abstract mosquitotransmitted arbovirus constitute a large proportion of emerging infectious disease that are both a public health problem and a threat to animal population many such virus were identified in east africa a region where they remain important and from where new arbovirus may emerge we set out to describe and review the relevant mosquitoborne virus that have been identified specifically in uganda we focused on the discovery burden mode of transmission animal host and clinical manifestation of those previously involved in disease outbreak a search for mosquitoborne arbovirus detected in uganda wa conducted using search term arbovirus in uganda and mosquito and virus in uganda in pubmed and google scholar in twentyfour mosquitoborne virus from different animal host human and mosquito were documented the majority of these were from family peribunyaviridae followed by flaviviridae togaviridae phenuiviridae and only one each from family rhabdoviridae and reoviridae sixteen of the virus were associated with febrile illness ten of them were first described locally in uganda six of these are a public threat a they have been previously associated with disease outbreak either within or outside uganda historically there is a high burden and endemicity of arbovirus in uganda given the many diverse mosquito specie known in the country there is also a likelihood of many undescribed mosquitoborne virus next generation diagnostic platform have great potential to identify new virus indeed four novel virus two of which were from human ntwetwe and nyangole virus and two from mosquito kibale and mburo virus were identified in the last decade using next generation sequencing given the unbiased approach of detection of virus by this technology it use will undoubtedly be critically important in the characterization of mosquito viromes which in turn will inform other diagnostic effort keywords uganda history mosquitoborne arbovirus outbreak abstract background there is a critical need to identify the driver of willingness to receive new vaccine against emerging and epidemic disease a discrete choice experiment is the ideal approach to evaluating how individual weigh multiple attribute simultaneously we assessed the degree to which six attribute were associated with willingness to be vaccinated among university student in uganda method we conducted a singleprofile discrete choice experiment at makerere university in participant were asked whether or not they would be vaccinated in unique scenario where attribute varied by disease risk disease severity advice for or against vaccination from trusted individual recommendation from influential figure whether the vaccine induced indirect protection and side effect we calculated predicted probability of vaccination willingness using mixed logistic regression model comparing health professional student with all other discipline finding of the participant were health professional student and were female vaccination willingness wa high and higher among health student than other student we observed the highest vaccination willingness for the most severe disease outcome and the greatest exposure risk along with the minister of health recommendation or a vaccine that extended secondary protection to others mild side effect and recommendation against vaccination diminished vaccination willingness interpretation our result can be used to develop evidencebased messaging to encourage uptake for new vaccine future vaccination campaign such a for covid vaccine in development should consider acknowledging individual risk of exposure and disease severity and incorporate recommendation from key health leader abstract background the burden of malaria infection in subsaharan africa among schoolaged child aged year is underappreciated and represents an important source of humantomosquito transmission of plasmodium falciparum additional intervention are needed to control and eliminate malaria we aimed to assess whether preventive treatment of malaria might be an effective mean of reducing p falciparum infection and anaemia in schoolaged child and lowering parasite transmission method in this systematic review and two metaanalyses we searched the online database pubmed embase cochrane central and clinicaltrialsgov for intervention study published between jan and dec we included randomised study that assessed the effect of antimalarial treatment among asymptomatic schoolaged child aged year in subsaharan africa on prevalence of p falciparum infection and anaemia clinical malaria and cognitive function we first extracted data for a studylevel metaanalysis then contacted research group to request data for an individual participant data metaanalysis outcome of interest included prevalence of p falciparum infection detected by microscopy anaemia study defined value or haemoglobin less than ageadjusted and sexadjusted value clinical malaria infection and symptom on the basis of studyspecific definition during followup and code transmission test score we assessed effect by treatment type and duration of time protected and explored effect modification by transmission setting for studylevel metaanalysis we calculated risk ratio for binary outcome and standardised mean difference for continuous outcome and pooled outcome using fixedeffect and randomeffects model we used a hierarchical generalised linear model for metaanalysis of individual participant data this study is registered with prospero crd finding of study identified were eligible for the studylevel metaanalysis n researcher from study contributed data on at least one outcome n for an individual participant data metaanalysis intervention and study design were highly heterogeneous overall risk of bias wa low in the studylevel metaanalysis treatment wa associated with reduction in p falciparum prevalence risk ratio rr ci anaemia and clinical malaria result for cognitive outcome are not presented because data were only available for three trial in our individual participant data metaanalysis we found treatment significantly decreased p falciparum prevalence adjusted rr arr ci p individual study anaemia arr p individual study and subsequent clinical malaria arr p individual four study across transmission setting we detected a marginal effect on cognitive function in child older than year adjusted mean difference in standardised test score p individual five study although we found no significant effect when combined across all age interpretation preventive treatment of malaria among schoolaged child significantly decrease p falciparum prevalence anaemia and risk of subsequent clinical malaria across transmission setting policy maker and programme manager should consider preventive treatment of malaria to protect this age group and advance the goal of malaria elimination while weighing these benefit against potential risk of chemoprevention funding u national institute of health and burroughs wellcome fundastmh fellowship abstract introduction in india contributed for of malaria case and of death in the south east asia region here we systematically and critically analyzed data published on malaria in pregnancy mip in india method epidemiological clinical parasitological preventive and therapeutic aspect of mip and it consequence on both mother and child were reviewed and critically analyzed knowledge gap and solution way are also presented and discussed several electronic database including google scholar google pubmed scopus wiley online library the malaria in pregnancy consortium library the world malaria report the who regional website and clinicaltrialsgov were used to identify article dealing with mip in india the archive of local scientific associationsjournals and website of national program were also consulted result malaria in pregnancy is mainly due to plasmodium falciparum pf and p vivax pv and on rare occasion to p ovale spp and p malariae too the overall prevalence of mip is for peripheral malaria and for placental malaria peripheral pf infection at antenatal care anc visit decreased from in to in in madhya pradesh while placental pf infection at delivery unit slightly decreased from in to in in jharkhand in contrast the prevalence of peripheral pv infection at anc increased from in to in in jharkhand and from in to in in chhattisgarh clinical presentation of mip is diverse ranging from asymptomatic carriage of parasite to severe malaria and associated with comorbidities and concurrent infection such a malnutrition covid dengue and cardiovascular disorder severe anemia cerebral malaria severe thrombocytopenia and hypoglycemia are commonly seen in severe mip and are strongly associated with tragic consequence such a abortion and stillbirth congenital malaria is seen at prevalence of infected baby are generally smallforgestational age premature with low birthweight and suffer mainly from anemia thrombocytopenia leucopenia and clinical jaundice main challenge and knowledge gap to mip control included diagnosis relapsing malaria mixed plasmodium infection treatment selfmedication low density infection and utility of artemisininbased combination therapy conclusion all taken together the finding could be immensely helpful to control mip in malaria endemic area keywords india epidemiology malaria outcome pregnancy prevention treatment abstract purpose of review malaria case and death decreased from to but remain increased since several new development and strategy could help reverse this trend the purpose of this review is to discus new world health organization who guideline and recent research on malaria prevention in child recent finding fifteen country have now rolled out seasonal malaria chemoprophylaxis smc in child at highest risk for severe malaria and new who recommendation provide more flexibility for smc implementation in term of target age group geographic region and number of cycle recent study confirm that malaria burden in school aged child and their contribution to transmission is high new guideline permit expanded chemoprevention option for these child two vaccine have been approved for use in malaria endemic country rtssas e and rmatrixm additionally pyrethroidchlorfenapyr bed net are being deployed to combat resistant mosquito summary while challenge remain in malaria control towards elimination new guideline and recently approved vaccine offer hope monitoring for continued vaccine and chemoprevention effectiveness and for possible epidemiologic shift in severe malaria presentation and death a additional prevention effort roll out will be paramount abstract background lao pdr ha made significant progress in malaria control the national strategic plan outline ambitious target aiming for the elimination of plasmodium falciparum and p vivax malaria from all northern province by and national elimination by this article present an overview of malaria epidemiology surveillance and response system in lao pdr emphasizing experience and achievement in transmission reduction method data on surveillance monitoring and evaluation system human resource infrastructure and community malaria knowledge during were systematically gathered from the national program and relevant document the collected information wa synthesized and discussion on challenge and future prospect were provided result malaria control and elimination activity in lao pdr were implemented at various level with a focus on health facility catchment area there ha been significant progress in reducing malaria transmission throughout the country targeted intervention such a case management vector control and community engagement using stratification of control intervention by catchment area have contributed to the decline in malaria case in elimination area active surveillance strategy including case and focus investigation are implemented to identify and stop transmission the surveillance system ha facilitated timely detection and response to malaria case enabling these targeted intervention in higherrisk area conclusion the malaria surveillance and response system in lao pdr ha played a crucial role in reducing transmission and advancing the country towards elimination challenge such a importation drug resistance and sustaining support require ongoing effort further strengthening surveillance improving access to service and addressing transmission determinant are key area of focus to achieve malaria elimination and enhance population health in lao pdr keywords elimination epidemiology lao pdr malaria surveillance abstract background plasmodium falciparum is the dominant malaria specie in the subsaharan africa and the main cause of severe disease and death notwithstanding severe malaria and death due to nonfalciparum infection have been reported but at much lower rate than p falciparum infection following increasing use of molecular detection technique in epidemiological study a higher prevalence of nonfalciparum specie ha been reported in the region than previously thought this article review the literature on the prevalence of nonfalciparum malaria specie in uganda and the clinical figure of their severe disease it aim to elucidate the extent to which mono nonfalciparum malaria infection in a highly malariaendemic country contribute to malaria mortality and outline it policy implication on malaria case management method the available englishlanguage published peerreviewed literature up to march wa sought via pubmed and google scholar the keywords used were severe malaria and p falciparum p malariae p vivax p ovale spp mixed infection and uganda the review encompassed article article using molecular diagnosis method were accounted for analysis result the literature reported a substantial prevalence of nonfalciparum infection in uganda plasmodium malariae and plasmodium ovale spp were the second and third most prevalent reported malaria specie respectively after p falciparum a dominant specie nonfalciparum malaria infection often occur a mixed infection rather than monoinfections besides molecular diagnostics revealed that of initially reported monoinfections of p falciparum were in fact mixed infection no article wa found on the prevalence of severe malaria or case fatality rate due to mixed or nonfalciparum infection conclusion a critical knowledge gap exists regarding the impact of mixed and nonfalciparum specie on severe malaria and death in uganda robust evidence on prevalence recurrent parasitaemia and severe clinical manifestation of mixed and nonfalciparum malaria infection is crucial for evidencebased and effective policymaking regarding malaria case management keywords p falciprum p malariae p ovale spp p vivax mixed infection nonfalciparum severe malaria uganda abstract introduction map of malaria risk are important tool for allocating resource and tracking progress most map rely on crosssectional survey of parasite prevalence but health facility represent an underused and powerful data source we aimed to model and map malaria incidence using health facility data in uganda method using month of individuallevel outpatient data collected from surveillance health facility located in district across uganda n laboratoryconfirmed case we estimated monthly malaria incidence for parish within facility catchment area n by estimating careseeking population denominator we fit spatiotemporal model to the incidence estimate to predict incidence rate for the rest of uganda informed by environmental sociodemographic and intervention variable we mapped estimated malaria incidence and it uncertainty at the parish level and compared estimate to other metric of malaria to quantify the impact that indoor residual spraying irs may have had we modelled counterfactual scenario of malaria incidence in the absence of irs result over parishmonths malaria incidence averaged case per personyears map indicated high burden in the north and northeast of uganda with lower incidence in the district receiving irs districtlevel estimate of case correlated with case reported by the ministry of health spearmans r p but were considerably higher case estimated compared with case reported indicating the potential for underreporting by the routine surveillance system modelling of counterfactual scenario suggest that approximately million case were averted due to irs across the study period in the district receiving irs estimated population conclusion outpatient information routinely collected by health system can be a valuable source of data for mapping malaria burden national malaria control programme may consider investing in robust surveillance system within public health facility a a lowcost high benefit tool to identify vulnerable region and track the impact of intervention keywords epidemiology geographic information system malaria abstract background while of million global malaria case are reported in uganda it is also a top refugee hosting country in africa with over million refugee despite malaria being an emerging challenge for humanitarian response in refugee settlement little is known about it risk factor this study aimed to investigate the risk factor for malaria infection among child under year of age in refugee settlement in uganda method we utilized data from uganda malaria indicator survey which wa conducted between december and february at the peak of malaria season in this national survey household level information wa obtained using standardized questionnaire and a total of child under year of age were tested for malaria using mainly the rapid diagnostic test we focused on malaria tested child under five in refugee settlement located in yumbe arua adjumani moyo lamwo kiryadongo kyegegwa kamwenge and isingiro district the extracted variable included prevalence of malaria demographic socialeconomic and environmental information multivariable logistic regression wa used to identify and define the malaria associated risk factor result overall malaria prevalence in all refugee settlement across the nine hosting district wa malaria infection were higher in refugee settlement located in isingiro kyegegwa and arua district several risk factor were significantly associated with acquisition of malaria including fetching water from open water source adjusted odds ratio aor ci p boreholes aor ci p and water tank aor ci p other factor included pitlatrines aor ci p open defecation aor ci p lack of insecticide treated bed net aor ci p and knowledge on the cause of malaria aor ci p conclusion the persistence of the malaria infection were mainly due to open water source poor hygiene and lack of preventive measure that enhanced mosquito survival and infection malaria elimination in refugee settlement requires an integrated control approach that combine environmental management with other complementary measure like insecticide treated bed net indoor residual spraying and awareness keywords child household malaria refugee risk factor settlement uganda abstract background understanding the relationship between malaria infection risk and disease outcome represents a fundamental component of morbidity and mortality burden estimation contemporary data on severe malaria risk among population of different parasite exposure are scarce using surveillance data we compared rate of paediatric malaria hospitalisation in area of varying parasite exposure level method surveillance data at five public hospital jinja mubende kabale tororo and apac were assembled among admission aged month to year between and the address of each admission wa used to define a local catchment population where national census data wa used to define personyearexposure to risk within each catchment historical infection prevalence wa assembled from previously published data and current infection prevalence defined using populationbased school survey among child poisson regression wa used to compute the overall and sitespecific incidence with confidence interval result both current and historical plasmodium falciparum prevalence varied across the five site current prevalence ranged from in kabale to in apac overall the malaria admission incidence rate ir wa per person year among child aged month to year of age ci the lowest rate wa described at kabale ir ci and highest at apac ir ci there wa a correlation between ir across the five site and the current parasite prevalence in school child though finding were not statistically significant across all site except kabale malaria admission were concentrated among young child were under year the median age of malaria admission at kabale hospital wa month iqr and at apac hospital wa month iqr overall severe anaemia wa the most common presentation and unconsciousness the least common conclusion malaria hospitalisation rate remain high in uganda particularly among young child the incidence of hospitalized malaria in different location in uganda appears to be influenced by past parasite exposure immune acquisition and current risk of infection interruption of transmission through vector control could influence agespecific severe malaria risk keywords age hospitalized incidence malaria uganda abstract background malaria is a critical global health issue particularly for child in endemic region however factor associated with recurrent severe malaria in child under year of age in northern uganda are poorly understood this study aimed to identify factor associated with readmission due to severe malaria within six month postdischarge among child in this age group method a crosssectional study wa conducted in otuke district encompassing twelve health facility a total of caregiver of child admitted with severe malaria were interviewed and hospital record were reviewed to verify the readmission data the primary outcome assessed wa readmission with severe malaria within six month after initial discharge data analysis wa performed via stata version result the prevalence of readmission with severe malaria among child under year of age wa factor significantly associated with readmission included having sickle cell anaemia adjusted prevalence ratio apr confidence interval ci living in house constructed with straw and thatch wall apr ci and seeking care after h when the child ha a fever apr ci conclusion the finding indicate a high proportion of severe malaria readmission in child under year of age sickle cell anaemia living in house built using straw and thatch wall and seeking care after h when a child ha fever were the key risk factor for readmission with severe malaria this study highlight the importance of targeted postdischarge intervention such a prophylactic antimalarial in addition to bed net to prevent recurrent infection especially among child with sickle cell disease in addition improvement in housing quality and timely treatment of child with malaria are essential for reducing the burden of malaria particularly in endemic region keywords associated factor child child under year of age readmission severe malaria uganda abstract background routine malaria surveillance data in africa primarily come from public health facility reporting to national health management information system although information on gender is routinely collected from patient presenting to these health facility stratification of malaria surveillance data by gender is rarely done this study evaluated gender difference among patient diagnosed with parasitological confirmed malaria at public health facility in uganda method this study utilized individual level patient data collected from january through april at public health facility in uganda and crosssectional survey conducted in target area around these facility in april association between gender and the incidence of malaria and nonmalarial visit captured at the health facility from patient residing within the target area were estimated using poisson regression model controlling for seasonality association between gender and data on healthseeking behaviour from the crosssectional survey were estimated using poisson regression model controlling for seasonality result overall incidence of malaria diagnosed per person year wa among female and among male irr ci p with larger difference among those year irr ci p and over year irr ci p compared to those under year irr ci p female gender wa also associated with a higher incidence of visit where malaria wa not suspected irr ci p with a similar pattern across age stratum these association were consistent across the individual health centre from the crosssectional survey female were more likely than male to report fever in the past week and seek care at the local health centre v p with these association significant for those year rr ci p and over year rr ci p conclusion female disproportionately contribute to the burden of malaria diagnosed at public health facility in uganda especially once they reach childbearing age contributing factor included more frequent visit to these facility independent of malaria and a higher reported risk of seeking care at these facility for febrile illness keywords age difference gender incidence malaria routine surveillance abstract background globally nearly half of all death among child under the age of year can be attributed to malaria diarrhoea and pneumonia a significant proportion of these death occur in subsaharan africa despite several programme implemented in subsaharan africa the burden of these illness remains persistently high to mobilise resource for such programme it is necessary to evaluate their cost costseffectiveness and affordability this study aimed to estimate the provider cost of treating malaria diarrhoea and pneumonia among child under the age of year in routine setting at the health facility level in rural uganda and mozambique method service and cost data wa collected from health facility in midwestern uganda and inhambane province mozambique from private and public health facility financial and economic cost of providing care for childhood illness were investigated from the provider perspective by combining a topdown and bottomup approach to estimate unit cost and annual total cost for different type of visit for these illness all cost were collected in ugandan shilling and mozambican meticais cost are presented in u dollar result in uganda the highest number of outpatient visit were for child with uncomplicated malaria and of inpatient admission were for respiratory infection including pneumonia the highest unit cost for outpatient visit wa for pneumonia and other respiratory infection and ranged from to while the highest unit cost for inpatient admission wa for malaria in mozambique the highest number of outpatient and inpatient admission visit were for malaria the highest unit cost were for malaria too ranging from to for outpatient visit and for inpatient admission the greatest contributor to cost in both country were drug and diagnostics followed by staff conclusion the finding highlighted the intensive resource use in the treatment of malaria and pneumonia for outpatient and inpatient case particularly at higher level health facility timely treatment to prevent severe complication associated with these illness can also avoid high cost to health provider and household trial registration clinicaltrialsgov identifier nct keywords cost diarrhoea malaria mozambique pneumonia uganda abstract background few recent description of severe childhood malaria have been published from hightransmission region in the current study the clinical epidemiology of severe malaria in mbale eastern uganda is described where the entomological inoculation rate exceeds infective bite per year method a prospective descriptive study wa conducted to determine the prevalence clinical spectrum and outcome of severe plasmodium falciparum malaria at mbale regional referral hospital in eastern uganda all child aged month year who presented on monday to friday between am and pm from th may until th april were screened for parasitaemia clinical and laboratory data were then collected from all p falciparum positive child with feature of whodefined severe malaria by use of a standardized proforma result a total of child were screened of which had a positive blood film of these child had clinical feature of severe malaria and were consented for the current study respiratory distress wa the most common severity feature while had hyperparasitaemia had clinical jaundice had severe anaemia had hyperlactataemia lactate mmoll had passed dark red or black urine had impaired consciousness and had hypoxaemia oxygen saturation inhospital mortality wa overall but wa higher in child with either cerebral malaria or severe anaemia factor that were independently associated with mortality on multivariate analysis included severe anaemia odds ratio or p hyperlactataemia or p hypoxaemia or ci p and hepatomegaly or p no independent association wa found between mortality and either coma or hyperparasitaemia conclusion severe childhood malaria remains common in eastern uganda where it continues to be associated with high mortality an unusually high proportion of child with severe malaria had jaundice or gave a history of having recently passed dark red or black urine an issue worthy of further investigation keywords child dark red or black urine p falciparum malaria severe anaemia severe malaria uganda abstract background accurate measure of malaria incidence are essential to track progress and target highrisk population while health management information system hmis data provide count of malaria case quantifying the denominator for incidence using these data is challenging because catchment area and careseeking behaviour are not well defined this study aim wa to estimate malaria incidence using hmis data by adjusting the population denominator accounting for travel time to the health facility method outpatient data from two public health facility in uganda kihihi and nagongera over a year period were used to model the relationship between travel time from patient village of residence available for each individual to the facility and the relative probability of attendance using poisson generalized additive model output from the model were used to generate a weighted population denominator for each health facility and estimate malaria incidence among child aged month to year monthly hmisderived incidence estimate with and without population denominator weighted by probability of attendance were compared with gold standard measure of malaria incidence measured in prospective cohort result a total of outpatient visit were recorded across the two site over the study period hmis incidence correlated with cohort incidence over time at both study site correlation in kihihi p correlation in nagongera p hmis incidence measure with denominator unweighted by probability of attendance underestimated cohort incidence aggregated over the year in kihihi case per personyear ppy v case ppy and nagongera case ppy v case ppy hmis incidence measure with denominator weighted by probability of attendance were closer to cohort incidence but remained underestimate case ppy in kihihi and case ppy in nagongera conclusion although malaria incidence measured using hmis underestimated incidence measured in cohort even when adjusting for probability of attendance hmis surveillance data are a promising and scalable source for tracking relative change in malaria incidence over time particularly when the population denominator can be estimated by incorporating information on village of residence keywords health facility health management information system incidence malaria surveillance uganda abstract background in subsaharan africa ssa malaria remains a public health problem despite recent report of declining incidence severe malaria is a multiorgan disease with wideranging clinical spectrum and outcome that have been reported to vary by age geographical location transmission intensity over time there are report of recent malaria epidemic or resurgence but few data if any focus on the clinical spectrum of severe malaria during epidemic this describes the clinical spectrum and outcome of childhood severe malaria during the disease epidemic in eastern uganda method this prospective cohort study from october to september wa nested within the malaria epidemiological pathophysiological and intervention study in highly endemic eastern uganda tmasfmepie study at mbale regional referral hospital uganda child aged day to year who at admission tested positive for malaria and fulfilled the clinical who criterion for surveillance of severe malaria were enrolled on the study followup wa performed until day data were collected using a customized proforma on social demographic characteristic clinical presentation treatment and outcome laboratory analysis included complete blood count malaria rdt sd bioline malaria ag pfpan ref fk and blood slide lactate glucose blood gas and electrolyte in addition urinalysis using dipstick multistix sg siemens ref at the bedside wa done data were analysed using stata v the study had prior ethical approval result a total of participant were recruited the median age wa year mean of month and iqr of month many child were under year and were male the common clinical feature were prostration jaundice in severe malarial anaemia in black water fever and multiple convulsion impaired consciousness acidosis respiratory distress and coma in prolonged hospitalization wa found in and wa associated with acidosis p the overall mortality wa day followup wa achieved in conclusion during the malaria epidemic in eastern uganda severe malaria affected much older child and the spectrum had more of prostration jaundice severe malarial anaemia black water fever and multiple convulsion with less of earlier reported respiratory distress and cerebral malaria keywords child clinical spectrum prolonged hospitalization and mortality severe malaria abstract background the risk of widespread resistance to artemisininbased combination therapy act remains high in uganda following detection of plasmodium falciparum parasite with delayed artemisinin clearance genotype and phenotype establishment of context specific intervention to mitigate emergence and spread of artemisinin resistance is thus key in the fight against malaria in the country the aim of this study wa to explore the experience of healthcare personnel on malaria diagnosis and selfreported efficacy of act in the management of malaria symptomatic patient in hospital in low and high malaria transmission setting in uganda method this wa a qualitative study in which data wa collected from healthcare personnel in hospital using key informant interview the key informant interview guide wa developed pretested prior to use and covered the following area i sociodemographic characteristic ii malaria diagnosis clinical and parasite based iii qualityassured artemisininbased combination therapy iv malaria patient followup v artemisinin resistance vi antimalarial selfmedication data wa entered in atlasti ver and analysis done following a framework criterion result a total of respondent were interviewed of which were clinician majority of the respondent were male the following theme were developed from the analysis malaria diagnosis procedure and challenge use of malaria laboratory test result malaria treatment in hospital use of quality assured act qaact in malaria treatment and efficacy of act in malaria treatment conclusion most healthcare personnelinitiated malaria treatment after a positive laboratory test case of malaria patient who report remaining symptomatic after prior use of act exist especially in high malaria transmission setting in uganda there is need for regular monitoring of artemisinin resistance emergence and spread in the country keywords malaria microscopy policy rapid diagnostic test testandtreat abstract background malaria in pregnancy contributes to substantial morbidity and mortality among woman in uganda however there is limited information on the prevalence and factor associated with malaria in pregnancy among woman in arua district northwestern uganda we therefore assessed the prevalence and factor associated with malaria in pregnancy among woman attending routine antenatal care anc clinic at arua regional referral hospital in northwestern uganda method we conducted an analytic crosssectional study between october and december we used a paperbased structured questionnaire to collect data on maternal sociodemographic and obstetric factor and malaria preventive measure malaria in pregnancy wa defined a a positive rapid malarial antigen test during anc visit we performed a modified poisson regression analysis with robust standard error to determine factor independently associated with malaria in pregnancy reported a adjusted prevalence ratio apr and confidence interval ci result we studied pregnant woman with a mean age of year that attended the anc clinic all without symptomatic malaria of the participant were in their second or third trimester were first or secondtime pregnant woman and reported sleeping under insecticidetreated bednets itns every day the prevalence of malaria in pregnancy wa by rapid diagnostic testing rdt with the independently associated factor being daily use of insecticidetreated bednets apr ci first anc visit after week of gestation apr ci and being in the second or third trimester apr ci conclusion the prevalence of malaria in pregnancy among woman attending anc in this setting is high we recommend the provision of insecticidetreated bednets to all pregnant woman and early anc attendance to enable access to malaria preventive therapy and related intervention abstract background appropriate malaria management is a key malaria control strategy the objective of this study wa to determine health care worker adherence level to malaria case management guideline in the busoga subregion uganda method health facility assessment health care worker hcw and patient exit interview pei survey were conducted at government and private health facility in the subregion all health centre hc iv iii and a sample of hc ii representative of the tiered structure of outpatient service delivery at the district level were targeted hcws at these facility were eligible for participation in the study for pei patient of all age presenting with a history of fever for outpatient care at selected facility in each district were targeted patient outcome measure included testing rate adherence to treatment dispensing and counselling service a per national guideline the primary outcome wa appropriate malaria case management defined a the proportion of patient tested and only prescribed artemetherlumefantrine al if positive hcw readiness eg training supervision and health facility capacity eg availability of diagnostics and antimalarial to provide malaria case management were also assessed data were weighted to cater for the disproportionate representation of hc ii in the study sample result a total of patient and hcw from facility were considered in the analysis the median age of patient wa year majority female most facility were hciis and were owned by the government malaria testing service were available at of facility al wa in stock at facility of those with a positive result nearly all were prescribed an antimalarial with al accounting for most prescription among those prescribed al were given al at the facility lowest at hc iv and government owned facility corresponding to al stock level overall ci of all enrolled patient received appropriate malaria case management however only of patient seen at pfps received appropriate malaria management conclusion adherence level to malaria case management guideline were good but with gap noted mainly in the private sector the supply chain for al need to be strengthened intervention to improve practise at pfp facility should be intensified keywords adherence malaria case management uganda abstract background few study have explored how vector control intervention may modify association between environmental factor and malaria method we used weekly malaria case reported from six public health facility in uganda environmental variable temperature rainfall humidity and vegetation were extracted from remote sensing source the nonlinearity of environmental variable wa investigated and negative binomial regression model were used to explore the influence of indoor residual spraying irs and longlasting insecticidal net llins on association between environmental factor and malaria incident case for each site a well a pooled across the facility with or without considering the interaction between environmental variable and vector control intervention result an average of weekly malaria case per site range occurred between and from the pooled model malaria risk related to environmental variable wa reduced by about with llins and with irs significant interaction were observed between some environmental variable and vector control intervention there wa sitespecific variability in the shape of the environmentmalaria risk relationship and in the influence of intervention to reduction in case with llins and to with irs conclusion the influence of vector control intervention on the malariaenvironment relationship need to be considered at a local scale in order to efficiently guide control program keywords bednets control environment epidemiology indoor residual spraying malaria prevention abstract background malaria risk factor at household level are known to be complex uncertain stochastic nonlinear and multidimensional the interplay among these factor make targeted intervention and resource allocation for malaria control challenging however few study have demonstrated malaria transmission complexity control and integrated modelling with no available evidence on uganda refugee settlement using the uganda malaria indicator survey umis data an alternative bayesian belief network bbn modelling approach wa used to analyse predict rank and illustrate the conceptual reasoning and complex causal relationship among the risk factor for malaria infection among child underfive in refugee settlement of uganda method in the umis household level information wa obtained using standardized questionnaire and a total of child under year were tested for malaria from the dataset a casefile containing malaria test result demographic socialeconomic and environmental information wa created the casefile wa divided into a training n and testing n datasets the training dataset wa used to develop the bbn model following well established guideline the testing dataset wa used to evaluate model performance result model accuracy wa with an area under the receiveroperating characteristic curve of the model spherical payoff wa with the logarithmic and quadratic loss of and respectively indicating a strong predictive and classification ability of the model the probability of refugee child testing positive and negative for malaria wa and respectively the top ranked malaria risk factor based on the sensitivity analysis included age of child roof material ie thatch roof wall material ie pole with mud and thatch wall whether child sleep under insecticidetreated net type of toilet facility used ie no toilet facility and pit latrine with slab walk time distance to water source between and min drinking water source ie open water source and piped water on premise conclusion ranking rather than the statistical significance of the malaria risk factor is crucial a an approach to applied research a it help stakeholder determine how to allocate resource for targeted malaria intervention within the constraint of limited funding in the refugee settlement keywords bayesian belief network child malaria ranking refugee risk factor settlement uganda abstract background village health worker vhws in uganda provide treatment for the childhood illness of malaria pneumonia and diarrhoea through the integrated community case management iccm strategy under the strategy child under five year receive treatment for these illness within h of onset of illness this study examined promptness in seeking treatment from vhws by child under five year with malaria pneumonia and diarrhoea in rural southwestern uganda method in august a database containing information from the vhws patient register over a year study period wa reviewed a total of child record drawn from village of bugoye subcounty kasese district were included in the study promptness wa defined a caregiver seeking treatment for a child from a vhw within h of onset of illness result sixtyfour percent of the child included in the study sought treatment promptly child with fever had the highest likelihood of seeking prompt treatment aor ci p a compared to those with diarrhoea aor ci p and pneumonia aor ci p conclusion the finding provide further evidence that vhws play a critical role in the treatment of childhood illness in rural context however the proportion of child seeking prompt treatment remains below the target set at the inception of the iccm strategy in uganda there is a need to continually engage rural community to promote modification of healthseeking behaviour particularly for child with danger sign evidence to inform the design of service and behaviour change communication can be provided through undertaking qualitative study to understand the underlying reason for decision about careseeking in rural setting codesign with community in these setting may increase the acceptability of these service keywords childhood illness community health worker promptness treatment abstract background the potential effect of sarscov and plasmodium falciparum coinfection on host susceptibility and pathogenesis remain unknown we aimed to establish the prevalence of malaria and describe the clinical characteristic of sarscov and p falciparum coinfection in a highburden malaria setting method this wa an exploratory prospective cohort study of patient with covid who were admitted to hospital in uganda patient of all age with a pcrconfirmed diagnosis of sarscov infection who had provided informed consent or assent were consecutively enrolled from treatment centre in eight hospital across the country and followed up until discharge or death clinical assessment and blood sampling were done at admission for all patient malaria diagnosis in all patient wa done by rapid diagnostic test microscopy and molecular method previous p falciparum exposure wa determined with serological response to a panel of p falciparum antigen assessed using a multiplex bead assay additional evaluation included complete blood count marker of inflammation and serum biochemistry the main outcome wa overall prevalence of malaria infection and malaria prevalence by age including age category of year year year and year the frequency of symptom wa compared between patient with covid with p falciparum infection versus those without p falciparum infection the frequency of comorbidities and covid clinical severity and outcome wa compared between patient with low previous exposure to p falciparum versus those with high previous exposure to p falciparum the effect of previous exposure to p falciparum on covid clinical severity and outcome wa also assessed among patient with and those without comorbidities finding of people with pcrconfirmed sarscov infection enrolled from april to oct had complete information and were included in our analysis the majority of were male individual with a median age of year iqr overall prevalence of p falciparum infection wa ci of participant with highest prevalence in the age group of year five of patient and older than year nine of patient confusion four of patient v eight of patient p and vomiting four of patient v five of patient p were more frequent among patient with p falciparum infection than those without patient with low versus those with high previous p falciparum exposure had a increased frequency of severe or critical covid clinical presentation of patient v three of patient p and a higher burden of comorbidities including diabetes of patient v two of patient p and heart disease seven of patient v zero of patient p among patient with no comorbidities those with low previous p falciparum exposure still had a higher proportion of case of severe or critical covid than did those with high p falciparum exposure six of patient v one of patient p multivariate analysis showed higher odds of unfavourable outcome in patient who were older than year adjusted or ci p interpretation although patient with covid with p falciparum coinfection had a higher frequency of confusion and vomiting coinfection did not seem deleterious the association between low previous malaria exposure and severe or critical covid and other adverse outcome will require further study these preliminary descriptive observation highlight the importance of understanding the potential clinical and therapeutic implication of overlapping coinfections funding malaria consortium usa abstract background the yield of tuberculosis tb contact tracing is historically low in uganda we determined factor associated with a positive contact tracing yield at an urban public tb clinic in kampala uganda method we reviewed contact tracing register of index tb case registered between and at kitebi health center a primary level facility contact who had symptom of tb were designated a having presumptive tb a contact investigation that yielded a new tb case wa designated a a positive yield we used logistic regression to determine factor associated with a positive yield of contact tracing result of index tb case had a contact investigation conducted index case with a telephone contact in the unit tb register adjusted odds ratio aor ci p were more likely to have a contact investigation conducted than those who did not of contact had presumptive tb of these were further evaluated for active tb and contact had active tb the contact tracing yield for active tb wa therefore the odds of a positive yield increased tenfold with each additional presumptive contact evaluated for active tb aor ci p also retreatment index tb case were more likely to yield a positive contact aor ci p than to new case conclusion tb contact tracing should aim to evaluate all contact with presumptive tb and contact of retreatment case to maximise the yield of contact tracing keywords active contact tracing presumptive tuberculosis uganda yield abstract background mycobacterium tuberculosis a bacterium that relies on it human host to achieve airborne transmission and existence is the primary cause of tuberculosis tb a disease that is vital to public health aim to update the society on tuberculosis diagnostic and treatment delay among patient in uganda material and method the review paper utilized different search engine such a pubmed central scopus web of science google scholar and so forth to conduct this review paper result delay in diagnosis could cause disease to spread throughout the community progress more quickly and increase mortality with many population experiencing tb diagnostic delay and less than a third of the population experiencing tb treatment delay the rate of tuberculosis diagnosis and treatment delay are high conclusion the delay in diagnosing and treating tuberculosis in men is positively correlated with knowledge of the disease symptom and the regular use of a handkerchief or both hand to cover the mouth and nose while coughing or sneezing keywords diagnosis patient treatment delay tuberculosis abstract background globally tuberculosis disease tb is more common among male than female recent research proposes that difference in social mixing by sex could alter infection pattern in tb we examine evidence for two mechanism by which socialmixing could increase men contact rate with tb case first men could be positioned in social network such that they contact more people or social group second preferential mixing by sex could prime men to have more exposure to tb case method we compared the network of male and female tb case and healthy matched control living in kampala uganda specifically we estimated their position in social network network distance to tb case degree betweenness and closeness and assortativity pattern mixing with adult men woman and child inside and outside the household result the observed network consisted of individual there were few difference in estimate of node position by sex we found distinct mixing pattern by sex and tb disease status including that tb case have proportionally more adult male contact and fewer contact with child conclusion this analysis used a network approach to study how social mixing pattern are associated with tb disease understanding these mechanism may have implication for designing targeted intervention strategy in highburden population keywords contact pattern malebias social network tuberculosis abstract background decentralised molecular testing for tuberculosis could reduce missed diagnosis and loss to followup in highburden setting the aim of this study wa to evaluate the cost and costeffectiveness of the xpert performance evaluation for linkage to tuberculosis care xpeltb study strategy a multicomponent strategy including decentralised molecular testing for tuberculosis in uganda method we conducted a costing and costeffectiveness analysis nested in a pragmatic clusterrandomised trial of onsite decentralised versus hubandspoke centralised testing for tuberculosis with xpert mtbrif ultra xpert in community health centre in uganda we collected empirical data on the cost of the xpeltb strategy decentralised xpert testing workflow redesign and performance feedback and routine tuberculosis testing onsite smear microscopy with specimen transport for centralised xpert testing from the health system perspective timeandmotion study were performed to estimate activitybased service cost costeffectiveness wa assessed a the incremental cost u per tuberculosis diagnosis and per day treatment initiation finding the xpeltb study ran from oct to march effectiveness and costeffectiveness outcome were assessed from dec to nov and included woman and men on a pertest basis the cost of decentralised range and centralised range xpert testing wa similar however decentralised testing resulted in more patient receiving appropriate xpert testing so the perpatient cost of decentralised testing wa higher range versus range the xpeltb strategy wa estimated to cost uncertainty range per incremental tuberculosis diagnosis and per incremental patient initiating tuberculosis treatment within day costeffectiveness wa reduced in site performing fewer than test annually interpretation the xpeltb strategy facilitated higher rate of xpert testing for tuberculosis at a similar pertest cost and modest incremental cost per tuberculosis diagnosis and treatment initiation decentralised xpert testing with appropriate implementation support should be scaled up to clinic with sufficient testing volume to support a singlemodule device funding the national heart lung and blood institute abstract background alcohol use is common among people with hiv and is a risk factor for tuberculosis disease and nonadherence to isoniazid preventive therapy ipt few intervention exist to reduce alcohol use and increase ipt adherence in subsaharan africa the aim of this study wa to test the hypothesis that financial incentive conditional on pointofcare negative urine alcohol biomarker testing and positive urine isoniazid testing would reduce alcohol use and increase isoniazid adherence respectively in people with hiv who have latent tuberculosis infection and hazardous alcohol use method we conducted an openlabel factorial randomised controlled trial in uganda eligible for the study were nonpregnant hivpositive adult aged year prescribed antiretroviral therapy for at least month with current heavy alcohol use confirmed by urine ethyl glucuronide biomarker of recent alcohol use and a positive alcohol use disorder identification testconsumption auditc for woman for men for the past month drinking no history of active tuberculosis tuberculosis treatment or tuberculosis preventive therapy and a positive tuberculin skin test we randomly assigned participant initiating month of ipt to no incentive group or incentive for recent alcohol abstinence group isoniazid adherence group or both group escalating incentive were contingent on monthly pointofcare urine test negative for ethyl glucuronide group and or positive on isoscreen biomarker of recent isoniazid use group and the primary alcohol outcome wa nonhazardous use by selfreport auditc for woman for men and phosphatidylethanol peth pastmonth alcohol biomarker ngml at month and month the primary isoniazid adherence outcome wa more than bottle opening of day prescribed we performed intentiontotreat analysis this trial is registered with clinicaltrialsgov nct and is complete finding from april to aug people were screened of whom were randomly assigned to group to group to group and to group the median age of participant wa year iqr were male of had hiv rna viral load of less than copy per ml median auditc score wa iqr and median peth wa ngml iqr among participant who completed the trial with alcohol use endpoint measure group group group group nonhazardous alcohol use wa more likely in the group with incentive for alcohol abstinence group and versus no alcohol incentive group and of versus of respectively adjusted risk difference ard ci to p among participant who completed the trial with isoniazid adherence endpoint measure group group group group incentive for isoniazid adherence did not increase adherence of in the isoniazid incentive group group and versus of in the no isoniazid incentive group group and ard ci to p overall of participant discontinued isoniazid due to grade or higher adverse event there wa no significant association between randomisation group and hepatotoxicity resulting in isoniazid discontinuation after adjusting for sex and site interpretation escalating financial incentive contingent on recent alcohol abstinence led to significantly lower biomarkerconfirmed alcohol use versus control but incentive for recent isoniazid adherence did not lead to change in adherence the alcohol intervention wa efficacious despite less intensive frequency of incentive and clinic visit than traditional programme for substance use suggesting that pragmatic modification of contingency management for resourcelimited setting can have efficacy and that further evaluation of implementation is merited funding national institute on alcohol abuse and alcoholism translation for the runyankole translation of the abstract see supplementary material section abstract background bcg vaccine are given to more than million child every year but there is considerable debate regarding the effectiveness of bcg vaccination in preventing tuberculosis and death particularly among older child and adult we therefore aimed to investigate the agespecific impact of infant bcg vaccination on tuberculosis pulmonary and extrapulmonary development and mortality method in this systematic review and individual participant data metaanalysis we searched medline web of science biosis and embase without language restriction for casecontact cohort study of tuberculosis contact published between jan and april search term included mycobacterium tuberculosis tb tuberculosis and contact we excluded cohort study that did not provide information on bcg vaccination or were done in country that did not recommend bcg vaccination at birth individuallevel participant data for a prespecified list of variable including the characteristic of the exposed participant contact the index case and the environment were requested from author of all eligible study our primary outcome wa a composite of prevalent diagnosed at or within day of baseline and incident diagnosed more than day after baseline tuberculosis in contact exposed to tuberculosis secondary outcome were pulmonary tuberculosis extrapulmonary tuberculosis and mortality we derived adjusted odds ratio aors using mixedeffects binary multivariable logistic regression analysis with studylevel random effect adjusting for the variable of interest baseline age sex previous tuberculosis and whether data were collected prospectively or retrospectively we stratified our result by contact age and mycobacterium tuberculosis infection status this study is registered with prospero crd finding we identified original record from our database search we included participantlevel data from cohort study done in country in our metaanalysis among participant developed tuberculosis of bcgvaccinated participant v of unvaccinated participant the overall effectiveness of bcg vaccination against all tuberculosis wa aor ci when stratified by age bcg vaccination only significantly protected against all tuberculosis in child younger than year aor ci among contact with a positive tuberculin skin test or ifn release assay bcg vaccination significantly protected against tuberculosis among all participant aor ci participant younger than year and participant aged year there wa no protective effect among those with negative test unless they were younger than year cohort reported on whether tuberculosis wa pulmonary or extrapulmonary n bcg vaccination significantly protected against pulmonary tuberculosis among all participant in vaccinated participant v in unvaccinated participant aor but not against extrapulmonary tuberculosis in vaccinated participant v in unvaccinated participant in the four study with mortality data bcg vaccination wa significantly protective against death interpretation our result suggest that bcg vaccination at birth is effective at preventing tuberculosis in young child but is ineffective in adolescent and adult immunoprotection therefore need to be boosted in older population funding national institute of health abstract introduction the involvement of private hospital in tuberculosis care in uganda is still limited there is a lack of literature about the barrier and motivator to private hospital engagement in tuberculosis care in uganda objective to explore the barrier to and motivator of private hospital engagement in tuberculosis care method the study employed a qualitative study design that utilized indepth interview with private healthcare worker purposively selected in june due to their active involvement in tuberculosis care from four urban private hospital in mbarara municipality an inductive content analytic approach framed by the consolidated framework for implementation research wa used for analysis the interview were transcribed and coded to identify key theme using content analysis result focusing through the consolidated framework for implementation research barrier to private hospital engagement were related to cost external policy and incentive structure characteristic network and communication and knowledge and belief about the intervention these include concern regarding the payment of care by patient indirect incomegenerating nature of tuberculosis management lack of drug register and diagnostic tool lack of accreditation from the ugandan ministry of health limited space for keeping tuberculosis patient lack of proper followup mechanism lack of training and qualified human resource and delayed seeking of health care by the patient perceived high quality of care in the private hospital privacy and confidentiality concern proximity of private hospital to patient and formalization of partnership between private hospital and the government were the motivator that arose from the three construct relative advantage patient need and resource and engaging conclusion the engagement of private hospital in tuberculosis care requires commitment from key stakeholder supplemented with the organizational shared belief towards this change there is a need for ensuring mechanism for lessening these barrier to ensure full engagement of private hospital in tuberculosis care keywords implementation framework public private mix tuberculosis challenge enablers abstract background in the tuberculosis molecular bacterial load assay tbmbla a ribosomal rnabased test wa acknowledged by who a a molecular assay that could replace smear microscopy and culture for monitoring tuberculosis treatment response in this study we evaluated the accuracy of tbmbla for diagnosis and monitoring of treatment response in comparison with standardofcare test method for this longitudinal prospective study patient aged year or older with presumptive tuberculosis coughing for at least week night sweat and weight loss were enrolled at chinauganda friendship hospital naguru kampala uganda participant were evaluated for tuberculosis by tbmbla in comparison with xpert mtbrif ultra xpertultra and smear microscopy with mycobacteria growth indicator tube mgit culture a a reference test participant who were positive on xpertultra were enrolled on a standard month antituberculosis regimen and monitored for treatment response at week and after initiation of treatment and then month after treatment finding between nov and june participant median age year iqr were enrolled participant were male and were hiv positive the pretreatment diagnostic sensitivity of tbmbla and xpertultra were similar both ci but the specificity wa higher for tbmbla than for xpertultra ten participant were xpertultra trace positive eight of whom were negative by tbmbla and mgit culture smear microscopy had lower diagnostic sensitivity but higher specificity than tbmbla and xpertultra among participant who were smear microscopy negative the sensitivity of tbmbla wa ci and wa ci in those who were hiv positive participant were identified a tuberculosis positive by xpertultra and these individual were enrolled in the treatment group and monitored for treatment response according to tbmbla of these patient cleared bacillary load to zero by week of treatment and remained negative throughout the month treatment followup positivity for tuberculosis decreased with treatment a measured by all test but the rate wa slower with xpertultra consequently of participant were still xpertultra positive at the end of treatment but were clinically well and negative on tbmbla and culture at month of treatment two patient were still xpertultra positive with a further month of posttreatment followup the rate of conversion to negative of the dnabased xpertultra wa time slower than that of the rrnabased tbmbla consequently for the same patient it would take week and week to reach complete tuberculosis negativity by tbmbla and xpertultra respectively participant who were positive on smear microscopy at week who received an extra month of intensive treatment had a similar tbmblameasured bacillary load at week to those who were smear microscopy negative interpretation tbmbla ha a similar performance to xpertultra for pretreatment diagnosis of tuberculosis but is more accurate at detecting and characterising the response to treatment than xpertultra and standardofcare smear microscopy funding european and developing country clinical trial partnership makerere university research and innovation fund u national institute of health abstract background globally displaced population face an increased burden of tuberculosis tb uganda is currently hosting unprecedented big number of refugee from the east african region recent evidence show increased spread of multidrug resistant tb mdrtb across east africa a a result of migrant from somalia a high mdrtb prevalent country calling for urgent identification and management of case for the country in the region one of the strategy recommended is optimization of diagnosis treatment and prevention of tb in refugee this study aimed at exploring the barrier to and facilitator for tb case finding and retention in care among urban slum refugee and suggestion on how to improve this wa to guide the development of intervention to improve tb case finding and retention in care among the said population method a crosssectional study utilizing qualitative method wa conducted among refugee in an urban slum in kampala city uganda key informant interview with health care worker and community leader and indepths interview with refugee tb patient and care taker of tb patient were conducted interview in total interview question were based on construct from the combb model capability opportunity and motivation model of behaviour change manual content analysis wa performed and identified targeted intervention strategy guided by the related behavior change wheel implementation framework result key barrier included physical capability availability of and easily accessible private facility in the community with no capacity to diagnose and treat tb psychological capability lack of knowledge about tb among refugee social opportunity wide spread tb stigma and language barrier physical opportunity poor living condition mobility of refugee reflective motivation lack of facilitation for health worker automatic motivation discrimination and rejection of tb patient facilitator were physical capability availability of free tb service in the public health facility social opportunity availability of translator we identified education incentivization training enablement and restructuring of the service environment a relevant intervention function with potential to address barrier to and enhance facilitator of tb case finding and retention among refugee in urban slum conclusion the key barrier to tb control among refugee living urban slum in kampala uganda included poor access to health service limited knowledge about tb tb stigma language barrier and lack of facilitation of community health worker identified intervention strategy included education training enablement environmental restructuring and persuasion the finding could serve a a guide for the design and implementation of intervention for improving the same keywords behaviour change wheel comb model refugee tb case finding and retention in care abstract background the occurrence of chronic pulmonary aspergillosis cpa among drug sensitive pulmonary tuberculosis ptb patient on optimal therapy with persistent symptom wa investigated method we consecutively enrolled participant with ptb with persistent pulmonary symptom after month of antitb treatment at mulago hospital kampala uganda between july and june cpa wa defined a a positive aspergillusspecific iggigm immunochromatographic test ict a cavity with or without a fungal ball on chest xray cxr and compatible symptom month result we enrolled participant median age year iqr were male were hivinfected and had prior ptb thirtyeight sputum sample grew a niger and a fumigatus specie complex six participant had intracavitary fungal ball and had cavity overall participant had cpa cpa wa associated with prior ptb adjusted odds ratio aor ci p and far advanced cxr change aor ci p the aspergillus iggigm ict wa positive in participant with cpa conclusion chronic pulmonary aspergillosis may cause persistent respiratory symptom in up to onefifth of patient after intensive treatment for ptb the aspergillus iggigm ict positivity rate wa very low and may not be used alone for the diagnosis of cpa in uganda keywords uganda chronic pulmonary aspergillosis persistent symptom pulmonary tuberculosis abstract background people with bacteriologically confirmed pulmonary tuberculosis require sputum smear monitoring at and month to establish treatment outcome however there is limited information about sputum smear monitoring in uganda similar to other developing country we examined factor associated with complete sputum smear monitoring among person with bacteriologically confirmed pulmonary tb aged year in central uganda method we retrospectively reviewed and abstracted data for person with bacteriologically confirmed pulmonary tb initiated on treatment between january and december across large tb unit in masaka district in central uganda complete sputum smear monitoring wa measured a the receipt of three sputum smear microscopy test at and month of tb treatment the data were summarized descriptively and the difference in the outcome with independent variable were examined using test of statistical significance namely the chisquare or fisher exact test and the student ttest the factor independently associated with the outcome were established using the modified poisson regression analysis with robust standard error reported a adjusted risk ratio arr along with the confidence interval ci result a total of participant were enrolled with a mean age of year of the participant were male were rural resident and had complete sputum smear monitoring urban residence arr ci and treatment under the communitybased directly observed therapy shortcourse strategy dot arr ci were associated with a higher likelihood of complete sputum smear monitoring while tb and human immunodeficiency virus tbhiv comorbidity arr ci wa associated with a lower likelihood of complete sputum smear monitoring conclusion we found a low magnitude of complete sputum smear monitoring among person with bacteriologically confirmed pulmonary tb aged year in central uganda strategy to enhance the performance of sputum smear monitoring should target rural health facility strengthen tbhiv collaboration and the implementation of communitybased dot keywords bacteriologically confirmed pulmonary tuberculosis smearpositive tuberculosis sputum smear monitoring uganda abstract background before the use of parallel tuberculosis tb reporting system wa resource intensive with duplication of effort and hence the need to select one that contributed to better tb case notification at the national tb and leprosy program nltp in uganda we sought to analyse the difference in reporting rate between the two system in order to improve ntlp tb case notification rate logistics management and planning for better health service delivery initiative method we conducted a comparative study to assess tb case notification between the webbased dhis and the district tb supervisorled health management information system between january to december we used poisson regression analysis to assess the statistical difference in reporting rate between the two reporting system result the association between tb case notification and the type of reporting system wa statistically significant prob chi the incident rate ratio irr for the webenabled dhis system versus the district tb supervisorled health management information system wa conclusion the webbased integrated dhis system wa more effective in reporting missing tb case it present an opportunity for better planning and allocation of resource for improved service delivery in a lowincome setting keywords dhis uganda case notification tuberculosis webbased reporting abstract background tuberculosistb is among the leading cause of infectious death worldwide contact investigation is an evidencebased world health organisationendorsed intervention for timely tb diagnosis treatment and prevention but ha not been widely and effectively implemented method we are conducting a steppedwedge clusterrandomised hybrid type iii implementationeffectiveness trial comparing a usercentred to a standard strategy for implementing tb contact investigation in healthcare facility in uganda the usercentred strategy consists of several clientfocused component including a tbeducation booklet a contactidentification algorithm an instructional sputumcollection video and a communityhealthrider service to transport client chws and sputum sample along with several healthcareworkerfocused component including collaborative improvement meeting regular auditandfeedback report and a digital groupchat application designed to develop a community of practice site will crossover from the standard to the usercentred strategy in six eightweek transition step following a randomly determined sitepairing scheme and timeline the primary implementation outcome is the proportion of symptomatic close contact completing tb evaluation within day of tb treatment initiation by the index person with tb the primary clinical effectiveness outcome are the proportion of contact diagnosed with and initiating active tb disease treatment and the proportion initiating tb preventative therapy within day we will assess outcome from routine source document using intentiontotreat analysis we will also conduct nested mixedmethods study of implementation fidelity and context and perform costeffectiveness and impact modelling the makerere school of public health irb the uganda national council for science and technologyhses and the yale institutional review board approved the study and waived informed consent for the main trial implementationeffectiveness outcome we will submit result for publication in peerreviewed journal and disseminate finding to local policymakers and representative of affected community discussion this pragmatic quasiexperimental implementation trial will inform effort to find and prevent undiagnosed person with tb in highburden setting using contact investigation it will also help assess the suitability of humancentred design and community of practice for tailoring implementation strategy and sustaining evidencebased intervention in lowandmiddleincome country trial registration the trial wa registeredclinicaltrialsgov identifier nct on november after the trial launch on march keywords contact investigation implementation science steppedwedge trial tuberculosis uganda abstract background the high casefatality rate among child with tuberculosis tb are reportedly driven by inhospital mortality and severe form of tb therefore there is need to better understand the predictor of mortality among child hospitalised with tb we examined the patient clinical profile length of hospital stay from date of admission to date of final admission outcome and predictor of mortality among child hospitalised with tb at two tertiary hospital in uganda method we conducted a caseseries study of child below year of age hospitalised with tb from january st to december st convenience sampling wa done to select tb case from paperbased medical record at mulago national referral hospital mnrh in urban kampala and fort portal regional referral hospital frrh in rural fort portal we fitted linear and logistic regression model with length of stay and inhospital mortality a key outcome result out of the child hospitalised with tb were at frrh and at mnrh the male to female ratio wa with median age of year interquartile rangeiqr there wa a high prevalence of hiv severe malnutrition reported a weightforage zscore sd among child with pulmonary tb who initiated antituberculosis therapy att either during hospitalisation or within seven day prior to hospitalisation cough fever and dyspnoea were common symptom child with tb meningitis commonly presented with fever convulsion and cough the median length of hospital stay wa day iqr of the child with known inhospital outcome died during hospitalisation tb meningitis wa associated with inhospital mortality aor ci p while male sex wa associated with reduced mortality aor ci p hospitalisation in the urban hospital predicted a day increase in natural logtransformed length of hospital stay lnlength of stay ci p but not age sex hiv malnutrition or tb meningitis conclusion inhospital mortality wa high and significantly driven almost four time higher by tb meningitis with longer hospital stay among child in urban hospital the high inhospital mortality and long hospital stay may be reduced by timely tb diagnosis and treatment initiation among child abstract objective this sequential prospective metaanalysis sought to identify risk factor among pregnant and postpartum woman with covid for adverse outcome related to disease severity maternal morbidity neonatal mortality and morbidity and adverse birth outcome data source we prospectively invited study investigator to join the sequential prospective metaanalysis via professional research network beginning in march study eligibility criterion eligible study included those recruiting at least consecutive case of covid in pregnancy within a defined catchment area method we included individual patient data from participating study data quality wa assessed and harmonized variable for risk factor and outcome were constructed duplicate case were removed pooled estimate for the absolute and relative risk of adverse outcome comparing those with and without each risk factor were generated using a stage metaanalysis result we collected data from country and territory including case of sarscov infection in pregnancy or postpartum we found that woman with comorbidities preexisting diabetes mellitus hypertension cardiovascular disease v those without were at higher risk for covid severity and adverse pregnancy outcome fetal death preterm birth low birthweight participant with covid and hiv were time confidence interval more likely to be admitted to the intensive care unit pregnant woman who were underweight before pregnancy were at higher risk of intensive care unit admission relative risk confidence interval ventilation relative risk confidence interval and pregnancyrelated death relative risk confidence interval prepregnancy obesity wa also a risk factor for severe covid outcome including intensive care unit admission relative risk confidence interval ventilation relative risk confidence interval any critical care relative risk confidence interval and pneumonia relative risk confidence interval anemic pregnant woman with covid also had increased risk of intensive care unit admission relative risk confidence interval and death relative risk confidence interval conclusion we found that pregnant woman with comorbidities including diabetes mellitus hypertension and cardiovascular disease were at increased risk for severe covidrelated outcome maternal morbidity and adverse birth outcome we also identified several less commonly known risk factor including hiv infection prepregnancy underweight and anemia although pregnant woman are already considered a highrisk population special priority for prevention and treatment should be given to pregnant woman with these additional risk factor keywords covid sarscov maternal mortality neonatal mortality pneumonia pregnancy preterm birth smallforgestationalage abstract background despite being a priority population for covid vaccination limited data are available regarding acceptability of covid vaccine among people living with hiv plwh in subsaharan africa we described covid vaccine acceptability and factor associated with vaccine acceptability among plwh in uganda method this wa a crosssectional study conducted among plwh aged year enrolled participant who were seeking hiv care from six purposely selected accredited art clinic in kampala we obtained data on vaccine acceptability defined a willingness to accept any of the available covid vaccine using intervieweradministered questionnaire in addition we assessed vaccination status complacency regarding covid disease vaccine confidence and vaccine convenience factor associated with covid vaccine acceptability were evaluated using modified poisson regression with robust standard error result we enrolled participant of whom were woman the median age wa year interquartile range iqr for woman and year iqr for men of the respondent confidence interval ci reported receiving at least one vaccine dose with woman significantly more likely than men to have been vaccinated v p among the unvaccinated ci were willing to accept vaccination had greater vaccine confidence had strong belief that the vaccine were effective that they were beneficial and safe for plwh had trust in health care professional or top government official and believed that it would be easy to obtain a vaccine if one decided to be vaccinated vaccine acceptability wa positively associated with greater vaccine confidence adjusted prevalence ratio apr ci and positive perception that it would be easy to obtain a vaccine apr ci conclusion vaccine acceptance wa high among this cohort of plwh and wa positively associated with greater vaccine confidence and perceived easiness convince to obtained the vaccine building vaccine confidence and making vaccine easily accessible should be a priority for vaccination program targeting plwh abstract background quarantine ha been adopted a a key public health measure to support the control of the coronavirus disease covid pandemic in many country uganda adopted institutional quarantine for individual suspected of exposure to severe acute respiratory syndrome coronavirus sarscov to be placed in institution like hotel andor hostel of institution for at least day this study explored experience of individual who underwent institutional quarantine in uganda to inform measure to increase it effectiveness and reduce it associated negative impact method we conducted a qualitative description study using indepth interview with purposively selected individual who had spent time in institutional quarantine facility these were mainly phonebased interview that were audio recorded and transcribed verbatim electronic data coding wa conducted using atlasti software thematic content analysis wa used to synthesize the finding with similar code grouped to form subthemes and ultimately study theme the finding are presented thematically with typical participant quote result study participant spent between to day in institutional quarantine four theme emerged describing the experience of study participant during institutional quarantine which determined whether participant experience were positive or negative these theme were quarantine environment including facility related factor and compliance with covid measure quarantine management factor of entity paying the cost communication and day spent in quarantine individual factor comprising attitude towards quarantine fear during and postquarantine and coping mechanism and linkage to other service such a health care and postquarantine followup conclusion the planning management and implementation of the quarantine process is a key determinant of the experience of individual who undergo the measure to improve the experience of quarantined individual and reduce it associated negative impact the prequarantine process should be managed to comply with standard quarantined person should be provided a much information a possible their quarantine duration should kept short and cost of the process ought to be minimised furthermore quarantine facility should be assessed for suitability and monitored to comply with guideline while avenue for access to healthcare for the quarantined need to be arranged and any potential stigma associated with quarantine thoroughly addressed keywords covid challenge coping experience institutional quarantine sarscov abstract background despite the discovery of vaccine the control and prevention of coronavirus disease covid relied on nonpharmaceutical intervention npis this article describes the development and application of the public health act to implement npis for covid pandemic control in uganda method this is a case study of uganda experience with enacting covid rule under the public health act cap the study assessed how and what rule were developed their influence on the outbreak progress and litigation the data source reviewed were applicable law and policy presidential speech cabinet resolution statutory instrument covid situation report and the registry of court case that contributed to a triangulated analysis result uganda applied four covid broad rule for the period march to october the minister of health enacted the rule which response team enforcement agency and the general population followed the presidential speech their expiry period and progress of the pandemic curve led to amendment of the rule twenty one time the uganda people defense force act no of the public finance management act no of and the national policy for disaster preparedness and management supplemented the enacted covid rule however these rule attracted specific litigation due to perceived infringement on certain human right provision conclusion country can enact supportive legislation within the course of an outbreak the balance of enforcing public health intervention and human right infringement is an important consideration in future we recommend public sensitization about legislative provision and reform to guide public health response in future outbreak or pandemic keywords covid nonpharmaceutical intervention pandemic public health law rule uganda abstract background between march and december due to cholera and coronavirus disease covid pandemic there were cholera case with death and covid case with death reported respectively in uganda this study investigated mass vaccination campaign for the prevention of the two pandemic namely oral cholera vaccine ocv and covid vaccine coverage adverse event following immunization aefi barrier and enablers for the vaccine uptake and assessed water sanitation and hygiene wash condition in the six cholera and covid hotspot district of uganda method a household survey wa conducted between january and february in the six cholera hotspot district of uganda which had recently conducted ocv mass vaccination campaign and had ongoing covid mass vaccination campaign the survey randomly enrolled household with person of whom were above year data were collected using a data entry application designed in kobotoolbox and analysed using stata version frequency percentage odds ratio mean confidence interval and map were generated and interpreted result the ocv coverage for dose one and two were ci and ci respectively among the ocv recipient reported mild aefi reported moderate aefi and none reported severe aefi the covid vaccination coverage for dose one and two were ci and ci respectively approximately of covid vaccine recipient reported aefi most were mild were moderate and case were severe the commonest reason for missing covid vaccine wa fear of the side effect for most district sanitation latrinetoilet coverage were low at conclusion there is high ocv coverage but low covid vaccine and sanitation coverage with high number of moderate case of aefi recorded due to covid vaccine the low covid vaccine coverage could indicate vaccine hesitancy for covid vaccine furthermore incorporation of wash condition assessment in the ocv coverage survey is recommended for similar setting to generate data for better planning however more study are required on covid vaccine hesitancy keywords adverse event following immunization africa covid cholera coronavirus pandemic sanitation uganda vaccine coverage vaccine hesitancy wash water coverage abstract objective to evaluate the impact of the coronavirus disease covid pandemic on the disease course life and psychosocial wellbeing of person with epilepsy pwe in uganda method from april till may we carried out a descriptive crosssectional study at four hospital located in four region of uganda pwe presenting at the study site were offered a structured questionnaire in the local language we used the phq questionnaire to screen for depression and the gad to screen for anxiety univariate and multivariable logistic regression wa used to investigate factor associated with anxiety and depression result a total of response were collected the median age of the respondent wa year iqr and were male during the lockdown period the seizure frequency increased in pwe various form of physical and psychological violence were inflicted upon pwe fiftyeight screened positive for anxiety and positive for depression both increased seizure frequency and experienced violence were associated with experiencing depression and anxiety conclusion the covid pandemic and lockdown impacted seizure frequency and the psychosocial wellbeing of pwe in uganda increased seizure frequency wa associated with higher rate of anxiety and depression this underline the importance of continued followup of pwe and a low threshold to screen for depression anxiety and domestic violence keywords anxiety covid depression epilepsy lockdown uganda abstract background identifying preventable cause of covid death is key to reducing mortality we investigated possible preventable cause of covid death over a sixmonth period in uganda method a casepatient wa a person testing reverse transcription polymerase chain reactionpositive for sarscov who died in kampala metropolitan area hospital from august to february we reviewed record and interviewed health worker and casepatient caretaker result we investigated of reported covid death during the investigation period were male and the median age wa year a total of had underlying medical condition most had advanced disease at admission to the hospital where they died a total of did not receive a covid test at their first presentation to a health facility despite having consistent symptom a total of needed intensive care unit admission of whom received it needed mechanical ventilation of whom received it conclusion among hospitalized patient with covid who died in this investigation early opportunity for diagnosis were frequently missed and there wa inadequate intensive care unit capacity emphasis is needed on covid a a differential diagnosis early testing and careseeking at specialized facility before the illness reach a critical stage increased capacity for intensive care is needed keywords covid coronavirus disease death pandemic uganda abstract background violence towards hiv positive men is one of the silent barrier to utilization of hiv care service hiv positive men are potential victim of violence from other people including woman and violence may interfere with treatment outcome this study determined the prevalence of violence towards hiv positive men in rural community of southwestern uganda method a crosssectional study wa conducted among hiv positive men at selected health center using an interviewer administered questionnaire data were analyzed in spss version using chisquare and multivariate regression at level of significance and a precision of result of the participant had experienced violence of these n had experienced kicking or slapping while reported sexual violence factor associated with violence were using alcohol and drug aor ci p knowledge of support structure or ci p and owning land for farming aor ci p conclusion the prevalence of violence at is quite high especially since violence against men is rarely talked about this should not be ignored there should be strategy to support this vulnerable group keywords hiv positive men uganda prevalence rural community violence abstract background interaction between substance use violence hiv and aid known a the sava syndemic are understudied among refugee youth we assessed the synergistic effect of frequent alcohol use depression and violence on hiv vulnerability among urban refugee youth aged year in kampala uganda method we conducted a crosssectional survey between january and april with a convenience sample of refugee youth aged year living in informal settlement in kampala kabalagala rubaga kansanga katwe nsambya we assessed noncommunicable health condition frequent time per week alcohol use fau depression violence young adulthood violence yav at age year intimate partner violence ipv and hiv vulnerability past month transactional sex recent past month multiple sex partner we calculated the prevalence and cooccurrence of noncommunicable health condition violence and hiv vulnerability variable we then conducted multivariable logistic regression analysis to first create unique profile of fau depression yav and ipv exposure and second to assess for interaction between exposure on hiv vulnerability outcome result most participant n mean age sd woman n men n reported at least one noncommunicable health condition or violence exposure n and over half n reported cooccurring exposure onefifth reported fau n and onetenth n major depression in logistic regression model including all twoway product term adjusted for sociodemographics we found a multiplicative interaction for joint effect of fau and ipv adjusted or aor ci to on multiple sex partner and b multiplicative interaction for joint effect of fau and ipv aor ci to and yav and depression aor ci to on transactional sex conclusion finding signal the importance of addressing the sava syndemic among urban refugee youth in uganda synergistic interaction indicate that addressing fau depression or violence may concomitantly reduce hiv vulnerability with urban refugee youth keywords child health communitybased survey hiv mental health psychiatry abstract background globally hivaids continues to rise among adolescent ugandan study have examined knowledge and attitude regarding hivaids among adult population this study specifically paid attention to this particular age group of adolescent year aim to explore hiv knowledge and attitude among adolescent attending secondary school mbarara uganda method a qualitative descriptive study wa conducted in three secondary school in south western uganda forty eight adolescent with age range between year were purposively recruited in the study data were collected from six focus group and analyzed thematically ethical approval received from must and unsct s review committee result four theme emerged knowledge about hiv source of information attitude towards person with hiv and prevention strategy most adolescent had the basic knowledge of hiv from multiple source like social medium health worker peer and parent their attitude toward individual with hiv included compassion shock and uneasiness participant suggested prevention program to be implemented in the school emphasizing hiv education life skill sex education and the formation of peer group conclusion the finding showed that most participant had knowledge about hiv and how it can be prevented however few had knowledge gap thinking that hiv doe not exist keywords adolescent hivaids attitude knowledge prevention abstract background young people year bear the highest burden of new infection and are particularly vulnerable because of their highly risky behavior such a early sexual activity there is paucity of information on the role of religious leader in the multisectoral fight against hivaids we examined the role of religious leader in the use of hiv prevention strategy among young people method a cross sectional study wa conducted between march and april among randomly selected young people in lira district uganda an interviewer administered a questionnaire to the young people in order to collect quantitative data a total key informant were purposively sampled and interview were conducted with religious leader using a key informant interview guide data wa collected on social demographic hiv prevention message and awareness about hiv prevention strategy data wa analyzed using stata version using proportion mean percentage frequency and logistic regression analysis at a level of significance qualitative data wa analyzed using thematic content analysis and the major theme were generated from the participant response result about of the respondent were female the prevalence of use of hiv prevention strategy among young people wa factor significantly associated with the use of hiv prevention included completing the primary level aor p completing at least a level aor p awareness of hiv prevention strategy advocated for by religious leader aor p religious leader provided targeted hiv prevention message aor p advocacy for abstinence outside marriage and fidelity in marriage aor p religious leader preaching about hiv prevention aor p qualitative data indicated that a section of religious leader recommended abstinencefaithfulness condom use wa the most discouraged hiv prevention strategy however most religious leader agree with the fact that they have a role to play in hiv prevention which includes sensitization teaching and organizing sermon about hiv prevention conclusion the use of hiv prevention strategy advocated for by religious leader among young people wa nearly this finding indicates that religious leader have a role to play in hivaids prevention among young people in the lira district this call for the involvement of religious leader in hiv prevention program tailored to prevent new infection of hiv among young people abstract background the prevalence of hypertension is increasing among people living with hivaids plwha in low and middleincome country lmics however knowledge of the complication and management of hypertension among plwha in uganda remains low we explored the acceptability of implementing hypertension htn specific health education by community health worker chws among plwha in rural uganda method we conducted a qualitative study consisting of indepth interview plwhahtn and chws focus group discussion fgds with plwhahtn and with chws from nakaseke district uganda participant were interviewed after a single session interaction with the chw data were transcribed from luganda local language into english and analyzed using thematic analysis we used sekhons model of acceptability of health intervention to explore participant perception result participant believed chws utilized easytounderstand colloquial nontechnical language during education delivery had a preexisting rapport with the chws that aided faster communication and had more time to explain illness than medical doctor had participant found the educational material pocketdoktor to be simple and easy to understand and perceived that the education would lead to improved health outcome participant stated their health wa a priority and sought further diseasespecific information we also found that chws were highly motivated to carry out the patientcentered education while delivering the education chws experienced difficulty in keeping up with the technical detail regarding hypertension in the pocketdoktor financial stress and patient question beyond their selfperceived skill level and experience plwhahtn had challenge accessing the health facility where the intervention wa delivered and preferred a household setting conclusion hypertension patientcentered education delivered by chws using the pocketdoktor wa acceptable to plwha and hypertension in nakaseke area in rural uganda there is need for further study to determine the cost implication of delivering this intervention among plwha across lmic setting keywords acceptability hypertension plwha patient education pocketdoktor abstract background although school have been identified a significant setting in the response to the hivaids pandemic limited research is available on how they can accommodate youth living with hivaids ylwha especially in resource limited country in this study we explored strategy by school stakeholder school staff parentscaretakers and student in western uganda to care for and support ylwha in their school method the article utilizes data collected between may and october from a qualitative inquiry based on focus group discussion and interview with school stakeholder purposively selected from secondary school in western uganda textual data wa analyzed thematically involving both inductive and deductive coding result we identified overarching interrelated theme in which participant reported strategy to care for and support ylwha counselling and guidance social support network and linkage knowledge and skill antistigma and antidiscrimination measure disclosure of hiv status treatment and management of hivaids and affirmative action for ylwha stakeholder strategy often differed regarding what wa considered appropriate the approach and who to take lead in supporting ylwha conclusion despite the limited care and support strategy specific for ylwha currently available in school our study point to optimism and high potential given stakeholder identified avenue for improvement we posit that promoting hivaidscare and support in school is a gradual process requiring each school to develop a strong knowledge base about hivaids and support need of ylwha develop a coherent and schoolwide approach and collaborate extensively with external stakeholder who are significant in supporting ylwha keywords hivaids hivaidscompetence qualitative social support youth abstract background who revised their hiv drug resistance hivdr monitoring strategy in enabling country to generate nationally representative hivdr prevalence estimate from survey conducted using this methodology in we adopted this strategy in uganda and conducted an hivdr survey among adult initiating or reinitiating art method a crosssectional survey of adult aged year initiating or reinitiating art wa conducted at site using a twostage cluster design sampling method participant provided written informed consent prior to enrolment whole blood collected in edta vacutainer tube wa used for preparation of dried blood spot db specimen or plasma sample were shipped from the site to the central public health laboratory cphl for temporary storage before transfer to the uganda virus research institute uvri for genotyping prevalence of hivdr among adult initiating or reinitiating art wa determined result specimen from participant median age year and female were collected between august and december specimen from participant were successfully genotyped fortynine had drug resistance mutation yielding an overall weighted hivdr prevalence of with the highest noted for nnrti at conclusion we observed a high hivdr prevalence for nnrti among adult prior to initiating or reinitiating art in uganda this is above who recommended threshold of when country should consider changing from nnrti to dolutegravirbased firstline regimen this recommendation wa adopted in the revised ugandan art guideline dolutegravircontaining art regimen are preferred for first and secondline art regimen abstract background we evaluated the efficacy of a community health worker chwled intervention in supporting disclosure among adult living with hiv in heterosexual relationship method we conducted a quasiexperimental study with arm allocated by geographically determined cluster and adjusted for betweengroup difference among adult living with hiv in the greater luwero region of uganda who had never disclosed their status to their current primary sexual partner cluster were allocated to either a chwled intervention or a control arm in both arm participant were consecutively recruited a opposed to receiving routine care for the control arm participant in the intervention arm received additional chw disclosure support the overall followup wa month and the primary outcome wa disclosure to the sexual partner data were analyzed using a clustered modified poisson regression model with robust standard error to determine independent factor associated with disclosure result of the participant who enrolled completed the study and of those were in the intervention arm the median age wa interquartile range year the majority were woman and most did not know their partner hiv status at study entry at the end of followup the overall disclosure prevalence wa confidence interval ci and participant in the intervention arm were more likely to disclose compared to those in the control adjusted relative ratio arr ci men were arr ci more likely to disclose compared to woman and membership in an hivaids association increased disclosure by arr ci conclusion chw support improved disclosure among adult living with hiv in heterosexual relationship when compared to routine care therefore chwled mechanism may be utilized in increasing disclosure among adult living with hiv in heterosexual relationship in rural setting abstract introduction with effective antiretroviral therapy art many person living with hiv plhiv live to old age caring for aged plhiv necessitates the engagement of caregiver and patient to establish agreedupon goal of treatment however there is limited literature on friendly and centered model of care for elderly plhiv we explored strategy to improve care in hiv clinic among plhiv aged year and above in uganda method we conducted indepth interview in two hospital with elderly plhiv aged year and above who had lived with hiv for more than ten year we explored strategy for improving care of elderly plhiv at both health facility and community level the indepth interview were audiorecorded and transcribed verbatim the thematic approach guided data analysis result the elderly plhiv suggested the following strategy to improve their care creating geriatric clinic increasing screening test for noncommunicable disease in the art clinic community and homebased art delivery workshop at health facility to provide health education on aging effectively creating community support group financial assistance for the elderly plhiv and advance in science conclusion there is need to improve community hiv care especially for the elderly and social and economic support in the community involving the elderly plhiv in developing strategy to improve their health go a long way to improve the patient quality of care there is a need to incorporate the raised strategy in hiv care or older adult keywords elderly plhiv improved care strategy uganda
