GOOD STORE MANAGEMENT

            The aim of this module is to lay down guidelines for pharmacists to adopt an effective system for storage and stock management.

Objectives To understand various steps in receiving, handling and storage of medicines and related  supplies To understand means and patterns of storage, stock control and expiry monitoring and minimize losses through expiration and deterioration To understand how storage of medicines directly affects their quality To protect from loss, damage, theft, or wastage To maintain reliable and continuous supply from source to user ·         To keep accurate inventory records. To provide stock movement information for   forecast needs.

           
Regular uninterrupted access to ARV medicines along with appropriate dispensing by the pharmacist is one of the prime requirements for the success of the National AIDS Control Programme. A reliable supply system to ensure availability of medicines in right conditions (quality, safety and efficacy) will be the major need under ARV Drugs Store Management. Under Operational Guidelines for ART Centers (March 2008) and a further instruction by the NACO, a pharmacist is required to perform specific tasks as listed under Chapter 4 “Role of pharmacists in promoting rational use of medicines including ARV medicines”.

            Drugs consumes maximum budget, next only to the manpower and therefore, one needs to optimize procurement, storage, distribution and use. SCHEDULE P¹ of   the Drugs

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¹Drugs specified in Schedule P and their preparations including combinations with other drugs shall bear on their labels the date of manufacture, and the date of expiry of potency, and the period between the date of manufacture Drugs and Cosmetics Rules, 1945,  and the date of expiry shall not exceed  that laid down in the said Schedule (under the conditions of storage specified therein).  Drugs and their preparations not included in Schedule P, shall bear on their labels the date of their manufacture and also the date of their expiry which shall not exceed sixty months from the date of manufacture.

& Cosmetics Act and Rules require that during the shelf life period of drugs, medicines are properly stored in proper conditions in a proper building. Managing stores is the responsibility of Pharmacists/Chief Pharmacists. Major focused activities under store management are: Quarantine and checking of stocks, Means and patterns of storage, Stock control and expiry monitoring and other related aspects of storage.

STANDARD OPERATING PROCEDURES (SOPs) for Pharmacist of ART Centres

I.  OBJECTIVE: To outline the responsibilities related to management of ARV and OI drugs and to establish appropriate procedures for indenting, dispensing, good clinical practices, record keeping, and disposal of expired drugs

II. RESPONSIBILITY of Pharmacist in Drug Stock Management

1.      It is the responsibility of the Pharmacist of ART Centre to assess the requirement of drugs based on number of patients enrolled, past consumption and put up the request to Medical Officer / Senior Medical Officer for next year requirement / interim requirement.

2.      Minimum three months stock should be available at any given time at the centre and Link ART Centre. Inform immediately your Regional Coordinator / SACS and NACO HQs if drugs are available for less than THREE months.

3.      Inform your Regional Coordinator/ SACS and NACO HQs if short expiry drugs are available for need based relocations.

4.      Maintaining accurate records for dispensing and maintaining all drugs received at ART.

·         Cross verify at the time of receiving the drugs that the exact amount is received against the allocated quantity and confirm the same to SACS/ Logistic coordinator / Supplier / procurement agency. Deviation if any should be highlighted for further actions.

·         Acknowledging the receipt after actual counting of drugs.

·         Mention receipt of quantity if received less or in seal broken condition.

·         Stacking of drugs should be based on expiry dates ( First Expiry First Out –FEFO)

·         Refer and comply with revised guidelines sent from time to time by NACO

5.      Drug stock and drug dispensing register should be maintained on daily basis as they subject to unannounced inspection.

6.      Periodical physical count of stocks should be done.

7.      Stocks should always be dispensed based on First Expiry First Out.

III.   Record Keeping:

• Keep all records of drugs entries and issues

• Enter all drugs dispensed in the daily drug dispensing register

• Drug stock register must be filled routinely. This is important because:

a)      It provides consumption rate

b)      Avoids stock outs

c)      Avoids expiry   

IV. Storage of drugs:

·         Arrange cartons with arrows pointing up and with identification labels, expiry dates and

manufacturing dates clearly visible.

