Treatment protocols managment guidelines for major communicable and nc ds

2

3

4

5

DEHYDRADEHYDRADEHYDRADEHYDRADEHYDRATION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTS(As per revised managementguidelines of GOl)

DEPARTMENT OF HEALTH AND FAMILY WELFAREGOVERNMENT OF KERALA

ASSESSMENT OF SEVERITY OF DEHYDRATION

Two of thefollowing signs Use

Two of thefollowing signs Use

• Lethargy or uncon-scious

• Sunken eyes• Not able to drink or

drink poorly• Skin pinch goes back

very slowly

SEVEREDEHYDRATION

PLANC

• Restless, irritable• Sunken eyes• Drinks eagerly, thirsty• Skin pinch goes back

slowly

Not enough signs to clas-sify as some or severedehyoration

SOMEDEHYDRATION

PLANB

NODEHYDRATION

PLANA

TREATMENT

PLAN A: Prevention of dehydration / Prevention of ongoing losses to prevent dehydration

Show the mother how much ORS to give after each stool and give her enough packets for two days

ORS for prevention of dehydration

Age Amount of ORS to giveafter each loose stool

Amount of ORS to provide foruse at home

Less than 24 months2 years to 10 years10 years or more

50- 100 ml100- 200 ml

As much as wanted

500ml/day1000ml/day2000ml/day

ORS is appropriate for both prevention and treatment of dehydration

Show the mother how to give ORS Show the mother how to mix the ORS• Give a teaspoonful every 1-2 minutes for a child under 2 years. • Give frequent sips from a cup for an older child.

• If the child vomits, wait for 10 minutes. Then give the solution more slowly (a spoonful every 2-3 minutes).• If diarrhoea continues after the ORS packets are used up, tell the mother to give other fluids or return for more

ORS. • The mother should be asked to continue feeding the child with diarrhoea

PLAN B: Patient with Physical signs of Dehydration

Guideline for deficit replacement/ rehydration therapy

75 ml /kg of ORS in the first 4 hours (patient’s age to be used only when the weight is not known)should be started immediately.

Approximate fluid estimates for deficit replacement are given in page 7

6

DEHYDRADEHYDRADEHYDRADEHYDRADEHYDRATION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTS(As per revised managementguidelines of GOl)

DEPARTMENT OF HEALTH AND FAMILY WELFAREGOVERNMENT OF KERALA

Guideline for treating patient with some (but not severe) dehydration when body weight is not known

Approximate amount of ORS solution to be given in the first 4 hours*

Approx local measure (glass)

Age Upto 4 mths

4 mths to12 mths

12 mths to2 yrs

2 yrs to5 yrs

5 yrs to14 yrs

More than 14 yrs

Approx wt in kg

ORS in ml

<6 6-10 10-12 12-19 20-30 >30

200-400

1-2

400-700 700-900 900-1400 1500-2200 2200-4000

2-3 3-4 4-6 6-11 12-20• More ORS should be offered if the child wants it • 100-200 ml clean water should be given during this period forinfants upto 6 months who are not breast fed. • Breast feeding should be encouraged and continued whenever the

child wants • If the child vomits, wait for 10 minutes, then continue, but more slowly

Guidelines for maintaining fluid therapy

How much ORS to give for replacement ofongoing stool losses to maintain hydration

Age After each liquid stool,offer

Less than or equal to6 months Quarter glass (50 ml)

7 months to less than 2 years

Quarter to half glass(50-100ml)

2 years - 10 years Half to one glass(100-200ml)

Other children and adults As much as desiredPlan C: Children with severe dehydration should be

given rapid intravenous rehydrationIV fluids should be started immediately. While the drip isbeing set up, ORS solution should be given if the child candrink.The best IV fluid solution is Ringer’s Lactate solution. IfRinger’s Lactate is not available, normal saline solution (0.9%NaCI) can be used. Dextrose on its own is not effective.

100mllkg ofthe chosen solution should bedivided as follows:First give30ml/kg in

Then give70ml/kg in

<12 months 1 hour * 5 hoursOlder children ½ hour * 2 ½ hours

ZINC IN DIARRHOEA MANAGEMENT

Zn as an adjunct to ORT indiarrhoea management in children.