tuberculosis treatment both inactive tuberculosis tb also called latent tb infection and active tb disease can be treatednit is important to take and finish all tb medicine exactly a your health care provider recommendsncompleting treatment for inactive tb and active tb disease can protect yourself your family and friend and your communitynnot everyone infected with tb germ becomessick a a result two tbrelated condition existinactive tbandactive tb disease both inactive tb and active tb disease can be treatedneven though you may not feel sick inactive tb can develop into active tb disease at any time and make you sick if you haveinactive tbtreating itis the best way to protect you from getting sick with active tb diseasenif you haveactive tb disease you can betreatedwith medicinentb germ are strong and it can take a long time for them to die it is important to take and finish all tb medicinesexactlyas your health care provider recommendsnthere are several safe and effective treatment plan recommended in the united state forinactive tbandactive tb disease atreatment planalso called treatment regimen for inactive tb or active tb disease is a schedule to take tb medicine to kill all the tb germ your treatment plan for inactive tb or active tb disease will includenthetypesof tb medicine to takenhow muchtb medicine to takenhow oftento take the tb medicinesnhow longto take the medicinesnhow to monitoryourself for any side effect of your tb medicine andnthe health care providerswho will support youthrough the treatment processnyou and your health care provider will discus which treatment plan is best for yountreatment for inactive tb can take three four six or nine month depending on the treatment plannthe treatment plan for inactive tb use different combination of medicine that may includenisoniazidnrifampinnrifapentinentreatment for active tb disease can take four six or nine month depending on the treatment plannthe treatment plan for active tb disease use different combination of medicine that may includenethambutolnisoniazidnmoxifloxacinnrifampinnrifapentinenpyrazinamidenthere are several treatment plan fordrugresistant tb diseasedepending on what medicine the tb germ are resistant to treating and curing drugresistant tb disease is complicated it should be treated by a tb medical expertnpeople with drugresistant tb disease must be treated with special medicine treatment may take a long time sometimes month or year and the medicine can cause side effectsnsome medicine can interact with the tb medicine and cause a possible side effect or reaction after taking medicinensome oral contraceptive birth control pill may not work a well when you take them with medicine for inactive tb or active tb diseasetb medicine can sometimes interfere with birth control pill and possibly make the birth control pill less effectiveif you are taking birth control pill talk with your health care provider before beginning any new medicinesntb medicine can sometimes interfere with birth control pill and possibly make the birth control pill less effectivenif you are taking birth control pill talk with your health care provider before beginning any new medicinesnyour health care provider can recommend a treatment plannalcoholic beverage include wine beer or liquor ask your health care provider about thing to avoid while taking medicine for inactive tb or active tb diseasenmost people can take their tb medicine without any problem however like all medicine the medicine you take for inactive tb or active tb disease can have side effectsnpeople react differently to medicine tell your health care provider about anything you think is wrongnfor example any tb medicine can cause a skin rash other tb medicine may cause an upset stomach or nausea taking your tb medicine with food can help your body absorb the medicine betternthe rifampin or rifapentine medicine may cause some body fluid to turn an orange color such asnurine peensalivantearsnsweat andnbreast milknthis is normal and harmless the color may fade over time also your health care provider may tell you not to wear soft contact lens because they may get permanently stainednif you have any of these side effect you can continue taking your medicinenif you have a serious side effect call your health care provider immediately your health care provider may tell you to stop taking your medicine or to return to the clinic for test serious side effect includenliver injuryabdominal painnausea and vomitingskin and eye turning yellow also called jaundicenabdominal painnnausea and vomitingnskin and eye turning yellow also called jaundicendizziness or lightheadednessnloss of appetitenflulike symptomsntingling or numbness in your hand or feetnif you are taking isoniazid you may have tingling or numbness in your hand and foot your health care provider may ad about tuberculosis tb is caused by a bacterium calledmycobacterium tuberculosisntwo tbrelated condition exist inactive tb and active tb diseasengetting tested and treated for tb can protect yourself your family and friend and your communityntuberculosis tb is caused by a bacterium or germ calledmycobacterium tuberculosis in the united state the majority of tb disease case in people are caused bymycobacterium tuberculosisother mycobacteria such asmycobacterium boviscan also cause tb disease in peoplentb usually affect the lung tb can also affect other part of the body such a the brain the kidney or the spine tb can also affect multiple part of the body at the same time for example tb can affect both the lung and lymph nodesnnot everyone infected with tb germ becomes sick a a result two tbrelated condition existinactive tbor latent tb infection andactive tb diseasenif not treated properly tb disease can be fatalntb germ can live in the body without making you sick this is calledinactive tb or latent tb infection people with inactive tb are infected with tb germ but they do not have active tb disease they do not feel sick do not have any symptom and can not spread tb to othersnwithouttreatment people with inactive tb can develop active tb disease at any time and become sickntb germ become active if the immune system canut stop them from growing when tb germ are active multiplying in your body this is calledactive tb disease people with active tb disease feel sick they may also be able to spread the germ to people they spend time with every day withouttreatment active tb disease can be fatalna cough that last three week or longernchest painncoughing up blood or sputum phlegm from deep inside the lungsnweakness or fatiguenweight lossnloss of appetitenchillsnfevernnight sweatsnpeople with inactive tb donothave symptom however without treatment they can develop active tb disease and become sicknanyone can get tb but you might have a higher risk for tb if younwere born in or frequently travel to country where tb is common including some country in asia africa and latin americanlive or used to live in large group setting where tb is more common such ashomeless sheltersprisons orjailsnrecently spent time with someone who hasactive tb diseasenhave a weaker immune system because of certain medication or health condition such asdiabetes cancer andhivnwork in place where tb is more likely to spread such ashospitals homeless shelter correctional facility and nursing homesntb is spread through the air from one person to another the tb germ are put into the air when a person with active tb disease of the lung or throat cough speaks or singsnthese germ can stay in the air for several hour depending on the environment tb germ are more likely to spread in indoor area or other place with poor air circulation such a a closed vehicle than in outdoor area people who breathe in the air become infected with tbnpeople with active tb disease are most likely to spread tb germ to people they spend time with every daynif you are diagnosed with inactive tb there aretreatmentsavailable that can help protect you from getting sick with active tb diseasentb disease is one of the world leading infectious disease killersncdc estimate up to million peoplein the united state live with inactive tbnwithout treatment in peoplewith inactive tb will get sick with active tb disease tb disease can spread to others and be deadlynin there were case of tb diseasereported in the united statesncdc recommends that people that are at increased risk should be tested for tb there are two type of test that can find tb infectionnthetb blood testis also called an interferongamma release assay or igra the tb blood test measure how your immune system reacts to the germ that cause tbnif you have ever received avaccine for tb your health care provider should recommend the tb blood test unlike the tb skin test tb blood test are not affected by the tb vaccine bcg vaccinenfor thetb skin test a health care provider us a small needle to put some testing material under the skin you will need to return to your health care provider in two to three day to see if there is a reactionnyou have tb germ in your body your health care provider will doother teststo determine if you have inactive tb or active tb diseasenthese test may include a chest xray and a test of the sputum phlegm you cough upnif you have inactive tb treating it is the best way to protect you from getting sick with active tb diseasenif you have active tb disease you can be treated with medicine you will need to take and finish all of your tb medicine a directed by your health care provider this is to help you feel better and prevent other people from getting sicknbacille calmetteguuerin bcgis a vaccine for tb disease the va symptom most individual with tuberculosis tb disease have one or more symptomsnsymptoms of tb disease may vary depending on the part of the body affectednusually tb disease is diagnosed when someone with symptom seek medical carenin a few instance tb disease can be diagnosed when someone is receiving care for an unrelated problem such a when trauma is evaluated with a chest radiograph that unexpectedly indicates tb in the lung in other instance tb disease can be diagnosed after recent infection a part of a tb contact investigationnthe onset of tb disease is usually gradual a rapid onset is rare and may be related to an immune deficiencynusually the symptom are mild at first developing slowly a patient might blame the symptom on something common like allergy for cough or daily stress for low energy the symptom might be present for week or month before reaching a tipping point that convinces the patient to seek medical carentb disease is not a common in the united state a it wa many year ago health care provider might not consider the possibility of tb disease when evaluating patient who have symptom a a result the diagnosis of tb disease may be delayed or even overlooked and the patient may remain ill and possibly infectious for a prolonged periodnsome symptom of tb disease like cough or weight loss can be the same a the symptom of other disease these symptom should prompt heath care provider to consider tb disease especially after more common problem are ruled outnsymptoms of tb disease may vary depending on the part of the body affectednsome general systemic symptom are common to tb in any part of the bodynfevernnight sweatsnweight lossnloss of appetitensense of illness or loss of energyntb disease most commonly affect the lung pulmonary tb disease most case of tb disease are pulmonarynsymptoms of pulmonary disease includencough especially lasting for week or longerncoughing up sputum or blood hemoptysisnchest painnshortness of breathnextrapulmonary tb disease affect organ in addition to or instead of the lung it may cause symptom related to the part of the body that is affectednsymptoms of extrapulmonary tb disease includenblood in the urine may indicate tb disease of the kidneynheadache or confusion may indicate tb meningitisnback pain may indicate tb disease of the spinenhoarseness may indicate tb disease of the larynxnswollen gland may indicate tb disease of the lymph nodesnswollen painful joint may indicate tb disease of the bone or cartilagenextrapulmonary tb disease should be considered in the differential diagnosis of ill person who have systemic symptom and who are at highriskfor tb diseasencore curriculum on tuberculosis what the clinician should knownselfstudy module on tuberculosisnwhy tb patient seek medical carencommon symptomsnresources diagnosis prevention people with inactive tuberculosis tb also called latent tb infection can take treatment to prevent the development of active tb diseasenpeople with active tb disease of the lung or throat may need to take step to prevent spreading tb germ to othersnit is important for people to take all tb medicine exactly a prescribedninfection control plan can minimize the risk for exposure to and spread of tb in health care settingsntbis spread through the air from one person to another the tb germ are put into the air when a person with tb disease of the lung or throat cough speaks or singsnthese germ can stay in the air for several hour depending on the environment tb germ are more likely to spread in indoor area or other place with poor air circulation such a a closed vehicle than in outdoor areasnpeople who breathe in the air become infected with tb not everyone infected with tb germ becomes sick a a result two tbrelated condition existninactive tbandnactive tb diseasenpeople with active tb disease are most likely to spread tb germ to people they spend time with every day such asnfamily membersnfriendsncoworkers ornschoolmatesncontact your health care provider or health department if you think you have beenexposedto someone with active tb disease be sure to tell the health care provider when you spent time with the person who ha active tb diseasenpeople at higher risk of being exposed to tb germ andnpeople at higher risk of developing active tb disease once infected with tb germsnwereborn in or frequently travel to country where tb is common including some country in asia africa and latin americanlive or used to live in large group setting where tb is more common such ashomeless sheltersprisons orjailsnrecently spent time with someone who ha active tb diseasenwork in place where tb is more likely to spread such a hospital homeless shelter correctional facility and nursing homesnwere recently infected with tb germsnhave a weaker immune system because of certain medication or health condition such asdiabetes cancer orhivnactive tb disease in the lung may causesymptomsincludingna cough that last week or longernchest painncoughing up blood or sputum phlegmnweakness or fatiguenweight lossnloss of appetitenchillsnfevernnight sweatsnpeople with inactive tb donothavesymptoms of tb disease however without treatment they can develop active tb disease and become sicknwithout treatment people with inactive tb can develop active tb diseasensome people with weakened immune system due tocertain medication or health condition are at veryhigh riskof developing active tb disease once infected with tb germ it is very important that they receive treatment for inactive tb to prevent the development of active tb diseasenif you have tb disease of the lung or throat you could be infectious this mean you could spread tb germ to others you and your health care provider will discus how to prevent the spread of tb germ to other peoplenthe most important way you can prevent the spread of tb is to take all medicine exactly a directed by your health care providernkeep all your clinic appointment your health care provider need to see how you are doing this often requires another chest xray or a test of the sputum or phlegm you may cough up these test will shownif the tb medicine are workingnif you can still spread tb germ to othersnbe sure to tell your health care provider about anything you think is wrongndo not miss any dos and do not stop treatment early it can be very dangerous to stop taking your medicine or not to take all your medicine regularlyntell your health care provider if you are having trouble taking the medicinesnif you are sick enough with tb disease to go to a hospital you may stay in a special room these room use air vent that keep tb germ from spreading to other room people who work in these special room must wear a special face mask to protect themselves from tb germ you must stay in the room so that you will not spread tb germ to other peoplentake your medicine a directed this is very importantnalways cover your mouth with a tissue when you cough or laugh put the tissue in a closed bag and throw it awayndo not go to work or school until your health care provider tell you it is safeseparate yourself from others and avoid close contact with anyonesleep in a bedroom away from other family membersnseparate yourself from others and avoid close contact with anyonensleep in a bedroom away from other family membersnair out your room often to the outside of the building if it is not too cold outsidetb germ spread in small closed space where air doe not moveput a fan in your window to blow air to the outside if you open other window in the room the fan also will pull in fresh air this will reduce the chance that tb germ will stay in the room and infect someone who breat cause tuberculosis tb germ spread through the air from one person to anotherntb germ can get into the air when someone with active tb disease cough speaks or singsnpeople nearby may breathe in these germ and become infectednpeople with inactive tb also called latent tb infection can not spread tb germ to othersntuberculosis tb is caused by a bacterium or germ calledmycobacterium tuberculosis when a person breathes in tb germ the germ can settle in the lung and begin to grow from there they can move through the blood to other part of the body such a the kidney spine and brainntb bacteria can live in the body without making you sick this is calledinactive tb or latent tb infection people with inactive tb are infected with tb germ but they do not haveactive tb disease they do not feel sick do not have symptom of tb disease and can not spread tb germ to othersnwithouttreatment people with inactive tb can develop active tb disease at any time and become sickntb germ become active if the immune system cant stop them from multiplying and growing in the body when tb germ are active multiplying in your body this is calledactive tb disease people with active tb disease feel sick they may also be able to spread the germ to people they spend time with every day withouttreatment active tb disease can be fatalntb germ can get into the air when a person withactive tb diseaseof the lung or throat cough speaks or sings these germ can stay in the air for several hour depending on the environmentntb germ are more likely to spread in indoor area or other place with poor air circulation such a a closed vehicle than in outdoor area people nearby may breathe in these germ and become infectedntb germ arenotspread bynshaking someone handnsharing food or drinkntouching bed linen or toilet seatsnsharing toothbrushesnkissingnwithout treatment people with inactive tb can develop active tb diseasenpeople with weakened immune system are at veryhigh riskof developing active tb disease once infected with tb germ it is very important that these people receive treatment for inactive tb to prevent the development of active tb diseasenif you have tb disease of the lung or throat you could be infectious this mean you could spread tb germ to othersnyour health care provider will tell you what step you can take to keep from spreading tb germ to others this may include thing like covering your mouth with a tissue when you cough or staying home from work or school after taking your medicine for a few week you will feel better and you may no longer be infectious to othersnactive tb disease in the lung or throat can be infectious this mean the germ can spread to other people tb disease in other part of the body such a the kidney or spine is usually not infectiousnpeople with active tb disease are most likely to spread it to people they spend time with every day this includes family member friend and coworkers or schoolmatesnif you think you have beenexposedto someone with active tb disease you should contact your health care provider or local or state health department about getting atb blood test or tb skin test be sure to tell the health care provider when you spent time with the person who ha active tb diseasenyou may have been exposed to tb germ if you spent time near someone with active tb diseasenyou have a higher risk of being exposed to tb germ if younwere born in or frequently travel to country where tb is common including some country in asia africa and latin americanlive or used to live in large group setting where tb is more common such ashomeless sheltersprisons orjailsnrecently spent time with someone who hasactive tb diseasenwork in place where tb is more likely to spreadnyou have a higher risk of developing active tb disease once infected if younwere recently infected with tb germsnhave a weaker immune system because of certain medication or health condition such asdiabetes cancer orhivnsome people develop active tb disease soon within week after becoming infected before their immune system can fight the tb germ other people may get sick year later when their immune system becomes weak for another reasonncausesnhow it spreadsnprevention methodsnwhen transmission is possiblenrisk factorsnresources malaria about symptom malaria symptom range from very mild to severe disease and even deathntravelers with symptom of malaria should see a healthcare provider a soon a possible even if still travelingnsome people are at higher risk of having serious malariarelated problem if they get sicknmalaria is a curable disease if diagnosed and treated quickly and correctlynmost people begin to feel ill asearly a one week after infection or a late a a year or morenmalaria symptom can includenfever and flulike illnessnchillsnheadache muscle ache and tirednessnnausea vomiting and diarrheansee a healthcare provider if you have any these symptomsnmalaria symptom may become more severenanemia low red blood cell and jaundice yellow coloring of the skin and eyesnif not treated right away the infection can become serious it may cause kidney failure seizure mental confusion coma and deathnthe type of mosquito that carry the malaria parasite is ananophelesmosquito when an infectiveanophelesmosquito bite you and pass on the malaria parasite there is a period of time before the first symptom show this time between mosquito bite and first sign of symptom is called the incubation periodnthe incubation period in most case of malaria range from u day different specie of parasite that cause malaria in human can cause shorter or longer incubation periodsnin addition some malaria parasite specie can remain dormant inactive in the liver for month or year after the initial infection later after returning from an area with malaria these parasite can then leave the liver and infect red blood cell and cause another episode of illness proper diagnosis and treatment can prevent malaria illness caused by these dormant parasitesnkeep readingmalaria incubation period prevention you can take medication to prevent malariancheck to see if malaria spread in the region or country you will be visiting before you travelntake medication to prevent malaria a prescribed including the period before travel and after you return from travelnavoid mosquito bite even if you are taking medication to prevent malarianif you experience symptom of malaria especially fever while traveling or after returning seek immediate medical attentionnthis information is for traveler who live in the united state traveler from other country should consult healthcare provider in their country for information on prevention recommendation and availability of antimalarial drugsfor more health recommendation for international travel visit thecdc yellow booknevery year million of u resident travel to country where malaria is present about case of malaria are diagnosed in the u in a typical year mostly in returned traveler you can prevent malaria when travelling in area where malaria spread by taking medication called antimalarial and preventing mosquito bite there is no vaccine for malaria currently available in the usnmalaria doe not regularly occur in the in the u so there is usually no exposure to the disease here traveler especially to subsaharan africa region of south america and southeast asia have the greatest risk of getting malaria and potentially dying from their infection if not diagnosed promptly and appropriately treated all traveler to country wheremalaria is presentmay be at risk for infectionnusbased traveler going to an area where malaria spread even if they had some level of immunity to malaria in the past are still at risk for infection it important to note that acquired immunity to protection from malaria weakens the longer you are away from an area where malaria is widespread or endemic if you have been away from your country of origin even a short time you can lose your protective immunity very quickly and should use the same preventative measure a all traveler preventative medication mosquito bite prevention etcnbefore you travellearn about the health risk and precaution for malaria and other disease for your destination get a detailed itinerary of all the possible destination or place you may visit during the trip check to see if malaria is present and spread in these location cdc yellow book chapter on malaria prevention by country provides detailed information about the specific part of country where malaria spread it also provides additional information including the specie of malaria that occur there if there is resistance to any of the antimalarial drug and the specific medicine that cdc recommends for use for malaria prevention in each country or regionnto understand your level of risk for getting malaria and if you need to take malaria prevention medication consider the followingndestination country or regionnspecific itinerary including specific city type of accommodation hotel with ac or openair tent season and style of travelnpregnancy status other medical condition and current medication you takenantimalarial drug resistance at your destinationnyou should discus with a healthcare provider a detailed itinerary of where you are traveling your activity accommodation and your medical history to understand your risk of malaria and if you need to take medication to prevent malarianthere are various option of medication available to prevent malaria and based on the countrycountries the urgency of the trip and how often you prefer to take medication daily v weeklynif your provider recommends malaria prevention medication it is important to take them a prescribed including the period before travel and after you return from travelnin some area where only a few case of malaria occur cdc recommends preventing mosquito bite a the only way to prevent malarianbe aware ofcounterfeit fake or substandard not made according to u standard drugssold in some country this includes country where malaria spread these drug may not be effective get all your medication including antimalarial drug in the u before traveling overseasnhealthcare provider can reference the risk assessment page to ensure they provide appropriate recommendation for all traveler at risk for malaria including those returning to visit friend and relativenit is important to take step toavoid mosquito biteseven if you are taking medication a an added layer to prevent malariansteps to prevent mosquito bitesnuseenvironmental protection agency eparegistered insect repellentswith one of the active ingredientsdeet insect repellent that contain deet offer the best protection against mosquito bitespicaridin known a kbr and icaridin outside the usiroil of lemon eucalyptus oleparamenthanediol pmdundecanonndeet insect repell diagnosis only a healthcare provider can diagnose malariana lab test will confirm malaria parasite infection using a small sample of your bloodnmalaria is a serious disease which can become severe if not treated quickly quick and accurate diagnosis of malaria is important to ensure treatment begin a soon a possible with the correct medication prompt treatment also help to prevent further infection in the community by breaking the cycle of infection from infected person via local mosquito delay in diagnosis and treatment is a leading cause of death in malaria patient in the united statesnonly a lab test using a small sample of your blood can confirm a malaria diagnosisnif you have traveled to an area in the last year where malaria spread you should get tested a soon a you experience symptom of malarianthere are a few diagnostic test to confirm if you have malarianblood smear microscopy test is where a small sample of blood is taken from a patient and sent to a laboratory to be examined under a microscope it is the best way to confirm if a patient ha malaria and to determine which specie only a healthcare provider can order a microscopy testnmalaria rapid diagnostic test or rdts are useful test option when reliable microscopic diagnosis is not readily available malaria rdts detect very small piece from malaria parasitesnin the u only a healthcare provider can order an rdt test a small sample of blood from the patient is collected and applied to the test card sample pad rdts are less sensitive than other lab test a blood smear microscopy test must always confirm both positive and negative rdt result in a patient with suspected malaria despite theselimitations rdts can provide result in less than minutesnpcr test or polymerase chain reaction test are also available to detect malaria parasite these test are more sensitive than routine blood smear microscopy test or rdts but the result take longer making them less ideal for initial diagnosis and treatment an advantage is that pcr test can confirm the exact specie of malaria parasite if microscopy testing is not able to do so this help guide which medicine to use to treat a patient with malariansee a healthcare provider immediately they can conduct the most appropriate diagnostic test a soon a possible if they suspect malarianif you test positive for malaria your healthcare provider will start you on medication to treat the disease immediately the medication prescribed will be based on the type of malaria you havenif you test negative for malaria work with your healthcare provider to determine the cause of your symptomsnwhy get testednwhen to get testedntypes of testsnhow to get testedntesting result treatment malaria is a medical emergency and can become lifethreatening if not quickly diagnosed and appropriately treatednonly a healthcare provider can diagnose and treat a patient for malarianprescription drug available in the u can cure malariansee a healthcare provider if you are sick and have recently been in an area where malaria is widespreadnstarting treatment immediately is the best way to treat malaria and prevent serious and lifethreatening issue the type of drug prescribed and length of treatment depend onnthe type of malarianthe geographic location where the infection likely happened and likelihood of drug resistancenyour agenif you are pregnant or breastfeedingnhow sick you are at the start of treatmentnpatients in the u are typically hospitalized for malaria treatmentnhealthcare provider can refer to the cdcsclinical guidance malaria diagnosis treatment in the usfor specific information cause most people get malaria from the bite of an infective mosquito also called a vectornmost case of malaria diagnosed in the u are in people who have traveled to or from other country where malaria is widespread we call this imported malarianlocally acquired mosquitotransmitted malaria is a rare event in the usnmalaria is a disease caused by a parasitenmost people get malaria when bitten by an infective mosquito carrying the malaria parasite only femaleanophelesmosquitoes can spread malaria from one person to another for theanophelesmosquito to become infective they must bite or take a blood meal from a person already infected with the malaria parasite about one week later that same mosquito will bite the next person and subsequently inject the parasite via her saliva and the cycle of infection continuesnin rare occasion malaria can spread throughnblood transfusionsnorgan transplantnsharing needle or syrinx contaminated with malariainfected blood orncongenitally meaning from a mother to her unborn infant before or during deliverynmalaria is not contagious people cant spread malaria to other people like a cold or the flu you cant get malaria through casual contact sitting next to a person with malaria close physical contact or even sexual contactnanyone can get malaria most case occur in people who live incountries with widespread malaria these country are also called malariaendemic region people from or living in country with no malaria can become infected when they travel to country with malarianplasmodium falciparumis the parasite specie causing malaria that can be severe and lifethreatening it is very common in many country in africa south of the sahara desertnindividuals with the most risk of getting very sick and dying from malaria includenpeople who have little or no recent exposure to malaria parasite this can include young child and pregnant woman or traveler coming from area with no malarianpeople heavily exposed to the bite of mosquito infected withp falciparumnpeople living in rural area who lack access to health carendue to these risk factor an estimated of death caused by malaria occur in africa south of the sahara desert and most of these death occur in child under year of agencausesnhow it spreadsnrisk factorsnpopulations most at risk hiv about hiv is a virus that attack the body immune systemnthe only way to know if you have hiv is to get testednthere are many way to prevent hiv like using prep pep condom and never sharing needlesnhiv treatment help people live long healthy life and prevents hiv transmissionnhiv human immunodeficiency virus is a virus that attack the body immune system without treatment it can lead to aid acquired immunodeficiency syndromenthere is currently no effective cure once people get hiv they have it for life but proper medical care can control the virusnpeople with hiv who get on and stay on effective hiv treatment can live long healthy life and protect their partnersnmost people haveflulike symptomswithin to week after infection symptom may last for a few day or several weeksnhaving these symptom alone doesnt mean you have hiv other illness can cause similar symptomsnsome people haveno symptomsat all theonly way to knowif you have hivis to get testednmost people who get hiv get it through anal or vaginal sex or sharing needle syrinx or other drug injection equipmentnonly certain body fluid can transmit hiv these fluid includenbloodnsemen cumnpreseminal fluid precumnrectal fluidsnvaginal fluid andnthese fluid must come in contact with a mucous membrane or damaged tissue or be directly injected into the bloodstream from a needle or syringe for transmission to occurnfactors like a person viral load other sexually transmitted infection and alcohol or drug use can increase the chance of getting or transmitting hivnbut there are powerful tool that can help prevent hiv transmissionntodaymoretools than ever are available to prevent hivnprevention strategy includenusing condom the right way every time you have sexnnever sharing needle syrinx or other drug injection equipmentnusing prep preexposure prophylaxis and pep postexposure prophylaxisnif you have hiv there are many way to prevent transmitting hiv to others including taking hiv treatment to get and keep an undetectable viral loadnthe only way to know your hiv status is to get tested knowing your status give you powerful information to keep you and your partner healthynthere are many option for quick free and painless hiv testing if yourtest result is positive you can take medicine to treat hiv to help you live a long healthy life and protect others if yourtest result is negative you can take action to prevent hivneveryonebetween the age of and should get tested for hivat least oncepeople with certain risk factor should get tested more oftennhiv treatment antiretroviral therapy or art involves taking medicine a prescribed by a health care provider you should start hiv treatmentas soon a possibleafter diagnosisnhiv treatment reduces the amount of hiv in the blood viral load hiv treatment can make the viral load so low that a test cant detect it undetectable viral load if you have an undetectable viral load you will not transmit hiv to others through sex having an undetectable viral load also reduces the risk of hiv transmission through sharing drug injection equipment and during pregnancy labor and deliverynwhen people with hiv dont get treatment they typically progress through three stage but hiv treatment can slow or prevent progression of the disease with advance in hiv treatment progression to stage aid is less common todaynpeople have a large amount of hiv in their blood and are very contagiousnmany people have flulike symptomsnif you have flulike symptom and think you may have been exposed to hiv get testednthis stage is also called asymptomatic hiv infection or clinical latencynhiv is still active and continues to reproduce in the bodynpeople may not have any symptom or get sick during this phase but can transmit hivnpeople who take hiv treatment a prescribed may never move into stage aidsnwithout hiv treatment this stage may last a decade or longer or may progress fasternat the end of this stage the amount of hiv in the blood viral load go up and the person may move into stage aidsnthe most severe stage of hiv infectionnpeople receive an aid diagnosis when their cd cell count drop below cell per milliliter of blood or they develop certain illness sometimes called opportunistic infectionsnpeople with aid can have a high viral load and may easily transmit hiv to othersnpeople with aid have damaged immune systemsnthey can get an increasing number of other serious illnessesnwithout hiv treatment people with aid typically survive about three yearsnoverviewnsymptomsnhow it spreadsnpreventionntestingntreatmentnhow it progress cause most people get hiv through anal or vaginal sex or sharing needle syrinx or other drug injection equipmentnonly certain body fluid can transmit hivnthere are powerful tool to help prevent hiv transmissionnthese fluid must come into contact with a mucous membrane or damaged tissue or be directly injected into the bloodstream from a needle or syringe for transmission to occur there are mucous membrane inside the rectum vagina penis and mouthnyou can get hiv if you have anal or vaginal sex with someone who ha hiv without using protection likecondomsormedicine to prevent hiv you can also get hiv from sharing needle syrinx or other drug injection equipment for example cooker with someone who ha hiv you can pas hiv to your baby during pregnancy childbirth and nursing breastfeedingneither partner can get hiv during anal sexnbeing the bottom or having your partner penis inside your rectum butthole make you more likely to get hiv than being the top or putting your penis inside your partner rectumnhiv can enter the body through the lining of the rectum butthole the opening at the tip of the penis urethra the foreskin or cut or sore on the penisneither partner can get hiv during vaginal sexnhiv can enter a person body through the tissue that line the vagina and cervixnvaginal fluid and blood can pas through the opening at the tip of the penis urethra the foreskin or cut or soresnused needle syrinx and other injection equipment may have someone elses blood in themnpeople who inject drug may be more likely to engage in sexual behavior that increase their chance of getting hivnhiv can pas to a baby during pregnancy childbirth and nursing breastfeeding this is calledperinatal transmissionnthis is the most common way that child get hivnhiv treatment reduces the chance of transmission to others through sex or syringe sharing and during pregnancy childbirth and nursing breastfeedingnyou cant get or transmit hiv from activity that dont involve contact with body fluid eg touching hiv doe not survive long outside the human body for example on surface and can not reproduce outside a human hostnviral load is the amount of hiv in the blood of someone who ha hiv the higher someone viral load the more likely that person is to transmit hiv viral load is highest during the earliest stage acute phase to week of having hiv and can remain high without hiv treatmentnlearn more about how takinghiv treatmentand having an undetectable viral load prevents hiv transmission through sex or sharing needle syrinx or other injection equipment and during pregnancy childbirth and nursing breastfeedingnif you haveanother sexually transmitted infection sti you may be more likely to get or transmit hiv getting tested and treated for stis can lower your chance of getting or transmitting hiv and other stis if youre sexually active you and your partner should get tested for stis even if you dont have symptomsnwhen you use drug you may be more likely to engage in behavior that increase your chance of getting or transmitting hiv such asnhaving anal or vaginal sex without protection like a condom or medicine to prevent hivnsharing needle syrinx or other drug injection equipmentufor example cookersnhaving sex with multiple partnersntrading sex for money or drugsnusing drug ordrinking alcoholcan alter your judgment lower your inhibition and impair your decision about sex or drug usenif youre going somewhere you know youll be drinking or using drug bring a condom to reduce your chance of getting or transmitting hiv through sexnthere is little to no risk of getting hiv from the activity below for transmission to occur something very unusual would have to happennoral sex involves putting the mouth on the penis fellatio vagina or vulva cunnilingus or anus rimming ejaculation in the mouth with oral ulcer bleeding gum or genital sore or the presence of other stis can increase the chance of hiv transmission you can get other stis from oral sexnthe most likely cause is injury with a contaminated needle or another sharp object careful practice of standard precaution protects patient and health care personnel from possibleoccupational hiv transmissionnthe u blood supply and donated organ and tissue are thoroughly tested it is very unlikely that you would get hiv from blood donation or transfusion blood product or organ and tissue transplant you can not get hiv from donating blood blood collection procedure are highly regulated and safenthe only known case of hiv transmission through food have been when blood from a caregiverus mouth mixed with prechewed food and an infant ha eaten it you can not get hiv from consuming food handled by someone with hivnthis rare transmission ha only occurred through contact between broken skin wound or mucous membr prevention many tool are available to help prevent hivnyou can choose not having sex activity with lower chance of hiv transmission never sharing needle and using condomsnyou can also use hiv prevention medicine such a prep or pepnif you have hiv you can prevent transmitting hiv to othersnmost people who get hiv get it through anal or vaginal sex or sharing needle syrinx or other drug injection equipment for example cooker however there are powerful tool that can help prevent getting or transmitting hivnthere is little to no chance of getting hiv through oral sexnyou cant get hiv from sexual activity that dont involve contact with semen vaginal fluid or bloodnmost condom are highly effective in preventing hiv and other stis like gonorrhea and chlamydiancondoms are less effective at preventing stis that can be transmitted through sore or cut like genital herpes and syphilisnyou can buy condom online instore or get them for free at your local clinicnprep preexposure prophylaxis is medicine people take to prevent getting hivnprep is highly effective for preventing hiv from sex and injection drug use when taken a prescribednnot having sex being abstinent is a effective way to make sure you wont get hiv through sexnyou can be abstinent at different time in your life for different reasonsnnot having sex also prevents other stis and pregnancynif you have another sti you are more likely to get hivnmany people with an sti may not know they have one because they dont have symptomsnuse new clean syrinx and injection equipment every time you injectnyou can get new needle and syrinx and safely dispose of used at syringe service program sspsfind an sspnear younsome pharmacy sell needle without a prescriptionnif you do share syrinx use bleach to clean them a disinfected syringe is not a good a a new sterile syringe but it can greatly reduce your chance for hiv and viral hepatitisnnot injecting drug is a effective way to make sure you wonut get hiv through injection drug usentalk with a counselor doctor or other health care provider about treatment for substance use disorder including medicationassisted treatmentnfind a treatment center near you atfindtreatmentgovorsamhsagovnpep postexposure prophylaxis is medicine people take to prevent hiv after a possible exposurenif you think you may have been exposed to hiv in the last hour talk to your health care provider an emergency room doctor or an urgent care provider right away about pepnthis is the most important thing people with hiv can do to stay healthynpeople with hiv who take hiv medicine and get and keep an undetectable viral load will not transmit hiv to their sex partnersnif your test result is negative and you or your partner engage in behavior that increase your chance of getting or transmitting hiv get tested again in your third trimesternif your test result is positive you can reduce the chance of transmitting hiv to your baby by taking hiv medicine a prescribed throughout pregnancy labor and delivery getting and keeping a suppressed viral load and giving hiv preventive medicine to your baby after giving birthnif you have a partner with hiv and are considering getting pregnant talk to your health care provider aboutprepnmale circumcision may decrease the chance of hiv transmission in some situation but less than some other prevention option talk to your health care provider about the benefit and drawback of male circumcisionnoverviewnprevention step and strategy diagnosis everyone between the age of and should get tested for hiv at least oncenpeople with certain risk factor should get tested more oftennmost hiv test are available for free or at a reduced costnvisit gettestedcdcgov to find hiv testing in your areanthe only way to know your hiv status is to get tested knowing your hiv status give you powerful information to keep you and your partner healthy if yourtest result is positive you can take medicine totreat hivto help you live a long healthy life and protect others if yourtest result is negative you can take action toprevent hivneveryone between the age of and should get tested for hiv at least oncenpeople with certain risk factor should get tested more often you should get testedat least once a yearifnyoure a man who ha had sex with another mannyouve had anal or vaginal sex with someone who ha hivnyouve had more than one sex partner since your last hiv testnyouve shared needle syrinx or other drug injection equipment for example cookersnyouve exchanged sex for drug or moneynyouve been diagnosed with or treated for another sexually transmitted infection hepatitis or tuberculosis tbnyouve had sex with someone who ha done anything listed above or you dont know their sexual historynbefore having sex with a new partner talk about your sexual and druguse history disclose your hiv status and consider getting tested together even if you and your partner are having sex only with each other you should both find out your hiv statusnsexually active gay or bisexual men may benefit from more frequent testing every to month talk to your health care provider about your risk factor and what testing option are available to younpregnant people should get tested for hiv during each pregnancy testing pregnant people and treating those who have hiv is a highly effective way to prevent baby being born with hivnthere are three type of hiv testsantibody testsantigenantibody test andnucleic acid test nat antibody are produced by your immune system when youre exposed to virus like hiv antigen are foreign substance that cause your immune system to activate if you have hiv an antigen called p is produced even before antibody developnhiv test are typically performed on blood or oral fluid they may also be performed on urinenanantibody testlooks for antibody to hiv in your blood or oral fluid most rapid test and the only hiv selftest approved by the u food and drug administration fda are antibody test antibody test that use blood from a vein can detect hiv sooner than test done with blood from a finger stick or with oral fluidnanantigenantibody testlooks for both hiv antibody and antigen antigenantibody test are recommended for testing done in lab and are common in the united state this lab test involves drawing blood from a vein there is also a rapid antigenantibody test available that is done with blood from a finger sticknanatlooks for the actual virus in the blood with a nat the health care provider will draw blood from your vein and send the sample to a lab for testing this test can tell if a person ha hiv or how much virus is present in the blood hiv viral load test a nat can detect hiv sooner than other type of test this test should be considered for people who have had a recent exposure or a possible exposure and have early symptom of hiv and who have tested negative with an antibody or antigenantibody testntalk to your health care provider about what type of hiv test is right for younvisitgettestedcdcgovto see if any organization in your area are offering free or reduced cost selftests you can also buy an hiv selftest at a pharmacy or onlinena selftest can be used at home or in a private location with an hiv selftest you can get your test result within minute you should always interpret hiv selftest result according to themanufacturers instruction if the hiv selftest is invalid then the test did not work you will need to use another hiv selftest or find testing at a health care provider or testing centernyou can ask your health care provider for an hiv test many medical clinic substance abuse program community health center and hospital offer them too use the locator below to find hiv testing service in your areanif you get an hiv test in a health care setting or lab the health care provider will take a sample of blood or oral fluid with a rapid test oral fluid or finger stick you may be able to wait for the result with a lab test it may take several day for your result to be availablenif you are tested outside of a health care setting or a lab you will likely receive a rapid test oral fluid or finger stick the counselor providing the test should be able to answer question and provide referral for followup testing if needednhiv test are covered by health insurance without a treatment there is no cure for hiv but hiv treatment can reduce the amount of hiv in your bodynthere are two type of hiv treatment pill and shotsnmost people can get hiv under control within six monthsnhiv treatment prevents transmission to others and help you stay healthynhiv treatment antiretroviral therapy or art involves taking medicine prescribed by a health care provider when taken a prescribed hiv medicine can make the amount of virus in your body viral load so low that a test cant detect it undetectable viral loadnall people with hiv should take hiv treatment no matter how long theyve had hiv or how healthy they are if you delay treatment hiv will continue to harm your immune system and increase your chance of transmitting hiv to others getting sick and developing aidsnthere are two type of hiv treatment pill and shotsnpills are recommended for people just starting hiv treatment there are many fdaapproved single pill and combination medicine availablenhiv treatment shot are longacting injection given once a month or once every other month depending on your treatment plannshots may be right for you if you are an adult with hiv whonhas had an undetectable viral load or ha achieved viral suppression for at least three monthsnhas no history of treatment failure andnhas no known allergy to the medicine in the shotnyoull need to visit your provider regularly to receive your shot tell your health care provider a soon a possible if youve missed or plan to miss an appointment for your shotna health care team that is knowledgeable about hiv care will help you manage your care and treatment your primary hiv care provider should lead your health care team they willndetermine which hiv medicine is best for younprescribe hiv medicinenmonitor your progress and help you manage your healthnrefer you to otherhiv providerswho can address your needsnyour care team may include other provider who are expert in hiv care like nurse mental health provider pharmacist nutritionist and dentist social service provider like social worker case manager substance use specialist and patient navigator may help you find support servicesnyou can also use the locator below to find a local health center or a ryan white hivaids provider who can help you access medical caremedications and essential support servicesnthis will help keep your viral load low and your cd count highntake your hiv medicine exactly how your health care provider tell you touat specific time of the day with or without certain kind of foodntalk to your health care provider or pharmacist if you have question about when or how to take your medicine or if you are experiencing any side effectsnuse a calendar to mark your appointmentsnset reminder on your phonenkeep your appointment card in a place where you will see itnask a family member or friend to help you remember your appointmentsnduring your appointment your health care provider may ask question and conduct routine medical exam to see how hiv is affecting your body they mayntake a blood sample to check your viral loadnask about your health historynlook for other kind of infection or health problem or give you immunizationsndiscuss prescribe and monitor your hiv medicinendiscuss way to help you follow your hiv treatment plannhelp identify other support you may neednask about your sexual or injection partner and discus way to prevent them from getting hivnyour health care provider will use blood test to monitor your hiv these test help your health care provider make decision about change to your treatmentnyour cd count is the number of cd cell you have in your bloodncd cell help your body fight infectionsnhiv attack and lower the number of cd cell in your bloodnthis make it difficult for your body to fight infectionsnyour health care provider will check your cd count every to monthsnthis test look at the amount of hiv in your bloodnwhen your viral load is high you have more hiv in your body this may mean your immune system is having difficulty fighting the virus or that your hiv medicine isnt working wellnyou should have a viral load testevery to monthsbefore you take a new hiv medicine andaround to week after starting or changing medicinenevery to monthsnbefore you take a new hiv medicine andnaround to week after starting or changing medicinenif your viral load go down after starting hiv treatment that mean treatment is working continue taking your hiv treatment a prescribednif you miss your hiv treatment even now and then hiv can multiply rapidly in your bodynthis could weaken your immune system and you could become sicknif you have an undetectable viral load you will not transmit hiv through sex this is also known asundetectable untransmittablenhaving an undetectable viral load likely reduces the risk of hiv transmission through sharing needl
National Guidelines for Management
"The overall goal of Ugandas health system is to provide accessible,"
"equitable and quality services to the population, in order to promote a"
"healthy and productive life, which is a necessary factor for achieving"
socio-economic growth and national development.
"Currently, the health system is faced with multiple challenges that include"
"a high burden of infectious diseases that remain major causes of morbidity and mortality, such as HIV, malaria, tuberculosis, lower respiratory"
"tract infections, malnutrition and meningitis. In addition, new threats"
"keep emerging, for example, epidemics of hepatitis B, yellow fever,"
"haemorrhagic fevers, COVID-19 and nodding disease. The increase of"
"non-communicable conditions including diabetes, hypertension, heart"
"diseases, cancer and mental disorders complicates the scenario."
"The push towards universal health coverage, including universal access"
"to AntiRetroviral Therapy (ART) and particular attention to neonatal,"
"child, adolescent and maternal health, is also placing more demands on"
a system with limited resources.
"To respond appropriately, the health system has to ensure high standards"
"of quality and efficiency in service delivery. The Uganda Clinical Guidelines manual helps to achieve these standards by presenting updated,"
"practical, and useful information on the diagnosis and management of"
common health conditions in Uganda. It also provides a rational basis for
an efficient procurement and supply system that ensures the availability
"of safe, efficacious, quality medicines and health supplies."
"The guidelines are based on principles of scientific evidence, cost effectiveness and prioritization of conditions to maximize the health benefit"
The regular update of clinical guidelines and essential medicines lists
is one of the key interventions in the Health Sector Development Plan
"2015-2020, to promote the appropriate use of health products and"
I wish to thank all the members of the Update Task
"Force, government parastatals, medical consultants, district health workers, the private sector, the Uganda Reproductive Maternal Child and"
Adolescent Health Improvement Project (URMCHIP) and development
partners for their immense input in developing the 2023 UCG edition.
"Finally, I thank the consultancy firm, Zenith Solutions Limited, that"
coordinated the overall inputs that led to the successful development
General Management of Poisoning 65
1.Removal and Elimination of Ingested Poison 68
Acute Organophosphate Poisoning 70
Paraffin and Other Petroleum Products Poisoning 72
Acetylsalicylic Acid (Aspirin) Poisoning 74
Methyl Alcohol (Methanol) Poisoning 81
Hypoxeamia Management and Oxygen Therapy Guidelines 87
"2.Septic Shock Management, In Adults 118"
Typhoid Fever (Enteric Fever) 124
Echinococcosis (Hydatid Disease) 154
Dracunculiasis (Guinea Worm) 156
Onchocerciasis (River Blindness) 159
Schistosomiasis (Bilharziasis) 161
2.ComplicatedSevere Malaria 166
2.Management of Complications of Severe Malaria 175
2.Malaria Prevention and Control 180
Human African Trypanosomiasis (Sleeping Sickness) 181
3 HIVAIDS AND SEXUALLY TRANSMITTED INFECTIONS 186
HIV Infection And Acquired Immunodeficiency Syndrome (AIDS).186
Diagnosis and Investigations of HIV 190
Measures before ARV Treatment 197
General Principles of Antiretroviral Treatment (ART) 200
Recommended First Line Regimens 206
Recommended Second Line Regimens 222
Mother-to-Child Transmission of HIV 229
3.Management of HIV Positive Pregnant Mother 231
Key Interventions for eMTCT 231
3.HIV-exposed infant care services 239
3.Care of HIV Exposed Infant 248
Opportunistic Infections In HIV 252
3.Tuberculosis and HIV Co-Infection 252
3.Hepatitis B and HIV Co-Infection 261
3.Post-Exposure Prophylaxis 265
3.Pre-Exposure Prophylaxis (PrEP) 269
Sexually Transmitted Infections (STI) 276
Urethral Discharge Syndrome (Male) 276
Abnormal Vaginal Discharge Syndrome 279
Pelvic Inflammatory Disease (PID) 283
Genital Ulcer Disease (GUD) Syndrome 283
3.Neonatal Conjunctivitis (Ophthalmia Neonatorum) 294
Deep Vein ThrombosisPulmonary Embolism (DVTP) 298
4.Hypertensive Emergencies and urgency 316
Ischaemic Heart Disease (Coronary Heart Disease) 317
Non-Infectious Respiratory Diseases 329
Chronic Obstructive Pulmonary Disease (COPD) 340
Infectious Respiratory Diseases 344
Acute Laryngotracheobronchitis (Croup) 353
5.Pneumonia in an Infant (up to 2 months) 358
5.Pneumonia in a Child of 2 months-5 years 360
5.Pneumonia in Children  5 years and adults 363
5.Pneumonia by Specific Organisms 364
5.Pneumocystis jirovecii Pneumonia 365
"Definition, Clinical Features and Diagnosis of TB 367"
5.Tuberculosis in Children and adolescents 373
5.Post-TB patient management 375
5.Anti-TB Drugs Side Effects382
5.Prevention and Infection Control of TB 385
5.Tuberculosis Preventive Treatment 386
5.TB Preventive Treatment Dosing Chart 388
6 GASTROINTESTINAL AND HEPATIC DISEASES 394
Gastrointestinal Emergencies 394
Upper Gastrointestinal Bleeding 400
Gastrointestinal Infections 405
Bacillary Dysentery (Shigellosis) 407
Gastroesophageal Reflux Disease (GERDGORD) 413
Haemorrhoids (Piles) and Anal Fissures 423
Hepatic and Biliary Diseases 425
Chronic Hepatitis B Infection 428
6.Inactive Hepatitis B Carriers 430
6.Pregnant Mother HbsAg Positive 430
Chronic Hepatitis C Infection 431
6.Spontaneous Bacterial Peritonitis (SBP) 436
6.Hepatic Encephalopathy (HE) 437
Jaundice (Hyperbilirubinemia) 443
Acute CholecystitisCholangitis 445
7 RENAL AND URINARY DISEASES448
Chronic Kidney Disease (CKD) 450
Use of Drugs in Renal Failure 453
Benign Prostatic Hyperplasia 465
8 ENDOCRINE AND METABOLIC DISEASES 468
Diabetic Ketoacidosis and Hyperosmolar Hyperglycaemic State 478
8.1.8. Central precocious puberty 486
"9 MENTAL, NEUROLOGICAL AND SUBSTANCE USE DISORDERS.488"
Delirium (Acute Confusional State) 504
Psychiatric And Substance Use Disorders 506
9.Suicidal BehaviourSelf Harm 511
Psychiatric And Substance Use Disorders 524
9.Suicidal BehaviourSelf Harm 531
Childhood Behavioural Disorders 550
Childhood Developmental Disorders 552
10 MUSCULOSKELETAL AND JOINT DISEASES 554
Pyogenic Arthritis (Septic Arthritis) 554
Tuberculosis of the Spine (Potts Disease) 560
InflammatoryDegenerative Disorders 562
11 BLOOD DISEASES AND BLOOD TRANSFUSION GUIDELINES...568
General Principles of Good Clinical Practice in Transfusion Medicine....589
Blood and Blood Products: Characteristics and Indications 590
11.Red Cell Concentrates (packed red cells) 591
11.Clinical Indications for Blood Transfusion 592
Adverse Reactions following Transfusion 595
11.Acute Transfusion Reactions 598
Special Groups at Increased Risk of Cancer 602
12.Urgent Signs and Symptoms 605
Clinical Features and Investigations 623
Nociceptive Pain Management 623
13.Pain Management In Adults 625
13.Pain Management In Children 627
Other Conditions In Palliative Care 633
Pressure Ulcer (Decubitus Ulcers) 634
14 GYNECOLOGICAL CONDITIONS 643
Pelvic Inflammatory Disease (PID) 644
Key steps to be followed in provision of FP services 651
Provide Information about FP 652
Pre-Conception Care with Clients Who Desire to Conceive 654
Discuss with PLW HIV Special Consideration for HIV Transmission 654
Educate and Counsel Clients to Make Informed Choice of FP Method 654
Obtain and Record Client History655
Perform a Physical Assessment 657
Perform a Pelvic Examination 658
Manage Client for Chosen FP Method 658
Summary of Medical Eligibility for Contraceptives 659
Overview Of Key Contraceptive Methods 664
Combined Oral Contraceptive Pill (COC) 667
Progestogen-Only Pill (POP) 671
Injectable Progestogen-Only Contraceptive 674
Progestogen-Only Sub-Dermal Implant 679
Emergency Contraception (Pill and IUD) 683
Natural FP: Cervical Mucus Method (CMM) and Moon Beads 688
Natural FP: Lactational Amenorrhoea Method (LAM) 689
Surgical Contraception for Men: Vasectomy 690
Surgical Contraception for Women: Tubal Ligation 691
Goal-Oriented Antenatal Care Protocol 693
Management of Common Complaints during Pregnancy 698
Management Of Selected Conditions in Pregnancy 701
Pregnancy and HIV Infection 704
16.Care for HIV Positive Women (eMTCT) 705
16.Counselling for HIV Positive Mothers 706
Chronic Hypertension in Pregnancy 708
Urinary Tract Infections in Pregnancy 713
Vaginal Bleeding in Early Pregnancy Abortion 715
Premature Rupture of Membranes (PROM  PPROM) 721
Antepartum Haemorrhage (APH)  Abruptio Placentae and Placenta Praevia.726
"Labour, Delivery and Acute Complications 737"
Postpartum Haemorrhage (PPH) 746
Care of Mother and Baby Immediately After Delivery752
16.Care of Mother Immediately After Delivery 753
16.Care of Baby Immediately After Delivery 754
Essential Care of the Newborn 756
General Care of Newborn After Delivery 759
Extra Care of Small Babies or Twins in the First Days of Life 761
16.Postpartum Examination of the Mother Up to 6 Weeks 767
Intrauterine Fetal Demise (IUFD) Or Fetal Death In Utero (FDIU).788
Newborn ExaminationDanger Signs 796
"Assess for Special Treatment Needs, Local Infection, and Jaundice 801"
Sick Young Infant Age Up To 2 Months 806
Check for Very Severe Disease and Local Bacterial Infection 807
Check for DiarrhoeaDehydration 811
Check for Feeding Problem or Low Weight-for-Age 817
17.All Young Infants Except HIV-exposed Infants Not Breastfed 817
17.HIV-exposed Non Breastfeeding Infants 820
Check Young Infants Immunization Status 823
Summary of IMNCI Medicines Used for Young Infants 823
Sick Child Age 2 Months to 5 Years 825
Check for General Danger Signs 826
Check for Cough or Difficult Breathing 827
Check for Malnutrition and Feeding Problems 842
"Check Immunization, Vitamin A, Deworming 850"
17.Medicines Used Only in Health Centers 851
17.Treatment of Local Infections at Home 856
17.Feeding Recommendation during Illness 858
17.Assessing Appetite and Feeding 858
17.Counselling for Feeding Problems 863
Integrated Community Case Management 866
Child Growth Weight Standards Charts 868
Routine Childhood Vaccination 875
National Immunization Schedule 875
18.Prophylaxis Against Neonatal Tetanus 883
Vaccination against COVID-19. 885
Nutrition Guidelines In Special Populations 887
Infant and Young Child Feeding (IYCF) 887
Introduction on Malnutrition 890
19.Classification of Malnutrition 892
19.Assessing Malnutrition in Children 6 months to 5 years 893
Management of Acute Malnutrition in Children 897
19.Management of Moderate Acute Malnutrition 897
19.Management of Uncomplicated Severe Acute Malnutrition 898
19.Management of Complicated Severe Acute Malnutrition 899
19.Treatment of Associated Conditions 914
19.Discharge from Nutritional Programme916
SAM in Infants Less than 6 Months 918
Infections And Inflammatory Eye Conditions 923
Notes on Use of Eye Preparations 923
Postoperative Endophthalmitis 931
Decreased or Reduced Vision Conditions 933
Trauma and Injuries to the Eye 941
20.Penetrating Eye Injuries 943
20.Chemical Injuries to the Eye 944
Squamous Cell Carcinoma of Conjunctiva 946
"21 EAR,NOSE THROAT CONDITIONS 947"
Glue Ear (Otitis Media with Effusion)953
Foreign Body (FB) in the Airway 965
Foreign Body in the Food Passage 967
Peritonsillar Abscess (Quinsy) 971
Inflamatory  Allergic Skin Infections 994
Skin Ulcers and Chronic Wounds 1001
Drug Induced Skin Reactions 1002
Steven-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) 1002
23 ORAL AND DENTAL CONDITIONS 1005
23.1.1. HalitosisBad Breath1005
23.2.1. Prevention of Dental Caries  Other Conditions Due to Poor Oral lannin...1009
Acute Periapical Abscess or Dental Abscess 1013
23.2.6. Acute Necrotizing Ulcerative Gingivitis (ANUG)PeriodontitisStomatitis 1018
HIVAIDS Associated Conditions 1030
"24. SURGERY, RADIOLOGY AND ANAESTHESIA 1036"
Management of Medical Conditions in Surgical Patient 1042
Newborn with Surgical Emergencies 1045
Surgical Antibiotic Prophylaxis 1046
Diagnostic Imaging: A Clinical Perspective 1047
Selection of Type of Anaesthesia for the Patient 1060
"As medicine is an ever-evolving field, this manual is to be used for guidance, but cannot replace clinical judgement in individual cases."
The and all those involved in updating the UCG
sincerely hope that the manual will make a significant contribution to
ongoing improvements in national therapeutic services and medicines
DIRECTOR GENERAL HEALTH SERVICES
"Mrs. Okuna Neville Oteba, CHS  PNM-MOH"
"Mr. Komakech Alfred, Pharmacist-UCDr. Katwesigye Elizabeth, SMO-MOH"
"Dr. Nakwagala Fred, Sen. Cons.-MNRH"
"Mr. Seru Morris, ACHS- Pharm-MOH"
"Mr. Opio Patrices Otuke, ASS. DHODMMS"
"Mr. Muwonge Raymond, Intern Pharm, Kiruddu NRH"
"Mr. Gidudu Ivan, Dispenser Soroti-RRH"
"Sr. Limio Christine, Mbale RRH-PNO"
"Mr. Sande Alex, Sen. Pharm Mbale RRH"
"Dr. Senjokyo Wilson, M.O Arua RRH"
"Mr. Manzi Mbabazize Gerald, Pharmacist-Mbarara RRH"
"Mr. Katugira Lauben, Pharmacist Mbarara RRH"
"Mr. Obua Thomas O, Sen. Pharm-MOH"
"Mr. Kabonero Timothy, Pharmacist Masaka RRH"
"Mr. Tabaruka Rodney, Sen. Pharm-Kabale RRH"
"Sr. Oyella M. Josephine, Pharmacist-Lacor Hospital"
"Mr. Aguma Daniel, Pharmacist-Lira RRH"
"Ms. Twemanye Vivian, Project Pharmacist-IDIGlobal Health"
"Mr. Lule Falisy, Pharmacist-Kiruddu NRH"
Ms. Marion A Murungi - USAID MTaPS
"Mr. Owona Joseph, PCO- Soroti RRH"
"Ms. Irene Bagaya Nurse -IDMr. Muwaza Eriabu, Sen. Pharm- Azan-Fort Portal"
"Mr. Gideon Kisuule, PPharmacist -Butabika NRH"
"Mr. Bewayo Victor, Pharmacist-Arua RRH"
"Ms. Nyombi Vicky R. Babirye, Sen. Pharm Mulago-NRH"
"Ms. Nanyonga Stella, Sen. Pharm-Mulago Women Hospital"
"Mr. Emmanuel Watongola, LSCO-MOHOPPU"
"Mr. Julius Mubiru, Regional Coordinator MSH"
"Ms. Gladys Karungi, Dispenser-Jinja RRH"
"Ms. Sandra Achiro, Dispenser-Lira RRH"
"Ms. Prossy Atimango, C.O Gulu RRH"
"Ms. Kabonesa Winnie, Dispenser- Mbarara RRH"
"Ms. Namirembe Maliyamu, C.O Masaka RRH"
"Dr. Florence Oyella Otim, Paed-Gulu RRH"
"Ms. Nambatya Winnie, Pharmacist-MUK  CHS"
"Ms. Pamela Achii, PSM Specialist-MOH"
"Mr. Mugerwa Ibrahim, PO AMRGHSA -MOH - NHLDS"
"Mr. Nankoola Dennis, Sen. Pharm -Gulu RRH"
"Ms. Akello Zainab, Pharmacist-Gulu RRH"
"Dr. Okot Christopher, Gen. Surgeon- Gulu RRH"
"Ms. Tino Harriet O, Pharmacist-Lira RRH"
"Mr. Olum William, Sen. Pharm-JRRH"
"Dr. Helen Byomire Ndagije, DPS-NDA"
"Dr. Denis Kibira, Coordinator-META"
"Dr. James Ntulume, Snakes Uganda"
Dr. Alfred Mubangizi ACHS -VB  MTD-MOH
"Dr. Mukajayaka Ritah, Intern Pharmacist"
Dr. Nabiryo Mary. Citycare Medical Centre- Jinja
"Dr. Nakireka Susan Tumwesigye, Mengo Hospital UNDA"
"Mr. Edson I. Munanura, Secretary PSU"
"Dr. Joanita Bamwanga Nanteza, Physician-Jinja RRH"
"Mr. Ambrose Jakira, SPQS-MOHDPNM"
"Mr. Rodgers Katusigye, Pharmacist-MJAP"
"Mr. Caroline Birungi, Psychiatrist -MJAPCHS"
"Dr. Martin Muddu, Physician- MJAP"
"Dr. Musimbaggo Douglas, Coordinator -MJAP"
"Dr. Patricia Alupo, Physician-MLDr. Cewa Ssenyange, SDA-NDA"
"Dr. Wabwona George William, Physician-Mubende RRH"
"Dr. Katagira Winceslaus, Physician-Lung Institute"
"Dr. Ann Akiteng, DDirector-UINCD"
"Dr. Lumu William, Physician Diabetologist -MENGO"
"Dr. John B. Kiggundu, Coordinator-IDRC"
"Dr. Omale William, Sen. Pharm- Arua RRH"
"Mr. Daniel Chans Mwandah, Clinical Pharmacist MRRHMUST"
"Dr. Kwizera Christopher, Proj. Manager-Uganda NCD Alliance"
"Dr. Isaac Kimera, Coordinator-MJAP"
"Dr. Oyoo Charles A, CHS  NCD-MOH"
"Dr. Gracious Ahumuza, ACHS  PSCL-MOH"
"Dr. Nantaba Deborah, MCOSelfcare Trainer-MDLG"
"Ms. Jacqueline Twemanye, Comms Officer-CEHURD"
"Dr. Kukundakwe Annah, SPO-CEHURD"
"Ms. Awilli Grace, Volunteer-CEHURD"
"Dr. Nsingo Simon Peter, M.O-Mukono C.O.U Hospital"
"Dr. Isaac Ssinabulya, Cons. Cardiologist-UHIUINCD"
"Ms. Kironde Stella M, PHO- Komamboga HCMr. Pascal Aliganyira, SCO-SAMASHA"
"Dr. Christopher Arineitwe, NFPP Advisor- USAID FPA"
"Ms. Aruho Carol, Proj. Officer-HEPS UG"
"Ms. Precious Mutoni, Advocacy  Partnership-PSI Uganda"
"Ms. Joyce Zalwango, Ag. Programs Manager-PCAU"
"Dr. Karima Amin Kamru K, Head-MPU -Hospice Africa Uganda"
"Mr. Ogwang Christopher, SPO-CEHURD"
"Dr. Niwagaba Peter, Technical Advisor, SCM-USAID RHITES EC"
"Mr. Lubogo Patrick, Clinical Pharmacist"
Mr. Tadele Mekuriya Yedesa Clinical Pharmacist - Mbarara RRH
Mr Aboda Alex Komakech Clinical Pharmacist - Kitgum District Hospital
"Dr. Isiiko John, Oncology Pharmacist - Mbarara RRH,"
"Mr. Aguma Bush Herbert, Makerere University, School of Pharmacy,"
Ms. Farida Khaukha. Pharmacist-NDA
Mr. Dennis Rogers Buwembo-Consultant R4D.
"Mr. Patrick Mpiima, Registrar-Allied Health Professionals"
"Mr. Eric Jemera Nabuguzi, Principal Advisor, RMNCH"
"Mr. Lawrence Were, - RCHSCTA-CHADr. Hafsa Lukwata, Mental HealthMOH"
"Dr. Benjamin Mwesige, Pharmacist, UCDr. Martin Ssendyona, Quality AssuranceMOH"
"Dr. J. Ddamulira, MUSPH, Makerere."
"Dr. Turyahabwe Stavia, ACHS-NTLPMOH"
"Dr. Winters Mutamba, Consultant -MLDr. Aldo Burua, TB case finding Advisor - NTLP LPHS"
"Ms. Hawa Nakato, Supply Chain Advisor -NTLPMOH"
"Mr. Abdunoor Nyombi, Lab  NTRL - NTLPMOH"
"Dr. Jeff Amanya, Epidemiologist - NTLPMOH"
"Dr. Joshua Muhumuza, PPM Advisor - NTLP LPHS"
"Dr. Simon Muchuro, TB Prevention Advisor -NTLP LPHS"
"Mr. Muzamir Bamuloba, CSS Advisor - NTLPMOH"
"Dr. Mary Mudiope, Project Director - LPHS TB Activity"
"Dr. Prossy Namuwenge, SPO TBHIV - ACPMOH"
"Dr. Raymond Byaruhanga, STA-Global Fund - NTLPMOH"
"Ms. Shamimu Masika, Adm Assistant - LPHS TB Activity"
"Mr. Busingye Evas, IT Officer - NTLPMOH"
"Dr. Ajuna Patrick, TB DSD Advisor - NTLPMOH"
"Mr. Kamara Vincent, Data Manager - NTLPMOH"
"Mr. Didas Tugumisirize, Laboratory Technologist - NTLPMOH"
"Mr. Ignatius Senteza, STA LPHS- TB Activity"
"Mr. Moses Arineitwe, TA-ME - NTLPMOH"
"Dr. Gemagaine Godfrey, Cons. Pathologist-Naguru Hospital"
"Dr. Susan N. Nabadda, CHS-NHLDS- UNHLSCPHL- MoH"
"Mr. Kenneth Mwehonge - HEPS-Uganda, ED."
"Mr. Serunkuuma Richard-Positive Mens Union, ED"
"Ms. Jackline Mutimba - HEPS-Uganda, Senior ME Officer"
"Ms. Bridget Jjuuko - ACTS101, ED"
"Ms. May Ndagire - Preventive Care International, Programs Officer"
Mr. Peter Eceru  CEHURD- Program Coordinator
"Mr. Ssebibubbu Stuart - HEPS-Uganda, Pharmacist"
Mr. Bukenya Denis Joseph - HURIC
"Ms. Joan Esther Kilande - HEPS-Uganda, Health Policy Advocacy Manager"
"Ms. Mable Kukunda Musinguzi  UNHCO, Head of Advocacy and networking"
Mr. Talibita Moses  UNHCO -Legal Officer
Ms. Kangabe Claire - Transparency International Uganda
"Ms. Ninsiima Dorothy - Action Group for Health, Human Rights  HIV"
"Ms. Nanteza Ruth - Uganda Young Positives (UYP), Peer Leader"
"Mr. Principle Edimon - Vision Group, Journalist"
Mr. Gilbert Musinguzi - Uganda Debt Network (UDN)-Quality Assurance
"Ms. Nabirah Namawanda - Lady Mermaid Empowerment Center, Communication  Advocacy Officer"
"Mr. Jude Opolot - Oxygen Task Force Logistician, MoH"
"Ms. Doreen Nyakato - Oxygen Task Force Coordinator, MoH"
"Dr. Samalie Namukose (Assistant Commissioner, Nutrition Division,"
"Dr. Alex Mokori (Nutrition Specialist, UNICEF)"
"Ms. Jeniffer Luande (Nutrition Supply Chain Consultant, UNICEF)"
"Mr. Tim Mateba (Senior Nutritionist, Nutrition Division, )"
"Dr. Hanifa Bachu (Technical Director Nutrition, USAID MCHN Activity)"
"Dr, Elizabeth Kiboneka (Nutrition Consultant)"
"Mr. George Kemugisha (Nutritionist, Mulago National Referral Hospital)"
"Ms. Amanda Murungi (Nutritionist, Mulago National Referral Hospital)"
"Ms. Agnes Kiro (Programme Officer, Nutrition Division, )"
Dr. Anne Mary Nanyonjo - Pharmacist Mubende RRH
"Mr. Absolom Zisanhi - Senior Associate, CHADr. Margaret Abigaba - Senior Pharmacist, Hoima RRH"
"Mr. Michael Lukunyanga - Distribution manager, NMS"
"Dr. Emily Tumwakire - Senior Medical Officer, MoH"
"Ms. Dorcas Kemigisha - Senior Coordinator, CHAEng. Owen Muhimbise - Biomedical Engineer, MoH"
"Blasio Kunihiira - ME coordinator, CHAEng. Saad Waigonda - Senior Biomedical Engineer, MoH"
"Eng. Tadeo Byabagambi - ACHS-BiomedicalElectromechanical Engineering, MoH"
"Dr. Yewande Kamuntu, Program Manager, CHADr. Santa Engol, Senior Coordinator, CHADr. Aanyu Hellen, Consultant Pediatrician, Mulago NRRH"
"Mr. Jovan Baryamujura, Oxygen Task Force Administrator"
Ms. Nakade Shamim  National Activity Manager SSCS Activity
Mr. Daniel Mawerere  Senior Technical Advisor MoH DPNM
Mr. Kasule Timothy  RHSC Analysts UNFPA
Mr. Joel Miti - Senior Technical Advisor NMCD MoH
Ms. Magona Sandra RMNCAH  Nutrition Senior Technical Officer
"Ms. Sarah Taratwebirwe, Condoms Logistics Management Officer MoH"
Mr. Tabu Fred  Senior Technical Officer MoH DPNM
"Mr. Ian Nyamitoro, HP Quantification Specialist MoH DPNM"
"Mr. Deogratius Kamulegeya - Administrator, IMT Logistics Pillar, MoH"
"Mr. Ambrose Jakira, HP Quantification Specialist MoH DPNM"
"Mr. Isaac Namoma, GHSA Senior Technical Officer USAIDSSCS Activity"
"Ms. Judith Kyokushaba, Laboratory Advisor MoH DPNM"
"Mr. Henry Oundo, Technical Advisor MoH DPNM"
"Ms. Linacy Nampa, Technical Advisor MoH DPNM"
"Mr. Emiku Joseph, HIVTB Technical Officer MoH DPNM"
"Mr. Denis Okidi Ladwar, Director Supply Chain USAIDSSCS Activity"
Mr. Bamwine Jeremiah - Support on AIDS and Life Through Telephone
"Mr. Raymond Ruyoka - YADNET UG, ED"
"Dr. Lutakome Jamadah Aldine - Hepatitis Aid Organisation, Programs"
Ms. Beatrice Ajonye- PC-International Community of Women Living
with HIV Eastern Africa (ICWEA)
"Mr. Moses Supachager  JABASA, ED"
Mr. Georgina Mugwera - Ministry of Trade
Mr. Grace Kiwanuka - Uganda Health Care Federation-ED
Mr. Ssebagereka Anthony - HEPS-Uganda- Research
Ms. Nakalute Mastulah - GHC Mbarara
"Ms. Baguma Anne Peace - SALT Helpline, ED"
Mr. Kirunda Anthony - Sub-National Activity Manager USAIDSSCS
"Mr. Charles Twesige - HEPS-Uganda, ME Officer"
"Ms. Barbara Amumphaire - HEPS-Uganda, Program Officer"
"Mr. Cliff Abenaitwe - HEPS-Uganda, Communication Officer"
"Dr. George Mukone Mudanga, MD- IFOTRODE"
"Dr. Sam Ononge (PhD), Sen. Lecturer- ObGyn Muk-CHS"
"Mr. Joshua Musasizi, Knowledge Exchange Specialist USAIDSSCS"
BPH Benign Prostatic Hyperplasia
CD4 Cluster Of Differentiation 4
CIN Cervical Intraepithelial Neoplasia
CLL Chronic Lymphocytic Leukaemia
COC Combined Oral Contraceptive
COPD Chronic Obstructive Pulmonary Disease
CPD Cephalopelvic Disproportion
CuIUD Copper Bearing Intra-Uterine Device
DIC Disseminated Intravascular Coagulation
DMPA Depot Medroxyprogesterone Acetate
"DOTS Directly Observed Treatment, Short-Course"
"DPT Diphtheria, Pertussis, And Tetanus"
DST Drug Susceptibility Testing
ECP Emergency Contraceptive Pill
ELISA Enzyme-Linked Immunosorbent Assay
eMTCT Elimination Of Mother-To-Child Transmission
ESR Erythrocyte Sedimentation Rate
Etravirine F-75F-100 Therapeutic Milk Formula 75 Or
FNAC Fine Needle Aspiration Cytology
FSH Follicle Stimulating Hormone
G6PD Glucose 6 Phosphate Dehydrogenase
GDM Gestational Diabetes Mellitus
GERD Gastroesophageal Reflux Disease
HAART Highly Active Antiretroviral Therapy
"HbA1c Glycated Haemoglobin, Haemoglobin A1c"
HBeAg Hepatitis B Envelope Antigen
HBsAg Hepatitis B Surface Antigen
HHS Hyperosmolar Hyperglycaemic State
Hib Haemophilus Influenzae Type B
HIV Human Immunodeficiency Virus
ICCM Integrated Community Case Management
IMNCI Integrated Management Of Neonatal And Childhood Illness
IMPAC Integrated Management Of Pregnancy And Childbirth
INR International Normalised Ratio
IPT Intermittent Preventive Treatment
IPT Isoniazid Preventive Therapy
Intermittent Preventive Treatment Of Malaria In
IRIS Immune Reconstitution Inflammatory Syndrome
IUGR Intrauterine Growth Restriction Iv
IYCF Infant And Young Child Feeding
LLINs Long-Lasting Insecticide Treated Nets
LMWH Low Molecular Weight Heparin
LTBI Latent Tuberculosis Infection
MCH Mean Corpuscular (Cell) Haemoglobin
MDR-TB Multi-Drug Resistant Tuberculosis
mhGAP Mental Health Gap Action Program
MRSA Multi-Resistant Staphylococcus Aureus
MUAC Mid-Upper Arm Circumference
NBTS National Blood Transfusion Services
NET-EN Norethisterone Enanthate
NMCP National Malaria Control Program
NNRTI Non-Nucleoside Reverse Transcriptase Inhibitors
NPH Neutral Protamine Hagedorn (Isophane Insulin)
NPO Nil Per Os (Nothing By Mouth)
NR National Referral (Hospital)
NSAID Nonsteroidal Anti-Inflammatory Drugs
NTLP National Tuberculosis And Leprosy Programme
NTRL National TB Reference Laboratory
NtRTI Nucleoside Reverse Transcriptase Inhibitors
PCP Pneumocystis Jirovecii Pneumonia
PCV Pneumococcal Conjugate Vaccine
PEM Protein Energy Malnutrition
Practical Guidelines For Dispensing At Lower Higher
PID Pelvic Inflammatory Disease
PIH Pregnancy Induced Hypertension
PMTCT Prevention of Maternal-To-Child Transmission
PPD Purified Protein Derivative
PPE Personal Protective Equipment
PrEP Pre-Exposure Prophylaxis Prn As Needed
PROM Premature Rupture Of Membrane
PTT Partial Thromboplastin Time
RHZE Rifampicin  Isoniazid  Pyrazinamide  Ethambutol
RR-TB Rifampicin-Resistant Tuberculosis
RUTF Ready-To-Use Therapeutic Food
SARS Severe Acute Respiratory Syndrome
SpO2 Arterial Oxygen Saturation
SSRI Selective Serotonin Reuptake Inhibitor
STI Sexually Transmitted Infections
TDF Tenofovir Disoproxil Fumarate
TIG Tetanus Immunoglobulin Human
TSH Thyroid Stimulating Hormone
UBTS Uganda Blood Transfusion Service
UCMB Uganda Catholic Medical Bureau
UHSC Uganda Health Supply Chain
UNEPI Uganda National Expanded Program On Immunisation
UNHLS Uganda National Health Laboratory Services
XLUSAID United States Agency For International Development
UVRI Uganda Virus Research Institute
VCT Voluntary Counselling And Testing
Venereal Disease Research Laboratory Test
VIA Visual Inspection With Acetic Acid
VILI Visual Inspection With Lugols Iodine
VSC Voluntary Surgical Contraception
XDR-TB Extensively Drug Resistant Tuberculosis
"This fully updated publication replaces the UCG 2023 and is being circulated to all public and private sector prescribers, pharmacists, Training"
Institutions and regulatory authorities in the country.
"For effective use of the UCG, it is recommended that carefully designed"
dissemination sessions be organized countrywide to ensure that users
"appreciate the new features, changes, structural arrangement and content"
The following sections will present the structure and main features of
the guideline to highlight the changes in this latest edition and help the
user become familiar with the book and use it effectively.
"The UCG aims to provide summarized easy-to-use, practical, complete and"
useful information on how to quickly and correctly diagnose and manage
common conditions you are likely to encounter. Thisw ill ensure that patients
receive the best possible clinical services and obtain prompt and effective relief
"from or cure of their complaint, thereby making the most appropriate use of"
"scarce diagnostic and clinical resources, including medicines. It should,"
"however, be emphasised that the UCG does not replace or substitute"
available textbooks on the subject.
Medicine is an ever-evolving and expanding field in terms of needs and
knowledge. The UCG helps the country to prioritize and effectively
use limited resources by guiding the procurement system to ensure the
availability of the most needed medicines and supplies.
XLRead all the introductory sections. They will give you useful advice
for your daily practice. There is always something new to learn or to
Use it in your daily practice. The UCG is designed as a simple reference
"manual to keep at your work station, where you can consult it any time."
Using it in front of patients and colleagues will show that you care deeply
"about the quality of your work, and it will provide good examples to"
The UCG cannot replace health workers knowledge and skills; like your
"thermometer and stethoscope, it is a tool to help improve clinical practice"
by providing a quick and easily available summary of the recommended
management of common health conditions.
What is the difference between the UCG and a textbook?
The UCG gives a summary of recommendations for managing priority
conditions in Uganda. It does not provide extensive or in-depth information
about all diseases and all treatments available in the world.
Conditions have been selected based on their prevalence in the country
and their impact on the populations health status. Treatments have been
selected based on the following criteria:
"XLScientific evidence: recommendations are evidence-based, from international literature and local experts. For example, the situation analysis on"
antimicrobial resistance in Uganda conducted by the National Academy of
Sciences was used to guide the choice of antibiotic treatments.
"Cost-effectiveness: treatments have been selected based on their effectiveness, but also their affordability, to get the best value for money,"
meaning the maximum benefit with the limited resources available.
"For example, a liver transplant is a very effective way to treat terminal"
"cirrhosis, but it is definitely not affordablemoney is better invested in"
treating patients with chronic hepatitis B!
What has changed compared to the previous edition?
 There are more chapters as explained before.
 The management sections have been re-edited to be more
"user-friendly, using the suggestions collected during a user"
" Information on new diseases has been added, following"
"new epidemics and public health priorities (e.g., viral haemorrhagic fevers, Covid-19, yellow fever, nodding disease,"
"sickle cell disease, newborn illnesses)."
" More attention has been paid to non-communicable chronic diseases; for example, stroke and chronic obstructive pulmonary disease (COPD), and sections on diabetes, hypertension, asthma and mental conditions including diseases"
of elderly and dementia have been expanded.
 Recommendations have been aligned with the most recent
"national and international guidelines related to ART, TB,"
"malaria, IMNCI, IMPAC, mhGAP (see the list of references"
 Medications have been added or deleted and level of care
has changed according to recent evidence and national policies.
XL Skin management of Albinos using a sunscreen protection
product has been included under the dermatological section.
 The essential medicines list has been removed from this
edition to make the book pocket friendly.
What about the Essential Medicines and Health Supply List (EMHSLU)?
The essential medicines list has been removed from this edition to make
the book pocket friendly. Always refer to the separate EMHSLU.
"To implement the recommendations in the UCG, the medicines listed in"
the EMHSLU have to be procured and distributed in adequate quantity.
This is why the procurement and supply system plays a fundamental role
in the provision of quality healthcare.
"The EMHSLU has all the medicines recommended in the UCG, with"
"specification of the level of care (LOC) at which they can start being used,"
"but it also has additional specialty medicines, which are items used at"
referral level (regional or national) or in the context of specialized services.
"They may not be included in the UCG, which focus more on primary care,"
but are still part of the list because they need to be procured to ensure the
provision of a wider range of services at secondary and tertiary levels. In
"the context of limited resources, it is very important to learn to prioritize"
"medicines for procurement: this is reflected by the vital, essential, necessary"
"(VEN) classification in the EMHSLU, introduced in 2012."
XLMedicines are classified into three categories according to health impact:
"V: vital medicines are potentially life-saving, and lack of availability"
would cause serious harm and side effects. These must ALWAYS be
"availablefor example insulin, metformin, most antibiotics, first-line"
"antimalarials, some anti-epileptics, and parenteral diuretics."
E: essential medicines are important; they are used to treat common
illnesses that are maybe less severe but still significant. They are not
"absolutely needed for the provision of basic health care (e.g., anti-helminthics, pain killers)."
N: necessary (or sometimes called non-essential) medicines are used
"for minor or self-limiting illnesses, or may have a limited efficacy, or"
a higher cost compared to the benefit.
Every effort has to be made to ensure health facilities do not suffer stock-outs
The WHO AWaRe classification was used to describe overall antibiotic
"use as assessed by the variation between use of Access, Watch, and"
Why is a laboratory test menu in the appendix?
Laboratory is an important tool in supporting the diagnosis and management of various conditions. Tests are listed according to the level at
"which they can be performed, in order to inform health workers about the"
available diagnostics at each level for the suspected condition and guide
on managemeent or referral decisions.
Primary healthcare is essential healthcare based on
"practical, scientifically sound and socially acceptable methods and"
technologies. Primary healthcare should be universally accessible
to individuals and families in the community through their full
participation and at a cost that the community and country can
afford in the spirit of self-reliance and self-determination.
Primary healthcare forms an integral part of both the countrys
"health system, of which it is the main focus, and of the communitys"
overall social and economic development.
Primary healthcare brings healthcare as close as possible to
where people live and work and is the communitys first level of
contact with the national health system.
Primary health care is the key to the attainment of the goal of
"Declaration of Alma-Ata International Conference on Primary Health Care,"
"Alma-Ata, USSR, 612 September 1978"
LHow to diagnose and treat in primary care
The principles of healthcare are the same wherever it takes place.
Listen to the patient; he is telling you the diagnosis
"Sir William Osler, MD, 18491919."
Communication skills in the consultation room
Good communication skills are essential for making a correct diagnosis and
"for explaining or counselling on the illness, its treatment, and prevention of"
"At the beginning of the consultation, use open questions, which allow"
"the patient to express him or herself freely, listen without interrupting, and"
"give him or her the chance to share their interpretations, fears and worries."
The golden 60 seconds at the start of the consultation
"is eliciting ideas, concerns and expectations without"
"Move to more specific questions later, to ask for further details and"
LThe Seven Steps in a Primary Care Consultation
 Greet and welcome the patient. Ensure adequate space and privacy!
02 Observe the patient as heshe walks into your room for degree
or state of illness. Look for danger signs and act immediately
" Ask about the main complaint or complaints, establish duration,"
and explore each symptom asking relevant questions
" Briefly ask about previous medical history, other past or present"
illnesses and current or recent medications
" Perform a complete medical examination, focused on but not"
" Write your findings, and think about possible diagnosis and"
 Request tests to confirm or exclude possible diagnosis
"07 Conclude on a diagnosis and decide on the treatment, if needed"
" Explain diagnosis, treatment, and follow-up to the patient"
 Give counselling and advice as appropriate
LThe Seven Steps in a Primary Care Consultation
 Greet and welcome the patient. Ensure adequate space and privacy!
02 Observe the patient as heshe walks into your room for degree
or state of illness. Look for danger signs and act immediately
" Ask about the main complaint or complaints, establish duration,"
and explore each symptom asking relevant questions
" Briefly ask about previous medical history, other past or present"
illnesses and current or recent medications
" Perform a complete medical examination, focused on but not"
" Write your findings, and think about possible diagnosis and"
 Request tests to confirm or exclude possible diagnosis
"07 Conclude on a diagnosis and decide on the treatment, if needed"
" Explain diagnosis, treatment, and follow-up to the patient"
 Give counselling and advice as appropriate
"Introduced a section on self-care interventions for sexual and reproductive health (SRH), in the categories of self-awareness, self-testing"
"and self-management, across the various health areas of Antenatal"
"Care, Family Planning, HIV and STIs and post abortion care."
"WHO defines self-care as the ability of individuals, families and"
"communities to promote health, prevent disease, maintain health,"
and cope with illness and disability with or without the support of a
The developed the National Guideline on Self-Care
Interventions for SRH. For details refer to the current guidelines
 Health workers are faced with an increasing number of
"chronic diseases and conditions that require additional attention, such as hypertension, chronic heart problems, diabetes, cancers, mental conditions, HIVAIDS, and TB."
 Communication is even more important to:
" Find out the duration of the symptoms, previous diagnosis,"
previous or current treatments and impact on daily life
 Explain the nature and management of the condition to the
patient and counsel on lifestyle and adjustment
 Chronic diseases require long-term (sometimes lifelong) follow-up and treatment:
 Counsel and advise the patient on the importance of follow- up and treatment adherence
 Set up a system for scheduling appointments (on the model
" At each monitoring visit, determine whether the patients"
"Lcondition is improving, stable, or deteriorating and assess"
whether patients are taking prescribed treatments properly
"(the right medicines, in the right doses, at the right time)."
Try to be consistent in prescribing and change the regimen
only if it is not working or has side effects. If a treatment is
"working and well tolerated, maintain it!"
" Counsel and motivate the patient to follow lifestyle recommendations, including selfcare."
" Assess the need for further support (e.g., pain management, counselling, etc.)"
 A chronic care system requires collaboration among and
integration of all levels of healthcare
 Higher levels of care may be responsible for initial diagnosis and prescription of treatment and periodic reviews and
re-assessment in case of problems or complications
" Lower levels of care (including the community) may be responsible for routine follow-up, counselling and education,"
medication refills and prompt and early referral in case of
"According to WHO, Rational appropriate use of medicines requires"
"that patients receive medications appropriate to their clinical needs, in"
"doses that meet their own individual requirements, for an adequate period"
"of time, and at the lowest cost to them and their community."
"Inappropriate medicine use can not only harm the patient, but by wasting"
"resources, may limit the possibility of other people accessing healthcare!"
Both health workers and patients have an important role to play in ensuring
 Prescribing (and taking) medicines ONLY when they are
 Avoiding giving unnecessary multiple medications to satisfy
patients demands or for financial gain
L Avoiding expensive alternative or second-line medications
when an effective and inexpensive first-line is available
 Avoiding injections when oral treatment is perfectly adequate
 Ensuring that the correct dose and duration of treatment
"is prescribed, especially for antibiotics, to avoid resistance"
 Providing adequate information and counselling to the patient to ensure adherence with instructions.
According to the WHO definition
"Antimicrobial resistance occurs when microorganisms such as bacteria,"
"viruses, fungi and parasites change in ways that render the medications"
used to cure the infections they cause ineffective. Antimicrobial resistance
"is facilitated by the inappropriate use of medicines, for example, when"
taking substandard doses or not finishing a prescribed course of treatment.
"Low-quality medicines, wrong prescriptions and poor infection prevention"
and control also encourage the development and spread of drug resistance.
The problem of AMR is a serious threat for the modern world:
 The resistance of malaria parasites has caused several
changes in antimalarial regimens in the last 15 years
 MDR-TB (multi-drug resistant tuberculosis) is spreading and
requires long and complex treatments
" HIV resistance is a serious concern, especially after longterm treatment"
" AMR is spreading and, in some cases, commonly used antimicrobials are not as effective as before"
 Antimicrobial resistance amomg bacteria other than TB
"and fungi (moulds and yeasts) that affect the immune-compromised is evolving, spreading and responsible for death"
from sepsis in general and high dependency units.
"LInappropriae use of antibiotics (in human medicine but also in animal agriculture), poor quality products and ineffective infection control measures"
are all contributing factors. We are seriously at risk of finding ourselves
in a situation with no affordable antimicrobial available to cure common
It is URGENT that both health workers and patients become aware of the
 Using antimicrobials only when it is really necessary and
according to recommendations (e.g. not for simple viral infections!)
 Avoiding self-prescription of antibiotics
 Avoiding using last generation and broad spectrum antibiotics as first-line treatment
 Prescribing correct dosages for the correct duration and
ensuring adherence to the prescription
 Practising strict measures of infection control in health facilities
" Improving hygiene and sanitation in the community, thereby reducing the circulation of germs."
 WHO has further introduced the AWaRE classification to
guide prescribers during prescribing of antibiotics. The major focus of AWaRe approach is to reduce on the increasing
" The principal of AWaRe prescribing is based on Access,"
 Prescribers are encouraged to adhere to the above.
The current PGD (Practical Guidelines for Dispensing at Lower Higher
"Level Health Facilities), provide comprehensive information about how"
to prescribe and dispense the medicines listed in the EMHSLU and UCG
2023. Carefully consider the following key questions before writing
Does the diag-  Not all patients or conditions need a
nosed condition prescription for medicines (condition
require drug treat- is self-limiting): non-medicine treatment? ments or simple advice may be more
Is the prescribed  Good therapeutics depends on:
 Accurate diagnosis of the condition
therapeutic effect  Knowledge of the relevant vavailable
 Ask patient about previous drug history (eg. drug reaction allergy)
" Selection of the most appropriate medicine, dose, route, and duration"
" In all cases, carefully consider the expected benefit of a prescribed medication against its potential risks"
"Is the selected dos-  For systemic medications, ALWAYS"
"age-form the most USE THE ORAL ROUTE if possible,"
appropriate? as it is the cheapest and least hazardous route
 Always resist patient demands for you
to prescribe injections or other expensive dose forms when they are not
clearly indicated or appropriate
require drug treatment?  Not all patients or conditions need a
prescription for medicines (condition
is self-limiting): non-medicine treatments or simple advice may be more
patient?  Good therapeutics depends on:
 Accurate diagnosis of the condition
 Knowledge of the relevant vavailable
 Ask patient about previous drug history (eg. drug reaction allergy)
" Selection of the most appropriate medicine, dose, route, and duration"
" In all cases, carefully consider the expected benefit of a prescribed medication against its potential risks"
Is the selected dosage-form the most
"appropriate?  For systemic medications, ALWAYS"
"USE THE ORAL ROUTE if possible,"
as it is the cheapest and least hazardous route
 Always resist patient demands for you
to prescribe injections or other expensive dose forms when they are not
clearly indicated or appropriate
where they are absolutely necessary
(they carry risks and are more expensive)
 Always explain to the patient the reasons for choosing a certain route
Can I justify using  Do not prescribe a combination of
a combination of medicines unless they have a proven
medicines? and significant therapeutic advantage
over corresponding single ingredient
to prescribe more  Do not practise multiple medicine
"than one medi- prescribing (polypharmacy), especially"
when the diagnosis is uncertain. It is
a tremendous waste of resources and
puts the patient at increased risk without clear benefit
Have I taken into Consider the following:
" Age, gender, weightespecially of"
vant patient crichildren and elderly
 Likelihood of side effects (including allergies)
 Presence of renal or hepatic disease
(many medicines may have to be used
in reduced doses or avoided completely)
 Any other medicines the patient may
be taking (risk of unwanted medicine
interactions or adverse effects)
where they are absolutely necessary
(they carry risks and are more expensive)
 Always explain to the patient the reasons for choosing a certain route
than one medicine?  Do not prescribe a combination of
medicines unless they have a proven
and significant therapeutic advantage
over corresponding single ingredient
 Do not practise multiple medicine
"prescribing (polypharmacy), especially"
when the diagnosis is uncertain. It is
a tremendous waste of resources and
puts the patient at increased risk without clear benefit
account all relevant patient criteria? Consider the following:
" Age, gender, weightespecially of"
 Likelihood of side effects (including allergies)
 Presence of renal or hepatic disease
(many medicines may have to be used
in reduced doses or avoided completely)
 Any other medicines the patient may
be taking (risk of unwanted medicine
interactions or adverse effects)
 Pregnancy and breastfeeding: only use
medicines in pregnancy if the expected benefit to the mother is greater than
any risk to the foetus baby and avoid
all medicines if possible during the
first trimester (the first three months
" Likely degree of adherence to treatment (simpler, shorter dosage regimes"
 the patient correctly following prescribed therapy)
"Avoid placebos whenever possible. Instead, spend some time reassuring"
"and educating the patient. Use home remedies when possible (e.g., honey"
for cough in adults and children above 1 year).