·         Store drugs and other supplies to facilitate FEFO (First-to-expire, First-out) procedures

·         Stack cartons at least 10cm (4 in) off the floor, 30cm (1ft) away from the walls and other stacks and no more than 2.5m (8ft) high.

·         Procure aluminum / Iron racks to for stacking from contingency funds.

·         Separate damaged and expired drugs and supplies from usable supplies.

·         Remove them from inventory immediately and dispose them off using established procedures for disposal of drugs

·         Keep fire safety equipment available, accessible and functional. Train other employees like staff nurse and counselors to use it.  

V.  Guidance on Usage of Near Expiry of Drugs

1. Always issue drugs based on First Expiry First out basis and not on First in first out basis because in relocations stocks of late expiry may be received.
2. Accidental usage of expired drugs can create a big problem so extra caution is to use in this respect.
3. The drugs being issued to PLHA should have at least 45 days left for expiry from date of issue.
4. THE DRUGS ARE ISSUED FOR ONE MONTH, so if a drug has expiry in August 2009, it can be used till 31^st August 2009. Hence, this can theoretically be issued to patients with one month remaining in expiry i.e. before 31^st of July 2009 
5.  Guide patients to use drugs before expiry and return unused drugs if not used due to any reason.

VI. Guidance on disposal of expired drugs:  In case some drugs expire at your centre, please do not send these drugs to NACO / SACS. These should be destroyed at the centre itself following the procedure adopted in hospital for other drugs that expire in the hospital.  Generally the procedure involves:

1.      Forming a committee of two- three persons including Nodal Officer,

2.      Listing out the drugs expired along with batch no. and quantity expired (with date of expiry)

3.      Separating the tablets from bottles

4.      Destroying the tablets in incinerator

5.      Removing the labels from the bottles (may be dipped in water for some time to separate out the labels)

6.      The empty bottles to be disposed off after removing labels in the municipal waste

7.      The quantity of expired drugs to be reduced from the balances and reported in the CMIS report. Details for the same are to be emailed to state’s SACS and to NACO HQs.

            In compliance of SOPs, the following conditions and systems can go a long way to help the stores staff in discharging their functions efficiently.

1.     Location: In general, bigger hospitals the drug store should be centrally located so that the consuming departments can procure the drugs easily. However, in ARV and related supplies, a firm structure with concrete roof work adjoining to ART clinics will be most ideal.

2.   Lay out:

i) The store should have a single entry for safety.

ii) All the openings other than the main entrance should be provided with steel grills and wire mesh to eliminate chances of any pilferage.

iii) The main electric switchboard should be placed near the main entrance so that it can be easily accessed; in case of an emergency.

iv) Quarantine Area and checking of stocks: Depending upon the bulk of stock handled, an area may be marked as quarantine/receipt area, where the stocks will be physically received, checked (visually inspection of the package, integrity of containers, completeness and legibility of labels, expiry date, etc.) and counted and tallied with the receipt documentation before they are moved to the allocated bins item wise.

v) Issue counter should be made near the main entrance.

vi) Near the issuance counter, an area may be marked for the storage of fast moving items, which require frequent handling.

vii) Appropriate storage of medicines is essential to maintain the potency, prevent deterioration/ spoilage, maintain physical integrity and maintain quality and safety throughout the shelf life. Certain products need specific storage to retain their therapeutic efficacy so they need specific storage.

viii) When placed in bins, no stock should touch the walls so as to allow free passage of air and check the growth of fungus, silver fishes, termites, rodents, etc.

ix) An adequate moving space should be available to ensure movement and easy identification.