2 months to 6 months 10 mg/day x 14 days

Children 6 monthsand above 20 mg/day x 14 days

Suspect CHOLERA in all cases ofsevere dehydration in adults.

Send Stool samples for ‘Hanging Drop’ todistrict lab and for vibrio to Medical College.

Repeat again if the radial pulse is still very weakor not detectable

All children should be started on ORS solution (about 5ml/kg/h) when they can drink without difficulty during thetime they are getting IV fluids (usually within 3-4 hoursfor infants or 1-2 hour for older children.)

If one is unable to give IV fluids, rehydration with ORSusing naso gastric tube at 20ml/kg/h should be startedimmdiately. The child should be reasssessed every 1-2hours; if there is repeated vomitting or abdominal disten-sion, the fluids should be given more slowly. If there is noimprovement in hydration after 3 hours, IV fluids shouldbe started as early as possible.

7

8

MALARIA TREATMENT ALGORITHM

Suspected Malaria Case

Do Blood Smear Microscopy/Blood test with Bivalent RDT

RDT / Microscopy+ve for P. vivax

Treat with CQ 25mg/kgbody wight divided

over 3 days + PQ 0.25mg/kg body weight

daily for 14 days

Note: PQ is contra indicated in pregnancy, in children under 1 year and individuals with G6PD Deficiency.

RDT / Microscopy+ve for P falciparum

Northe East- Treat with agespecific ACT- AL for 3 days +PQ 0.75 mg / kg body weightsingle doze on the second day

Other States- use ACT-SPinstead of ACT-AL

(Use SP on day 1 only)

RDT/ Microscopy+ve for Mixed Infection

North East- Treat withage spacific ACT- AL for3days + PQ 0.25 mg/

kg body weight daily for14 days

Other States- Use ACT-SP instead of ACT-AL

RDT Negative

However, if malaria issuspected,cross check

microscopy.If microscopy also

negative, no antimalariatreatment. Treat as per

clinical diagnosis

DEPARTMENT OFHEALTH AND FAMILY WELFARE

GOVERNMENT OF KERALA

Age Specific Dosage Chart for Malaria Plasmodium vivax Malaria (Common for all States)

Age Day 1 Day2 Day3 Day 4-14

CQ PQ CQ PQ CQ PQ PQ

150mgbase*

2.5 mg 150mgbase*

2.5 mg 150mgbase*

2.5 mg 2.5 mg

Less than 1 yr

1-4 yrs

5-8 yrs

9-14 yrs

15 yrs & more

Pregnancy

0

1

2

4

6

0

½

1

2

3

4

4

½

1

2

3

4

4

0

1

2

4

6

0

¼

½

1

1½

2

2

0

1

2

4

6

0

0

1

2

4

6

0

9

* 250 mg chloroquine phosphate tab = 150 mg chloroquine base

Mixed (vivax & falciparum) Malaria (From North Eastern States)Age Day 1 Day 2 Day 3

ACT - AL(Artemether +Lumefantrine)

(20mg + 120mg)


(20mg + 120mg)

PQ *(2.5mg)

(Extra to ACT-AL Kit))


(20mg + 120mg)

PQ*(2.5mg)


5m-2 Yrs (5-14kg)(Yellow blister)

1 Tablet twice daily(1 - 0 - 1)


5m - < 1yr : 0>1yr - < 2 yr : 1

1 Tablettwice daily(1 - 0 - 1)

5m - < 1yr : 0>1yr - < 2 yr : 1

3-8 Yrs (15-24kg) 2 Tablet twice daily(2 - 0 - 2)


>2yr - < 5 yr : 1>5yr -< 9 yr : 2


>2yr - < 5 yr : 1>5yr -< 9 yr : 2

9-14 Yrs(25-35kg)


3 Tablet twice daily(3 - 0 - 3) 4 43 Tablet twice daily

(3 - 0 - 3)

15 yrs and more(More than 35 kg)


4 Tablet twice daily(4 - 0 - 4) 6


PQ* : O.25 mg per kg body weight daily for 14 days

ACT -AL : Not recommended during the 1st trimester of pregnancy and for children weighing < 5 kg