A wrong prescription is very risky for you and your patient.
"Unclear, incomplete, or inaccurate prescriptions are very dangerous for"
"the patient. To avoid problems, follow the guidance below in writing"
 Write all prescriptions legibly in ink
 Poor writing may lead to errors in interpretation by
"the dispenser, which may have harmful and possibly"
life-threatening consequences for the patient
  Pregnancy and breastfeeding: only use
medicines in pregnancy if the expected benefit to the mother is greater than
any risk to the foetus baby and avoid
all medicines if possible during the
first trimester (the first three months
" Likely degree of adherence to treatment (simpler, shorter dosage regimes"
 the patient correctly following prescribed therapy)
 Write all prescriptions legibly in ink
 Poor writing may lead to errors in interpretation by
"the dispenser, which may have harmful and possibly"
life-threatening consequences for the patient
 Avoid use of instructions like prn or to be usedtaken
as required. Indicate a suitable dose frequency instead
" In the few cases where as required is appropriate, always state the actual quantity of the medicine to be supplied, when to take it and maximum amount"
" Where relevant, always remember to include on the prescription any special instructions necessary for the correct use of"
"a medicine or preparation, for example before food or apply sparingly."
Controlled medicine prescriptions
These medicines are covered by the provisions of the National Drug
"Policy and Authority Act 1993, which should be consulted for details of the"
appropriate legal requirements as stipulated. Medicines covered by the Act
and appear in the UCG 2023 or EMHSLU 2023 include:
 Papaveretum  hyoscine injection
These are all medicines of potential abuse that may result in dependence. All procedures involving them should be carefully recorded in the
appropriate record books. They may only be prescribed by authorised
prescribers who must observe the following legal requirements:
" Prescriptions must be in the prescribers own handwriting,"
"with a signature, date and the prescribers address"
 Avoid use of instructions like prn or to be usedtaken
as required. Indicate a suitable dose frequency instead
" In the few cases where as required is appropriate, always state the actual quantity of the medicine to be supplied, when to take it and maximum amount"
" Where relevant, always remember to include on the prescription any special instructions necessary for the correct use of"
"a medicine or preparation, for example before food or apply sparingly."
 Prescriptions must state the name and address of the patient
 Prescriptions must state the total amount of the product to
be supplied in words and figures
 It is an offence for a prescriber to issue and for a pharmacy
to dispense prescriptions for controlled medicines unless
they are in full compliance with the requirements of the
 Specialised palliative care nurses and clinical officers are authorised to prescribe oral morphine and other medicines used in palliative care.
 Morphine rarely causes psychological dependence when prescribed for severe pain.
" In certain exceptional circumstances, senior nurses in charge of"
"departments, wards or theatres and midwives may also obtain"
and administer certain specified controlled medicines. Consult
the relevant sections of the Act for details of the appropriate
legal requirements in each case.
 Hospital in-patient prescriptions written on treatment cards or
case sheets and signeddated by the person administering the
medicine are considered as compliant under the Act.
Prescribing in children and the elderly
"In these guidelines, paediatric medicine doses are usually given according"
"to body weight and not age, and are therefore expressed as mgkg."
The main reason for this is that children of the same age may vary
"significantly in weight. Thus, it is safer and more accurate to prescribe"
"medicines according to body weight. Moreover, this should encourage"
the good practice of weighing children whenever possible.
"LHowever, as a guide to prescribing by weight when a weighing scale is not"
"available, the weight-for-age charts at the end of Chapter 17 can be used as"
"an estimate for children from 1-24 months and 2-15 years, respectively."
Always use leanideal body weight for children who are overweightobese
to avoid giving them overdoses.
Note: Paediatric doses calculated using mgkg should not exceed
In the case of some medicines that have a wide therapeutic range and a
"good safety profile, dosages are given for age ranges for easy reference."
Prescriptions in the elderly also need additional attention because the
elderly are more prone to side effects; they are more likely to take several
"medications (polypharmacy) with possible interactions, and they often have"
co-morbidities that can affect their response to medicines. Reduced doses
"and careful monitoring are always advised, and specific warnings have"
"Before prescribing any medicine, take care to avoid problems of interactions"
with other medicines by obtaining details of any other medication that the
"patient is taking, whether the medication is:"
 Also prescribed at the same time
 Previously prescribed by another prescriber for the same or another condition and currently being taken by the patient
 Purchased or otherwise obtained by the patient for the purposes of self-medication at home.
"LNote on interactions with alcohol. If a prescribed medicine interacts with alcohol (for example, metronidazole, diazepam, anti-diabetic"
"medicines, and tricyclic antidepressants), caution the patient to avoid taking"
alcoholic drinks during the course of treatment and for 48 hours afterwards.
"This vital part of patient management is often neglected with potentially serious consequences. Although counselling the patient may take time,"
"if done systematically, it should only take a few minutes and could"
make the difference between treatment success and failure.
Include the following key components when counselling the patient:
 Explain the diagnosis and the likely cause of the disease or
condition and discuss the proposed approach to treatment
 Describe the prescribed medicine therapy in detail including:
" Dose regimen (size, frequency, duration)"
 Any additional instructions on correct use or storage of the medicine
L Any likely side effects and what to do if they occur
 Advise on important medicine interactions (including with alcohol)
" Give advice on how to contribute to the success of the treatment (for example, rest, diet, fluids and other lifestyle changes) and how to avoid the same problem in future"
 Ensure the patient or caretaker fully understands the information and advice providedask him or her to repeat key points
" For health conditions that require self-care, proper advice"
"should be given to the patient on self-awareness, self-testing"
 Ensure the patient is satisfied with the proposed treatment and has
an opportunity to raise any problems or queries with you.
Anaphylactic Shock ICD10 CODE: T78.2
Severe allergic reaction that occurs rapidly (seconds or minutes) after
"administration, or exposure, and may be life threatening. It generally affects"
" Allergy to pollens, some medicines (e.g., penicillins, vaccines, acetylsalicylic acid), or certain foods (e.g. eggs, fish,"
"cows milk, nuts, some food additives)"
" Reaction to insect bites, e.g., wasps and bees"
" Body itching, hives (urticarial rash), swelling of lips, eyes,"
" Difficulty in breathing (stridor, wheezing)"
" Hypotension and sudden collapse, excessive sweating, thin"
" Abdominal cramps, vomiting and diarrhoea."
" Other causes of shock, e.g., haemorrhagic (due to bleeding), hypovolemic (severe dehydration), septic"
" Asthma, foreign body in airways."
Restore BP: lay the patient flat and raise feet
Sodium chloride 0.9 infusion 20 mlkg by IV infusion HC3
 Start rapidly then adjust rate according to BP
Adrenaline (epinephrine) injection 1 in 1000 (1 mgml) HC2
"mg (ml) IM immediately, into anterolateral thigh"
" Repeat every 5-10 minutes according to BP, pulse"
"rate, and respiratory function until better"
Child 6 years: 150 micrograms (ml)
Child 6-12 years: 300 micrograms (ml)
Hydrocortisone 200 mg IM or slow IV stat
Give an antihistamine as useful adjunctive treatment
"HC2e.g., chlorpheniramine 4 mg every six hours"
Child 1-2 years: 1mg every 12 hours
Child 2-5 years: 1 mg every 6 hours
Child 5-12 years: 2 mg every 6 hours
-Or Cetrizine 5mg once daily for adults Child 6 and above
Child 1-6 years: 2.5mg once daily.
Restore BP: lay the patient flat and raise feet
Sodium chloride 0.9 infusion 20 mlkg by IV infusion
 Start rapidly then adjust rate according to BP
"Adrenaline (epinephrine) injection 1 in 1000 (1 mgml) mg (ml) IM immediately, into anterolateral thigh"
" Repeat every 5-10 minutes according to BP, pulse"
"rate, and respiratory function until better"
Child 6 years: 150 micrograms (ml)
Child 6-12 years: 300 micrograms (ml)
Hydrocortisone 200 mg IM or slow IV stat
Give an antihistamine as useful adjunctive treatment
"e.g., chlorpheniramine 4 mg every six hours"
Child 1-2 years: 1mg every 12 hours
Child 2-5 years: 1 mg every 6 hours
Child 5-12 years: 2 mg every 6 hours
-Or Cetrizine 5mg once daily for adults Child 6 and above
Child 1-6 years: 2.5mg once daily. HC2
or promethazine 25-50 mg by deep IM or very slow IV (or oral)
Child 1-5 years: 5 mg by deep IM
Child 5-10 years: 6.25-mg by deep IM
Repeat dose every 8 hours for 24-48 hours to prevent relapse
Repeat adrenaline and hydrocortisone every
2-6 hours prn depending on the patients progress
 Adrenaline: IM is the route of choice: absorption is rapid and
 Monitor the patient for several hours (reaction may recur after
" If drug reaction, compile adverse drug reaction reporting form"
 Always ask about allergies before giving patients new medicine
 Keep emergency drugs at hand at health facilities and in
"situatiuons where risk of anaphlaxis is high, e.g. visiting"
bee hives or places that usually harbour snakes
 Counsel allergic patients to wear alert bracelet or tag.
Hypovolaemic Shock ICD10 CODE: R57.1
Condition caused by severe acute loss of intravascular fluids leading to inadequate circulating volume and inadequate perfusion.
" Loss of blood due to internal or external haemorrhage (e.g.,"
"post partum haemorrhage, splenic rupture etc.)"
or promethazine 25-50 mg by deep IM or very slow IV (or oral)
Child 1-5 years: 5 mg by deep IM
Child 5-10 years: 6.25-mg by deep IM
Repeat dose every 8 hours for 24-48 hours to prevent relapse
Repeat adrenaline and hydrocortisone every
2-6 hours prn depending on the patients progress HC4
 Adrenaline: IM is the route of choice: absorption is rapid and
 Monitor the patient for several hours (reaction may recur after
" If drug reaction, compile adverse drug reaction reporting form"
" Acute loss of fluids, e.g. in gastroenteritis, or extensive"
" High heart rate, fast breathing rate"
" Thin or absent pulse, cold extremities, slow capillary refill"
Classification of hypovolaemia in adults
Indicator Class 1 Class 2 Class 3 Class 4 End
volume loss 15 15- 30 30  40 40
Capillary refill Normal á áá Absent
Respiratory rate Normal 20  30 30  40 45 or
Mental state Alert Anxious Confused Confused
volume loss 15 15- 30 30  40 40
Capillary refill Normal á áá Absent
Respiratory rate Normal 20  30 30  40 45 or
Mental state Alert Anxious Confused Confused
 Control obvious bleeding with pressure HC3
 Keep patient lying down with raised legs.
If established hypovolaemia class 2 and above
 IV fluids Normal Saline 0.9 (or Ringers lactate) 2030 mlkg over 60 minutes according to response
"- Assess response to fluid resuscitation: BP, HR, RR,"
"capillary refill, consciousness and urinary output"
" If internal or external haemorrhage, consider blood"
If rapid improvement and stable (blood loss 20 and
 Slow IV fluids to maintenance levels
 No immediate transfusion but do cross-matching
 Detailed examination and definitive treatment according
If transient improvement (blood loss 20-40 or ongoing bleeding)
 Initiate blood transfusion (see section 11.2)
 Detailed examination and early surgery
 Control obvious bleeding with pressure
 Keep patient lying down with raised legs. HC3
If established hypovolaemia class 2 and above
 IV fluids Normal Saline 0.9 (or Ringers lactate) 2030 mlkg over 60 minutes according to response
"- Assess response to fluid resuscitation: BP, HR, RR,"
"capillary refill, consciousness and urinary output"
" If internal or external haemorrhage, consider blood"
If rapid improvement and stable (blood loss 20 and
 Slow IV fluids to maintenance levels
 No immediate transfusion but do cross-matching
 Detailed examination and definitive treatment according
If transient improvement (blood loss 20-40 or ongoing bleeding)
 Initiate blood transfusion (see section 11.2)
 Detailed examination and early surgery
Do not use glucose solution or plain water as replacement
1.Hypvovolaemic Shock In Children
Principles of management are similar to the ones in adults BUT:
- Recognising this may be more difficult than in adults
"- Vital signs may change little, even when up to 25 of blood"
volume is lost (class 1 and 2 hypovolaemia)
- Tachycardia is often the first response to hypovolaemia but may
Classification of hypovolaemia in children
Indicator Class 1 Mild Class 2 Class 3 Class 4 End
 of total blood volume loss 15-25 25-40 40
Mental state Normal Irritable Lethargic Comatose
Do not use glucose solution or plain water as replacement
Mental state Normal Irritable Lethargic Comatose
Normal ranges for vital signs in children
Age (Years) Pulse Systolic Bp Respiration Blood Vol
(RateMin) (Mmhg) (RateMin) (MlKg)
 Initial fluid challenge should represent 25 of blood
volume as signs of hypovolaemia may only show after
" If there are signs of class 2 hypovolaemia or greater,"
give 20-30 mlkg of Normal Saline 0.9 (or Ringers
- Reduce rate depending on BP response
" Dependingo n response,r epeat upt o 3t imesi f necessary i.e. up to max 60 mlkg"
 Give further IV fluids and blood transfusion
 Initially transfuse 20 mlkg of whole blood or 10 ml HC4
kg of packed cells (only in severe anaemia)
 Initial fluid challenge should represent 25 of blood
volume as signs of hypovolaemia may only show after
" If there are signs of class 2 hypovolaemia or greater,"
give 20-30 mlkg of Normal Saline 0.9 (or Ringers
- Reduce rate depending on BP response
" Dependingo n response,r epeat upt o 3t imesi f necessary i.e. up to max 60 mlkg"
 Give further IV fluids and blood transfusion
 Initially transfuse 20 mlkg of whole blood or 10 ml
kg of packed cells (only in severe anaemia) HC3
A condition brought about by the loss of significant quantities of fluids
" Excessive loss of fluids, e.g. due to polyuria in diabetes,"
"excessive sweating as in high fever, burns"
" Apathy, sunken eyesfontanel, loss of skin turgor (especially"
" Hypotension, tachycardia, deep (acidotic) breathing, dry mucosae, poor or no urine output."
1.Dehydration in Children under 5 years
Assess degree of dehydration following the table below:
Clinical features of dehydration in children
"General Well, alert Restless, irritable Lethargic, drowsy or"
Fontanel Not sunken Sunken Sunken
"Ability to Drinks Drinks eagerly, Drinks poorly or not"
drink normally thirsty able to drink
Skin pinch Goes back Goes back slowly; Goes back very slowly;
"condition Well, alert Restless, irritable Lethargic, drowsy or"
Fontanel Not sunken Sunken Sunken
2 seconds Goes back very slowly;
Plan A (No dehydration and for prevention)
 Counsel the mother on the 4 rules of home treatment: HC2
"extra fluids (ORS), continue feeding, zinc supplementation, when to return"
 Give extra fluids: as much as the child will take
"- If child exclusively breastfed, give ORS or safe"
clean water in addition to breast milk
"- If child not exclusively breastfed, give one or more"
"of: ORS, soup, rice-water, yoghurt, clean water"
"- In addition to the usual fluid intake, give ORS after"
each loose stool or episode of vomiting Child 2
- Give the mother 2 packets to use at home
- Giving ORS is especially important if the child
has been treated with Plan B or Plan C during
- Give frequent small sips from a cup
 Advice the mother to continue or increase breastfeeding.
"If child vomits, wait 10 minutes, then give more slowly"
"- In a child with high fever or respiratory distress,"
give plenty of fluids to counter the increased fluid
- Continue giving extra fluid as well as ORS until
- the diarrhoea or other cause of dehydration stops
" If diarrhoea, give Zinc supplementation Child 6 months:"
10 mg once a day for 10 days Child 6 months: 20 mg
 Counsel the mother on the 4 rules of home treatment:
"extra fluids (ORS), continue feeding, zinc supplementation, when to return"
 Give extra fluids: as much as the child will take
"- If child exclusively breastfed, give ORS or safe"
clean water in addition to breast milk
"- If child not exclusively breastfed, give one or more"
"of: ORS, soup, rice-water, yoghurt, clean water"
"- In addition to the usual fluid intake, give ORS after"
each loose stool or episode of vomiting Child 2
- Give the mother 2 packets to use at home
- Giving ORS is especially important if the child
has been treated with Plan B or Plan C during
- Give frequent small sips from a cup
 Advice the mother to continue or increase breastfeeding.
"If child vomits, wait 10 minutes, then give more slowly"
"- In a child with high fever or respiratory distress,"
give plenty of fluids to counter the increased fluid
- Continue giving extra fluid as well as ORS until
- the diarrhoea or other cause of dehydration stops
" If diarrhoea, give Zinc supplementation Child 6 months:"
10 mg once a day for 10 days Child 6 months: 20 mg
 Give ORS in the following approximate amounts during HC2
Ors (Ml) 200400 400700 700900 9001400
- Only use childs age if weight is not known
- You can also calculate the approximate amount
of ORS to give a child in the first 4 hours as
 Show the mother how to give the ORS
- Give frequent small sips from a cup
"- If the child wants more than is shown in the table,"
"- If the child vomits, wait 10 minutes, then continue"
" For infants 6 months who are not breastfed, also give"
100-200 ml of clean water during the first 4 hours
 Reassess patient frequently (every 30-60 minutes) for
classification of dehydration and selection of Treatment Plan
 Reclassify the degree of dehydration
" Select the appropriate Treatment Plan A, B or C"
 Begin feeding the child in the clinic
 Give ORS in the following approximate amounts during
Ors (Ml) 200400 400700 700900 9001400
- Only use childs age if weight is not known
- You can also calculate the approximate amount
of ORS to give a child in the first 4 hours as
 Show the mother how to give the ORS
- Give frequent small sips from a cup
"- If the child wants more than is shown in the table,"
"- If the child vomits, wait 10 minutes, then continue"
" For infants 6 months who are not breastfed, also give"
100-200 ml of clean water during the first 4 hours
 Reassess patient frequently (every 30-60 minutes) for
classification of dehydration and selection of Treatment Plan
 Reclassify the degree of dehydration
" Select the appropriate Treatment Plan A, B or C"
 Begin feeding the child in the clinic HC2
Ors (Ml) 200400 400700 700900 9001400
If mother must leave before completing the childs treatment
 Show her how to prepare ORS at home and how much
ORS to give to finish the 4-hour treatment
- Give her enough packets to complete this and 2
more to complete Plan A at home
 Counsel mother on the 4 rules of home treatment: extra
"fluids, continue feeding, zinc, when to return"
If you are unable to give IV fluids and this therapy is not HC2
available nearby (within 30 minutes) but a nasogastric
tube (NGT) is available or the child can drink
 Start rehydration with ORS by NGT or by mouth: Give
20 mlkghour for 6 hours (total  120 ml kg)
 Reassess the child every 1-2 hours
- If there is repeated vomiting or increasing
"abdominal distension, give more slowly"
"- If hydration status is not improving within 3hours,"
refer the child urgently for IV therapy
" After 6 hours, reassess the child"
 Classify the degree of dehydration
" Select appropriate Plan A, B, or C to continue treatment"
If mother must leave before completing the childs treatment
 Show her how to prepare ORS at home and how much
ORS to give to finish the 4-hour treatment
- Give her enough packets to complete this and 2
more to complete Plan A at home
 Counsel mother on the 4 rules of home treatment: extra
"fluids, continue feeding, zinc, when to return "
If you are unable to give IV fluids and this therapy is not
available nearby (within 30 minutes) but a nasogastric
tube (NGT) is available or the child can drink
 Start rehydration with ORS by NGT or by mouth: Give
20 mlkghour for 6 hours (total  120 ml kg)
 Reassess the child every 1-2 hours
- If there is repeated vomiting or increasing
"abdominal distension, give more slowly"
"- If hydration status is not improving within 3hours,"
refer the child urgently for IV therapy
" After 6 hours, reassess the child"
 Classify the degree of dehydration
" Select appropriate Plan A, B, or C to continue treatment HC2"
If you are unable to give IV fluids but IV treatment is HC2
available nearby (i.e. within 30 minutes)
 Refer urgently for IV treatment
 Provide mother with ORS and show her how to give
frequent sips during the trip to the referral facility
If you are able to give IV fluids HC3
"- If child can drink, give ORS while the drip is set"
 Give 100 mlkg of Ringers Lactate
- Or half-strength Darrows solution in glucose
- Divide the IV fluid as follows:
 Reassess patient frequently (every 30-60 minutes) to
re-classify dehydration and treatment plan
If the patient is not improving
 Give the IV fluids more rapidly
"As soon as patient can drink, usually after 3-4 hours in"
infants or 1-2 hours in children
 Continue to reassess patient frequently; classify degree
"of dehydration; and select appropriate Plan A, B, or C"
"If possible, observe child for at least 6 hours after rehydration to ensure"
that the mother can correctly use ORS to maintain hydration.
If you are unable to give IV fluids but IV treatment is
available nearby (i.e. within 30 minutes)
 Refer urgently for IV treatment
 Provide mother with ORS and show her how to give
frequent sips during the trip to the referral facility HC2
If you are able to give IV fluids
"- If child can drink, give ORS while the drip is set"
 Give 100 mlkg of Ringers Lactate
- Or half-strength Darrows solution in glucose
- Divide the IV fluid as follows:
 Reassess patient frequently (every 30-60 minutes) to
re-classify dehydration and treatment plan
If the patient is not improving
 Give the IV fluids more rapidly HC3
"As soon as patient can drink, usually after 3-4 hours in"
infants or 1-2 hours in children
 Continue to reassess patient frequently; classify degree
"of dehydration; and select appropriate Plan A, B, or C"
"If possible, observe child for at least 6 hours after rehydration to ensure"
that the mother can correctly use ORS to maintain hydration. 
1.Dehydration in Older Children and Adults
Assess degree of dehydration following the table below.
CLINICAL FEATURE DEGREE OF DEHYDRATION
"General appearance Thirsty, alert Thirsty, alert Generally conscious, anxious,"
"extremities, cyanosis, wrinkly skin"
"Pulse Normal Rapid Rapid, thready,"
"Respiration Normal Deep, may Deep and rapid"
"Systolic BP Normal Normal Low, may be"
Skin pinch Rturns Rturns Returns very slowrapidly slowly ly (2 seconds)
"Urine output Normal Reduced, Anuria, empty"
At least 2 of these signs must be present
CLINICAL FEATURE DEGREE OF DEHYDRATION 
"General appearance Thirsty, alert Thirsty, alert Generally conscious, anxious,"
"extremities, cyanosis, wrinkly skin"
"Pulse Normal Rapid Rapid, thready,"
"Systolic BP Normal Normal Low, may be"
slowly Returns very slowly (2 seconds)
At least 2 of these signs must be present 
 Give oral ORS 25 mlkg in the first 4 hours
- Increase or maintain until clinical improvement
 Give oral ORS 50 mgkg in the first 4 hours
" Ringers lactate (or Normal Saline 0.9) IV, 50 mlkg"
"- Give IV fluids rapidly until radial pulse can be felt,"
- Re-evaluate vitals after 4 hours
Volumes that are given over the first 24 hours in adults are
" After 4 hours, evaluate rehydration in terms of clinical signs (NOT"
in terms of volumes of fluid given)
" As soon as signs of dehydration have disappeared (but not before),"
"start fluid maintenance therapy, alternating ORS and water (to avoid"
hypernatraemia) as much as the patient wants
Continue for as long as the cause of the original dehydration persists.
 Give oral ORS 25 mlkg in the first 4 hours
- Increase or maintain until clinical improvement
 Give oral ORS 50 mgkg in the first 4 hours
" Ringers lactate (or Normal Saline 0.9) IV, 50 mlkg"
"- Give IV fluids rapidly until radial pulse can be felt,"
- Re-evaluate vitals after 4 hours
Volumes that are given over the first 24 hours in adults are
" Volumes shown are guidelines only. If necessary, volumes can"
be increased or initial high rate of administration maintained
until clinical improvement occurs
" In addition to ORS, other fluids such as soup, fruit juice and safe"
"- Initially, adults can take up to 750 ml ORShour."
 If sodium lactate compound IV infusion (Ringers Lactate) is
"not available, use half-strength Darrows solution in glucose"
"2.5 or sodium chloride infusion 0.9. However, both of"
" Continued nutrition is important, and food should be"
continued during treatment for dehydration.
 Avoid artificially sweetened juices.
Prevention (for all age groups)
 Encourage prompt use of ORS at home if the personis
vomiting andor having diarrhoea.
Fluids and Electrolytes Imbalances ICD10 CODE: E87.8
A condition where losses of bodily fluids from whatever cause has
led to significant disturbance in the normal fluid and electrolyte
levels needed to maintain physiological functions.
"Disorders may occur in the fluid volume, concentration (sodium composition), and distribution of fluid and other electrolytes and ph. The"
"main cause is problems in intake, loss andor distribution and balance"
"between water and electrolytes, as shown in the table below:"
" Volumes shown are guidelines only. If necessary, volumes can"
be increased or initial high rate of administration maintained
until clinical improvement occurs
" In addition to ORS, other fluids such as soup, fruit juice and safe"
"- Initially, adults can take up to 750 ml ORShour."
 If sodium lactate compound IV infusion (Ringers Lactate) is
"not available, use half-strength Darrows solution in glucose"
"2.5 or sodium chloride infusion 0.9. However, both of"
" Continued nutrition is important, and food should be"
continued during treatment for dehydration.
 Avoid artificially sweetened juices.
Gastrointestinal  Excessive vomiting and diarrhoea
Haemorrhage  Internal or external
"Fluid sequestration  Paralytic ileus, intestinal obstruction"
Urinary loss  Decompensated diabetes
"Fluid retention  Renal, hepatic and heart failure"
and electrolytes or (see specific section for managewater imbalances ment)
Reduced intake  Post operative patients
"Excessive intake  Water intoxication, IV fluids overload"
 Dehydration in mildmoderate fluid (water and electrolytes)
 Hypovolaemic shock in severe fluid deficiency
 Oedema (including pulmonary oedema) in fluid excess
 Specific effects due to electrolytes imbalances
IV fluids and electrolytes therapy has three main objectives:
loss  Excessive vomiting and diarrhoea
Haemorrhage  Internal or external
"Fluid sequestration  Paralytic ileus, intestinal obstruction"
Urinary loss  Decompensated diabetes
"water imbalances  Renal, hepatic and heart failure"
(see specific section for management)
Reduced intake  Post operative patients
"Excessive intake  Water intoxication, IV fluids overload"
 Replace lost body fluids and continuing losses
 Maintain daily fluid requirements.
Always use an IV drip for patients who are seriously ill (except patients
"with congestive heart failure; for these, use only an indwelling needle)"
"and may need IV drugs or surgery. If the fluid is not needed urgently, run"
it slowly to keep the IV line open.
Administer daily fluid and electrolyte requirements to any HC3
 The basic 24-hour maintenance requirement for an
- One third of these daily fluids should be (isotonic)
- sodium chloride 0.9 infusion (or Ringers
"Lactate), the other two thirds Glucose 5 infusion"
" As well as the daily requirements, replace fluid lost due"
to the particular condition according to the assessed
 Closely monitor all IV drips to ensure that the rate is adjusted as
 Check the drip site daily for any signs of infection; change
drip site every 2-3 days or when the drip goes into tissues
Administer daily fluid and electrolyte requirements to any
 The basic 24-hour maintenance requirement for an
- One third of these daily fluids should be (isotonic)
- sodium chloride 0.9 infusion (or Ringers
"Lactate), the other two thirds Glucose 5 infusion"
" As well as the daily requirements, replace fluid lost due"
to the particular condition according to the assessed
 Closely monitor all IV drips to ensure that the rate is adjusted as
 Check the drip site daily for any signs of infection; change
drip site every 2-3 days or when the drip goes into tissues
Replecment therapy in specific conditions
" see section Diarrhoea and vomiting with severe dehydration, paralytic ileus,"
 Replace fluid losses with isotonic (sodium) solutions containing
potassium e.g. compound sodium lactate infusion (Ringers
 Or half-strength Darrows solution in 2.5 glucose infusion
If there is blood loss and the patient is not in shock
 Use sodium chloride 0.9 infusion for blood volume replacement
giving 0.5-1 L in the 1st hour and not more than 2-3 L in 4 hours
 Give 1-2 units of blood to replace volume and concentration
 Give Ringers Lactate or sodium chloride 0.9 infusion 20 ml
kg IV over 60 minutes for initial volume resuscitation
"- Start rapidly, closely monitor BP"
- Reduce the rate according to BP response
" In patients with severe shock and significant haemorrhage, give"
 Closely monitor all IV drips to ensure that the rate is adjusted as
 Check the drip site daily for any signs of infection; change drip site
every 2-3 days or when the drip goes into tissues (extravasation).
"Diarrhoea and vomiting with severe dehydration, paralytic ileus,"
 Replace fluid losses with isotonic (sodium) solutions containing
potassium e.g. compound sodium lactate infusion (Ringers
 Or half-strength Darrows solution in 2.5 glucose infusion 
If there is blood loss and the patient is not in shock
 Use sodium chloride 0.9 infusion for blood volume replacement
giving 0.5-1 L in the 1st hour and not more than 2-3 L in 4 hours
 Give 1-2 units of blood to replace volume and concentration 
 Give Ringers Lactate or sodium chloride 0.9 infusion 20 ml
kg IV over 60 minutes for initial volume resuscitation
"- Start rapidly, closely monitor BP"
- Reduce the rate according to BP response
" In patients with severe shock and significant haemorrhage, give"
 Closely monitor all IV drips to ensure that the rate is adjusted as
 Check the drip site daily for any signs of infection; change drip site
every 2-3 days or when the drip goes into tissues (extravasation). 
1.IV Fluid management in children ICD10 CODE: E87.8
 Total daily maintenance fluid requirement is 100 mlkg HC4
- 50 mlkg for the next 10 kg plus 25 mlkg for each
 Give more than above if child is dehydrated or in fluid loss
or fever (10 more for each 1C of fever)
" Encourage mother to breastfeed or if child unable, give HC4"
" Withhold oral feeding in case of bowel obstruction, necrotizing enterocolitis, or if feeding is not tolerated (abdominal"
"distension, vomiting everything)"
" Withhold oral feeding in acute phase of severe sickness, in"
"infants who are lethargic, unconscious or having frequent"
Total amount of fluids (oral andor IV)
Day 1: 60 mlkgday of Dextrose 10
Day 2: 90 mlkgday of Dextrose 10
Day 3: 120 mlkgday of half normal saline and dextrose 5
" If only IV fluids are given, do not exceed 100 ml kg"
"day unless child is dehydrated, under a radiant heater or"
" If facial swelling develops, reduce rate of infusion"
" When oral feeding is well established, raise the total amount"
 Total daily maintenance fluid requirement is 100 mlkg
- 50 mlkg for the next 10 kg plus 25 mlkg for each
 Give more than above if child is dehydrated or in fluid loss
or fever (10 more for each 1C of fever) HC4
" Encourage mother to breastfeed or if child unable, give"
" Withhold oral feeding in case of bowel obstruction, necrotizing enterocolitis, or if feeding is not tolerated (abdominal"
"distension, vomiting everything)"
" Withhold oral feeding in acute phase of severe sickness, in"
"infants who are lethargic, unconscious or having frequent"
Total amount of fluids (oral andor IV)
Day 1: 60 mlkgday of Dextrose 10
Day 2: 90 mlkgday of Dextrose 10
Day 3: 120 mlkgday of half normal saline and dextrose 5
" If only IV fluids are given, do not exceed 100 ml kg"
"day unless child is dehydrated, under a radiant heater or"
" If facial swelling develops, reduce rate of infusion"
" When oral feeding is well established, raise the total amount"
Shock in non-malnourished child
 Use Ringers lactate or normal saline HC3
 Infuse 20 mlkg as rapidly as possible
" If bleeding, give blood at 20 mlkg"
 Give another 20 mlkg of IV fluids
If no improvement further still
 Repeat 20 mlkg IV fluids and consider adrenaline or
"If improvement noted at any stage (reducing heart rate,"
"increase in blood pressure and pulse volume, capillary"
 Give 70 mlkg of Ringers lactate (or Normal saline if
Ringers not available) over 5 hours (if infant 12 months)
" In children with suspected malaria or anaemia with shock, IV fluids"
should be administered cautiously and blood should be used in severe
" In malnourished children, give 15 mlkg over 1 hour, HC3"
- Ringers lactate with 5 glucose
- Half strength darrows solution with 5 glucose
- 0.45 Sodium chloride plus 5 glucose
 Use Ringers lactate or normal saline
 Infuse 20 mlkg as rapidly as possible HC3
" If bleeding, give blood at 20 mlkg"
 Give another 20 mlkg of IV fluids
If no improvement further still
 Repeat 20 mlkg IV fluids and consider adrenaline or
"If improvement noted at any stage (reducing heart rate,"
"increase in blood pressure and pulse volume, capillary"
 Give 70 mlkg of Ringers lactate (or Normal saline if
Ringers not available) over 5 hours (if infant 12 months)
or hours (if child 12 months) HC4
" In children with suspected malaria or anaemia with shock, IV fluids"
should be administered cautiously and blood should be used in severe
" In malnourished children, give 15 mlkg over 1 hour,"
- Ringers lactate with 5 glucose
- Half strength darrows solution with 5 glucose
- 0.45 Sodium chloride plus 5 glucose HC3
 Switch to oral or NGT ReSoMal at 10 mlkghour for
 Give maintenance IV fluids 4 mlkghour f Transfuse
10 mlkg slowly (over 3 hours) f Start refeeding
Commonly used IV fluids and indication
"Sodium Chloride Na 154 mmolL Shock, dehydration in"
0.9 (normal saline) Cl 154 mmolL adults (and children)
Dextrose (Glucose) Glucose 25 g in Maintenance fluid in
Dextrose (Glucose) Glucose 50 g in Hypoglycaemia in chil101 (to be pre- 500 ml dren and adults Maintepared) nance fluids in newborns
Dextrose 50 Glucose 50 g in Hypoglycaemia in adults
"Ringers lactate (So- Na 130 mmolL Shock, dehydration in"
dium lactate com- K mmolL children (and adults)
"pound, Harmanns Ca mmolL Maintenance fluid in"
½ strenghth Dar- Na 61 mmolL Shock and dehydration
rows solution in 5 in malnourished children
 Switch to oral or NGT ReSoMal at 10 mlkghour for
 Give maintenance IV fluids 4 mlkghour f Transfuse
10 mlkg slowly (over 3 hours) f Start refeeding
0.9 (normal saline) Na 154 mmolL
"Cl 154 mmolL Shock, dehydration in"
101 (to be prepared) Glucose 50 g in
500 ml Hypoglycaemia in children and adults Maintenance fluids in newborns
"Ringers lactate (Sodium lactate compound, Harmanns"
½ strenghth Darrows solution in 5
Half normal saline Na 77 mmolL Maintenance fluid in
Glucose 25 g in Shock and dehydration
52 500 ml in malnourished children
Normal saline or Na 154130 K Maintenance fluid in
1 Prepare from Dextrose 5 and 50:
 Remove 50 ml from Dextrose 5 500 ml bottle and discard
 Replace with 50 ml of Dextrose 50. Shake
 Follow normal aseptic techniques
2 Prepare from Normal saline 500 ml bottle and dextrose 5 and 50
 Replace 250 ml of Normal saline with 225 ml of
 Dextrose 5 and 25 ml of Dextrose 50
3 Prepare by replacing 50 ml of normal saline or Ringers 500 ml
bottle with 50 ml of Dextrose 50
Febrile Convulsions ICD10 CODE: R56
A generalized tonic-clonic seizure associated with a rapid rise in temperature due to an extracranial illness. It is a diagnosis of exclusion: specific
"conditions (cerebral malaria, meningitis, epilepsy) should be excluded. It"
commonly affects children from age 3 months to 6 years.
" Convulsions usually brief and self-limiting (usually 5 minutes, always 15 minutes) but may recur if temperature remains high"
 No neurological abnormality in the period between convulsions
 Generally benign and with good prognosis
" Epilepsy, brain lesions, meningitis, encephalitis"
 If intracranial pathology cannot be clinically excluded (especially in children 2 years) consider lumbar puncture or
treat children empirically for meningitis
 Blood: SlideRDT for malaria parasites
"¾ Urinalysis, culture and sensitivity"
 Use tepid sponging to help lower temperature HC2
 Give an antipyretic: paracetamol 15 mgkg every 6 hours
 Use tepid sponging to help lower temperature
 Give an antipyretic: paracetamol 15 mgkg every 6 hours
 Give diazepam 500 microgramskg rectally (using suppositoriesrectal tube or diluted parenteral solution)
 Position the patient on the side (recovery position) and
"ensure airways, breathing and circulation (ABC)"
Educate caregivers on how to control fever (tepid sponging and paracetamol)
Hypoglycaemia ICD10 CODE: E16.2
A clinical condition due to reduced levels of blood sugar (glucose). Symptoms generally occur with a blood glucose mmolL (55 mgdl).
 Overdose of insulin or anti-diabetic medicines
" Excessive alcohol intakeSepsis, critical illnesses"
 Operations to reduce the size of the stomach (gastrectomy)
 Tumours of the pancreas (insulinomas)
" Hormone deficiencies (cortisol, growth hormone)"
" Early symptoms: hunger, dizziness, tremors, sweating, nervousness and confusion"
 Give diazepam 500 microgramskg rectally (using suppositoriesrectal tube or diluted parenteral solution)
 Position the patient on the side (recovery position) and
"ensure airways, breathing and circulation (ABC)"
" Profuse sweating, palpitations, weakness"
" Other causes of loss of consciousness (poisoning, head injury etc.)"
 Specific investigations: to exclude other causes of hypoglycaemia
If patient is able to swallow HC2
 Oral glucose or sugar 10-20 g in 100-200 ml water (2-4
teaspoons) is usually taken initially and repeated after 15
 Adults: glucose 50 20-50 ml IV slowly (3 ml minute)
"or diluted with normal saline, followed by 10  glucose"
"minute until patient regains consciousness, then encourage"
" If patient does not regain consciousness after 30 minutes,"
 Monitor blood sugar for several hours (at least 12 if hypoglycaemia caused by oral antidiabetics) and investigate
 Oral glucose or sugar 10-20 g in 100-200 ml water (2-4
teaspoons) is usually taken initially and repeated after 15
 Adults: glucose 50 20-50 ml IV slowly (3 ml minute)
"or diluted with normal saline, followed by 10  glucose"
"minute until patient regains consciousness, then encourage"
" If patient does not regain consciousness after 30 minutes,"
 Monitor blood sugar for several hours (at least 12 if hypoglycaemia caused by oral antidiabetics) and investigate
the cause  manage accordingly. HC2
" After dextrose 50, flush the IV line to avoid sclerosis of the vein"
 Preparation of Dextrose 10 from Dextrose 5 and Dextrose
- Remove 50 ml from Dextrose 5 bottle and discard
- Replace with 50 ml of Dextrose 50. Shake
- Follow normal aseptic techniques
"- Use immediately, DO NOT STORE."
 Educate patients at risk of hypoglycaemia on recognition
"of early symptoms e.g. diabetics, patients who have had a"
 Advise patients at risk to have regular meals and to always
have glucose or sugar with them for emergency treatment
 Advise diabetic patients to carry an identification tag
"Wounds caused by teeth, fangs or stings."
" Animals (e.g. dogs, snakes), humans or insects"
 Immediately clean the wound thoroughly with plenty of
clean water and soap to remove any dirt or foreign bodies
 Stop excessive bleeding by applying pressure where
 Rinse the wound and allow to dry
 Apply an antiseptic: Chlorhexidine solution 0.05 or
 Treat anaphylactic shock (see section 1.1.1) HC3
" Treat swelling if significant as necessary, using ice packs"
 Reassure and immobilise the patient
 Give only for infected or high-risk wounds including:
- Moderate to severe wounds with extensive tissue
- Deep puncture wounds (especially by cats)
"- Wounds on hands, feet, genitalia or face"
- Wounds with underlying structures involved
- Wounds in immunocompromised patients
" See next sections on wound management, human and"
" Give TT immunisation (tetanus toxoid, TT ml) if not"
previously immunised within the last 10 years
 Immediately clean the wound thoroughly with plenty of
clean water and soap to remove any dirt or foreign bodies
 Stop excessive bleeding by applying pressure where
 Rinse the wound and allow to dry
 Apply an antiseptic: Chlorhexidine solution 0.05 or
Povidone iodine solution 10 HC2
 Treat anaphylactic shock (see section 1.1.1)
" Treat swelling if significant as necessary, using ice packs"
 Reassure and immobilise the patient HC3
 Give only for infected or high-risk wounds including:
- Moderate to severe wounds with extensive tissue
- Deep puncture wounds (especially by cats) 
"- Wounds on hands, feet, genitalia or face"
- Wounds with underlying structures involved
- Wounds in immunocompromised patients
" See next sections on wound management, human and"
" Give TT immunisation (tetanus toxoid, TT ml) if not"
previously immunised within the last 10 years 
Snakebites can cause both local and systemic effects. Non-venomous
"snakes cause local effects (swelling, redness, laceration) and venomous"
snakes cause both local and systemic effects due to envenomation. Over
70 of snakes in Uganda are non-venomous and most bites are from
"non-venomous snakes. Of the venomous snakes, more than 50 of"
bites are dry i.e. no envenomation occurs. In the event that venom is
"injected, the effect of the venom depends on the type of venom, quantity,"
location of the bite and size and general condition of the victim.
" Common venomous snakes in Uganda: Puff adder, Gaboon"
"viper, black mambas, Brown Forest cobra, Egyptian cobra"
and Boomslang (see below images of some of the common
Local symptoms and signs Generalized (systemic) symptoms
 Malaise  Difficulty in breathing
"If cytotoxic venom (Puff adder, Gaboon viper)"
" Extensive local swelling, pain, lymphadenopathy  starting"
Local symptoms and signs Generalized (systemic) symptoms
"If neurotoxic venom (Jamesons mamba, Egyptian Cobra, Forest"
" Weakness, paralysis, difficulty in breathing, drooping eyelids, difficulty in swallowing, double vision, slurred speech"
 starting 15-30 minutes after the bite
 Excessive sweating and salivation
"If hemotoxic venom (Boomslang, VineTwig snake)"
 Excessive swelling and oozing from the site
" Excessive bleeding, bloody blisters"
" Haematuria, haematemesis  even after some days"
 Late appearance of signs and symptoms
 Whole blood clotting test at arrival and every 4-6 hours
 Put 2-5 ml of blood in a dry tube and observe after 30 minutes
" If incomplete or no clotting, it indicates coagulation abnormalities"
" Other useful tests depending on severity, level of care and"
 HaemoglobinPCVPlatelet countPTAPTTD-Dimer
 Biochemistry for Serum CreatinineUreaPotassium
 Urine Tests for ProteinuriaHaemoglobinuria Myoglobinuria
 Reassure the patient to  Do not panic
stay calm  Do not lay the patient on
 Lay the patient on the their back as it may block
around the affected area  Do not attempt to suck the
area alone  Do not try to kill or attack
 Immobilize the patient the snake
 Irrigate eyes with plenty of water
 Assess skin for fang penetration HC2
 Analgesic e.g. paracetamol (avoid NSAIDS like
"aspirin, diclofenac, ibuprofen)"
If no signs and symptoms for 6-8 hours: most likely bite
 Observation for 12-24 hours recommended
 Tetanus toxoid (TT) IM ml if not previously
" Remove blisters, clean and dress daily, debride"
after lesions stabilise (minimum 15 days)
 Immobilize the patient  Do not panic
 Assess skin for fang penetration
 Analgesic e.g. paracetamol (avoid NSAIDS like
"aspirin, diclofenac, ibuprofen)"
If no signs and symptoms for 6-8 hours: most likely bite
 Observation for 12-24 hours recommended
 Tetanus toxoid (TT) IM ml if not previously
" Remove blisters, clean and dress daily, debride"
after lesions stabilise (minimum 15 days) HC2
Criteria for referral for administration of antivenom
" Signs of systemic envenoming (paralysis, respiratory difficulty, bleeding)"
- Swelling of hand or foot (site of most bites) within 1 hour of
- Swelling of elbow or knee within 3 hours of bite
- Swelling of groin or chest at any time
- Significant swelling of head or neck
 Antivenom sera polyvalent (Africa)
- Check package insert for IV dosage details. Ensure the
solution is clear and check that patient has no history of allergy
 Indicated only if wound is infected
Images of some common snakes in Uganda
Puff Adder (Bitis arietans) Black Mamba (Dendroaspispolylepis)
Egyptian cobra (Najahaje) Black-necked spitting cobra (Najanigricollis)
Criteria for referral for administration of antivenom
" Signs of systemic envenoming (paralysis, respiratory difficulty, bleeding)"
- Swelling of hand or foot (site of most bites) within 1 hour of
- Swelling of elbow or knee within 3 hours of bite
- Swelling of groin or chest at any time
- Significant swelling of head or neck
 Antivenom sera polyvalent (Africa)
- Check package insert for IV dosage details. Ensure the
solution is clear and check that patient has no history of allergy
 Indicated only if wound is infected 
Jamesons mamba (Dendroaspisjamesoni) Boomslang (Dispholidus typus)
"Vine, bird, twig or tree snakes (Thelotornisspp.) Rhino-horned Viper (Bitis nasicornis)"
Egyptian Cobra (Naja haje) Eastern Forest Cobra (Naja subfulva)
Rock Python (Python sebae) Gaboon Adder (Bitis gabonica)
Battersbys green snake (Philothamnus battersbyi) Olive House Snake (Lycodonomorphis inornatus)
1.Insect Bites  Stings ICD10 CODE: T63.4
" Bees, wasps, hornets and ants: venom is usually mild and"
causes only local reaction but may cause anaphylactic
shock in previously sensitized persons
 Spiders and scorpions: Most are non-venomous or only
Other stinging insectsClinical features
" Swelling, discolouration, burning sensation, pain at the site"
 There may be signs of anaphylactic shock.
" If the sting remains implanted in the skin, carefully remove HC2"
" If the sting remains implanted in the skin, carefully remove"
 Give chlorpheniramine 4 mg every 6 hours (max: 24 HC2
mg daily) until swelling subsides Child 1-2 years: 1 mg
Child 2-5 years: 1 mg every 6 hours (max: 6 mg daily)
Child 6-12 years: 2 mg every 6 hours (max: 12 mg daily)
 Apply calamine lotion prn every 6 hours
 Infiltrate 2 ml of lignocaine 2 around the area of the bite
If signs of systemic envenomation
 Clear overgrown vegetationbushes around the home
 Prevent children from playing in the bush
 Cover exposed skin while moving in the bush
 Use pest control methods to clear insect colonies.
"1.Animal and Human Bites ICD10 CODE: W50.3, W54.0"
" Teeth marks or scratches, lacerations"
 Puncture wounds (especially cats)
" Complications: bleeding, lesions of deep structures, wound"
"infection (by mixed flora, anaerobs), tissue necrosis, transmission of diseases (tetanus, rabies, others)"
 Immediately clean the wound thoroughly with plenty of
clean water and soap to remove any dirt or foreign bodies
 Give chlorpheniramine 4 mg every 6 hours (max: 24
mg daily) until swelling subsides Child 1-2 years: 1 mg
Child 2-5 years: 1 mg every 6 hours (max: 6 mg daily)
Child 6-12 years: 2 mg every 6 hours (max: 12 mg daily)
 Apply calamine lotion prn every 6 hours
 Infiltrate 2 ml of lignocaine 2 around the area of the bite
If signs of systemic envenomation
 Immediately clean the wound thoroughly with plenty of
clean water and soap to remove any dirt or foreign bodies HC2
 Stop excessive bleeding where necessary by applying HC2
 Rinse the wound and allow to dry
 Apply an antiseptic: Chlorhexidine solution 0.05 or
 Soak punture wounds in antiseptic for 15 minutes
" Thorough cleaning, exploration and debridement (under"
" Refer wounds on hands and face, deep wounds, wounds"
with tissue defects to hospital for surgical management
" Give TT immunisation (tetanus toxoid, TT ml) if not"
previously immunised within the last 10 years
 Indicated in the following situations:
- Deep puncture wounds (especially Cats)
"- Severe (deep, extensive) wounds"
"- Wounds on face, genitalia, hands"
- Wounds in immunicompromised hosts
 Amoxicillin 500 mg every 8 hours for 5-7 days
 Plus Metronidazole 400 mg every 12 hours
 Do not use routine antibiotics for small uncomplicated dog
 Stop excessive bleeding where necessary by applying
 Rinse the wound and allow to dry
 Apply an antiseptic: Chlorhexidine solution 0.05 or
 Soak punture wounds in antiseptic for 15 minutes
" Thorough cleaning, exploration and debridement (under"
" Refer wounds on hands and face, deep wounds, wounds"
with tissue defects to hospital for surgical management
" Give TT immunisation (tetanus toxoid, TT ml) if not"
previously immunised within the last 10 years HC2
 Indicated in the following situations:
- Deep puncture wounds (especially Cats)
"- Severe (deep, extensive) wounds"
"- Wounds on face, genitalia, hands"
- Wounds in immunicompromised hosts
 Amoxicillin 500 mg every 8 hours for 5-7 days
 Plus Metronidazole 400 mg every 12 hours
 Do not use routine antibiotics for small uncomplicated dog
1.Rabies Post Exposure Prophylaxis ICD10 CODE:
Post exposure prophylaxis effectively prevents the development of rabies
"after the contact with saliva of infected animals, through bites, scratches,"
licks on broken skin or mucous membranes. For further details refer to
"Rabies Post-Exposure Treatment Guidelines, Veterinary Public Health"
"Unit, Community Health Dept,, September 2001"
If the animal can be identified and caught HC2
" If domestic, confirm rabies vaccination"
 If no information on rabies vaccination or
If the animal can be identified and caught HC2
" If domestic, confirm rabies vaccination"
 If no information on rabies vaccination or
"wild: quarantine for 10 days (only dogs, cats or endangered"
species) or kill humanely andsend the head to the veterinary
 If no signs of rabies infection shown within 10
" days: release the animal, stop immunisation"
" If it shows signs of rabies infection: kill the animal,"
"remove its head, and send to the Veterinary"
Department for verification of the infection
 Presume animal infected and patient at risk
 Consumption of properly cooked rabid meat is not harmful
" Animals at risk: dogs, cats, bats, other wild carnivores"
 Non-mammals cannot harbour rabies
If the animal can be identified and caught
" If domestic, confirm rabies vaccination"
 If no information on rabies vaccination or HC2
If the animal can be identified and caught
" If domestic, confirm rabies vaccination"
 If no information on rabies vaccination or
"wild: quarantine for 10 days (only dogs, cats or endangered"
species) or kill humanely andsend the head to the veterinary
 If no signs of rabies infection shown within 10
" days: release the animal, stop immunisation"
" If it shows signs of rabies infection: kill the animal,"
"remove its head, and send to the Veterinary"
Department for verification of the infection
 Presume animal infected and patient at risk HC2
 Consumption of properly cooked rabid meat is not harmful
" Animals at risk: dogs, cats, bats, other wild carnivores"
 Non-mammals cannot harbour rabies 
 The combination of local wound treatment plus passive
immunisation with rabies immunoglobulin (RIG) plus vaccination with rabies vaccine (RV) is recommended for all
" if the RI is not available, the patient should still be vaccinated with the Rabies Vaccine alone"
" Since prolonged rabies incubation periods are possible,"
persons who present for evaluation and treatment even
months after having been bitten should be treated in the
same way as if the contact occurred recently
 Administration of Rabies IG and vaccine depends on the
type of exposure and the animals condition
 LOCAL WOUND TREATMENT: Prompt and thorough HC2
local treatment is an effective method to reduce risk of
" For mucous mebranes contact, rinse throroughly with"
 if the wound is deep Tetanus Toxoid (TT) should
be given as well to prevent tetanus
 Local cleansing is indicated even if the patient presents late H
If Veterinary Department confirms rabies infection or if
animal cannot be identifiedtested
 Give rabies vaccine- rabies immunoglobulin human
as per the recommendations in the next table.
 LOCAL WOUND TREATMENT: Prompt and thorough
local treatment is an effective method to reduce risk of
" For mucous mebranes contact, rinse throroughly with"
 if the wound is deep Tetanus Toxoid (TT) should
be given as well to prevent tetanus HC2
 Local cleansing is indicated even if the patient presents late
If Veterinary Department confirms rabies infection or if
animal cannot be identifiedtested
 Give rabies vaccine- rabies immunoglobulin human
as per the recommendations in the next table. H
Recommendations for Rabies VaccinationSerum
Nature Of At Time Of 10 Days Recommended
Saliva in contact Healthy Healthy Do not vaccinate
Suspect Healthy Do not vaccinate
Saliva in Healthy Healthy Do not vaccinate
bites on trunk Suspect Healthy Vaccinate; but
or proximal unknown stop course if
Saliva in contact Domestic or Suspect Vaccinate and give
"with mucosae, wild rabid ani- antirabies immuserious bites mal or suspect noglobulin"
"(face, head, fingers or multiple"
" Vaccinate all domestic animals against rabies e.g. dogs,"
skin lesion Healthy Healthy Do not vaccinate
Unknown Healthy Do not vaccinate
limbs Healthy Healthy Do not vaccinate
"(face, head, fingers or multiple"
wild rabid animal or suspect Suspect Vaccinate and give
wild rabid animal or Suspect Vaccinate but
Administration of Rabies Vaccine (RV)
The following schedules use Purified VERO Cell Culture Rabies Vaccine
"(PVRV), which contains one intramuscular immunising dose (at least IU) in ml of reconstituted vaccine."
RV and RIG are both very expensive and should only be used
when there is an absolute indication
Post-Exposure Vaccination in Non-Previously Vaccinated Patients
Give RV to all patients unvaccinated against rabies together with local
"wound treatment. In severe cases, also give rabies immunoglobulin"
The 2-1-1 intramuscular regimen
This induces an early antibody response and may be particularly effective when post-exposure treatment does not include administration
 Day 0: One dose (ml) in right arm  one dose in left arm
 Doses are given into the deltoid muscle of the arm. In young
"children, the anterolateral thigh may also be used"
 Never use the gluteal area (buttock) as fat deposits may interfere
with vaccine uptake making it less effective.
Alternative: 2-site intradermal (ID) regimen
 This uses PVRV intradermal (ID) doses of ml (i.e. one fifth
 Day 0: one dose of ml in each arm (deltoid)
 Day 3: one dose of ml in each arm
The 2-1-1 intramuscular regimen
This induces an early antibody response and may be particularly effective when post-exposure treatment does not include administration
 Day 0: One dose (ml) in right arm  one dose in left arm
 Doses are given into the deltoid muscle of the arm. In young
"children, the anterolateral thigh may also be used"
 Never use the gluteal area (buttock) as fat deposits may interfere
with vaccine uptake making it less effective.
Alternative: 2-site intradermal (ID) regimen
 This uses PVRV intradermal (ID) doses of ml (i.e. one fifth
 Day 0: one dose of ml in each arm (deltoid)
 Day 3: one dose of ml in each arm
 Day 3: one dose of ml in each arm
 Day 7: one dose of ml in each arm
 Day 28: one dose of ml in each arm
 Much cheaper as it requires less vaccine
 Requires special staff training in ID technique using 1 ml syringes
 Compliance with the Day 28 is vital but may be difficult to
 Patients must be followed up for at least 6-18 months to confirm
" If on malaria chemoprophylaxis, do NOT use."
Post-exposure immunisation in previously vaccinated patients
In persons known to have previously received full pre- or post-exposure
rabies vaccination within the last 3 years
 If incompletely vaccinated or immunosuppressed: give full post
Passive immunisation with rabies immunoglobulin (RIG) Give in all high-risk rabies cases irrespective of the time between exposure and start of treatment
BUT within 7 days of first vaccine.DO NOT USE in patient previously immunised.
 Day 3: one dose of ml in each arm
 Day 7: one dose of ml in each arm
 Day 28: one dose of ml in each arm
 Much cheaper as it requires less vaccine
 Requires special staff training in ID technique using 1 ml syringes
 Compliance with the Day 28 is vital but may be difficult to
 Patients must be followed up for at least 6-18 months to confirm
" If on malaria chemoprophylaxis, do NOT use."
 If incompletely vaccinated or immunosuppressed: give full post
Human rabies immunoglobulin (HRIG)
- Infiltrate as much as possible of this dose around the wounds
"(if multiple wounds and insufficient quantity, dilute it 2 to 3"
- Give the remainder IM into gluteal muscle
- Follow this with a complete course of rabies vaccine
- The first dose of vaccine should be given at the same time
"as the immunoglobulin, but at a site as far away as possible"
from the site where the vaccine was injected. If the bite is at
"or near the upper arm, do not infiltrate the wound with the"
immunoglobulin unless the vaccine wont be injected in the
deltoid muscle of that arm. If the wound near the deltoid is
"infiltrated with the immunoglobulin, use the deltoid muscle of"
the opposite arm for the vaccine.
" If RIG not available at first visit, its administration can be delayed"
up to 7 days after the first dose of vaccine.
Offer rabies vaccine to persons at high risk of exposure such as:
 Laboratory staff working with rabies virus
 Any other persons considered to be at high risk
- Infiltrate as much as possible of this dose around the wounds
"(if multiple wounds and insufficient quantity, dilute it 2 to 3"
- Give the remainder IM into gluteal muscle
- Follow this with a complete course of rabies vaccine
- The first dose of vaccine should be given at the same time
"as the immunoglobulin, but at a site as far away as possible"
from the site where the vaccine was injected. If the bite is at
"or near the upper arm, do not infiltrate the wound with the"
immunoglobulin unless the vaccine wont be injected in the
deltoid muscle of that arm. If the wound near the deltoid is
"infiltrated with the immunoglobulin, use the deltoid muscle of"
the opposite arm for the vaccine.
DAY Vaccine No. of Doses Comments
0 0.5ml 2 (one in each Into the deltoid muscle
deltoid) NEVER IN THE GLUTEAL MUS7 0.5ml 1 CLE (buttocks)
Children with less muscle mass:
Anterolateral aspect of the thigh
The 2:1:1 regimen uses 4doses in
It has fewer patient appointments
If the patient is on anti-malarial
"prophylaxis with Chloroquine, it"
should be withheld and an alternative malaria prophylaxis should be
2-site Intradermal (ID) Regimen
0 0.1ml 2 (one in each It is cheaper since it uses less drug
It requires special staff training in ID
3 0.1ml 2 (one in each technique using 1ml syringes with
Note: Days 14 and 21 are skipped
deltoid) Into the deltoid muscle
NEVER IN THE GLUTEAL MUSCLE (buttocks)
Children with less muscle mass:
Anterolateral aspect of the thigh
The 2:1:1 regimen uses 4doses in
It has fewer patient appointments
If the patient is on anti-malarial
"prophylaxis with Chloroquine, it"
should be withheld and an alternative malaria prophylaxis should be
2-site Intradermal (ID) Regimen 
deltoid) It is cheaper since it uses less drug
It requires special staff training in ID
technique using 1ml syringes with
Note: Days 14 and 21 are skipped
DAY Vaccine No. of Doses Comments
0 20IU Infiltrate in the The Immunoglobulin should be adkg area around ministered as far as possible from the
and in the vaccine to avoid antibody-antigen
A fracture is a complete or incomplete break in a bone.
" Trauma e.g. road traffic accident, assault, falls, sports"
" Bone weakening by disease, e.g., cancer, TB, osteomyelitis, osteoporosis"
" Pain, tenderness, swelling, deformity"
 Inability to usemove the affected part
 May be open (with a wound) or closed
" Infection (bone, joints and muscles)"
the wound The Immunoglobulin should be administered as far as possible from the
vaccine to avoid antibody-antigen
 X-ray: 2 views (AP and lateral) including the joints above and below
Suspected fractures should be referred to HC4 or Hospital after initial care.
 Assess and treat shock (see section 1.1.2)
 Assess nerve and blood supply distal to the injury: if
"no sensationpulse, refer as an emergency"
 Immobilise the affected part with a splint
 Give Tetanus Toxoid if not fully vaccinated
- Amoxicillin 500 mg every 8 hours
- Child: 25 mgkg every 8 hours (or 40 mgkg
 Add gentamicin mgkg every 8 hours
 Refer URGENTLY to hospital for further management
" Treat sprains, strains and dislocations as above"
" Treat sprains, strains and dislocations as above"
 Do not give pethidine and morphine for rib fractures and head
injuries as they cause respiratory depression
 Assess and treat shock (see section 1.1.2)
 Assess nerve and blood supply distal to the injury: if
"no sensationpulse, refer as an emergency"
 Immobilise the affected part with a splint
 Give Tetanus Toxoid if not fully vaccinated
- Amoxicillin 500 mg every 8 hours
- Child: 25 mgkg every 8 hours (or 40 mgkg
 Add gentamicin mgkg every 8 hours
 Refer URGENTLY to hospital for further management HC3
" Treat sprains, strains and dislocations as above"
" Treat sprains, strains and dislocations as above "
 Do not give pethidine and morphine for rib fractures and head
injuries as they cause respiratory depression 
"Tissue injury caused by thermal, chemical, electrical, or radiation energy."
" Thermal, e.g., hot fluids, flame, steam, hot solids, sun"
" Chemical, e.g., acids, alkalis, and other caustic chemicals"
" Electrical, e.g., domestic (low voltage) transmission lines"
" Radiation, e.g., exposure to excess radiotherapy or radioactive materials"
" Skin changes (hyperaemia, blisters, singed hairs)"
" Skin loss (eschar formation, charring)"
 Reduced ability to use the affected part
" Systemic effects in severeextensive burns include shock,"
"low urine output, generalised swelling, respiratory insufficiency, deteriorated mental state"
" Breathing difficulty, hoarse voice and cough in smoke inhalation injury  medical emergency"
Criteria for classification of the severity of burns
The following criteria are used to classify burns:
Depth of the burn (a 1st Degree burns
"factor of temperature, Superficial epidermal injury with no"
"of agent, and of du- blisters. Main sign is redness of the skin,"
"ration of contact with tenderness, or hyper sensitivity with"
the skin) intact two-point discrimination. Healing in 7 days
"of agent, and of duration of contact with"
 Superficial epidermal injury with no
"blisters. Main sign is redness of the skin,"
"tenderness, or hyper sensitivity with"
intact two-point discrimination. Healing in 7 days
2nd Degree burns or Partial thickness burns
It is a dermal injury that is sub-classified as
"superficial and deep 2nd degree burns. In superficial 2nd degree burns, blisters result, the"
pink moist wound is painful. A thin eschar is
"In deep 2nd degree burns, blisters are lacking,"
"the wound is pale, moderately painful, a thick"
"1 month, requiring surgical debridement"
"Full thickness skin destruction, leather- like"
rigid eschar. Painless on palpation or pinprick.
"Full thickness skin and fascia, muscles, or bone"
destruction. Lifeless body part
Percentage of total Small areas are estimated using the open palm
body surface area of the patient to represent 1 TBSA. Large
(TBSA) areas estimated using the rules of nines or
a Lund-Browder chart. Count all areas except
"The body parts Face, neck, hands, feet, perineum and major"
injured joints burns are considered severe
"Agegeneral con- In general, children and the elderly fare worse"
dition than young adults and need more care. A person
who is sick or debilitated at the time of the burn
will be more affected than one who is healthy
 2nd Degree burns or Partial thickness burns
It is a dermal injury that is sub-classified as
"superficial and deep 2nd degree burns. In superficial 2nd degree burns, blisters result, the"
pink moist wound is painful. A thin eschar is
"In deep 2nd degree burns, blisters are lacking,"
"the wound is pale, moderately painful, a thick"
"1 month, requiring surgical debridement"
"Full thickness skin destruction, leather- like"
rigid eschar. Painless on palpation or pinprick.
"Full thickness skin and fascia, muscles, or bone"
destruction. Lifeless body part
(TBSA) Small areas are estimated using the open palm
of the patient to represent 1 TBSA. Large
areas estimated using the rules of nines or
a Lund-Browder chart. Count all areas except
"injured Face, neck, hands, feet, perineum and major"
joints burns are considered severe
"Agegeneral condition In general, children and the elderly fare worse"
than young adults and need more care. A person
who is sick or debilitated at the time of the burn
will be more affected than one who is healthy
Categorisation of severity of burns
"Using the above criteria, a burn patient may be categorised as follows:"
Minormild - Adult with 15 TBSA affected or
burn - Childelderly with 10 TBSA affected or
- Full thickness burn with 2 TBSA
affected and no serious threat to function
Minormild - Adult with 15 TBSA affected or
burn - Childelderly with 10 TBSA affected or
- Full thickness burn with 2 TBSA
affected and no serious threat to function
Moderate Adult with partial thickness burn 15- 25 TBSA or
(intermediate) Childelderly with partial thickness
All above with no serious threat to function and no
"cosmetic impairment of eyes, ears, hands, feet or"
- Partial thickness burn 25 TBSA or
- Partial thickness burn 20 TBSA or full
thickness burn of 5 TBSA affected
"- Any burns of the face and eyes, neck, ears,"
"hand, feet, perineum and major joints with"
"cosmetic or functional impairment risks,"
"- Chemical, high voltage, inhalation burns"
- Any burn with associated major trauma
burn - Adult with 15 TBSA affected or
- Childelderly with 10 TBSA affected or
- Full thickness burn with 2 TBSA
affected and no serious threat to function
burn - Adult with 15 TBSA affected or
- Childelderly with 10 TBSA affected or
- Full thickness burn with 2 TBSA
affected and no serious threat to function
burn Adult with partial thickness burn 15- 25 TBSA or
Childelderly with partial thickness
All above with no serious threat to function and no
"cosmetic impairment of eyes, ears, hands, feet or"
- Partial thickness burn 25 TBSA or
- Partial thickness burn 20 TBSA or full
thickness burn of 5 TBSA affected
"- Any burns of the face and eyes, neck, ears,"
"hand, feet, perineum and major joints with"
"cosmetic or functional impairment risks,"
"- Chemical, high voltage, inhalation burns"
- Any burn with associated major trauma
Chart for Estimating Percentage of Total Body Surface Area (TBSA) Burnt
LUND AND BROWDER CHARTS Ignore simple erythema
Relative percentage of body surface area affected by growth
B  ½ of one thigh 2¾ 3¼ 4 4½ 4½ 4¾
C  ½ of one lower leg 2½ 2½ 2¾ 3 3¼ 3½
Mildmoderate burns  First aid HC1
 Stop the burning process and move the patient to safety
 Roll on the ground if clothing is on fire
B  ½ of one thigh 2¾ 3¼ 4 4½ 4½ 4¾
C  ½ of one lower leg 2½ 2½ 2¾ 3 3¼ 3½
 Stop the burning process and move the patient to safety
 Roll on the ground if clothing is on fire HC1
 Cool the burn by pouring or showering or soaking the
"affected area with cold water for 30 minutes, especially"
in the first hour after the burn (this may reduce the depth
of injury if started immediately)
" Remove soaked clothes, wash off chemicals, remove any"
 Clean the wound with clean water
 Cover the wound with a clean dry cloth and keep the
 Give oral or IV analgesics as required
" If TBSA 10 and patient able to drink, give oral fluids"
otherwise consider  Give TT if not fully immunised
" Leave small blisters alone, drain large blisters and dress"
if closed dressing method is being used the urine output.
The normal urine output is: Children (30 kg) 1-2 mlkg
hour and adults mlkghour (30-50 ml hour)
" Dress with silver sulphadiazine cream 1, add saline HC3"
moistened gauze or paraffin gauze and dry gauze on top
 Small superficial 2nd degree burns can be dressed directly
 Patient may be exposed in a bed cradle if there are extensive burns
 Saline bath should be done before wound dressing 49
 Cool the burn by pouring or showering or soaking the
"affected area with cold water for 30 minutes, especially"
in the first hour after the burn (this may reduce the depth
of injury if started immediately)
" Remove soaked clothes, wash off chemicals, remove any"
 Clean the wound with clean water
 Cover the wound with a clean dry cloth and keep the
 Give oral or IV analgesics as required
" If TBSA 10 and patient able to drink, give oral fluids"
otherwise consider  Give TT if not fully immunised
" Leave small blisters alone, drain large blisters and dress"
if closed dressing method is being used the urine output.
The normal urine output is: Children (30 kg) 1-2 mlkg
hour and adults mlkghour (30-50 ml hour) HC2
" Dress with silver sulphadiazine cream 1, add saline"
moistened gauze or paraffin gauze and dry gauze on top
 Small superficial 2nd degree burns can be dressed directly
 Patient may be exposed in a bed cradle if there are extensive burns
 Saline bath should be done before wound dressing HC3
 If wound infected dress more frequenly with silver sulphadiazine cream until infection is controlled.
 First aid and wound management as above PLUS
 Give IV fluid replacement in a total volume per 24 hours
"according to the calculation in the box below (use crystalloids, i.e., Ringers lactate, or normal saline)"
" If patient in shock, run the IV fluids fast until BP improves"
 Monitor vital signs and urine output
 Use antibiotics if there are systemic signs of infection:
benzylpenicillin 3 MU every 6 hours
- gentamicin 5-7 mgkg IV or IM once a day
 Blood transfusion may be necessary
" If signssymptoms of inhalation injury, give oxygen and"
refer for advanced life support (refer to regional level) H
" Escharotomy and fasciotomy for circumferential finger,"
 Escharectomy to excise dead skin
 Skin grafting to cover clean deep burn wounds
 Irrigate with abundant sterile saline
 Place eye pad over eye ointment and refer
 If wound infected dress more frequenly with silver sulphadiazine cream until infection is controlled.
 First aid and wound management as above PLUS
 Give IV fluid replacement in a total volume per 24 hours
"according to the calculation in the box below (use crystalloids, i.e., Ringers lactate, or normal saline)"
" If patient in shock, run the IV fluids fast until BP improves"
 Monitor vital signs and urine output
 Use antibiotics if there are systemic signs of infection:
benzylpenicillin 3 MU every 6 hours
- gentamicin 5-7 mgkg IV or IM once a day
 Blood transfusion may be necessary
" If signssymptoms of inhalation injury, give oxygen and"
refer for advanced life support (refer to regional level)
" Escharotomy and fasciotomy for circumferential finger,"
 Escharectomy to excise dead skin
 Skin grafting to cover clean deep burn wounds
 Irrigate with abundant sterile saline
 Place eye pad over eye ointment and refer HC3
 Counselling and psychosocial support
 Health education on prevention (e.g. epilepsy control)
" Silver sulphadiazine contraindicated in pregnancy, breastfeeding and premature babies"
 The objective is to maintain normal physiology as shown by
"urine output, vital signs and mental status"
 Fluid is lost from the circulation into the tissues surrounding
"the burns and some is lost through the wounds, especially"
 Low intravascular volume results in tissue circulatory insufficiency (shock) with results such as kidney failure and
 The fluid requirements are often very high and so should be
given as necessary to ensure adequate urine output
 Give oral fluids (ORS or others) andor IV fluids e.g. normal HC2
saline or Ringers Lactate depending on the degree of loss HC3
V The total volume of IV solution required in the first 24 hours
4 ml x weight (kg) x  TBSA burned plus the normal daily
 Give 50 of fluid replacement in the first 8 hours and 50
in the next 16 hours. The fluid input is balanced against
 Counselling and psychosocial support
 Health education on prevention (e.g. epilepsy control) 
" Silver sulphadiazine contraindicated in pregnancy, breastfeeding and premature babies "
 Give oral fluids (ORS or others) andor IV fluids e.g. normal
saline or Ringers Lactate depending on the degree of loss
V The total volume of IV solution required in the first 24 hours
4 ml x weight (kg) x  TBSA burned plus the normal daily
 Give 50 of fluid replacement in the first 8 hours and 50
in the next 16 hours. The fluid input is balanced against HC2
 Public awareness of burn risks and first aid water use in
 Construction of raised cooking fire places as safety measure
" Ensure safe handling of hot water and food, keep well out"
" Particular care of high risk persons near fires e.g. children,"
"epileptic patients, alcohol or drug abusers"
 Encourage people to use closed flames e.g. hurricane
 Beware of possible cases of child abuse
Any break in the continuity of the skin or mucosa or disruption in the
integrity of tissue due to injury.
" Sharp objects, e.g. knife, causing cuts, punctures"
" Blunt objects causing bruises, abrasions, lacerations"
" Bites, e.g. insect, animal, human"
" Missile and blast injury, e.g. gunshot, mines, exlosives,"
" Crush injury, e.g. RTA, building collapse"
 Raw area of broken skin or mucous membrane
" Pain, swelling, bleeding, discharge"
 Abrasions: loss of surface skin
 Bruises: subcutaneous bleeding e.g. black eye
" First aid, tetanus prophylaxis, dressing and pain management"
 Antibiotics are not usually required but if the wound is
- Cloxacillin or amoxicillin 500 mg every 6 hours
Child: 125-250 mg every 6 hours
 Identify the cause of the wound or injury if possible
 Wash affected part and wound with plenty of water or
- (you can also clean with chlorhexidine 0.05
- or hydrogen peroxide 6 diluted with equal
amount of saline to 3 if wound is contaminated)
 Explore the wound under local anesthesia to ascertain the
extent of the damage and remove foreign bodies
 Surgical toilet: carry out debridement to freshen the wound
" Tetanus prophylaxis, pain management, immobilization"
" First aid, tetanus prophylaxis, dressing and pain management"
 Antibiotics are not usually required but if the wound is
- Cloxacillin or amoxicillin 500 mg every 6 hours
Child: 125-250 mg every 6 hours HC2
 Identify the cause of the wound or injury if possible
 Wash affected part and wound with plenty of water or
- (you can also clean with chlorhexidine 0.05
- or hydrogen peroxide 6 diluted with equal
amount of saline to 3 if wound is contaminated)
 Explore the wound under local anesthesia to ascertain the
extent of the damage and remove foreign bodies
 Surgical toilet: carry out debridement to freshen the wound
" Tetanus prophylaxis, pain management, immobilization HC4"
If wound is clean and fresh (8 hours) HC3
 Carry out primary closure by suturing under local anaesthetic
- Use lignocaine hydrochloride 2 (dilute to 1 with
equal volume of water for injection)
If wound is 8 hours old or dirty
 Clean thoroughly and dress daily f Check the state of
the wound for 2-3 days f Carry out delayed primary
- Use this for wounds up to 2-4 days old
"If wound 4 days old or deep pucture wound, contaminated"
"wounds, bitegunshot wounds, abscess cavity"
 Let it heal by secondary closure (granulation tissue)
" Dress daily if contaminateddirty, every other day if clean"
 Pack cavities (e.g. abscesses) with saline-soaked gauzes
 Consider closure with skin graftflap
" Use SOP for collection of wound discharge, or"
" Start on treatment, change treatment when results return"
" If MDR, gramnegative or MRSA or VRE impleme"
the respective transmission-based precautions.
" Where can, use chlorine release for environmental decontamination or alternate fumigation (not"
If wound is clean and fresh (8 hours)
 Carry out primary closure by suturing under local anaesthetic
- Use lignocaine hydrochloride 2 (dilute to 1 with
equal volume of water for injection) HC3
If wound is 8 hours old or dirty
 Clean thoroughly and dress daily f Check the state of
the wound for 2-3 days f Carry out delayed primary
- Use this for wounds up to 2-4 days old
"If wound 4 days old or deep pucture wound, contaminated"
"wounds, bitegunshot wounds, abscess cavity"
 Let it heal by secondary closure (granulation tissue)
" Dress daily if contaminateddirty, every other day if clean"
 Pack cavities (e.g. abscesses) with saline-soaked gauzes
 Consider closure with skin graftflap 
" Use SOP for collection of wound discharge, or"
" Start on treatment, change treatment when results return"
" If MDR, gramnegative or MRSA or VRE impleme"
the respective transmission-based precautions.
" Where can, use chlorine release for environmental decontamination or alternate fumigation (not"
Head Injuries ICD10 CODE: S00-S09
Trauma to the head resulting in brain injuries due to:
"- Direct damage to the brain (contusion, concussion,"
"penetrating injury, diffuse axonal damage)"
- Haemorrhage from rupture of blood vessels around and in
- Severe swelling of the cerebral tissue (cerebral oedema)
" Assault, fall or a blow to the head"
 May be closed (without a cut) or open (with a cut)
 Swelling on the head (scalp hematoma)
" Fracture of the skull, e.g., depressed area of the skull, open"
fracture (brain matter may be exposed)
" Racoon eyes (haematoma around the eyes), bleeding and"
"or leaking of CSF through nose, ears  signs of possible"
" Altered level of consciousness, agitation, coma (see GCS"
" Seizures, focal neurological deficits, pupil abnormalities"
" Transient and short lived loss of mental function, e.g., loss"
"of consciousness (5 minutes), transient amnesia, headache, disorientation, dizziness, drowsiness, vomiting"
- symptoms should improve by 4 hours after the trauma
Severity classification of head injuries
Head injuries are classified based on Glasgow Coma Scale (GCS) score as:
Eye Opening Verbal Response Motor Response
2  Open in 2  2 Extension to painful
response to Incomprehensible sounds stimuli
pain (grunting in children) (decerebrate)
3  Open in 3  Inappropriate words 3  Abnormal flexion to
response to (cries and screams painful stimuli (decortivoice cries inappropriately in cate)
4  Open 4  Disoriented able 4  Flexion withdrawal
spontane- to converse (use words from painful stimuli
ously inappropriately  cries in
NA 5  Oriented able to con- 5  Localize pain
For infants and children use AVPU
Eye Opening Verbal Response Motor Response
(grunting in children) 2 Extension to painful
children) 3  Abnormal flexion to
spontaneously 4  Disoriented able
children) 4  Flexion withdrawal
NA 5  Oriented able to converse (use words appropriately
Mild injuries can still be associated with significant brain damage and
can be divided into low and high risk according to the following criteria:
Low Risk Mild Head Injury High Risk Mild Head Injury
 GCS 15 at 2 hours  GCS 15 at 2 hours
 No focal neurologi-  Deterioration of GCS
of skull fracture  Clinical suspicion of
 No recurrent vomiting  Recurrent vomiting
 No risk factors (age  Known bleeding disor-
"disorders, danger-  Age 65 years"
minutes) and post  LOC 5 minutes
traumatic amnesia  Persistent amnesia
¾ Skull X ray useful only to detect fracture
¾ CT scan is the gold standard for detection of head injury
 Alcoholic coma - may occur together with a head injury
Low Risk Mild Head Injury High Risk Mild Head Injury
"disorders, dangerous mechanism)"
(30 minutes)  GCS 15 at 2 hours
Management (general principles)
 GCS and clinical features at first assessment
" Risk factors (mechanism of trauma, age, baseline conditions)"
 GCS and clinical features at follow up
 Assess mechanism of injury to assess risks of severe injury HC3
(which may not be apparent at the beginning)
 Assess medical history to assess risk of complication
"(e.g., elderly, anticoagulant treatment etc.)"
 Assess level of consciousness using GCS or AVPU
" Perform general (including ears) and neurological examination (pupils, motor and sensory examination, reflexes)"
- Assess other possible trauma especially if road
"traffic accident, e.g., abdominal or chest trauma"
 DO NOT SEDATE. Do NOT give opioids
 Do NOT give NSAIDs (risk of bleeding)
Low Risk Mild Head Injury High Risk Mild Head Injury
 No persistent head-  Large scalp haemaache toma
" Isolated head injury (fall from height, car"
information  Unclear information
 Assess mechanism of injury to assess risks of severe injury
(which may not be apparent at the beginning)
 Assess medical history to assess risk of complication
"(e.g., elderly, anticoagulant treatment etc.)"
 Assess level of consciousness using GCS or AVPU
" Perform general (including ears) and neurological examination (pupils, motor and sensory examination, reflexes)"
- Assess other possible trauma especially if road
"traffic accident, e.g., abdominal or chest trauma"
 DO NOT SEDATE. Do NOT give opioids
 Do NOT give NSAIDs (risk of bleeding) HC3
Low Risk Mild Head Injury High Risk Mild Head Injury
information  Large scalp haematoma
" Monitor GCS, pupils and neurological signs"
" Early CT if available, otherwise observe and refer immediately if not improving in the following hours"
Management of severe traumatic head injury
" Early CT if available, otherwise observe and refer im- NR"
mediately if not improving in the following hours Refer
immediately for specialist management f Supportive care
"as per moderate head injury f If open head injury, give"
first dose of antibiotic prereferral
- Ceftriaxone 2 g Child: 100 mgkg
 Careful (defensive) driving to avoid accidents
 Use of safety belts by motorists
" Wearing of helmets by cyclists, motor-cyclists and people"
working in hazardous environments
" Avoid dangerous activities (e.g., climbing trees)"
Early recognition of spinal injury.
Immobilizations with a rigid cervical collar or thoracolumbar corset to
"Non operative Skull traction, Skin traction of lower limbs"
"Operative e.g., discectomy, anterior or posterior spinal decompression"
" Monitor GCS, pupils and neurological signs H"
" Early CT if available, otherwise observe and refer immediately if not improving in the following hours "
" Early CT if available, otherwise observe and refer immediately if not improving in the following hours Refer"
immediately for specialist management f Supportive care
"as per moderate head injury f If open head injury, give"
first dose of antibiotic prereferral
- Ceftriaxone 2 g Child: 100 mgkg NR
Sexual AssaultRape ICD10 CODE Z04.4
"Rape is typically defined as oral, anal or vaginal penetration that involves"
threats or force against an unwilling person.