3.   Arrangement of stocks/ Bins:

Bin is a particular space allotted for keeping an item. Irrespective of any type of storage, bins are provided for each and every item in alphabetical order at smaller ART centre stores, where the quantum of stocks handled are small and usually only one or two persons are handling the total activity. In case the same product is available in different dosage forms, a separate bin is provided for each one of them separately. These bins are also allotted numbers. This number is indicated in the stock ledger and Bin Card also to ensure easier location and identification. Arrangement in each Bin is again made batch wise/expiry date wise. Stocks expiring first should be placed first, followed by the next date of expiry and so on. The objective here is to ensure that the stocks expiring first are issued first to minimize loss by way of their getting expired. In case, in a later receipt event, the stocks received are expiring earlier than the existing stocks, the arrangement will have to be redone ensuring the principle of "first expiry date, first out" (FEFO). At times the allotted bins fall deficient and alternate bins have to be arranged when the receipt are abnormally high. Such arrangements normally are then made on the pallets only. Not more than 5/6 cartons are allowed to be stored one over the other. Higher stocks have the danger of their falling down resulting into breakage, spoilage and damages.

4.   Storage:

Appropriate storage is most important in all levels of supply chain. Some medicines are moisture sensitive and are required to be stored in tightly closed containers in a dry place, while light sensitive medicines should be stored in a dark place or light resistant containers. Items like antibiotics, hormones, vitamin, vaccines, serums, ARVs etc. require storage at lower temperature. This can further be sub-divided into two parts.

i)         Cool Storage: By cool we mean, temperature falling in the zone 8-25°C which can easily be obtained by locating an appropriate place in the premises or with the help of air conditioners depending, upon the cubic area of the space and the capacity of the A/C's fixed. First line ARVs are required to be stored in tightly closed containers in a cool and dry place (to protect from moisture). This area may be provided with a thermometer and the temperature record shall be kept on daily basis.

ii)       Cold Storage: Preparations like vaccine and serums require a much lower temperature to retain their requisite potency. This varies in the range of 2 to 8°C. This storage is designated as cold storage. In this case also measurement and recording of temperature is a must in hospitals. The products falling under this category are Amphotericin B, various vaccines, serums, etc. Unless specifically allowed, such medicines shall never be stored in freezer so that preparations do not freeze. Monitoring of storage temperature is vital. The minimum requirement is to monitor temperature using a thermometer that measures maximum and minimum temperature. The thermometer should be read and reset daily and the temperatures recorded. Some supplies bears the indicator chart along with labels to indicate whether cold chain / temperature control has been maintained during transportation of supplies.

In order to maintain efficacy of medicines during storage it is necessary to adhere prescribed storage conditions and patients shall also be asked maintain similar condition so as to avail full benefits of the medications. The storage conditions of first-line ARVs and medicines for opportunistic medicines (OIs) are listed below for the information of pharmacists and patients.

