This was a continuous process over the two year period following completion of distribution of MSTG 1 up to the final drafting of MSTG 2. Comments were received from individual prescribers by the Secretary of the NDC. These were discussed and suitable amendments approved by the NDC in the course of five meetings of the Committee held during 1991 and 1992.
Even by mid-1991, only a few months after distribution of MSTG 1, the need for an updated edition was already becoming apparent. An NDC meeting of July 1991 agreed to commence preparations for a new edition (planned to be completed by early 1992). Subsequent editions should include an index and be produced approximately every three years.
Several developments/changes in the treatment of important diseases occurred around this time:
• A major review of the treatment of clinical presentations in HIV/AIDS patients was initiated by the MOH AIDS Control Programme in order to standardise treatments and produce an HIV Management Guidelines booklet. The final draft of this was completed in July 1992.
• Increasing resistance of malaria to the recommended 1st line therapy with chloroquine was documented. In October 1991, new malaria treatment guidelines were introduced with sulfadoxine/pyrimethamine (Fansidar®) as the 1st line drug and administration of i/m quinine for severe cases at health centre level.
• Similarly, resistance of STDs, especially gonorrhoea and chancroid, to recommended treatment regimes was documented. Following further studies, consultancies and a special workshop, revised STD treatment guidelines were drafted in June 1993 shortly before the MSTG 2 was due to be printed. In fact the final version of the MSTG had to be retrieved from the printers and re-edited to include the changes made.
• WHO guidelines on a new approach to the treatment of acute respiratory infections in children and updated guidelines for management of acute diarrhoea became available.
In each of the above cases, draft treatment schedules for the MSTG 2, based on the new material, were prepared either by the editor or the relevant disease control programme. These were subjected to review by the appropriate specialists and subsequently submitted to the NDC for approval. The schedules passed through several further draft stages prior to their final adoption.
Remaining material in the MSTG 1, not covered by the above, was divided into logical sections, e.g. skin conditions, paediatric treatments, obstetric/gynaecological conditions, ophthalmic conditions, etc. and sent out to the relevant specialist(s) for comprehensive review and comment. This process took a considerable time and required intensive follow-up to obtain the required feedback.
After all comments had been received and incorporated into the master document, a special meeting of the NDC was arranged for July 1992, to which approximately 20 co-opted experts were invited. Background documentation summarising all the amendments to MSTG 1 agreed by the NDC in its previous meetings, and including all the new draft material produced, was distributed to participants prior to the meeting.
On the first day of the two-day meeting, the draft material was reviewed in plenary session and necessary amendments proposed and agreed. On the second day participants were split into four working groups, of about 10 persons each, to draft new treatment schedules and treatment guidance points (key clinical or patient management points to be noted at the start of each schedule). The working groups then presented their material in turn to the full meeting for further discussion and approval.
A sample page of the draft MSTG 2 had been prepared to illustrate the improved format and layout of the text and the presentation of the dose regime information. This was also reviewed and approved. The editor was given the go ahead to prepare the remaining sections of the MSTG 2: an index; preface; foreword; prescribing guidelines section (to be adapted from that included in the 1991 Malawi National Formulary); a section summarising the presentation of information (e.g. dose regimes, arrangement of sections, indexing and cross-referencing, routes of drug administration, alternative drugs) and the cover page.
A few minor queries remaining were left for follow-up clarification with the appropriate specialists. Any further amendments arising out of this, providing they were not substantive, were then permitted to be incorporated by the editor without further approval from the NDC.