"Such penetration, whether wanted or not, is considered statutory rape"
if victims are younger than the age of consent (18 years).
Sexual assault or any other sexual contact that results from coercion is
"rape, including seduction of a child through offers of affection or bribes;"
"it also includes being touched, grabbed, kissed or shown genitals."
Rape may result in the following:
Management of mild traumatic head injury
 Mild analgesia if necessary e.g. paracetamol
" Observe for at least 4-6 hours, monitor GCS and neurological symptoms"
 Advise home observation and return to the facility in case
 Refer immediately if GCS worsens or other clinical signs
" If patient is fine at the end of observation period, send"
home with instructions to come back in case of any problem
"(severe headache, seizures, alteration of consciousness,"
"lethargy, change in behaviour etc.)"
 Mild analgesia if necessary e.g. paracetamol
" Observe for at least 4-6 hours, monitor GCS and neurological symptoms"
 Advise home observation and return to the facility in case
 Refer immediately if GCS worsens or other clinical signs
" If patient is fine at the end of observation period, send"
home with instructions to come back in case of any problem
"(severe headache, seizures, alteration of consciousness,"
"lethargy, change in behaviour etc.) HC3"
" Genital injury (usually minor, but some vaginal lacerations"
 Psychologic symptoms: often the most prominent
"- Short term: fear, nightmares, sleep problems, anger,"
"- Long term: Post traumatic Stress Disorder, an anxiety"
"- disorder; symptoms include re-experiencing (e.g., flashbacks,"
"intrusive upsetting thoughts or images), avoidance (e.g.,"
"of trauma-related situations, thoughts, and feelings) and"
"hyperarousal (e.g., sleep difficulties, irritability, concentration"
- Symptoms last for 1 month and significantly impair social
"- Shame, guilt or a combination of both"
"- Sexually transmitted infections (STIs, e.g., hepatitis, syphilis,"
"gonorrhea, chlamydial infection, trichomoniasis, Hinfection)"
 Headaches and dizziness following mild traumatic brain injury
Management of moderate traumatic head injury
 Refer to hospital for appropriate management H
 Careful positioning (head 300 up)
 Keep oxygen saturation 90 and systolic BP
 Refer to hospital for appropriate management
 Careful positioning (head 300 up)
 Keep oxygen saturation 90 and systolic BP H
"Whenever possible, assessment of a rape case should be done by a specially"
trained provider. Victims are traumatized so should be approached with
empathy and respect. Explain and ask consent for every step undertaken.
 Medical assessment and treatment of injuries
" Assessment, treatment and prevention of pregnancy and"
Collection of forensic evidence
 Psychologic evaluation and support
" Advise not to throw out or change clothing, wash, shower, HC2"
"douche, brush their teeth or use mouthwash; doing so"
 Initial assessment (history and examination)  use standard HC4
- Type of injuries sustained (particularly to the
"- mouth, breasts, vagina and rectum)"
- Any bleeding from or abrasions on the patient or
assailant (to help assess the risk of transmission of
"- Description of the attack (e.g., the orifices which"
"- were penetrated, whether ejaculation occurred, or"
" Advise not to throw out or change clothing, wash, shower,"
"douche, brush their teeth or use mouthwash; doing so"
 Initial assessment (history and examination)  use standard
- Type of injuries sustained (particularly to the
"- mouth, breasts, vagina and rectum)"
- Any bleeding from or abrasions on the patient or
assailant (to help assess the risk of transmission of
"- Description of the attack (e.g., the orifices which"
"- were penetrated, whether ejaculation occurred, or"
"- Assailants use of aggression, threats, weapons HC4"
"- Use of contraceptives (to assess risk of pregnancy),"
previous coitus (to assess validity of sperm testing)
"- Clearly describe size, extent, nature of any injury."
- If possible take photos of the lesions (with patients
" Test for HIV, RPR, hepatitis B and pregnancy, to assess HC4"
- If possible test for flunitrazepam and gamma
 Collect forensic evidence (with standard kits if available)
"- Condition of clothing (e.g., damaged, stained,"
- Small samples of clothing including an unstained
"sample, given to the police or laboratory"
"- Hair samples, including loose hairs adhering to"
"- the patient or clothing, semen-encrusted pubic"
"hair, and clipped scalp and pubic hairs of the"
patient (at least 10 of each for comparison)
"- Semen taken from the cervix, vagina, rectum,"
- Dried samples of the assailants blood taken from
- Fingernail clippings and scrapings
- Other specimen as indicated by the history or
"- Assailants use of aggression, threats, weapons"
"- Use of contraceptives (to assess risk of pregnancy),"
previous coitus (to assess validity of sperm testing)
"- Clearly describe size, extent, nature of any injury."
- If possible take photos of the lesions (with patients
" Test for HIV, RPR, hepatitis B and pregnancy, to assess"
- If possible test for flunitrazepam and gamma
hydroxybutyrate (rape drugs) HC4
 Collect forensic evidence (with standard kits if available)
"- Condition of clothing (e.g., damaged, stained,"
- Small samples of clothing including an unstained
"sample, given to the police or laboratory"
"- Hair samples, including loose hairs adhering to"
"- the patient or clothing, semen-encrusted pubic"
"hair, and clipped scalp and pubic hairs of the"
patient (at least 10 of each for comparison)
"- Semen taken from the cervix, vagina, rectum,"
- Dried samples of the assailants blood taken from
- Fingernail clippings and scrapings
- Other specimen as indicated by the history or
 Prophylaxis for STD including: HC4
- Ceftriaxone 1g IM or cefixime 400 mg orally stat
- Azithromycin 1 g stat or doxycycline 100 mg
- HIV Post Exposure Prophylaxis if within 72 hours:
 Hepatitis B vaccine if not already immunised
 Emergency contraception if within 72 hours (but may
- Levonorgestrel mg (double the dose if patient
" Counselling: use common sense measures (e.g., reassurance, general support, non-judgmental attitude) to"
relieve strong emotions of guilt or anxiety
- Long-term psycho-social support
"- Police investigations, restraining orders"
"- Economic empowerment, emergency shelters"
 Because the full psychologic effects cannot always be
"ascertained at the first examination, follow-up visits"
should be scheduled at 2 weeks intervals
 Reporting: Health facilities should use HMIS 105 to
report Gender-Based Violence (GBV)
- Ceftriaxone 1g IM or cefixime 400 mg orally stat
- Azithromycin 1 g stat or doxycycline 100 mg
- HIV Post Exposure Prophylaxis if within 72 hours:
 Hepatitis B vaccine if not already immunised
 Emergency contraception if within 72 hours (but may
- Levonorgestrel mg (double the dose if patient
" Counselling: use common sense measures (e.g., reassurance, general support, non-judgmental attitude) to"
relieve strong emotions of guilt or anxiety
- Long-term psycho-social support
"- Police investigations, restraining orders"
"- Economic empowerment, emergency shelters"
 Because the full psychologic effects cannot always be
"ascertained at the first examination, follow-up visits"
should be scheduled at 2 weeks intervals
 Reporting: Health facilities should use HMIS 105 to
report Gender-Based Violence (GBV) 
Harm classification for police reporting
" Harm: any body hurt, disease or disorders,"
 Grievous harm: any harm which amounts to a
"main or dangerous harm, or seriously or permanently injures health, or causes permanent"
disfigurement or any permanent injeury to any
"internal or external organ, membrane or sense"
 Dangerous harm: means harm endangering life
 Main means the destruction or permanent disabling of any external membrane or sense
General Management of Poisoning ICD10 CODE: T36-T50
Bodily entry of toxic substances in amounts that cause dysfunction of
 Microorganisms (food poisoning)
" Fluids and gases (organic), e.g., agricultural chemicals, petrol, paraffin, carbon monoxide"
" Metal poisoning (inorganic), e.g., lead, mercury, copper"
" Alcohol, drugs of abuse, medicines (in excessive amounts)"
"Acute poisoning can occur by ingestion, inhalation, injection or cutaneousmucosal absorption."
"Exposure can be intentional (e.g., suicide or homicide attempt), unintentional (e.g., medication error) or environmental occupational."
Harm classification for police reporting
" Harm: any body hurt, disease or disorders,"
 Grievous harm: any harm which amounts to a
"main or dangerous harm, or seriously or permanently injures health, or causes permanent"
disfigurement or any permanent injeury to any
"internal or external organ, membrane or sense"
 Dangerous harm: means harm endangering life
 Main means the destruction or permanent disabling of any external membrane or sense 
Principles of general management
" If possible, refer patients showing signs of poisoning to hospital"
for admission. Send a note of what is known about the poison and
 Also referadmit patients who have taken slow-acting poisons even
"if they appear well. These include: acetylsalicylic acid, iron, paracetamol, tricyclic antidepressants (e.g., amitriptyline, imipramine),"
"paraquat, modified-release products"
 Optimal management of the poisoned patient depends upon the
"specific poison(s) involved, the presenting and predicted severity of"
illness and time that has elapsed between exposure and presentation
" Treatment includes supportive care, decontamination, antidotal"
therapy and enhanced elimination techniques
 It may not always be possible to identify the poison and the amount
 Only a few poisons have specific antidotes
 Few patients need active removal of the poison
 Most patients must be treated symptomatically
"However, knowledge of the poison will help you anticipate the likely"
Supportive Treatment in Poisoning
 Ensure safety of the patient and minimizestop exposure HC2
"e.g., wash offclean skin with water and soap"
" Monitor and stabilize all vitals (blood pressure, heart rate,"
"respiratory rate, oxygen saturation AND temperature)"
 Ensure safety of the patient and minimizestop exposure
"e.g., wash offclean skin with water and soap"
" Monitor and stabilize all vitals (blood pressure, heart rate,"
"respiratory rate, oxygen saturation AND temperature) HC2"
Airway and breathing (often impaired in unconscious HC2
 Ensure the airway is cleared and maintained
 Insert an airway cannula if necessary
 Position patient semiprone to minimise risk of inhalation
 Assist ventilation if necessary
- Hypotension is common in severe poisoning with
CNS depressants. A systolic BP 70 mmHg may
cause irreversible brain or renal damage
 Carry the patients head down on the stretcher and
nurse in this position in the ambulance
 Set up an IV normal saline line HC3
- Fluid depletion without hypotension is common
after prolonged coma and after aspirin poisoning
"due to vomiting, sweating and hyperpnoea"
 Hypertension is less common but may be associated
"with sympathomimetic poisoning e.g. amphetamines,"
- Cardiac conduction defects and arrhythmias may
occur in acute poisoning especially with tricyclic
"antidepressants, but the defects usually respond"
to correction of any hypoxia or acidosis
Airway and breathing (often impaired in unconscious
 Ensure the airway is cleared and maintained
 Insert an airway cannula if necessary
 Position patient semiprone to minimise risk of inhalation
 Assist ventilation if necessary
 Administer oxygen if necessary HC2
- Hypotension is common in severe poisoning with
CNS depressants. A systolic BP 70 mmHg may
cause irreversible brain or renal damage
 Carry the patients head down on the stretcher and
nurse in this position in the ambulance HC2
 Set up an IV normal saline line
- Fluid depletion without hypotension is common
after prolonged coma and after aspirin poisoning
"due to vomiting, sweating and hyperpnoea"
 Hypertension is less common but may be associated
"with sympathomimetic poisoning e.g. amphetamines,"
- Cardiac conduction defects and arrhythmias may
occur in acute poisoning especially with tricyclic
"antidepressants, but the defects usually respond"
to correction of any hypoxia or acidosis HC4
- Hypothermia may develop in patients with
prolonged unconciousness especially after
"overdose of barbiturates or phenothiazines e.g.,"
"chlorpromazine, trifluoperazine"
- Hypothermia may be missed unless temperature
- Treat by covering the patient with a blanket
- f Hyperthermia may occur with anticholinergics
- Treat by tepid sponging and antipyretics if
 Diazepam 10 mg rectally repeated if necessary Child:
"mgkg per dose (1.5-mg if 1 month, 5 mg if"
"1 month-2 years, 5-10 mg if 2-12 years) Or diazepam"
5- 10 mg slow IV repeated if necessary max 30 mg
Child: 200 micrograms (mg)kg max 10 mg
 Counsel patient and families concerning poisoning
 A psychiatric evaluation is necessary if poisoning was
" If environmental or ccupational exposure, follow up"
to assess if other people have been affected and take
1.Removal and Elimination of Ingested Poison
Removal and elimination of poison (decontamination) has to be implemented AFTER stabilization of vital signs.
- Hypothermia may develop in patients with
prolonged unconciousness especially after
"overdose of barbiturates or phenothiazines e.g.,"
"chlorpromazine, trifluoperazine"
- Hypothermia may be missed unless temperature
- Treat by covering the patient with a blanket
- f Hyperthermia may occur with anticholinergics
- Treat by tepid sponging and antipyretics if
 Diazepam 10 mg rectally repeated if necessary Child:
"mgkg per dose (1.5-mg if 1 month, 5 mg if"
"1 month-2 years, 5-10 mg if 2-12 years) Or diazepam"
5- 10 mg slow IV repeated if necessary max 30 mg
Child: 200 micrograms (mg)kg max 10 mg HC2
 Counsel patient and families concerning poisoning
 A psychiatric evaluation is necessary if poisoning was
" If environmental or ccupational exposure, follow up"
to assess if other people have been affected and take
 Balance the dangers of attempting to empty the stomach
against the likely toxicity of any swallowed poison as determined by the type of poison and amount swallowed against
 Only useful if done within 2 hours of poisoning (except with salicylates
or anticholinergics when it may be of use within 4 to 6 hours)
 Seldom practicable or necessary before the patient reaches hospital
 Contraindications: drowsy or comatose patients and if poisoning with
corrosive or petroleum products
Prevention of absorption and active elimination
 Oral activated charcoal can bind many poisons in the stomach and reduce their absorption
 It is more effective the sooner it is given but may still work
up to 2 hours after poisoning (longer with modified-release
- Ingestion of corrosives and petroleum products
"- Toxins poorly absorbed by charcoal (e.g. metals like iron,"
 It is generally safe and especially useful for poisons toxicn ismall
 Dose: activated charcoal powder 50 g
- Grind tablets into a fine powder before mixing
with 100-200 ml of water (50 g  200 tablets of
- If patient unable to swallow the charcoalwater
"- mixture (slurry), give by gastric lavage tube"
 Repeated doses of activated charcoal may be beneficial
"in some cases, e.g., acetylsalicylic acid, carbamazepine, phenobarbital, phenytoin, quinine, theophylline"
- Give activated charcoal 50 g repeated every
 Treat any vomiting as this may reduce the effectiveness
" Reduce dose and increase frequency, e.g., 25 g every"
Acute Organophosphate Poisoning ICD10 CODE: T60.0
Organophosphates are ingredients of some pesticides and insecticides
"intended for agricultural and household use. Poisoningo ccursb yi ngestion,"
inhalation or absorption through the skin.
" May be accidental, e.g., contamination of food"
" Intended poisoning, i.e., suicidal or homicidal"
 Dose: activated charcoal powder 50 g
- Grind tablets into a fine powder before mixing
with 100-200 ml of water (50 g  200 tablets of
- If patient unable to swallow the charcoalwater
"- mixture (slurry), give by gastric lavage tube"
 Repeated doses of activated charcoal may be beneficial
"in some cases, e.g., acetylsalicylic acid, carbamazepine, phenobarbital, phenytoin, quinine, theophylline"
- Give activated charcoal 50 g repeated every
 Treat any vomiting as this may reduce the effectiveness
" Reduce dose and increase frequency, e.g., 25 g every"
" Occupational hazard, e.g., agricultural workers"
 Patient may smell of the chemicals
" Cold sweat, anxiety, restlessness"
" Abdominal pain, diarrhoea and vomiting"
" Excessive salivation, difficulty in breathing, abundant respiratory secretions"
" Headache, hypotension, urine incontinence"
 Remove contaminated clothing (use gloves) HC4
 Wash contaminated skin with lots of water
 Establish and maintain the airway
 Assisted respiration with air or oxygen may be required
during the first 24 hours after poisoning
" Give IV fluids, e.g., normal saline prn for dehydration,"
 Prevent and treat convulsions with diazepam 10 mg Child: mgkg IV or mgkg rectal
 Salbutamol 5 mg (mg for children 5 years) nebulisation if bronchospasm:
 Remove contaminated clothing (use gloves)
 Wash contaminated skin with lots of water
 Establish and maintain the airway
 Assisted respiration with air or oxygen may be required
during the first 24 hours after poisoning
" Give IV fluids, e.g., normal saline prn for dehydration,"
 Prevent and treat convulsions with diazepam 10 mg Child: mgkg IV or mgkg rectal
 Salbutamol 5 mg (mg for children 5 years) nebulisation if bronchospasm: HC4
 Perform gastric lavage if the poison was ingested (up to
6 hours after ingestion) but consider risk of aspiration
 Give standard dose of activated charcoal if patient presents
 Monitor patient for a few days (worsening can occur a
In moderate to severe poisoning (only if not responding to
 Add pralidoxime mesylate 30 mgkg IV over 30 minutes
Child: 25-50 mgkg - Continue with infusion 8 mgkghour
 Pralidoxime: Only effective if given within 24 hours of
 Label agricultural and domestic pesticides properly  do
not use unlabelled bottles for pesticides
 Store such products away from children
 Wear protective clothing when using the products
Paraffin and Other Petroleum Products Poisoning ICD10
"Includes paraffin, petrol, paint thinners, organic solvents, and turpentine."
 Patient may smell of paraffinother petroleum product
 Burning sensation in mouth and throat
 Patient looks pale (transient cyanosis)
 Perform gastric lavage if the poison was ingested (up to
6 hours after ingestion) but consider risk of aspiration
 Give standard dose of activated charcoal if patient presents
 Monitor patient for a few days (worsening can occur a
In moderate to severe poisoning (only if not responding to
 Add pralidoxime mesylate 30 mgkg IV over 30 minutes
Child: 25-50 mgkg - Continue with infusion 8 mgkghour
" Vomiting, diarrhoea, bloody stools"
" Cough, dyspnoea, wheezing, tachypnoea, nasal flaring (due"
" Lethargy, convulsions, difficulty in breathing"
The main risk is damage to lung tissue due to aspiration. AVOID
gastric lavage or use of emetics as this may lead to inhalation of
gastric content and pneumonitis
Treatment is supportive and symptomatic HC4
 Remove clothes and wash skin if contaminated
 Avoid gastric lavage or use of an emetic
 Give oxygen if patient has hypoxia
 Atropine 2-4 mg IM or IV (according to the severity of
- Double dose every 3-5 minutes until signs of
atropinisation occur (stopping of bronchial
secretions and broncoconstrictions)
- Continuous infusion of atropine mgkg
- Reduce dose of atropine slowly over 24 hours but
Treatment is supportive and symptomatic
 Remove clothes and wash skin if contaminated
 Avoid gastric lavage or use of an emetic
 Give oxygen if patient has hypoxia HC4
 Atropine 2-4 mg IM or IV (according to the severity of
- Double dose every 3-5 minutes until signs of
atropinisation occur (stopping of bronchial
secretions and broncoconstrictions)
- Continuous infusion of atropine mgkg
- Reduce dose of atropine slowly over 24 hours but
 Store paraffin and other petroleum products safely (e.g. in
"a locked cupboard, out of reach of children)"
 Do not store paraffin and other petroleum products in common beverage bottles.
Acetylsalicylic Acid (Aspirin) Poisoning
"Overdose of ASA, due to consumption of 10 g of ASA in adults and"
" Mild to moderate toxicity (after 1-2 hours): hyperventilation, tinnitus, deafness, nausea, vomiting, dizziness, vasodilation"
" Severe toxicity: hyperpyrexia, convulsions, altered mental"
"status, non cardiac pulmonary oedema, coma"
 Complex acid-base disturbances (acidosis)
 Oxygen and IV fluids as necessary
 Gastric lavage: worthwhile up to 4 hours after poisoning
 Activated charcoal 50 g repeated as needed every 4 hours
or 25 g repeated prn every 2 hours
- It delays absorption of any remaining salicylate
 Treatprevent hypoglycaemia with Dextrose 50
50-100 ml (Dextrose 10 2-5 mlkg in children)
 Oxygen and IV fluids as necessary
 Gastric lavage: worthwhile up to 4 hours after poisoning
 Activated charcoal 50 g repeated as needed every 4 hours
or 25 g repeated prn every 2 hours
- It delays absorption of any remaining salicylate
 Treatprevent hypoglycaemia with Dextrose 50
50-100 ml (Dextrose 10 2-5 mlkg in children) H
 Tepid sponging for hyperpyrexia
 Treat convulsions with IV diazepam 10 mg prn
"Refer to higher level of care if coma, pulmonary oedema,"
"renal insufficiency, clinical deterioration in spite of above"
 Treat acidosis and enhance renal excretion in symptomatic
patients with Sodium bicarbonate
- Bolus 1-2 mEqkg (max 100 mEq) in 3-5 minutes RR
- Followed by an infusion of 50-75 mEq in 500 ml
of Dextrose 5; run at 250 mlhour in adults
(run at 1.5-2 times maintenance in children)
Paracetamol Poisoning ICD10 CODE: T39.1
Accidental or intentional assumption of excessive amount of paracetamol.
Toxic dose: 150 mgkg or g (200 mgkg for children 6 years)
 First 24 hours: asymptomatic or aspecific symptoms such
"as nausea and vomiting, malaise, anorexia, abdominal pain"
" In patients with mild poisoning, symptoms will resolve"
"and patient will recover. In patients with severe poisoning,"
symptoms will progress to the next phase
 In 24-72 hours: progressive signs of hepatic toxicity (e.g.
"right upper quadrant abdominal pain, enlarged tender liver,"
 After 72 hours: signs and symptoms peak at 72-96 hours
and this may be followed by full recovery in 5-7 days or progression into irreversible hepatic failure (less frequently renal failure)
 Tepid sponging for hyperpyrexia
 Treat convulsions with IV diazepam 10 mg prn
"Refer to higher level of care if coma, pulmonary oedema,"
"renal insufficiency, clinical deterioration in spite of above"
 Treat acidosis and enhance renal excretion in symptomatic
patients with Sodium bicarbonate
- Bolus 1-2 mEqkg (max 100 mEq) in 3-5 minutes
- Followed by an infusion of 50-75 mEq in 500 ml
of Dextrose 5; run at 250 mlhour in adults
(run at 1.5-2 times maintenance in children)
" Monitor liver function, renal funtion, INR"
 Rule out pregnancy (it crosses the placental barrier)
 Give repeated doses of activated charcoal (25-50 g HC2
" If ingestion was 2 hours, empty the stomach to remove"
any remaining medicine using gastric lavage
 Give acetylcysteine IV preferrably within8 hours from
"ingestion; if patient presents later, give it anyway"
H - 150 mgkg (max 15 g) in 200 ml of Dextrose 5 in
- 50 mgkg (max 5 g) in Dextrose 5 500 ml in 4 hours
- 100 mgkg (max 10 g) in Dextrose 5 1000 ml in
" Acetylcysteine may cause histamine release, mimicking an"
"allergic reaction. If patient is stable, slow the infusion. If"
"bronchospasm, stop the infusion"
Iron Poisoning ICD10 CODE: T45.4
"Common in children, due to the candy-like aspect of iron tablets. Ingestion"
of a quantity 40 mgkg of elemental iron is unlikely to cause problems.
Doses 60 mgkg can cause serious toxicity.
Note: the common tablet of 200 mg of an iron salt contains 60-65 mg
 Give repeated doses of activated charcoal (25-50 g
" If ingestion was 2 hours, empty the stomach to remove"
any remaining medicine using gastric lavage
 Give acetylcysteine IV preferrably within8 hours from
"ingestion; if patient presents later, give it anyway"
- 150 mgkg (max 15 g) in 200 ml of Dextrose 5 in
- 50 mgkg (max 5 g) in Dextrose 5 500 ml in 4 hours
- 100 mgkg (max 10 g) in Dextrose 5 1000 ml in
" Acetylcysteine may cause histamine release, mimicking an"
"allergic reaction. If patient is stable, slow the infusion. If"
"bronchospasm, stop the infusion "
 Clinical symptoms vary according to the time from ingestion
Phase 1 Initial symptoms (by corrosive action of iron in GIT):
"(30 minutes nausea, vomiting (may be blood stained), abdominal"
"to 6 hours) pain, shock, metabolic acidosis"
Phase 2 Symptoms improve or disappear
"Phase 3 Severe shock, vascular collapse, metabolic"
"(12-48 hours) acidosis, hypoglycaemia, convulsions, coma"
"Phase 4 Liver and renal failure, pulmonary oedema"
Phase 5 Gastrointestinal scarring and obstruction
 IV fluids to manage shock and hypovolaemia
Indication for use of antidote:
 Desferroxamine continuous infusion 15 mgkg hour in NR
- Do not use for more than 24 hours
- Increase IV fluids if BP drops
- Continue until metabolic acidosis clears or clinical
- Contraindication: renal failureanuria
Carbon Monoxide Poisoning ICD10 CODE: T58
"Usually due to inhalation in confined spaces of smoke, car exhaust or"
fumesc ausedb yi ncompletec ombustiono ff uel gases e.g. use of charcoal
to 6 hours) Initial symptoms (by corrosive action of iron in GIT):
"nausea, vomiting (may be blood stained), abdominal"
"pain, shock, metabolic acidosis"
(612 hours) Symptoms improve or disappear
"(12-48 hours) Severe shock, vascular collapse, metabolic"
"acidosis, hypoglycaemia, convulsions, coma"
"(2-4 days) Liver and renal failure, pulmonary oedema"
(4 days) Gastrointestinal scarring and obstruction
 IV fluids to manage shock and hypovolaemia
Indication for use of antidote:
 Desferroxamine continuous infusion 15 mgkg hour in
- Do not use for more than 24 hours
- Increase IV fluids if BP drops
- Continue until metabolic acidosis clears or clinical
- Contraindication: renal failureanuria NR
" Carbon monoxide, a colourless and odourless non- irritating gas"
" Headache, nausea, vomiting, dizziness, confusion, weakness"
" Collapse, seizures, coma, death"
 Give oxygen 100 (use non-rebreather masks) as soon
Barbiturate Poisoning ICD10 CODE: T42.3
Barbiturates are used in the treatment of epilepsy and convulsions (e.g.
" Confusion, irritability, combativeness"
" Hypotension, bradycardia or tachycardia, until shock"
" Respiratory depression, until coma"
 Give oxygen 100 (use non-rebreather masks) as soon
 Charcoal may be useful but only if given within 1 hour
from ingestion and if the patient is not drowsy (risk of
 Refer for ventilatory support if necessary
 Alkalinisation to increase renal excretion RR
- Sodium bicarbonate 1 mEqkg bolus followed by
Opioid Poisoning ICD10 CODE: T40
"Voluntary or accidental overdose of opioid drugs like codeine,"
"morphine, heroin used for therapeutic or recreational purposes."
 Decreased mental status until coma
 Gastric lavage if ingestion within 1 hour from arrival or H
pills visible in the stomach at X-ray
 Patients who are asymptomatic after 6 hours from ingestion most likely do not need specific treatment. Monitor
 IV fluids to manage shock and hypovolaemia
 Charcoal may be useful but only if given within 1 hour
from ingestion and if the patient is not drowsy (risk of
 Refer for ventilatory support if necessary
 Alkalinisation to increase renal excretion
- Sodium bicarbonate 1 mEqkg bolus followed by
 Gastric lavage if ingestion within 1 hour from arrival or
pills visible in the stomach at X-ray
 Patients who are asymptomatic after 6 hours from ingestion most likely do not need specific treatment. Monitor
 IV fluids to manage shock and hypovolaemia H
" Naloxone 0.4-2 mg IV or IM, repeat every 2-3 minutes"
"if not improving until max 10 mg Child: mgkg,"
 Aim at restoring ventilation not consciousness f Repeated
doses or infusion may be necessary f Manage complications accordingly
 Naloxone doses used in acute poisoning may not be suitable for
treating opioid-induced respiratory depression and sedation in
palliative care and in chronic opioid use
Warfarin Poisoning ICD10 CODE: T45.5
Overdose may result from accidental ingestion of rat poison (containing
a warfarin-like substance) or overdose of warfarin used for therapeutic
purposes. Warfarin inhibits the production of coagulation factors in the liver.
 Bleeding (can be life threatening) internal or from mucosae
 Usually evident 24 hours after ingestion
 Give activated charcoal 50 g if presenting early
 Phytomenadione (vitamin K1) 5 mg IV slowly RR
" Naloxone 0.4-2 mg IV or IM, repeat every 2-3 minutes"
"if not improving until max 10 mg Child: mgkg,"
 Aim at restoring ventilation not consciousness f Repeated
doses or infusion may be necessary f Manage complications accordingly H
 Naloxone doses used in acute poisoning may not be suitable for
treating opioid-induced respiratory depression and sedation in
palliative care and in chronic opioid use 
 Give activated charcoal 50 g if presenting early
 Phytomenadione (vitamin K1) 5 mg IV slowly HC2
" Supportive treatment (IV fluids, bloodtransfusion, fresh HC2"
frozen plasma if active bleeding)
 Intoxication with rat poison may require prolonged treatment
Methyl Alcohol (Methanol) Poisoning
Methanol is used as an industrial solvent and is an ingredient of methylated
spirits. It is often ingested for self-harm or as a substitute for alcohol. It
can form in home-distilled crude alcohol due to incomplete conversion
to ethanol. A dose 1 gkg is potentially lethal: it is transformed into
toxic metabolites and causes profound acidosis.
 Initial inebriation (as in alcohol assumption)
 Latent asymptomatic period of 12-24 hours
" Headache, dizziness, nausea, vomiting, visual disturbances,"
CNS depression and respiratory failure
 Toxic metabolites may cause severe acidosis and retinal
 Gastric aspiration and lavage H
- Only use if done within 2 hours of ingestion (it has
" Supportive treatment (IV fluids, bloodtransfusion, fresh"
frozen plasma if active bleeding) HC2
- Only use if done within 2 hours of ingestion (it has
" Give 1.5-2 mlkg of oral alcohol 40 (e.g. waragi, H"
"whisky, brandy) in 180 ml of water as loading dose,"
 Sodium bicarbonate 50-100 ml IV over 30-45 minutes
 Check for and correct hypoglycaemia
Alcohol (Ethanol) Poisoning ICD10 CODE: T51
Alcohol poisoning may be acute or chronic.
Symptoms of alcoholic poisoning following ingestion of a large amount
of alcohol over a short period.
 Deliberate consumption of excessive alcohol in a short period of time
 Accidental ingestion (may occur in children)
" Slurred speech, uninhibited behaviour,"
 Altered cognition and perception
" Excessive sweating, dilated pupils"
" In later stages, stupor and coma develop"
" Give 1.5-2 mlkg of oral alcohol 40 (e.g. waragi,"
"whisky, brandy) in 180 ml of water as loading dose,"
 Sodium bicarbonate 50-100 ml IV over 30-45 minutes
 Check for and correct hypoglycaemia H
As coma deepens the following appear:
 Malaria and other intracranial infections
 Stroke (cerebrovascular accidents)
Low blood sugar (hypoglycaemia) due to other causes
" Poisoning by other medicines e.g., narcotics"
" Blood: alcohol content, glucose level"
 Manage airways (ventilation may be needed) H
 Correct hypothermia and hypovolaemia if present f Check
and correct hypoglycaemia with Dextrose 50 20-50 ml - Give it via NGT or rectal if IV not available
- Maintain infusion of Dextrose 5-10 until patient
 Thiamine IV 100 mg in 1 L of Dextrose 5 H
 Manage airways (ventilation may be needed)
 Correct hypothermia and hypovolaemia if present f Check
and correct hypoglycaemia with Dextrose 50 20-50 ml - Give it via NGT or rectal if IV not available
- Maintain infusion of Dextrose 5-10 until patient
 Thiamine IV 100 mg in 1 L of Dextrose 5 H
 Heavy habitual drinking combined with poor nutrition
" Brittle discolored hair, pale mucous membranes"
" Memory loss, hallucinations, tremors"
 Fluid in the abdomen (ascites) as a result of cirrhosis
" Mild: 12-48 hours after the last drink, with anxiety, agitation, insomnia, tremors, palpitation, sweating. If not progressing it may resolve over 24-48 hours"
" Severe: seizures, hallucinations (from 12 to 48 hours after"
" Very severe: delirium tremens characterized by hallucinations, disorientation, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis In the absence of complications, symptoms of delirium tremens typically persist for up"
 Due to thiamine deficiency. Common in chronic alcohol
" Characterized by acute mental confusion, ataxia (unstable"
gait) and nystagmusophthalmoplegia (abnormal eye movements)
" Supportive care (IV fluids, nutrition)"
 Check and correct hypoglycaemia with Dextrose 50
20-50 ml - Give it via NGT or rectal if IV not available
- Maintain infusion of Dextrose until patient wakes up
 Diazepam 5-10 mg every 10 minutes until appropriate
- Very high doses may be required
" If not responsing, consider phenobarbital 100- 200 mg HC4"
slow IV but it has a risk of respiratory depression and
 Thiamine IV 100 mg in 1 L of Dextrose 5
" If delirium or hallucinations persist in spite of treatment,"
consider haloperidol 2.5-5 mg up to 3 times a day
 Thiamine 100 mg IV or IM every 8 hours for 3-5 days
 See section for general management of alcohol use
Illness caused by consumption of food or water contaminated by certain
pathogenic microorganisms. It usually affects large numbers of people
"after ingestion of communal food in homes, hospitals, hotels and parties."
" Supportive care (IV fluids, nutrition)"
 Check and correct hypoglycaemia with Dextrose 50
20-50 ml - Give it via NGT or rectal if IV not available
- Maintain infusion of Dextrose until patient wakes up
 Diazepam 5-10 mg every 10 minutes until appropriate
- Very high doses may be required
" If not responsing, consider phenobarbital 100- 200 mg"
slow IV but it has a risk of respiratory depression and
 Thiamine IV 100 mg in 1 L of Dextrose 5
" If delirium or hallucinations persist in spite of treatment,"
consider haloperidol 2.5-5 mg up to 3 times a day
 Thiamine 100 mg IV or IM every 8 hours for 3-5 days HC4
" Infective: by bacteria e.g. Salmonella typhimurium, Campylobacter jejuni, Bacillus cereus"
 Toxic: by toxins from Staphylococcus aureus and Clostridium botulinum
 Intermittent abdominal pain (colic) with associated diarrhoea
 Fever (especially if poisoning is the infective type)
" Paralysis of skeletal, ocular, pharyngeal and respiratory"
 Other causes of stomach and intestinal infections
 Good history and examination is important for diagnosis
 Establish the cause and treat accordingly HC2
 Give oral (ORS) or IV fluids (Normal saline) for rehydration as required
" For pain, give paracetamol 1 g every 4-6 hours"
"If diarrhoea severe and persisting or bloody, high fever"
" Give an antibiotic for 3-7 days, depending on response:"
- Ciprofloxacin 500 mg every 12 hours
- Or erythromycin 500 mg every 6 hours
 Establish the cause and treat accordingly
 Give oral (ORS) or IV fluids (Normal saline) for rehydration as required
" For pain, give paracetamol 1 g every 4-6 hours"
"If diarrhoea severe and persisting or bloody, high fever"
" Give an antibiotic for 3-7 days, depending on response:"
- Ciprofloxacin 500 mg every 12 hours
- Or erythromycin 500 mg every 6 hours
 Heat cooked foods thoroughly before eating and avoid eating cold left-over cooked foods
 Ensure adequate personal and domestic hygiene
HYPOXEAMIA MANAGEMENT AND OXYGEN THERAPY GUIDELINES
Hypoxaemia is the low concentration of Oxygen in blood or oxygen
saturation (SpO2) less than 90 in peripheral arterial blood detected
on pulse oximeter reading. Hypoxaemia is a life-threatening condition
correlated with disease severity and an emergency stat. Left untreated
"and for prolonged periods of time, it results into low tissue oxygen"
"concentration (Hypoxia), and this leads to death."
"- Severe Asthma, Pneumonia, Sepsis, Shock, Malaria,"
"Covid-19, Heart Failure, Cardiac arrest, Upper airway"
"obstruction, Severe anaemia, Pertussis, Carbon Monoxide"
" Obstetric, gynaecological, and perioperative causes."
"- Obstructed labour, Ruptured uterus, Pre-eclampsia and"
"eclampsia, Post caesarean section,"
"- Transient tachypnoea of the new-born, Hypoxic Ischaemic"
"encephalopathy (Birth asphyxia), Respiratory distress"
"Syndrome, Neonatal Septicaemia."
 Do a clinical assessment (history taking for symptoms and physical
 Pulse oximetry and blood gas analysis. The findings on clinical
assessment (symptoms and signs) It is non-invasive but associated
with missed opportunities for diagnosis.
" Fastvery slow breathing, Difficulty in breathing,"
" Inability to talk, complete sentences"
Fast breathing rate for age (Tachypnoea)
" Chest in drawing (Intercostal, subcostal recession)"
 Cyanosis (peripheral or central)
 Use of any accessory muscles of respiration
 Pulse oximetry use. Always refer to the manufacturers insert or the steps outlined below for guidance on how to use
 The steps involved in conducting pulse-oximetry
 Attach the Oximeter probe to the finger or toe.
 Wait until there is a consistent pulse -wave signal before you take
"the reading, this may take 20-30 seconds."
 Record the reading and act accordingly.
 Interpreting pulse-oximetry results
 SpO2  90 without danger signs  Normal
 SpO2  90 Low oxygen concentration in blood (Hypoxaemia)
 SpO2 92- 95 in Pregnancy  Low oxygen concentration in
 SpO2  94  with danger signs  Low oxygen concentration in
Blood gas analysis-direct measurement of the partial pressure of oxygen
"(Pao2) and Carbon dioxide (PC02) 2, the PH and electrolytes concentration in blood. It is the most accurate, but it is highly skill dependant,"
The treatment of hypoxaemia includes the use of Medical Oxygen (Oxygen
therapy) and specifically treating the underlying cause.
 All patients with documented Hypoxaemia-arterial Carbondioxide tension (Paco2) of  60 mmHg or peripheral arterial oxygen saturation (SpO2) OF  90.
" Patients with the following dangeremergency signs irrespective of the documented SpO2, PaCO2."
" Absent or obstructed breathing, Features of severe respiratory distress, Central cyanosis, Convulsions, Signs of"
 All acute conditions in which Coma is suspected like:
" Acute Asthma, Severe Trauma, Acute myocardial Infarction, Carbon monoxide poisoning"
" Severe burns, Poisoning, Multiple injuries, Severe infections"
Medical Oxygen dosing and appropriate use of delivery device.
 The dosing of oxygen is dependent on the age of the patient and severity of disease while the choice of appropriate
delivery devices depends on the amount or dose of oxygen
Titrate oxygen based on oxygen saturation and delivery device.
De- Neo- Infants Pre- School Adults Comments
livery nates (1month school age
De- Neo- Infants Pre- School Adults Comments
livery nates (1month school age
Face NA NA NA NA 10- Resermask 15L  voir must
CPAP When When When When NA -Bubble
nasal nasal nasal nasal CPAP with
can- canulae can- can- modified
to SpO2 to raise to raise an oxygen
raise above SpO2 SpO2 concenSpO2 90 above above trator
90 -CPAP decreases atelectasis and
Illnessdisease FiO2 O2 flow rate Delivery devices
1 Mild 25-40 1-5lmin 3L Nasal Cannula
2 Moderate 40-60 6-10l 8L Face Mask
3 Severe 60-90 10-15l 13L Face mask with
-CPAP decreases atelectasis and
categorization FiO2 O2 flow rate Delivery devices
Illnessdisease FiO2 O2 flow rate Delivery devices
4 Critical 100 20-60l 40l High flow nasal
5? 16-20l 18l Mechanical ventimin min lation?
NB: Mild Moderate illness start with 5lmin by nasal cannula
" For older children and adults with severe disease, give 10-15lmin"
via face mask with a reservoir bag.
 Older children and severe disease with mild moderate disease give
6-10lmin via a simple face mask
" Children below 5years of age that require 5lmin of oxygen, the"
preferred delivery device is CPAP.
 Titration and weaning patients off Oxygen
 How to Escalate or increase oxygen in non-Responsive Adult
patients with consistent Spo2 below 90.
Start oxygen therapy at a rate of 1-5litresmin
Worsening respiratory distress with
"Use a simple face mask, give 5-10litresminute"
Worsening respiratory distress with
"Use a mask with a reservoir bag, ensure the bag is well inflated."
Give 10-15litresminute. Assess for response.
Worsening respiratory distress with
Continue to try to find a higher level of care and consider one of the following if
available and adequate O2 supply:
HFNO: 30-60 LPM (may also adjust FiO2) CPAP: 10-15 cmH20
BIPAP: PS (ΔP) 5-15PEEP (EPAP) 5-15
categorization FiO2 O2 flow rate Delivery devices
"Use a mask with a reservoir bag, ensure the bag is well inflated."
Give 10-15litresminute. Assess for response. 
 Worsening respiratory distress with
 The oxygen flowrate dose should be decreased if patient stabilizes
or improves with SpO2 above 90.
 Decrease oxygen flow by 1-2Litremin once patient is stable with
" Observe the patient for 2-3 minutes, reassess after 15 mins to ensure Sp02 is still above 90 (by recording clinical exam and SpO2)"
" If a patient does not tolerate less oxygen, then maintain the flow"
rate that the patient has been on prior to reducing until the patient
 If a patient is in increased respiratory distress or Sp02 less than
"90, then increased the oxygen flow rate to the previous rate until"
 If a patient remains stable after 15 mins of reassessment and Sp02
"92, continue to titrate oxygen down as tolerated."
Recheck clinical status and Sp02 on the patient after 1 hour for
delayed hypoxemia or respiratory distress.
Basic use and Maintenance of Oxygen sources
Anthrax ICD10 CODE: A22.10-A22.9
Anthrax is an acute zoonotic infectious disease caused by the bacterium
"Bacillus anthracis. It most commonly occurs in wild and domestic animals,"
"such as cattle, sheep, goats, camels, antelopes, and other herbivores."
B. anthracis spores can live in the soil for many years.
It occurs in humans when they are exposed to infected animals or tissue from infected animals. The incubation period is usually 1-3 days.
Anthrax is a notifiable disease.
 Exposure to B. anthracis spores by handling products
from infected animals or by inhaling anthrax spores from
 Anthrax can also be spread by eating undercooked meat
"Symptoms vary depending on how the disease was contracted, and"
Cutaneous  95 of anthrax infections occur through
 Starts as raised itchy bump that resembles
" Within 1-2 days, it develops into a vesicle"
"and then a painless ulcer, usually 1-3 cm"
"in diameter, with a characteristic black"
 necrotic (dying) area in the centre (eschar)
 Lymph glands in adjacent area may swell
 About 20 of untreated cutaneous anthrax results in death
Inhalation  Initial symptoms resemble a cold
" After several days, symptoms may progress to severe breathing problems and"
 Inhalation anthrax is usually fatal
Gastro- in-  Acute inflammation of the intestinal tract
" Initial signs of nausea, loss of appetite,"
" Then abdominal pain, vomiting blood,"
 Intestinal anthrax results in death in 25
"¾ Isolation of Bacillus anthracis from blood, skin lesions,"
or respiratory secretions- Smear-many bacilli
¾ Or measure specific antibodies in the blood of persons
Cutaneous  95 of anthrax infections occur through
 Starts as raised itchy bump that resembles
" Within 1-2 days, it develops into a vesicle"
"and then a painless ulcer, usually 1-3 cm"
"in diameter, with a characteristic black"
 necrotic (dying) area in the centre (eschar)
 Lymph glands in adjacent area may swell
 About 20 of untreated cutaneous anthrax results in death
Inhalation  Initial symptoms resemble a cold
" After several days, symptoms may progress to severe breathing problems and"
 Inhalation anthrax is usually fatal
Gastro- intestinal  Acute inflammation of the intestinal tract
" Initial signs of nausea, loss of appetite,"
" Then abdominal pain, vomiting blood,"
 Intestinal anthrax results in death in 25
 First line is ciprofloxacin 500 mg every 12 hours
 Alternatives: doxycycline 100 mg every 12 hours
 Or amoxicillin 1 g every 8 hours
The following public measures are key for quick prevention and control of
 Health education and information
" Proper disposal by burying of carcasses, hides and skins;"
(no burning as it can spread spores)
" No skinning of dead animals; this allows spore formation,"
which can stay in soil for decades
 No eating of meat from dead animals
 Restrict movement of animals and animal by-products from
 Mass vaccination of animals in endemic areas
 Vaccination using human anthrax vaccine for:
- Persons who work directly with the organism in the laboratory
- Persons who handle potentially infected animal products
"(Undulant fever, malta fever, abortus fever)"
A zoonotic bacterial infection of acute onset. Common as an occupational
 First line is ciprofloxacin 500 mg every 12 hours
 Alternatives: doxycycline 100 mg every 12 hours
 Or amoxicillin 1 g every 8 hours HC2
disease among people working with infected livestock or associated fresh
"animal products, for example butchers, farmers, abattoir workers, and"
vendors of contaminated roasted meat (muchomo). Incubation is 2-4
"weeks on average, but it can be from 1 to 8 weeks."
 Brucella melitensis (goats and sheep)
 Intermittent (fluctuating) fever
 Orchitis (inflammation of the testes)
 Vertebrae osteomyelitis (uncommon but characteristic)
" Typhoid fever, malaria, tuberculosis"
 Trypanosomiasis (sleeping sickness)
 Other causes of prolonged fever
¾ Blood: complement fixation test or agglutination
"The interpretation of serological tests can be difficult, particularly in"
endemic areas where a high proportion of the population has antibodies
against brucellosis. Positive serological test results can persist long after
recovery in treated individuals so results have to be interpreted on the basis
"Isolation of the infectious agent from blood, bone marrow, or other"
 Doxycycline 100 mg every 12 hours for 6 weeks
Child  8 years: 2 mgkg per dose
 Plus gentamicin 5-7 mgkg IV daily for 2 weeks
Child  8 years: mgkg daily in 1-3 divided doses
- Or ciprofloxacin 500 mg twice daily for 2 weeks
 Cotrimoxazole 24 mgkg every 12 hours for 6 weeks
 Plus gentamicin 5-7 mgkg IV in single or divided doses
 Treatment duration must be adhered to at all times
 Ciprofloxacin is contraindicated in children 12
" Doxycyline, gentamicin: Contraindicated in"
 Provide public health education on
- Drinking only pasteurised or boiled milk
"- Careful handling of pigs, goats, dogs, and cattle if a person"
- Provide veterinary services for domestic animals
 Doxycycline 100 mg every 12 hours for 6 weeks
Child  8 years: 2 mgkg per dose HC4
 Plus gentamicin 5-7 mgkg IV daily for 2 weeks
Child  8 years: mgkg daily in 1-3 divided doses
- Or ciprofloxacin 500 mg twice daily for 2 weeks
 Cotrimoxazole 24 mgkg every 12 hours for 6 weeks
 Plus gentamicin 5-7 mgkg IV in single or divided doses
 Treatment duration must be adhered to at all times
 Ciprofloxacin is contraindicated in children 12
" Doxycyline, gentamicin: Contraindicated in"
"An acute bacterial infection caused by Corynebacterium diphtheriae,"
which is spread through droplet infection and mainly occurs in the
nasopharynx. The bacteria produce a toxin which is responsible for the
systemic effects. Incubation period is 2-7 days.
 Toxin of Corynebacterium diphtheriae
" Pseudomembranous tonsillitis (grey, tough and very stickly"
"membranes) with dysphagia, cervical adenitis, at times progressing to massive swelling of the neck"
 Airway obstruction and possible suffocation when infection
"extends to the nasal passages, larynx, trachea and bronchi"
 Effects of the toxin: cardiac dysfunction (myocarditis with
"heart failure), neuropathies 1-3 months after the onset affecting swallowing, vision, breathing and ambulation"
 Isolate (contact and droplet precautions) until 3 throat
"swabs (nose, throat, or skin) are negative"
 Give procaine benzylpenicillin MIU daily IM until
 Isolate (contact and droplet precautions) until 3 throat
"swabs (nose, throat, or skin) are negative"
 Give procaine benzylpenicillin MIU daily IM until
"Child: procaine benzylpenicillin 50,000 IUkg per H"
day IM once daily until patient can swallow
When patient is able to swallow
 Give Penicillin V 250 mg every 6 hours per day to
Child 1-6 years: 125 mg 6 hourly
Child 1 years: mgkg every 6 hours
 Erythromycin 500 mg every 6 hours for 14 days
 Isolation of patient and proper management of close contacts
- Monitor close contacts for 7 days and give prophylactic
- antibiotics: single dose benzathine penicillin IM (child
"- 10 years: 600,000 IU, child 10 yrs and adults: MIU)"
"- Verify immunisation status, complete if needed, give a booster"
if the last dose was more than a year before
 Immunise all children during routine childhood immunisation
LeprosyHansens disease ICD10 CODE: A30.0
A chronic infectious disease caused by Mycobacterium lepraeHansens
"bacillus - an acid-fast bacillus. It mainly affects the skin, peripheral nerves"
and mucous membranes. It is transmitted from one person to another
"via the respiratory tract (possibly, very rarely, through broken skin). It is"
classified into paucibacillary (PB) or Multibacillary (MB) Leprosy.
"Child: procaine benzylpenicillin 50,000 IUkg per"
day IM once daily until patient can swallow
When patient is able to swallow
 Give Penicillin V 250 mg every 6 hours per day to
Child 1-6 years: 125 mg 6 hourly
Child 1 years: mgkg every 6 hours
 Erythromycin 500 mg every 6 hours for 14 days
 Pale or reddish patches on the skin (The most common
 Loss or decrease in feeling in the skin patch
 Numbness or tingling of the hands or feet.
" Weakness of the hands, feet or eyelids"
 Swelling or lamps in the face or earlobes
 Painless wounds or burns on the hands or feet
A case of leprosy is a person with clinical signs of leprosy who
Diagnosis of Leprosy must be based on careful clinical examination of
"the patient and when necessary, backed by bacteriological examination"
Leprosy is diagnosed by finding at least one of the three cardinal signs:
- Hypopigmented patches with definite loss of sensation in
"- Thickened or enlarged peripheral nerves, with loss of"
sensation andor weakness of the muscles supplied by those
- The presence of acid-fast bacilli in a slit skin smear
Paucibacillary (PB) leprosy - 1-5 patches
Multibacillary (MB) Leprosy - More than 5 patches
" Hypopigmentation e.g. birthmark, early vitiligo"
" Other nodular conditions, e.g. Kaposis sarcoma, neurofibromatosis, secondary syphilis"
" Other causes of peripheral nerve damage, e.g. diabetes"
" Psoriasis, molluscum contagiosum"
"¾ In most cases, a definite diagnosis of leprosy can be"
made using clinical signs alone
¾ At referral centre: stain slit skin smears for Acid
¾ Skin biopsies NOT recommended as a routine procedure
Multi-drug therapy (MDT) for leprosy is presented in the form of various
monthly dose blister packs. The same three drugs are used for both PB
"leprosy and MB leprosy, with special packs for children"
Summary of Treatment of leprosy
All for 6 months All for 12 months
All for 6 months All for 12 months
Recommended treatment (drugs and their doses)
Drug Dosage and frequency Duration
Adult Rifampicin 600 mg once a month 6 12
Clofazimine 300 mg once a month months months
Children Rifampicin 450 mg once a month 6 12
"(1014 Clofazimine 150 mg once a month,"
Children Rifampicin 10 mgkg once 6 12
years old Clofazimine 6 mgkg once a
Steroids for treatment of severe leprae reactions RR
 Prednisolone 40 mg once daily in morning
- Treat for 12 weeks in PB and 24 weeks in MB
- Reduce dose gradually by 105 mg once every 2
" In patients co-infected with HIV and on cotrimoxazole, do"
 Health worker should directly observe that the medicines
taken once a month are actually swallowed
 Treatment durations longer than 12 months and steroids for
leprae reactions should only be prescribed by specialists at
" Lepra reactions: sudden inflammation (pain, redness, swelling,"
"new lesions, loss of nerve function) in skin lesions or nerves of"
"a person with leprosy. They can occur before, during or after"
 Drug Dosage and frequency Duration 
Adult Rifampicin 600 mg once a month 6
 Clofazimine 300 mg once a month
years) Rifampicin 450 mg once a month 6
" Clofazimine 150 mg once a month,"
Steroids for treatment of severe leprae reactions
 Prednisolone 40 mg once daily in morning
- Treat for 12 weeks in PB and 24 weeks in MB
- Reduce dose gradually by 105 mg once every 2
" In patients co-infected with HIV and on cotrimoxazole, do"
 Health worker should directly observe that the medicines
taken once a month are actually swallowed
 Treatment durations longer than 12 months and steroids for
leprae reactions should only be prescribed by specialists at
" Lepra reactions: sudden inflammation (pain, redness, swelling,"
"new lesions, loss of nerve function) in skin lesions or nerves of"
"a person with leprosy. They can occur before, during or after"
 Severe leprae reaction (Type 2) are also known as Erythema
Nodosum Leprosum (ENL or Type 2 reactions)
 All patients should undergo rehabilitation and physiotherapy
"Counsel patient on: need to complete treatment, presence of"
residual signs after completion of treatment
 Presence of residual signs or post-treatment reactions is NOT
an indication to re-start the treatment
 Refer to the National Tuberculosis and Leprosy Programme
(NTLP) manual 2016 for more details
 Early diagnosis of cases and effective treatment
 Screening of contacts of known patients
 Administration of Single dose rifampicine in contacts of
leprosy patients to prevent contacts of leprosy patients
from developing leprosy disease
 Rifampicine dose used in contacts of leprosy patiients
Ageweight Rifampicin single dose
Children 6-9years (weight 20kg) 300mg
Children 20kg (2years) 10-15mgkg
Leprosy commonly causes physical disabilities which generate social
stigma. Disability refers to an impairment (primary or secondary) that
makes it difficult or impossible for the affected person to carry out certain
"activities, e.g. affecting manual dexterity, personal care, mobility and"
"Grade 0  No anesthesia, no visible deformity or damage"
"Grade 1  Anaesthesia, but no visible deformity or damage"
Ageweight Rifampicin single dose
Children 6-9years (weight 20kg) 300mg
Children 20kg (2years) 10-15mgkg
Grade 2  Visible deformity or damage present
"Grade 0  no eye problem due to leprosy, no evidence of visual loss"
"Grade 1  eye problem due to presence of leprosy, but vision not severy"
"affected as a result (660 or better, can count fingers at six meters)"
Grade 2  severe visual impairment (vision worse than 660; inability to
"count fingers at six meters), lagophthalmos, iridocyclitis, corneal opacities"
Management of Disability in the hand and feet
"Resting of the affected limb in the acute phase can be aided by splinting,"
 Soaking and oiling for about 30 minutes every day of dry
skin helps to prevent cracking and preserves the integrity
 Use of a clean dry cloth to cover the wounds and walking
"as little as possible and walk slowly, taking frequent rest."
Passive exercise and stretching to avoid contractures and
 Use of a rough stone to smoothen the skin on the feet or
" Protective foot wear (MCR Sandals) al, the time. For insensitive feet and protective appliances like gloves for insensitive hands"
Eye complications due to Leprosy
1. Lagophthalmos: whole spectrum
2.Corneal hypoesthesia: withwithout corneal ulcers
4.Chronic iritis and iris atrophy
Treatment  Management of eye complications
Medical therapy for eye complications due to Leprosy- use of the topical antibiotics and topical steroids. It is strongly recommended that an
"ophthalmologist and a trained leprologist, if available, be included in the"
treatment of Hansen disease with ocular manifestations.
"ICD10 CODES: A39.0 (MENINGOCOCCAL), G00, G01, G02"
Meningitis is acute inflammation of the meninges (the membranes covering the brain). Bacterial meningitis is a notifiable disease.
"Most commonly bacterial: Streptococcus pneumoniae, Haemophilus"
"influenzae type b (mainly in young children), Neisseria meningitidis,"
" Viral (HSV, enteroviruses, HIV, VZV etc)"
 Cryptococcus neoformans (in the immune-suppressed)
 Severe headache and neck stiffness or pain
 PhotophobiaHaemorrhagic rash (N.meningitidis infection)
" Convulsions, altered mental state, confusion, coma"
" In mycobacterial and cryptococcal meningitis, the clinical"
"presentation can be sub-acute, over a period of several"
 Space-occupying lesions in the brain
 Drug reactions or intoxications
" CSF: usually cloudy if bacterial, clear if viral. Analyse for white"
"cell count and type, protein, sugar, Indian-ink staining (for Cryptococcus), gram stain, culture and sensitivity"
 Blood: For serological studies and full blood count
 Blood: for culture and sensitivity
 Chest X-ray and ultrasound to look for possible primary site
"Because of the potential severity of the disease, refer all patients to hospital"
after pre-referral dose of antibiotic. Carry out lumbar puncture promptly
and initiate empirical antibiotic regimen
Treatment depends on whether the causative organisms are already identified or not.
 Nutrition support (NGT if necessary)
Causative organisms not yet identified
 Start initial appropriate empirical broad spectrum therapy
- Ceftriaxone 2 g IV or IM every 12 hours for 1014 days
 Nutrition support (NGT if necessary)
Causative organisms not yet identified
 Start initial appropriate empirical broad spectrum therapy
- Ceftriaxone 2 g IV or IM every 12 hours for 1014 days HC4
- Child: 100 mgkg daily dose given as above
- Change to cheaper effective antibiotic if and
when CS results become available
If ceftriaxone not availablenot improving
 Use chloramphenicol 1 g IV every 6 hours for up to 14
days (use IM if IV not possible)
Once clinical improvement occurs
- Change to 500-750 mg orally every 6 hours to
Causative organisms identified H
Streptococcus pneumoniae (10-14 day course; up to
 Benzylpenicillin 3-4 MU IV or IM every 4 hours
 Or ceftriaxone 2 g IV or IM every 12 hours
Haemophilus influenzae (10 day course) H
 Ceftriaxone 2 g IV or IM every 12 hours
 Only if the isolate is reported to be susceptible to the
 Change to chloramphenicol 1 g IV every 6 hours
 Or ampicillin 2-3 g IV every 4-6 hours
- Child: 100 mgkg daily dose given as above
- Change to cheaper effective antibiotic if and
when CS results become available
If ceftriaxone not availablenot improving
 Use chloramphenicol 1 g IV every 6 hours for up to 14
days (use IM if IV not possible)
Once clinical improvement occurs
- Change to 500-750 mg orally every 6 hours to
Streptococcus pneumoniae (10-14 day course; up to
 Benzylpenicillin 3-4 MU IV or IM every 4 hours
 Or ceftriaxone 2 g IV or IM every 12 hours
Haemophilus influenzae (10 day course)
 Ceftriaxone 2 g IV or IM every 12 hours
 Only if the isolate is reported to be susceptible to the
 Change to chloramphenicol 1 g IV every 6 hours
 Or ampicillin 2-3 g IV every 4-6 hours
Neisseria meningitidis (up to 14 day course)
 Benzylpenicillin IV 5-6 MU every 6 hours
"Child: 100,000-150,000 IUkg every 6 hours"
 Or Ceftriaxone 2 g IV or IM every 12 hours
 Or Chloramphenicol 1 g IV every 6 hours (IM if IV not
Once clinical improvement occurs
- Change to chloramphenical 500-750 mg orally
every 6 hours to complete the course
Note: Consider prophylaxis of close contacts (especially
 Adults and children 12 years: Ciprofloxacin 500 mg
Child 12 yrs: 10 mgkg single dose
 Alternative (e.g. in pregnancy): ceftriaxone 250 mg IM
Child  12 yrs: 150 mg IM single dose
Listeria monocytogenes (at least 3 weeks course) H
 Common cause of meningitis in neonates and immunosuppressed adults
Benzylpenicillin 3 MU IV or IM every 4 hours
 Or ampicillin 3 g IV every 6 hours
 Both medicines are equally effective
 Therapy may need to be prolonged for up to 6 weeks
Neisseria meningitidis (up to 14 day course)
 Benzylpenicillin IV 5-6 MU every 6 hours
"Child: 100,000-150,000 IUkg every 6 hours"
 Or Ceftriaxone 2 g IV or IM every 12 hours
 Or Chloramphenicol 1 g IV every 6 hours (IM if IV not
Once clinical improvement occurs
- Change to chloramphenical 500-750 mg orally
every 6 hours to complete the course
Note: Consider prophylaxis of close contacts (especially
 Adults and children 12 years: Ciprofloxacin 500 mg
Child 12 yrs: 10 mgkg single dose
 Alternative (e.g. in pregnancy): ceftriaxone 250 mg IM
Child  12 yrs: 150 mg IM single dose H
Listeria monocytogenes (at least 3 weeks course)
 Common cause of meningitis in neonates and immunosuppressed adults
Benzylpenicillin 3 MU IV or IM every 4 hours
 Or ampicillin 3 g IV every 6 hours
 Both medicines are equally effective
 Therapy may need to be prolonged for up to 6 weeks
 Improve sanitation and nutrition
 Prompt treatment of primary infection (e.g. in respiratory
 Immunisation as per national schedules
 Mass immunisation if N. Meningitis epidemic
Bacterial infection of the meninges in the first month of life.
 Organisms causing neonatal meningitis are similar to those
"causing neonatal septicaemia and pneumonia, i.e. S.pneumoniae, group A  B streptococci, and enteric Gram-negative bacilli."
"Meningitis due to group B streptococci: These organisms often colonise the vagina and rectum of pregnant women, can be transmitted to"
"babies during labour, and cause infection. Meningitis and septicaemia"
during the 1st week after birth may be particularly severe.
" Clinical presentation is aspecific with temperature disturbances, lethargy, irritability, vomiting, feeding problems,"
"convulsions, apnoea, bulging fontanel"
Refer to hospital after initial dose of antibiotics Supportive H
" For high temperature control environment (undress), avoid"
Refer to hospital after initial dose of antibiotics Supportive
" For high temperature control environment (undress), avoid"
" Prevent hypoglycaemia (breastfeeding if toleratedpossible,"
 Give oxygen if needed (SpO2 92)
Empirical regimen (for 21 days)
 Ampicillin Neonate  7 days: 50-100 mgkg every 12 hours
Neonate  7 days: 50-100 mgkg every 8 hours
 Plus Gentamicin mgkg IV every 12 hours Need for
" Benzylpenicillin 100,000-150,000 IUkg IV every 4-6 hours"
" Neonates 7 days: 50,000-100,000 IUkg IV every 8 hours"
 Plus gentamicin mgkg IV every 12 hours
 Continue treatment for a total of 3 weeks
2.Cryptococcal Meningitis ICD10 CODE: B45.1
Fungal meningitis caused by Crypotococcus neoformans and usually
"occurs in severely immunosuppressed patients (e.g. advanced HIV,"
" It commonly presents with headache, fever, malaise developing over 1 or 2 weeks, progressing into confusion, photophobia, stiff neck"
 Diagnosis is through identification of the microorganism in the
"CSF with Indian Ink stain, antigen in CSF or culture"
" Prevent hypoglycaemia (breastfeeding if toleratedpossible,"
 Give oxygen if needed (SpO2 92)
Empirical regimen (for 21 days)
 Ampicillin Neonate  7 days: 50-100 mgkg every 12 hours
Neonate  7 days: 50-100 mgkg every 8 hours
 Plus Gentamicin mgkg IV every 12 hours Need for
" Benzylpenicillin 100,000-150,000 IUkg IV every 4-6 hours"
" Neonates 7 days: 50,000-100,000 IUkg IV every 8 hours"
 Plus gentamicin mgkg IV every 12 hours
 Continue treatment for a total of 3 weeks H
2.TB Meningitis ICD10 CODE: A17.0
"Meningitis caused by M. tuberculosis. Onset may be gradual with fatigue,"
"fever, vomiting, weight loss, irritability, headache, progressing to confusion,"
"focal neurological deficits, meningeal irritation, till coma."
" For diagnosis: check CSF (raised protein, lymphocytosis), look"
 Treat as per pulmonary TB but continuation phase is
10 months instead of 4 (2RHZE10RH)
Severe acute bacterial infection with high fatality rate transmitted by
infected rodent fleas. It is a notifiable disease.
 Yersinia pestis (a coccobacillus) transmitted from ground
rodents to man by bites from infected fleas
 It may also be spread from person to person by droplet
infection and may occur in epidemics
Bubonic (A20.0)  Involves lymph nodes (usually
 Treat as per pulmonary TB but continuation phase is
10 months instead of 4 (2RHZE10RH)
Bubonic (A20.0)  Involves lymph nodes (usually
Pneumonic (A20.2)  Very infectious and highly fatal: PATIENT MUST BE ISOLATED
- Death occurs within 2 days if
"lungs with fever, general malaise, headache, and frothy"
 May be complicated by respiratory and cardiac distress
" Bubo aspirate: for microscopy, CS"
 Blood and sputum: check for presence of the bacilli
 Doxycycline 100 mg every 12 hours for 14 days HC2
Child  8 years: 2 mgkg per dose
 Chloramphenicol 500 mg orally or IV every 6 hours
 Or gentamicin mgkg (adult and child) IV or IM
Pneumonic (A20.2)  Very infectious and highly fatal: PATIENT MUST BE ISOLATED
- Death occurs within 2 days if
"lungs with fever, general malaise, headache, and frothy"
 May be complicated by respiratory and cardiac distress
 Doxycycline 100 mg every 12 hours for 14 days
Child  8 years: 2 mgkg per dose
 Chloramphenicol 500 mg orally or IV every 6 hours
 Or gentamicin mgkg (adult and child) IV or IM
every 8 hours for 7-10 days HC2
" For use in pregnancy, consider gentamicin"
 Destruction of rats (rodents) and fleas
 Early detection and treatment to reduce further spread
Blood infection due to various bacteria which may be associated with
"infection in specific sites (e.g., lungs, urinary tract, gastrointestinal tract)"
or there may be no specific focus. It is life threatening because it can
progress into multi-organ dysfunction and septic shock.
" Organisms commonly involved are Staphylococcus aureus,"
"Klebsiella, Pseudomonas, Staphylococcus epidermidis, fungal (Candida spp), Coliforms and Salmonella spp, Pneumococci, Proteus spp"
" Extremes of age (children, elderly)"
" Diabetes, cancer, immunosuppression"
" Fever, prostration (extreme tiredness)"
" Signs and symptoms of the primary site of infection (e.g.,pneumonia)"
¾ Look for possible primary source of infection
 (If identified use SOP for respective sample collection coey
"¾ Blood: WBC count, culture and sensitivity"
 (Use the aseptic technique and collect sample(s) for culture
"and sensitivity, to RRH (if service present) before initiation"
"Septicaemia is a life-threating condition, refer to hospital after pre-referral"
 Nutrition support (NGT if necessary)
 Monitoring of vitals and urinary output
"If known focus of infection, treat immediately with antibiotics as per guidelines. If unknown focus, give:"
 Nutrition support (NGT if necessary)
 Monitoring of vitals and urinary output
"If known focus of infection, treat immediately with antibiotics as per guidelines. If unknown focus, give: H"
Use aseptic technique to tale blood sample before initi- H
 Gentamicin 7 mgkg IV every 24 hours or 1.5-2 mg
 Plus either cloxacillin 2 g IV every 4-6 hours f Or
chloramphenicol 750 mg IV every 6 hours
 Gentamicin 3.5-4 mgkg IV every 8 hours (neonate:
 Plus either: Ceftriaxone 50 mgkg every 8 hours (
 Or cloxacillin 50 mgkg IV every 4-6 hours
" Or benzylpenicillin 50,000 IUkg IV every 4-6 hours"
" Protect groups at risk, for example immunosuppressed and"
 Follow strictly aseptic surgical procedures
Organisms causing neonatal septicemia are similar to the ones causing
neonatal pneumonia and meningitis. Refer to hospital after pre-referral
Use aseptic technique to tale blood sample before initiating treatment
 Gentamicin 7 mgkg IV every 24 hours or 1.5-2 mg
 Plus either cloxacillin 2 g IV every 4-6 hours f Or
chloramphenicol 750 mg IV every 6 hours
 Gentamicin 3.5-4 mgkg IV every 8 hours (neonate:
 Plus either: Ceftriaxone 50 mgkg every 8 hours (
 Or cloxacillin 50 mgkg IV every 4-6 hours
" Or benzylpenicillin 50,000 IUkg IV every 4-6 hours H"
" For high temperature, control environment i.e."
 Prevent hypoglycaemia (breastfeeding if tolerated
 Give oxygen if needed (SpO2  90)
 Give ampicillin 50 mgkg IV every 6 hours plus
gentamicin 5 mgkg every 24 hours for 10 days
If risk of staphylococcus infection (infected umbilicus
 Give cloxacillin 50 mgKg IVIM every 6 hours and
gentamicin 5-7 mgKg every 24 hours
- Clean infected umbilicus and pustules and
If no improvement after 48-72 hours change from
"2.Septic Shock Management, In Adults"
 Early recognition and resuscitation with iv crystalloids Or Blood
 Empirical Broad spectrum antibiotics Treatment:
 Early and adequate broad-spectrum antibiotics
 Intravenous access. Administer 30mlkg of crystalloids. A large
"bore cannula, in an adult (gauge 16) is preferred."
 Urinary catheterization: UOP in an adult is 0.5mlkghr or
"more, an equivalent of 30-50mlshr."
 Transfer for management to ICU if not responding to
" For high temperature, control environment i.e."
 Prevent hypoglycaemia (breastfeeding if tolerated
 Give oxygen if needed (SpO2  90) 
 Give ampicillin 50 mgkg IV every 6 hours plus
gentamicin 5 mgkg every 24 hours for 10 days
If risk of staphylococcus infection (infected umbilicus
 Give cloxacillin 50 mgKg IVIM every 6 hours and
gentamicin 5-7 mgKg every 24 hours
- Clean infected umbilicus and pustules and
If no improvement after 48-72 hours change from
"2. At ICU, Intubation and Mechanical Ventilation."
" The recommended tidal volume is kept at 6mlKg, with plateau"
pressure kept at or below 30ml of water.
 Iv vasopressor Norepinephrine; 5-20µgmin.
" Second line is synthetic human angiotensin ii,"
 Ionotropic therapy and Augumented oxygen therapy
" Iv hydrocortisne200mgKgday in 4 divided dosages,"
 Maintenance infusion of methyl prednisolone 1mgkgday for 7
"days, then tapper down for at least another 7 days."
 Glycemic control Maintain glycemic level below 180mgdl
 Deep Venous Thrombosis prophylaxis
 UFH 2 or 3 times a day and LMWH
Disseminated Intravenous Coagulation Management
 Platelets and plasma transfusion
 Antifibrinolytic e.g. tranexamic acid 1g 8hly
Bacterial disease characterised by intermittent spasms (twitching) of
voluntary muscles. Incubation period is from few days to few weeks
 Common sources of infection: tetanus spores enter the
"body through deep penetrating skin wounds, the umbilical"
"cord of the newborn, ear infection, or wounds produced"
during delivery and septic abortions
" Stiff jaw, difficulty in opening mouth (trismus)"
" Generalised spasms induced by sounds andor strong light,"
characterised by grimace (risus sardonicus)
 Arching of back (opisthotonus) with the patient remaining
 Glottal spasms and difficulty in breathing
 Absence of a visible wound does not exclude tetanus
" Meningoencephalitis, meningitis"
" If at HC2 or 3, refer to hospital"
 Nurse patient intensively in a quiet isolated area
" Maintain close observation and attention to airway,"
" Insert nasogastric tube (NGT) for nutrition, hydration,"
" If at HC2 or 3, refer to hospital"
 Nurse patient intensively in a quiet isolated area
" Maintain close observation and attention to airway,"
" Insert nasogastric tube (NGT) for nutrition, hydration,"
 Prevent aspiration of fluid into the lungs
 Avoid IM injections as much as possible; use alternative
"routes (e.g. NGT, rectal) where possible"
 Maintain adequate nutrition as spasms result in hugh
 Treat respiratory failure in ICU with ventilation
 Give tetanus immunoglobulin human (TIG) H
- 150 IUkg (adults and children). Give the dose
"in at least 2 different sites IM, different from the"
" In addition, administer full course of age- appropriate TT"
vaccine (TT or DPT)  starting immediately
 See section Treatment to eliminate source of toxin H
 Clean wounds and remove necrotic tissue.
 Metronidazole 500 mg every 8 hours IV or by mouth
 Benzylpenicillin MU every 6 hours for 10 days
"Child: 50,000-100,000 IUkg per dose"
Control muscle spasms First line H
 Diazepam 10 mg (IV or rectal) every 1 to 4 hours
Child: mgkg IV or mgkg rectal (maximum of
 Prevent aspiration of fluid into the lungs
 Avoid IM injections as much as possible; use alternative
"routes (e.g. NGT, rectal) where possible"
 Maintain adequate nutrition as spasms result in hugh
 Treat respiratory failure in ICU with ventilation 
 Give tetanus immunoglobulin human (TIG)
- 150 IUkg (adults and children). Give the dose
"in at least 2 different sites IM, different from the"
" In addition, administer full course of age- appropriate TT"
vaccine (TT or DPT)  starting immediately
Treatment to eliminate source of toxin
 Clean wounds and remove necrotic tissue.
 Metronidazole 500 mg every 8 hours IV or by mouth
 Benzylpenicillin MU every 6 hours for 10 days
"Child: 50,000-100,000 IUkg per dose H"
Control muscle spasms First line
 Diazepam 10 mg (IV or rectal) every 1 to 4 hours
Child: mgkg IV or mgkg rectal (maximum of
 Magnesium sulphate (alone or with diazepam): 5 g (or
75 mgkg) IV loading dose then 2 ghour till spasm
"- Monitor knee-jerk reflex, stop infusion if absent"
 Or chlorpromazine (alone or alternate with diazepam)
Child: 4-12 mg IM every 4-8 hours or
 mg-25 mg by NGT every 4-6 hours
- Continue for as long as spasmsrigidity lasts
 Morphine 2.5-10 mg IV every 4-6 hours (monitor for
 Immunise all children against tetanus during routine childhood immunisation
 Proper wound care and immunisation (see chapter 18):
- Full course if patient not immunised or not fully immunised
- Booster if fully immunised but last dose 10 years ago
- Fully immunised who had a booster 10 years ago do not
 Prophylaxis in patients at risk as a result of contaminated wounds: give Tetanus immunoglobulin human (TIG) IM
Child  10 years and adults: 250 IU
Double the dose if heavy contamination or wound obtained  24
 Magnesium sulphate (alone or with diazepam): 5 g (or
75 mgkg) IV loading dose then 2 ghour till spasm
"- Monitor knee-jerk reflex, stop infusion if absent"
 Or chlorpromazine (alone or alternate with diazepam)
Child: 4-12 mg IM every 4-8 hours or
 mg-25 mg by NGT every 4-6 hours
- Continue for as long as spasmsrigidity lasts 
 Morphine 2.5-10 mg IV every 4-6 hours (monitor for
2.Neonatal Tetanus ICD10 CODE: A33
Neonatal tetanus is a notifiable disease
 Caused by infection of the umbilicus through cutting of the
cord with unsterile instruments or from putting cow dung
or other unsuitable materials on the stump
 Usually presents 3-14 days after birth with irritability and
"difficulty in feeding due to masseter ( jaw muscle) spasm,"
"rigidity, generalised muscle spasms. The neonate behaves"
normally for the first few days before the symptoms appear.
 Refer to hospital immediately H
" Nurse in quite, dark and cool environment"
 Suction the mouth and turn the infant 30 min after
sedative. A mucous extractor or other suction should be
- Start with IV fluids (half saline and dextrose 5)
- Put NGT and start feeding with expressed breast milk
24 hours after admission in small frequent feeds
- Monitor and maintain body temperature
- Monitor cardiorespiratory function closely. Refer for
 Give tetanus immunoglobulin human (TIG)
- 500 IU IM. Give the dose in at least 2 different sites
"IM, different from the tetanus toxoid site"
 In addition give 1st dose of DPT
" Nurse in quite, dark and cool environment"
 Suction the mouth and turn the infant 30 min after
sedative. A mucous extractor or other suction should be
- Start with IV fluids (half saline and dextrose 5)
- Put NGT and start feeding with expressed breast milk
24 hours after admission in small frequent feeds
- Monitor and maintain body temperature
- Monitor cardiorespiratory function closely. Refer for
 Give tetanus immunoglobulin human (TIG)
- 500 IU IM. Give the dose in at least 2 different sites
"IM, different from the tetanus toxoid site"
 In addition give 1st dose of DPT H
Treatment to eliminate source of toxin H
 Clean and debride the infected umbilicus
 Metronidazole loading dose 15 mgkg over 60 min then
- Infant 4 weeks: mgkg every 12 hours for 14
- Infant 4 weeks: mgkg every 8 hours for 14 H
" Benzylpenicillin 100,000 IUkg every 12 hours for 1014 days"
 Diazepam mgkg IV or mgkg rectal every 1 to
 Chlorpromazine oral 1 mgkg 8 hourly via NGT
 Immunise all pregnant women during routine ANC visits
Bacterial infection characterised by fever and abdominal symptoms. It is
spread through contaminated food and water.
 Salmonella typhi and S. paratyphi A  B
" Gradual onset of chills and malaise, headache, anorexia,"
"epistaxis, backache, and constipation"
Treatment to eliminate source of toxin
 Clean and debride the infected umbilicus
 Metronidazole loading dose 15 mgkg over 60 min then
- Infant 4 weeks: mgkg every 12 hours for 14
- Infant 4 weeks: mgkg every 8 hours for 14
" Benzylpenicillin 100,000 IUkg every 12 hours for 1014 days H"
 Diazepam mgkg IV or mgkg rectal every 1 to
 Chlorpromazine oral 1 mgkg 8 hourly via NGT 
 Usually occurring 10-15 days after infection
 Abdominal pain and tenderness are prominent features
 Delirium and stupor in advanced stages
" Tender splenomegaly, relative bradycardia, cough"
" Complications may include perforation of the gut with peritonitis, gastrointestinal hemorrhage"
" Severe malaria, other severe febrile illnesses"
¾ Blood culture (most reliable)
"¾ Rapid antibody test (e.g. Tubex, Typhidot)  not"
"very sensitive or specific, possibly useful in epidemics"
Widals agglutination reaction is neither sensitive nor specific for typhoid
diagnosis: a single positive screening does not indicate presence of infection
 Do culture and sensitivity to confirm right treat- HC3
 Ciprofloxacin 500 mg every 12 hours for 1014 days
 Do culture and sensitivity to confirm right treatment
 Ciprofloxacin 500 mg every 12 hours for 1014 days
 Chloramphenicol 500 mg 6 hourly for 10 days
"Child: 25 mgkg IV, IM or oral for 10-14 days"
"In severe, resistant forms or pregnancy"
 Ceftriaxone 1 g IV every 12 hours for 10-14 days
 Amoxicillin 1 g every 8 hours for 10 days
" Early detection, isolation, treatment, and reporting"
 Use of safe clean water for drinking
 Personal hygiene especially hand washing
Febrile infection caused by Rickettsia species
 Epidemic louse-borne typhus fever: caused by Rickettsia
"prowazeki; the common type in Uganda, which is transmitted to man (the reservoir) by lice"
 Murine (endemic) typhus fever: caused by Rickettsia typhi
(mooseri) and transmitted by rat fleas. Rats and mice are
 Scrub typhus fever (mite-borne typhus): caused by R. tsutsugamushi and transmitted by rodent mites
 Chloramphenicol 500 mg 6 hourly for 10 days
"Child: 25 mgkg IV, IM or oral for 10-14 days"
"In severe, resistant forms or pregnancy"
 Ceftriaxone 1 g IV every 12 hours for 10-14 days
 Amoxicillin 1 g every 8 hours for 10 days
" Headaches, fever, chills, severe weakness, muscle pains"
 Macular rash that appears on the 5th day on the rest of the
"body except the face, palms, and soles"
" Jaundice, confusion, drowsiness"
 Murine typhus has a similar picture but is less severe
" Any cause of fever such as malaria, HIV, UTI, or typhoid"
¾ Blood: For Weil-Felix reaction
 Doxycycline 100 mg every 12 hours for 5-7 days HC2
Child  8 years: 2 mgkg per dose
 Or chloramphenicol 500 mg orally or IV every 6 hours
 One single dose of doxycycline 200 mg may cure epidemic
typhus but there is risk of relapse
 Destruction of lice and rodents
 Doxycycline 100 mg every 12 hours for 5-7 days
Child  8 years: 2 mgkg per dose
 Or chloramphenicol 500 mg orally or IV every 6 hours
Fungal infection usually confined to the mucous membranes and external
"layers of skin. Severe forms are usually associated with immunosuppressive conditions, such as HIVAIDS, diabetes, pregnancy, cancer,"
"prolonged antibiotic use, and steroids."
" Candida albicans, transmitted by direct contact"
 Intertrigo (between skin folds)
 Vulvo vaginitis and abnormal vaginal discharge (vaginal
candida is not a sexually transmitted disease)
 Chronic paronychia (inflammation involving the proximal
 Gastrointestinal candidiasis may present with pain on
"swallowing, vomiting, diarrhoea, epigastric and retrosternal pain"
" In case of vaginitis, sample collection a high vaginal swab"
"(protected by a speculum), pH, KOH, wet preparation and"
 Smear examination with potassium hydroxide (KOH)
" In case of vaginitis, sample collection a high vaginal swab"
"(protected by a speculum), pH, KOH, wet preparation and"
 Smear examination with potassium hydroxide (KOH)
" In case of vaginitis, sample collection a high vaginal swab (protected by a speculum), pH, KOH, wet preparation and"
 Smear examination with potassium hydroxide (KOH)
" Nystatin tablets 500,000-1,000,000 IU every 6 hours"
for 10 days (chewed then swallowed)
"Child  5 years: Nystatin oral suspension 100,000 IU"
"Child 5-12 years: 200,000 IU per dose every 6 hours"
 Fluconazole 150-200 mg daily for 14 days
"Child: loading dose 6 mgkg, then 3 mgkg daily"
 Insert clotrimazole pessary 100 mg high into the
vagina with an applicator each night for 6 days or
" Or insert one nystatin pessary 100,000 IU each"
" For recurrent vaginal candidiasis, give fluconazole"
150-200 mg once daily for 5 days
Fluconazole is associated with spontaneous abortions and
congenital anomalies and should be avoided in pregnancy
" Nystatin tablets 500,000-1,000,000 IU every 6 hours"
for 10 days (chewed then swallowed)
"Child  5 years: Nystatin oral suspension 100,000 IU"
"Child 5-12 years: 200,000 IU per dose every 6 hours"
 Fluconazole 150-200 mg daily for 14 days
"Child: loading dose 6 mgkg, then 3 mgkg daily HC3"
 Insert clotrimazole pessary 100 mg high into the
vagina with an applicator each night for 6 days or
" Or insert one nystatin pessary 100,000 IU each"
" For recurrent vaginal candidiasis, give fluconazole"
150-200 mg once daily for 5 days
Fluconazole is associated with spontaneous abortions and
congenital anomalies and should be avoided in pregnancy HC2
 Keep hand dry and wear gloves for wet work
 Hydrocortisone cream twice daily
 Fluconazole 150-200 mg once a day for 5-7 days
 Clotrimazole cream twice a day for 2-4 weeks
 In severe forms use fluconazole 150-200 mg once
Avian Influenza ICD10 CODE: J09.X2
Influenza caused by avian (bird) influenza Type A viruses (mainly H5N1
strain). It is endemic in the poultry population in Eurasia and can occasionally be transmitted to humans through direct contact with sick
birds (inhalation of infectious droplets). Disease can be mild or severe
and has limited potential to spread from person to person but there is
risk of mutations giving rise to a very infectious virus which could cause
widespread epidemics. Avian flu is a notifiable disease.