Box 6.1

Storage Condition of ARVs and OIs Medicines and Patient Information
Keep all medicine out of the reach of children and pets and never share your medicine with anyone
Antiretrovirals
STAVUDINE	Store the capsules at room temperature in a closed container, away from heat, moisture, and direct light. Store the oral liquid in the refrigerator. Do not freeze the liquid. Throw away any unused medicine after 30 days, but do not throw it in the trash. Flush it down the toilet or take it to a community take-back program when available.
LAMIVUDINE	Store the medicine at room temperature in a tightly closed container away from heat, moisture, and direct light. Do not freeze.
ZIDOVUDINE	Store this medicine at room temperature in a closed container, away from heat, moisture, and direct light. Do not freeze the oral liquid.
NEVIRAPINE	Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light.
EFAVIRENZ	Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light.
Medicines for OIs
METRONIDAZOLE	Keep the medicine at room temperature in a tightly closed container, away    from heat, direct light, and moisture.
NITAZOXANIDE	Store the medicine at room temperature in a closed container, away from heat and direct light. The liquid medicine is good for only 7 days after it is mixed. Throw away any liquid medicine you have left after 7 days.
ITRACONAZOLE	Store the medicine in a closed container at room   temperature, away from heat, moisture, and   direct light.
PREDNISOLONE	Store the medicine in a closed container at room   temperature, away from heat, moisture, and direct light. You might need to store the oral   liquid in the refrigerator.   Do not freeze.
FLUCONAZOLE	Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Do not freeze the liquid medicine. Throw away any unused liquid medicine after 14 days.
ALBENDAZOLE	Store the tablets at room temperature, away from heat, direct light, and moisture.
CIPROFLOXACIN	Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. You may store the oral liquid at room temperature or in the refrigerator. Do not freeze. Do not keep the oral liquid for more than 14 days of opening the container.
ACYCLOVIR Acyclovir Injection,	Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. If stored at home, keep it at room temperature, away from heat, moisture, and direct light. After the medicine powder in the bottle has been mixed with the liquid, store the mixture in the refrigerator in a closed container. Bring it to room temperature before using. This mixture must be used within 12 hours after mixing.  Throw away used needles in a hard, closed container that the needles cannot poke through.
AZITHROMYCIN	Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Use the oral liquid within 10 days after you fill the prescription. Throw away any medicine that is left over when you are finished with your treatment time.
GANCICLOVIR Ganciclovir Injection	Store the medicine at room temperature, away from heat, moisture, and direct light. Store the medicine in a refrigerator. Do not freeze. Take it out of the refrigerator an hour before it is time for your next dose and allow it to warm to room temperature in a clean, dry place. Throw away used needles in a hard, closed container that the needles cannot poke through.
CLARITHROMYCIN	Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Do not store the oral liquid in the refrigerator.
CLINDAMYCIN	Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Do not refrigerate or freeze the oral liquid. Discard any of the unused oral liquid after 14 days.
ETHAMBUTOL	Store at room temperature and protect from direct heat, moisture, and light.
SULFADIAZINE	Store at room temperature, away from heat, moisture, and direct light.
AMPHOTERICIN B	Store in a refrigerator. Do not freeze. Take it out of the refrigerator an hour before the time for your next dose and allow it to warm to room temperature in a clean, dry place.  Do not use if any particles are noticed.
CEFOTAXIME	Store in a refrigerator. Do not freeze. Take it out of the refrigerator an hour before the time for your next dose and allow it to warm to room temperature in a clean, dry place.  Do not use if any particles are noticed.
LEVOFLOXACIN	Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light.
AMOXICILLIN/ CLAVULANATE POTASSIUM	Store the tablets at room temperature, away from heat, moisture, and direct light. Store the liquid in the refrigerator. Do not freeze. Use the liquid within 10 days after you fill the prescription, and throw away any medicine that is left over when you are finished with your treatment time.
CLOTRIMAZOLE Tubes	Keep your medicine at room temperature, away from direct heat or light. Do not freeze.
SULFAMETHOXAZOLE/ TRIMETHOPRIM DS	Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Do not freeze the oral liquid.

5.       Safety Measures:

i) Palletting : The entire stores space should have wooden/plastic pellets to avoid placing of the drug packages with the ground. Wooden pallets measuring 2'x3'  6"x6" can be used. These days PVC pallets are also available in different sizes.

  ii)  No smoking Zone : Drugs store is strictly a no smoking area. A board to this effect should be displayed on the gate and other suitable points in the store. This should be strictly implemented and the stores personnel should take this activity with a will and seriousness.

iii)   Fire Fighting Equipment:

a)                  All purpose Fire Extinguishers has replaced the old different types of fire- extinguishers, and also the buckets of sand and water.

b)                                    The new all purpose fire extinguishers can be used against all types of fires irrespective of their origin.

c)                                     The new all purpose fire extinguishers have specific life span - 5 years. A record of their life has to be maintained and life marked on the cylinder should be distinctly legible.

d)        All the personnel working in the stores should be trained in handling the fire extinguishers.

e)         Periodically mock fire fighting exercise should be carried out to keep the staff fully trained and familiar with the use of the extinguishers.

iv)    Treatment against Termites, Rodents, Cockroaches, bugs etc.