Mixed (vivax & falciparum) Malaria (from States other than NE)Age Day 1 Day 2 Day 3

PQ* : O.25 mg per kg body weight daily for 14 days

PQ*(2.5mg)

(Extra to ACT-SP Kit))

Day 4 to 15

AS SP AS ASPQ*

(2.5mg)(Extra to ACT-SP Kit))

PQ*(2.5mg)

(Extra to ACT-SP Kit))Less than 1 year

(Pink blister)1

( 25mg) 1 (250+12.5mg)1

( 25mg) 01

( 25mg) 0 0

1-4 yrs(Yellow Blister)

1 (50mg)

1(500+25mg)

1 (50mg) 1

1 (50mg) 1 1

5-8 yrs(Green Blister)

1 (100 mg) 1 (750+37.5mg)

1 (100 mg)

2 1 (100 mg)

2 2

9-14 yrs(Red Blister)

1 (150mg)

2 (500+25mg)

1 (150mg) 4

1 (150mg) 4 4

15 yrs and more(White Blister)

1 (200mg)

2 (750+37.5mg)or

3 (500+25mg)

1 (200mg)

6 1 (200mg)

6 6

Plasmodium falciparum Malaria (From North Eastern States)Age Day 1 Day 2 Day 3

PQ* : 0.75mg per kg body weight on day 2

ACT - AL(Artemether + Lumefantrine)

(20mg + 120mg)


(20mg + 120mg)

PQ*(7.5mg)



(20mg + 120mg)

5m-2 Yrs (5-14kg)(Yellow blister)



5m - < 1yr : 0>1yr - < 2 yr : 1


3-8 Yrs (15-24kg)2 Tablet twice daily

(2 - 0 - 2)2 Tablet twice daily

(2 - 0 - 2)2 2 Tablet twice daily

(2 - 0 - 2)9-14 Yrs

(25-35kg)3 Tablet twice daily

(3 - 0 - 3)3 Tablet twice daily

(3 - 0 - 3)4 3 Tablet twice daily

(3 - 0 - 3)15 yrs and

more (More than35 kg




ACT -AL : Not recommended during the 1st trimester of pregnancy and for children weighing < 5 kg

Plasmodium falciparum Malaria (from States other than NE)Age Day 1 Day 2 Day 3

AS SP AS

PQ*(7.5mg)

(Extra to ACT-SP Kit)Less than 1 year

(Pink blister)1

( 25mg) 1 (250+12.5mg) 1(25mg) 0

AS

1( 25mg)

1-4 yrs(Yellow Blister)

1( 50mg) 1 (500+25mg) 1

(50mg) 1 1( 50mg)

5-8 yrs(Green Blister)

1( 100mg) 1 (750+37.5mg) 1

(100mg)

4

1( 100mg)

9-14 yrs(Red Blister)

1( 150mg) 2 (500+25mg) 1

(150mg)

2

1( 150mg)

15 yrs and more(White Blister)

1( 200mg)

2 (750+37.5mg)or

3 (500+25mg)

1(200mg) 6 1

( 200mg)

PQ* : 0.75mg per kg body weight on day 2

10

PQ*(2.5mg)


5m - < 1yr : 0>1yr - < 2 yr : 1

>2yr - < 5 yr : 1>5yr -< 9 yr : 2

4

6

Day 4-15

VIRAL HEPATITIS- MANAGEMENT GUIDELINECase Definition

Patient with Sudden onset of fever with mlaise, anorexia, vomiting, ab-dominal discomfort following jaun-dice within few days occurrence ofsimilar cases from a locality in-creases the suspision of feco orallytransmitted infection. History ofhigh risk sexual behaviour or con-tact with blood or blood productsindicates parentally translitted infec-tion

Patient with history of symptoms of the sus-pected case, along with the laboratory find-ings suggestive of altered liver function:a) altered serum bilirubin: Normal

level<1mg/dljaundice usually becomes aparant at lev-els over >2mg/dl

b) Elevated amino transferace:i) Aspartate amino transferace (AST)-

Normal level for adults 10-35 U/Litii) Alanine amino transferace (ALT) nor-

mal level for adults- 10- 45U/lit

Probable caseSupect Case Confirmed case

A patient with hystory, symp-toms, and laboratory findingsof the suspected case alongwith serologic evidenceagainst specific hepatitis vi-ruses or detection of viralparticiles.