 Avian (bird) influenza Type A viruses
 Keep hand dry and wear gloves for wet work
 Hydrocortisone cream twice daily
 Fluconazole 150-200 mg once a day for 5-7 days HC3
 Clotrimazole cream twice a day for 2-4 weeks
 In severe forms use fluconazole 150-200 mg once
" Flu symptoms: fever, cough, sore throat, muscle aches"
 Gastrointestinal (diarrhoea) and neurological symptoms
" In some cases, severe acute respiratory syndrome (SARS)"
" Blood and respiratory specimens, nose swab: lab test for influenza"
and rule out bacterial infection
- Testing must be in a special laboratory
If patient requires hospitalisation RR
 Hospitalise patient under appropriate infection control
 Administer oxygen as required. Avoid nebulisers and high
 Give paracetamol or ibuprofen for fever prn RR
 Give oseltamivir phosphate in patients  1 year who have
been symptomatic for no more than two days. Treat for 5
Adults and children  13 years: 75 mg twice daily
Child  1 year and  15 kg: 30 mg twice daily
Child 15 23 kg: 45 mg twice daily
Child 2340 kg body weight:60 mg twice daily
Child  40 kg body weight: 75 mg twice daily If a case does
not require hospitalisation f Educate the patient and hisher
Personal hygiene and infection control measures
"Hand-washing, use of a paper or surgical mask by the ill person"
Seek prompt medical care if the condition worsens
Prophylactic use of oseltamivir
If patient requires hospitalisation
 Hospitalise patient under appropriate infection control
 Administer oxygen as required. Avoid nebulisers and high
 Give paracetamol or ibuprofen for fever prn
 Give oseltamivir phosphate in patients  1 year who have
been symptomatic for no more than two days. Treat for 5
Adults and children  13 years: 75 mg twice daily
Child  1 year and  15 kg: 30 mg twice daily
Child 15 23 kg: 45 mg twice daily
Child 2340 kg body weight:60 mg twice daily
Child  40 kg body weight: 75 mg twice daily If a case does
not require hospitalisation f Educate the patient and hisher
Personal hygiene and infection control measures
"Hand-washing, use of a paper or surgical mask by the ill person"
Seek prompt medical care if the condition worsens
Prophylactic use of oseltamivir RR
 Indicated in persons 13 years and above who have come RR
into contact with affected birdspatients
 Close contact: 75 mg once daily for at least 7 days
 Community contacts: 75 mg once daily up to 6 weeks
 Protection lasts only during the period of chemoprophylaxis
 Infection control precautions for adult patients should remain in place for 7 days after resolution of fever and for 21
days in children younger than 12 years
 Children should not attend school during this period
Control and Prevention of Nosocomial Spread of Influenza A (H5N1)
Health workers should observe the following to prevent the spread of
avian influenza in the health care facilities:
" Observe droplet and contact precautions. In addition, get"
negative pressure room if available
 Isolate the patient to a single room
" Place beds more than 1 metre apart and preferably separated by a physical barrier (e.g., curtain, partition)"
 Appropriate personal protective equipment (APPE) in all
"those entering patients rooms. APPE includes high efficiency mask, gown, face shield or goggles, and gloves"
 Limit the number of health care workers (HCWs) and other
hospital employees who have direct contact with the patient(s). These HCWs should:
 Be properly trained in infection control precautions
 Monitor their own temperature twice daily and report any
febrile event to hospital authorities
 A HCW who has a fever (380C) and who has had direct
patient contact should be treated immediately
 Indicated in persons 13 years and above who have come
into contact with affected birdspatients
 Close contact: 75 mg once daily for at least 7 days
 Community contacts: 75 mg once daily up to 6 weeks
 Protection lasts only during the period of chemoprophylaxis RR
" Restrict the number of visitors, provide them with APPE,"
A highly contagious viral infection. Patients are contagious from 2 days
before onset of the rash until all lesions have crusted. An attack of
chicken pox usually confers lifelong immunity. Disease is more severe
 Varicella Zoster virus (VZV) by droplet infection
" Incubation period is 14 days, but shorter in immuno- compromised host"
 Mild fevers occur 10-20 days after exposure
" Prodromal symptoms consisting of low fever, headache,"
and malaise occurring 2 to 3 days before the eruption
" Eruptive phase: they appear as macules, papules, vesicles,"
pustules and crusts. The most characteristic lesion is a vesicle looking like a drop of water on the skin. Vesicles rupture
 The rash begins on the trunk and spreads to the face and
 Lesions of different stages (crops) exist together at the same
" Complications may include septicaemia, pneumonia, fulminating haemorrhagic varicella, and meningoencephalitis"
 Other viral infections with fever and skin rash
¾ Virus isolation possible but not necessary
¾ Diagnosis is practically clinical
Symptomatic and supportive treatment HC2
" Apply calamine lotion every 12 hours f Cool, wet"
Chlorpheniramine: Adult 4 mg every 12 hours Child 5
years: 1-2 mg every 12 hours for 3 days
Pain relief: paracetamol 10 mgkg every 6 hours
In adults and children 12 years consider antivirals: Oral
aciclovir 800 mg every 6 hours for 7 days Keep child at
HC4 homeremove from school till healed to avoid spread
 Avoid contact between infected persons and immuno- suppressed persons
"An acute, highly communicable viral infection characterized by a generalised skin rash, fever, and inflammation of mucous membranes. Measles"
 Measles virus spreads by droplet infection and direct
Symptomatic and supportive treatment
" Apply calamine lotion every 12 hours f Cool, wet"
Chlorpheniramine: Adult 4 mg every 12 hours Child 5
years: 1-2 mg every 12 hours for 3 days
Pain relief: paracetamol 10 mgkg every 6 hours
In adults and children 12 years consider antivirals: Oral
aciclovir 800 mg every 6 hours for 7 days Keep child at
homeremove from school till healed to avoid spread HC2
" Catarrhal stage: high fever, Kopliks spots (diagnostic) runny nose, barking cough, conjunctivitis"
" Misery, anorexia, vomiting, diarrhoea"
 Later: generalised maculopapular skin rash followed by desquamation after few days
" Secondary bacterial respiratory tract infection, e.g. bronchopneumonia, otitis media"
 Severe acute malnutrition especially following diarrhoea
 Cancrum oris (from mouth sepsis)
 Corneal ulceration and panophthalmitis  can lead to blindness
 Other viral diseases causing skin rash
 Clinical diagnosis is sufficient though virus isolation is possible
 Isolate patients (at home or health centre) HC2
Apply tetracycline eye ointment 1 every 12 hours
 Increase fluid and nutritional intake (high risk of malnutrition and dehydration
 Isolate patients (at home or health centre)
Apply tetracycline eye ointment 1 every 12 hours
 Increase fluid and nutritional intake (high risk of malnutrition and dehydration HC2
" Give 3 doses of vitamin A: first dose at diagnosis, 2nd"
dose the next day and 3rd dose on day 14 Child 6
 Monitor for and treat secondary bacterial infections
with appropriate antibiotics immediately
 Refer to hospital in case of complications
 Measles vaccination (see chapter 18)
 Avoid contact between infected and uninfected persons
 Educate the public against the common local myths e.g.
stopping to feed meat and fish to measles patients
Poliomyelitis ICD10 CODE: A80.3
An acute viral infection characterised by acute onset of flaccid paralysis
of skeletal muscles. It is transmitted from person to person through the
faecal-oral route. Poliomyelitis is a notifiable disease.
" Polio virus (enterovirus) types I, II, and Clinical features"
" Majority of cases are asymptomatic, only 1 result in flaccid paralysis"
" Non-paralytic form: minor illness of fever, malaise, headache, and vomiting, muscle pains, spontaneous recovery"
" Paralytic form: after the aspecific symptoms, rapid onset"
"(from morning to evening) of asymmetric flaccid paralysis,"
" Give 3 doses of vitamin A: first dose at diagnosis, 2nd"
dose the next day and 3rd dose on day 14 Child 6
 Monitor for and treat secondary bacterial infections
with appropriate antibiotics immediately
 Refer to hospital in case of complications 
"predominantly of the lower limbs, with ascending progression"
 Paralysis of respiratory muscles is life threatening (bulbar
 Aseptic meningitis may occur as a complication
Consider all cass of Acute Flaccid Paralysis as possible Poliomyelitis: alert
"the district focal person for epidemic control, and send 2 stool samples"
 Isolation of the virus from stool samples
" Ensure that Giardia intestinalis, Entamoeba histolytica, Cryptosporidium, Cyclospora, sarcocystis, Toxoplasma gondii are"
Poliomyelitis in this stage without paralysis is difficult to
" If paralysis is recent, rest the patient completely Note:"
Do not give IM injections as they make the paralysis
Poliomyelitis in this stage without paralysis is difficult to
" If paralysis is recent, rest the patient completely Note:"
Do not give IM injections as they make the paralysis
 Refer the patient to a hospital for supportive care H
" After recovery (if partiallynot immunised), complete"
recommended immunisation schedule
 Encourage active use of the limb to restore muscle
" In event of severe contractures, refer for corrective"
" Isolate patient for nursing and treatment, applying contact"
 Immunise all children below 5 years from the area of the
" If case is confirmed, organize mass immunisation campaign"
 Proper disposal of childrens faeces
"Rabies is a viral infection of wild and domestic animals, transmitted to"
"humans by saliva of infected animals through bites, scratches or licks"
"on broken skin or mucuos membranes. Once symptoms develop, rabies"
presents as a fatal encephalitis: there is no cure and treatment is palliative.
"Before symptomatic disease has developed, rabies can effectively be"
prevented by post-exposure prophylaxis.
 Rabies virus. Incubation is average 20-90 days but can be
 Refer the patient to a hospital for supportive care
" After recovery (if partiallynot immunised), complete"
recommended immunisation schedule
 Encourage active use of the limb to restore muscle
" In event of severe contractures, refer for corrective"
"shorter in severe exposure (multiple bites, bites on face"
neck) of even longer ( a year) in a few cases
 Itching or paraesthesiae (abnormal sensation) around site
 Furious form: psychomotor agitation or hydrophobia (throat
"spasm and panic, triggered by attempt to drink or sight"
soundtouch of water) and aerophobia (similar response to
 Paralytic form (rarer): progressive ascending paralysis
" There is no cure. In case of suspected exposure, take H"
all the appropriate steps to prevent the infection (see
 Start as soon as the exposure happens or as soon as
"the patient comes for medical attention, regardless of"
whatever time has passed from the exposure
 Observe strict hygienic precautions
Avoid contact with patients body fluids or secretions
PPE (personal protective equipment)
 Counsel caregivers on rabies and consequences
" There is no cure. In case of suspected exposure, take"
all the appropriate steps to prevent the infection (see
 Start as soon as the exposure happens or as soon as
"the patient comes for medical attention, regardless of"
whatever time has passed from the exposure H
 Observe strict hygienic precautions
Avoid contact with patients body fluids or secretions
PPE (personal protective equipment)
 Counsel caregivers on rabies and consequences H
2.Ebola and Marburg ICD11 CODE: A99
Ebola and Marburg are severe zoonotic multisystem febrile diseases
caused by RNA viruses. They are notifiable diseases.
 Ebola and Marburg viruses. Transmission to humans happens through contact with meat or body fluids of an infected animal. The disease can then be transmitted from
human to human through body fluids (including semen for
months after recovery) and it is highly contagious.
 Cultural practices like burial rituals
 Poor infection control practices
 History of exposure to infected people in the last 2 to 21
"days i.e sexual partner, breastfeeding mothers"
" Recent contact with infected animals e.g. monkeys, bats,"
" Early signs (non specific): sudden fever, weakness, headache,"
"muscle pains, loss of appetite, conjunctivitis"
" Diarrhoea (watery or bloody), vomiting"
" Mucosal and gastrointestinal bleeding: chest pain, respiratory"
" CNS dysfunction, confusion, seizures"
" Elevated AST and ALT, kidney injury, electrolyte abnormalities"
Note: Haemorrhage is seen in less than a third of Ebola patients
" Malaria, rickettsiosis, meningitis"
" Anthrax, sepsis, viral hepatitis, dengue, leptospirosis"
 Send blood sample to a referral laboratory for specific testing (taking off blood samples from patients suspected of viral
hemorrhagic fever should be done by a trained healthcare
 Notify district surveillance focal person
 Refer all patients to regional referral hospital for man- RR
agement in an appropriate setting
 Notify the district health team
Safety of health workers: maximum level of infection control
Health workers should maintain a high level of suspicion for Ebola
virus disease. While standard precautions should be followed for all
"patients at all times, implementation of transmission-based precautions for cases suspected or confirmed to have Ebola or Marburg virus"
diseases is essential. This includes: screening for rapid identification
 Refer all patients to regional referral hospital for management in an appropriate setting
 Notify the district health team RR
 Hand hygiene according to the WHO 5 moments safe injection
"practices use of personal protective equipment (e.g. eye protection, mask (medical or respirator), gloves, gown or coverall, head"
"covering, apron and gum (rubber) boots."
 Handling and disposing of all waste related to the care of an Ebola
 Safe handling and disinfection of linens (or disposal if not possible)
and thorough cleaning and disinfection of the environment and
 Disinfectants (e.g. chlorine mixture of 0.5 for surfaces) used
must be prepared and used ensuring adequate concentration and
 Handling of the deceased is particularly high risk and should be
kept to a minimum. Strict adherence to IPC measures including
"hand hygiene, use of personal protective equipment (e.g. eye"
"protection, mask (medical or respirator), gloves, gown or coverall,"
"head covering, apron and gum (rubber) boots is required."
Refer to the MoH recent guidelines for management of viral hemorrrhagic fevers
 Optimised Supportive treatment of signs and symptoms
 Replace and monitor fluids and electrolytes for patients with
 Triage patient (those who had contact with a patient or not)
" Contact identification, contact listing and contact follow up"
 Avoid washing or touching the dead f There should be no gathering
at funerals. The dead should be buried promptly by a designated
 Health education of the population (e.g. avoid eating wdil animals)
 Effective outbreak communication and having haemorrhagic
 Appropriate safety gear for patientshealth workers ni suspect
 Modification of burial practices
An acute viral haemorrhagic fever transmitted through the bite of infected
female Aedes aegypti mosquito. Incubation period is 3 to 6 days. It is
 Hunters and settlers around game parks
" Fever, chills, headache, backache, muscle pain, prostration,"
"nausea, vomiting, fatigue. Usually resolves within 3-4 days."
" About 15 of cases enter into a second or toxic stage after 1-2 day of remission: high fever, prostration, signs and"
"symptoms of hepatic failure, renal failure and bleeding ("
"jaundice, nose bleeding, gingival bleeding, vomiting blood,"
 About half of these patients die within 7-10 days
 ELISA in the late stageIt is a notifiable disease.
 Refer all cases to regional referral hospital RR
 Notify the district health team
 There is no specific antiviral drug treatment
 Supportive treatment is recommended:
- Management of liver and kidney failure
 Treat associated bacterial infections with antibiotics
 Individuals who have recovered from a yellow fever infection
 Elimination of mosquito breeding sites
 Epidemic preparedness i.e prompt detection and treatment
Coronavirus disease (COVID-19) results from infection with the Severe
Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). It is a novel
"virus in humans, knowledge of which and its pathogenesis still evolving."
"Additionally, the population-level immunity is uncertain. Complications"
of the severe infection can result in death.
 Refer all cases to regional referral hospital
 Notify the district health team
 There is no specific antiviral drug treatment
 Supportive treatment is recommended:
- Management of liver and kidney failure
 Treat associated bacterial infections with antibiotics RR
 Individuals who have recovered from a yellow fever infection
Early symptoms are non-specific and may include:
" fever, cough, myalgia, fatigue, shortness of breath, sore throat,"
"headache, flu-like symptoms, diarrhea, nausea, respiratory"
"distress, features of renal failure, pericarditis, and Disseminated"
Intravascular Coagulation (DIC).
It is important to know that many individuals with COVID-19 are asymptomatic. It is therefore paramount that all health workers observe strict
infection prevention and control (IPC) measures at all times.
Classification of COVID 19 disease
Disease Stage Hallmark Features
Mild Disease No Respira- Normal Vital Signs
Moderate Non-Severe Crackles in chest but Normal
mild respiratory distress (Resp
Severe Oxygen Severe Respiratory distress
"Disease De saturation (Resp Rate 30)  SPO2 90,"
Critical Organ Dys-  CNS: Altered Mental State
function  CVS: Hypotension  Shock
Groups at High Risk of Developing Severe Disease or Complications
" Lung diseases (e.g. asthma, TB, COPD)"
Disease Stage Hallmark Features
Mild Disease No Respiratory Distress Normal Vital Signs
Pneumonia Crackles in chest but Normal
mild respiratory distress (Resp
De saturation Severe Respiratory distress
Critical Organ Dysfunction  CNS: Altered Mental State
Patient enters health facility grounds
Take temperature (if infrared or
axillary thermometer available)
COVID-19: 1. Is the temperature T37.5OC?
Direct to facil- 2. Have had a fever?
"3. Do you have symptoms such as cough,"
"shortness of breath, muscle aches, weakness,"
"management sore throat, or headache?"
Provide a medical mask to the 40 per min (child 1-5y)
patient and direct to designated
(Oxygen if availa- Danger signs more days
"ble) in a designat-  Disorientation, seizures or"
ed isolation area No convulsions
"Collect samples for:  Lethargy (excessive weakness,"
 Malaria RDT (if fever)  Sunken eyes or other signs of
serious illness or complications
Admit for isolation to hos- ADMIT FOR ISOLATION
"facility (if available), or Prioritize for admission to"
home (case-by-case basis: isolation ward with critical
must have ability for close care capability
 Heart conditions such as history of heart attack or stroke
 Cancer patients whether or not on chemotherapy
 Person living with H Kidney disease
 Malaria and other febrile illnesses.
" common respiratory, infectious, cardiovascular, oncological,"
 Perform SARS-CoV-2 Rapid Diagnostic Test (RDT)
 Carry out nasopharyngeal swabs for RT-RNA test
COVID-19 screening and triage process at health facilities
 COVID-19 triage aims to flag suspected patients at first
point of contact within the healthcare system in order to
 protect other patients and staff from potential exposure.
" identify and rapidly address severe symptoms, rule out other conditions with features similar to COVID-19, ascertain"
if suspect case definition is met
 All suspected patients should be directed to a designated
area away from other patients and handled as per standard
 Refer to the Comprehensive COVID-19 Case Management
Safety of health workers and caregivers: maximum HC2
level of infection control procedures
Strict isolation of suspect cases
Use of adequate protective gear
Appropriate use of chlorine mixtures
Proper disposal of health care waste
Educate the patient and care givers on appropriate infection
No Hospitalization (mild to moderate diseases) HC2
Safety of health workers and caregivers: maximum
level of infection control procedures HC2
Strict isolation of suspect cases
Use of adequate protective gear
Appropriate use of chlorine mixtures
Proper disposal of health care waste
Educate the patient and care givers on appropriate infection
No Hospitalization (mild to moderate diseases) HC2
All patients with no risk of developing severe COVID-19
" symptom management, supportive care, and monitoring"
"(at home, or in the community)."
" Control fevers with paracetamol, multivitamins and"
Adults and Children 40kg at increased risk of developing severe COVID-19 diseases. Refer to current
 nimatrelvirritonavir 300100mg orally (PO) twice
daily for 5 days (must be initiated within 5 days of
 OR remdesivir IV infusion Once daily for 3 days with a
loading dose 200mg on Day 1 and 100mg on subsequent days. (initiated within 7 days of symptom onset)
 OR molnupiravir 800mg orally (PO) twice daily for 5
days ONLY when ritonavir-boosted nirmatrelvir or
remdesivir cannot be used; treatment should be initiated
as soon as possible and within 5 days of symptom
onset (contraindicated in pregnant or breastfeeding
If the patient requires hospitalization (Severe to Critical RR
 And Venous thromboembolism prophylaxis
 And Interleukin-6 receptor blocker (tocilizumab
For details refer to the Comprehensive COVID-19 case
All patients with no risk of developing severe COVID-19
" symptom management, supportive care, and monitoring"
"(at home, or in the community)."
" Control fevers with paracetamol, multivitamins and"
Adults and Children 40kg at increased risk of developing severe COVID-19 diseases. Refer to current
 nimatrelvirritonavir 300100mg orally (PO) twice
daily for 5 days (must be initiated within 5 days of
 OR remdesivir IV infusion Once daily for 3 days with a
loading dose 200mg on Day 1 and 100mg on subsequent days. (initiated within 7 days of symptom onset)
 OR molnupiravir 800mg orally (PO) twice daily for 5
days ONLY when ritonavir-boosted nirmatrelvir or
remdesivir cannot be used; treatment should be initiated
as soon as possible and within 5 days of symptom
onset (contraindicated in pregnant or breastfeeding
If the patient requires hospitalization (Severe to Critical
 And Venous thromboembolism prophylaxis
 And Interleukin-6 receptor blocker (tocilizumab
For details refer to the Comprehensive COVID-19 case
 Vaccination (Refer to chapter 18: Immunization)
 Epidemic preparedness i.e. prompt detection and treatment
 Infection Prevention and control measures including Mask
"wearing, social distancing, regular handwashing, avoid"
Intestinal Worms ICD10 CODE: B83.9
Intestinal worms enter the human body through ingestion of the worm eggs
in food or water via dirty hands or through injured skin when walking barefoot.
Ascariasis: Ascaris lum-  Oro-faecal transmission
bricoides (round worm).  Usually few or no symptoms
Infests small intestines  Persistent dry irritating cough
 Patient may pass out live worms
"through the anus, nose, or mouth"
 Pneumonitis- Loefflers syndrome
 Worms may also cause obstruction
"to bowel, bile duct, pancreatic duct,"
Enterobiasis: (thread-  Transmitted by faecal-oral route
worm) Enterobias ver-  Mainly affects children
micularis  Intense itching at the anal orifice
Ascariasis: Ascaris lumbricoides (round worm).
Infests small intestines  Oro-faecal transmission
 Persistent dry irritating cough
 Patient may pass out live worms
"through the anus, nose, or mouth"
 Pneumonitis- Loefflers syndrome
 Worms may also cause obstruction
"to bowel, bile duct, pancreatic duct,"
Enterobiasis: (threadworm) Enterobias vermicularis  Transmitted by faecal-oral route
 Intense itching at the anal orifice
Hook worm Caused by  Chronic parasitic infestation of the
Necator americanus and intestines
Ancylostoma duodenale  Transmitted by penetration of the
trachea (tracheitis) common during
 Reduced blood proteins in heavy
 Reduced blood proteins in heavy
Strongyloidiasis  Skin symptoms: Itchy eruption at
Strongyloides stercoralis the site of larval penetration
 Intestinal symptoms e.g. abdominal
"pain, diarrhoea, and weight loss"
"the lungs, e.g. cough and wheezing"
" Specific organ involvement, e.g."
Infests human caecum  Heavy infestation may cause
"and upper colon bloody, mucoid stools, and"
Ancylostoma duodenale  Chronic parasitic infestation of the
 Transmitted by penetration of the
trachea (tracheitis) common during
 Reduced blood proteins in heavy
 Reduced blood proteins in heavy
Strongyloides stercoralis  Skin symptoms: Itchy eruption at
 Intestinal symptoms e.g. abdominal
"pain, diarrhoea, and weight loss"
"the lungs, e.g. cough and wheezing"
" Specific organ involvement, e.g."
and upper colon  May be symptomless
" Other causes of cough, diarrhea"
 Other causes of intestinal obstruction and nutritional deficiency
 Other causes of iron-deficiency anaemia
" Stool examination for ova, live worms or segments"
"Roundworm, threadworm, hookworm, whipworm HC1"
 Albendazole 400 mg every 12 hours for 3 days
 Or Ivermectin 150 microgramskg single dose
 Regular deworming of children every 3-6 months
"Roundworm, threadworm, hookworm, whipworm"
 Albendazole 400 mg every 12 hours for 3 days
 Or Ivermectin 150 microgramskg single dose HC1
2.Taeniasis (Tapeworm) ICD10 CODE: B68
An infestation caused by Taenia (Taenia saginata (from undercooked
"beef ), Taenia solium (from undercooked pork), Diphyllobothrium latum"
" Adult Tapeworms: intestinal infestation, by ingestion of"
undercooked meat containing cysticerci (larval form of the
 Larvae forms (cysticercosis): by ingestion of foodwater
contaminated by eggs of T.solium. The eggs hatch in the
"intestine, the embryos invade the intestinal walls and disseminate in the brain, muscles or other organs"
"T. saginata, T.solium (adult tapeworm)"
" Usually asymptomatic, but live segments may be passed"
" Epigastric pain, diarrhoea, sometimes weight loss"
" Muscular: muscle pains, weakness, fever, subcutaneous nodules"
" Neurocysticercosis: headache, convulsions, coma, meningoencephalitis, epilepsy"
" Ocular: exophthalmia, strabismus, iritis"
" Usually asymptomatic, but mild symptoms may occur"
 Megaloblastic anaemia may occur as a rare complication
 Other intestinal worm infestations
" Laboratory: eggs, worm segments in stool or collected from"
perianal skin (scotch tape method)
 Cysticercosis: hypereosinophilia in blood and CSF
 Praziquantel 5-10 mgkg single dose Alternative
Adult and child  6 years: 2 g single dose
- Give Bisacodyl 2 hours after the dose
 Antiparasitic treatment without diagnosis of location
"by CT or MRI scan can worsen symptoms, and even"
threaten the life of the patient.
 Neurosurgical treatment required
 Cook all fish and meat thorougly
" Proper hygiene: handwashing, nail cutting, proper disposal of"
Echinococcosis (Hydatid Disease) ICD 10 CODE: B67
Tissue infestation by larvae of Echinococcus granulosus. It is transmitted
through direct contact with dogs or by ingesting water and food contaminated by dog faeces.
 Praziquantel 5-10 mgkg single dose Alternative
Adult and child  6 years: 2 g single dose
- Give Bisacodyl 2 hours after the dose HC3
 Antiparasitic treatment without diagnosis of location
"by CT or MRI scan can worsen symptoms, and even"
threaten the life of the patient.
 Neurosurgical treatment required RR
" Liver cysts may be asymptomatic but may also give abdominal pain, palpable mass and jaundice (if the bile duct is"
" Rupture of cysts may cause fever, urticaria, or anaphylactic"
" Pulmonary cysts can be seen on chest X-ray and may rupture to cause cough, chest pain and haemoptysis"
 Other causes of liver mass and obstructive jaundice
 Chest X-ray: for pulmonary cysts
 Needle aspiration under Ultrasound Sonography (US) or CTscan guidance
Refer for specialist management RR
 Prior to surgery or in cases not amenable to surgery
- Child 2 years and adults: mgkg every 12
Refer for specialist management
 Prior to surgery or in cases not amenable to surgery
- Child 2 years and adults: mgkg every 12
Dracunculiasis (Guinea Worm) ICD10 CODE: B72
An infestation of the subcutaneous and deeper tissue with the guinea
worm. It is a notifiable disease.
" Dracunculus medinensis, transmitted to man by drinking"
water containing cyclops (waterflea or small crustacean) infected with larvae of the guinea worm
 Adult worm may be felt beneath the skin
" Local redness, tenderness, and blister (usually on the foot)"
at the point where the worm comes out of the skin to discharge larvae into the water
" There may be fever, nausea, vomiting, diarrhoea, dyspnoea, generalised urticaria, and eosinophilia before vesicle formation"
" Complications may include cellulitis, septicaemia, and"
aseptic or pyogenic arthritis; tetanus may also occur
 Cellulitis from any other causes
¾ Recognition of the adult worm under the skin
¾ X-ray may show calcified worms
There is no known drug treatment for guinea worm HC2
" To facilitate removal of the worm, slowly and carefully"
roll it onto a small stick over a period of days
 Dress the wound occlusively to prevent the worm passing
 Give analgesics for as long as necessary
If there is ulceration and secondary infection give:
 Amoxicillin 500 mg every 8 hours for 5 days
Child: 250 mg every 8 hours for 5 days
 Or cloxacillin 500 mg every 6 hours for 5 days
 Infected persons should avoid all contact with sources o fdrinking
Lymphatic Filariasis ICD10 CODE: B74.9
"Lymphatic filariasis is a disease caused by tissue dwelling nematode,"
transmitted by the Aedes aegypti mosquito bite
" Adenolymphangitis- inflammation of lymph nodes and lymphatic vessels (lower limbs, external genitalia, testis, epididymis or breast)"
There is no known drug treatment for guinea worm
" To facilitate removal of the worm, slowly and carefully"
roll it onto a small stick over a period of days
 Dress the wound occlusively to prevent the worm passing
 Give analgesics for as long as necessary
If there is ulceration and secondary infection give:
 Amoxicillin 500 mg every 8 hours for 5 days
Child: 250 mg every 8 hours for 5 days
 Or cloxacillin 500 mg every 6 hours for 5 days HC2
" With or without general signs like fever, nausea, vomiting"
 Attacks resolve spontaneously in one week and recur regularly in patients with chronic disease
 Lymphoedema (chronic hard swelling) of limbs or external
"genitalia, hydrocele, chronic epididymo orchitis, initially reversible but progressively chronic and severe (elephantiasis)"
 Blood slide for Microfilaria (collect specimen between 9 pm
" Supportive treatment during an attack (bed rest, limb"
"elevation, analgesics, cooling, hydration)"
 Doxycycline 100 mg twice a day for 4-6 weeks (do not
administer antiparasitic treatment during an acute attack)
" Supportive treatment: bandage during the day, elevation of"
"affected limb at rest, analgesics and surgery (hydrocelectomy)"
Large scale treatmentpreventive chemotherapy Give annually
"to all population at risk, for 4-6 years"
 Ivermectin 150-200 mcgkg plus albendazole 400 mg
" Supportive treatment during an attack (bed rest, limb"
"elevation, analgesics, cooling, hydration) HC2"
 Doxycycline 100 mg twice a day for 4-6 weeks (do not
administer antiparasitic treatment during an acute attack)
" Supportive treatment: bandage during the day, elevation of"
"affected limb at rest, analgesics and surgery (hydrocelectomy) "
Large scale treatmentpreventive chemotherapy Give annually
"to all population at risk, for 4-6 years"
 Ivermectin 150-200 mcgkg plus albendazole 400 mg
Not effective against adult worms
"Ivermectin is not recommended in children  5 years, pregnancy,"
No food or alcohol to be taken within 2 hours of a dose
Onchocerciasis (River Blindness) ICD10 CODE: B73.0
Chronic filarial disease present in areas around rivers
" Onchocerca volvulus, transmitted by a bite from a female"
"black fly (Simulium damnosum, S. naevi and S. oodi, etc),"
which breeds in rapidly flowing and well-aerated water
 Onchocercoma: painless smooth subcutaneous nodules
"containing adult worms, adherent to underlying tissues,usually on body prominences like iliac crests, pelvic girdle,"
" Acute papular onchodermatitis: Intense pruritic rash, oedema (due to microfilariae)"
 Late chronic skin lesions: dry thickened peeling skin (lizard
"skin), atrophy, patchy depigmentation Eye"
" Inflammation of the eye (of the cornea, uvea, retina) leading to visual disturbances and blindness"
" Other causes of skin depigmentation (e.g. yaws, burns, vitiligo)"
 Other causes of fibrous nodules in the skin (e.g. neurofibromatosis) 159
Not effective against adult worms
"Ivermectin is not recommended in children  5 years, pregnancy,"
No food or alcohol to be taken within 2 hours of a dose 
Case treatment (adult worms) HC3
 Doxycycline 100 mg twice a day for 6 weeks followed by
 Ivermectin 150 microgramskg single dose
 Ivermectin 150 microgramskg once yearly for 10-14
years (see also dose table below)
" Not recommended in children 5 years, pregnancy,"
 No food or alcohol should be taken within 2 hours of
a dose Ivermectin dose based on height
 Skin snip after sunshine to show microfilariae in fresh preparations
 High eosinophils at the blood slideCBC
 Excision of nodules for adult worms
 Slit-lamp eye examination for microfilariae in the anterior
 Doxycycline 100 mg twice a day for 6 weeks followed by
 Ivermectin 150 microgramskg single dose
 Ivermectin 150 microgramskg once yearly for 10-14
years (see also dose table below)
" Not recommended in children 5 years, pregnancy,"
 No food or alcohol should be taken within 2 hours of
a dose Ivermectin dose based on height HC3
Schistosomiasis (Bilharziasis) ICD10 CODE: B65.1
Disease of the large intestine and the urinary tract due to infestation by
 The larvae form (cercariae) of Schistosoma penetrate the
skin from contaminated water and they migrate to different
"parts of the body, usually the urinary tract (Schistosoma"
haematobium) and the gut (S. mansoni)
 Painless blood stained urine at the end of urination - terminal haematuria
 Frequent and painful micturition
 In females: low abdominal pain and abnormal vaginal discharge
" Late complications: fibrosis of bladder and ureters with increased UTI risks, hydronephrosis, infertility"
S. mansoni (gastrointestinal tract)
" Abdominal pain, frequent stool with blood-stained mucus,"
" Chronic cases: hepatic fibrosis with cirrhosis and portal hypertension, haematemesismelena are frequent"
 Cancer of the bladder (S. haematobium)
 History of staying in an endemic area (exposure to water bodies)
 Urine examination (for S. haematobium ova)
 Stool examination (for S. mansoni ova)
 Praziquantel 40 mgkg single dose HC4
 Refer patient if they develop obstruction or bleeding
 Avoid urinating or defecating in or near water
 Avoid washing or stepping in contaminated water
 Clear bushes around landing sites
A chronic systemic infectious disease transmitted by the bite of a sand fly.
 Flagellated protozoa Leishmania species
Visceral Leishmaniasis (Kala-azar)
" Chronic disease characterized by fever, hepatosplenomegaly, lymphadenopathy, anaemia, leucopenia, progressive"
" Fever of gradual onset, irregular, with 2 daily peaks and"
162 alternating periods of apyrexia
 Praziquantel 40 mgkg single dose
 Refer patient if they develop obstruction or bleeding HC4
 The disease progresses over several months and is fatalif
" After recovery from Kala-azar, skin (cutaneous) leishmaniasis may develop"
Cutaneous and Mucosal Leishmaniasis (Oriental sore)
" Starts as papule, enlarges to become an indolent ulcer"
 Secondary bacterial infection is common
" Other causes of chronic fever, e.g. brucellosis"
" (For dermal leishmaniasis) Other causes of cutaneous lesions, e.g. leprosy"
"¾ Stained smears from bone marrow, spleen, liver, lymph"
"nodes, or blood to demonstrate Leishman Donovan bodies"
¾ Culture of the above materials to isolate the parasites
"¾ Serological tests, e.g. indirect fluorescent antibodies"
¾ Leishmanin skin test (negative in Kala-azar)
Refer all cases to regional referral hospital
Cutaneous Leishmaniasis (all patients) RR
" Frequently heals spontaneously but if severe or persistent,"
treat as for Visceral Leishmaniasis below
Visceral Leishmaniasis (Kala-azar): All patients
 Combination: Sodium stibogluconate 20 mg kg per
 Plus paromomycin 15 mgkg 11 mg base per day IM
Cutaneous Leishmaniasis (all patients)
" Frequently heals spontaneously but if severe or persistent,"
treat as for Visceral Leishmaniasis below
Visceral Leishmaniasis (Kala-azar): All patients
 Combination: Sodium stibogluconate 20 mg kg per
 Plus paromomycin 15 mgkg 11 mg base per day IM
 Plus paromomycin 15 mgkg 11 mg base per day IM RR
Alternative first line treatment is:
 Sodium Stibogluconate 20 mgkg per day for 30 days
(in case paromomycin is contraindicated)
 Liposomal amphotericin B (e.g. AmBisome) 3 mgkg
 Liposomal amphotericin B 5 mgkg per day for 8 days
Post Kala-Azar Dermal Leishmaniasis (PKDL) RR
 Sodium Stibogluconate injection 20 mgkgday until
clinical cure. Several weeks or even months of treatment
Continue treatment until no parasites detected in 2 consecutive splenic aspirates taken 14 days apart
Patients who relapse after a 1st course of treatment with
Sodium stibogluconate should immediately be re- treated
with Ambisome 3 mgkgday for 10 days
 Case detection and prompt treatment
Malaria is an acute febrile illness caused by infection with Plasmodium
parasites and is transmitted from person to person by an infected female
 Plus paromomycin 15 mgkg 11 mg base per day IM
Alternative first line treatment is:
 Sodium Stibogluconate 20 mgkg per day for 30 days
(in case paromomycin is contraindicated)
 Liposomal amphotericin B (e.g. AmBisome) 3 mgkg
 Liposomal amphotericin B 5 mgkg per day for 8 days RR
Post Kala-Azar Dermal Leishmaniasis (PKDL)
 Sodium Stibogluconate injection 20 mgkgday until
clinical cure. Several weeks or even months of treatment
Continue treatment until no parasites detected in 2 consecutive splenic aspirates taken 14 days apart
Patients who relapse after a 1st course of treatment with
Sodium stibogluconate should immediately be re- treated
with Ambisome 3 mgkgday for 10 days 
 There are five Plasmodium species of malaria parasites which
"infect humans namely: P. falciparum, P. vivax, P. ovale, P. malariae"
 P. falciparum is the most virulent and also the most common
" It may be asymptomatic, mild illness (uncomplicated malaria) or"
severe illness (severe malaria)
 Intermittent fever is the most characteristic symptom of malaria.
Three classical stages can be distinguished in a typical attack of
 The cold stage: the patient feels cold and shivers
 The hot stage: the patient feels hot
 The sweating stage: associated with sweating and relief of
 A complete physical examination has to be performed n iany patient
presenting with fever or history of fever.
" When people are frequently exposed to malaria, they develop"
"partial immunity. In such people, the classical stages of a malaria"
attack above may not be observed.
" Also, in people who have had partial treatment with antimalarial"
"medicines, these classical stages may not be pronounced."
2.Uncomplicated Malaria ICD 10 CODE: B50.9
Common symptomssigns of uncomplicated malaria
 Fever: above 37.5C (taken from the axilla ) or history of
" Loss of appetite, mild vomiting, diarrhoea"
" Weakness, headache, joint and muscle pain"
 Mild anaemia (mild pallor of palms and mucous membranes); occurs commonly in children.
" Enlarged spleen (in acute malaria it may be minimally enlarged, soft and mildly tender)"
"2.ComplicatedSevere Malaria ICD10 CODE: B50.0, B50.8"
It is an immediate threat to life and is therefore a medical emergency.
Malaria is regarded as severe if there are asexual forms of P. falciparum in
blood plus one or more of the following complications in the table below.
Classical definition of severe malaria
COMPLICATION CRITERION FOR DIAGNOSIS
Cerebral malaria Deep coma (unable to localise a painful
"stimulus), Normal CSF, parasitaemia"
Severe anaemia Hb 5gdl with parasitaemia
"Respiratory distress Tachypnoea, nasal flaring and intercostal"
recession in a patient with parasitaemia
Hypoglycaemia Blood glucose 40 mgdl
Circulatory collapse Clinical shock (systolic pressure 50
mmHg for children and 80mmHg for
"adults, with cold peripheries, clammy"
Renal failure Urine output  12 mlkg in 24 hours
"and plasma creatinine  mgdl, with"
"Spontaneous bleeding Parasitaemia with unexplained spontaneous bleeding (haematemesis, melaena,"
"or prolonged bleeding from nose, gum or"
"Repeated convulsions 2 or more convulsions in 24 hours, with"
COMPLICATION CRITERION FOR DIAGNOSIS
Cerebral malaria Deep coma (unable to localise a painful
"stimulus), Normal CSF, parasitaemia"
Severe anaemia Hb 5gdl with parasitaemia
"Respiratory distress Tachypnoea, nasal flaring and intercostal"
recession in a patient with parasitaemia
Hypoglycaemia Blood glucose 40 mgdl
Circulatory collapse Clinical shock (systolic pressure 50
mmHg for children and 80mmHg for
"adults, with cold peripheries, clammy"
Renal failure Urine output  12 mlkg in 24 hours
"and plasma creatinine  mgdl, with"
"Spontaneous bleeding Parasitaemia with unexplained spontaneous bleeding (haematemesis, melaena,"
"or prolonged bleeding from nose, gum or"
"Repeated convulsions 2 or more convulsions in 24 hours, with"
COMPLICATION CRITERION FOR DIAGNOSIS
"Acidosis Deep (acidotic) breathing and plasma bicarbonate 15 mmolL, with parasitaemia"
"Haemoglobinuria Parasitaemia, haemoglobin in urine (dark"
"Pulmonary Oedema Deep breathing, fast breathing, laboured"
"breathing (nasal flaring, intercostal recession and chest in- drawing), Cheyne"
Supporting manifestations (some other signs in addition to above
Impaired conscious- Parasitaemia with depressed level of
ness consciousness but can localize a painful
"stimulus, or change of behavior, confusion, drowsiness"
Jaundice Parasitaemia with unexplained jaundice
"Prostration Unable to sit, in a child normally able to"
do so or unable to drink in one too young
"Severe vomiting Vomiting everything, not able to drink or"
"Severe dehydration Sunken eyes, coated tongue, lethargy,"
"Hyperpyrexia Temperature C, with"
"Hyper- parasitaemia Parasite count  250,000 µl,  10"
Threatening abortion Uterine contractions and vaginal bleeding
COMPLICATION CRITERION FOR DIAGNOSIS
"Acidosis Deep (acidotic) breathing and plasma bicarbonate 15 mmolL, with parasitaemia"
"Haemoglobinuria Parasitaemia, haemoglobin in urine (dark"
"Pulmonary Oedema Deep breathing, fast breathing, laboured"
"breathing (nasal flaring, intercostal recession and chest in- drawing), Cheyne"
Supporting manifestations (some other signs in addition to above
Impaired consciousness Parasitaemia with depressed level of
consciousness but can localize a painful
"stimulus, or change of behavior, confusion, drowsiness"
Jaundice Parasitaemia with unexplained jaundice
"Prostration Unable to sit, in a child normally able to"
do so or unable to drink in one too young
"Severe vomiting Vomiting everything, not able to drink or"
"Severe dehydration Sunken eyes, coated tongue, lethargy,"
"Hyperpyrexia Temperature C, with"
"Hyper- parasitaemia Parasite count  250,000 µl,  10"
Threatening abortion Uterine contractions and vaginal bleeding
" Meningitis, otitis media, tonsillitis"
 Measles or other infections with rashes (before rash comes)
Note: All suspected malaria patients MUST be tested by blood slide
or RDT before they are treated. NOT all fevers are malaria.
 RDT or thick blood slide for diagnosis of malaria
 Random blood sugar and Hb level if clinically indicated
 Lumbar puncture: in case of convulsioncoma and negative
¾ Thin film for parasite identification
 RDTs (Rapid Diagnostic tests) detect malaria antigen (not whole
parasites like the blood slide) and remain positive for 2 to 3
weeks after effective treatment
 RDT do not become negative if the patient has already taken
" RDTs are reliable, quick and easily accessible tools for malaria"
A blood slide for microscopy is specifically recommended over
RDT in the following situations:
¾ Patients who have completed antimalarial treatment and
¾ Patients who completed treatment but comes back within
¾ RDT negative patients without any other evident cause of fever
NATIONAL MALARIA TREATMENT POLICY
All patients: including children First line medicine
4 months of age and pregnant ArtemetherLumefantrine
in 2nd and 3rd trimesters ArtesunateAmodiaquine
If not available: quinine tablets
Pregnant women 1st trimester ACT currently used
All age groups or patient categories First line IV Artesunate
Rectal artesunate for children 6
"years and below only. IM Artesunate, IM artemether or quinine"
Intermittent preventive treatment in pregnancy
SulfadoxinePyrimethamine (SP) for IPT. Start at 13 weeks and give
Treatment of uncomplicated malaria
The following tables contain dosages for medicines used in treatment of
NATIONAL MALARIA TREATMENT POLICY 
All patients: including children
in 2nd and 3rd trimesters First line medicine
If not available: quinine tablets
Pregnant women 1st trimester ACT currently used
All age groups or patient categories First line IV Artesunate
Rectal artesunate for children 6
"years and below only. IM Artesunate, IM artemether or quinine"
Intermittent preventive treatment in pregnancy 
SulfadoxinePyrimethamine (SP) for IPT. Start at 13 weeks and give
Dosage of artemetherlumefantrine 20120 mg
14 1 tablet at 0 hours 1 tab twice 1 tab twice
"1524 2 tablets at 0 hours, 2 tab twice 2 tab twice"
"then, 2 tablets at 8 daily daily"
2534 3 tablets at 0 hours 3 tab twice 3 tab twice
35 4 tablets at 0 hours 4 tab twice 4 tab twice
then 4 tablets at 8 daily daily
Note: Give day 2 and day 3 doses every 12 hours
Dosage of artesunate (AS) tablets 50 mg once a day
011 25 mg (½ tab) 25 mg (½ tab) 25 mg (½ tab)
"Note: Do not use artesunate alone, give with amodiaquine tabs"
Note: Give day 2 and day 3 doses every 12 hours 
months 25 mg (½ tab) 25 mg (½ tab) 25 mg (½ tab)
"Note: Do not use artesunate alone, give with amodiaquine tabs "
Dosage of amodiaquine (AQ) 153 mg tablets
011 76 mg (12 tab) 76 mg (12 tab) 76 mg (12 tab)
16 years 153 mg (1 tab) 153 mg (1 tab) 153 mg (1tab)
713 years 306 mg (2 tabs) 306 mg (2 tabs) 306 mg (2 tabs)
13 years 612 mg (4 tabs) 612 mg (4 tabs) 612 mg (4 tabs)
"Note: Do not use amodiaquine alone, use with artesunate tabs"
Dosage of dihydroartemisinin (DHA)Piperaquine tablets (PPQ) (40320
WEIGHT (KG) AGE DAY 1 DAY 2 DAY 3
56 month 1 year 1020 27 years 1 1 1
Dosage for Pyronaridine Tetraphosphate  Artesunate
PYRONARIDINE TETRAPHOSPHATE ARTESUNATE (PYRAMAX)
Body Weight Product Description Day 1 Dose Day 2 Dose Day 3 Dose
5kg to  8kg PyronaridineArtesunate 1 Sachet 1 Sachet 1 Sachet
8kg to  15kg 2 Sachet 2 Sachet 2 Sachet
15kg to  20kg Suspension 3 Sachet 3 Sachet 3 Sachet
20kg to  24kg 1 Tablet 1 Tablet 1 Tablet
24kg to  45kg PyronaridineArtesunate 2 Tablet 2 Tablet 2 Tablet
45kg to  65kg Coated Tablet 3 Tablet 3 Tablet 3 Tablet
  65kg 4 Tablet 4 Tablet 4 Tablet
months 76 mg (12 tab) 76 mg (12 tab) 76 mg (12 tab)
16 years 153 mg (1 tab) 153 mg (1 tab) 153 mg (1tab)
713 years 306 mg (2 tabs) 306 mg (2 tabs) 306 mg (2 tabs)
13 years 612 mg (4 tabs) 612 mg (4 tabs) 612 mg (4 tabs)
"Note: Do not use amodiaquine alone, use with artesunate tabs "
WEIGHT (KG) AGE DAY 1 DAY 2 DAY 3
56 month 1 year 1020 27 years 1 1 1
PYRONARIDINE TETRAPHOSPHATE ARTESUNATE (PYRAMAX) 
Body Weight Product Description Day 1 Dose Day 2 Dose Day 3 Dose
5kg to  8kg PyronaridineArtesunate 1 Sachet 1 Sachet 1 Sachet
8kg to  15kg 2 Sachet 2 Sachet 2 Sachet
15kg to  20kg Suspension 3 Sachet 3 Sachet 3 Sachet 
20kg to  24kg 1 Tablet 1 Tablet 1 Tablet
24kg to  45kg PyronaridineArtesunate 2 Tablet 2 Tablet 2 Tablet
45kg to  65kg Coated Tablet 3 Tablet 3 Tablet 3 Tablet
  65kg 4 Tablet 4 Tablet 4 Tablet 
Dosage of quinine tablets (1 quinine tab  300 mg salt)
WEIGHT AGE DOSE (TO BE GIVEN EVERY 8
510 3 months1 year 75 mg (¼ tab)
3040 1013 years 375 mg (1¼ tab)
4050 1315 years 450 mg (1½ tab)
Manage complications as recommended in the section below
"Manage fluids very carefully. Adults with severe malaria are very vunerable to fluid overload, while children are more likely to be dehydrated"
"Monitor vitals signs carefully, including urine output."
Intravenous artesunate is the medicine of choice
- At a health unit without admission and IV drug administration
"facilities, give a pre-referral dose of rectal artesunate only"
recommended for children of 6 years and below( see dosing
tables below) as soon as possible and refer for further
- At a health unit with admission and IV drug administration
"facilities, treat with IV artesunate as in the table below"
"- If IV route is not possible, use IM route."
"- If Iv artesunate is not available, use IM artemether (into the"
"thigh, never in the buttock) or IV quinine"
(KG) AGE DOSE (TO BE GIVEN EVERY 8
510 3 months1 year 75 mg (¼ tab)
3040 1013 years 375 mg (1¼ tab)
4050 1315 years 450 mg (1½ tab)
WEIGHT (KG) AGE ARTESUNATE REGIMEN (SINGLE
5kg to14 4 months to 100mg 1 supp (100 mg)
14-19 3 years to 100 mg 2 supp of 100mg
 In the event that an artesunate suppository is expelled from
"the rectum within 30 minutes of insertion, insert a repeat"
 Hold the buttocks (especially in young children) together for
10 minutes to ensure retention of rectal dose
Dosage of intravenous artesunate for severe malaria
First dose: on admis- At 0 hours Child less than 20 kg: 3 mgkg
"Then once a day until patient is able to tolerate oral medication, then"
give a full course of oral ACT. currently all severe malaria cases to
be discharged on DP. Then reviewed every month for 3 months and
given monthly DP for post severe malaria chemoprevention.
Preparation of IV or IM artesunate
" IV artesunate is usually dispensed in powder vial of 30mg,"
"60mg,120mg, pre-packed with sodium bicarbonate solution 1 ml"
 In the event that an artesunate suppository is expelled from
"the rectum within 30 minutes of insertion, insert a repeat"
 Hold the buttocks (especially in young children) together for
10 minutes to ensure retention of rectal dose 
First dose: on admission Loading dose At 0 hours Child less than 20 kg: 3 mgkg
"Then once a day until patient is able to tolerate oral medication, then"
give a full course of oral ACT. currently all severe malaria cases to
be discharged on DP. Then reviewed every month for 3 months and
given monthly DP for post severe malaria chemoprevention. 
Preparation of IV or IM artesunate
" IV artesunate is usually dispensed in powder vial of 30mg,"
"60mg,120mg, pre-packed with sodium bicarbonate solution 1 ml"
 Calculate the dose in mg according to the weight and the
" Reconstitute each vial separately, and use within 1 hour"
 Reconstitution: inject all the content of the bicarbonate ampoule (1 ml) in the artesunate vial. Shake gently till solution
become clear (discard if not clear after 2 minutes)
 Dilution: dilute solution by adding 5 ml of sodium chloride
"0.9 (normal saline) or Dextrose 5, obtaining a concentration of 10 mgml"
 Calculate the required volume and withdraw
 Give by IV injection slowly over 5 minutes
 Dilution: dilute solution by adding 2 ml of sodium chloride
"0.9, obtaining a concentration of 20 mgml"
" Inject into the upper outer anterior thigh, NEVER in the"
Do not use water for injection for dilution
First dose: on admission At 0 hours mgkg
"Then once a day until patient is able to tolerate oral medication, then"
give a full course of oral ACT. If after 48hours (day 3) the patient is
still un stable and parasites density is still almost the same as at day
"0, switch to IV quinine for 3 to 4 doses then discharge on ACT (DP)."
"Then once a day until patient is able to tolerate oral medication, then"
give a full course of oral ACT. If after 48hours (day 3) the patient is
still un stable and parasites density is still almost the same as at day
"0, switch to IV quinine for 3 to 4 doses then discharge on ACT (DP). "
Dosage of quinine Dose  10 mgkg in dextrose 5 every 8 hours till patient is able
 Then complete with a full dose of ACT (3 days) or quinine
2.Management of Complications of Severe Malaria
Hyperpyrexia Give paracetamol 1 g every 6 hours Child: 10 mg
Convulsions Give diazepam mgkg (max 10 mg) slow IV or
(in adults) IM or mgkg rectally
Give phenobarbital 200 mg IMChild: 10-15 mgkg loading dose then
mgkg once or twice daily if still necessary or
Hypoglycaemia Adult: dextrose 25 2 mlkg by slow IV bolus over
"3-5 min (to prepare, take dextrose 50 1 mlkg and"
dilute with an equal volume of water for injections)
Child: dextrose 10 5 mlkg by slow IV bolus over
"5-7 min (to prepare, take 1 mlkg of dextrose 50"
and dilute with 4 mlkg water for injection)
DO NOT GIVE UNDILUTED 50 dextrose
Monitor blood glucose frequently
Acidosis Correct fluid  electrolyte balance
If there is severe acidosis without sodium depletion:
Dose  10 mgkg in dextrose 5 every 8 hours till patient is able
 Then complete with a full dose of ACT (3 days) or quinine
Hyperpyrexia Give paracetamol 1 g every 6 hours Child: 10 mg
Convulsions Give diazepam mgkg (max 10 mg) slow IV or
(in adults) IM or mgkg rectally
Give phenobarbital 200 mg IMChild: 10-15 mgkg loading dose then
mgkg once or twice daily if still necessary or
Hypoglycaemia Adult: dextrose 25 2 mlkg by slow IV bolus over
"3-5 min (to prepare, take dextrose 50 1 mlkg and"
dilute with an equal volume of water for injections)
Child: dextrose 10 5 mlkg by slow IV bolus over
"5-7 min (to prepare, take 1 mlkg of dextrose 50"
and dilute with 4 mlkg water for injection)
DO NOT GIVE UNDILUTED 50 dextrose
Monitor blood glucose frequently
Acidosis Correct fluid  electrolyte balance
If there is severe acidosis without sodium depletion:
- Give sodium bicarbonate 8.4 infusion
Severe anaemia  Do blood grouping and cross- matching
 Transfuse patient with packed cells 10-15 ml
kg or whole blood 20 ml kg especially if the
anaemia is also causing heart failure
 Repeat Hb before discharge and preferably 28
Pulmonary Regulate the IV infusion (do not overload with Oedema fluids)
Acute Renal  Urine output: 17 mlhour for adult or Failure mlkghour for a child
 Check to ensure that the cause of oliguria is
 If due to acute renal failure: Give a challenge dose of furosemide 40 mg IM or
 Refer for peritoneal dialysis or haemodialysis
Shock  If systolic BP 80 mmHg (adult) or
50 mmHg (child) or if peripheral pulse absent
and capillary refill is slow (2 seconds)
- Give sodium chloride 0.9 by fast infusion bolus 20 mlkg in 15 min
- Review fluid balance and urinary outputs
- Look for evidence of haemorrhage or
septicaemia and treat accordingly
 - Give sodium bicarbonate 8.4 infusion
Severe anaemia  Do blood grouping and cross- matching
 Transfuse patient with packed cells 10-15 ml
kg or whole blood 20 ml kg especially if the
anaemia is also causing heart failure
 Repeat Hb before discharge and preferably 28
Oedema Regulate the IV infusion (do not overload with fluids)
Failure  Urine output: 17 mlhour for adult or mlkghour for a child
 Check to ensure that the cause of oliguria is
 If due to acute renal failure: Give a challenge dose of furosemide 40 mg IM or
 Refer for peritoneal dialysis or haemodialysis
Shock  If systolic BP 80 mmHg (adult) or
50 mmHg (child) or if peripheral pulse absent
and capillary refill is slow (2 seconds)
- Give sodium chloride 0.9 by fast infusion bolus 20 mlkg in 15 min
- Review fluid balance and urinary outputs
- Look for evidence of haemorrhage or
septicaemia and treat accordingly
Haemoglo- bi-  Rehydrate the patient
nuria (intravas-  Assess for anaemia and transfuse if necessary
Dehydration  Rehydrate using ORS or IV RL or NS (see
 Over-enthusiasitc IV infusion may harm the
patient and lead to fluid overlaod and pulmonary oedema
Bleeding  Transfuse patient with whole fresh blood to
provide lacking clotting factors
"Coma  Check and treat for hypoglycaemia: if not responding within 20 min, consider another cause"
 f Provide intensive nursing care with:
- IV drip (for rehydration and medication)
- Urethral catheter (to monitor urine
- Turning of patient frequently to avoid
Criteria for referral to regionaltertiary hospital
 Persistent renal failure needing dialysis
 Any complication that cannot be managed locally
Management of RDTBlood Smear Negative Ptients
"Patients who have a negative malaria test (most likely, if RDT is used)"
do not have malaria so other causes of fever have to be investigated for
Haemoglo- binuria (intravascular haemolysis)  Rehydrate the patient
 Assess for anaemia and transfuse if necessary
Dehydration  Rehydrate using ORS or IV RL or NS (see
 Over-enthusiasitc IV infusion may harm the
patient and lead to fluid overlaod and pulmonary oedema
Bleeding  Transfuse patient with whole fresh blood to
provide lacking clotting factors
"Coma  Check and treat for hypoglycaemia: if not responding within 20 min, consider another cause"
 f Provide intensive nursing care with:
- IV drip (for rehydration and medication)
- Urethral catheter (to monitor urine
- Turning of patient frequently to avoid
" Re-assess patient history, clinical signs and laboratory results. Consider other frequent causes of fever such as:"
" If running nose, sore throat and cough: viral upper respiratory"
 If swollen tonsils with exudate on it: tonsilitis
 If ear pain and discharge: otitis
" If cough, rapid breathing and difficulty in breathing: pneumonia"
 If urinary symptoms: urinary tract infection
" If vomiting, diarrhoea and abdominal pain: gastro-enteritis"
 If skin rash: measles or other viral rash
" If malaria is still suspected, investigate according to the"
" If signssymptoms of severe malaria, RDT and blood slide negative"
"but no other diagnosis is found, consider treating for malaria anyway but repeat RDTs after 24 hours to confirm.Also add a broad"
" If RDT and blood slide negative, no signs of other illness and no"
"signs of severe sickness (patient has no danger signs) treat symptomatically with antipyretics, advise patient to return immediately"
if condition worsens or in 2 days if fever persists.
Possible reasons for false negative tests (test is negative but patient has
 Technical error in performing the test or test reagents that
 Sequestration of parasites in the internal organs
" Having already taken antimalarial drugs, inadequate or"
"incomplete dose: this affects only microscopy, while RDT"
remains positive even if the patient has already taken an
antimalarial using prophylactic treatment for malaria
Treat non-malarial Are there signs and
"Treat for severe disease Withhold treatment for malaria, give"
with artesunate and broad- symptomatic treatment and ask the
spectrum antibiotics. Repeat patient to come back immediately
testing (RDT) in 12-24 hours if the illness becomes worse or if it
persists for more than two days.
Not recommended for all those living in a highly endemic area like
"Uganda. However, it is recommended for certain high-risk groups but"
Pregnancy  Give intermittent preventive treatment
"(IPT) to ensure the well-being of mothIn endemic areas,"
pregnant women carry malaria  SP single dose (3 tabs) given at 13 weeks and
parasites in their continued monthly until delivery
"blood or placenta,  Ensure doses are taken under supervision"
which is harmful to by the health provider as directly observed
the health of both therapy (DOT)
 Record doses on the patients card and treatment
register and summarise further in the delivery
 Do not give SP in HIV patients on cotrimoxazole
Sicke cell disease  Sulphadoxine- pyrimethamine (SP) -
see section Chloroquine is the alteranative:
People living with  Cotrimoxazole daily as per national
2.Malaria Prevention and Control
Give effective treatment and prophylaxis
 Eliminate parasites from the human population by early diagnosis and effective treatment
 Protect vulnerable groups with chemoprophylaxis
mother and foetus  Give intermittent preventive treatment
(IPT) to ensure the well-being of mother and foetus
 SP single dose (3 tabs) given at 13 weeks and
continued monthly until delivery
 Ensure doses are taken under supervision
by the health provider as directly observed
 Record doses on the patients card and treatment
register and summarise further in the delivery
 Do not give SP in HIV patients on cotrimoxazole
Sicke cell disease  Sulphadoxine- pyrimethamine (SP) -
see section Chloroquine is the alteranative:
HIV  Cotrimoxazole daily as per national
Non-immune visitorstourists  Mefloquine
 Use insecticide-treated materials (e.g. bed nets)
 Destroy adult mosquitoes by indoor residual spraying of
dwellings with insecticide or use of knock-down sprays
 Carefully select house sites avoiding mosquito-infested areas
 Wear clothes which cover the arms and legs and use repellent mosquito coils and creamssprays on the skin when sitting outdoors at night
Control mosquito breeding sites
 Eliminate collections of stagnant water where mosquitoes
"breed, e.g. in empty cans containers, potholes, old car"
"tyres, plastic bags, and footprints by disposal, draining, or"
 Destroy mosquito larvae by dosing stagnant water bodies
with larvicides or with biological methods (e.g. larvae- eating
Give public health education on the above measures include the need
for self testing (self-care) using RDT before any medication.
Human African Trypanosomiasis (Sleeping Sickness)
A disease caused by trypanosomes (a protozoa) and transmitted to
humans by several species of tsetse fly
 Trypanosoma rhodesiense (mostly in the Central and Eastern regions of Uganda)
 Trypanosoma gambiense (mostly in West Nile region)
 May be history of tsetse fly bite and swelling at site of bite
"after 7-14 days (more often in T. rhodesiense, rarely in T."
" Early stage (haemolymphatic stage): headache not responding to common analgesics, fever, generalised lymphadenopathy, joint pains"
" Late stage (meningoencephalitis stage): after some weeks,"
"neurological and psychiatric symptoms like apathy, day"
"sleepiness, paralysis, seizures"
" If not treated: cachexia, lethargy, coma and death within 3-6"
 Similar to the rhodesiense but less acute and with slower
 Incubation can last several years
" CSF: For trypanosomes, lymphocyte count"
 Aspirate from chancrelymph node: for trypanosomes
"This is based on the findings of the CSF analysis, determining the stage"
"of disease. To determine the medicine of choice, the disease is divided"
into two stages: early and late stage
Early (first) stage  CSF is normal
dye-binding protein assay) or  25
mgdl (by Double Standard  Centrifuge Metod)
 Absence of trypanosomes (by Double Standard and Centrifuge Method)
Late (second) stage  Lymphocytes  5 cell mm3 And
Patient with suspected or diagnosed sleeping sickness should be managed
T. rhodesiense sleeping sickness
 Suramin - A test dose of 5 mgkg of body weight should first
be administered to test for anaphylactic reaction
- Followed by five injections of 20 mgkg every 5
If anaphylaxis: do not administer
Early (first) stage  CSF is normal
dye-binding protein assay) or  25
mgdl (by Double Standard  Centrifuge Metod)
 Absence of trypanosomes (by Double Standard and Centrifuge Method)
Late (second) stage  Lymphocytes  5 cell mm3 And
T. rhodesiense sleeping sickness
 Suramin - A test dose of 5 mgkg of body weight should first
be administered to test for anaphylactic reaction
- Followed by five injections of 20 mgkg every 5
If anaphylaxis: do not administer RR
 Pentamidine IM 4 mgkg daily for 7 days
- Give food 1 hour before to prevent hypoglycaemia
- The patient should be in a supine position
during administration and 1 hour after to prevent
T. rhodesiense sleeping sickness
 IV Melarsoprol mgkg body weight daily for 10 days
- T.gambiense sleeping sickness Children  12 years
- f Eflornithine IV 150 mgkg 6 hourly for 14 days RR
(total dose of 600 mgkgday. Dilute 150 mg
kg dose of eflornithine into the 100 ml of distilled
water. Administer the infusion over at least 2 hours
- Children 12 years up to 15 years
 Eflornithine IV 100 mgkg 6 hourly for 14 days (total dose
of 400 mgkg per day). Dilute the eflornithine dose of
100 mgkg into the 100 ml of distilled water. Administer
the infusion over at least 2 hours (rate 20 dropsminute)
- NifurtimoxElfornithine combination therapy (NECT)
- Nifurtimox: 5 mgkg every 8 hours orally for 10
- Plus Eflornithine 200 mgkg 12 hourly for 7 days (400
mgkgday). Dilute Eflornithine dose of 200 mgkg into
250 ml of distilled water and administer the infusion over
at least 2 hours (50 dropsminute)
- Infusions are given slowly to prevent convulsions
 Pentamidine IM 4 mgkg daily for 7 days
- Give food 1 hour before to prevent hypoglycaemia
- The patient should be in a supine position
during administration and 1 hour after to prevent
T. rhodesiense sleeping sickness
 IV Melarsoprol mgkg body weight daily for 10 days
- T.gambiense sleeping sickness Children  12 years
- f Eflornithine IV 150 mgkg 6 hourly for 14 days
(total dose of 600 mgkgday. Dilute 150 mg
kg dose of eflornithine into the 100 ml of distilled
water. Administer the infusion over at least 2 hours
- Children 12 years up to 15 years
 Eflornithine IV 100 mgkg 6 hourly for 14 days (total dose
of 400 mgkg per day). Dilute the eflornithine dose of
100 mgkg into the 100 ml of distilled water. Administer
the infusion over at least 2 hours (rate 20 dropsminute) RR
 IV melarsoprol mgkg once daily for 10 days
 Corticosteroids: Should be given to patients with late trypanosomiasis on melarsoprol who may have
 hypoadrenalism - the steroids may also reduce any drug
" Do not give hydrocortisone after day 24, even though the"
melarsoprol treatment is not yet complete
" If prednisolone is used instead of hydrocortisone, the anti-inflammatory action is similar but the correction of the"
hypoadrenalism will be much less marked
 Suramin: Do not use this medicine for early or late stage
T. gambiense treatment in onchocerciasis-endemic areas as it may
cause blindness in any onchocerciasis-infected patients by killing the
 Clearing of bushes around homes and paths
 Early detection and treatment of cases
 IV melarsoprol mgkg once daily for 10 days
 Corticosteroids: Should be given to patients with late trypanosomiasis on melarsoprol who may have
 hypoadrenalism - the steroids may also reduce any drug
" Do not give hydrocortisone after day 24, even though the"
melarsoprol treatment is not yet complete
" If prednisolone is used instead of hydrocortisone, the anti-inflammatory action is similar but the correction of the"
hypoadrenalism will be much less marked
 Suramin: Do not use this medicine for early or late stage
T. gambiense treatment in onchocerciasis-endemic areas as it may
cause blindness in any onchocerciasis-infected patients by killing the
HIVAIDS and Sexually Transmitted
"Always refer to the latest PMTCT, ART, and STGuidelines for the management of HIV and Sexually Transmitted Infections. This section has been adapted from the current Consolidated"
guidelines for prevention and treatment of HIV in Uganda.
HIV INFECTION AND ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) ICD 10 CODE: B20
Acquired Immunodeficiency Syndrome (AIDS) is a condition of reduced
immunity as a result of infection with the Human Immunodeficiency
Virus (HIV). HIV should be confirmed with an HIV test.
"Uganda has adopted the Test and Treat Policy, which involves providing lif long antiretroviral therapy (ART) to ALL people living with"
HIV irrespective of CD4 count or clinical staging.
 Sexual intercourse with an HIV-infected person
 Transfusion with HIV-infected blood
" Mother-To-Child Transmission during pregnancy, delivery,"
" HIV-contaminated sharp instruments, e.g., dental and surgical equipment, needles, scalpels, razors, hair shaving equipment, nail cutters, and other sharp objects"
 Exposure to HIV-infected materials through an open wound
Epidemiological risk factors for H Present or past high-risk behaviour (multiple sexual partners)
 Loss of a spouse or partner from HIV disease
" Having sexually transmitted infections, especially Herpes"
 Being in an HIV-discordant sexual relationship or marriage
 History of blood transfusion between 1975 and 1986
Clinical Features of HThe WHO Clinical Staging of HIV for adults and children in the tables
below shows the typical clinical features of HIV infection. The staging is
based on demonstration of one or more opportunistic infections or key
findings and correlates with disease progression and prognosis. Clinical
"staging should be performed at HIV diagnosis, on entry into HIV care,"
at ART initiation and at every visit hereafter to help guide patient care
WHO Staging for HIV Infection and Disease in Adults and Adolescents
2. Persistent generalised lymphadenopathy
"Performance Scale 1: asymptomatic, normal activity"
1. Moderate unexplained weight loss ( 10 of presumed or measured
"2. Minor mucocutaneous manifestations (seborrheic dermatitis, popular"
"pruritic eruptions, fungal nail infections, recurrent oral ulcerations,"
"4. Recurrent upper respiratory tract infections (e.g., bacterial sinusitis,"
"tonsillitis, otitis media, pharyngitis)"
Andor performance scale 2: symptomatic but normal activity
1. Unexplained severe weight loss (more than 10 of presumed or
2. Unexplained chronic diarrhoea for longer than one month
3. Unexplained persistent fever (intermittent or constant for longer
"7. Severe bacterial infections (such as pneumonia, pyomyositis, empyema, bone or joint infection, bacteraemia, meningitis)"
2. Persistent generalised lymphadenopathy
"Performance Scale 1: asymptomatic, normal activity"
1. Moderate unexplained weight loss ( 10 of presumed or measured
"2. Minor mucocutaneous manifestations (seborrheic dermatitis, popular"
"pruritic eruptions, fungal nail infections, recurrent oral ulcerations,"
"4. Recurrent upper respiratory tract infections (e.g., bacterial sinusitis,"
"tonsillitis, otitis media, pharyngitis)"
Andor performance scale 2: symptomatic but normal activity
1. Unexplained severe weight loss (more than 10 of presumed or
2. Unexplained chronic diarrhoea for longer than one month
3. Unexplained persistent fever (intermittent or constant for longer
"7. Severe bacterial infections (such as pneumonia, pyomyositis, empyema, bone or joint infection, bacteraemia, meningitis)"
"8. Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis"
"9. Unexplained anaemia (below 8 gdl), neutropenia (below 0.5109per"
"litre), or chronic thrombocytopenia (below 50 109 per litre)"
Andor performance scale 3: Bed ridden for less than 50 of the day
2. Pneumocystis jirovecii pneumonia (PCP)
3. Recurrent severe bacterial pneumonia ( 2 episodes within 1 year)
5. Cryptosporidiosis with diarrhoea for longer than 1 month
7. Extrapulmonary cryptococcosis including meningitis
8. Cytomegalovirus infection (retinitis or infection of other organs
"other than liver, spleen or lymph nodes)"
"9. Chronic oro-labial, genital or ano-rectal herpes simplex virus (HSV)"
10. Progressive multifocal leukoencephalopathy (PML)
"11. Any disseminated endemic mycosis such as histoplasmosis, coccidioidomycosis"
"12. Candidiasis of the oesophagus, trachea, bronchi, or lungs"
13. Disseminated non-tuberculous mycobacterial infection
14. Recurrent septicaemia (including non-typhoid salmonella)
15. Extrapulmonary tuberculosis
16. Lymphoma (cerebral or B-cell non-Hodgkin)
17. Invasive cancer of the cervix
"8. Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis"
"9. Unexplained anaemia (below 8 gdl), neutropenia (below 0.5109per"
"litre), or chronic thrombocytopenia (below 50 109 per litre)"
Andor performance scale 3: Bed ridden for less than 50 of the day
2. Pneumocystis jirovecii pneumonia (PCP)
3. Recurrent severe bacterial pneumonia ( 2 episodes within 1 year)
5. Cryptosporidiosis with diarrhoea for longer than 1 month
7. Extrapulmonary cryptococcosis including meningitis
8. Cytomegalovirus infection (retinitis or infection of other organs
"other than liver, spleen or lymph nodes)"
"9. Chronic oro-labial, genital or ano-rectal herpes simplex virus (HSV)"
10. Progressive multifocal leukoencephalopathy (PML)
"11. Any disseminated endemic mycosis such as histoplasmosis, coccidioidomycosis"
"12. Candidiasis of the oesophagus, trachea, bronchi, or lungs"
13. Disseminated non-tuberculous mycobacterial infection
14. Recurrent septicaemia (including non-typhoid salmonella)
15. Extrapulmonary tuberculosis
16. Lymphoma (cerebral or B-cell non-Hodgkin)
17. Invasive cancer of the cervix
20. Atypical disseminated leishmaniasis
21. Symptomatic HIV-associated nephropathy or symptomatic Hassociated cardiomyopathy andor performance scale 4: Bed-ridden
for more than 50 of the day during the last month
Diagnosis and Investigations of HHIV testing is the point of entry into comprehensive care HIV services.
The aim of HIV testing services (HTS) is to promptly identify HIV status
"to ensure early linkage to prevention, treatment, and support services."
"Early diagnosis is fundamental for early treatment, good prognosis and"
reduction in transmission. HTS should be availed to all persons at risk
of HIV infection using cost-effective and high-impact approaches. HTS
should be differentiated to subpopulations and geographical locations
because less than 20 of PLHIV aged 15 years and above do not know
their status. Uganda is currently implementing targeted HIV testing to
optimize HIV case identification and linkage to care. People at high risk
of HIV acquisition include: being in a sexual relationship with multiple
"concurrent partners; belonging to a key, vulnerable or priority population (e.g., children, adolescent girls and young women, pregnant or"
breastfeeding women); being a sexual contact to an index client; being
a biological child to an HIV positive client; not knowing your partners
HIV status; or being in a serodiscordant relationship.
The following approaches are utilized in targeted HIV testing.
"1. Screening for HIV testing eligibility for children, adolescents and adults"
"2. Index client testing (ICT), including Assisted Partner notification (APN)"
and testing for biological children Know Your Child Status (KYCS).
3. Social Network Strategy (SNS)
Pre and post counselling and consent are needed except in the following
" Diagnostic testing: test carried out on very sick,"
"unconscious, symptomatic or mentall ill by attending health care team"
for the purpose of better patient management
 Routine testing: for individuals likely to pose a risk of HIV infection
"to others e.g. pregnant and breastfeeding mothers, sexual offenders"
"and survivors, blood or body tissue or organ donors. Individuals"
tested using this appraoch must be given an opportunity to know
"If a patient is positive, heshe must be IMMEDIATELY connected to"
"In adults and children 18 months, testing is based on serological (antibody) testing."
"Due to the window period between infection and production of detectable levels of antibodies, patients who are negative should be re-tested"
after three months if they had a possible exposure in the 3 months
Serial HIV Testing Algorithm for testing persons above 18 months of
HIV Testing Algorithm using the HIV-Syphilis Duo Kit in MCH Settings
"No, Only HIV Does client need both syphilis and HIV No, Only syphilis"
"test (new, or previously negative)"
Client tested positive Screening Test Client already know
for syphilis and on HIVSyphilis Duo Test HIV postitiveve treatment within 1 year (TRRK)
Test for HIV using the Non-Reactive for using the single
National Algorithm HIV and Syphilis Reactive for HIV Reactive for syphilis syphilis rapid test
Reactive as Negative for HIV and
Re-test immediately Report HIV positive
Serological testing is available from HC2 level.
"In children below 18 months, testing is virological, that is based on direct"
detection of viral DNA (DNA-PCR).
Virological testing (DNA-PCR and viral load) is done on DBS (dried
blood spots) samples which can be collected from HC2 and are sent to
a central national laboratory through the hub system.
HIV testing in children less than 18 months
The recommended test for children 18 months is virological (DNA-PCR)
"testing, since antibody tests will detect antibodies passed to the child"
from the mother (so the test can give a false positive).
f The child is classified as HIV negative
 Do DNA PCR at 6 weeks of age or at an earlier opportunity
 Start cotrimoxazole prophylaxis and Niverapine syrup till
HIV status is confirmed for the child
" If PCR is positive, enroll child for ART"
 If PCR is negative and child never breasted the child is negative.
 Stop cotrimoxazole and Niverapine.
 Follow up every 3 months and do HIV rapid test (serological) at 18 months.
 If PCR is negative BUT child is breastfeedinghas breasfed
"in the last 6 weeks, re-check PCR 6 weeks after cessation of"
 Test the mother and continue management according to the
 Perform rapid antibody testing on the child. The result will give
indication on the mothers status:
- If the test is negative: child negative
"- If the test is positive, follow algorithm for managing a child"
CD4 It measures the level of CD4 T lym- HC2
"phocytes, a subtype white blood cell. It"
reflects the level of compromise of the
immune system. It is used for initial assessment pre ART and for monitoring
Viral Load It measures the quantity of virus in the HC2
blood. It is used to monitor the effect
of ARVs. It is currently done by DBS
Genotype HIV genotypic resistance test is a qualiTesting tative test that detects mutations associated with ARV drug resistance. The test
evaluates if the HIV strain infecting the
individual has developed resistance to
one or more ARV drugs. This is useful
in identifying a combination of ARVs to
which the HIV strain is susceptible
"CD4 It measures the level of CD4 T lymphocytes, a subtype white blood cell. It"
reflects the level of compromise of the
immune system. It is used for initial assessment pre ART and for monitoring
Viral Load It measures the quantity of virus in the
blood. It is used to monitor the effect
of ARVs. It is currently done by DBS
Testing HIV genotypic resistance test is a qualitative test that detects mutations associated with ARV drug resistance. The test
evaluates if the HIV strain infecting the
individual has developed resistance to
one or more ARV drugs. This is useful
in identifying a combination of ARVs to
which the HIV strain is susceptible 
HIV-Exposed Infants Testing Algorithm?sutats VIH srehtom eht si tahW
"soP ) s t h se tn il o ra m e, 8 re 1 t f o a t d p e u if i y t t n in ed u i t r f o i p ro p ( o"
seY?R d C ah P r d o n 2 gn f i o d e s e k f w ts 6 a e n rb ih
d ti l w ih c d e e f h ts t a s e I rb
o it t a r s e s h e r t a c o e m r y e t 1 e fa s o i k v t d e p e A u w g d 6 n e i e d R f e t C s e a P ft e s r A a b e N rb D f d o r3 geN
s V ht IH om:E 8 M 1 O ta C g T n U it O se
"a ffo ekat,gnideeftsaerb llits elihw citamptpmys"
skeewb6 ro shtnok 9 rehtie mhtirogla eht ot gnidrocca
"VIH enimreted ot selbab ni tset dipar esu yam,deniatrecsa"
"ro dehsiruoniam,citamotpmys si ohw"
tniop yna ta enod eb nac RCP AND lanif a neht
fo emit eht ta SBD 2 ffo ekat:nemiger
CHAPTER 3: HIVAIDS and Sexually
"Even without the use of specific ARV treatment, there are many ways"
in which good HIV management can help patients:
Prophylaxis against opportunistic infections HC2
The following groups have been prioritized for cotrimoxazole preventive therapy:
 All PLHIV newly initiating on ART.
 Those having a current WHO stage 3 or 4 event or other
 Pregnant and breast-feeding women.
Note: Additional intermittent preventive treatment for malaria
using Sulfadoxine-Pyrimethamine (SP) is not required for
 Children and adolescents aged 0-15 years.
Patients suspected to have treatment failure
 Cotrimoxazole 960 mg once daily for adults and children
Child 5 kg: 120 mg once daily Child 5-kg: 240 mg
once daily Child 15-kg: 480 mg once daily
" Contraindications: known allergies, severe anaemia and"
Guidance for when to stop CPT in stable PLH Patient should be older than 15 years of age.
 Patient should not be pregnant.
Prophylaxis against opportunistic infections
The following groups have been prioritized for cotrimoxazole preventive therapy:
 All PLHIV newly initiating on ART.
 Those having a current WHO stage 3 or 4 event or other
 Pregnant and breast-feeding women.
Note: Additional intermittent preventive treatment for malaria
using Sulfadoxine-Pyrimethamine (SP) is not required for
 Children and adolescents aged 0-15 years.
Patients suspected to have treatment failure
 Cotrimoxazole 960 mg once daily for adults and children
Child 5 kg: 120 mg once daily Child 5-kg: 240 mg
once daily Child 15-kg: 480 mg once daily
" Contraindications: known allergies, severe anaemia and"
Guidance for when to stop CPT in stable PLH Patient should be older than 15 years of age.
 Patient should not be pregnant. HC2
 Patient should have been on ART for at least one year. HC2
 Patients last VL should be suppressed.
 Patient should not have a current WHO stage 3 or 4 event
or other symptoms of advanced HIV disease at the time
When to re-start CPT in PLHCPT can be restarted in the following scenarios:
 New Treatment WHO stage 3 or 4 condition
Adults and child 12 years: dapsone 100 mg daily
Children below 12 years: dapsone 2 mgkg daily
TPT (TB Preventive treatment) HC3
 such as; isoniazid  rifapentine(3HP) weekly for 3
"months in all adults, adolescents and children 12"
months living with HIV and in whom TB disease has
been excluded (other medications for TPT refer to the
" If child 12 months, give only if history of contact with"
TB case and no active disease (one-month daily rifapentine and isoniazid (1HP).)
Prompt and appropriate medical care HC3
By treating opportunistic infections as they occur
"By treating symptoms, such as pain, diarrhoea, and skin"
Going for treatment promptly if unwell
 Patient should have been on ART for at least one year.
 Patients last VL should be suppressed.