Termites, rodents, cockroaches, bugs, silver fish, mud tubes etc. are a very common feature in the stores. The treatment of all these perils is available. Central Ware Housing Corporation, a Government of India undertaking, is providing these treatments on contractual basis. Private commercial organizations are also available who undertake this job. To make this treatment more effective it is advisable that they are undertaken a day before a holiday when the store is not to function. Saturday is an ideal day where Sunday is a closed day for a store.

v) Insurance cover: Commercial organizations normally get the drug stores insured invariably against fire, burglary, terrorism, floods, water inundation etc. In Government stores it is for the Management to consider this aspect as a policy matter.

vi)   Locking, Sealing System and Custody of the Keys:

The store after locking should be sealed daily with the monogram of the institution. Metallic monograms can be made for this purpose. This sealing Monogram will be in the custody of the store officer who will put this on the seal daily and make an entry in the register daily to this effect. The register should be signed by the chowkidar / watchman also. The chowkidar is a witness having seen the seal on the lock should also sign the Register. This register should be in the charge of the security/Administration Department. The keys should he scaled in a wooden box provided with one side made of glass. This box after scaling by the stores officer should be kept with the security department and will be available in the hospital round the clock. In case of any mishap, security department/head of the Institution can break open the glass side of the sealed box and use the keys strictly in the interest of security of stores. The store officer daily in the morning should check the seal of the store in the presence of the security and record the seal status in the register kept with them.

6.   Physical Verification of Store:

i) The in-charge of the stocks should conduct physical verification of costly fast moving items on weekly basis and reconcile with the balances divided in the bin Card/Stock Ledger.

ii) For all the items of stock, physical verification should be conducted by the stock in-charge every month. Stocks will be taken physically in a physical verification Register.

iii) The stock Ledger/Bin Card should be completed for all the receipts and issues entries before the physical balances are tallied with the balances in the Bin Card/Stock Ledger.

iv) While physically verifying the stocks, the expiry dates must be checked to ensure that all the arrangements of stocks is exactly as per arrangement explained under the section "Arrangement of stock".

v) Stocks already expired, broken, unfit for consumption, gone obsolete, expiring within next six months will be recorded with their specific Batch Number, expiry date, quantity, simultaneously while carrying out physical verification.

vi) The physical balances now should be reconciled with the Bin Card/ Stock Ledger balances.

vii) A detailed analysis of the verification report should be made to identify the following parameters:

a)              Total inventory status

b)      Discrepancies, if any, showing shortages excesses

c)              Expired stocks

d)     Obsolete stocks

e)  Breakage's/spoilages unfit for consumption
f)   Stocks expiring within next six months

g)  Stock outs.

viii)     Actions:

a)      The discrepancies enlisted under sub section vii(b) above should be investigated and necessary correction should be made if the discrepancy is resolved; failing which stock Adjustment entries should be made under clearance, by the competent Authority.

b)     With regard to the breakages/spoilages, date expired stocks, full facts and circumstances should be examined with a view to identify corrective measures so that this does not reoccur. The loss incurred should be put up for write off to the competent authority with full facts and justification for the same. Stocks should be struck off in the Bin Card/Stock ledgers only under authority of competent authority.

c)   Stocks identified as slow/non moving, expired, gone obsolete require liquidation/disposal action. A fortnightly store bulletin may be issued to all the consuming departments under discussion with the Medical Officer in-charge informing the status and requesting liquidation action for stocks expiring in near future and slow/non moving products. It may be through request for preferred prescriptions for these products over their therapeutic equivalents. This, of course, will require a vigorous follow up action and monitoring the status, periodically. List of these products can also be put up to the central stores coordinating authority who may consider reshuffling of these stocks among the various hospitals/clinics centes/dispensaries under the organization.

ix) Stock outs should not occur if Section II-RESPONSIBILITY of Pharmacist in Drug Stock Management of SOPs is complied with.

x)     The obsolete stocks need to be pointed out to the Medical Officer In-charge of the store who may initiate suitable action and look for alternative consumption or return to the supplying firms.