Specific DiagnosisTypes of Healtitis Specific tests for confirmatory case

Hepatis A IgM (Anti- HAV)Hepatis B

specific Antigen HBsAg (surface Antigen), HBcAg (Core Antigen), HBeAgspecific Antibody IgM (Anti- HBc)

Hepatis C Anti- HCV/ HCV RNA in serumHepatis D Anti- HDV/ HDV RNA in serumHepatis E Anti- HEV/ HEV RNA in serum

Level clinical Features Investigations Management Referral criteria

Primary care facility-PHC/ CHC/ singledoctor/ few doctorclinic

Spcialty Hospitals-THQH/FRU/ MajorHospitals

Ter tiary Carecentres- MCH/Majorprivate Hospitals

Sudden onset of fever withmlaise, anorexia, vomiting,abdominal discomfor tfollowing jaundice withinfew days

Signs of hepaticencephalopathy, deepjaundice, intractablevomiting posing risk ofdehydration

In advanced stage of illness,or with complications;hepatitis already confirmed;

BRE, SerumBilirubin, LFT

SerumBilirubin, LFT,HBsAg

LFT, Specificdiagnosis (SeeTable 2), Liverbiopsy

Bed rest till jaundice is completely resolved;most drugs are to be avoided during acutehepatitis but antipyretics and anti emiticsmay be used till patient is symptomaticwith: paracetamol 10-15mg/kg for childrenand 0.5-1g X three time a day,metachlopromide, 0.2 mg/kg for children,10mg for adults 3-4 times per day

Essentially supportive; IV Fluids,

Constant close monitoring of liver functionparameters; ICU care with absolute bed rest,low protein diet, enemas to cleanse bowel,oral neomycin, all sedatives contra indicated, watchfor GI bleeding, monitor level of coma

Signs of hepaticencepha lopa thy,deep jaundice,pregnancy in thirdtrimester, intractablevomiting posing riskof dehydration

In case of no sign ofimprovement in 2-3days

11

Cardinals signs

1. Anesthetic Patch,2. Thickened Peripheral Nerve,3. Smear Positive

Diagnostic Criteria

Symptoms Paucibacillary (PB) Multi Bacillary (MB)

Anesthetic Patch 1 - 5 numbers Above 5 numbers

Thickness and Tenderness No or only one nerve involved More than one nerve involved

Smear Examination Negative in all patches Positive in anyone or more patch/ nerve

* Positive for any one of the three criteria for MB will be treated as MB

Treatment Protocol

Age Paucibacillary (PB)(duration- 6 months)

Multi Bacillary (MB)(duration 12 months)

Rifampicin Dapsone Rifampicin Dapsone Clofazimine

more than14 years

10-14 years

Less than 10 years

600 mg 100 mg 600 mg 100 mg 300mg - once in a month50mg daily

450 mg 50 mg 450 mg 50 mg 150mg - once in a month50mg alternate days

300 mg 25 mg 300 mg 25 mg 100mg - once in a month50mg twice a week

DEPARTMENT OFHEALTH AND FAMILY WELFARE

GOVERNMENT OF KERALA

LEPROSY- TREATMENTGUIDELINE

12

TUBERCULOSIS (RNTCP) TREATMENT REGIMEN

Cat I: This category is generally prescribed to new sputum smear positive cases.

Cat II: This category is generally prescribed to patients who have previous anti tuberculartreatment.

Paediatric TB: This category is for treating children who are infected with mycobacteriumtuberculosis.

Cat IV/MDR TB: This category is for treating patients who are infected with specific form ofdrug resistant mycobacterium tuberculosis.

Category of treatment Type of Patient Regimen

Category INew sputum smear-positive sputumsmear-negative extra-pulmonary

2(HRZE)3+4(HR)3

Category II

Sputum smear-positive relapseSputum smear-positive failure Sputumsmear-positive treat-ment after defaultothers. EP.Pul –neg.