 Patient should not have a current WHO stage 3 or 4 event
or other symptoms of advanced HIV disease at the time
When to re-start CPT in PLHCPT can be restarted in the following scenarios:
 New Treatment WHO stage 3 or 4 condition
Adults and child 12 years: dapsone 100 mg daily
Children below 12 years: dapsone 2 mgkg daily HC2
 such as; isoniazid  rifapentine(3HP) weekly for 3
"months in all adults, adolescents and children 12"
months living with HIV and in whom TB disease has
been excluded (other medications for TPT refer to the
" If child 12 months, give only if history of contact with"
TB case and no active disease (one-month daily rifapentine and isoniazid (1HP).)
Prompt and appropriate medical care
By treating opportunistic infections as they occur
"By treating symptoms, such as pain, diarrhoea, and skin"
Going for treatment promptly if unwell HC3
"Positive health, dignity, and prevention intervention"
Preventing HIV trans- PLHIV should be encouraged to
"mission adopt safer sexual practices including abstinence, correct and consistent condom use. Condom use"
"prevents HIV transmission, reduces"
"risk of other STIs, and prevents"
Disclosure and partner PLHIV should actively explore ways
testing of disclosing their HIV status to
"sexual partners, family members"
and significant others. Offer provider- andor counselor-mediated or
supported disclosure as options for
those who do not feel comfortable
Family planning Encourage PLHIV to discuss their
reproductive choices and support
them to adopt those which do not
compromise their health. For women
"who choose to conceive, link them"
Alcohol and other risk Educate on risks of alcohol abuse
reduction leading to poor treatment adherence
"resulting in disease progression,"
and the likelihood of engaging in
"risky sexual behaviours, placing"
themselves at increased risk for
acquiring STIs and placing their
Preventing HIV transmission PLHIV should be encouraged to
"adopt safer sexual practices including abstinence, correct and consistent condom use. Condom use"
"prevents HIV transmission, reduces"
"risk of other STIs, and prevents"
testing PLHIV should actively explore ways
of disclosing their HIV status to
"sexual partners, family members"
and significant others. Offer provider- andor counselor-mediated or
supported disclosure as options for
those who do not feel comfortable
Family planning Encourage PLHIV to discuss their
reproductive choices and support
them to adopt those which do not
compromise their health. For women
"who choose to conceive, link them"
reduction Educate on risks of alcohol abuse
leading to poor treatment adherence
"resulting in disease progression,"
and the likelihood of engaging in
"risky sexual behaviours, placing"
themselves at increased risk for
acquiring STIs and placing their
General Principles of Antiretroviral Treatment (ART)
 Level of understanding of HIVAIDS
 Length of time since the diagnosis of HIV infection
 Demographics and lifestyle: whether employed and nature
" Pregnancy risks: contraception options and choices, current"
"or planned pregnancy, access to contraceptive services"
" Sexual risks and disclosure: willingness to practice safer sex,"
"disclosure of HIV serostatus, use of condoms, HIV counselling, and testing of sex partners and children"
 Symptoms of chronic pain and depression
" History of opportunistic infections and other significant illnesses e.g. TB and STIs, hospitalisations, and surgeries"
" Current medications (including anti-TB drugs, traditional"
 Functional capacity and level of disability
" Vital signs, skin, eyes, oropharynx (presence of thrush),"
"lymph nodes, lungs, heart, abdomen, genital tract (STIs), extremities, nervous system"
Baseline laboratory tests to assess immunosuppression and disease
 Full blood count particularly for patients starting on a
Baseline Labs to assess general health and diagnose any pre-existing Hcomplications
 Sputum smear for AFB for patients who have coughed for
 2-3 weeks and a chest X-ray for patients who have unproductive cough or whose AFB smears are negative
" Urine analysis for proteinuria, particularly for patients starting on TDF-containing regimen"
 Syphilis and Hepatitis B screening
 Liver and renal function tests if available
 Cryptococcal antigen and urine LAM screening for patients
whose CD4 count is  200 cellsml
 Symptom-directed lab tests to diagnose pre-existing illnesses
 Using WHO clinical criteria (see tables above) Counselling
and assessment of patients readiness to start therapy
" Assess for education, information or counselling support"
Goals of treatment with antiretroviral medicines are to:
 Inhibit viral replication as reflected in plasma HIV concentration to as low as possible and for as long as possible.
This promotes restoration of the immune system.
" Preserve or enhance the immune function (CD4 restoration), which preventsdelays the clinical progression of"
 Minimise toxicities and side effects associated with the
 Improve quality of life and reduce HIV-related morbidity and
 Promote growth and neurological development in children
Tools to achieve the goals of therapy
 Maximisation of adherence to ART: adequate support to patient to adhere to treatment andor access to community
facility level adherence counselling
  Disclosure of HIV serostatus reinforces patients adherence
 Rational sequencing of medicines to preserve future treatment options
 Use of ARV medicine resistance testing when appropriate
 Use of viral load estimates for monitoring
 Antiretroviral therapy is part of comprehensive HIV care.
The guiding principles of good ART include:
 Efficacy and durability of the chosen medicine regimens
 Freedom from serious adverse effects; low toxicity
" Ease of administration including no food restrictions, better"
"palatability, and lower pill burden"
 Affordability and availability of medicines and medicine combinations
 Organised sequencing  spares other available formulations
for use in second line while allowing for harmonisation of
regimens across age and population
 Ongoing support of the patient to maintain adherence
 Antiretroviral medicines are not a cure for HIV but greatly
improve quality of life when used appropriately
" ARVs are relatively expensive, require an adequate infrastructure, and knowledgeable healthcare workers"
 Medicine interactions and resistance may decrease the potency of ARVs
 Patients may develop adverse medicine reactions
 Patients have to take at least 95 of their pills in order to
respond well (adherence is key to successful therapy)
 The medications have to be taken for life
 Some patients may not respond (benefit) to treatment and
continue to regress in spite of high adherence
 Children are dependent on adults for adherence to ART
"At present, antiretroviral medicines come in six classes, which attack"
"different sites and stages of the HIV life cycle, thereby interfering with"
Nucleoside reverse transcriptase inhib- Tenofovir (TDF) Zidovuitors (NtRTIs) incorporate themselves into dine (AZT) Lamivudine
"the DNA of the virus, thereby stopping the (3TC)"
Non-nucleoside reverse transcriptase Efavirenz (EFV) Neviinhibitors (NNRTIs) stop HIV production rapine (NVP) Etravirine
by binding directly onto the reverse (ETV)
"transcriptase enzyme, and prevent the conversion of RNA to DNA"
Nucleoside reverse transcriptase inhibitors (NtRTIs) incorporate themselves into
"the DNA of the virus, thereby stopping the"
building process Tenofovir (TDF) Zidovudine (AZT) Lamivudine
Non-nucleoside reverse transcriptase
inhibitors (NNRTIs) stop HIV production
by binding directly onto the reverse
"transcriptase enzyme, and prevent the conversion of RNA to DNA Efavirenz (EFV) Nevirapine (NVP) Etravirine"
Integrase inhibitors interfere with the HIV Dolutegravir
DNAs ability to insert itself into the host DNA
Protease inhibitors (PIs) prevent HIV from Atazanavir (ATV)
being successfully assembled and released Lopinavir (LPV) Darunfrom the infected CD4 cell. Boosted PIs are avir (DRV)
combinations of low-dose ritonavir (RTV) with
"Ritonavir (RTV, abbrea PI for pharmacoenhancement"
Entry inhibitors (HIV fusion inhibitors) Enfuvirtide
prevent the HIV virus particle from infecting
CCR5 antagonists block the CCR5 co-re- Maraviroc
ceptor molecules that HIV uses to infect
new target T-cells. Some forms of HIV use
"a different coreceptor and thus, some patients may not"
It is recommended to initiate ART at the earliest opportunity in all do
"umented HIV-infected adults, adolescents and children regardless of"
CD4 count and WHO clinical staging (Test and Treat)
Evidence and programmatic experience have shown that early initiation
"of ART results in reduced mortality, morbidity and HIV transmission"
priority should be given to patients with lower CD4 counts as well as
Integrase inhibitors interfere with the HDNAs ability to insert itself into the host DNA
Protease inhibitors (PIs) prevent HIV from
being successfully assembled and released
from the infected CD4 cell. Boosted PIs are
combinations of low-dose ritonavir (RTV) with
a PI for pharmacoenhancement Atazanavir (ATV)
Lopinavir (LPV) Darunavir (DRV)
"Ritonavir (RTV, abbreviated as r if boosting"
Entry inhibitors (HIV fusion inhibitors)
prevent the HIV virus particle from infecting
CCR5 antagonists block the CCR5 co-receptor molecules that HIV uses to infect
new target T-cells. Some forms of HIV use
"a different coreceptor and thus, some patients may not"
benefit from maraviroc Maraviroc
A CD4 count is not necessary for initiation but should be used to identify
patients with advanced HIV disease.
The vast majority (about 90) of infants and children with HIV acquire
the infection through mother-to-child transmission.
HIV infection follows a more aggressive course among infants and children
than among adults; 30 die by age 1 year and 50 die by age 2 years
"without access to life-saving medicines, including ART and preventive"
"interventions, such as cotrimoxazole prophylaxis."
Early HIV diagnosis and ARV treatment is critical for infants. A significant
number of lives can be saved by initiating ART for HIV-positive infants
immediately after diagnosis within the first 12 weeks of life.
" ARV doses need to be adjusted from time to time as the children grow quickly and thus, their weight changes."
" Before a child begins ART, the following assessments must"
 Readiness of parentscaretakers or child (if older) to start
 Complete pre-treatment baseline assessment (see previous sections)
Health workers should do the following before initiating ART:
Assess all clients for any evidence of opportunistic infections (OIs). If
"the patient has TB or cryptococcal meningitis, ART should be deferred"
and initiated after starting treatment of these OIs.
"For patients without TB or cryptococcal meningitis, offer ART on the"
"same day through an opt-out approach. In this approach, patients should"
be prepared and assessed for readiness to start ART on the same day.
"If a client is ready, ART should be initiated on the same day. If a client is"
"not ready or opts out of same-day initiation, a timely ART preparation"
plan should be agreed upon with the aim of initiating ART within seven
"days for children and pregnant women, and within one month for adults."
"Recommended First Line Regimens in Adults, Adolescents,"
HIV management guidelines are constantly being updated according
to evidence and public policy decisions. Always refer to the latest
The 2022 guidelines recommend DOLUTEGRAVIR (DTG) an
integrase inhibitor as the anchor ARV in the preferred first and
"second-line treatment regimens for all HIV infected clients; children,"
"adolescents, men, women (including pregnant women, breastfeeding"
"women, adolescent girls and women of child bearing potential)."
"ART regimens in children are age and weight dependent. When children grow, doses and regimens have to be changed according to the"
"Recommended first-line ARV regimens in adults, adolescents,"
pregnant or breastfeeding women and children
Patient Category Preferred Alternative regimens
Adults (including TDF 3TC If DTG is contraindicated1 use:;:
and breast feedIf TDF is contraindicated use: TAFing mothers and
"If TDF or TAF is contraindicated,"
HIV management guidelines are constantly being updated according
to evidence and public policy decisions. Always refer to the latest
The 2022 guidelines recommend DOLUTEGRAVIR (DTG) an
integrase inhibitor as the anchor ARV in the preferred first and
"second-line treatment regimens for all HIV infected clients; children,"
"adolescents, men, women (including pregnant women, breastfeeding"
"women, adolescent girls and women of child bearing potential)."
"ART regimens in children are age and weight dependent. When children grow, doses and regimens have to be changed according to the"
DTG If DTG is contraindicated1 use:;:
If TDF is contraindicated use: TAF-
"If TDF or TAF is contraindicated,"
Patient Cate- Preferred Alternative regimens
If TDF or TAF and DTG are contraindicated:
If EFV and DTG are contraindicated:
Children ABC  If DTG is contraindicated:
TAFFTC DTG (For Children 6 years and
if ABC and TAF are contraindicated
C h i l - ABC  If intolerant or appropriate DTG formulations
ABC  3TC  EFV (in children  3 years and
If TDF or TAF and DTG are contraindicated:
If EFV and DTG are contraindicated:
TAFFTC DTG (For Children 6 years and
if ABC and TAF are contraindicated
DTG If intolerant or appropriate DTG formulations
ABC  3TC  EFV (in children  3 years and
1. Contraindications for 3 TAF can be used in sub populations with
DTG (use DTG screening bone density anomalies.
tool prior to DTG initi4. Children will be assessed individually
for ability to correctly take the different
"anticonvulsants (carbamazepine, phenytoin,"
TDF and TAF: Renal disease andor GFR
Drug Family ARV Drug Interaction Action
Anti-TB NVP Rifampicin decreases Do not co-adminmedicines NVP concentrations ister NVP and riin blood. fampicin
Could cause liver tox- See Table 30 and
DTG Rifampicin lowers DTG Adjust DTG dose
"AT V  r, Rifampicin boosts me- If given together"
"LPVr, DRV tabolism of PIs with LPVr inand RTV crease the dose"
tool prior to DTG initiation) including: known
"anticonvulsants (carbamazepine, phenytoin,"
TDF and TAF: Renal disease andor GFR
30Kg 3 TAF can be used in sub populations with
4. Children will be assessed individually
for ability to correctly take the different
Drug Family ARV Drug Interaction Action
medicines NVP Rifampicin decreases
Could cause liver toxicity Do not co-administer NVP and rifampicin
"LPVr, DRand RTV Rifampicin boosts metabolism of PIs If given together"
Drug Family ARV Drug Interaction Action
Combined EFV or AT- Risk of contraceptive Use additional
"oral contra- Vr, LPVr, failure due to increased barrier method"
metabolism of contrahormonal im- RTceptives Use Depo-Proplants (etonovera or IUDs
"Anxiolytics, A T V  r, Risk of respiratory de- Reduce dose of"
"e.g. mida- LPVr, DRV pression midazolam or"
"Simvastatin, A T V  r, Inhibition of CYP450 Use atorvastarosuvastatin, LPVr, DRV 3A4 (reduced metabo- tin with lowered"
atorvastatin and RTV lism of statins) dose and monitor for side effects like muscle
"Anti-epi- EFV, DTG, Carbamazepine de- Use valproic"
"leptics, e.g. creases DTG levels by acid"
Drugs for ATVr Reduced concentrations Use alternatives
"acid reflux or of Atazanavir like ranitidine,"
Drug Family ARV Drug Interaction Action
"hormonal implants (etonogestrel) EFV or ATVr, LPVr,"
metabolism of contraceptives Use additional
"e.g. midazolam, diazepam A T V  r,"
"LPVr, DRand RTV Risk of respiratory depression"
Increased sedation (diazepam) Reduce dose of
"LPVr, DRand RTV Inhibition of CYP450"
3A4 (reduced metabolism of statins) Use atorvastatin with lowered
dose and monitor for side effects like muscle
"carbamazepine, phenobarbital, and"
Etravirine Carbamazepine decreases DTG levels by
pantoprazole ATVr Reduced concentrations
Drug Family ARV Drug Interaction Action
Polyvalent DTG Reduce DTG levels Use DTG 2
"ing Mg, Al, after the prodFe, Ca, Zn uct to avoid"
Antimalarial ATV Both could prolong QT When
Metformin DTG DTG increases met- Close folformin levels. May low-up
Drug Family ARV Drug Interaction Action
"cation products containing Mg, Al,"
and antacids) DTG Reduce DTG levels Use DTG 2
halofantrine ATV Both could prolong QT
monitor closely for undesired effects
Metformin DTG DTG increases metformin levels. May
metabolic acidosis Close follow-up
The purpose of monitoring patients on ART is to assess:
 Response to ART and early detection of treatment failure
The schedule of monitoring visits follow a pre-set calendar for the 1st
"one year after initiation of ART, i.e:"
" At 1, 2 and 3 months from start of ART"
"After 12 months from initiation of ART, the Differentiated Model of"
"Care Delivery is followed, in which schedule and modalities of periodic"
checks are based on individual needs and characteristics of the patient.
" A client centered approach, so that stable patients have spaced"
checks and fast tracks drug pick ups
 More efficient use of resources by avoiding overcrowding and long
 More focus on unstablecomplex patients
(Refer to MOH HIVART guidelines for more details).
opportunistic infections (OI) and
"ST- Assess for pregnancy, andor"
- Screen and manage comorbidities including depression
Clinical Monitoring - Screen for and manage
opportunistic infections (OI) and
"ST- Assess for pregnancy, andor"
- Screen and manage comorbidities including depression
"- Growth and development, school"
"attendance, behavioural issues,"
"ATVr, LPVr, DRV and RTLaboratory Monitoring  Viral load"
 Is preferred method to monitor response to ART and treatment failure:
 Children and adolescents under 19
years of age: first VL at 6 and 12
"months from initiation, if suppressed"
 Adults: First VL at 6 months after
"initiation. Second VL following suppressed viral load at 12 months,"
then every 12 months if suppressed.
 HIV positive pregnant and breastfeeding women: If newly initiated on
"ART at ANC, conduct a VL test at"
3 months on ART. If VL suppressed
repeat VL every 3 months throughout
pregnancy and until cessation of
 HIV-positive pregnant and breastfeeding women already on ART at
ANC1 or MBCP: conduct a VL test
at first ANC or MBCP visit. If VL is
supressed repeat VL every 3 months
throughout pregnancy until cessation
"- Growth and development, school"
"attendance, behavioural issues,"
"ATVr, LPVr, DRV and RTLaboratory Monitoring  Viral load"
 Is preferred method to monitor response to ART and treatment failure:
 Children and adolescents under 19
years of age: first VL at 6 and 12
"months from initiation, if suppressed"
 Adults: First VL at 6 months after
"initiation. Second VL following suppressed viral load at 12 months,"
then every 12 months if suppressed.
  HIV positive pregnant and breastfeeding women: If newly initiated on
"ART at ANC, conduct a VL test at"
3 months on ART. If VL suppressed
repeat VL every 3 months throughout
pregnancy and until cessation of
 HIV-positive pregnant and breastfeeding women already on ART at
ANC1 or MBCP: conduct a VL test
at first ANC or MBCP visit. If VL is
supressed repeat VL every 3 months
throughout pregnancy until cessation
" If unsuppressed in the above, refer"
 After every switch in treatment (after
failure): VL at 6 months after a switch
 Third line ART patients: VL every 6
"months. If VL is un-suppressed, then"
genotype testing is recommended.
 Recommended at baseline to screen
for risk of opportunistic infections
 In patients who are suppressed butare
 In patients on prophylaxis for cryptococcus to inform decison on when
- According to clinical findings
"  If unsuppressed in the above, refer"
 After every switch in treatment (after
failure): VL at 6 months after a switch
 Third line ART patients: VL every 6
"months. If VL is un-suppressed, then"
genotype testing is recommended.
 Recommended at baseline to screen
for risk of opportunistic infections
 In patients who are suppressed butare
 In patients on prophylaxis for cryptococcus to inform decison on when
- According to clinical findings
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"x If VL is not suppressed, call the patient back for intensive adherence counseling"
"x This is to be done in children, adolescents, pregnant and"
"VL testing algorithm for children, adolescents and adults for health"
facilities using plasma and DBS samples:gnirotinom daol lariV enituoR
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"ARV drugs can cause a wide range of toxicities, from mild to life threatening. Active monitoring and management of toxicities and side effects"
is important not only to avoid negative medical outcome but also to
ensure that they do not negatively affect adherence.
Severe Life- Immediately discontinue all ARV drugs
"Threatening (possibly all drugs in general), manage the"
medical event and substitute the offending
drug when the patient is stabilised
Severe Stop the offending drug and substitute
Reactions it without stopping the ART (if
"clinically possible) (e.g. Hepatitis, anaemia)"
"Moderate Reactionsy Substitute with a drug in the same AR(Gynaecomastia, lipo- class but with a different toxicity profile, or"
with a drug in a different class
Do not discontinue ART. Continuation
of ART as long as feasible. If the patient
"does not improve on symptomatic therapy, consider single- drug substitution"
Mild Reactions (Head- Do not discontinue or substitute ART.
"ache, minor rash, nauReassure the patient or caregiver that"
"while the reaction may be bothersome, it"
does not require a change in therapy and
often it subsides in few weeks.
Provide support to mitigate the adverse
reactions as well as counseling about the
severe hepatitis Immediately discontinue all ARV drugs
"(possibly all drugs in general), manage the"
medical event and substitute the offending
drug when the patient is stabilised
"(e.g. Hepatitis, anaemia) Stop the offending drug and substitute"
it without stopping the ART (if
"(Gynaecomastia, lipodystrophy) Substitute with a drug in the same ARclass but with a different toxicity profile, or"
with a drug in a different class
Do not discontinue ART. Continuation
of ART as long as feasible. If the patient
"does not improve on symptomatic therapy, consider single- drug substitution"
"Mild Reactions (Headache, minor rash, nausea) Do not discontinue or substitute ART."
Reassure the patient or caregiver that
"while the reaction may be bothersome, it"
does not require a change in therapy and
often it subsides in few weeks.
 Provide support to mitigate the adverse
reactions as well as counseling about the
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"Recommended Second Line Regimens in Adults, Adolescents, Pregnant Women and Children"
Patients may need to be switched to second line regimens in case of
"treatment failure, and to third line if they fail on second line drugs. Third"
line regimens require resistancetesting to inform the choice of appropriate
"drugs, and needs referral to specialised ART centres."
"Factors involved in treatment failure are poor adherence, inadequate"
drug levels or prior existing drug resistance.
"Before switching therapy, it is essential to assess and address adherence issues, and provide intensive adherence counselling if necessary."
Criteria for defining treatment failure are presented in the following table:
VIROLOGICAL FAILURE Patient should
"Two consecutive viral loads 1000 copiesml,"
"done at three to six months apart, with intensive"
adherence support following the 1st VL test
CLINICAL FAILURE The condition must be
New or recurrent WHO clinical stage 3 or 4 (with
exception of TB) in a patient who has been on efReconstitution
fective ART regimen for at least six months
New or recurrent WHO clinical stage 3 or stage 4
event (with the exception of TB) in a patient who has occurring after
been on effective ART regimen for at least six months initiating ART
"Two consecutive viral loads 1000 copiesml,"
"done at three to six months apart, with intensive"
adherence support following the 1st VL test Patient should
New or recurrent WHO clinical stage 3 or 4 (with
exception of TB) in a patient who has been on effective ART regimen for at least six months
New or recurrent WHO clinical stage 3 or stage 4
event (with the exception of TB) in a patient who has
been on effective ART regimen for at least six months The condition must be
drihT snemiger VIH -tset -itpecsus eht -anretla
"enil dediug fo,sgurd ot ro.seciohc"
FAT rVPLCT3TZA rVRDCT3TZA rVPLCT3TZA
CBA GTDCT3TZA GTDCT3CBA VFECT3CBA PVNCT3CBA rVPLCT3CBA GTDCT3CBA
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 GTDCT3TZA GTDCT3TZA GTDCT3CBA GTDCT3CBA rVRDCT3CBA
gniliaF VFECT3TZA PVNCT3TZA rVPLCT3TZA GTDCT3TZA VFECT3CBA PVNCT3CBA rVPLCT3CA VFECT3TZA PVNCT3TZA rVPLCT3TA GTDCT3TZA
Dosing Tables for ARV Medicines
stnec stluda gk53 MP - 1 - 1 1 1
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"1. For children10kg that are able to swallow tablets, give LPVr"
2. tablets of LPVr 10025mg can be substituted with 1 tablet of
LPVr 20050mg in order to reduce the pill burden. These tablets
should be administered fully intactwhole i.e. not cut or crushed.
3. DRV must be administered with 0.5mL of RTV 80mgmL oral
"suspension in children 15kg, with 2 tab of RTV 25mg in children"
15 to 25kg and 3 tab of RTV 25mg in children above 25kg. DRis always taken with food.
4. DRV 600mg must be co-administered with RTV 100mg.
Mother-to-Child Transmission of HApproximately one-third of the women who are infected with HIV can
 During time of labour and delivery (60-70)
 After delivery through breast feeding (15-20)
 Depleted maternal immunity (e.g. very low CD4 count)
 Intra-partum haemorrhage and invasive obstetrical procedures
" If delivering twins, first twin is at higher risk of infection than"
 Premature baby is at higher risk than term baby
 Mixed feeding carries a higher risk than exclusive breastfeeding or use of replacement feeding
 HIV DNA PCR testing of babies (see algorithm in section above)
 Viral load testing every 6 months
All HIV services for pregnant mothers are offered in the MCH clinic.
"After delivery, mother and baby will remain in the MCH postnatal clinic"
till HIV status of the child is
"confirmed, then they will be transferred to the general ART clinic."
The current policy aims at elimination of Mother-to-Child Transmission
(eMTCT) through provision of a continuum of care with the following
"- Primary HIV prevention for men, women and adolescents"
- Prevention of unintended pregnancies among women living
with H- Prevention of HIV transmission from women living with Hto their infants
"- Provision of treatment, care and support to ALL women"
"infected with HIV, their children and their families"
3.Management of HIV Positive Pregnant Mother
eMTCT Services for Pregnant Women
Provide HTS and   Offer routine HTS and testing for syphilis
syphilis testing in to pregnant women and their partner(s)
ANC with same-day results using the SDBioline duo HIVsyphilis test according to
algorithm If found positive treat for syphilis
in order to reduce HIV transmission from
mother to child using the following:
 o Pregnant womengirls with early syphilis:
give Benzathine Penicillin G million
units intramuscularly once. Early syphilis
"for this guideline is: (primary, secondary"
and early latent syphilis of not more than
 o In late syphilis or unknown stage of
syphilis: give Benzathine Penicillin G million units intramuscularly once weekly
for three consecutive weeks. Late syphilis
for this guideline is defined as infection
of more than two years duration without
evidence of treponemal infection.
 o Note: Adequate maternal treatment for
prevention of congenital syphilis is defined
as at least one injection of million units
of intramuscular Benzathine Penicillin at
least 30 days prior to delivery.
 o Alternative treatment with Procaine
"Penicillin or Erythromycin, Azithromycin"
and Ceftriaxone if allergic to penicillin.
ANC   Offer routine HTS and testing for syphilis
to pregnant women and their partner(s)
with same-day results using the SDBioline duo HIVsyphilis test according to
algorithm If found positive treat for syphilis
in order to reduce HIV transmission from
mother to child using the following:
 o Pregnant womengirls with early syphilis:
give Benzathine Penicillin G million
units intramuscularly once. Early syphilis
"for this guideline is: (primary, secondary"
and early latent syphilis of not more than
 o In late syphilis or unknown stage of
syphilis: give Benzathine Penicillin G million units intramuscularly once weekly
for three consecutive weeks. Late syphilis
for this guideline is defined as infection
of more than two years duration without
evidence of treponemal infection.
 o Note: Adequate maternal treatment for
prevention of congenital syphilis is defined
as at least one injection of million units
of intramuscular Benzathine Penicillin at
least 30 days prior to delivery.
 o Alternative treatment with Procaine
"Penicillin or Erythromycin, Azithromycin"
and Ceftriaxone if allergic to penicillin.
 Offer syphilis screening using syphilis
rapid tests for mothers who are already on
"o Offer HTS (including PITC, VCT and couple testing) and support mutual disclosure."
 Link all HIV-positive seroconcordant couples as well as HIV-positive individuals in
serodiscordant relationships to ART.
 Offer PrEP to all pregnant and breastfeeding mothers at substantial risk of Hacquisition as well as negative partners in
" For HIV-negative pregnant women, retest in the third trimester, during labor,"
"or shortly after delivery, because of the"
high risk of acquiring HIV infection during
 Re-test HIV-negative pregnant women
in a discordant relationship every three
 Re-test the following HIV negative pregnant women within four weeks of the first
"o STI, HBV or TB-infected pregnant woen."
o Those with a specific incident of HIV-exposure within the past three months
 Provide risk reduction counseling to
 Test pregnant womengirls and their partners for Hepatitis B during antenatal
  Offer syphilis screening using syphilis
rapid tests for mothers who are already on
"o Offer HTS (including PITC, VCT and couple testing) and support mutual disclosure."
 Link all HIV-positive seroconcordant couples as well as HIV-positive individuals in
serodiscordant relationships to ART.
 Offer PrEP to all pregnant and breastfeeding mothers at substantial risk of Hacquisition as well as negative partners in
" For HIV-negative pregnant women, retest in the third trimester, during labor,"
"or shortly after delivery, because of the"
high risk of acquiring HIV infection during
 Re-test HIV-negative pregnant women
in a discordant relationship every three
 Re-test the following HIV negative pregnant women within four weeks of the first
"o STI, HBV or TB-infected pregnant woen."
o Those with a specific incident of HIV-exposure within the past three months
 Provide risk reduction counseling to
 Test pregnant womengirls and their partners for Hepatitis B during antenatal
"o For patients who are HBsAg positive, assess"
the HBeAg and HBV viral load. Patients
who are HBeAG negative with a HBV VL of
"200,000 IUml should be monitored with"
"CBC, LFTs and VL at 6 and 12 months (see"
o For patients who are HBsAg positive assess
the HBeAg and HBV viral load. Patients
who are HBeAg positive with HBV VL of
"200,000 IUml should initiate prophylactic"
treatment at 24 weeks gestation or at the
earliest contact. Discontinue medication 3
"months after delivery. After starting treatment, LFTs should be monitored at 4, 8,"
12 and 24 weeks and thereafter annually.
Monitor HBV viral load at 6 and 12 months
Antenatal care pack- General care:
 All pregnant womengirls should have
at least eight ANC visits: encourage and
support mothers to start ANC in the first
" Routinely provide iron, folic acid, and multivitamin supplements"
 Deworm in the 2nd trimester using Mebendazole
" Provide nutrition assessment, counseling"
 Counsel and encourage women to deliver at
Screen for TB and take appropriate action
Take weight and BP at every visit
" o For patients who are HBsAg positive, assess"
the HBeAg and HBV viral load. Patients
who are HBeAG negative with a HBV VL of
"200,000 IUml should be monitored with"
"CBC, LFTs and VL at 6 and 12 months (see"
o For patients who are HBsAg positive assess
the HBeAg and HBV viral load. Patients
who are HBeAg positive with HBV VL of
"200,000 IUml should initiate prophylactic"
treatment at 24 weeks gestation or at the
earliest contact. Discontinue medication 3
"months after delivery. After starting treatment, LFTs should be monitored at 4, 8,"
12 and 24 weeks and thereafter annually.
Monitor HBV viral load at 6 and 12 months
Antenatal care package for all pregnant
 All pregnant womengirls should have
at least eight ANC visits: encourage and
support mothers to start ANC in the first
" Routinely provide iron, folic acid, and multivitamin supplements"
 Deworm in the 2nd trimester using Mebendazole
" Provide nutrition assessment, counseling"
 Counsel and encourage women to deliver at
Screen for TB and take appropriate action
Take weight and BP at every visit
"Screen and treat for syphilis, HIV, hepatitis"
"B, other STIs and anemia. Use syndromic"
Perform urinalysis to detect a urinary tract
"infection (UTI), protein in the urine (proteinuria), or blood in the urine (hematuria)"
"indicating kidney damage, or sugar in urine"
Do a blood slide for malaria for all pregnant women.
Perform a blood group test in anticipation
of blood transfusion and check for hereditary conditions if suspected (sickling test)
"Laboratory investi- For HIV-positive women, perform a"
gations specific to baseline CD4 count. The test result is not
HIV-positive pregnant required for ART initiation.
Do Hb test for womengirls beginning
AZT-based ART at baseline and four weeks
For HIV-positive pregnant womengirls
"already on ART, do VL test at first ANC"
"visit, then follow the VL testing algorithm"
for pregnant and breast feeding women.
For newly diagnosed HIV-positive pregnant
"womengirls, do VL test 3 months after"
initiating ART and then every 3 months
"Screen and treat for syphilis, HIV, hepatitis"
"B, other STIs and anemia. Use syndromic"
Perform urinalysis to detect a urinary tract
"infection (UTI), protein in the urine (proteinuria), or blood in the urine (hematuria)"
"indicating kidney damage, or sugar in urine"
Do a blood slide for malaria for all pregnant women.
Perform a blood group test in anticipation
of blood transfusion and check for hereditary conditions if suspected (sickling test)
Laboratory investigations specific to
"women For HIV-positive women, perform a"
baseline CD4 count. The test result is not
Do Hb test for womengirls beginning
AZT-based ART at baseline and four weeks
For HIV-positive pregnant womengirls
"already on ART, do VL test at first ANC"
"visit, then follow the VL testing algorithm"
for pregnant and breast feeding women.
For newly diagnosed HIV-positive pregnant
"womengirls, do VL test 3 months after"
initiating ART and then every 3 months
Comprehensive care At each visit provide:
Comprehensive clinical evaluation
with HPregnant women on CPT should not be
given Sulphadoxine-Pyrimethamine (Fansidar) for intermittent preventive treatment
Screen for TB and take appropriate action
Screening and management of opportunistic infections (OIs)
Assess risk of unborn  Conduct a risk assessment of the unborn
baby among pregnant baby at 1st ANC among all HIV positive
women with HIV at pregnant women and at every visit and flag
ANC 1 those at high-risk including:
o Newly initiated on ART in the 3rd trimester or breastfeeding period
o Most recent VL is non-suppressed
o Mothers testing HIV positive later in pregnancy or during breastfeeding
 Closely monitor all high-risk pregnancies
with HIV At each visit provide:
Comprehensive clinical evaluation
Pregnant women on CPT should not be
given Sulphadoxine-Pyrimethamine (Fansidar) for intermittent preventive treatment
Screen for TB and take appropriate action
Screening and management of opportunistic infections (OIs)
ANC 1  Conduct a risk assessment of the unborn
baby at 1st ANC among all HIV positive
pregnant women and at every visit and flag
o Newly initiated on ART in the 3rd trimester or breastfeeding period
o Most recent VL is non-suppressed
o Mothers testing HIV positive later in pregnancy or during breastfeeding
 Closely monitor all high-risk pregnancies
ART o All womengirls living with HIV identified
"during pregnancy, labour and delivery or"
while breastfeeding should be started on
"o ART should be initiated on the same day,"
and adherence counseling should be initiated and sustained intensively for the first
three months then maintained for life.
o Initiate mother on once-daily FDC of TDF3TCDTG with pharmacovigilance
o The mothers initiated on TDF  3TC
EFV400 shall be transitioned to TDF 
3TC  DTG at 6-9 months post-partum if
VL within past 6 months is suppressed.
o If mother is already on ART 6 months
"with TDF3TCEFV, do VL test. If she"
"is virally suppressed, maintain her on"
TDF3TCEFV400 until 6-9 months after
delivery and then substitute EFV with DTG
if VL within the past 6 months is suppressed.
o If she is already on a DTG-based 1st-line
"regimen and virally suppressed, maintain"
o If she is already on ART and VL is not
"suppressed, manage as treatment failure"
and switch to DTG-based 2nd line regimen
(if no previous exposure to DTG).
ART o All womengirls living with HIV identified
"during pregnancy, labour and delivery or"
while breastfeeding should be started on
"o ART should be initiated on the same day,"
and adherence counseling should be initiated and sustained intensively for the first
three months then maintained for life.
o Initiate mother on once-daily FDC of TDF3TCDTG with pharmacovigilance
o The mothers initiated on TDF  3TC
EFV400 shall be transitioned to TDF 
3TC  DTG at 6-9 months post-partum if
VL within past 6 months is suppressed.
o If mother is already on ART 6 months
"with TDF3TCEFV, do VL test. If she"
"is virally suppressed, maintain her on"
TDF3TCEFV400 until 6-9 months after
delivery and then substitute EFV with DTG
if VL within the past 6 months is suppressed.
o If she is already on a DTG-based 1st-line
"regimen and virally suppressed, maintain"
o If she is already on ART and VL is not
"suppressed, manage as treatment failure"
and switch to DTG-based 2nd line regimen
(if no previous exposure to DTG).
ART o If she is on 2ndline ART with ATVr or
"LPVr and virally suppressed, maintain on"
the same regimen until 6-9 months after
delivery and then substitute PI with DTG if
VL within the past 6 months is suppressed
and no previous exposure to DTG.
o All women should receive Pre-ART adherence counseling before initiating ART and
ongoing adherence support after that
o ART should be initiated and maintained in
What to do if mum refuses ART or if you
"Maternal VL suppression is key for preventing breastfeeding transmission, so if VL"
suppression is not certain infant prophylaxis may serve as a back up to prevent
MTCT - similar to Option A. Clinical
providers should continue infant prophylaxis with NVP for these specific scenarios. Continuation of prophylaxis should be
seen as an interim measure while maternal
Risk reduction coun-  Encourage consistent and correct condom
 Encourage women to deliver at the health
" For negative pregnant women, offer other"
prevention services like SMC to partner
ART o If she is on 2ndline ART with ATVr or
"LPVr and virally suppressed, maintain on"
the same regimen until 6-9 months after
delivery and then substitute PI with DTG if
VL within the past 6 months is suppressed
and no previous exposure to DTG.
o All women should receive Pre-ART adherence counseling before initiating ART and
ongoing adherence support after that
o ART should be initiated and maintained in
 What to do if mum refuses ART or if you
"Maternal VL suppression is key for preventing breastfeeding transmission, so if VL"
suppression is not certain infant prophylaxis may serve as a back up to prevent
MTCT - similar to Option A. Clinical
providers should continue infant prophylaxis with NVP for these specific scenarios. Continuation of prophylaxis should be
seen as an interim measure while maternal
Risk reduction counseling and support  Encourage consistent and correct condom
 Encourage women to deliver at the health
" For negative pregnant women, offer other"
prevention services like SMC to partner
and mitigate or manage GBService Description
Visit schedules HIV-positive pregnant HIV-positive pregnant
for HIV-infected woman girl already on womangirl initiating
pregnant women ART and stable: ART in ANC (new
breastfeeding mother Unstable pregnant
 Poor viral supprestests in the next twomsion: most recent
pregnant women HIV-positive pregnant
"tests in the next twomonths,e.g., viral load"
 Has disclosed to significant other household member family
 Poor viral suppression: most recent
"refills and adherence  After that, monthly"
support with the ANC until delivery
3.HIV-exposed infant care services
Identification of  Identify all HIV-exposed infants; document the
HIV-exposed in- HIV status of the mother in the child card and
fants mothers passport. Infants whose HIV status
is not documented or is unknown should be
offered rapid HIV testing; including those whose
mothers did not receive eMTCT services or have
become newly infected after pregnancy. Rapid
diagnostic tests for HIV serology can be used
to assess HIV exposure among infants younger
than four months of age. HIV-exposure status
among infants and children 418 months of age
should therefore be ascertained by HIV serological testing the mother. The mother should be
tested every 3 months until end of breastfeeding.
"The entry points for identification of HIV-exposed infants include YCC, OPD pediatric"
NutritionTB wards and outreaches. Special attention should be paid during immunization both
at static and outreach areas to ensure that all
children have their exposure status ascertained.
HIV-exposed infants  Identify all HIV-exposed infants; document the
HIV status of the mother in the child card and
mothers passport. Infants whose HIV status
is not documented or is unknown should be
offered rapid HIV testing; including those whose
mothers did not receive eMTCT services or have
become newly infected after pregnancy. Rapid
diagnostic tests for HIV serology can be used
to assess HIV exposure among infants younger
than four months of age. HIV-exposure status
among infants and children 418 months of age
should therefore be ascertained by HIV serological testing the mother. The mother should be
tested every 3 months until end of breastfeeding.
"The entry points for identification of HIV-exposed infants include YCC, OPD pediatric"
NutritionTB wards and outreaches. Special attention should be paid during immunization both
at static and outreach areas to ensure that all
children have their exposure status ascertained.
HIV test-  8 ANC visits Provide 1st
Follow the infant testing algorithm in
to test and interpret the test results:
 Provide 1st PCR within 4-6 weeks
or the earliest opportunity thereafter.
Follow the infant testing algorithm in Provide 1st
to test and interpret the test results: PCR within
 Provide 1st PCR within 4-6 weeks
or the earliest opportunity thereafter.
 Provide 2nd PCR at 9months thereafter
 Provide 3rdPCR 6 weeks after cessation of breastfeeding
 Do DBS for confirmatory DNA PCR
for all infants who test positive on the
 Do a DNA PCR test for all HEI who
develop signssymptoms suggestive
"of HIV during follow-up, irrespective"
"months for all infants who test negative at 1st, 2nd and 3rdPCR"
nucleic acid testing should be used
to diagnose HIV among infants and
children younger than 18 months of
HIV testing for infants  8 ANC visits
Follow the infant testing algorithm in
to test and interpret the test results:
 Provide 1st PCR within 4-6 weeks
or the earliest opportunity thereafter. Provide 1st
 Follow the infant testing algorithm in
to test and interpret the test results:
 Provide 1st PCR within 4-6 weeks
or the earliest opportunity thereafter.
 Provide 2nd PCR at 9months thereafter
 Provide 3rdPCR 6 weeks after cessation of breastfeeding
 Do DBS for confirmatory DNA PCR
for all infants who test positive on the
 Do a DNA PCR test for all HEI who
develop signssymptoms suggestive
"of HIV during follow-up, irrespective"
"months for all infants who test negative at 1st, 2nd and 3rdPCR"
nucleic acid testing should be used
to diagnose HIV among infants and
children younger than 18 months of
HIV test- Follow the infant testing algorithm in Provide 1st
ing for in- to test and interpret the test results: PCR within 4-6
 Provide 1st PCR within 4-6 weeks
earliest opportor the earliest opportunity thereafter.
 ART for mothers and ePNP causing Guidance for
"low viral particles difficult to detect, indetermisometimes below cycle threshold. nate test:"
An indeterminate range of viral copy
equivalents should be used to improve
the accuracy of all nucleic acidbased
 Indeterminate range: a range of in 2 days
viral copy equivalents that would be
too low to be accurately diagnosed
as HIV infected. The indeterminate
range suggested is currently estimatCommunicated to be approximately equivalent to
ing results to a cycle threshold of 33 on the Roche
TaqMan HIV-1 Qualitative Test Testing interv2.0 assay vals for infants
Indeterminate range: a range of viral
copy equivalents that would be too
low to be accurately diagnosed as
HIV infected. The indeterminate
range suggested is currently estimated to be approximately equivalent to
a cycle threshold of 33 on the Roche
HIV testing for infants Follow the infant testing algorithm in
to test and interpret the test results:
 Provide 1st PCR within 4-6 weeks
or the earliest opportunity thereafter. Provide 1st
  ART for mothers and ePNP causing
"low viral particles difficult to detect,"
sometimes below cycle threshold.
An indeterminate range of viral copy
equivalents should be used to improve
the accuracy of all nucleic acidbased
 Indeterminate range: a range of
viral copy equivalents that would be
too low to be accurately diagnosed
as HIV infected. The indeterminate
range suggested is currently estimated to be approximately equivalent to
a cycle threshold of 33 on the Roche
Indeterminate range: a range of viral
copy equivalents that would be too
low to be accurately diagnosed as
HIV infected. The indeterminate
range suggested is currently estimated to be approximately equivalent to
a cycle threshold of 33 on the Roche
Routine immuni-  HIV-infected children are more susceptible
zation to diseases preventable by immunization than
their HIV-uninfected counterparts.
 HIV-infected infants and children can safely
receive most childhood vaccines if given at the
right time. All HIV-infected and exposed children should be immunized as per EPI immunization schedule.
 Health workers should review child immunization status at every visit
 Some special considerationsmodifications for
o BCG: When considering BCG vaccination at a
later age (re-vaccination for no scar or missed
"earlier vaccination), exclude symptomatic Hinfection. Children with symptomatic HIV infection should not receive BCG."
o Measles: Although the measles vaccine is a
"live vaccine, it should be given at six and nine"
months even when the child has symptoms of
HIV. The measles illness from the vaccine is
"milder than that from the wild measles virus,"
which is more severe and likely to cause death.
o Yellow Fever: Do not give yellow fever vaccine
to symptomatic HIV-infected children; asymptomatic children in endemic areas should receive
the vaccine at nine months of age
Routine immunization  HIV-infected children are more susceptible
to diseases preventable by immunization than
their HIV-uninfected counterparts.
 HIV-infected infants and children can safely
receive most childhood vaccines if given at the
right time. All HIV-infected and exposed children should be immunized as per EPI immunization schedule.
 Health workers should review child immunization status at every visit
 Some special considerationsmodifications for
o BCG: When considering BCG vaccination at a
later age (re-vaccination for no scar or missed
"earlier vaccination), exclude symptomatic Hinfection. Children with symptomatic HIV infection should not receive BCG."
o Measles: Although the measles vaccine is a
"live vaccine, it should be given at six and nine"
months even when the child has symptoms of
HIV. The measles illness from the vaccine is
"milder than that from the wild measles virus,"
which is more severe and likely to cause death.
o Yellow Fever: Do not give yellow fever vaccine
to symptomatic HIV-infected children; asymptomatic children in endemic areas should receive
the vaccine at nine months of age
Growth moni-  Growth and child nutrition should be
"toring and nu- monitored using weight, lengthheight,"
"tritional assess- and MUAC at all encounters with a child,"
and recorded on the growth monitoring
 MUAC should only be measured starting
" Failure to gain weight or height, slow"
"weight or height gain, and loss of weight"
may be an indication of HIV infection in
an infantyoung child. Failure to thrive
affects as many as 50 of HIV-infected
infants and children. HIV-infected infants
and children who are failing to thrive have
a significantly increased risk of mortality.
 Counsel the mothercaregiver on the
childs growth trend and take appropriate
Development  At each visit assess the infants age-specific
monitoring developmental milestones.
 Infants are at high risk for Hencephalopathy and severe neurologic
 Early identification of developmental
delay can facilitate intervention and these
children can improve with treatment.
  Some forms of development delay are:
 The child may reach some developmental
 The child may reach some milestones but
 The child may fail to reach any
developmental milestones at all.
 Test children with developmental delay for
"HIV and, if infected, initiate on ART."
 Measure the infants head circumference.
Growth monitoring and nutritional assessment  Growth and child nutrition should be
"monitored using weight, lengthheight,"
"and MUAC at all encounters with a child,"
and recorded on the growth monitoring
 MUAC should only be measured starting
" Failure to gain weight or height, slow"
"weight or height gain, and loss of weight"
may be an indication of HIV infection in
an infantyoung child. Failure to thrive
affects as many as 50 of HIV-infected
infants and children. HIV-infected infants
and children who are failing to thrive have
a significantly increased risk of mortality.
 Counsel the mothercaregiver on the
childs growth trend and take appropriate
monitoring  At each visit assess the infants age-specific
 Infants are at high risk for Hencephalopathy and severe neurologic
 Early identification of developmental
delay can facilitate intervention and these
children can improve with treatment.
  Some forms of development delay are:
 The child may reach some developmental
 The child may reach some milestones but
 The child may fail to reach any
developmental milestones at all.
 Test children with developmental delay for
"HIV and, if infected, initiate on ART."
 Measure the infants head circumference.
Early Childhood  The first two years of life are the most
Development critical for brain development and
influences during this period significantly
contribute to longer-term developmental
 ECD therefore comprises all the essential
care and support a young child needs to
survive and thrive in life and spans the
period from prenatal to eight years of
age across multiple domains consisting
"of physical, cognitive, language and"
"communication, social and emotional and"
spiritual development. Years 0-8 most
critical stage of life because the brain
 It is well established that infants and young
children exposed or affected by Hhave poorer health and developmental
"outcomes compared to their non-Haffected peers. Prevention of motherto-child transmission (PMTCT) services,"
which focus on mothers and infants
throughout the exposure period provide
an ideal platform during a period of life
that affects both longer-term health and
"developmental potential, moreover, the"
services along the PMTCT cascade are
well aligned with intervention points for
 ECD services and messages will therefore
be well integrated into PMTCTHEservices to improve outcomes of HEI.
Development  The first two years of life are the most
critical for brain development and
influences during this period significantly
contribute to longer-term developmental
 ECD therefore comprises all the essential
care and support a young child needs to
survive and thrive in life and spans the
period from prenatal to eight years of
age across multiple domains consisting
"of physical, cognitive, language and"
"communication, social and emotional and"
spiritual development. Years 0-8 most
critical stage of life because the brain
 It is well established that infants and young
children exposed or affected by Hhave poorer health and developmental
"outcomes compared to their non-Haffected peers. Prevention of motherto-child transmission (PMTCT) services,"
which focus on mothers and infants
throughout the exposure period provide
an ideal platform during a period of life
that affects both longer-term health and
"developmental potential, moreover, the"
services along the PMTCT cascade are
well aligned with intervention points for
 ECD services and messages will therefore
be well integrated into PMTCTHEservices to improve outcomes of HEI.
ARV prophy-  Provide NVP syrup to HEI from birth until six
" For high-risk infants, give NVP syrup from"
 High-riskinfants are breastfeeding infants
o Have received ART for four weeks or less
o Have VL 1000 co.pies in four weeks before
o Diagnosed with HIV during 3rd trimester or
breastfeeding period (postnatal).
What to do if baby presents after 6
b. Give ART (First Line Paed regimen; give
weight appropriate dose) for 6weeks
"c. If PCR results are negative, give NVP for 6"
weeks (after completing the 6 weeks of ART)
"d. If PCR results are positive, continue with ART"
"Irrespective of timing, the mother should be"
started on ART as soon as possible for her own
health and to decrease risk of transmission to
ARV prophylaxis  Provide NVP syrup to HEI from birth until six
" For high-risk infants, give NVP syrup from"
 High-riskinfants are breastfeeding infants
o Have received ART for four weeks or less
o Have VL 1000 co.pies in four weeks before
o Diagnosed with HIV during 3rd trimester or
breastfeeding period (postnatal).
 What to do if baby presents after 6
b. Give ART (First Line Paed regimen; give
weight appropriate dose) for 6weeks
"c. If PCR results are negative, give NVP for 6"
weeks (after completing the 6 weeks of ART)
"d. If PCR results are positive, continue with ART"
"Irrespective of timing, the mother should be"
started on ART as soon as possible for her own
health and to decrease risk of transmission to
Opportunistic Cotrimoxazole prophylaxis
infection prophCotrimoxazole (CTX) prophylaxis significantly reylaxis
duces the incidence and severity of Pneumocystis
Jiroveci pneumonia. It also offers protection
"against common bacterial infections, Toxoplasmosis and Malaria."
 Provide CTX prophylaxis to all HIV-exposed
infants from six weeks of age until they are proven to be uninfected.
 Infants who become HIV-infected should continue to receive CTX prophylaxis for life.
" If CTX is contraindicated, offer Dapsone at"
dose of 2mgkg once daily (up to 100mg).
 Give INH for six months to HEI who are exposed to TB after excluding TB disease.
" For newborn infants, if the mother has TB"
disease and has been on anti-TB drugs for at
"least two weeks before delivery, INH prophylaxis"
 All HEI and HIV-infected children should
receive insecticide treated nets and CTX. Using
both reduces risk of malaria by 97.
Actively look HEI are susceptible to common infections and
 Counsel caregivers to seek care to receive
infection prophylaxis Cotrimoxazole prophylaxis
Cotrimoxazole (CTX) prophylaxis significantly reduces the incidence and severity of Pneumocystis
Jiroveci pneumonia. It also offers protection
"against common bacterial infections, Toxoplasmosis and Malaria."
 Provide CTX prophylaxis to all HIV-exposed
infants from six weeks of age until they are proven to be uninfected.
 Infants who become HIV-infected should continue to receive CTX prophylaxis for life.
" If CTX is contraindicated, offer Dapsone at"
dose of 2mgkg once daily (up to 100mg).
 Give INH for six months to HEI who are exposed to TB after excluding TB disease.
" For newborn infants, if the mother has TB"
disease and has been on anti-TB drugs for at
"least two weeks before delivery, INH prophylaxis"
 All HEI and HIV-infected children should
receive insecticide treated nets and CTX. Using
both reduces risk of malaria by 97.
infections early HEI are susceptible to common infections and
 Counsel caregivers to seek care to receive
" At every visit, assess HEI for signs and symptoms of common childhood illnesses using the"
"Integrated Maternal, New-born and Childhood"
Illnesses Guidelines and provide treatment.
Counseling and Provide infant feeding counseling and advice
feeding advice according to guidance.
Educate the  HEI depend on their caregivers to receive care.
 Provide information to the caregivers and family
about the care plan including what to expect and
how to provide care for the infant.
 Caregivers should participate in making decisions
"and planning care for the child, including decisions"
about therapy and where the child should receive
 Empower caregivers to be partners with the health
 Provide key aspects of home-based care for the
o Dispensing prophylaxis and treatment
o Complying with the follow-up schedule
o Ensuring good personal and food hygiene to prevent common infections
o Seeking prompt treatment for any infections or
The most important thing for the child is to have a
healthy mother. Ensure the motherinfected caregiver
"is receiving their care. If the mother is sick, the infant"
"  At every visit, assess HEI for signs and symptoms of common childhood illnesses using the"
"Integrated Maternal, New-born and Childhood"
Illnesses Guidelines and provide treatment.
feeding advice Provide infant feeding counseling and advice
family  HEI depend on their caregivers to receive care.
 Provide information to the caregivers and family
about the care plan including what to expect and
how to provide care for the infant.
 Caregivers should participate in making decisions
"and planning care for the child, including decisions"
about therapy and where the child should receive
 Empower caregivers to be partners with the health
 Provide key aspects of home-based care for the
o Dispensing prophylaxis and treatment
o Complying with the follow-up schedule
o Ensuring good personal and food hygiene to prevent common infections
o Seeking prompt treatment for any infections or
 The most important thing for the child is to have a
healthy mother. Ensure the motherinfected caregiver
"is receiving their care. If the mother is sick, the infant"
" When members of the same family such as mother-baby pair are in care, their appointments should"
Referrals and  Link the caregiver and HEI to appropriate
"Linkage services like OVC care, psychosocial support"
including FSG and other community support
ART for infect- Initiate ART in infants who become infected accorded infants ing to guidance
HIV-exposed infants should receive care at the mother-baby care point
together with their mothers until they are 18 months of age. The goals
of HIV-exposed infant care services are:
 To prevent the infant from being HIV infected
 Among those who get infected: to diagnose HIV infection
 Offer child survival interventions to prevent early death from
preventable childhood illnesses
The HIV Exposed Infant and the mother should consistently visit the
health facility at least nine times during that period.
"The visits are synchronised with the childs immunisation schedule (i.e.,"
"at 6, 10 and 14 weeks, then at 5, 6, 9, 12, 15 and"
"  When members of the same family such as mother-baby pair are in care, their appointments should"
Linkage  Link the caregiver and HEI to appropriate
"services like OVC care, psychosocial support"
including FSG and other community support
ART for infected infants Initiate ART in infants who become infected according to guidance
 Provide NVP suspension from birth for 6 weeks
" Give NVP for 12 weeks for babies at high risk,"
that is breastfeeding infants who mothers:
- Have received ART for 4 weeks or less before
- Have VL 1000 copies in 4 weeks before
- Diagnosed with HIV during 3rd trimester or
breastfeeding period (Postnatal)
 Do PCR at 6 weeks (or at first encounter after
this age) and start cotrimoxazole prophylaxis
"- If PCR positive, start treatment with ARVs and"
- cotrimoxazole and repeat PCR (for confirmation)
"- If PCR negative and baby never breastfed, child"
"is confirmed HIV negative. Stop cotrimoxazole,"
- continue clinical monitoring and do HIV serology
- If PCR negative but baby has breastfedis
"breasfeeding, startcontinue cotrimoxazole prophylaxis and"
repeat PCR 6 weeks after stopping breastfeeding
 Follow up any exposed child and do PCR if they develop
any clinical symptom suggestive of HIV at any time and
independently of previously negative results
" For negative infants, do serology at 18 months before"
 Provide NVP suspension from birth for 6 weeks
" Give NVP for 12 weeks for babies at high risk,"
that is breastfeeding infants who mothers:
- Have received ART for 4 weeks or less before
- Have VL 1000 copies in 4 weeks before
- Diagnosed with HIV during 3rd trimester or
breastfeeding period (Postnatal)
 Do PCR at 6 weeks (or at first encounter after
this age) and start cotrimoxazole prophylaxis
"- If PCR positive, start treatment with ARVs and"
- cotrimoxazole and repeat PCR (for confirmation)
"- If PCR negative and baby never breastfed, child"
"is confirmed HIV negative. Stop cotrimoxazole,"
- continue clinical monitoring and do HIV serology
- If PCR negative but baby has breastfedis
"breasfeeding, startcontinue cotrimoxazole prophylaxis and"
repeat PCR 6 weeks after stopping breastfeeding
 Follow up any exposed child and do PCR if they develop
any clinical symptom suggestive of HIV at any time and
independently of previously negative results
" For negative infants, do serology at 18 months before"
"- Child 0-6 weeks, 2-Kg: 10 mg once daily (1"
"- Child 0-6 weeks, kg: 15 mg once daily (ml"
- Child 6 weeks  12 weeks: 20 mg once daily (2
 Provide cotrimoxazole prophylaxis to all HIV- exposed
infants from 6 weeks of age until they are proven to be
 Infants who become HIV infected should continue to
receive cotrimoxazole prophylaxis for life
" If cotrimoxazole is contraindicated, offer dapsone at a"
dose of 2 mgkg once daily ( up to 100 mg max)
TB preventive therapy (TPT) HC3
 Give INH for six months to HIV-exposed infant who
are exposed to TB (close contact with PTB case) after
excluding TB disease (see section 5.3.2.3)
 Dose: Isoniazid 10 mgkg  pyridoxine 25 mg daily
" For newborn infants, if the mother has TB disease and"
has been on anti-TB drugs for at least two weeks before
"delivery, INH prophylaxis is not required."
"- Child 0-6 weeks, 2-Kg: 10 mg once daily (1"
"- Child 0-6 weeks, kg: 15 mg once daily (ml"
- Child 6 weeks  12 weeks: 20 mg once daily (2
 Provide cotrimoxazole prophylaxis to all HIV- exposed
infants from 6 weeks of age until they are proven to be
 Infants who become HIV infected should continue to
receive cotrimoxazole prophylaxis for life
" If cotrimoxazole is contraindicated, offer dapsone at a"
dose of 2 mgkg once daily ( up to 100 mg max) HC2
 Give INH for six months to HIV-exposed infant who
are exposed to TB (close contact with PTB case) after
excluding TB disease (see section 5.3.2.3)
 Dose: Isoniazid 10 mgkg  pyridoxine 25 mg daily
" For newborn infants, if the mother has TB disease and"
has been on anti-TB drugs for at least two weeks before
"delivery, INH prophylaxis is not required. HC3"
 Immunise HIV exposed children as per national immunisation schedule
" In case of missed BCG at birth, do not give if child has"
symptomatic H Avoid yellow fever vaccine in symptomatic H Measles vaccine can be given even in symptomatic HCounselling on infant feeding choice
- Explain the risks of HIV transmission by breastfeeding (15)
"and other risks of not breastfeeding (malnutrition, diarrhoea)"
- Mixed feeding may also increase risk of HIV transmission
"- Tell her about options for feeding, advantages, and risks"
"- Help her to assess choices, decide on the best option, and"
- Recommended option: Exclusive breastfeeding then
complementary feeding after child is six months old
- Exclusive breastfeeding stopping at 3-6 months old if
- replacement feeding possible after this
"- If replacement feeding introduced early, mother must stop"
- Replacement feeding with home-prepared formula or
commercial formula and then family foods (provided this is
"acceptable, feasible, safe, and sustainable affordable)"
If mother chooses breastfeeding
- The risk may be reduced by keeping the breasts healthy
(mastitis and cracked nipples raise HIV infection risk)
- Advise exclusive breastfeeding for 3-6 months
 Immunise HIV exposed children as per national immunisation schedule
" In case of missed BCG at birth, do not give if child has"
symptomatic H Avoid yellow fever vaccine in symptomatic H Measles vaccine can be given even in symptomatic HIf mother chooses replacement feeding
" Counsel and teach her on safe preparation, hygiene, amounts,"
 Follow up within a week from birth and at any visit to
OPPORTUNISTIC INFECTIONS IN H3.Tuberculosis and HIV Co-Infection
Active TB may be present when ART needs to be initiated or it may
TB and HIV care for co-infected patients should be provided in an
integrated manner under one roof by one care team (one-stop-shop).
Co-management of TB and HIV is complicated by:
 Drug interactions between rifampicin and both the NNRTand PI classes
 Immune reconstitution inflammatory syndrome (IRIS)
" Pill burden, overlapping toxicities and adherence issues."
ART should be initiated in all TBHIV co-infected people irrespective
"of their clinical stage or CD4 count. However, the timing of initiation"
of treatment may differ based on whether the patient is diagnosed with
TB before or after initiating ART.
"TB patients diagnosed with Start anti-TB medicines immediately, THEN"
HIV start ARVs 2 weeks later (see table below)
"Patient already on ART, di- Start anti-TB medicines immediately,"
agnosed with TB adjust regimen as per guidelines below
"ADULT TB patients diag- Start anti-TB medicines immediately,"
nosed with TB start ARVs before completing 2 weeks
ARV regimen in ART-naive patients on TB treatment
"Adults, Pregnant and Breast- TDF3TCEFfeeding Women, and Adolescents"
Children aged 3 -  12 years ABC3TCEFChildren 0 -  3 years ABC3TCAZT
ARV regimen substitution for patients initiating TB treatment while on ART
Regimen When Di- Recommended Action SubAge Group
"Adults, If on EFV- based Continue the same regimen but"
Pregnant and regimen double the dose of DTG (give
"Women and If on NVP based Substitute NVP with EFV. If EFAdolescents regimen is contraindicated, give DTG as"
give a triple NRTI regimen (ABC3TCAZT).
"HIV Start anti-TB medicines immediately, THEN"
start ARVs 2 weeks later (see table below)
"Patient already on ART, diagnosed with TB Start anti-TB medicines immediately,"
adjust regimen as per guidelines below
"ADULT TB patients diagnosed with TB Start anti-TB medicines immediately,"
start ARVs before completing 2 weeks
"Adults, Pregnant and Breastfeeding Women, and Adolescents TDF3TCEFChildren aged 3 -  12 years ABC3TCEFChildren 0 -  3 years ABC3TCAZT"
Age Group Regimen When Diagnosed With Tb Recommended Action Substitution
regimen Continue the same regimen but
"regimen Substitute NVP with EFV. If EFis contraindicated, give DTG as"
give a triple NRTI regimen (ABC3TCAZT).
ARV regimen substitution for patients initiating TB treatment while on ART
Regimen When Di- Recommended Action SubAge Group
"Adults, Preg- If on LPVr based Continue the same regimen but"
na nt a nd regimen double the dose of DTG (give
If on ATVr based Continue the same regimen and
regimen give Rifabutin for TB treatment
Children aged If on EFV- based Continue the same regimen
If on NVP or based Substitute NVP with EFV.
"If EFV is contraindicated, give"
a triple NRTI regimen (ABC3TCAZT)
LPVr Continue the same regimen and
give Rifabutin for TB treatment
Children 0 - 3 If on LPVr or Give triple NRTI regimen AByears NVP based regi- C3TCAZT
Second line ART for patients with TB
 There are significant drug interactions with PIs and rifampicin.
" If rifabutin is available, it may be used in place of rifampicin"
"with ATVr or LPVr, but it is contraindicated in patients"
 Maintaining PI in second line regimens while switching from
Age Group Regimen When Diagnosed With Tb Recommended Action Substitution
regimen Continue the same regimen but
regimen Continue the same regimen and
give Rifabutin for TB treatment
regimen Continue the same regimen
regimen Substitute NVP with EFV.
"If EFV is contraindicated, give"
a triple NRTI regimen (ABC3TCAZT)
 LPVr Continue the same regimen and
give Rifabutin for TB treatment
NVP based regimen Give triple NRTI regimen ABC3TCAZT
Rifampicin to Rifabutin (if available) is ideal
 BCG immunisation: it protects children against severe
"forms of TB. It can be given at birth. If delayed, avoid in"
symptomatic H IPT (Isoniazid Preventive Treatment) (see section 5.3.2.3)
3.Cryptococcal Meningitis ICD10 CODE: B45
Crytococcal meningitis is an opportunistic infection caused by a fungus
" In Uganda, cryptococcal meningitis (CM) associated mortality is up to 39. Patients with a CD4 cell count of 100"
"are at the highest risk, so early screening and management"
 Screening In ART-Naive Patients
 Screen routinely for Cryptococcal Meningitis with the cryptococcal antigen (CrAg) test (a bedside finger prick test):
- All ART naive individuals with CD4 100 cellsµL
- Patients on ART with viral load (VL 1000 copiesml) or
clinical (stage 3 or 4 disease) failure
 If serum CrAg negative and no signs of meningitis: start
ART immediately (or switch regimen)
 If CrAg positive andor signs or symptoms of meningitis
"(headache, presence of seizures, altered consciousness,"
"photophobia, neck stiffness, and a positive Kernigs sign)"
- Perform lumbar puncture and test for CSF CrAg (culture if
" If CSF CrAg positive, diagnose and treat for Cryptococcal"
" If CSF CrAg negative but blood CrAg positive, give pre"
emptive treatment for asymptomatic cryptococcal disease
or non CNS cryptococcal disease
Start Fluconazole Treat as Cryptococcal Meningitis
Start ART 2 weeks after starting Cryptococcal Meningitis
Art Naive start ART at for 4-6 ART regimen as
"ART experienced reportedly Stop ART at Wait restart 1st, 2nd"
not adherent or uncertain Admission for 4-6 or 3rd line ART
ART experienced reportedly Stop ART at
adherent on ART  6 months Admission
"Wait restart 1st, 2nd adherent on ART  14 days-6 Stop ART at"
months very recent ART intro- Admission
adherent on ART  14 days-6 Continue ART at
months Recent ART introduction Admission
Decision on which ART regimen to restart should be made according
"to patients history, ART guidelines, HIV viral and genotypic resistance"
testing if possible. If it is considered likely that the patient has developed
"resistance to 1stline ARVs, then restart with 2ndline containing boosted"
PI or DTG is possible.  Unless documented to have a suppressed viral
"load at time of admission or within the month prior to admission, in"
Induction Recommended: Preventing Amphotericin H
(2 weeks) liposomal single To prevent nephrotoxicity
"high dose (10mg and hypokalemia, for pakg)  Flucytosine tients on amphotericin"
es)  Fluconazole Pre-hydration with 1L nor1200mg day for mal saline before starting
 Monitor serum potassium H B deoxycholate
"tablet of 600mg twice daiadults, 12 mgkg"
four divided doses)  Fluconazole
"and hypokalemia, for patients on amphotericin"
Pre-hydration with 1L normal saline before starting
tablet of 600mg twice daily while on amphotericin B
Induction  Fluconazole  For electrolyte supplemen- H4
"Phase (1200 mg dai- tation, two tablets daily of"
"ly for adults, 12 Magnesium Chloride 310"
mgkgday for mg or slow Magnesium Chlochildren and ride 535mg or Magnesium
"(100 mgkg  Consider alternate day Amday, divided photericin B if creatinine is"
" Amphotericin (5FC) toxicity, CBC with difB deoxycholate ferential counts at least twice"
(1mgkgday)  weekly is recommended
Consol- Fluconazole Initiate ART 46 weeks after H4
idation 800mgday starting CM treatment and
phase there is clinical response to
"1200mgday.  For electrolyte supplementation, two tablets daily of"
mg or slow Magnesium Chloride 535mg or Magnesium
 Consider alternate day Amphotericin B if creatinine is
"(5FC) toxicity, CBC with differential counts at least twice"
and adolescents) Initiate ART 46 weeks after
Mainte- Fluconazole Criteria to stop after a minimum H4
nance 200mgday of 18 months of maintenance
"months) up to 200mg Adults: VL1,000 copiesmm3"
in children and  CD4  200 or CD4 200 (if
adolescents) viral load not available) after
Presents with a recurrence of symptoms of Meningitis and
have a positive cerebrospinal fluid culture following a prior
confirmed diagnosis of Cryptococcal Meningitis.
Evaluate for drug resistance: Send CSF to Central Public Health
"Laboratory (CPHL) for culture and sensitivity testing, if there"
"are no drug resistance results, re-initiate the induction therapy"
for two weeks and complete other phases of treatment.
Adequate control of elevated CSF pressure
 Control of increased intracranial pressure improves survival
by 25 in persons with Cryptococcal Meningitis.
 All patients with a CSF Pressure 250mm H2O will need a
therapeutic LP the following day to reduce the CSF pressure
" In the absence of a manometer, one may use an IV giving"
set to create an improvised manometer measuring the height
Removing 20-30mL of CSF (even in the absence of a manometer)
may be adequate to decrease CSF pressure. Most patients
will need 2-3LPs during the induction phase.
adolescents) Criteria to stop after a minimum
viral load not available) after
Presents with a recurrence of symptoms of Meningitis and
have a positive cerebrospinal fluid culture following a prior
confirmed diagnosis of Cryptococcal Meningitis. 
Evaluate for drug resistance: Send CSF to Central Public Health
"Laboratory (CPHL) for culture and sensitivity testing, if there"
"are no drug resistance results, re-initiate the induction therapy"
for two weeks and complete other phases of treatment. 
Adequate control of elevated CSF pressure 
 Control of increased intracranial pressure improves survival
by 25 in persons with Cryptococcal Meningitis.
 All patients with a CSF Pressure 250mm H2O will need a
therapeutic LP the following day to reduce the CSF pressure
" In the absence of a manometer, one may use an IV giving"
set to create an improvised manometer measuring the height
Removing 20-30mL of CSF (even in the absence of a manometer)
may be adequate to decrease CSF pressure. Most patients
will need 2-3LPs during the induction phase. 
3.Hepatitis B and HIV Co-Infection ICD10 CODE: B18
 Hepatitis B virus (HBV) is the leading cause of chronic liver
"disease among HIV patients. In Uganda, the prevalence of"
Hepatitis B among HIV patients is estimated to be at 17.
(see section for more details on hepatitis B infection)
 All HIV-infected patients initiating and those failing ART
should be routinely screened for HBV infection using Hep
 People living with HIV with a positive HBsAg should have
other complementary tests at baseline and repeated every
" Liver function tests: ALT, AST, albumin, bilirubin, PT-INR"
 Liver ultrasound scan: to assess stage of liver fibrosis
 Repeat tests every 6 months since patients with chronic
HBV infection are at increased risk for hepatocellular carcinoma
Management of HBVHIV co-infection
The goal of HBVHIV treatment is to prevent dual disease progression
and to reduce HBV-related morbidity and mortality
Preferably ART regimen containing:
 TDF 300 mg  3TC 300 mg PO once daily for life
" After 6 months of treatment, patients should be evaluated"
Preferably ART regimen containing:
 TDF 300 mg  3TC 300 mg PO once daily for life
" After 6 months of treatment, patients should be evaluated"
"If jaundice, malaise and abdominal right upper quadrant pain"
are present or if liver function tests are abnormal
 Do HBV DNA (hepatitis viral load) if any of the above
 Patients with HB VL 2000 IUml at 24 weeks of
therapy should be referred for further evaluation and
 Counseling: emphasize sexual transmission as well as the
"risks associated with sharing needles and syringes, tattooing or body-piercing"
 Advise patients with chronic HBV disease to avoid alcohol
 All household members and sexual partners of people living with HIV with HBV should be screened for HBsAG
 HBV Vaccination is the most effective way to prevent HBinfection and its consequences
- All HIV-infected patients who test negative on HBsAg
- should be vaccinated with HBV vaccine
- All sexual partners and contacts should receive HBvaccination regardless of whether they are HIV-infected or
"If jaundice, malaise and abdominal right upper quadrant pain"
are present or if liver function tests are abnormal
 Do HBV DNA (hepatitis viral load) if any of the above
 Patients with HB VL 2000 IUml at 24 weeks of
therapy should be referred for further evaluation and
3.Pneumocystis Pneumonia ICD10 CODE: B59
Interstitial pneumonitis caused by the parasite Pneumocystis jirovecii
(formerly carinii). It is common in severely immunosuppresed patients
 Shortness of breath (significant hypoxemia)
 Chest x-ray shows characteristic bilateral interstitial infiltrates
Pre-emptive treatment for cryptococcal disease
Pneumocystis Jirovecii pneumonia HC4
 Cotrimoxazole 120 mgkgdaily in 2-4 divided doses
- For example cotrimoxazole 480 mg tablets:
- If patient is  60 kg: give 3 tablets If patient 60
 Plus prednisolone 2 mgkg daily in 3 divided doses for 5
"days, then reduce dose to complete 21 days of treatment"
Or (in patients who cannot tolerate or do not respond
 Pentamidine 4 mgkg by IV infusion daily for 21 days
- Reduce dose in renal impairment
Pneumocystis Jirovecii pneumonia
 Cotrimoxazole 120 mgkgdaily in 2-4 divided doses
- For example cotrimoxazole 480 mg tablets:
- If patient is  60 kg: give 3 tablets If patient 60
 Plus prednisolone 2 mgkg daily in 3 divided doses for 5
"days, then reduce dose to complete 21 days of treatment"
Or (in patients who cannot tolerate or do not respond
 Pentamidine 4 mgkg by IV infusion daily for 21 days
- Reduce dose in renal impairment HC4
- Reduce dose in renal impairment
- Avoid direct bolus injections whenever possible
"but if unavoidable, never give rapidly"
Alternative regimen (21-day course) if above not available tolerated
- Clindamycin 600 mg every 8 hours
Give to all patients with history of PCP infection and consider
also for severely immunocompromised patients
- Cotrimoxazole 960 mg daily or
- Continue until immunity recovers sufficiently
People living with HIV are at higher risk of acquiring any other infection and
"diseases, including non-communicable diseases, due to HIV itself and drug"
"- Treat any other infection (e.g. malaria, STI) as per guidelines"
"- Screen regularly for NCD (diabetes, hypertension and"
- Screen women at enrolment in HIV care and then annually
for cervical cancer using Visual Inspection with Acetic Acid
Prevention of HBehavioural change
 Always follow safe sex practices (e.g. use condoms; avoid
" Never share used needles, syringes, razors, hair shavers,"
"264 nail cutters, and other sharp objects"
- Reduce dose in renal impairment
- Avoid direct bolus injections whenever possible
"but if unavoidable, never give rapidly"
Alternative regimen (21-day course) if above not available tolerated
- Clindamycin 600 mg every 8 hours
Give to all patients with history of PCP infection and consider
also for severely immunocompromised patients
- Cotrimoxazole 960 mg daily or
- Continue until immunity recovers sufficiently 
" Avoid tattooing, body-piercing, and scarification unless"
carried out under strictly hygienic conditions in properly
 Delay start of sexual activity in adolescence
 Discourage cross generational and transactional sex
Biomedical prevention interventions
 PEP (Post Exposure Prophylaxis)
 PrEP (Pre Exposure Prophylaxis)
 Safe infusion and injection practices
 Adherence to infection control procedures
3.Post-Exposure Prophylaxis ICD10 CODE: Z20.6
Post-exposure prophylaxis (PEP) is the short-term use of ARVs to reduce
the likelihood of acquiring HIV infection after potential occupational or
 Occupational exposures: Occur in health care settings and
include sharps and needlestick injuries or splashes of body
fluids to the skin and mucous membranes
" Non-occupational exposures: Include unprotected sex, exposure following assault like in rape  defilement, road"
traffic accidents and injuries at construction sites where exposure to body fluids occur
Step 1: Rapid assessment and first aid HC2
Conduct a rapid assessment of the client to assess exposure
and risk and provide immediate care
After a needle stick or sharp injury:
 Do not squeeze or rub the injury site
 Wash the site immediately with soap or mild disinfectant
"(chlorhexidine gluconate solution) or, use antiseptic hand"
rub gel if no running water (do not use strong irritating
antiseptics (like bleach or iodine)
After a splash of blood or body fluids in contact with intact
 Wash the area immediately or use antiseptic hand
rub gel if no running water (dont use strong irritating
After a splash of blood or body fluids contact with mucosae:
- Exposure occurred within the past 72 hours; and
- The exposed individual is not infected with HIV;
- The source is HIV-infected or has unknown Hstatus or high risk
- The exposed individual is already HIV positive;
- When the source is established to be Hnegative;
Step 1: Rapid assessment and first aid
Conduct a rapid assessment of the client to assess exposure
and risk and provide immediate care
After a needle stick or sharp injury:
 Do not squeeze or rub the injury site
 Wash the site immediately with soap or mild disinfectant
"(chlorhexidine gluconate solution) or, use antiseptic hand"
rub gel if no running water (do not use strong irritating
antiseptics (like bleach or iodine)
After a splash of blood or body fluids in contact with intact
 Wash the area immediately or use antiseptic hand
rub gel if no running water (dont use strong irritating
After a splash of blood or body fluids contact with mucosae:
- Exposure occurred within the past 72 hours; and
- The exposed individual is not infected with HIV;
- The source is HIV-infected or has unknown Hstatus or high risk
- The exposed individual is already HIV positive;
- When the source is established to be Hnegative; 
 Exposure to bodily fluids that do not pose a
"significant risk: e.g. to tears, non-blood-stained saliva, urine,"
"and sweat, or small splashes on intact skin"
 Exposed people who decline an HIV test
- The risk of HIV from the exposure
- Provide enhanced adherence counseling if PEP
- Link for further support for sexual assault cases
" PEP should be started as early as possible, and not"
 A complete course of PEP should run for 28 days
 Do not delay the first doses because of lack of baseline
 To monitor adherence and manage side effects
" Perform follow-up HIV testing 6-week, 3 and 6 months"
"- If HIV infected, provide counseling and link to"
- HIV clinic for care and treatment
"- If HIV uninfected, provide HIV prevention"
 Exposure to bodily fluids that do not pose a
"significant risk: e.g. to tears, non-blood-stained saliva, urine,"
"and sweat, or small splashes on intact skin"
 Exposed people who decline an HIV test 
- The risk of HIV from the exposure
- Provide enhanced adherence counseling if PEP
- Link for further support for sexual assault cases
" PEP should be started as early as possible, and not"
 A complete course of PEP should run for 28 days
 Do not delay the first doses because of lack of baseline
 To monitor adherence and manage side effects
" Perform follow-up HIV testing 6-week, 3 and 6 months"
"- If HIV infected, provide counseling and link to"
- HIV clinic for care and treatment
"- If HIV uninfected, provide HIV prevention"
Post-rape care (see also section 1.2.6)
Health facilities should provide the following clinical services as
 Initial assessment of the client
 Rapid HIV testing and referral to care and treatmentif
 Post-exposure prophylaxis (PEP) for H STI screeningtesting and treatment
 Forensic interviews and examinations
 Emergency contraception  if person reached within the
"The health facility should also identify, refer and link clients to"
 Some of the services include the following:
 Long-term psycho-social support
" Police investigations, restraining orders"
" Child protection services (e.g. emergency out of family care,"
reintegration into family care or permanent options when reintegration into family is impossible)
Reporting: Health facilities should use HMIS 105 to report Gender
Post-rape care (see also section 1.2.6)
Health facilities should provide the following clinical services as
 Initial assessment of the client
 Rapid HIV testing and referral to care and treatmentif
 Post-exposure prophylaxis (PEP) for H STI screeningtesting and treatment
 Forensic interviews and examinations
 Emergency contraception  if person reached within the
"The health facility should also identify, refer and link clients to"
 Some of the services include the following:
 Long-term psycho-social support
" Police investigations, restraining orders"
" Child protection services (e.g. emergency out of family care,"
reintegration into family care or permanent options when reintegration into family is impossible)
Reporting: Health facilities should use HMIS 105 to report Gender
3.Pre-Exposure Prophylaxis (PrEP)
Oral Pre-Exposure Prophylaxis (PrEP)
Definition: PrEP is the use of ARV drugs by HIV uninfected persons
to prevent the acquisition of HIV before exposure to HIV. Table below
describes processes involved in offering PrEP.
The process of providing pre-exposure prophylaxis (PrEP)
Screening for risk PrEP provides an effective additional biomedical prevention
of HIV option for HIV-negative people at substantial risk of acquiring
HIV infection. These include people who:
a) Live in discordant sexual relationships
b) Have had unprotected vaginal sexual intercourse with
more than one partner of unknown HIV status in the
c) Have had anal sexual intercourse in the past six months
"d) Have had sex in exchange for money, goods or a service"
e) Use or abuse of drugs especially injectable drugs in the
f) Have had more than one episode of a STI within the
"g) Are part of a discordant couple, especially if the"
HIV-positive partner is not on ART or has been on
ART for less than six months or not virally suppressed.
h) Recurrent post-exposure prophylaxis (PEP) users. (Recurrent implies PEP use more than 3 times a years).
i) Are members of key or priority populations who are
unable or unwilling to achieve consistent use of condoms.
of HIV PrEP provides an effective additional biomedical prevention
option for HIV-negative people at substantial risk of acquiring
HIV infection. These include people who:
a) Live in discordant sexual relationships
b) Have had unprotected vaginal sexual intercourse with
more than one partner of unknown HIV status in the
c) Have had anal sexual intercourse in the past six months
"d) Have had sex in exchange for money, goods or a service"
e) Use or abuse of drugs especially injectable drugs in the
f) Have had more than one episode of a STI within the
"g) Are part of a discordant couple, especially if the"
HIV-positive partner is not on ART or has been on
ART for less than six months or not virally suppressed.
h) Recurrent post-exposure prophylaxis (PEP) users. (Recurrent implies PEP use more than 3 times a years).
i) Are members of key or priority populations who are
unable or unwilling to achieve consistent use of condoms.
NB: Eligibility is likely to be more prevalent in populations
"such as discordant couple, sex workers, fisher folk,"
"long-distance truck drivers, men who have sex with"
"men (MSM), uniformed forces, and adolescents and"
young women including pregnant and lactating AGYW
Screening for After meeting the substantial risk for HIV criteria:
PrEP eligibility  Confirm HIV-negative status using the
 Rule out signs and symptoms of acute Hinfection
" Assess for hepatitis B infection: if negative,"
"patient is eligible for PrEP; if positive, refer"
patient for Hepatitis B management.
 HEP B positive test is not a contraindication for
"initiating PrEP, however precaution"
needs to be taken when making a decision to stop PrEP to
 Creatinine test and creatinine clearance
calculation using GFR formula is done. Do
not offer PrEP if Creatinine clearance is
Note: Absence of this should not delay PrEP initiation in
persons with no signs and symptoms of renal impairment.
"If available, creatinine test can be done at initiation and"
I. Assess for contraindications to TDFFTC or TDF3TC.
 NB: Eligibility is likely to be more prevalent in populations
"such as discordant couple, sex workers, fisher folk,"
"long-distance truck drivers, men who have sex with"
"men (MSM), uniformed forces, and adolescents and"
young women including pregnant and lactating AGYW
PrEP eligibility After meeting the substantial risk for HIV criteria:
 Confirm HIV-negative status using the
 Rule out signs and symptoms of acute Hinfection
" Assess for hepatitis B infection: if negative,"
"patient is eligible for PrEP; if positive, refer"
patient for Hepatitis B management.