7.   ARV Drugs Supply and Requisitions:

All ART centers are provided with ARV drugs directly by NACO. The number of patients for which drugs are supplied is estimated in consultation with the ART center concerned. The drugs are generally procured annually. The different types of ARV drugs and their proportions being supplied to ART centers in the ratio of Zidovudine (AZT) Vs Stavudine (d4T) based combination is 60:40. The individual centres do not need to mention the quantity of each drug separately. The proportion of Efaviranz is 20% of total (as many patients have TB co-infection and need simultaneous ATT and ART). The patient should be shifted to NVP after ATT is complete.

The drugs are supplied in at least 2-3 installments, preferably on quarterly system in a year. The drugs supply chain management is . All centers should also ensure that they have a minimum stock of drugs for three months at their centers. New patients should not be enrolled for ART without having 3 months stock of medicine. In such situations, information should be sent regarding non-availability of drugs    with a copy to  to NACO supply chain coordinator (artdrugs@gmail.com) with copy to  and concerned Regional Coordinator. These drugs shall be stored in the main pharmacy of the institution and the centre will utilize them following first expiry first out principle (FEFO). The drugs for PEP shall be made available in the casualty and one more place where they have easy round the clock accessibility.

Process for requisition and acceptance of ARV drugs :

Nodal Officer of ART center should send requisition for ARV drugs to NACO under information to SACS. The requisition should indicate full consignee address (Nodal Officer, ART) with pin code, phone/fax numbers and e-mail and quantity of each drug received, utilised, balance available and additional requirement. Supply would be made to the consignee of ART center who would accept and receive drugs and store in medical store of the hospital/institution. Weekly/fortnightly indents would be sent by the ART center to the Store. Drug stock register

should be kept with the store-keeper and a sub-stock register should be maintained at the ART center by Staff Nurse/Pharmacist.

Process of reporting ARV drug status :

Monthly report would be sent by ART center in prescribed format (Annexure 1) to SACS and NACO indicating quantity of drugs received, utilised, balance and additional requirement, if any. Empty bottles should be destroyed to prevent recirculation.

Impending drug expiry and Expired medicines:

Poor planning, over supply, lack of communication, decrease in patient load, faulty expected number could lead to impending drug expiry. Regular reporting and timely intimation to SACS, NACO and RCs is necessary to avoid such situations. ART center should inform NACO/SACS when expiry date of drugs supplied is within 6 months. Guidelines for Disposal of Expired Drugs have been dealt under Section VI. Guidance on disposal of expired drugs of SOPs as per “Operational Guidelines”

Drugs for Opportunistic Infections:

Requirement of different drugs required for treatment of Opportunistic Infections may vary from place to place. Bulk supplying all drugs may lead to expiry of uncommonly used drugs and shortage of more frequently used drugs. It has been seen that some of the drugs required for management of OI’s are available in the hospitals formularies for treating these infections in non HIV infected persons. Hence the drugs for OI can be divided into three categories.

