 70%, liquid

Disinfectant

NA

Liquid

D08AX08

Charcoal, activated

Ingested poisons absorbent

NA

50 g in 300 mL purified water

A07BA01

Permethrin 1% lotion

Ectoparasiticides, scabicides

Loxazol, Elimite, Nix

Lotion

P03AC04

Permethrin 5% lotion

Ectoparasiticides, scabicides

Lyclear

Lotion

P03AC04

Povidone iodine ointment 10% and solution 10%

Anti-infectives and antiseptics

Betadine, Povidine

Ointment, liquid

G01AX11

Oxymetazoline 0.5% (or equivalent)

Nasal decongestion

Drixine

Drops

R01AA05

Fluorescein 1%, strips

Cornea damage detector

NA

NA

S01JA01

Zinc oxide

Protective for irritated skin

NA

Paste or ointment, 20%

D02AB

NA – not available

Discussion

The problem of provisions of medicinal products on board ships is not simple due to the diversity of laws and regulations on the distribution and use of medicinal products for different countries. Several countries have updated in the last years the content of the ship’s medicine chest for their own fleets [3, 13–16]. A comparative analysis of regulations and contents reveals significant non-homogeneity probably reflecting the different points of views in delivering assistance to patients. The international standard of the minimum provision of medicines that each ship must carry is reported as an appendix of the WHO International Medical Guide for Ships and the Medical First Aid Guide for use in Accidents Involving Dangerous Goods [6]. Ships usually undertake voyages, at times, far away from their own country for extended periods. Apart from the psychological problems that extended periods at sea, away from families can cause, the distance from the country of origin of the ship, which is common for vessels employed in international long-haul routes, can also cause problems in the supply of medicines for the ship’s pharmacy. Regularly prescribed medicinal products cannot be mailed abroad and therefore the only possibility to obtain medical supplies is to purchase them in a port where the ship lands. This situation makes some practical problems for the handling agent to purchase medicines at a local pharmacy, to acquire same product required by the flag state of the ship or the difficulty, if not the impossibility for the seafarers to understand what medicinal compounds, are present inside the newly obtained medicines. For instance, medicinal products obtained in other countries with indications in foreign languages that the ship’s officer may not be able to understand. As an example, extensively used, anti-hypertensive drug nifedipine in Chinese is ‘硝苯地平’, in Greek is ‘νιφεδιϖίνη’, in Russian is ‘нифедипин’, in Persian ‘نیفدیپین’. In this regard, if the supplier is not careful in providing indications in English or in the language of the ship’s country, identification of a compound purchased abroad can be extremely difficult. Medicinal products are identified by the international non-proprietary name of the active principle and/or by their chemical or invented (branded) names. The list of WHO [6] as well as the majority of flag states national lists [3, 13, 15–19] indicates medicinal products to be on board by the name of the active principle. Some explanations and brand names of the most common medicines are also elaborated [6, 17, 19]. Other lists such as the Norwegian, are more generic and indicate the categories of drugs required, without specific indication of names of medicinal compounds [14]. All these instructions are usually self-explanatory, but have the limitation in the correspondence, in case a medicine which has consumed or expired, and has to be replaced with another one obtained abroad. This apparently difficult situation can be easily solved, if that is the one next to the generic name of the active ingredient which is international, as used throughout the world, the addition of the ATC code definitely increase security. In this way they will avoid many identification errors, often due also to lack of clarity in the international treaties which should serve as a reference. As a reference to this point “paracetamol” that in International Medical Guide for Ships third edition is also labelled as acetaminophen, on the contrary generic name of the drug known as paracetamol in Europe is referred to as acetaminophen in the United States and Canada. The ATC classification system is based on the principle that each pharmaceutical preparation is associated with a single code and drugs are classified according to their main therapeutic use. In case a drug can be used for two or more therapeutic indications of equal importance, this leads to different alternatives for its classification. A drug may also be provided in two or more dosages or pharmaceutical forms for different therapeutic uses: the actual therapeutic use in such cases will determine the classification [11, 12]. The preparations which cannot be unequivocally classified in a given group are encoded to a level IV with the letter X. A medicinal product may be used for two or more equally important indications, and the main therapeutic use of a drug may differ from one country to another. This will often give several classification alternatives. Such drugs are usually only given one code, the main indication being decided on the basis of the available literature. For example, the preparations of nifedipine are classified with C08CA05 code, where: C indicates the cardiovascular system (level I), C08 – calcium (level II), C08C – selective calcium antagonists with predominant vascular effects (level III), C08CA – dihydropyridine derivatives (level IV) and C08CA05 – nifedipine (level V). Pharmaceuticals are classified on the basis of main therapeutic use, following the principle that all similar formulations, comparable to ingredients, unit dose and route of administration, may have only one ATC code. The indication of the ATC code in the list of medicinal compounds required to be on board ships will offer the advantage not only of an easy identification of the product irrespective of the place where it has been obtained. It will be also useful to place a proper order of a given medicinal compound when stocks have been sold or expired. Moreover, the identification through ATC system also facilitates the initiation of a review of the contents of the medicine chest given by the WHO in International Medical Guide for Ships third edition. ATC attribution queues could justify or contradict, the presence of some active principles using the system. For example misoprostol, as can be seen from the ATC code: A02BB01, A refers to the prostaglandin analogue, primarily used to prevent and not treat gastric and duodenal ulcers and not simply as a prevention of postpartum haemorrhage, as indicated by International Medical Guide for Ships third edition. In addition to emergency physicians in the United States, the prevention and treatment of severe bleeding after childbirth is an off-label in the sea, child-birth is very rare on the sea and therefore the presence of this drug in this indication makes little relevance. Vitamin K is also another example of a drug included by International Medical Guide for Ships third edition for its use as a haemostatic in case of bleeding caused by the use of warfarin (anticoagulant), although warfarin is rarely used in the ships, which also makes the presence of vitamin K on board ships questionable. At the present the only flag state national list reporting besides to the classic list per therapeutic principle the ATC code is the is Italian one [20]. This represents a real progress and a relevant effort for making handling of the ship’s pharmacy easier and more effective.

An alternative strategy to ATC code, due to the difficulty for seafarers, who often lack proper technical prowess of ATC code interpretation, could be achieved by replacing in the computer each letter that makes up the specific ATC code (from A to Z) with a two-digit number based on its position in the alphabet: A = 01, B = 02, C = 03, D = 04 ... V = 22, Z = 26, so that each ATC code becomes a numeric sequence of ten digits. In this way, for example, paracetamol, whose ATC code is NO2BE01 would be assigned the new code 1402020501. This identification strategy can be used only within the same company, as pharmacists around the world will have no familiarity with the system. Such a system has been used successfully for years by some cruise companies which lists of medication are far more extensive than the WHO list. In these cases, the drugs have been listed through their ATC codes to 10 digits, accordingly, ships of the same company have their medicines organised in a uniform manner. Of course, introduction of such a new identification system of medicinal compounds on ships would require agreements and issuing guidelines from authoritative sources.

Conclusions

In this paper we have added the international ATC code to the WHO list of medicinal products to be present on board ships [6]. This alphanumeric code will allow the purchase and identification of a product in any country of the world without the need to know the brand name of the drug that may be different from country to country. The adoption of a classification system such as the ATC by all national flag states would allow seafarers on any ship finding, in whatever country they are, necessary medications. This will allow moving towards a more universal system of classification of medicinal compounds for the ship’s medicine chest. Last but not least, the adoption of this international standard will allow efficient organisation of the contents of the ship’s medical chest by competent authorities without the need of relatively high level pharmacological competence that could be not always available.

References

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