 HEP B positive test is not a contraindication for
"initiating PrEP, however precaution"
 needs to be taken when making a decision to stop PrEP to
 Creatinine test and creatinine clearance
calculation using GFR formula is done. Do
not offer PrEP if Creatinine clearance is
Note: Absence of this should not delay PrEP initiation in
persons with no signs and symptoms of renal impairment.
"If available, creatinine test can be done at initiation and"
I. Assess for contraindications to TDFFTC or TDF3TC.
Steps to initiation Provide risk-reduction and PrEP medication adherence
II. Provide condoms and education on their use
III. Initiate a medication adherence plan
IV. Prescribe a once-daily pill of TDF (300mg) and FTC
(200mg) or TDF (300mg) 3TC (300mg)
"V. Initially, provide a 1-month TDFFTC or TDF3TC"
"prescription (1 tablet orally, daily) together with a"
VI. Counsel client on side effects of TDFFTC or TDF3TC
"Follow-up mon- VII. After the initial visit, the patient should be given a twoitoring clients month follow-up appointment and thereafter quarterly"
on PrEP VIII. Perform an HIV antibody test using the national HTS
algorithm and every three months. Note: Blood based
HIVST is an alternative for PrEP refill in case of absence
of the national HTS standard recommended in patients
"IX. For women, perform a pregnancy test if there is history"
"X. Review the patients understanding of PrEP, any barriers"
"to adherence, tolerance to the medication as well as any"
XI. Review the patients risk exposure profile and perform
XII. Evaluate and support PrEP adherence at each clinic
XIII. Evaluate the patient for any symptoms of STIs at every
visit and treat according to current STI treatment Guidelines.
of PrEP Provide risk-reduction and PrEP medication adherence
II. Provide condoms and education on their use
III. Initiate a medication adherence plan
IV. Prescribe a once-daily pill of TDF (300mg) and FTC
(200mg) or TDF (300mg) 3TC (300mg)
"V. Initially, provide a 1-month TDFFTC or TDF3TC"
"prescription (1 tablet orally, daily) together with a"
VI. Counsel client on side effects of TDFFTC or TDF3TC
"Follow-up monitoring clients VII. After the initial visit, the patient should be given a twomonth follow-up appointment and thereafter quarterly"
on PrEP VIII. Perform an HIV antibody test using the national HTS
algorithm and every three months. Note: Blood based
HIVST is an alternative for PrEP refill in case of absence
of the national HTS standard recommended in patients
"IX. For women, perform a pregnancy test if there is history"
"X. Review the patients understanding of PrEP, any barriers"
"to adherence, tolerance to the medication as well as any"
XI. Review the patients risk exposure profile and perform
XII. Evaluate and support PrEP adherence at each clinic
XIII. Evaluate the patient for any symptoms of STIs at every
visit and treat according to current STI treatment Guidelines.
Guidance on dis-  Acquisition of HIV infection
continuing PrEP  Suspected signs and symptoms of acute HIV infection
following a recent exposure within 4 weeks
 Changed life situations resulting in lowered risk of
HIV acquisition (no longer at substantial risk of Hacquisition)
 Intolerable toxicities and side effects of ARVs
 Chronic non-adherence to the prescribed regimen despite
efforts to improve daily pill-taking.
 HIV-negative in a sero-discordant relationship when the
positive partner on ART for 6months has achieved
sustained viral load suppression (condoms should still
be used consistently). The HIV negative partner can be
allowed to continue PrEP even if the positive partner
is virally suppressed if they choose to.
"For detailed guidance on the provision of PrEP, please refer to the"
Technical Guidance on Pre-Exposure Prophylaxis for Persons at High
The PrEP ring is a long-acting HIV prevention method developed specifically for clients who are unable or do not want to take oral PrEP or
when oral PrEP is not available. The ring is made of a flexible silicone
material containing 25 mg of an ARV drug called dapivirine. It is inserted
into the vagina and should remain in place for one month. Dapivirine
belongs to a class of ARVs called non-nucleoside reverse transcriptase
inhibitors (NNRTI) that reduce the ability of HIV to replicate itself inside
a healthy cell. The ring delivers the drug directly to the site of potential
"infection over the course of one month, with low absorption elsewhere"
"in the body, lowering the likelihood of systemic side effects."
Guidance on discontinuing PrEP  Acquisition of HIV infection
 Suspected signs and symptoms of acute HIV infection
following a recent exposure within 4 weeks
 Changed life situations resulting in lowered risk of
HIV acquisition (no longer at substantial risk of Hacquisition)
 Intolerable toxicities and side effects of ARVs
 Chronic non-adherence to the prescribed regimen despite
efforts to improve daily pill-taking.
 HIV-negative in a sero-discordant relationship when the
positive partner on ART for 6months has achieved
sustained viral load suppression (condoms should still
be used consistently). The HIV negative partner can be
allowed to continue PrEP even if the positive partner
is virally suppressed if they choose to.
"For detailed guidance on the provision of PrEP, please refer to the"
Technical Guidance on Pre-Exposure Prophylaxis for Persons at High
Possible Side Effects of the PrEP Ring
Possible side effects of the ring are typically mild and include urinary
"tract infections (UTIs  experienced by about 15 of users), vaginal discharge (experienced by about 7 of users), vulvar itching (experienced"
"by about 6 of users), and pelvic and lower abdominal pain (experienced"
Contraindications for PrEP Ring Use
The ring should not be provided to people with:
 An HIV-positive test result according to the national HIV testing
 Known exposure to HIV in the past 72 hours (because such
clients may derive more benefit from post-exposure prophylaxis
(PEP) if the potential for HIV exposure was high)
 Signs of AHI (Box 1) AND potential exposure within the past
 Inability to commit to effectively using the ring and attend
 Allergy or hypersensitivity to active substance or other
substances listed in the product information sheet
Long acting injectable cabotegravir (CAB-LA)
The long acting injectable cabotegravir: Is a long acting injectable drug
"containing Cabotegravir, an integrase inhibitor, is effective in preventing"
HIV among people at high risk of acquiring HIV.
It is indicated in all HIV negative persons at high risk of HIV.
"Before initiation, individuals must be screened for HIV using the national"
HTS algorithm and rule out signs of Acute HIV infection as for oral PrEP.
- Administration: Its administrated in the buttock once every
- Side effects: The injectable cabotegravir is safe and welltolerated.
- EfficacyEffectiveness: The injectable cabotegravir was found
- Safety: No safety concerns have been associated
- Acceptability and barriers: In a study setting it was highly
- Contraindications: Hypersensitivity to active substance
" For detailed guidance on the provision of CAB-LA, please"
refer to the Technical Guidance on Pre-Exposure Prophylaxis
"for Persons at High Risk of HIV in Uganda, 2022."
Psychosocial Support for HIV-Positive Persons
HIV-positive persons benefit greatly from the following support after the
first impact of the test result is overcome:
" Help the person understand the social, medical, and psychological implications for himherself, the unborn child (in"
"the case of a pregnant woman), and any sexual partners"
" Connect the person with support services, including (religious) support groups, orphan care, income- generating"
"activities, home care and others"
 Help the person find strategies to involve hisher partner
and extended family in sharing responsibility
 Help the person identify someone from the community to
 Discuss with HIV positive mothers how to provide for the
 Help himher identify a person from the extended family or
community who will provide support
" As appropriate, confirm and support information given in"
"HIV counselling and testing on mother-to-child transmission, possibility of ARV treatment, safer sex, infant feeding"
 Help the person to understand and develop strategies to
apply new information within daily life.
HIV-positive persons benefit greatly from the following support after the
first impact of the test result is overcome:
" Help the person understand the social, medical, and psychological implications for himherself, the unborn child (in"
"the case of a pregnant woman), and any sexual partners"
" Connect the person with support services, including (religious) support groups, orphan care, income- generating"
"activities, home care and others"
 Help the person find strategies to involve hisher partner
and extended family in sharing responsibility
 Help the person identify someone from the community to
 Discuss with HIV positive mothers how to provide for the
 Help himher identify a person from the extended family or
community who will provide support
" As appropriate, confirm and support information given in"
"HIV counselling and testing on mother-to-child transmission, possibility of ARV treatment, safer sex, infant feeding"
 Help the person to understand and develop strategies to
apply new information within daily life.
SEXUALLY TRANSMITTED INFECTIONS (STI)
"STIs are a collection of disorders, several of which are better"
regarded as syndromes for more effective management using a
 General preventive measures include:
 Give health education about STIs
 Provide specific education on the need for early reporting
 Ensure notification and treatment of sexual partners
 Counsel patient on risk reduction e.g. practice of safe sex
"by using condoms, remaining faithful to one sexual partner,"
" If necessary and possible, schedule return visits"
Urethral Discharge Syndrome (Male)
"It refers to urethral discharge in men with or without dysuria,"
"caused by a number of diseases usually spread by sexual intercourse, which produce similar manifestations in males and may"
be difficult to distinguish clinically.
" Common: Neisseria gonorrhoea (causing gonorrhoea),"
 Chlamydia trachomatis and Ureaplasma urealyticum
 Uncommon: Trichomonas vaginalis
 Mucus or pus at the tip of the penis; staining underwear
" Burning pain on passing urine (dysuria), frequent urition"
" Pus swab: Gram stain, culture and sensitivity"
 Blood: Screen for syphilis and H Examine patient carefully to confirm discharge
Patient complains of urethral discharge or dysuria
Cefixime 400 mg stat plus Doxycycline
100 mg 12 hourly for 7 days. Treat
"If partner is pregnant, instead of Doxycycondoms"
cline give Erythromycim 500 mg every 6 Offer or refer for HCT
repeat Doxycycline 100 treated: Re-start
mg 12 hourly for 7 days treatment all over
If discharge persists management
 Take history and examine the client. Milk urethra if HC2
Retract prepuce and examine for ulcers f Treat both patient
and sexual partners f Advise abstinence or condom use
 Ceftriaxone 250 mg IM or Cefixime 400 mg single
 Doxycycline 100 mg every 12 hours for 7 days
 Substitute doxycycline with erythromycin 500 mg every
 or Azithromycin 1 g stat if available
If discharge or dysuria persists and partners were treated:
 Exclude presence of ulcers under prepuce
 Repeat doxycycline 100 mg every 12 hours for 7 days
 Also give metronidazole 2 g single dose
If discharge or dysuria persists and partners were not treated:
 Start the initial treatment all over again and treat partners
 Refer for specialist management if not better
 Take history and examine the client. Milk urethra if
Retract prepuce and examine for ulcers f Treat both patient
and sexual partners f Advise abstinence or condom use
 Ceftriaxone 250 mg IM or Cefixime 400 mg single
 Doxycycline 100 mg every 12 hours for 7 days
 Substitute doxycycline with erythromycin 500 mg every
 or Azithromycin 1 g stat if available
If discharge or dysuria persists and partners were treated:
 Exclude presence of ulcers under prepuce
 Repeat doxycycline 100 mg every 12 hours for 7 days
 Also give metronidazole 2 g single dose
If discharge or dysuria persists and partners were not treated:
 Start the initial treatment all over again and treat partners
 Refer for specialist management if not better HC2
Abnormal Vaginal Discharge Syndrome
"Often the first evidence of genital infection al, though absence of abnormal vaginal discharge does not mean absence"
of infection. Normal discharge is small in quantity and white to colourless.
Not all vaginal infections are sexually transmitted diseases.
 Can be a variety and often mixture of organisms
" Vaginitis: by Candida albicanis, Trichomonas vaginalis or"
"bacterial vaginosis (by Gardnerella vaginalis, Mycoplasma"
 Cervicitis: commonly due to gonorrhoea and chlamydia:
usually asymptomatic and rarely a cause of abnormal vaginal discharge.
" Increased quantity of discharge, abnormal colour and odour"
" Lower abdominal pain, itching and pain at sexual intercourse may be present"
 In Candida albicans vaginitis: very itchy thick or lumpy
"white discharge, red inflamed vulva"
 Trichomonas vaginalis: itchy greenish-yellow frothy discharge with offensive smell
 Bacterial vaginosis: thin discharge with a fishy smell from
Candida vaginitis and bacterial vaginosis are NOT sexually transmitted
"diseases, even though sexual activity is a risk factor."
 Gonorrhoea causes cervicitis and rarely vaginitis. Thereis a
purulent thin mucoid slightly yellow pus discharge with no
" Chlamydia causes cervicitis which may present with a nonitchy, thin, colourless discharge"
 Cancer of the cervix (blood-stained smelly discharge)
" Intra-vaginal use of detergents, chemicals, physical agents"
"and herbs, chronic tampon use, allergic vaginitis"
" Pus swab: microscopy, Gram stain, CS"
 Blood: syphilis tests (RPRVDRL)
"If there are ulcers, tion for cervical lesions. If there is abdominal"
"treat as genital tenderness, treat as"
Refer to Gynaecolo- Check for erythema
gist immediately excoriations or thrush
Fluconazole 150 mg-200mg plus Doxycycline 100 mg 12 hourly
"Metronidazole tablets, 2 g single for 7 days plus Metronidazole"
dose. 2 g single dose. Treat sexual
If pregnant replace Fluconazole partners. If pregnant replace
with Clotrimazole pessary 100 mg Doxycycline with Erythromycin
once for 6 days and add Metroni- 500 mg 6 hourly for 7 days
dazole only after 1st trimester
"If discharge persists treated, refer for specialists"
doxycycline 100 mg 12 hourly for 7
days and if pregnant give Erythromycin 500 mg 6 hourly for 7 days
"days and partners were treated,"
refer for specialists management
" Take history and examine for genital ulcers, abdominal"
 Perform speculum examination for cervical lesions
 Assess risk for sexually transmitted disease
If there is lower abdominal tenderness and sexually active:
 Treat as in PID (see section 14.1.2)
"If no lower abdominal pain and discharge is thick and lumpy, vagina HC2"
is itchy and erythema or excoriations are present: likely Candida
 Give clotrimazole pessaries 100 mg; insert high in
vagina once daily before bedtime for 6 days or twice
" Or fluconazole 200 mg tablets single dose, orally"
If abundantsmelly dischargevaginosis: possible trichomonas HC2
"If purulent discharge, or high risk of STD, or previous treatment HC3"
"non effective: treat for gonorrhea, and chlamydia, and trichomonas"
 Give cefixime 400 mg stat or ceftriaxone 1g
 Plus doxycycline 100 mg 12 hourly for 7 days
" Take history and examine for genital ulcers, abdominal"
 Perform speculum examination for cervical lesions
 Assess risk for sexually transmitted disease
If there is lower abdominal tenderness and sexually active:
 Treat as in PID (see section 14.1.2) 
"If no lower abdominal pain and discharge is thick and lumpy, vagina"
is itchy and erythema or excoriations are present: likely Candida
 Give clotrimazole pessaries 100 mg; insert high in
vagina once daily before bedtime for 6 days or twice
" Or fluconazole 200 mg tablets single dose, orally"
  Metronidazole 2 g stat dose HC2
If abundantsmelly dischargevaginosis: possible trichomonas
"If purulent discharge, or high risk of STD, or previous treatment"
"non effective: treat for gonorrhea, and chlamydia, and trichomonas"
 Give cefixime 400 mg stat or ceftriaxone 1g
 Plus doxycycline 100 mg 12 hourly for 7 days
Plus metronidazole 2 g stat HC3
However if client is pregnant HC3
 Replace doxycycline with erythromycin 500 mg 6
If discharge or dysuria still persists and partners treated:
Pelvic Inflammatory Disease (PID)
See section Genital Ulcer Disease (GUD) Syndrome ICD10 CODES:
Genital ulcer syndrome is one of the commonest syndromes that affect
men and women. Single or multiple ulcers can be present.
"Multiple organisms can cause genital sores, commonly:"
 Treponema pallidum bacteria: syphilis
 Herpes simplex virus: genital herpes
 Donovania granulomatis: Granuloma inguinale
 Chlamydia strains: lymphogranuloma venerium (LGV)
 Primary syphilis: the ulcer is at first painless and may be
between or on the labia or on the penis
" Secondary syphilis: multiple, painless ulcers on the penis"
" Genital Herpes: small, multiple, usually painful blisters,"
 Replace doxycycline with erythromycin 500 mg 6
If discharge or dysuria still persists and partners treated:
 Refer for further management HC3
"vesicles, or ulcers. Often recurrent"
 Granuloma inguinale: an irregular ulcer which increases in
size and may cover a large area
" Chancroid: multiple, large, irregular ulcers with enlarged"
painful suppurating lymph nodes
 Cancer of the penis in elderly men
 Cancer of the vulva in women 50 years
Patient complains of ulcers or sores
"Ciprofloxacin 500 mg bd for 3 days and perform RPR test, if"
"positive, give Bezathine penicillin"
into each buttock). If allergic to
into each buttock). If allergic to
"penicillin, give Erythromycin 500"
"penicillin, give Erythromycin 500"
mg every 6 hours for 14 days. In
If vesicle or blisters persist If ulcers persist for 10 days
Refer for specialists management
Multiple painful blisters or vesicles: likely herpes HC4
 Aciclovir 400 mg every 6 hours for 7 days HC3
 If RPR positive add Benzathine penicillin MU IM
single dose (half in each buttock)
" If lesions persist, repeat acyclovir for 7 days"
 Ciprofloxacin 500 mg every 12 hours for 3 days plus
Benzathine penicillin MU IM single dose (half into
" In penicillin allergy, give Erythromycin 500 mg every"
If ulcer persists 10 days and partner was treated
 Add Erythromicin 500 mg every 6 hours for 7 days
 Refer for specialist management
 Negative RPR does not exclude early syphilis
 Genital ulcers may appear with enlarged and
fluctuating inguinal lymph nodes (buboes). Do not
Multiple painful blisters or vesicles: likely herpes
 Aciclovir 400 mg every 6 hours for 7 days
 If RPR positive add Benzathine penicillin MU IM
single dose (half in each buttock)
" If lesions persist, repeat acyclovir for 7 days HC4"
 Ciprofloxacin 500 mg every 12 hours for 3 days plus
Benzathine penicillin MU IM single dose (half into
" In penicillin allergy, give Erythromycin 500 mg every"
If ulcer persists 10 days and partner was treated
 Add Erythromicin 500 mg every 6 hours for 7 days
 Refer for specialist management 
 Negative RPR does not exclude early syphilis
 Genital ulcers may appear with enlarged and
fluctuating inguinal lymph nodes (buboes). Do not
Inguinal Swelling (Bubo) ICD 10 CODE: A57
It is an STI syndrome presenting as localised swellings or enlarged lymph
glands in the groin and femoral area.
 Chlamydia strains: lymphogranuloma venerium (LGV)
 Excessively swollen inguinal glands
 Swellings may become fluctuant if pus forms
" Other causes of swollen inguinal lymph nodes, e.g. leg ulcer"
Patient complains of inguinal swelling
Take history and examine for genital
"ulcers, rule out infection of the foot, leg"
or buttock and exclude inguinal hernia
If genital ulcer is present Inguinalfemoral buboes
Give Doxycycline 100 mg 12 hourly for 14 days.
"Treat partner. If partner pregnant, instead of Doxycycline give Erythromycin 500 mg every 6 hours"
for 14 days. Do not incise bubo. Aspirate through
normal skin with a large bore needle gauge 20
"If buboes persist, check to see if partner"
was treated. If partner not treated
Continue with Doxycycline 100 mg 12
hourly for 14 days or Erythromycin 500
If no improvement Refer for specialists management
" Examine for genital ulcers, rule out infection of the foot, HC2"
leg or buttock and exclude inguinal hernia
" If genital ulcer is present, treat as per above protocol"
 Give doxycycline 100 mg 12 hourly for 14 days
 Give erythromycin 500 mg every 6 hours for 14 days
"If bubo persisting, and partner was not treated"
 Refer for specialist management
 Do not incise bubo. Aspirate through normal skin with a large
bore needle gauge 20 every 2 days until resolution
 Alternative to doxycycline: azithromycin 1 g single dose
Genital Warts ICD10 CODE: A63.0
Superficial mucocutaneous infection
 Human papilloma virus (HPV): causes viral warts (condyl
 Treponema pallidum: causes syphilitic warts (condylomata
" Examine for genital ulcers, rule out infection of the foot,"
leg or buttock and exclude inguinal hernia
" If genital ulcer is present, treat as per above protocol"
 Give doxycycline 100 mg 12 hourly for 14 days
 Give erythromycin 500 mg every 6 hours for 14 days
"If bubo persisting, and partner was not treated"
 Refer for specialist management HC2
 Do not incise bubo. Aspirate through normal skin with a large
bore needle gauge 20 every 2 days until resolution
 Alternative to doxycycline: azithromycin 1 g single dose 
" Penis, foreskin, labia and vagina are the most common sites"
" Warts can be variable in number and size, either few or"
 HPV warts: soft fleshy growth on genitals
 Syphilitic warts: flat-topped and broad based growth
" Molluscum contagiosum: light coloured, umbilicated"
growths on the face and genital areas
 Apply podophyllum resin paint 15 to the warts 13
times weekly until warts have resolved; may require
- Protect normal skin with petroleum jelly before
- Apply precisely on the lesion avoiding normal
- Wash off with water 4 hours after each application
If no improvement after 3 applications
 Refer for specialist management
 Give: benzathine penicillin injection MU single dose
 Apply podophyllum resin paint 15 to the warts 13
times weekly until warts have resolved; may require
- Protect normal skin with petroleum jelly before
- Apply precisely on the lesion avoiding normal
- Wash off with water 4 hours after each application
If no improvement after 3 applications
 Refer for specialist management
 Give: benzathine penicillin injection MU single dose
 Treat underlying conditions that may be compromising
Complex chronic bacterial infection affecting a variety of organs and
" Transmitted sexually and from mother to foetus, rarely"
through blood transfusion or non sexual contact
" Primary syphilis: 10-90 days following inoculation, characterized by a painless genital ulcer with clean base and"
"indurated margins, regional lymphadenopathy. It can heal"
spontaneously but the disease will progress to secondary
 Secondary syphilis: few weeks to months (max 6 months)
"from primary lesions, characterised by:"
 Mucous membranes lesions (patches and ulcers)
 Weeping papules (condyloma alata) in moist skin areas
 Generalized non tender lymphadenopathy
 Treat underlying conditions that may be compromising
" Fever, meningitis, hepatitis, osteitis, arthritis, iritis"
 Early latent syphilis (1 year in duration): clinically quiescent but possible relapse of secondary syphilis
" Late latent syphilis: clinically quiescent, not very infectious"
(but possible maternal foetal transmission)
 Late (tertiary) syphilis: at any time after secondary syphilis
"- nfiltrative tumour of skin, bones, liver"
"- Aortitis, aneurysms, aortic regurgitation"
- Central nervous system disorders (neurosyphilis): meningo
"vascular syphilis, hemiparesis, seizures, progressive"
"degeneration with paraesthesias, shooting pains, dementia,"
 Non-treponemal antibody tests (VDRL and RPR)
- Positive 4-6 weeks after infection
- Possibility of false positive
- Remains positive 6-12 months after treatment
" Treponemal antibody tests (TPHA): very sensitive, used to confirm"
a positive non-treponemal test. Remains positive for long even
after treatment so its positivity may not indicate active disease.
"Primary, seconday and early latent syphilis HC3"
" Benzathine penicillin million IU IM stat, half in"
 or Doxycycline 100 mg every 12 hours for 14 days
"Primary, seconday and early latent syphilis"
" Benzathine penicillin million IU IM stat, half in"
 or Doxycycline 100 mg every 12 hours for 14 days HC3
"Late latent or uncertain duration, or tertiary without HC3"
 Benzathine penicillin million IU IM weekly for 3 weeks
 Or Doxycycline 100 mg every 12 hours for 28 days
 Benzylpenicillin 4 million IU IV every 4 hours or HC3
 Ceftriaxone 2 g IV or IM daily for 10-14 days
 Benzathine penicillin million IU IM weekly for 3 weeks
" Treat partner(s), abstain from sex during treatment and"
Inflammation of the glans penis
" Usually caused by Candida, rarely by Trichomonas"
"Late latent or uncertain duration, or tertiary without"
 Benzathine penicillin million IU IM weekly for 3 weeks
 Or Doxycycline 100 mg every 12 hours for 28 days HC3
 Benzylpenicillin 4 million IU IV every 4 hours or
 Ceftriaxone 2 g IV or IM daily for 10-14 days HC2
 Benzathine penicillin million IU IM weekly for 3 weeks
" Treat partner(s), abstain from sex during treatment and"
 Plus metronidazole 400 mg every 12 hours for 7 days
 Advise on hygiene and circumcision
3.Painful Scrotal Swelling ICD10 CODE: N45
 Inflammation of epididymis and testis
" Usually caused by N. gonorrhoea, Chlamydia"
" Acute painful and tender unilateral swelling of epididymus and testis,"
with or without urethral discharge
 Treat as per urethral discharge protocol above (section HC3
 Plus metronidazole 400 mg every 12 hours for 7 days
 Advise on hygiene and circumcision
 Treat as per urethral discharge protocol above (section
Congenital STIs in newborns occur as a result of infection of babies
in utero or during delivery as a complication of untreated STIs among
"mothers. Syphilis, HIV, gonococcal, chlamydia and herpes simplex are"
the most serious congenital STIs.
3.Neonatal Conjunctivitis (Ophthalmia Neonatorum)
Refers to conjunctival infection of neonates by STI organisms in the
infected mothers birth canal. It is a very serious condition that can lead
to corneal ulceration and ultimately to blindness. Blindness in children
is associated with high infant morbidity and mortality.
 Commonly caused by Neisseria gonorrhoeae and
" Other non-STI causes of neonatal conjunctivitis predisposed by difficult labour such as early rupture of membranes, vacuum extraction or other assisted vaginal delivery"
 Purulent discharge from one or both eyes within 30 days
" Complications of untreated conjuctivitis: corneal ulceration,"
"perforation, scarring and blindness"
" Pus swab: Gram stain, Culture  Sensitivity"
Treatment should cover both gonorrhoea and chlamydia HC2
 Start cleaning with normal saline and apply tetracycline
ointment every hour while referring for systemic treatment
 Ceftriaxone 125 mg single dose IM plus azithromycin
"syrup 20 mgkg orally, once daily for 3 days"
 Irrigate the eyes with saline or sterile water
 Use gloves and wash hands thoroughly after handling
 Cover the eye with gauze while opening the eyelid as
 Topical tetracycline eye ointment has NO added benefit
 Treat both parents for Gonorrhoea and Chlamydia and
 Screen and treat all infected mothers in antenatal care
 Apply prophylactic tetracycline eye ointment 1 to both
eyes of ALL newborns at the time of delivery
3.Congenital Syphilis ICD10 CODE: A50
It is a serious debilitating and disfiguring condition that can be fatal.
About one third of syphilis infected mothers have adverse pregnancy
"outcome, one third give birth to a healthy baby, while the remaining"
third may result into congenital syphilis infection.
Treatment should cover both gonorrhoea and chlamydia
 Start cleaning with normal saline and apply tetracycline
ointment every hour while referring for systemic treatment
 Ceftriaxone 125 mg single dose IM plus azithromycin
"syrup 20 mgkg orally, once daily for 3 days"
 Irrigate the eyes with saline or sterile water
 Use gloves and wash hands thoroughly after handling
 Cover the eye with gauze while opening the eyelid as
 Topical tetracycline eye ointment has NO added benefit
 Treat both parents for Gonorrhoea and Chlamydia and
screen for HIV and syphilis HC2
 Early congenital syphilis: begins to show after 6-8 weeks
"- Snuffle, palmarplantar bullae, hepatosplenomegaly, pallor,"
joint swelling with or without paralysis and cutaneous lesions.
 Late congenital syphilis: begins to show at 2 years
"- Microcephaly, depressed nasal bridge, arched palate,"
"perforated nasal septum, failure to thrive, mental sub"
normality and musculoskeletal abnormalities
Preferably perform the tests on mother:
Management of congenital syphilis
 Assume cerebrospinal involvement in all babies less HC3
" Aqueous benzylpenicillin 150,000 IUkg body weight"
IV every 12 hours for a total of 10 days
" OR procaine penicillin, 50,000 IUkg body weight, IM"
 Treat both parents for syphilis with benzathine penicillin
MU single dose (half on each buttock)
 Assume that infants whose mothers had untreated
syphilis or started treatment within 30 days of
delivery have congenital syphilis
 If mother is diagnosed with syphilis during
 Assume cerebrospinal involvement in all babies less
" Aqueous benzylpenicillin 150,000 IUkg body weight"
IV every 12 hours for a total of 10 days
" OR procaine penicillin, 50,000 IUkg body weight, IM"
 Treat both parents for syphilis with benzathine penicillin
MU single dose (half on each buttock) HC3
 Assume that infants whose mothers had untreated
syphilis or started treatment within 30 days of
delivery have congenital syphilis
 If mother is diagnosed with syphilis during 
" pregnancy, use benzathine penicilln as first line"
since erythromycin does not cross the placental
barrier and therefore does not effectively prevent in
utero acquisition of congenital syphilis
 Do not use doxycycline in pregnancy
 Routine screening and treatment of syphilis infected mothers in antenatal clinics
" pregnancy, use benzathine penicilln as first line"
since erythromycin does not cross the placental
barrier and therefore does not effectively prevent in
utero acquisition of congenital syphilis
 Do not use doxycycline in pregnancy 
ThrombosisPulmonary Embolism (DVTPE)
"Clot formation within the deep venous system, usually of the calf, thigh,"
or pelvic veins. The clot can cause a local problem at site of formation
"or dislodge, leading to thromboembolism in various parts of the body,"
particularly the lungs (pulmonary embolism).
 Venous stasis (slowing of blood flow)
" Immobilisation, prolonged bed rest, surgery, limb paralysis"
" Heart failure, myocardial infarction"
" Blunt trauma, venous injury including cannulation"
" Oral contraceptive pills, pregnancy and postpartum"
 Malignancies and some forms of chemotherapy
 For PE: any other cause of dyspnoea and chest pain e.g.
bronchopneumonia and myocardial infarction
 50 of cases may be clinically silent
" Pain, swelling and warmth of the calf, thigh, and groin"
" Dislodgement of the thrombus may lead to pulmonary embolism characterised by dyspnoea, tachycardia, chest pain,"
 Half of the cases of PE are associated with silent DVT
" Cellulitis, myositis, phlebitis, contusion"
 For PE: any other cause of dyspnoea and chest pain
Compression ultrasound - doppler
 In case of pulmonary embolism: chest CT angiogram
" Other useful tests (not specific): blood D-dimer, ECG, Chest X ray,"
Enoxaparin (Low molecular weight heparin- LMWH) 1 mg H
kg every 12 hours for at least 5 days
"Plus warfarin 5 mg single dose given in the evening, commencing on the same day as the heparin"
"- Maintenance dose: 2.5-mg single dose daily, H"
- adjusted according to the INR 2 -3
- Unfractionated heparin given as: 5000 units bolus and then 1000 units hourly or 17500 units
subcutaneuosly 12 hourly for 5 days. Adjust dose
according to activated partial thromboplastin
Enoxaparin (Low molecular weight heparin- LMWH) 1 mg
kg every 12 hours for at least 5 days
"Plus warfarin 5 mg single dose given in the evening, commencing on the same day as the heparin"
"- Maintenance dose: 2.5-mg single dose daily,"
- adjusted according to the INR 2 -3
- Unfractionated heparin given as: 5000 units bolus and then 1000 units hourly or 17500 units
subcutaneuosly 12 hourly for 5 days. Adjust dose
according to activated partial thromboplastin
- Or 333 unitskg SC as an initial dose followed by H
Alternative to warfarin and heparin combination:
- No need to initiate with heparin
- Dose: 15mg orally twice a day for 3 weeks then
20mg daily for the duration of anticoagulation.
- Patients must take the drug at the same time
every day to prevent re-thrombosis.
- Not to be used in pregnant or breast feeding
- Associated with reduced bleeding risk compared
- Dose: 10mg twice a day for 7 days then 5mg
twice a day for the duration of the anticoagulation
- Associated with a reduced bleeding risk than
- Not to be used in pregnant or breast-feeding
 Monitor for bleeding complications
" When using Apixaban, patients should be asked to"
 See section 1.3.10. for treatment of warfarin
overdose and PGD 2015 monograph on protamine
 Do not start therapy with warfarin alone because it
initially increases risk of thrombus progression
- Or 333 unitskg SC as an initial dose followed by
Alternative to warfarin and heparin combination:
- No need to initiate with heparin
- Dose: 15mg orally twice a day for 3 weeks then
20mg daily for the duration of anticoagulation.
- Patients must take the drug at the same time
every day to prevent re-thrombosis.
- Not to be used in pregnant or breast feeding
- Associated with reduced bleeding risk compared
- Dose: 10mg twice a day for 7 days then 5mg
twice a day for the duration of the anticoagulation
- Associated with a reduced bleeding risk than
- Not to be used in pregnant or breast-feeding
 Monitor for bleeding complications
" When using Apixaban, patients should be asked to"
 See section 1.3.10. for treatment of warfarin
overdose and PGD 2015 monograph on protamine
 Do not start therapy with warfarin alone because it
initially increases risk of thrombus progression 
 Prophylaxis with enoxaparin 40 mg SC daily in any acutely ill
medical patient and in prolonged admission
Infective Endocarditis ICD10 CODE: I33.0
An infection of the heart valves and lining of the heart chambers by
"microorganisms, usually bacterial, rarely fungal."
 Low molecular weight heparin- H
"- (LMWH) e.g., Enoxaparin given as 1 mgkg"
"- every 12 hours or 1.5mgkg once a day, for at"
" Plus warfarin 5 mg single dose given in the evening,"
commencing on the same day as the heparin. Overlap
treatment of warfarin and heparin. Heparin is stopped
when the warfarin dose leads to an optimal INR of 2-3.
" Maintenance dose: single dose daily, that need a higher"
maintenance dose than others especially when there are
drugs that may interact with warfarin. Typical dose may
range between  10mg daily. adjusted according to
"- (LMWH) e.g., Enoxaparin given as 1 mgkg"
"- every 12 hours or 1.5mgkg once a day, for at"
" Plus warfarin 5 mg single dose given in the evening,"
commencing on the same day as the heparin. Overlap
treatment of warfarin and heparin. Heparin is stopped
when the warfarin dose leads to an optimal INR of 2-3. H
" Maintenance dose: single dose daily, that need a higher"
maintenance dose than others especially when there are
drugs that may interact with warfarin. Typical dose may
range between  10mg daily. adjusted according to
 Sub-acute endocarditis: caused by low virulence organisms such
 Acute endocarditis: caused by common pyogenic organisms
 Post-operative endocarditis: following cardiac surgery and
prosthetic heart valve placement. The most common organism
involved is Staphylococcus aureus
 Disease may present as acute or chronic depending on the
microorganism involved and patients condition
 Low grade fever and chills or acute severe septicaemia
 Embolic phenomena affecting various body organs (e.g. brain)
" Heart failure, prominent and changing heart murmurs"
 Splinter haemorrhages (nail bed and retina)
" Diagnostic triad: persistent fever, emboli, changing murmur"
" Rheumatic heart disease, congenital heart disease"
 Invasive dentaldiagnosticsurgical procedures (including cardiac
Note: Any unexplained fever in a patient with a heart valve
problem should be regarded as endocarditis
 Cardiac failure with heart murmurs
 Febrile conditions associated with anaemia
 Blood cultures: These are usually positive and all efforts should
be made to identify the responsible pathogen and obtain
 At least 3 sets of blood cultures (8 ml) each should be obtained
(each from a separate venipucture) at least one hour apart
" Blood: Complete blood count, ESR"
" Urinalysis for microscopic haematuria, proteinuria"
Treat complications e.g. heart failure Initial empirical
Benzylpenicillin 5 MU IV every 6 hours for 4 weeks
"Child: Benzylpenicillin 50,000 IUkg every 6 hours for"
Plus gentamicin 1 mgkg IV every 8 hours for 2 weeks
"If staphylococcus suspected, (acute onset) add:"
Cloxacillin IV 3 g every 6 hours
Child: 50 mgkg every 6 hours for 4 weeks
If MRSA (Multi-Resistant Staphylococcus aureus)
Vancomycin 500 mg IV every 6 hours
Child: 10 mgkg (infused over 1 hour) 6 hourly for 6
Once a pathogen has been identified
Amend treatment to correspond with the sensitivity
 Prophylaxis in case of dental procedures and tonsillectomy
"in patients at risk (valvular defects, congenital heart disease,"
prosthetic valve). Give amoxicillin 2 g (50 mgkg for children) as
"a single dose, 1 hour before the procedure."
Clinical syndrome caused by inadequate cardiac output for the bodys
"needs, despite adequate venous return."
"For management purposes, it can be classified into:"
- Congestiveacute heart failure
Treat complications e.g. heart failure Initial empirical
Benzylpenicillin 5 MU IV every 6 hours for 4 weeks H
"Child: Benzylpenicillin 50,000 IUkg every 6 hours for"
Plus gentamicin 1 mgkg IV every 8 hours for 2 weeks
"If staphylococcus suspected, (acute onset) add:"
Cloxacillin IV 3 g every 6 hours
Child: 50 mgkg every 6 hours for 4 weeks
If MRSA (Multi-Resistant Staphylococcus aureus)
Vancomycin 500 mg IV every 6 hours
Child: 10 mgkg (infused over 1 hour) 6 hourly for 6
Once a pathogen has been identified
Amend treatment to correspond with the sensitivity
- Acute pulmonary oedema (see section 4.1.4)
" Valvular heart disease, e.g. rheumatic heart disease"
 Prolonged rapid irregular heartbeat (arrhythmias)
" Severe anaemia, thyroid disease"
" Respiratory distress with rapid respiration, cyanosis, wheezing,"
"subcostal, intercostal, and sternal recession"
" Rapid pulse, gallop rhythm, excessive sweating"
" Palpitations, shortness of breath, exercise intolerance"
" Fatigue, orthopnea, exertional dyspnoea, wheezing"
 Raised jugular venous pressure (JVP)
" Dependent oedema, enlarged tender liver"
" Severe anaemia, severe acute malnutrition"
" Blood: Haemogram (for ESR, anaemia)"
Bed rest with head of bed elevated HC4
Prop up patient in sitting position
Reduce salt intake and limit fluid intake (1-L day)
Furosemide 20-40 mg oral or IV daily for every 12
hours increasing as required to 80-160 mg according HC4
Child: 1 mgkg oral or IV daily or every 12 hours
according to response (max: 8 mgkg daily)
"ACE inhibitors: start with low dose Enalapril mg once daily, increase gradually over 2 weeks to 1020 mg (max 40 mg) if tolerated (or Lisinopril 5mg"
increase gradually over 2 weeks to 40mg)
Child: Enalapril 0.1-1 mgkg daily in 1-2 doses Or
"Captopril 6.25-mg 8 -12 hourly, increase over"
2-4 weeks to max 150 mg daily in divided doses H
Child: Captopril 0.1-mgkg daily every 8-12 hours
If available and when patient stable add:
"Adults: Carvedilol mg every 12 hours, increase"
gradually every 2 weeks to max 25 mg 12 hourly
(or Bisoprolol 1.25mg once daily increase gradually to
"Child: Carvedilol mgkg every 12 hours, increase"
gradually to max mgkg every 12 hours
Bed rest with head of bed elevated
Prop up patient in sitting position
Reduce salt intake and limit fluid intake (1-L day)
Furosemide 20-40 mg oral or IV daily for every 12
hours increasing as required to 80-160 mg according
Child: 1 mgkg oral or IV daily or every 12 hours
according to response (max: 8 mgkg daily)
"ACE inhibitors: start with low dose Enalapril mg once daily, increase gradually over 2 weeks to 1020 mg (max 40 mg) if tolerated (or Lisinopril 5mg"
increase gradually over 2 weeks to 40mg)
Child: Enalapril 0.1-1 mgkg daily in 1-2 doses Or
"Captopril 6.25-mg 8 -12 hourly, increase over"
2-4 weeks to max 150 mg daily in divided doses
Child: Captopril 0.1-mgkg daily every 8-12 hours
If available and when patient stable add:
"Adults: Carvedilol mg every 12 hours, increase"
gradually every 2 weeks to max 25 mg 12 hourly
(or Bisoprolol 1.25mg once daily increase gradually to
"Child: Carvedilol mgkg every 12 hours, increase"
gradually to max mgkg every 12 hours HC4
Additional medicines (secondthird line) H
Spironolactone 25-50 mg once a day
Child: Initially 1.5-3 mgkg daily in divided doses
Digoxin 125-250 microgramsdaily
Child maintenance dose: 15 microgramskg daily
Use ACE inhibitors and beta blockers with caution if systolic BP is
less than 90 mmHg: monitor renal function
Use digoxin with caution in elderly and renal disease
 Early diagnosis and treatment of the cause (e.g. hypertension)
Patients with chronic heart failure need continuous treatment to control
symptoms and prevent disease progression and complications
"Periodic monitoring of body weight, blood pressure, HC2"
"heart rate, respiratory rate and oxygen saturation"
Regular exercise within limits of symptoms
"Continued treatment with the medicines listed above,"
with doses progressively increased to achieve control
Additional medicines (secondthird line)
Spironolactone 25-50 mg once a day
Child: Initially 1.5-3 mgkg daily in divided doses
Digoxin 125-250 microgramsdaily
Child maintenance dose: 15 microgramskg daily H
Use ACE inhibitors and beta blockers with caution if systolic BP is
less than 90 mmHg: monitor renal function
Use digoxin with caution in elderly and renal disease 
"Periodic monitoring of body weight, blood pressure,"
"heart rate, respiratory rate and oxygen saturation"
Regular exercise within limits of symptoms
"Continued treatment with the medicines listed above,"
with doses progressively increased to achieve control HC2
Pulmonary Oedema ICD10 CODE: I50.21
"Congestion of the lung tissue with fluid, usually due to heart failure."
 Severe fluid overload e.g. in renal failure or iatrogenic
" Non-cardiogenic pulmonary oedema: severe pneumonia, altitude"
"sickness, inhalation of toxic gases, acute respiratory distress"
" Severe dyspnoea, rapid breathing, breathlessness"
 Cough with frothy blood stained sputum
" Trauma (pneumothorax, pulmonary contusion)"
Prop up patient in sitting position
"High concentration oxygen: start with 5 Lmin, aim"
Prop up patient in sitting position
"High concentration oxygen: start with 5 Lmin, aim"
Furosemide 40-80 mg IM or slow IV - Repeat prn up HC4
to 2 hourly according to response
Child: 0.5-mgkg every 8-12 hours (max: 6 mg
Glyceryl trinitrate 500 microgram sublingually every H
Give morphine 5-15 mg IM or 2-4 mg slow HC4
Child: mgkg slow IV single dose
Repeat these every 4-6 hours till there is improvement
Digoxin loading dose IV 250 micrograms 3-4 times
in the first 24 hours then maintenance dose of 125250 micrograms daily
Child: 10 mgKg per dose as above then
maintenance dose of 15 microgramkgday
Do not give loading dose if patient has had digoxin within the
past 14 days but give maintenance dose
 Early diagnosis and treatment of cardiac conditions
 Compliance with treatment for chronic cardiac conditions
Atrial Fibrillation ICD10 CODE: I48
Common cardiac arrhythmia characterised by irregular pulse due to
the loss of the regular atrial electrical activity. Its onset can be acute or
"chronic, and it can be symptomatic or asymptomatic."
Furosemide 40-80 mg IM or slow IV - Repeat prn up
to 2 hourly according to response
Child: 0.5-mgkg every 8-12 hours (max: 6 mg
Glyceryl trinitrate 500 microgram sublingually every
Give morphine 5-15 mg IM or 2-4 mg slow Child: mgkg slow IV single dose
Repeat these every 4-6 hours till there is improvement
Digoxin loading dose IV 250 micrograms 3-4 times
in the first 24 hours then maintenance dose of 125250 micrograms daily
Child: 10 mgKg per dose as above then
maintenance dose of 15 microgramkgday HC4
Do not give loading dose if patient has had digoxin within the
past 14 days but give maintenance dose 
" Heart disease (heart failure, valvular heart diseases, ischaemic"
 Thyroid disease (hyperthyroidism)
" Irregular pulse (frequency and volume), heart rate can be either"
" Acute onset (often with high heart rate): palpitations, dizziness,"
"fainting, chest pain, shortness of breath"
 Chronic (with normal or almost normal heart rate): often
"asymptomatic, discovered at routine checks"
 It can precipitate heart failure or pulmonary oedema
 It can cause embolic stroke if clots form in the heart and are then
dislodged to the brain circulation
 Restore normal rhythm if possible (specialist only)
"If acute onset, high heart rate or patient in congestive heart failure and HC4"
"Treat heart failure as per guidelines (section 4.1.3),"
use digoxin and or Carvedilol (or Bisoprolol) to reduce
If acute onset and high heart rate but no signs of heart HC4
Use atenolol 50 mg to control heart rate
"If acute onset, high heart rate or patient in congestive heart failure and"
"Treat heart failure as per guidelines (section 4.1.3),"
use digoxin and or Carvedilol (or Bisoprolol) to reduce
If acute onset and high heart rate but no signs of heart
Use atenolol 50 mg to control heart rate HC4
If chronic but normal heart rate: H
Only treat underlying conditions
Refer to regional level to assess indication for
anticoagulation with aspirin or warfarin to prevent
Persistently high resting blood pressure (14090 mmHg for at least
two measurements five minutes apart with patient seated) on at least 2
Classification of blood pressure (BP)
Pre-hypertension 120-139 or 80-89
"Hypertension, stage 1 140-159 or 90-99"
"Hypertension, stage 2 160 or 100"
SBPsystolic blood pressure; DBPdiastolic blood pressure
" In the majority of cases, the cause is not known (essential"
If chronic but normal heart rate:
Only treat underlying conditions
Refer to regional level to assess indication for
anticoagulation with aspirin or warfarin to prevent
Pre-hypertension 120-139 or 80-89
"Hypertension, stage 1 140-159 or 90-99"
"Hypertension, stage 2 160 or 100"
SBPsystolic blood pressure; DBPdiastolic blood pressure 
Secondary hypertension is associated with:
 Medicines (steroids and decongestants containing caffeine and
 Excessive intake of salt and alcohol
The majority of cases are symptomless and are only discovered on routine
Hypertension may present as a complication affecting:
To identify complications and possible cases of secondary hypertension:
Target: blood pressure below 14090 mmHg
"Do not add extra salt to cooked food, increase physical"
"activityexercise, reduce body weight"
"If all the above fail (within 3 months), initiate medicine"
Emphasize lifestyle changes with medicines
Give amlodipine 5 mg once daily
"If not controlled after 1 month, treat as in stage 2"
Give Amlodipine 5 mg once daily Plus
Angiotensin II receptor blocker (ARB) e.g. Losartan 50mg
(or Valsartan 80mg or Telmisartan 40mg) once daily
"Note: Instead of ARBs, you can use angiotensin converting enzyme inhibitors (ACEI) like Lisinopril 20mg"
"Do not add extra salt to cooked food, increase physical"
"activityexercise, reduce body weight"
"If all the above fail (within 3 months), initiate medicine"
Emphasize lifestyle changes with medicines
Give amlodipine 5 mg once daily
"If not controlled after 1 month, treat as in stage 2 HC3"
Give Amlodipine 5 mg once daily Plus
Angiotensin II receptor blocker (ARB) e.g. Losartan 50mg
(or Valsartan 80mg or Telmisartan 40mg) once daily
"Note: Instead of ARBs, you can use angiotensin converting enzyme inhibitors (ACEI) like Lisinopril 20mg"
or Enalapril 5mg once daily. HC3
If blood pressure  14090 mmHg after 1 month
Give Amlodipine 10 mg once daily
Losartan 50mg (or Valsartan 80mg or Telmisartan 40mg)
If blood pressure  14090 mmHg after 1 month
Give Amlodipine 10 mg once daily
Losartan 100mg (or Valsartan 160mg or Telmisartan
Thiazide diuretic like Hydrochlorothiazide 12.5mg (or
Bendroflumethiazide 5mg) once in the morning
If blood pressure  14090 mmHg after 1 month
Give Amlodipine 10 mg once daily
Losartan 100mg (or Valsartan 160mg or Telmisartan
Thiazide diuretic like Hydrochlorothiazide 12.5mg (or
Bendroflumethiazide 5mg) once in the morning
If blood pressure  14090 mmHg after 1 month
Give Amlodipine 10 mg once daily
Losartan 50mg (or Valsartan 80mg or Telmisartan 40mg)
If blood pressure  14090 mmHg after 1 month
Give Amlodipine 10 mg once daily
Losartan 100mg (or Valsartan 160mg or Telmisartan
Thiazide diuretic like Hydrochlorothiazide 12.5mg (or
Bendroflumethiazide 5mg) once in the morning HC3
If blood pressure  14090 mmHg after 1 month
Give Amlodipine 10 mg once daily
Losartan 100mg (or Valsartan 160mg or Telmisartan
Thiazide diuretic like Hydrochlorothiazide 12.5mg (or
Bendroflumethiazide 5mg) once in the morning HC3
"If BP is  14090mmHg, refer for further management to a higher"
Provision for specific patients
Assess the cardiovascular disease (CVD) risk in all patients with
"Patients with diabetes, coronary heart disease, stroke or chronic"
kidney disease are considered having a high CVD risk.
The target BP is 13080 mmHg in people with high CVD risk.
Start statin (atorvastatin 20-40 mg once daily or simvastatin 20-40
mg once daily) and aspirin 75mg in people with prior heart attack
or ischemic stroke. Consider statin in people at high risk.
Start beta blocker (Atenolol 50mg or Bisoprolol 5mg or Nebivolol
5mg once daily) in people with heart attack in past 3 years.
A combination of ACEI or ARB and a CCB or a diuretic is recommended as initial therapy in patients with chronic kidney disease.
For hypertension secondary to thyroid disease consider adding
"In pregnancy, do NOT use ACEI or ARBs and diuretics."
Methyldopa and calcium channel blockers are safe to use
Dont use both an ACEI and ARB due to increased risk
Choice of antihypertensive medicine
Choice of medicine may depend on concomitant risk factors other conditions: the table below indicates the suitable medicines for such patients.
"If BP is  14090mmHg, refer for further management to a higher"
Provision for specific patients
Assess the cardiovascular disease (CVD) risk in all patients with
"Patients with diabetes, coronary heart disease, stroke or chronic"
kidney disease are considered having a high CVD risk.
The target BP is 13080 mmHg in people with high CVD risk.
Start statin (atorvastatin 20-40 mg once daily or simvastatin 20-40
mg once daily) and aspirin 75mg in people with prior heart attack
or ischemic stroke. Consider statin in people at high risk.
Start beta blocker (Atenolol 50mg or Bisoprolol 5mg or Nebivolol
5mg once daily) in people with heart attack in past 3 years.
A combination of ACEI or ARB and a CCB or a diuretic is recommended as initial therapy in patients with chronic kidney disease.
For hypertension secondary to thyroid disease consider adding
"In pregnancy, do NOT use ACEI or ARBs and diuretics."
Methyldopa and calcium channel blockers are safe to use
Dont use both an ACEI and ARB due to increased risk
Advanced chronic kidney disease
 Periodic screening of blood pressure
4.Hypertensive Emergencies and urgency
BP 180110 mmHg with symptoms and acute life threatening complications:
" Hypertensive encephalopathy (severe headache, confusion,"
 Acute angina or acute myocardial infarction (AMI)
 Eclampsia or pre-eclampsia (section and 16.3.8)
Advanced chronic kidney disease 
Admit and give parenteral medicines. Aim at lowering HC4
the blood pressure over 24 hours (not too rapidly except if
Treatment depends also on the presenting complications
"- In acute ischaemic stroke, do not lower below"
"- In acute aortic dissection, lower BP rapidly"
"- In pulmonary oedema, AMI: treat the complication"
"If aggressive BP lowering is needed, use IV hydralazine 5-10"
"mg slowly over 20 minutes. Check blood pressure regularly,"
repeat dose after 20-30 minutes if necessary
"BP  180110 mmHg without evidence of target organ damage, such"
"as pulmonary edema, cardiac ischemia, neurologic deficits, or acute"
Treat with combination of oral antihypertensive therapy
(ACEIARB inhibitor  calcium channel blocker  diuretics)
Aim at lowering blood pressure over the next 48- 72 hours
Ischaemic Heart Disease (Coronary Heart Disease)
"A condition in which there is insufficient blood flow through the coronary arteries of the heart, thus leading to ischaemia andor infarction."
Admit and give parenteral medicines. Aim at lowering
the blood pressure over 24 hours (not too rapidly except if
Treatment depends also on the presenting complications
"- In acute ischaemic stroke, do not lower below"
"- In acute aortic dissection, lower BP rapidly"
"- In pulmonary oedema, AMI: treat the complication"
"If aggressive BP lowering is needed, use IV hydralazine 5-10"
"mg slowly over 20 minutes. Check blood pressure regularly,"
repeat dose after 20-30 minutes if necessary HC4
Treat with combination of oral antihypertensive therapy
(ACEIARB inhibitor  calcium channel blocker  diuretics)
Aim at lowering blood pressure over the next 48- 72 hours HC4
 Deposition of fatty material (cholesterol plaques) and platelet
aggregation inside the coronary arteries causing partial or total
" Hypertension, diabetes mellitus"
" Obesity, unhealthy diet, physical inactivity"
 Family history of heart disease
 Acute coronary syndrome (including acute myocardial infarction):
"prolonged chest pain, which may be localised on the left or"
"central part of the chest, ranging from mild to severe, at times"
"radiating to the left arm, neck and back,"
" and associated with sweating, dyspnoea, vomiting, anxiety, low"
 Stable angina: tightness in the chest or a sense of oppression
"worsening on exertion, relieved by rest and lasting only a few"
 Sudden cardiac death: usually due to fatal arrhythmias
" Indigestion, hiatus hernia, peptic ulcer"
" Pleurisy, pericarditis, pulmonary embolism"
" Cardiac enzymes (CPK, troponin)"
Management of acute coronary syndrome
Give acetylsalicylic acid 300 mg single dose (to be chewed) HC2
Glyceryl trinitrate 500 micrograms sublingually Repeat after H
Morphine 2.5-5 mg IV if persisting pain
Simvastatin 40 mg or atorvastatin 40 mg
Enoxaparin 1 mgkg SC every 12 hours
"Treat complications accordingly (pulmonary oedema,"
"Beta blockers if no contraindications (SBP 90 mmHg, HR"
60 bpm) e.g. Atenolol 25-50 mg daily
 Ensure close observation of the pulse rate and circulatory
ACE inhibitor e.g. Enalapril 2.5-10 mgdaily
Refer for further management to higher level of care if unstable
"When patient is stable, continue with:"
"Acetylsalicylic acid 75 mg once daily,"
Beta blocker (Atenolol or Carvedilol or Bisoprolol) and ACE
"Emphasize life changes (healthy diet, no smoking, regular"
"exercise, control of other risk factors)"
Give acetylsalicylic acid 300 mg single dose (to be chewed)
Glyceryl trinitrate 500 micrograms sublingually Repeat after
Morphine 2.5-5 mg IV if persisting pain
Simvastatin 40 mg or atorvastatin 40 mg
Enoxaparin 1 mgkg SC every 12 hours
"Treat complications accordingly (pulmonary oedema,"
"Beta blockers if no contraindications (SBP 90 mmHg, HR"
60 bpm) e.g. Atenolol 25-50 mg daily
 Ensure close observation of the pulse rate and circulatory
ACE inhibitor e.g. Enalapril 2.5-10 mgdaily
Refer for further management to higher level of care if unstable
"When patient is stable, continue with:"
"Acetylsalicylic acid 75 mg once daily,"
Beta blocker (Atenolol or Carvedilol or Bisoprolol) and ACE
"Emphasize life changes (healthy diet, no smoking, regular"
"exercise, control of other risk factors) H"
"Aggressive control of risk factors (hypertension, diabetes, HC2"
Acetylsalicylic acid 75-150 mg once a day
Beta blockers (e.g. Atenolol 25-100 mg) if not diabetic
Refer to higher level if still uncontrolled
 Effective control of hypertension and diabetes mellitus
 Consider treatment with acetylsalicylic acid and statin in patients
"Inflammation of the heart membrane (pericardium), which may be:"
" Acute and self-limiting, sub-acute or chronic"
" Fibrinous, serous, haemorrhagic or purulent"
 Idiopathic or viral (most common causes) e.g. CoxsackieA 
" Bacterial e.g. mycobacterium, staphylococcus, meningococcus,"
"streptococcus, pneumococcus, gonococcus, mycoplasma"
 Severe kidney failure (less common)
 Hypersensitivity such as acute rheumatic fever
"Aggressive control of risk factors (hypertension, diabetes,"
Acetylsalicylic acid 75-150 mg once a day
Beta blockers (e.g. Atenolol 25-100 mg) if not diabetic
Refer to higher level if still uncontrolled HC2
 Pericarditis without effusion: retrosternal pain radiating to
"shoulder, which worsens on deep breathing, movement,"
change of position or exercise; pericardial rub is a diagnostic sign
" Pericardial effusion: reduced cardiac impulses, muffled"
" Cardiac tamponade (compression) in case of massive effusion or constrictive pericarditis: dyspnoea, restlessness,"
"rising pulmonary and systemic venous pressure, rapid heart"
"rate, pulsus paradoxus, low BP, and low output cardiac failure"
" If there is fluid, perform tapping"
"If other causes, treat accordingly"
 Early detection and treatment of potential (treatable) causes
" If there is fluid, perform tapping"
"If other causes, treat accordingly H"
"Rheumatic Fever ICD10 CODE: I00, I01"
A systemic connective tissue disease which follows a streptococcal
"upper respiratory tract infection. It may involve the heart, joints, skin,"
"subcutaneous tissue, and CNS. The first attack usually occurs between"
 Hypersensitivity reaction to group A streptococcal throat
 Arthritis (migrating asymmetric polyarthritis)
" Acute rheumatic carditis, signs of cardiac failure, murmurs"
 Chorea (involuntary movements of limbs)
" Other minor signssymptoms: fever, arthralgia, laboratory"
" Any form of arthralgiaarthritis including sickle cell disease,"
 Antistreptolysin O titre (ASOT)
Diagnostic criteria (revised Jones criteria)
 Evidence of recent streptococcal infection
 Elevated ASO-titer or other streptococcal Ab titres or positive
throat swab for group A beta-hemolyticus streptococcus
 Two major manifestations or one major and two minor
MAJOR MANIFESTATIONS MINOR MANIFESTATIONS
 Erythema margina-  Acute phase reactum tants (increased ESR
 Subcutaneous nodules  ECG: prolonged PR
 Phenoxymethylpenicillin (Pen V) 250 mg every 6 hours
 Or Benzathine benzylpenicillin dose MU IM stat
 Acetylsalicylic acid 4-8 gday untill signs of inflammation
Child: 80-100 mgkgday in 3 doses
 Plus magnesium trisilicate compound 2-4 tablets every 8 hours
MAJOR MANIFESTATIONS MINOR MANIFESTATIONS
 Sydehnams chorea  Polyarthralgia
 Acute phase reactants (increased ESR
 Phenoxymethylpenicillin (Pen V) 250 mg every 6 hours
 Or Benzathine benzylpenicillin dose MU IM stat
 Acetylsalicylic acid 4-8 gday untill signs of inflammation
Child: 80-100 mgkgday in 3 doses
 Plus magnesium trisilicate compound 2-4 tablets every 8 hours HC4
Taken 30 minutes after the acetylsalicylic acid tablets HC4
If carditisheart failure symptoms H
 Treat as per heart failure guidelines (section 4.1.3)
 Consider high dose steroids (specialist only)
 Or Benzathine benzylpenicillin MU IM every 4 weeks
Duration of prophylaxis depends on severity of disease:
- Rheumatic fever without carditis: for 5 years or
- Carditis but no residual heart disease: for 10 years
- Carditis with residual heart disease: untill age 4045 years or for life
Taken 30 minutes after the acetylsalicylic acid tablets
If carditisheart failure symptoms
 Treat as per heart failure guidelines (section 4.1.3)
 Consider high dose steroids (specialist only)
 Or Benzathine benzylpenicillin MU IM every 4 weeks
Duration of prophylaxis depends on severity of disease:
- Rheumatic fever without carditis: for 5 years or
- Carditis but no residual heart disease: for 10 years
- Carditis with residual heart disease: untill age 4045 years or for life HC3
 Early diagnosis and treatment of group A Streptococcus
" Avoid overcrowding, good housing"
Rheumatic Heart Disease ICD10 CODE: I05-I09
Disease of the heart valves following an episode of rheumatic fever. The
" Mitral valve, leading to stenosis, incompetence, or both"
" Aortic valve, leading to stenosis and incompetence or both"
 Thromboembolic problems e.g. stroke
 Heart murmurs depending on valves affected and nature of
 The patient may be asymptomatic and the valvular lesion
discovered as an incidental finding
 Increased cardiac demand as in pregnancy and anaemia
may present as congestive cardiac failure
 Other causes of cardiac failure
 Treat heart failure if present HC4
 Prophylaxis for life as in rheumatic fever above NR
 Cardiac surgery if necessary (only at national referral
A cerebral neurological dysfunction due to a problem in blood circulation:
a clot (ischaemic stroke) or bleeding (haemorrhagic stroke).
 Clot (a thrombus in a brain vessel or an embolus from a clot
 Haemorrhage (from trauma or spontaneous)
" Focal neurological deficits as one-sided weakness (face,"
"arm, leg. Note that eyes are not affected)  hemiparesis or"
 Difficulty in speakingswallowing
 Severe headache (especially in haemorrhage)
"In the absence of neuroimaging, the following clinical features may help"
to distinguish the stroke subtypes:
 Prophylaxis for life as in rheumatic fever above
 Cardiac surgery if necessary (only at national referral
"Intracerebral Gradual Hypertension, Patients may"
"haemorrhage progression trauma, bleeding have reduced"
"over minutes disorders, illicit alertness and"
"Subarachnoid Abrupt onset Smoking, hy- Patients may"
"haemorrhage of very severe pertension, illicit have reduced"
"headache, fo- drugs, but at times alertness"
cal symptoms none (due to rupIt may hapture of congenital
"Ischaemic Gradual de- Age, smoking, dia- Symptoms can"
"(thrombotic) velopment of betes, dyslipidemia improve and"
Ischaemic Sudden onset As above plus val- Often improves
(embolic) of focal defi- vular heart disease slowly
 Ensure airways and respiration if unconscious
 Do not give anything by mouth before assessing the
"ability to swallow, to avoid risk of inhalation"
 IV or NGT for hydration and nutrition if unable to swallow
 Control blood sugar with insulin if diabetic
Course Risk Factors Other Clues
"less common Smoking, hypertension, illicit"
none (due to rupture of congenital
(thrombotic) Gradual development of
"days Age, smoking, diabetes, dyslipidemia Symptoms can"
of focal deficits As above plus valvular heart disease
 Ensure airways and respiration if unconscious
 Do not give anything by mouth before assessing the
"ability to swallow, to avoid risk of inhalation"
 IV or NGT for hydration and nutrition if unable to swallow
 Control blood sugar with insulin if diabetic H
 Aspirin 150-300 mg every 24 hours
" In the acute phase, treat hypertension only if extreme"
(more than 220120) or if there are other complications
"(pulmonary oedema, angina, etc), otherwise re-start"
antihypertensive 24 hours after the event and reduce
 Consider DVT prophylaxis with enoxaparin 40 mg
If stroke clinically haemorrhagic
 Refer for CT scan and neurosurgical evaluation
Chronic care of ischaemic stroke
 Early mobilization and physiotherapy f Aspirin 75-100
mg once daily for life f Atorvastatin 40 mg daily for life
 Aspirin 150-300 mg every 24 hours
" In the acute phase, treat hypertension only if extreme"
(more than 220120) or if there are other complications
"(pulmonary oedema, angina, etc), otherwise re-start"
antihypertensive 24 hours after the event and reduce
 Consider DVT prophylaxis with enoxaparin 40 mg
If stroke clinically haemorrhagic
 Refer for CT scan and neurosurgical evaluation
Chronic care of ischaemic stroke
 Early mobilization and physiotherapy f Aspirin 75-100
mg once daily for life f Atorvastatin 40 mg daily for life
NON-INFECTIOUS RESPIRATORY DISEASES
A chronic inflammatory disease of the airways which leads to muscle
"spasm, mucus plugging and oedema. It results in recurrent wheezing,"
"cough, breathlessness and chest tightness."
Acute attacks may be precipitated by upper respiratory tract infections
"(e.g., flu) and exposure to irritant substances (e.g. dust, exercise, and cold)."
" Not known but associated with allergies, inherited and environmental factors"
" No fever (if fever present, refer to pneumonia)"
 Difficulty in breathing (usually recurrent attacks) with chest
"tightness, with or without use of accessory muscles. Patients may not appear very distressed despite a severe attack"
" Cough  usually dry, may be intermittent, persistent, or"
"Severe forms: failure to complete sentences, darkening of lips, oral"
mucosa and extremities (cyanosis)
 Diagnosis is mainly by clinical features
 Peak flow rate: the peak flow rate increases to about 200 ml
following administration of a bronchodilator
 Spirometry (an increase in Forced Expiratory Volume (FEV) of
If evidence of bacterial infection
General principles of management
"The four essential components of Asthma Management: Patient education, control of asthma triggers, monitoring for changes in symptoms"
"or lung function, and pharmacologic therapy."
" Inhalation route is always preferred as it delivers the medicines directly to the airways; the dose required is smaller,"
" E.g., nebuliser solutions for acute severe asthma are given"
" over 5-10 minutes, usually driven by oxygen in hospital"
" In children having acute attacks, use spacers to administer inhaler puffs"
" Oral route may be used if inhalation is not possible but systemic side-effects occur more frequently, onset of action is"
slower and dose required is higher
 Parenteral route is used only in very severe cases when
Asthma attack is a substantial worsening of asthma symptoms. The severity
and duration of attacks are variable and unpredictable. Most attacks are
triggered by viral infections. Assess severity using the following table:
Not all features may be present. If the patient says they feel very
 Able to talk in setenc-  Able to talk
predicted or best  Respiratory rate  25
Children Below 12 Years Adults And Children
 Cannot complete  Cannot complete
sentences in one sentences in one
less to talk or feed  Pulse 110 bpm
Life threatening (Adults and Children)
" Silent chest, feeble respiratory effort, cyanosis"
" Hypotension, bradycardia or exhaustion, agitation"
 Peak flow  33 of predicted or best
 Reassure patient; place him in a ½ sitting position HC3
- Inhaler 2-10 puffs via a large volume spacer
Children Below 12 Years Adults And Children
"breath or, too breathless to talk or feed"
Life threatening (Adults and Children)
" Silent chest, feeble respiratory effort, cyanosis"
" Hypotension, bradycardia or exhaustion, agitation"
 Peak flow  33 of predicted or best
 Reassure patient; place him in a ½ sitting position
- Inhaler 2-10 puffs via a large volume spacer HC3
- Or 5 mg (mg in children) nebulisation HC3
- Repeat every 20-30 min if necessary
 Prednisolone 50 mg (1 mgkg for children)
Monitor response for 30-60 min. If not improving or
 Prednisolone 50 mg (1 mgkg for children) once a day
for 5 days (3 days for children)
 Institute or step up chronic treatment (see section 5.1.1.2)
 Instruct the patients on self-treatment and when to
 Do not give routine antibiotics unless there are clear
Patients with severe asthma need to be referred to HC4
or hospital after initial treatment
 Admit patient; place him in a ½ sitting position
" Give high flow oxygen continuously, at least 5 litres"
"minute, to maintain the SpO2 94 if available"
- Inhaler 2-10 puffs via a large volume spacer
- Or 5 mg (mg in children) nebulisation HC4
- Repeat every 20-30 min if necessary during the
- Or 5 mg (mg in children) nebulisation
- Repeat every 20-30 min if necessary
 Prednisolone 50 mg (1 mgkg for children)
Monitor response for 30-60 min. If not improving or
 Prednisolone 50 mg (1 mgkg for children) once a day
for 5 days (3 days for children)
 Institute or step up chronic treatment (see section 5.1.1.2)
 Instruct the patients on self-treatment and when to
 Do not give routine antibiotics unless there are clear
signs of bacterial infection HC3
Patients with severe asthma need to be referred to HC4
or hospital after initial treatment
 Admit patient; place him in a ½ sitting position
" Give high flow oxygen continuously, at least 5 litres"
"minute, to maintain the SpO2 94 if available"
- Inhaler 2-10 puffs via a large volume spacer
- Or 5 mg (mg in children) nebulisation
- Repeat every 20-30 min if necessary during the
 Prednisolone 50 mg (1 mgkg for children) or f Or hydrocortisone 100 mg (children 4 mgkg max 100 mg)
IV every 6 hours until patient can take oral prednisolone
 Monitor response after nebulisation
 Ipratropium bromide nebuliser 500 micrograms (250
microgram in children below 12) every 20- 30 min for
the first 2 hours then every 4-6 hours
 Or aminophylline 250 mg slow IV bolus (child 5 mg
kg) if patient is not taking an oral theophylline
"Alternatively, if symptoms have improved, respiration and"
"pulse settling, and peak flow 50"
 And continue with prednisolone to complete 5 days
- Monitor symptoms and peak flow
 Arrange for immediate hospital referral and admission
 Admit patient; place him in a ½ sitting position
" Give high flow oxygen continuously, at least 5 litres"
"minute, to maintain the SpO2 94 if available"
- Inhaler 2-10 puffs via a large volume spacer
- Or 5 mg (mg in children) nebulisation
- Repeat every 20 min for 1 hour
 Prednisolone 50 mg (1 mgkg for children) or f Or hydrocortisone 100 mg (children 4 mgkg max 100 mg)
IV every 6 hours until patient can take oral prednisolone
 Monitor response after nebulisation
 Ipratropium bromide nebuliser 500 micrograms (250
microgram in children below 12) every 20- 30 min for
the first 2 hours then every 4-6 hours
 Or aminophylline 250 mg slow IV bolus (child 5 mg
kg) if patient is not taking an oral theophylline
"Alternatively, if symptoms have improved, respiration and"
"pulse settling, and peak flow 50"
 And continue with prednisolone to complete 5 days
- Monitor symptoms and peak flow
- Arrange self-management plan HC4
 Arrange for immediate hospital referral and admission
 Admit patient; place him in a ½ sitting position
" Give high flow oxygen continuously, at least 5 litres"
"minute, to maintain the SpO2 94 if available"
- Inhaler 2-10 puffs via a large volume spacer
- Or 5 mg (mg in children) nebulisation
- Repeat every 20 min for 1 hour HC4
 Hydrocortisone 100 mg (children 4 mgkg max 100
mg) IV stat or prednisolone 50 mg (1 mgkg for children)
 Ipratropium bromide nebuliser 500 micrograms (250
microgram in children below 12) every 20- 30 minutes
for the first 2 hours then every 4-6 hours
 Monitor response for 15-30 minutes
 Aminophylline 250 mg slow IV bolus (child 5 mgkg) if
patient is not taking an oral theophylline HC4
 The use of aminophylline and theophylline in the management
of asthma exacerbations is discouraged because of their poor
efficacy and poor safety profile
 Hydrocortisone 100 mg (children 4 mgkg max 100
mg) IV stat or prednisolone 50 mg (1 mgkg for children)
 Ipratropium bromide nebuliser 500 micrograms (250
microgram in children below 12) every 20- 30 minutes
for the first 2 hours then every 4-6 hours
 Monitor response for 15-30 minutes
 Aminophylline 250 mg slow IV bolus (child 5 mgkg) if
patient is not taking an oral theophylline HC4
 The use of aminophylline and theophylline in the management
of asthma exacerbations is discouraged because of their poor
efficacy and poor safety profile 
PRIMARY CARE - Patient presents with
acute or sub-acute asthma exacerbation
ASSESS the PATIENT - Is it asthma? Risk factor
for asthma related death? Severity of exacerbation
"MILD OR MODER- SEVERE Talks in words, LIFE THREATATE Talks in phrases, sits hunched forwards, ENING Cyanosis,"
"prefers sitting not agitated Respiratory drowsy, confused"
"lying, not agitated. rate 30min Accessory or silent chest"
Respiratory rate muscles in use Pulse
increased Accessory rate 120 bpm
TRANSFER TO HIGHSTART TREATMENT - ER CARE FACILITYHC3 Salbutamol: 5mg by While waiting: repeat
nebulizer or inhaler spacer inhaled Salbutamol
4 - 6 puffs (200µg) every 20 WORSENING Aminophylline: 250mg
minutes for 1 hour Predni- slow IV bolus if not taksolone: adults 1 mgkg max ing an oral theophylline
CONTINUE TREATMENT with salbutamol as needed
ASSESS FOR RESPONSE AT 1 HOUR (or earlier) IMPROVING
"Symptoms improved, not needReliever: continue as needed"
"Controller: start or step up, check"
"techniques, adherence Prednisoinhaler or predicted Oxygen"
lone: continue usually for 5 days
FOLLOW UP Reliever: reduce to as needed Controller: continue
"higher dose for short term (3 months), depending on background to exacerb tion Risk factor: check and correct modifiable"
"risk factors that may have contributed to exacerbation, including"
inhaler technique and adherence.
Adapted with modification GINA Pocket Guide for Health Professionals 2016
General principles of management
" Before initiating a new drug, check that diagnosis is correct, compliance and inhaler technique are correct and eliminate trigger factors"
 Start at the step most appropriate to initial severity
 Give a 3-5 days rescue course of prednisolone at any step and
at any time as required to control acute exacerbations of asthma
Child  1 year: 1-2 mgkg daily; 1-5 years: up to 20 mg daily; 5-15
years: Up to 40 mg daily; adult: 40-60 mg daily for up to 3-5 days.
 Review treatment every 3-6 months
" If control is achieved, stepwise reduction may be possible"
 If treatment started recently at Step 4 (or contained corticosteroid
"tablets, see below), reduction may take place after a short interval;"
in other patients 1-3 months or longer of stability may be needed
before stepwise reduction can be done
 Intermittent symptoms ( onceweek) HC3
 Night time symptoms  twicemonth
Occasional relief bronchodilator
 Inhaled short-acting beta2 agonist e.g. salbutamol inhaler
 Intermittent symptoms ( onceweek)
 Night time symptoms  twicemonth
Occasional relief bronchodilator
 Inhaled short-acting beta2 agonist e.g. salbutamol inhaler
1-2 puffs (100-200 micrograms) HC3
- Use with spacer for children HC3
 Move to Step 2 if use of salbutamol needed more
than twice a week or if there are night-time symptoms
" Symptoms  onceweek, but  onceday"
 Night time symptoms  twicemonth
 Symptoms may affect activity HC3
Regular inhaled preventer therapy HC4
 Salbutamol inhaler 1-2 puffs prn
 Plus regular standard-dose inhaled
"corticosteroid, e.g. beclomethasone 100-400 micrograms"
every 12 hours (children: 100-200 micrograms every 12 hours)
- Assess after 1 month and adjust the dose prn
- Higher dose may be needed initially to gain
- Doubling of the regular dose may be useful to
STEP 3: Moderate persistent asthma HC4
Children below 5 years: refer to specialist
Regular high-dose inhaled corticosteroids
 Move to Step 2 if use of salbutamol needed more
than twice a week or if there are night-time symptoms
" Symptoms  onceweek, but  onceday"
 Night time symptoms  twicemonth
Regular inhaled preventer therapy
 Salbutamol inhaler 1-2 puffs prn
 Plus regular standard-dose inhaled
"corticosteroid, e.g. beclomethasone 100-400 micrograms"
every 12 hours (children: 100-200 micrograms every 12 hours)
- Assess after 1 month and adjust the dose prn
- Higher dose may be needed initially to gain
- Doubling of the regular dose may be useful to
STEP 3: Moderate persistent asthma
Children below 5 years: refer to specialist
Regular high-dose inhaled corticosteroids HC4
 Salbutamol inhaler 1-2 puffs prn up to 2-3 hourly Usually 4-12 hourly
 PLUS beclomethasone inhaler 400-1000 micrograms
every 12 hours (In child 5-12 years: 100-400 micrograms every 12 hours)
"In adults, also consider 6-week trial with"
 Aminophylline 200 mg every 12 hours
STEP 4: Severe persistent asthma
Refer to specialist clinic especially children 12 years RR
 Regular high-dose beclomethasone (as in Step 3)
 Plus regular prednisolone 10-20 mg daily after breakfast
" If inhaler not available, consider salbutamol tablets"
Child  2 years: 100 microgramskg per dose
Child 2-5 years: 1-2 mg per dose
" Do not give medicines such as morphine, propranolol, or"
other B-blockers to patients with asthma as they worsen
" Do not give sedatives to children with asthma, even if they"
 Salbutamol inhaler 1-2 puffs prn up to 2-3 hourly Usually 4-12 hourly
 PLUS beclomethasone inhaler 400-1000 micrograms
every 12 hours (In child 5-12 years: 100-400 micrograms every 12 hours)
"In adults, also consider 6-week trial with"
 Aminophylline 200 mg every 12 hours 
STEP 4: Severe persistent asthma
Refer to specialist clinic especially children 12 years
 Regular high-dose beclomethasone (as in Step 3)
 Plus regular prednisolone 10-20 mg daily after breakfast RR
" If inhaler not available, consider salbutamol tablets"
Child  2 years: 100 microgramskg per dose
Child 2-5 years: 1-2 mg per dose 
" Do not give medicines such as morphine, propranolol, or"
other B-blockers to patients with asthma as they worsen
" Do not give sedatives to children with asthma, even if they"
 Avoid precipitating factors e.g.
" Known allergens such as dust, pollens, animal skins"
" Exercise can precipitate asthma in children, advise them to"
keep an inhaler handy during sports and play
 Effectively treat respiratory infections
Chronic Obstructive Pulmonary Disease (COPD)
Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal
breathing and is not fully reversible.
- The more familiar terms chronic bronchitis and emphysema
"are no longer used, but are now included within the COPD"
- Such a diagnosis should be considered in any patient who
"- has symptoms of cough, sputum production, or dyspnea"
"(difficult or labored breathing), andor a history of exposure"
to risk factors for the disease.
A COPD exacerbation is an acute worsening of the patients respiratory
symptoms needing a change in medications.
Causes and predisposing factors
 Tobacco smoking is the commonest cause
" Indoor air pollution: Biomass fuel smoke (firewood, charcoal and cow dung) exposure in poorly ventilated kitchens"
" Exposure to occupational dust and chemicals (cement,"
"paint, saw dust, fumes) without adequate protection"
 It may frequently follow TB disease (residual symptoms)
 Chronic cough in a current or previous smoker who is over
" Breathlessness: persistent, progressive and worse with exercise - tight chest and wheezing"
 Chronic sputum (mucuos) production and bronchitis for at
least 3 months in 2 successive years
" On examination, there may be a barrel chest (increased"
" Rapid breathing, reduced chest expansion, with or without"
"increased use of accessory muscles of respiration, rhonchi,"
" Decreased breath sounds, ankle swelling and other signs of"
 Spirometry: gold standard for diagnosis but if not available use
all available tools (history of exposure to risk factors  clinical
symptoms  any available investigations).
 History of exposure to risk factors
 Chest X-ray (Hyper-inflated lungs)
 Echocardiography  when one suspects right-sided heart failure
 Removing risk factors and preventing further damage
 Relief of symptoms and prevention of the severity and frequency
 Improving the patients exercise tolerance and maintaining
 Inhalers are the preferred formulation for the treatment of
- COPD is chronic lung damage and there is no HC2
"- Treatment is to prevent exacerbations, further"
- They must stop smoking  it is the only way to
- Reduce exposure to charcoal and wooddung
- cooking smoke. Keep cooking areas wellventilated by opening windows and doors. Use
"alternative clean energy sources like Biogas,"
- Use masks for respiratory protection or stop
working in areas with occupational dust or
- Physical exercise to train lung capacity
- (pulmonary rehabilitation) under supervision
- Get treatment quickly in case of increased
"breathlessness, cough or sputum"
 Physiotherapy is beneficial to improve exercise tolerance
- COPD is chronic lung damage and there is no
"- Treatment is to prevent exacerbations, further"
- They must stop smoking  it is the only way to
- Reduce exposure to charcoal and wooddung
- cooking smoke. Keep cooking areas wellventilated by opening windows and doors. Use
"alternative clean energy sources like Biogas,"
- Use masks for respiratory protection or stop
working in areas with occupational dust or
- Physical exercise to train lung capacity
- (pulmonary rehabilitation) under supervision
- Get treatment quickly in case of increased
"breathlessness, cough or sputum"
 Physiotherapy is beneficial to improve exercise tolerance HC2
" Inhaled salbutamol 2 puffs 2-4 times a day, may be used"
periodically for short periods. The main purpose of this
treatment is to reduce or prevent symptoms.
"If inhalers not available, consider:"
 Aminophylline 200 mg twice dail
 Inhaled salbutamol 2 puffs 2-4 times a day
 Plus inhaled steroid beclomethasone 100-400 micrograms 2-4 times a day
 As in step 2 plus ipratropium inhaler 2 puff 2-4 times
" If available, long acting bronchodilators salmeterol"
and formeterol can be used in moderate and severe
COPD in combination with inhaled steroids
" If more sputum, changed to more yellowgreen"
"coloured, andor breathlessness, temp 38C"
"and or rapid breathing (bronchitis), then"
 Treat with antibiotic e.g. amoxicillin 500 mg every 8
hours for 7-10 days or doxycycline 100 mg every 12
 Oral Prednisolone 40 mg once daily in the morning for
5 days. Do NOT use oral steroids for extended periods
- Refer urgently to hospital if:
- Rapid pulse (100 beats per minute) or breathing
" Inhaled salbutamol 2 puffs 2-4 times a day, may be used"
periodically for short periods. The main purpose of this
treatment is to reduce or prevent symptoms.
"If inhalers not available, consider:"
 Aminophylline 200 mg twice dail HC3
 Inhaled salbutamol 2 puffs 2-4 times a day
 Plus inhaled steroid beclomethasone 100-400 micrograms 2-4 times a day HC4
 As in step 2 plus ipratropium inhaler 2 puff 2-4 times
" If available, long acting bronchodilators salmeterol"
and formeterol can be used in moderate and severe
COPD in combination with inhaled steroids RR
" If more sputum, changed to more yellowgreen"
"coloured, andor breathlessness, temp 38C"
"and or rapid breathing (bronchitis), then"
 Treat with antibiotic e.g. amoxicillin 500 mg every 8
hours for 7-10 days or doxycycline 100 mg every 12
 Oral Prednisolone 40 mg once daily in the morning for
5 days. Do NOT use oral steroids for extended periods
- Refer urgently to hospital if:
- Rapid pulse (100 beats per minute) or breathing
- Tongue or lips are blue (central cyanosis)
" Give oxygen by nasal cannula (1-3 litresmin) if available,"
 Give oxygen with care (minimum flow required to reach the
target SpO2) because COPD patients are at risk of hypercapnia
(CO2 retention) which cause respiratory depression and coma
INFECTIOUS RESPIRATORY DISEASES
Acute inflammatory obstructive disease of small airways (bronchioles)
common in children less than 2 years.