Box 6.2

Drugs to be supplied by the Institution where ART center is located		Drugs to be procured by SACS and supplied to ART centers		Drugs to be procured by SACS/ centre as per requirement
1	Metronidazole 400mg	1	Nitazoxanide 500 mg	1	Fluconazole IV- 200 mg
2	Albendazole 400 mg	2	TMP-SMX DS 160/800mg	2	Acyclovir IV 250mg
3	Ciprofloxacin 500mg	3	Azithromycin 500mg	3	Inj.Ganciclovir 500mg
4	Prednisolone 10 mg	4	Fluconazole 150 mg	4	Cap.Ganciclovir 250 mg
		5	Fluconazole 400mg	5	Itraconazole 200mg
		6	Clotrimazole tubes	6	Clarithromycin 500mg
		7	Clindamycin 300 mg	7	Ethambutol 800mg
		8	Sulfadiazine 500 mg
		9	Inj Amphotericin B 50 mg
		10	Acyclovir 400 mg
		11	Cefotaxime 1g
		12	Levofloxacin 500 mg
		13	Cap. Amoxyclav 625

8.    Management Information Service:

The Pharmacist should maintain a stock register and every month put up status report covering points identified under Drug/ Reagent Stock at ART Centre (for the reporting month) in a Excel sheet (prepared on the basis of ARV Drug Stock Register)– as per Annexure 1.

Antiretroviral Drug Stock Register:

All supplies coming in and out of store for whatever reasons must be entered in Antiretroviral Drug Stock Register on daily basis with working out of balance on every encounter. As Link ART Centres (LAC) are part of ART centre, the medicines issued to LAC should not be entered in main Antiretroviral Drug Stock Register. However, the consumption at LACs shall be reflected in monthly consumption of the parent ART centre in the monthly stock movement report.

Antiretroviral Drug Stock Register

(Maintain a separate page for each drug)

Name of the drug ______________________________________________

Date	A	B	C	D	E	F	G	H
	Opening stock	Stock received (from supplier or other centre)	Stock transferred out officially	Total Stock returned (by patients or families)	Stock dispensed / Consumption	Stock expired/  discarded/ (Non reusable   stock to be added here)	Balance stock	Remarks

• This register must be maintained by the pharmacist/drug dispenser in the ART centre.
• Divide the register into different sections; dedicate one section for each drug.
• On each page, drug stock details can be maintained for a period of one month.

−      Name of the drug: Write the name of the drug e.g., Virolans. All the details on this page should then relate to Virolans.

−      Date: Write the date in dd/mm/yy format.

−      Opening stock (A): Write the number of tablets available at the start of the day.

−      Stock received (B): If new stock was received, then write the number of tablets received, otherwise write ‘0’.

−      Stock transferred out officially (C): If stock is transferred out officially to any other ART centre.

−      Stock returned from patients (D): If stock was returned due to death or non adherence by patients or their guardian, enter the number of tablets returned, otherwise write ‘0”.  

−      Stock dispensed (E): Write the total number of tablets dispensed to patients during the day. Obtain this information from the drug dispensing register.

−      Stock expired (F): Write the total number of tablets that expired or were discarded for any other reason. Stocks returned by patients with broken seal will be treated as discarded and will be reduced from inventory and  shown in Column F

−       

−      Balance Stock (G): Calculate the balance number of tablets at the end of the day using the formula: Balance stock = (A+B+D) − (C+E+F).

−      Remarks (H): Use this space for comments or reminders

At the end of the month, complete the monthly summary.  Use this summary for preparing the monthly ART report.

Calculation of Reusable / Non usable stocks returned by the patients

It has been observed that at some ART Centres, the physical balance of drugs is more than the balance as per drug stock register because some reusable stocks returned by the patients (due to side effects or by the relatives of the dead patients) are not accounted for. Hence in such cases, it is advised to follow the   instructions given below.

1)      Enter returned reusable drugs in Column ‘D’  in drug stock register- to show the accurate balance available in the ART Centre

2)      Utilize /Dispense stock which received back in intact sealed / unopened bottles.

3)      Stock returned in loose tablets (opened bottles) should be reported in Column ‘F’ as discarded (not to be used.)

4)      Always describe reason in Column ‘H’ i.e. remarks column.

5)      Balance available in the ART Centre should tally with Column ‘G’ as explained in the sample given below.