2(HRZES)3+1(HRZE)35(HRE)3

Medication Dose(thrice a week) Number of pills in combipack

Isoniazid 600 mg (300x2)

Rifampicin 450 mg (450x1)

Pyrazinamide 1500 mg (750x2)

Ethambutol 1200 mg (600x2)

Streptomycin 0.75 g

Treatment Regimens

Information of the dosage is shown on the chart given bellow.

13

In Paediatric case the regimen is same but dosage is adjusted according to the weight of patient.

Pediatric regimen

Suggested paediatric dosage for intermittent therapyDrugs Dosage(Thrice a week)

Isoniazid 10-15 mg/kgRifampicin 10mg/kgPyrazinamide 30-35 mg/kgEthambutol 30 mg/kgStreptomycin 15 mg/kg

Regimen for MDR –TBThis regime comprises of 6 drugs- Kanamycin, Levofloxacin, Ethionamide, Pyrazinamide, Ethambutol and Cycloserineduring 6-9 months of intensive phase and 4 drugs Levoflox,Ethionamide,Ethambutol and cycloserine during the 18months of the continuation phase.Pyridoxin should be administered to all patients on regime for MDR TB.

Regimen for MDR TB drugs and band recommendationsSL No Drugs 16-25 Kgs 26-45 Kgs >45 Kgs

1 Kanamycin 500 mg 500 mg 750 mg2 Levofloxacin 250 mg 750 mg 1000 mg3 Ethionamide 375 mg 500 mg 750 mg4 Ethamvuton 400 mg 800 mg 1200 mg5 Pyrazinamide 500 mg 1250 mg 1500 mg6 Cycloserane 250 mg 500 mg 750 mg7 Pyridoxine 50 mg 100 mg 100 mg

Na-PAS(80% weight/volume)2 5 gm 10 gm 10 gmMoxifloxacin 400mg 400mg 400mgCapreomycin 500mg 750mg 1000mg

Drug Daily Dosage-mg/kg body wtkanamycin 15-30Levofloxacin 7.5-10Ethionamide 15-20Cycloserane 15-20Ethamvuton 25Pyrazinamide 30-40Na-PAS 150

Drug regimen for MDR Paediatric age group less than 16 kg

For more details and latest updates please visit the web site www.tbcindia.nic.in

14

TREATMENT PROTOCOL FOR DIABETES MELLITUS

• Assess habits - Tobacco use, Alcohol use, Diet and Exercise• Check height, weight and calculate BMI• Check BP and RBS

If RBS < 200 mg%

Reassess when develops diabeticsymptoms or every 2 years

If RBS > 200 mg% check FBS and PPBS

If FBS < 126 mg% and PPBS <200 mg% Advise LSM

If FBS> 126 mg% and orPPBS > 200 mg%

Advise LSM and refer to MO

If BMI < 23 & no highrisk behaviour reassess

every 6 months

If BMI >23 or have highrisk behaviour reassess

every 3 months

Tab Metformin 500 mg OD or BIDReassess monthly and may increase upto 2000 mg per day in 2 divided doses

Monitor abnormal value monthly

If no complication recheck after one month If complications1. Foot ulcer2. Nephropathy3. Retinopathy4. Neuropathy5. Sepsis

If undercontrolcontinue andreassess every3 months

If not under control addone second drug1. Glibenclamide 2.5 mg to 10 mg2. Glypizide 2.5 mg to 5 mg BID3. Glimepride 1 mg to 4 mg Refer to Physician

If not under control refer toHospital/Physician to start Insulin

If under control continueand reassess 3 months

State NCD DivisionGovernment of Kerala

LSMLife Style Modification

• Restrict sugar and sweets• Restrict fatty and fried

foods• Increase fibre rich food

(leafy vegetables)• Substitute as much starch

(rice, wheat, tubers) withvegetables

• Brisk walking for 20 - 30min• 5 to 6 days a week• 5 minutes warm up• 5 minutes cool down

• Avoid tobacco &alcohol use

BMI

18.5-22.9: Normal23.0-24.9: Overweight

>25.0: Obese

Screen all individuals of age above 30 years

15

16

Healthcare

Treatment protocols managment guidelines for major communicable and nc ds