Sample Example - Antiretroviral Drug Stock Register
(Maintain a separate page for each drug)
Name of the drug______________________
Date	A	B	C	D	E	F	G	H
	Op. stock	Stock received (from supplier or other centre)	Stock transferred out officially	Total Stock returned (by patients or families)	Stock dispensed / Consumption	Stock expired / discarded/ (Non reusable   stock to be added here)	Balance stock	Remarks
	200	500	0	80	480	20	280	20  tabs discarded as they were returned loose

SUMMARY GUIDELINES FOR PROPER STORAGE Clean and disinfect store room regularly, and take precautions to discourage harmful insects and           rodents from entering the storage area. Store health commodities in a dry, well-lit, well-ventilated storeroom, out of direct sunlight. Protect store room from water penetration. Keep fire safety equipment available, accessible, and functional, and train employees to use it. Store latex products away from electric motors and fluorescent lights. Maintain cold storage, including a cold chain, as required. Limit storage area access to authorized personnel and lock up controlled substances. Stack cartons at least 10 cm (4 in.) off the floor, 30 cm (1 ft.) away from the walls and other stacks, and not more than 2.5 m (8 ft.) high. Arrange cartons with arrows pointing up, and with identification labels, expiry dates, and manufacturing dates clearly visible. Store health commodities to facilitate "first-to-expire, first-out" (FEFO) procedures and stock management. Store health commodities away from insecticides, chemicals, flammable products, hazardous     materials, old  files, office supplies, and equipment; always take appropriate safety precautions. Separate damaged and expired health commodities from usable commodities, remove them from inventory immediately, and dispose of them using established procedures.

Key Learning Points         •          The proper storage of medicines is a critical in the distribution cycle •          Proper storage, stock control and expiry monitoring helps in minimizing losses through       expiration and deterioration of supplies •          Storage of medicines directly affects their quality, therefore store the medicines appropriately and       STORE THEM RIGHT •          Take adequate steps to protect supplies from loss, damage, theft, or wastage •         Optimum stock should be maintained to avoid stock out and expiry of medicines •         Keep accurate inventory records to provide stock movement information for   forecast needs

Activity : Prepare a list of storage requirement mentioned on the label of five ART medicines in your centre. 

Annexure 1   ART

Unique ID. Number of ART

0

1.2.1 Schedule Code

000000000000

9.  Drug Stock at ART Centre (for the reporting month)

Generic Drug Name

a) Opening stock

b) Receipts

c)Stock transferred out to other ART Centres

d) Stock given to Link ART Centres

e) Consumption

f) Expiry during the month

g) Balance Stock on last day of the month

h) Approx. number of months for which stock is sufficient (11/9)

i) Qty. of stock going to expire in coming 6 months

b1) Stock received during month from supplier

b 2) Stock recd. during month from  other  ARTCentres

b 3) Usable stock received from patients this month

e1) at ART Centre during the month

e2)  at Link Centre during the month

e3)Total Consumption

1 AZT+3TC (tab)

2  d4T30+3TC (tab)

3  AZT+3TC+NVP (tab)

4  d4T30+3TC+NVP (tab)

5  EFV 600mg (tab)

6  TDF+3TC

7  LPV/r

8  NVP

9  AZT

10  d4T6+3TC (disp.tab)

11  d4T6+3TC+NVP (disp.tab)

12  EFV 200  mg(Tab)

13  EFV 50 mg (tab)

14  AZT60+3TC30

15  AZT60+3TC30+NVP50

16  ABC60+3TC30

17  NVP Syrup

18  DDI 125

19. DDI 200

20. LPV/ r 125

21. LPV/ r syrup

22  Cotrimoxazole (DS)

23  Cotrimoxazole (SS)

24 Cotrimoxazole Suspension

Note:

9.2. Are sufficient OI Drugs available for next 3 month? 1=yes 2=No

If No, kindly indicate the drugs required with quantity.

Drug

Quantity

Drug

Quantity

Drug

Quantity

Drug

Quantity

Drug

ART