" Mainly viral (often respiratory syncitial virus, RSV)"
 First 24-72 hours: rhinopharyngitis with dry cough
" Later tachypnoea, difficulty in breathing, wheezing (poorly"
" Cough (profuse, frothy, obstructive secretions)"
" Criteria for severity: child  3 months, worsening of general"
"condition, pallor, cyanosis, respiratory distress, anxiety, respiratory rate 60minute, difficulty feeding, SpO2  92"
- Tongue or lips are blue (central cyanosis)
" Give oxygen by nasal cannula (1-3 litresmin) if available,"
 Give oxygen with care (minimum flow required to reach the
target SpO2) because COPD patients are at risk of hypercapnia
(CO2 retention) which cause respiratory depression and coma 
 X-ray: Chest (to exclude pneumonia)
"Wheezing, 50-60 breathsminute, no cyanosis, able to drinkfeed"
 Treat the symptoms (possibly as an out-patient)
- Nasal irrigation with normal saline
- Increased fluids and nutrition
"Wheezing, fast breathing  60 breathsmin, cyanosis"
 Admit and give supportive treatment as above f Give
humidified nasal oxygen (1-2 litresmin) f Salbutamol
"inhaler 100 microgramspuff: 2 puffs with spacer, every"
30 minutes or nebulisation salbutamol mg in 4 ml
"- If symptoms improve, continue salbutamol every"
"- If symptoms non-responsive, stop the salbutamol"
" Nebulise Adrenaline 1:1000, 1 ml diluted in 2-4 ml"
 Give as much oral fluids as the child will take:
e.g. ORS. Use NGT or IV line if child cannot take orally
- Give basic total fluid requirement of 150 mlkg in
24 hours plus extra to cover increased losses due
"Wheezing, 50-60 breathsminute, no cyanosis, able to drinkfeed"
 Treat the symptoms (possibly as an out-patient)
- Nasal irrigation with normal saline
- Increased fluids and nutrition
"Wheezing, fast breathing  60 breathsmin, cyanosis"
 Admit and give supportive treatment as above f Give
humidified nasal oxygen (1-2 litresmin) f Salbutamol
"inhaler 100 microgramspuff: 2 puffs with spacer, every"
30 minutes or nebulisation salbutamol mg in 4 ml
"- If symptoms improve, continue salbutamol every"
"- If symptoms non-responsive, stop the salbutamol"
" Nebulise Adrenaline 1:1000, 1 ml diluted in 2-4 ml"
 Give as much oral fluids as the child will take:
e.g. ORS. Use NGT or IV line if child cannot take orally
- Give basic total fluid requirement of 150 mlkg in
24 hours plus extra to cover increased losses due
 Antibiotics are usually not needed for bronchiolitis since
 Avoid exposure to cold and viral infections
 Proper handwashing after contact with patients
Acute Bronchitis ICD10 CODE: J20
Acute inflammatory disease of the bronchi.
" In older children, can be caused by Mycoplasma pneumonae"
" Secondary Bacterial infection: Streptococcus pneumoniae,"
" Often starts with rhinopharyngitis, descend progressively"
" Irritating, productive cough sometimes with scanty mucoid, blood streaked sputum"
" Chest tightness, sometimes with wheezing"
" Secondary bacterial infection: fever  38.5C, dyspnoea,"
 Antibiotics are usually not needed for bronchiolitis since
 Diagnosis based on clinical features
 Most cases are viral and mild HC2
 Paracetamol 1 g every 4-6 hours (max: 4 g daily)
 Child: 10 mgkg (max: 500 mg) per dose f Plenty of
 Children: nasal irrigation with normal saline to clear
" Local remedies for cough (honey, ginger, lemon)"
"If there is suspicion of bacterial infection, especially if patient is"
"in general poor conditions (malnutrition, measles, rickets, severe"
"anaemia, elderly, cardiac disease)"
 Give Amoxicillin 500 mg every 8 hours
Child: 40 mgkg dispersible tablets every 12 hours
 Or Doxycycline 100 mg every 12 hours
 Avoid predisposing factors above.
Coryza (Common Cold) ICD10 CODE: J00
Acute inflammation of the upper respiratory tract; rhinitis (nasal mucosa)
and rhinopharyngitis (nasal and pharyngitis).
" Viruses - several types, often rhinoviruses"
 Paracetamol 1 g every 4-6 hours (max: 4 g daily)
 Child: 10 mgkg (max: 500 mg) per dose f Plenty of
 Children: nasal irrigation with normal saline to clear
" Local remedies for cough (honey, ginger, lemon)"
"If there is suspicion of bacterial infection, especially if patient is"
"in general poor conditions (malnutrition, measles, rickets, severe"
"anaemia, elderly, cardiac disease)"
 Give Amoxicillin 500 mg every 8 hours
Child: 40 mgkg dispersible tablets every 12 hours
 Or Doxycycline 100 mg every 12 hours
Child 8 years: 2 mgkg per dose HC2
 Tickling sensation in nose and sneezing
" Profuse nasal watery or purulent discharge, tearing"
 Lower respiratory tract infection (pneumonia)
" Ear ache, deafness, otitis media"
Common cold is a viral disease and so does NOT require any antibiotics. Antibiotics do not promote recovery or prevent complications
and cause patients unnecessary side effects
"No antibiotics, give only symptomatic treatment HC2"
" Increase fluid intake, preferably warm drinks f Give"
 Xylometazoline - 0.1 nasal drops 2-3 drops into
each nostril 3 times daily (max: 5 days)
 Clear the nose with normal saline to ease breathing
"No antibiotics, give only symptomatic treatment"
" Increase fluid intake, preferably warm drinks f Give"
 Xylometazoline - 0.1 nasal drops 2-3 drops into
each nostril 3 times daily (max: 5 days)
 Clear the nose with normal saline to ease breathing
 Avoid cough syrups in children below 6 years
 Avoid contact with infected persons
 Include adequate fresh fruits and vegetables in the diet
Acute Epiglottitis ICD10 CODE: J05.1
"An acute inflammation of the epiglottis, a rare but serious disease of"
"young children. Airway obstruction is always severe, and intubation or"
tracheostomy is often needed. It is rare since routine childhood mmunization with Hib vaccine was introduced.
" Bacterial infection, commonly Haemophilus influenzae"
" Typical: tripod or sniffing position, preferring to sit, leaning forward with an open mouth, appears anxious"
" Sore throat, difficulty swallowing, drooling, respiratory distress"
" Appears critically ill (weak, grunting, crying, drowsy, does"
"not smile, anxious gaze, pallor, cyanosis)"
 Asphyxia leading to quick death
" Laryngeal cause of stridor e.g., laryngotracheobronchitis"
 Avoid tongue depression examination as this may cause
complete airway blockage and sudden death
 Do not force child to lie down as it may precipitate airway
 Avoid cough syrups in children below 6 years 
 Admit and treat as an emergency  intubation or tra- H
 Avoid examination or procedures that agitate child as
this may worsen symptoms. Avoid IM medication
 Insert IV line and provide IV hydration
 Ceftriaxone 50 mgkg once daily for 7-10 days
 Hib vaccine is part of the pentavalent DPTHepBHib vaccine used in routine immunisation of children
Influenza ( Flu) ICD10 CODE: J9-11
A specific acute respiratory tract illness occurring in epidemics and occasionally pandemics. Influenza virus strains can be transmitted to humans
"from animals (pigs, birds) and can occasionally mutate and spread from"
"person to person (e.g., swine flu, or H1N1)."
 Influenza viruses of several types and strains
" Headache, pain in back and limbs"
" Anorexia, sometimes nausea and vomiting"
 Fever for 2-3 days with shivering
 Admit and treat as an emergency  intubation or tracheostomy may often be needed
 Avoid examination or procedures that agitate child as
this may worsen symptoms. Avoid IM medication
 Insert IV line and provide IV hydration
 Ceftriaxone 50 mgkg once daily for 7-10 days H
 Secondary bacterial infection: bronchopneumonia
 Toxic cardiomyopathy and sudden death
 Other respiratory viral infections
 Viral serology to identify virus
"If no complications, treat symptoms HC2"
 Paracetamol 1 g every 4-6 hours (max: 4 g day)
 Or xylometazoline nose drops -0.1 2-3 drops HC4
into each nostril 3 times daily (max: 5 days)
" If blockage interferes with breastfeeding, clean clear"
" Frequent warm drinks, home remedies (honey, ginger)"
 Avoid contact with infected persons
 Inactivated Influenza vaccine yearly (for vulnerable populations)
"If no complications, treat symptoms"
 Paracetamol 1 g every 4-6 hours (max: 4 g day)
 Or xylometazoline nose drops -0.1 2-3 drops
into each nostril 3 times daily (max: 5 days)
" If blockage interferes with breastfeeding, clean clear"
" Frequent warm drinks, home remedies (honey, ginger) HC2"
"Inflammation of the larynx which may involve surrounding structures,"
" Viruses: Para-influenza group, influenza  by far the most"
common cause. Usually acute (up to 3 weeks)
" Excessive use of the voice, allergic reactions, inhalation of"
"irritating substances, e.g., cigarette smoke, gastroesophageal reflux. Often chronic symptoms (3 weeks)"
 Onset similar to any upper respiratory tract infection
" Laryngotracheobronchitis, epiglottitis"
" Airway compression by extrinsic mass (e.g., tumours, haemangioma, cysts)"
The cause is usually viral for which there is no specific treat- HC2
ment and no need for antibiotics f Give analgesics
 Use steam inhalations 2-3 times daily
 For chronic laryngitis: identify and treat the cause
Acute Laryngotracheobronchitis (Croup)
"An acute inflammation of larynx, trachea and bronchi primarily in children  3 years, usually viral."
 Influenza and Parainfluenza type 1 viruses
 Rarely - superinfection with bacteria e.g. H. influenzae
"Note: Secondary bacterial infection is rare, therefore antibiotics are"
" Barking cough, hoarse voice or cry"
 Inspiratory stridor (abnormal high-pitched sound)
 Severe dyspnoea and stridor at rest
 Cyanosis (blue colour of child - especially extremities and
The cause is usually viral for which there is no specific treatment and no need for antibiotics f Give analgesics
 Use steam inhalations 2-3 times daily
 For chronic laryngitis: identify and treat the cause HC2
 Avoid throat examination. Gagging can cause acute
" Isolate patient, ensure plenty of rest"
 Keep well hydrated with oral fluids
- Use oral rehydration solution
- Prednisolone 1-2 mgkg single dose
- or Dexamethasone mgkg single dose
 Admit the patient f Ensure close supervision
 Keep well hydrated with IV fluids
 Use Darrows solution ½ strength in glucose
 Steroids: hydrocortisone slow IV or IM
- Or dexamethasone 300 microgramskg IM
 Repeat steroid dose after 6 hours if necessary
" If not controlled, nebulise adrenaline mgkg (max"
"5 mg) diluted with normal saline, repeat after 30 min"
" Isolate patient, ensure plenty of rest"
 Keep well hydrated with oral fluids
- Use oral rehydration solution
- Prednisolone 1-2 mgkg single dose
- or Dexamethasone mgkg single dose
 Admit the patient f Ensure close supervision
 Keep well hydrated with IV fluids
 Use Darrows solution ½ strength in glucose
 Steroids: hydrocortisone slow IV or IM
- Or dexamethasone 300 microgramskg IM
 Repeat steroid dose after 6 hours if necessary
" If not controlled, nebulise adrenaline mgkg (max"
"5 mg) diluted with normal saline, repeat after 30 min"
If severe respiratory distress develops RR
 Carry out nasotracheal intubation or tracheostomy if
Suspect bacterial infection if child does not improve or appears critically ill
 Treat as epiglottitis (see section 5.2.4)
 Avoid cough mixtures in children  6 years
 Avoid contact with infected persons
Pertussis (Whooping Cough) ICD10 CODE: A37
An acute bacterial respiratory infection characterised by an inspiratory
whoop following paroxysmal cough. It is highly contagious with an
incubation period of 7-10 days. It is a notifiable disease.
" Bordetella pertussis, spread by droplet infection"
Stage 1: Coryzal (catarrhal: 1-2 weeks)
" Running nose, mild cough, slight fever"
Stage 2: Paroxysmal (1-6 weeks)
 More severe and frequent repetitive cough ending in a
"whoop, vomiting, conjuctival haemorrhage"
 Fever may be present; patient becomes increasingly tired
If severe respiratory distress develops
 Carry out nasotracheal intubation or tracheostomy if
Suspect bacterial infection if child does not improve or appears critically ill
 Treat as epiglottitis (see section 5.2.4) 
 Avoid cough mixtures in children  6 years 
" In infants 6 months: paroxyms lead to apnoea, cyanosis"
(coughing bouts and whoops may be absent)
 Paroxysmal symptoms reduce over weeks or months
" Respiratory: pneumonia (new onset fever a symptom), atelectasis, emphysema, bronchiectasis, otitis media"
" Nervous system: convulsions, coma, intracranial haemorrhage"
" Others: malnutrition, dehydration, inguinal hernia, rectal"
 Chlamydial and bacterial respiratory tract infection
 Maintain nutrition and fluids HC4
 Give oxygen and perform suction if the child is cyanotic
" For the unimmunised or partly immunised, give DPT (three"
doses) as per routine immunisation schedule
 Isolate the patient (avoid contact with other infants) until
after 5 days of antibiotic treatment
 Treatment should be initiated within 3 weeks from onset
of cough: Erythromycin 500 mg every 6 hours for 7 days
Child: 10-15 mgkg every 6 hours
 Give oxygen and perform suction if the child is cyanotic
" For the unimmunised or partly immunised, give DPT (three"
doses) as per routine immunisation schedule
 Isolate the patient (avoid contact with other infants) until
after 5 days of antibiotic treatment
 Treatment should be initiated within 3 weeks from onset
of cough: Erythromycin 500 mg every 6 hours for 7 days
Child: 10-15 mgkg every 6 hours HC4
" Cough mixtures, sedatives, mucolytics, and"
antihistamines are USELESS in pertussis and should
 Educate parents on the importance of following the routine
childhood immunisation schedule:
 Booster doses of vaccine in exposed infants
Acute infection and inflammation of the lungs alveoli. There are two
 Bronchopneumonia: involves both the lung parenchyma
and the bronchi. Common in children and the elderly
 Lobar pneumonia: involves one or more lobes of the lung.
"Causative agents can be viral, bacterial or parasitic. Pathogens vary"
"according to age, patients condition and whether infection was acquired in the community or hospital (Gram negative are more common"
" Neonates: group B streptococcus, Klebsiella, E.coli, Chlamydia and S. aureus"
" Children 5 years: Pneumococcus, Haemophilus influenzae, less frequently: S. aureus, M. catarrhalis, M. Pneumoniae, viruses (RSV, influenza, measles)"
 Adults and children 5 years: most commonly S.pneumo357
" Cough mixtures, sedatives, mucolytics, and"
antihistamines are USELESS in pertussis and should
"niae, followed by atypical bacteria, e.g. Mycloplasma pneumoniae, viruses"
 Immunosuppressed: Pneumocystis (in HIV infected)
" Immunosuppression (HIV, cancer, alcohol dependence)"
" Pre-existing lung or heart diseases, diabetes"
" Do a chest X-ray and look for complications, e.g."
- Pneumonitis suggestive of pneumocystis jiroveci pneumonia
- Pneumatocoeles (cavities filled with air) suggestive of
" Sputum: For Gram stain, Ziehl-Neelsen (ZN) stain, culture for"
5.Pneumonia in an Infant (up to 2 months)
"In infants, not all respiratory distress is due to infection. But as pneumonia"
"may be rapidly fatal in this age group,"
suspected cases should be treated promptly and referred for parenteral
treatment with antimicrobials. Consider all children  2 months with
 Rapid breathing ( 60 breathsminute)
" Severe chest in drawing, grunting respiration"
" Stridor in a calm child, wheezing"
 Fever may or may not be present
 Cyanosis and apnoeic attacks (SpO2 less than 90)
Infants with suspected pneumonia should be referred to hospital after
pre-referral dose of antibiotics.
 Prevent hypoglycaemia by breastfeedinggiving expressed
" If child is lethargic, do not give oral feeds. Use IV fluids"
 Give oxygen to keep SpO2 94 f Ampicillin 50 mg
kg IV every 6 hours f Plus gentamicin mgkg once daily
 Neonates  7 days old: 5 mgkg IV once daily
" In premature babies, the doses may need to be reduced"
 Ceftriaxone 100 mgkg IV once daily
Alternative (only use if above not available)
 Chloramphenicol 25 mgkg IV every 6 hours (contraindicated in premature babies and neonates  7 days old)
 Prevent hypoglycaemia by breastfeedinggiving expressed
" If child is lethargic, do not give oral feeds. Use IV fluids"
 Give oxygen to keep SpO2 94 f Ampicillin 50 mg
kg IV every 6 hours f Plus gentamicin mgkg once daily
 Neonates  7 days old: 5 mgkg IV once daily
" In premature babies, the doses may need to be reduced"
 Ceftriaxone 100 mgkg IV once daily
Alternative (only use if above not available)
 Chloramphenicol 25 mgkg IV every 6 hours (contraindicated in premature babies and neonates  7 days old) H
" Continue treatment for at least 5 days, and for 3 days H"
" If meningitis is suspected, continue for 21 days"
" If septicaemia is suspected, continue for 10 days"
5.Pneumonia in a Child of 2 months-5 years
" Fever - may be high, low grade or absent (in severe illness)"
" Fast breathing (2-12 months: 50 bpm, 1-5 years: 40"
 As above plus at least one of the following
" Central cyanosis (blue lips, oral mucosa, finger nails or oxygen saturation  90 using a pulse oximeter)"
" Inability to feed, vomiting everything"
" Convulsions, lethargy, decreased level of consciousness"
" Severe respiratory distress (severe chest indrawing, grunting, nasal flaring)"
" Extrapulmonary features, e.g. confusion or disorientation,"
may predominate and may be the only signs of pneumonia
in malnourished or immunosuppressed children
" Continue treatment for at least 5 days, and for 3 days"
" If meningitis is suspected, continue for 21 days"
" If septicaemia is suspected, continue for 10 days H"
 Give oral amoxicillin dispersible tabs (DT) 40 mgkg
- 2-12 months 250 mg (1 tab) every 12 hours for
- 1-3 years 500 mg (2 tabs) every 12 hours for 5
- 3-5 years 750 mg (3 tabs) every 12 hours for 5
 Salbutamol inhaler 1-2 puffs every 4-6 hours until
 Reassess child for progress after 3 days
 Refer to hospital after 1st dose of antibiotic
 Give Oxygen if SpO2  90 with nasal prongs and HC4
 Give ampicillin 50 mgkg IV every 6 hours or
" benzyl penicillin 50,000 IUkg IM or  Plus gentamicin mgkg IM or IV once daily"
"- Continue treatment for at least 5 days, up to 10"
" If not better after 48 hours, use second line f Ceftriaxone 80 mgkg IM or IV once daily f If staphylococcus"
"is suspected (empyema, pneumatocele at X ray), give"
gentamicin mg kg once daily plus cloxacillin 50
 Give oral amoxicillin dispersible tabs (DT) 40 mgkg
- 2-12 months 250 mg (1 tab) every 12 hours for
- 1-3 years 500 mg (2 tabs) every 12 hours for 5
- 3-5 years 750 mg (3 tabs) every 12 hours for 5
 Salbutamol inhaler 1-2 puffs every 4-6 hours until
 Reassess child for progress after 3 days HC2
 Refer to hospital after 1st dose of antibiotic
 Give Oxygen if SpO2  90 with nasal prongs and
 Give ampicillin 50 mgkg IV every 6 hours or
" benzyl penicillin 50,000 IUkg IM or  Plus gentamicin mgkg IM or IV once daily"
"- Continue treatment for at least 5 days, up to 10"
" If not better after 48 hours, use second line f Ceftriaxone 80 mgkg IM or IV once daily f If staphylococcus"
"is suspected (empyema, pneumatocele at X ray), give"
gentamicin mg kg once daily plus cloxacillin 50
mgkg IM or IV every 6 hours HC4
 Switch to oral amoxicillin 40 mgkg every 12 hours for
5 days to complete a total of at least 5 days of antibiotics
Alternative (if above not availablenot working)
 Chloramphenicol 25 mgkg IV every 6 hours
 Give Paracetamol 10 mgkg every 4-6 hours for fever
" If wheezing, give salbutamol 1-2 puffs every 4-6 hours"
 Gentle suction of thick secretions from upper airway
 Daily maintenance fluids  careful to avoid overload
especially in small and malnourished children (see
" If convulsions, give diazepam mgkg rectally or"
mgkg If convulsions are continuous
" Give a long-acting anticonvulsant, e.g., phenobarbital"
10-15 mgkg IM as a loading dose. Depending on
"response, repeat this dose after 12 hours or switch to"
oral maintenance dose of 3-5 mgkg every 8-12 hours
- Respiratory rate (every 2 hours)
- Body temperature (every 6 hours)
- Oxygen saturation (every 12 hours)
- Improvement in appetite and playing
- Use of accessory muscles of respiration
"- Ability to breastfeed, drink and eat"
 Switch to oral amoxicillin 40 mgkg every 12 hours for
5 days to complete a total of at least 5 days of antibiotics
Alternative (if above not availablenot working)
 Chloramphenicol 25 mgkg IV every 6 hours 
 Give Paracetamol 10 mgkg every 4-6 hours for fever
" If wheezing, give salbutamol 1-2 puffs every 4-6 hours"
 Gentle suction of thick secretions from upper airway
 Daily maintenance fluids  careful to avoid overload
especially in small and malnourished children (see
" If convulsions, give diazepam mgkg rectally or"
mgkg If convulsions are continuous
" Give a long-acting anticonvulsant, e.g., phenobarbital"
10-15 mgkg IM as a loading dose. Depending on
"response, repeat this dose after 12 hours or switch to"
oral maintenance dose of 3-5 mgkg every 8-12 hours 
- Respiratory rate (every 2 hours)
- Body temperature (every 6 hours)
- Oxygen saturation (every 12 hours)
- Improvement in appetite and playing
- Use of accessory muscles of respiration
"- Ability to breastfeed, drink and eat "
5.Pneumonia in Children  5 years and adults
" Fever, chest pain, cough (with or without sputum), rapid"
"breathing ( 30 bpm), no chest indrawing"
" Extrapulmonary features, e.g. confusion or disorientation, may"
predominate and may be the only signs of pneumonia in elderly
Moderate pneumonia (ambulatory patients)
 Amoxicillin 500 mg-1 g every 8 hours for 5 days
 Children: 40 mgkg every 12 hours for 5 days.
 Preferably use dispersible tablets in younger children
If penicillin allergy or poor response after 48 hours
"(possible atypical pneumonia), give:"
 Doxycycline 100 mg every 12 hours for 7-10 days
 Child  8 years only: 2 mgkg per dose
 Or Erythromycin 500 mg every 6 hours for 5 days
Moderate pneumonia (ambulatory patients)
 Amoxicillin 500 mg-1 g every 8 hours for 5 days
 Children: 40 mgkg every 12 hours for 5 days.
 Preferably use dispersible tablets in younger children
If penicillin allergy or poor response after 48 hours
"(possible atypical pneumonia), give:"
 Doxycycline 100 mg every 12 hours for 7-10 days
 Child  8 years only: 2 mgkg per dose
 Or Erythromycin 500 mg every 6 hours for 5 days 
 14 days in cases of atypical pneumonia HC3
Severe pneumonia (hospitalised patients)
 Give oxygen and monitor SpO2 saturation with pulse
 Benzylpenicillin 2 MU IV or IM daily every 4-6 hours
"Child: 50,000-100,000 IUkg per dose"
 Ceftriaxone 1 g IV or IM every 24 hours
Child: 50 mgkg per dose (max: 1 g)
 Cloxacillin 500 mg IV every 6 hours
If other options are not available
 Chloramphenicol 1 g IV every 6 hours for 7 days
Child: 25 mgkg per dose (max: 750 mg)
5.Pneumonia by Specific Organisms
This form is especially common following a recent
influenza infection. It can cause empyema and pneumatocele.
 Cloxacillin 1-2 g IV or IM every 6 hours for 10-14 days
Child 5 years: 50 mgkg per dose (max: 2 g)
 14 days in cases of atypical pneumonia
Severe pneumonia (hospitalised patients)
 Give oxygen and monitor SpO2 saturation with pulse
 Benzylpenicillin 2 MU IV or IM daily every 4-6 hours
"Child: 50,000-100,000 IUkg per dose"
 Ceftriaxone 1 g IV or IM every 24 hours
Child: 50 mgkg per dose (max: 1 g)
 Cloxacillin 500 mg IV every 6 hours
If other options are not available
 Chloramphenicol 1 g IV every 6 hours for 7 days
Child: 25 mgkg per dose (max: 750 mg) HC3
This form is especially common following a recent
influenza infection. It can cause empyema and pneumatocele.
 Cloxacillin 1-2 g IV or IM every 6 hours for 10-14 days
Child 5 years: 50 mgkg per dose (max: 2 g)
 Cloxacillin 25-50 mgkg IV or IM every 6 hours
 Plus gentamicin mgkg IV in 1-3 divided doses daily
- Continue both medicines for at least 21 days
 Doxycycline 100 mg every 12 hours for 7-10 days
 Or erythromycin 500 mg every 6 hours for 5 days
 Gentamicin 5-7 mgkg IV daily in divided doses
 Or ciprofloxacin 500 mg every 12 hours
Child: chloramphenicol 25 mgkg every 6 hours
- Amend therapy as guided by CS results
" Benzylpenicillin 50,000 IUkg IV or IM every 6 hours"
for 2-3 days then switch to oral Amoxicillin 500 mg-1
g every 8 hours for 5 days Children: 40 mgkg every
Preferably use dispersible tablets in younger children
5.Pneumocystis jirovecii Pneumonia
 Cloxacillin 25-50 mgkg IV or IM every 6 hours
 Plus gentamicin mgkg IV in 1-3 divided doses daily
- Continue both medicines for at least 21 days 
 Doxycycline 100 mg every 12 hours for 7-10 days
 Or erythromycin 500 mg every 6 hours for 5 days
 Gentamicin 5-7 mgkg IV daily in divided doses
 Or ciprofloxacin 500 mg every 12 hours
Child: chloramphenicol 25 mgkg every 6 hours
- Amend therapy as guided by CS results H
" Benzylpenicillin 50,000 IUkg IV or IM every 6 hours"
for 2-3 days then switch to oral Amoxicillin 500 mg-1
g every 8 hours for 5 days Children: 40 mgkg every
Preferably use dispersible tablets in younger children H
5.Lung Abscess ICD10 CODE: J85.0-1
Localised inflammation and necrosis (destruction) of lung tissue leading
to pus formation. It is most commonly
caused by aspiration of oral secretions by patients who have impaired
 Infection of lungs with pus forming organisms: e.g.
" Klebsiella pneumoniae, Staphylococcus aureus"
" Malaise, loss of appetite, sweating with chills and fever"
" Cough with purulent sputum, foul-smelling breath (halitosis)"
 Pus in the pleural cavity (empyema)
 Coughing out blood (haemoptysis)
" Septic emboli to various parts of the body, e.g. brain (causing brain abscess)"
 Bronchiectasis (pus in the bronchi)
 Primary empyema communicating with a bronchus
 Liver abscess communicating into the lung
 Early stages: Signs of consolidation
 Later stages: A cavity with a fluid level
 Sputum: For microscopy and culture and sensitivity
 Benzylpenicillin 1-2 MU IV or IM every 4-6 hours HC4
" Child: 50,000-100,000 IUkg per dose (max: 2 MU)"
 Plus metronidazole 500 mg IV every 8-12 hours
"Once improvement occurs, change to oral medication and"
continue for 4-8 weeks f Metronidazole 400 mg every 12 hours
Plus Amoxicillin 500 mg-1 g 8 hourly
Child: 25-50 mgkg per dose for 4-6 weeks
Surgical drainage may be necessary
 Early detection and treatment of pneumonia
TUBERCULOSIS (TB) ICD11 CODE: A15-A19
"5.3.1Definition, Clinical Features and Diagnosis of TB"
A chronic infection caused by Mycobacterium tuberculosis complex. It
"commonly affects lungs but can affect any organ (lymph nodes, bones,"
 Benzylpenicillin 1-2 MU IV or IM every 4-6 hours
" Child: 50,000-100,000 IUkg per dose (max: 2 MU)"
 Plus metronidazole 500 mg IV every 8-12 hours
"Once improvement occurs, change to oral medication and"
continue for 4-8 weeks f Metronidazole 400 mg every 12 hours
Plus Amoxicillin 500 mg-1 g 8 hourly
Child: 25-50 mgkg per dose for 4-6 weeks
Surgical drainage may be necessary HC4
For more information on the management of TB see:
 Manual of the National TBLeprosy Programme (NTLP) in
 National drug resistant TB guidelines
" Mycobacterium tuberculosis complex (e.g. M. tuberculosis,"
" M. bovis, M. avium, M. africanum and M. Microti)"
 M. tuberculosis is the commonest cause of tuberculosis
 Transmission by droplet inhalation (cough from a patient
with open pulmonary TB); can also be through drinking
"unpasteurised milk, especially M.bovis"
" Fevers especially in the evening,"
 Weight loss and loss of appetite
" Chronic cough of 2 weeks (however, in HIV settings,"
" Chest pain, purulent sputum occasionally blood-stained,"
 Lymphnode TB: Localized enlargement of lymph nodes depending on the site affected (commonly neck)
 Pleural or pericardial effusion
 Abdominal TB: ascites and abdominal pain
" TB meningitis: subacute meningitis (headache, alteration of"
 Bone or joint TB: swelling and deformity
 Massive haemoptysis - coughing up 250 mL blood per
 Spontaneous pneumothorax and pleural effusion
" TB pericarditis, TB meningitis, TB peritonitis"
" Bone TB: can be TB spine with gibbus, TB joints with"
Presumptive TB Any patient who presents with
patient symptoms and signs suggestive of
TB or found to have chest X-ray
suggestive of active TB disease
Bacteriologically Patient in whom biological
confirmed TB patient specimen is positive by smear
"microscopy, culture or molecular"
cases should be notified (registered in the unit TB register)
Clinically diagnosed Patient who does not fulfil the
TB patient criteria for bacteriological confirmation but has been diagnosed
with active TB by a clinician on
the basis of clinical signs and
patient Any patient who presents with
symptoms and signs suggestive of
TB or found to have chest X-ray
suggestive of active TB disease
confirmed TB patient Patient in whom biological
"microscopy, culture or molecular"
cases should be notified (registered in the unit TB register)
TB patient Patient who does not fulfil the
criteria for bacteriological confirmation but has been diagnosed
with active TB by a clinician on
the basis of clinical signs and
Site of the disease Pulmonary TB: bacteriologically
confirmed or clinically diagnosed
"case, affecting lung parenchyma or"
Isolated TB pleural effusion and
without lung tissue involvement is
If the patient has pulmonary and
she will be classified as pulmonary
History of treatment New: no previous TB treatment (or
Relapse: patient who completed a
"previous course of treatment, was"
"completed, and is now diagnosed"
Treatment after failure: those who
have previously been treated for
TB and whose treatment failed at
the end of their most recent course
Treatment after loss to follow-up:
treated for TB and were declared
lost to follow-up at the end of their
most recent course of treatment.
Site of the disease Pulmonary TB: bacteriologically
confirmed or clinically diagnosed
"case, affecting lung parenchyma or"
Isolated TB pleural effusion and
without lung tissue involvement is
If the patient has pulmonary and
she will be classified as pulmonary
History of treatment New: no previous TB treatment (or
 Relapse: patient who completed a
"previous course of treatment, was"
"completed, and is now diagnosed"
 Treatment after failure: those who
have previously been treated for
TB and whose treatment failed at
the end of their most recent course
 Treatment after loss to follow-up:
treated for TB and were declared
lost to follow-up at the end of their
most recent course of treatment.
treated for TB but whose Outcome
after their most recent course of
treatment is unknown or undocumented
Drug susceptibility Drug Sensitive TB (DS-TB): These
status (based on are sensitive to 1st line anti-TB
Drug resistant TB (DR-TB): Resistant to any anti-TB drug. Can be
Rifampicin resistant: any case of
rifampicin resistance (isolated or in
combination with other resistance)
Monoresistant: resistant to only
Poly drug resistant: resistant to
more than one first line anti TB
Multi drug resistant: resistant to rifampicin and isoniazid (MDR TB)
"Extensive drug resistance (XDRTB): resistant to rifampicin,"
fluoroquinolone and at least one of
either bedaquiline or Linezolid )
HIV status Positive: patients who tested
HIV-positive at time of diagnosis
or already enrolled in HIV care
treated for TB but whose Outcome
after their most recent course of
treatment is unknown or undocumented
Tests) Drug Sensitive TB (DS-TB): These
are sensitive to 1st line anti-TB
Drug resistant TB (DR-TB): Resistant to any anti-TB drug. Can be
Rifampicin resistant: any case of
rifampicin resistance (isolated or in
combination with other resistance)
 Monoresistant: resistant to only
 Poly drug resistant: resistant to
more than one first line anti TB
 Multi drug resistant: resistant to rifampicin and isoniazid (MDR TB)
" Extensive drug resistance (XDRTB): resistant to rifampicin,"
fluoroquinolone and at least one of
either bedaquiline or Linezolid )
HIV status Positive: patients who tested
HIV-positive at time of diagnosis
or already enrolled in HIV care
HIV status Negative: patients who tested negative at the moment of diagnosis
"treatment, patient should be re"
" Histoplasma pneumonia, trypanosomiasis, brucellosis"
" COPD, asthma, bronchiectasis, emphysema etc."
 Fungal infection of the lungs e.g. Aspergillosis
Screening and diagnosis of TB disease
"TB screening: is defined as the systematic identification of people at risk for TB disease, in a predetermined target group, by"
"assessing using tests, examinations or other procedures that can"
 All individuals seeking health care should be screened for TB at each
Obtain sputum sample or other relevant samples from presumptive
 Xpert MTBRIF is the recommended diagnostic test for TB diagnosis
HIV status Negative: patients who tested negative at the moment of diagnosis
"treatment, patient should be re"
" Where Xpert MTBRIF test is not available, do"
Sputum smear microscopy for AAFBs (ZN stain) but send the sample
"GeneXpert MTBRif: automated DNA test on body samples (sputum,"
"lymphonodes tissue, pleural fluid, CSF etc) which can diagnose pulmonary"
TB and determine susceptibility to Rifampicin. It is superior to microscopy.
" X- ray, abdominal ultrasound, biopsies etc. can be used"
for sputum and GeneXpert negative patients or in case of
extrapulmonary TB according to clinical judgement
 TST can be used as a supportive test to guide decision to treat
 putum culture and Drug susceptibility test: is a confirmatory
test for TB and also provides resistance pattern to TB medicines.
 Patients with Rifampicin resistance reported with GeneXpert
 Also patients on first-line treatment who remain positive at 2 months
and are reported Rifampicin sensitive on GeneXpert
 Patients suspected to be failing on first-line treatment
Note: All presumed and diagnosed TB patients should be
5.3.1.1Tuberculosis in Children and adolescents
TB may present at any age in children though the risk is highest below
"the age of two years. When compared to adults, children are more prone"
"to TB infection, TB disease, and severe forms of TB disease."
 Contact with infectious (pulmonary) case of TB
" Immunosuppression (HIV, malnutrition, diabetes, etc)."
 Age  1 year and lack of BCG vaccination are risk factors
 Suspect TB in all children with
- Poor weight gain for one month
- Close (home) contact of pulmonary TB case.
"- In young children, reduced playfulness, poor feeding,"
"- Other signs include swollen lymph nodes in the neck, groin"
 Bacteriological confirmation of TB is more difficult in children.
The diagnosis of TB in children is dependent on conducting a
detailed clinical assessment combined with available tests
" Whenever possible, geneXpert should be performed"
The principles and objectives of TB treatment are similar to those of
"adults. In addition, effective treatment of TB in children promotes growth"
Drug resistance is said to occur when TB organisms continue to grow
in the presence of one or more anti-TB medicines.
 Although several factors can contribute to the development
"of drug-resistant TB, inadequate anti-TB treatment is probably the most important. Inadequate anti-TB treatment"
leads to mutation in drug-susceptibility bacilli making them
Who is at risk for drug-resistant TB:
 Contact with known drug-resistant tuberculosis
" Retreatments (relapses, treatment after failures, return after loss"
 History of frequent interruption of drug treatment
 Patients who remain sputum smear-positive at month 2 or 3 of
 Patients presumed to have DR-TB should be screened
using rapid drug susceptibility testing (DST) of rifampicin
 All patients who are drug-resistant TB suspects should therefore
have sputumother specimens taken for culture and DST.
 Patients with drug-resistant TB should be linked to desi nated MDR TB treatment initiation centers in the respective
DRUG RESISTANT TB IS A MAJOR PUBLIC HEALTH PROBLEM. INADEQUATE TB TREATMENT IS THE MAJOR CONTRIBUTING FACTOR
A post-TB patient is one who was successfully treated for TB but presents
"with respiratory symptoms (chest pain, shortness of breath, cough)."
 Re-do standard TB diagnostic evaluation (sputum geneXpert and Chest X ray)
" If negative, evaluate for post-TB lung disease e.g., bronchiectasias, COPD, pulmonary hypertension."
 In most cases these patients have residual lung damage
"on Chest X-ray from previous TB, BUT they do not need"
retreatment if bacteriologically negative
" Counsel the patient and give supportive treatment e.g.,"
 The country has adopted patient centered care. It is recommended that all TB medicines are taken under direct
observation by a treatment supporter (DOT). Digital Adherence Technologies (DAT) have been introduced to support
 Anti-TB drugs are given in fixed dose combination (FDC)
regimens according to the patients TB classification
 Treatment is divided into two phases: an initial (intensive)
phase of 2 months and a continuation phase of 4 months
(longer in severe forms of TB particularly TB meningitis and
osteoarticular TB)TB treatment regimens are expressed in a
"standard format, e.g. 2RHZE4RH where:"
- Letters represent abbreviated drug names
- Numbers show the duration in months
- shows the division between treatment phases
 Other shorter term (4-months) treatment regimen recently
 2 HRE(Z)2RH for children 2 months to 16 years
 Anti-TB drugs have side effects and they should be managed appropriately (see section 5.3.2.1)
" TB treatment monitoring should be done by clinical, sputum and where possible radiological"
 A conclusion of treatment outcome status should be done
for every patient treated for TB.
Drug Adult Dose Children Contraindications
"Isoniazid (H) 5 mgkg 10 mg C: Liver disease,"
oral (max 300 kg (range known hypersensitivity
"Rifampicin 10 mgkg 15 mg C: Liver disease, known"
kg (range hypersensitivity I: Oral
"1020 contraceptives, nevirapmg)"
"mgkg) ine, warfarin, phenytoin,"
"Pyrazina- mide 30-40 35 mg C: Liver disease, known"
(Z) oral mgkg (max Hypersensitivity
Etham- butol 15 mgkg 20 mg C: Pre existing optic neu-
"(E) oral kg (range ritis, established kidney"
Moxifloxacin 10-15mg  Resistance to a fluoro-
 Rifampicin interacts with oestrogen-containing contraceptives
and reduces the protective efficacy of the contraceptives. Use
high dose contraceptive or use an additional barrier method.
"contraceptives, nevirapine, warfarin, phenytoin,"
"mgkg) C: Pre existing optic neuritis, established kidney"
Kg Resistance to a fluoroquinolone
 Rifampicin interacts with oestrogen-containing contraceptives
and reduces the protective efficacy of the contraceptives. Use
high dose contraceptive or use an additional barrier method. 
Important: The choice of regimen now depends on rifampicin
sensitivity and not on the previous history of treatment:
 All patients without rifampicin resistance (either new or re-treatments) are treated with 1st line regimen.
 Patients with rifampicin resistance (either new or re- treatments)
are treated with second line medication in a designated MDR-TB
Susceptible TB: 1st line treatment regimens
For patients without rifampicin resistance to Gene Xpert MTBRif (both
New cases not belonging to priority (risk) groups and in which diagnosis
was done by sputum examination will also be treated with this regimen.
Type Of TB Disease Regimen For LOC
All forms of TB in adults 2RHZE 4RH HC3
TB meningitis Bone (Osteo- 2RHZE 10RH H C 4 a n d
Alternative 1st-line treatment regimen
All forms of TB in children 2 HRE(Z) 2RH G e n e r a l
(2 months to 16 years) with Hospital and
All forms of TB in adults 2 HPMZ 2HPM
TB meningitis Bone (Osteoarticular) TB 2RHZE 10RH H C 4 a n d
Alternative 1st-line treatment regimen 
non-severe disease 2 HRE(Z) 2RH G e n e r a l
"Patients with drug-resistant TB should undergo culture and Drug Sensitivity testing, and be treated with second line regimens according to"
Notify the relevant TB focal persons and organize referral to MDR-TB
treatment initiation center for appropriate management.
Type Of TB Regimen For Drug LOC
INH mono-resist- 6(H)REZlevoflox- DTUS
RRMDR TB Treatment at des- Hospital and above
"Pre XDR, XDR Treatment at des- Hospital and above in"
ignated MDR TB consultation with national
 Vitamin B6 (pyridoxine): 25 mg per day; given con- HC3H
"comitantly with isoniazid for the duration of therapy,"
to prevent peripheral neuropathy
 Prednisolone in TB patients in whom complications of
fibrosis are anticipated because of severe inflammation
- Prednisolone is given in a dose of 1-2 mgkg
body weight (not more than 60 mgday) as a
"single dose for 4 weeks, and then tapered off"
INH mono-resistance 6(H)REZlevofloxacin) DTUS
RRMDR TB Treatment at designated MDR TB
national guidelines Hospital and above
"Pre XDR, XDR Treatment at designated MDR TB"
national guidelines Hospital and above in
" Vitamin B6 (pyridoxine): 25 mg per day; given concomitantly with isoniazid for the duration of therapy,"
to prevent peripheral neuropathy
 Prednisolone in TB patients in whom complications of
fibrosis are anticipated because of severe inflammation
- Prednisolone is given in a dose of 1-2 mgkg
body weight (not more than 60 mgday) as a
"single dose for 4 weeks, and then tapered off"
Laboratory Monitoring (For Pulmonary Tb)
At the end of the initial 2 months:
- Sputum smear-negative; start continuation phase
- Sputum smear-positive; do GeneXpert to rule out rifampicin
"resistance, start continuation phase and Xpert MTBXDR"
"where accessible, to rule out resistance to other drugs"
"- If Rifampicin-resistant, refer for MDR-TB treatment and"
"- If Rifampicin-sensitive, continue with first-line"
"- treatment, explore adherence issues but repeat smear at"
"- Sputum smear-negative, continue with continuation"
"- Sputum smear-positive, diagnose Treatment Failure"
- Take sputum for GeneXpert to rule out Rifampicin
"Resistance and Xpert MTBXDR where accessible, to rule"
"- If Rifampicin Resistant, refer for DR treatment"
- If INH resistant manage as INH mono-resistant TB as
"- If TB detected but not Rifampicin Resistant, restart first line"
regimen but explore adherence issues
"- Sputum smear-negative, complete treatment and declare"
"- Sputum smear-positive, diagnose treatment failure"
- Take sputum for GeneXpert to rule out rifampicin
"resistance and Xpert MTBXDR where accessible, to rule"
"- If Rifampicin-resistant, refer for MDR-TB treatment"
"- If Rifampicin-sensitive, restart first-line treatment, explore"
Laboratory Monitoring (For Pulmonary Tb)
At the end of the initial 2 months:
- Sputum smear-negative; start continuation phase
- Sputum smear-positive; do GeneXpert to rule out rifampicin
"resistance, start continuation phase and Xpert MTBXDR"
"where accessible, to rule out resistance to other drugs"
"- If Rifampicin-resistant, refer for MDR-TB treatment and"
"- If Rifampicin-sensitive, continue with first-line"
"- treatment, explore adherence issues but repeat smear at"
"- Sputum smear-negative, continue with continuation"
"- Sputum smear-positive, diagnose Treatment Failure"
- Take sputum for GeneXpert to rule out Rifampicin
"Resistance and Xpert MTBXDR where accessible, to rule"
"- If Rifampicin Resistant, refer for DR treatment"
- If INH resistant manage as INH mono-resistant TB as
"- If TB detected but not Rifampicin Resistant, restart first line"
regimen but explore adherence issues
Clinical Monitoring (For All Tb Cases)
- Monitor wellbeing and weight gain
- Assess and reinforce treatment adherence
- Assess and manage side effects
 Radiological monitoring this method should not be used as
Management of treatment interruptions
A conclusion should be made regarding treatment outcome of EVERY
TB patient who has been started on anti-TB treatment.
Cure A pulmonary TB patient with bacteriologically confirmed TB at the beginning of treatment who was smear- or
culture-negative in the last month of
treatment and on at least one previous
Treatment A TB patient who completed treatment
completed without evidence of failure BUT with
no record to show that sputum smear
or culture results in the last month of
treatment and on at least one previous
"occasion were negative, either because"
tests were not done or because results
"Lost to fol- A TB patient who did not start treatlow-up ment, or completed more than one"
treatment was interrupted for two or
Clinical Monitoring (For All Tb Cases)
- Monitor wellbeing and weight gain
- Assess and reinforce treatment adherence
- Assess and manage side effects
 Radiological monitoring this method should not be used as
Cure A pulmonary TB patient with bacteriologically confirmed TB at the beginning of treatment who was smear- or
culture-negative in the last month of
treatment and on at least one previous
completed A TB patient who completed treatment
without evidence of failure BUT with
no record to show that sputum smear
or culture results in the last month of
treatment and on at least one previous
"occasion were negative, either because"
tests were not done or because results
"Lost to follow-up A TB patient who did not start treatment, or completed more than one"
treatment was interrupted for two or
Died A TB patient who dies for any reason
before starting or during the course of
Treatment A TB patient whose sputum smear or
failure culture is positive at month five or later
Not evaluated A patient for whom no treatment outcome is assigned. This includes cases
transferred out to another treatment
unit as well as cases for whom the
treatment outcome is unknown to the
Treatment The sum of cured and treatment
"Isoniazid Hepatitis, peripheral neuropathy"
"Rifampicin Flu-like syndrome, dermatitis, hepatitis,"
reddish-brown colouration of urine
"Pyrazin- Joint pains, hepatitis"
Ethambutol Impaired visual acuity and colour vision
"Moxifloxacin Tendonitis, arthralgia, GI disturbance,"
Treatment A TB patient who completed treatment
completed without evidence of failure BUT with
no record to show that sputum smear
or culture results in the last month of
treatment and on at least one previous
"occasion were negative, either because"
tests were not done or because results are
Died A TB patient who dies for any reason
before starting or during the course of
failure A TB patient whose sputum smear or
culture is positive at month five or later
Not evaluated A patient for whom no treatment outcome is assigned. This includes cases
transferred out to another treatment
unit as well as cases for whom the
treatment outcome is unknown to the
success The sum of cured and treatment
"Isoniazid Hepatitis, peripheral neuropathy"
"Rifampicin Flu-like syndrome, dermatitis, hepatitis,"
reddish-brown colouration of urine
"Pyrazinamide Joint pains, hepatitis"
Ethambutol Impaired visual acuity and colour vision
"Moxifloxacin Tendonitis, arthralgia, GI disturbance,"
completed A TB patient who completed treatment
without evidence of failure BUT with
no record to show that sputum smear
or culture results in the last month of
treatment and on at least one previous
"occasion were negative, either because"
tests were not done or because results are
Side-Effects Drug(S) Likely Management
"Low appe- Pyrazinamide, Ri- Give drugs with small meal or"
"tite, nausea, fampicin just before going to bed"
Joint pains Pyrazinamide Give an analgesic
Burning Isoniazid Pyridoxine 25-100 mg daily
Orangered Rifampicin Reassure the patient that it
"Skin rash Any anti-TB drug Depending on degree, see"
Deafness Streptomycin Stop streptomycin. Use Eth-
"Jaundice Pyrazinamide, Ri- Stop anti-TB drugs see guide-"
(other caus- fampicin and Iso- lines below
"Mental con- Isoniazid, 1. If jaundiced, suspect"
"fusion Rifampicin and liver failure, stop drugs (see"
"pain Pyrazinamide, Rifampicin Give drugs with small meal or"
Joint pains Pyrazinamide Give an analgesic
the feet Isoniazid Pyridoxine 25-100 mg daily
urine Rifampicin Reassure the patient that it
"reaction) Any anti-TB drug Depending on degree, see"
nystagmus Streptomycin Stop streptomycin. Use Ethambutol
"(other causes excluded) Pyrazinamide, Rifampicin and Isoniazid Stop anti-TB drugs see guidelines below"
"Pyrazinamide 1. If jaundiced, suspect"
Side-Effects Drug(S) Likely Management
Visual Ethambutol Stop Ethambutol. Use
Most anti-TB drugs can cause hypersensitisation between week 3 and
"week 8 of treatment in order of frequency: ethambutol, pyrazinamide,"
"If mild (simple itchy rash), give antihistamine (e.g. chlorpheniramine) and"
moisturizer and continue treatment.
Severe reactions are characterised by
- Macular dark erythematous rash which can progress to a
Steven Johnson-Toxic Epidermal Necrolysis syndrome
 Refer for specialised management
"Severe hepatic damage, presenting with jaundice, vomiting, severe malaise."
"In order of frequency, the implicated drugs are Isoniazid, Pyrazinamide,"
" When jaundice has resolved, re-introduce single drugs at"
"3-7 days interval, starting from the least likely involved"
excluded) Ethambutol Stop Ethambutol. Use
 Refer for specialised management H
" When jaundice has resolved, re-introduce single drugs at"
"3-7 days interval, starting from the least likely involved H"
" If reaction very severe, do not try to restart pyrazina- H"
"mide. If RH tolerated, do not try pyrazinamide"
 Use alternative regimen avoiding the causative drug
5.Prevention and Infection Control of TB
A TB patient is more infectious before they start TB treatment.
 Provide PPE to sputum-positive patients
 Early detection of cases and initiation of appropriate TB
 Treatment under directly observed treatment (DOT) and follow up to ensure adherence and cure
 Tracing of contacts of TB patients
 Routine screening of health workers for latent  active TB
High Priority Patients For Contact Tracing
 Bacteriologically confirmed PTB (Smear positive or Xpert
 MDR TB  PLHOther preventive measures
 BCG vaccination at birth to prevent severe forms of TB
 TB Preventive Treatment for categories at risk
" If reaction very severe, do not try to restart pyrazinamide. If RH tolerated, do not try pyrazinamide"
 Use alternative regimen avoiding the causative drug H
" Cough hygiene (cover cough with pieces of cloth, washing"
"hands with soap, proper disposal of sputum)"
 Promote good ventilation in housing  transport
" Open ventilators, windows  doors that allow air exchange"
5.Tuberculosis Preventive Treatment
Tuberculosis preventive treatment is recommended to prevent the
development of active TB disease in an individual who has latent TB
Uganda guidelines for programmatic management of Latent TB infection
recommend TB preventive treatment (TPT ) in the following categories
- Persons living with H- Child  adult contacts of pulmonary TB patients
Do not use TPT in cases of active TB
Do not use TPT in contacts of MDR-TB
"- Assess for cough, fever, weight loss and nights"
"sweats (Children: cough, fever, poor weight"
"- If any of the TB symptoms are present, do"
"- If none is present, TB is unlikely, then rule out"
"contra-indications for TPT medicines. If none,"
 Give TPT as per dosing chart below.
 HIV-positive children  1 year should receive TPT only if they
have history of contact with TB case and active TB has been
"- Assess for cough, fever, weight loss and nights"
"sweats (Children: cough, fever, poor weight"
"- If any of the TB symptoms are present, do"
"- If none is present, TB is unlikely, then rule out"
"contra-indications for TPT medicines. If none,"
 Give TPT as per dosing chart below. Hc3
 HIV-positive children  1 year should receive TPT only if they
have history of contact with TB case and active TB has been
5.TB Preventive Treatment Dosing Chart
Medicine frequency Formulation Dose of TPT Dose Recommended number of tablets per body weight in kilograms
3HP (once weekly Fixed Doze Rifapentine 35.9kgs 69.9Kgs 10 16 24 31- 35- 45kgs
rifapentine plus isoni- Combination 300mg Iso- 15kgs 23kgs 30kgs 34kgs 45kgs
azid for 3 months) (FDC) Tablet niazid 300mg
Single medicine Pyridoxine 1 2 3 3
6H (daily isoniazid 361 0  1 4  2 0  2 5 - 3 5 - 4 5 - 50 kgs
Isoniazid 100 10 years 1 2 Single medicine mg
Single medicine Pyridoxine 25 1 1 1 1 1 1 1
3RH (daily Rifampic- Fixed Doze  4kgs 4-7 kgs 8-11 12-15 1624 25- 33- 40-54
in Isoniazid for 3 Combination 32 39
 duration Formulation Dose of TPT
rifapentine plus isoniazid for 3 months) Fixed Doze
300mg Isoniazid 300mg 3Single medicine
mg 3RH (daily Rifampicin Isoniazid for 3
Medicine frequency Formulation Dose of TPT Dose Recommended number of tablets per body weight in kilograms
3HP (once weekly Fixed Doze Rifapentine 35.9kgs 69.9Kgs 10 16 24 31- 35- 45kgs
rifapentine plus isoni- Combination 300mg Iso- 15kgs 23kgs 30kgs 34kgs 45kgs
azid for 3 months) (FDC) Tablet niazid 300mg
Single medicine Pyridoxine 1 2 3 3
6H (daily isoniazid 361 0  1 4  2 0  2 5 - 3 5 - 4 5 - 50 kgs
Isoniazid 100 10 years 1 2 Single medicine mg
Single medicine Pyridoxine 25 1 1 1 1 1 1 1
3RH (daily Rifampic- Fixed Doze  4kgs 4-7 kgs 8-11 12-15 1624 25- 33- 40-54
in Isoniazid for 3 Combination 32 39
mended number of tablets per body weight in kilograms 
Single medicine Pyridoxine 1 1 1 1 1 1 1
Medicine frequency Formulation Dose of TPT Dose Recommended number of tablets per body weight in kilograms
1HP (once daily 35.9kgs 69.9Kgs 10 16 24 31- 35- 45kgs
rifapentine plus isoni- 15kgs 23kgs 30kgs 34kgs 45kgs
Single medicine ne Isoniazid 1 2 1 1
 duration Formulation Dose of TPT
rifapentine plus isoniazid for 1 month - 28
Single medicine Pyridoxine 1 1 1 1 1 1 1
Medicine frequency Formulation Dose of TPT Dose Recommended number of tablets per body weight in kilograms
1HP (once daily 35.9kgs 69.9Kgs 10 16 24 31- 35- 45kgs
rifapentine plus isoni- 15kgs 23kgs 30kgs 34kgs 45kgs
Single medicine ne Isoniazid 1 2 1 1
mmended number of tablets per body weight in kilograms 
Preferred options for TB Preventive Treatment
TPT medicine option Target population (active TB ruled out)
Isoniazid monotherapy Contacts of PBC TB patients  2 years of age
3. Pregnant women living with HIV with;
a. history of contact with a TB patient
Isoniazidco-trimoxazolepyridoxine (Q-TIB) PLHIV;
3 months of RifapentineIsoniazid PLHIV  2 years of age (not on protease inhibitors (PI)
Contacts of PBC TB patients  2 years
1 month of RifapentineIsoniazid Prisoners
Isoniazidco-trimoxazolepyridoxine (Q-TIB) PLH new (
3 months of RifapentineIsoniazid PLH Conta
1 month of RifapentineIsoniazid Priso
Preferred options for TB Preventive Treatment
TPT medicine option Target population (active TB ruled out)
Isoniazid monotherapy Contacts of PBC TB patients  2 years of age
3. Pregnant women living with HIV with;
a. history of contact with a TB patient
Isoniazidco-trimoxazolepyridoxine (Q-TIB) PLHIV;
3 months of RifapentineIsoniazid PLHIV  2 years of age (not on protease inhibitors (PI)
Contacts of PBC TB patients  2 years
1 month of RifapentineIsoniazid Prisoners
et population (active TB ruled out)
cts of PBC TB patients  2 years of age
gnant women living with HIV with;
tory of contact with a TB patient
V  2 years of age (not on protease inhibitors (PI)
cts of PBC TB patients  2 years
" Pyelonephritis, ureteritis (inflammation of the ureter)"
 No special investigations - good history and physical examination
 Complete blood count: look for leucocytosis
 Abdominal X ray (to assess for perforation and intestinal occlusion)
" If surgery is delayed, start antibiotic treatment while"
- ceftriaxone 2 g IV once daily
- plus metronidazole 500 mg IV every 8 hours
 Start antibiotic prophylaxis before the surgery and
continue for a duration depending on the findings (
"24 hours for unperforated appendix, at least 5 days"
Acute Pancreatitis ICD10 CODE: K85
Acute inflammation of the pancreas.
" Gall stones, biliary tract disease (obstructive cancer or anatomical abnormalities)"
" Infections, e.g. mumps, HIV, hepatitis A, ascaris"
" Drugs, e.g. sulphonamides, furosemide, lamivudine, analgesics, organosphosphate poisoning"
" If surgery is delayed, start antibiotic treatment while"
- ceftriaxone 2 g IV once daily
- plus metronidazole 500 mg IV every 8 hours
 Start antibiotic prophylaxis before the surgery and
continue for a duration depending on the findings (
"24 hours for unperforated appendix, at least 5 days"
 Acute abdominal pain usually in the epigastrium radiating
 Pain worsened by eating or lying down and relieved by
" Nausea, vomiting, abdominal distension"
" Fever, tachycardia, dehydration (may be severely ill with"
 Abdomen is very tender but in the absence of peritonitis
there is no rigidityrebound tenderness
 Necrotizing pancreatitis with infection
" Perforated peptic ulcer, peritonitis"
" Acute cholecystitis, inflammation of the biliary tract"
" Blood: Serum analysis, complete blood count, random blood sugar"
 Raised pancreatic amylase and lipase  3 times normal
" Ultrasound: gallstones, pancreatic oedema, abdominal fluid"
 Liver function tests: raised liver enzymes
"(No organ failure, no local or systematic complications, no signs of peritonitis, normal serum"
"creatinine, normal haematocrit not increased"
Early aggressive fluid resuscitation and acid-base
 Prevent volume depletion (adequate fluids with
Ringers Lactate). Give 5-10 mlkghour or
250500 ml of isotonic crystalloids in the first 12-24
hours or urine output of at least mlkg
 Give IV fluids to correct metabolic and electrolyte
disturbances and to prevent hypovolaemia and
 Goal is to decrease haematocrit and BUN in 48
"hours, evaluate every 4-6 hours"
" Opioids, paracetamol, epidural anaesthesia avoid"
- RectalIV paracetamol 500 mg 6-8 hourly
- or Pethidine 25-100 mg SC or IM or 25-50
mg slow IV. Repeat prn every 4-6 hours
- IV morphine 1-3 mg every 4 hours
"- Be aware of complications e.g. constipation,"
"dysphagia, respiratory depression, confusion"
- Metoclopramide 10 mg IVIM every 8 hours
 Pass a nasogastric tube for suction when persistent
"(No organ failure, no local or systematic complications, no signs of peritonitis, normal serum"
"creatinine, normal haematocrit not increased"
Early aggressive fluid resuscitation and acid-base
 Prevent volume depletion (adequate fluids with
Ringers Lactate). Give 5-10 mlkghour or
250500 ml of isotonic crystalloids in the first 12-24
hours or urine output of at least mlkg
 Give IV fluids to correct metabolic and electrolyte
disturbances and to prevent hypovolaemia and
 Goal is to decrease haematocrit and BUN in 48
"hours, evaluate every 4-6 hours"
" Opioids, paracetamol, epidural anaesthesia avoid"
- RectalIV paracetamol 500 mg 6-8 hourly
- or Pethidine 25-100 mg SC or IM or 25-50
mg slow IV. Repeat prn every 4-6 hours
- IV morphine 1-3 mg every 4 hours
"- Be aware of complications e.g. constipation,"
"dysphagia, respiratory depression, confusion"
- Metoclopramide 10 mg IVIM every 8 hours
 Pass a nasogastric tube for suction when persistent
 No feeding by mouth until signs and symptoms of
acute inflammation subside (i.e. cessation of abdominal
"tenderness and pain, return of hunger and well-being)"
 Provide energy with dextrose 50 300-500 ml a
day (add 50 ml to 500 ml Normal saline) to prevent
" Start early oral re-feeding on demand, start within"
48-72 hours as soon as the patient is able and can
" Start with clear liquids, then low fat semi-solid feeds"
then a normal diet  according to tolerance
" Monitor daily for vital signs, fluid intake, urinary output,"
" If oral feeding not possible, consider peripheral parenteral and central parenteral nutrition"
Glycaemic control (hyperglycaemia is common)
 Keep serum blood sugar between 6-9 mmoll f Avoid
 Avoid inappropriate use of antibiotics and other medications e.g. for prophylaxis
" In case of specific infection, e.g. biliary sepsis, pulmonary infection, or UTI, treat vigorously with appropriate"
 Address the underlying cause as is appropriate
 No feeding by mouth until signs and symptoms of
acute inflammation subside (i.e. cessation of abdominal
"tenderness and pain, return of hunger and well-being) "
 Provide energy with dextrose 50 300-500 ml a
day (add 50 ml to 500 ml Normal saline) to prevent
" Start early oral re-feeding on demand, start within"
48-72 hours as soon as the patient is able and can
" Start with clear liquids, then low fat semi-solid feeds"
then a normal diet  according to tolerance
" Monitor daily for vital signs, fluid intake, urinary output,"
" If oral feeding not possible, consider peripheral parenteral and central parenteral nutrition"
Glycaemic control (hyperglycaemia is common)
 Keep serum blood sugar between 6-9 mmoll f Avoid
 Avoid inappropriate use of antibiotics and other medications e.g. for prophylaxis
" In case of specific infection, e.g. biliary sepsis, pulmonary infection, or UTI, treat vigorously with appropriate"
 Address the underlying cause as is appropriate
 Evaluation for gall stones by ultrasound scans
 Manage complications e.g. acute peri-pancreatic fluid
"collections, acute necrosis, pseudocyst"
Moderately acute pancreatitis RR
 Transient organ failure ( 48 hours)
 Local or systematic complications without
 Persistent organ failure ( 48 hours)
 Either single or multiple organ failure
 Refer or consult with specialist at higher level
 HDUICU (monitoring and nursing) f Volume resuscitation
 Pain management f Nutrition re-feeding f Glycaemic
 Address the cause where possible
 Manage complications as appropriate e.g. acute
"peri-pancreatic fluid collection, acute necrosis, pseudocyst."
 Look out for diabetes mellitus as a consequence of damage
 Evaluation for gall stones by ultrasound scans
 Manage complications e.g. acute peri-pancreatic fluid
"collections, acute necrosis, pseudocyst "
 Transient organ failure ( 48 hours)
 Local or systematic complications without
 Persistent organ failure ( 48 hours)
 Either single or multiple organ failure RR
 Refer or consult with specialist at higher level
 HDUICU (monitoring and nursing) f Volume resuscitation
 Pain management f Nutrition re-feeding f Glycaemic
 Address the cause where possible
 Manage complications as appropriate e.g. acute
"peri-pancreatic fluid collection, acute necrosis, pseudocyst. RR"
 Look out for diabetes mellitus as a consequence of damage
 Reduce alcohol intake - moderate consumption
Upper Gastrointestinal Bleeding ICD10 CODE: K92.2
"Bleeding from the upper gastrointestinal tract (oesophagus, stomach"
and duodenum). It can be a medical emergency.
 Peptic ulcer diseasesevere gastritiscancer
 Mallory Weiss tear (a tear in the oesophageal mucosa
 Vomiting of fresh blood (haematemesis)
 Coffee brown emesis (degraded blood mixed with stomach
 Melena: passing of soft dark red smelly stool
 Black stools (in case of minor bleeding)
" Acute hypovolaemia (if acute and abundant): syncope, hypotension, tachycardia, sweating"
 Chronic anaemia (if subacutechronic loss)
" Blood: Complete blood cell count, culture and sensitivity"
 Renal function and electrolytes
 Start initial treatment before referral
" Monitor BP, pulse, Sp02, urine output, mention"
 Put up an IV drip with normal saline or ringers
lactate or any other crystalloid: 1 L every 1-2 hours
"until BP is normal, then 1 L every 4-6 hours when"
 Nil by mouth. Pass a nasogastric tube and start suction
 Ask patient to lie on their side in a comfortable position
 Give oxygen if patient is hypoxic
- Pethidine 50 mg IM or - Child: 0.5-2 mgkg
- Or Morphine 5-15 mg IV or IM or SC
" Refer patient to hospital for further management,"
including possible exploratory laparotomy
In suspected bacterial infection and fever: (minimum
 Ceftriaxone 1-2 g IV once daily
 Plus gentamicin 7 mgkg IV daily in divided doses
 Start initial treatment before referral
" Monitor BP, pulse, Sp02, urine output, mention"
 Put up an IV drip with normal saline or ringers
lactate or any other crystalloid: 1 L every 1-2 hours
"until BP is normal, then 1 L every 4-6 hours when"
 Nil by mouth. Pass a nasogastric tube and start suction
 Ask patient to lie on their side in a comfortable position
 Give oxygen if patient is hypoxic
- Pethidine 50 mg IM or - Child: 0.5-2 mgkg
- Or Morphine 5-15 mg IV or IM or SC
" Refer patient to hospital for further management,"
including possible exploratory laparotomy
In suspected bacterial infection and fever: (minimum
 Ceftriaxone 1-2 g IV once daily
 Plus gentamicin 7 mgkg IV daily in divided doses
 Plus metronidazole 500 mg by IV infusion every
8 hours; change when possible to 400 mg orally
Child: mgkg IV per dose; change when
 Identify and control the source of infection
 Prevent and control complications through: proper
"nutrition, early ambulation, rehabilitation"
Diarrhoea ICD10 CODE: DEPENDING ON THE CAUSE
Occurrence of 3 or more loose watery stools in 24 hrs. Acute diarrhoea:
"3 loose, watery stools within 24 hours Dysentery: bloody diarrhoea,"
visible blood and mucus Persistent diarrhoea: episodes of diarrhoea
" Viruses: Rotavirus, Norovirus, adenovirus, measles, hepatitis A virus, hepatitis E virus, Ebola"
" Bacteria: Vibrio cholera, E.coli, Salmonella, shigella, campylobacter"
" Protozoa: giardiasis, malaria, cryptosporia"
" Heliminthes e.g. strongyloidiasis, schistosomiasis"
" Infectious diseases, e.g. measles, malaria, and other fevercausing conditions"
" Drugs e.g., prolonged use of purgatives and broad-spectrum antibiotics"
 Plus metronidazole 500 mg by IV infusion every
8 hours; change when possible to 400 mg orally
Child: mgkg IV per dose; change when
 Identify and control the source of infection
 Prevent and control complications through: proper
"nutrition, early ambulation, rehabilitation "
" Metabolic: diabetes, thyroid disease"
 Inflammatory bowel disease (persistent diarrhoea usually
" Dehydration - thirst, sunken eyes, loss of skin elasticity, low"
 Signs of malnutrition if diarrhoea persists for  14 days
 Other investigations may be necessary according to history and
- History of travel from a known endemic area
"- Shock, failure to feed, mental confusion"
 Prevent or correct dehydration with ORS or IV HC2
"fluids according to treatment plans A, B or C (see"
 Find and treat the cause if indicated
- Avoid inappropriate use of antibiotics e.g.
"metronidazole, ciprofloxacin HC4"
" Prevent or correct dehydration with ORS or fluids according to treatment plans A, B or C (see"
 Find and treat the cause if indicated
- Avoid inappropriate use of antibiotics e.g.
"metronidazole, ciprofloxacin HC2"
" Routinely use zinc supplementation, at a dosage of HC2"
20 milligrams per day for children older than six
 Prevent or treat undernutrition and micronutrient
Persistent or chronic diarrhoea:
 Adults only: As above plus codeine phosphate
30 mg every 8-12 hours as required
"- 6-11 months: 100,000 IU; 1-6 years:"
" Vaccination: measles, rotavirus, polio, hepatitis A virus"
" Notify in case of suspected epidemics e.g. cholera, hepatitis A or E virus infections, Ebola"
" Encourage handwashing, use of clean drinking water, and"
A common parasitic infection of the gastrointestinal system acquired
through oral-faecal transmission.
 Protozoan Entamoeba histolytica
" Routinely use zinc supplementation, at a dosage of"
20 milligrams per day for children older than six
 Prevent or treat undernutrition and micronutrient
Persistent or chronic diarrhoea:
 Adults only: As above plus codeine phosphate
30 mg every 8-12 hours as required
"- 6-11 months: 100,000 IU; 1-6 years:"
 Persistent mucoidbloody diarrhoea
 Chronic carriers are symptomless
Amoebic abscess (as a result of spread via the blood stream):
" Liver abscess: swellingpain in the right sub-costal area,"
"fever, chills, sweating, weight loss"
 Brain: presenting as space-occupying lesion
 Lungs: cough and blood stained sputum
" Amoeboma: swelling anywhere in the abdomen, especially"
 Anal ulceration: may occur by direct extension from the
 Any other cause of bloody diarrhoea
 Other causes of swelling in the liver
 Stool: Microscopy for cysts and motile organisms
 Correct any dehydration (section 1.1.3) HC2
 Metronidazole 800 mg every 8 hours for 10 days
 Or tinidazole 2 g daily for 5 days
 Correct any dehydration (section 1.1.3)
 Metronidazole 800 mg every 8 hours for 10 days
 Or tinidazole 2 g daily for 5 days
 Metronidazoletinidazole: do not use in 1st trimester of
pregnancy; avoid alcohol during treatment and for 48 hours
 Educate the public on personal and food hygiene (washing
"hands before eating), proper faecal disposal"
 Ensure proper management of carriers and patients
 Promote use of clean drinking water
Bacillary Dysentery (Shigellosis) ICD10 CODE: A03.9
"An acute bacterial disease involving the large and small intestine, characterised by bloody mucoid diarrhoea."
Bacillary dysentery is a notifiable disease.
" Shigella dysenteriae, Shigella flexneri, Shigella sonnei, all"
" Nausea, vomiting, abdominal cramps"
 Tenesmus (sensation of desire to defecate without production of significant amounts of faeces)
" S. flexneri infection may be complicated with Reiters syndrome  urethritis, conjutivitis and arthritis"
 Metronidazoletinidazole: do not use in 1st trimester of
pregnancy; avoid alcohol during treatment and for 48 hours
 Other causes of bloody diarrhoea
 Mobile vibrios under microscope
Up to 90 of patients with cholera only require prompt oral rehydration.
Only severely dehydrated patients need IV fluids and antimicrobials
 Start rehydration with ORS at HC12 and refer for HC2
 Give oral (ORS) or IV fluids (Ringers lactate) according
to degree of dehydration (see section 1.1.3)
 Give glucose IV for hypoglycemia
 Give maintenance fluid; at least 4-5 litresday
 Doxycycline 300 mg single dose (children 4 mg
Or erythromycin 25-50 mgkg every 6 hours for
3 days in children under 12 years
 Or ciprofloxacin 1 g single dose or 20 mgkg 12
" Ciprofloxacin, doxycycline: usually contraindicated in"
pregnancy and children  8 years but single dose in cholera
should not provoke adverse effect
 Alternative: erythromycin 500 mg every 6 hours for 5 days
 Start rehydration with ORS at HC12 and refer for
 Give oral (ORS) or IV fluids (Ringers lactate) according
to degree of dehydration (see section 1.1.3)
 Give glucose IV for hypoglycemia
 Give maintenance fluid; at least 4-5 litresday
 Doxycycline 300 mg single dose (children 4 mg
Or erythromycin 25-50 mgkg every 6 hours for
3 days in children under 12 years
 Or ciprofloxacin 1 g single dose or 20 mgkg 12
" Ciprofloxacin, doxycycline: usually contraindicated in"
pregnancy and children  8 years but single dose in cholera
should not provoke adverse effect
 Alternative: erythromycin 500 mg every 6 hours for 5 days 
 Rehydrate with plenty of fluids
 Continue breastfeeding or weaning
" Personal and food hygiene, e.g. washing hands before preparing and eating food and after using the toilet"
 Using and drinking clean safe water
" Prompt isolation, treatment, and reporting of cases"
A protozoan infection of the upper small intestine transmitted by faecal-oral route.
 Giardia lamblia (a flagellated protozoan)
" Prolonged diarrhoea, steatorrhoea"
 Malabsorption of fats and fat-soluble vitamins
" Severe giardiasis may cause reactive arthritis, damage to"
 Other causes of prolonged diarrhoea
 Stool: For cysts and trophozoites
Metronidazole 2 g after food daily for 3 days HC2
Child: 30 mgkg (max: g) per dose
" Metronidazole, tinidazole: Avoid in first trimester, avoid alcohol"
during treatment and for 48 hours after
- Personal and food hygiene e.g. washing hands before
handling or eating food and after using toilets
- Proper disposal of human faeces
- Use of safe clean drinking water
Dysphagia is difficulty in swallowing. It may be oropharyngeal dysphagia
" Neurological: stroke, parkinsons, dementia, multiple sclerosis, Guillianbarre, myasthenia, cerebral palsy, tardive dyskinesia, brain tumours, trauma"
" Myopathy: connective tissue diseases, sarcoidosis, dermatomyositis"
" Structural: Zenkers diverticulum, webs, oropharyngeal tumours, osteophytes"
" Infections: syphilis botulism, rabies, mucositis"
" Metabolic: Cushings, thyrotoxicosis, Wilsons disease"
" Iatrogenic: chemotherapy, neuroleptics, post surgery, post"
Metronidazole 2 g after food daily for 3 days
Child: 30 mgkg (max: g) per dose
" Metronidazole, tinidazole: Avoid in first trimester, avoid alcohol"
during treatment and for 48 hours after
 Tumours: cancer of the oesophagus
" Oesophagiitis: gastroesophageal reflux disease, candidiasis,"
"pill oesophagitis (e.g. doxycycline), caustic soda injury"
" Extrinsic compression: tumors, lymph nodes"
" Motility: achalasia, scleroderma, oesophageal spasms"
" Difficulty initiating a swallow, repetitive swallowing"
" Coughing, nasal speech, drooling"
 Choking (aspiration may occur without concurrent choking
 Dysarthria and diplopia (may accompany neurologic conditions that cause oropharyngeal dysphagia)
" Halitosis in patients with a large, residue-containing Zenkers diverticulum or in patients with advanced achalasia or"
long-term obstruction with luminal accumulation of decomposing residue
 Other features due to causative problem
 Medical history and physical examination
 Timed water swallow test (complemented by a food test)
" HIV serology, RBS, electrolytes"
 Ensure rehydration with IV fluids HC3
 Prevent malnutrition through appropriate energy
 Treat cause if possible (e.g. fluconazole trial in case
of suspected oral candidiasis among HIV patients)
 Consult andor refer the patient
Upper abdominal discomfort arising from the upper gastrointestinal tract
usually lasting more than 24 weeks.
 Gastroesophageal reflux disease (GERD)
" Oesophagitis (drugs, candida, and others)"
 Gastroparesis or gastric outlet obstruction
" Epigastric pain or discomfort, heartburn"
" Bloating, early satiety andor fullness after meals"
 Repeated belching or regurgitation (often rumination)
 Ensure rehydration with IV fluids
 Prevent malnutrition through appropriate energy
 Treat cause if possible (e.g. fluconazole trial in case
of suspected oral candidiasis among HIV patients)
 Consult andor refer the patient HC3
 Heartburn: a burning sensation in the chest. Usually
brought about by bending or exertion or lying down
 Unpleasant sour taste (due to stomach acid reflux)
 Oesophagitis with pain and difficulty when swallowing
" Halitosis, bloating and belching"
" Peptic ulcer, gastritis, pancreatitis"
Lifestyle modifications include the following:
" Avoiding alcohol, chocolate, citrus juice, and tomato-based products"
"also suggest avoiding peppermint, coffee, and possibly the onion"
"family, spicy foods, food with high fat content, carbonated beverages)"
 Waiting 3 hours after a meal before lying down or eating within
2-3 hours before bedtime should be avoided
 Elevating the head of the bed by 8 inches
 Modify diet: avoid precipitating causes and increase HC2
Magnesium trisilicate compound 1-2 tablets every
If no response and no alarm signs HC3
 Omeprazole 20 mg once daily for 8 weeks
"If not responding to 4 weeks of omeprazole, refer"
Acute or chronic inflammation of the gastric mucosa.
" Non-steroidal anti-inflammatory drugs (NSAIDS), e.g. acetylsalicylic acid, diclofenac, ibuprofen"
 Regurgitation of bile into the stomach
 Bacterial infection (Helicobacter pylori)
" May be asymptomatic or have associated anorexia, nausea,"
" Peptic and duodenal ulcers, cancer of the stomach"
 Modify diet: avoid precipitating causes and increase
Magnesium trisilicate compound 1-2 tablets every
If no response and no alarm signs
 Omeprazole 20 mg once daily for 8 weeks
"If not responding to 4 weeks of omeprazole, refer"
 Barium meal for chronic gastritis
 Modify diet: Avoid precipitating causes and increase HC2
Magnesium trisilicate compound 2 tablets every 8 HC3
 Omeprazole 20 mg in the evening for 4 weeks
 Metoclopramide 10 mg IM repeated when necessary
 Or chlorpromazine 25 mg deep IM or oral (if tolerated)
 Acetylsalicylic acid and other NSAIDS are contraindicated in
" Avoid spices, tobacco, alcohol, and carbonated drinks"
" Encourage regular, small, and frequent meals"
 Modify diet: Avoid precipitating causes and increase
Magnesium trisilicate compound 2 tablets every 8
 Omeprazole 20 mg in the evening for 4 weeks
 Metoclopramide 10 mg IM repeated when necessary
 Or chlorpromazine 25 mg deep IM or oral (if tolerated)
 Acetylsalicylic acid and other NSAIDS are contraindicated in
Peptic Ulcer Disease (PUD) ICD10 CODE: K27
Ulceration of gastro-duodenal mucosa. It tends to be chronic and recurrent if untreated.
" Drugs (NSAIDS e.g. acetylsalicylic acid, corticosteroids)"
 Epigastric pain typically worse at night and when hungry
"(duodenal ulcer) alleviated by food, milk, or antacid medication"
" Epigastric pain, worse with food (gastric ulcer)"
" Vomiting, nausea, regurgitation"
 Discomfort on palpation of the upper abdomen
 Haematemesis (coffee brown or red vomitus)
" Cold, clammy skin (when patient has lost a lot of blood)"
" Acute abdominal pain, signs of peritonitis such as rigid abdomen"
 Ground coffee-brown vomitus (due to blood)
" Shock (weak pulse, clammy skin, low blood pressure)"
" Disease of aorta, myocardial infarction"
 Positive stool antigen for H. pylori. Used for diagnosis and to
- This test may give false negative if the patient has been taking
antibiotics or omeprazole in the previous 2 weeks
SERUM ANTIBODY TEST IS NOT USEFUL FOR DIAGNOSIS
 Modify diet: avoid precipitating causes and increase HC3
- Magnesium trisilicate compound 2 tablets
 Modify diet: avoid precipitating causes and increase
- Magnesium trisilicate compound 2 tablets
Treatment for eradication of H. pylori (Triple HC3
 Amoxycillin 1 g every 12 hours PLUS metronidazole
400 mg every 12 hours PLUS omeprazole 20 mg
 Check eradication with a stool antigen test after
For bleeding and perforated ulcer
 Refer patient to hospital immediately for
- IV fluids and blood if necessary
- IV ranitidine 50 mg in 20 ml slowly every 8
 Tinidazole 500 mg every 12 hours can be used instead of
 Confirm eradication with stool antigen test a month after
completion of treatment; test should be negative
Chronic Pancreatitis ICD10 CODE: K86.0-K86.1
Chronic pancreatitis is a disease of the pancreas in which recurrent
"episodes of inflammation lead to replacement of the pancreatic parenchyma with fibrotic connective tissue, formation of calculous and loss"
of duct architecture. This leads to progressive loss of pancreas function.
" Toxicmetabolic: alcohol, tobacco, hypercalcemia, hyperlipidemia, chronic renal failure"
 Recurrent and severe acute pancreatitis
 Obstructive cancer or anatomical abnormalities
Treatment for eradication of H. pylori (Triple
 Amoxycillin 1 g every 12 hours PLUS metronidazole
400 mg every 12 hours PLUS omeprazole 20 mg
 Check eradication with a stool antigen test after
For bleeding and perforated ulcer
 Refer patient to hospital immediately for
- IV fluids and blood if necessary
- IV ranitidine 50 mg in 20 ml slowly every 8
 Tinidazole 500 mg every 12 hours can be used instead of
 Confirm eradication with stool antigen test a month after
completion of treatment; test should be negative 
 Chronic pain: main symptom in chronic pancreatitis
Complications of chronic pancreatitis
 Stenosis of the pancreatic duct
 Increased risk of cancer of the pancreas
" Blood: Serum analysis, complete blood count, random blood sugar"
 Raised pancreatic amylaselipase  3 times normal
" Ultrasound: gallstones, pancreatic oedema, abdominal fluid"
 Liver function tests: raised liver enzymes
 Refer for specialist management RR
 Pethidine 50-100 mg IM or Tramadol 50-100
 Refer for specialist management
 Pethidine 50-100 mg IM or Tramadol 50-100
 Avoid alcohol and fatty foods RR
A condition characterised by hardened faeces and difficulty emptying
" Dietary: lack of roughage, inadequate fluid intake"
" Lack of exercise, bedridden patient especially in elderly"
" Certain drugs e.g. narcotic analgesics, antidepressants, diuretics, antipsychotics, iron"
" Colon or anorectal disorders: stricture, cancer, fissure,"
"proctitis, congenital bowel abnormalities, irritable bowel"
"syndrome, volvulus, intussusception"
" Metabolic: hypercalcemia, diabetes, hypothyroidism"
" Neurological disorders: spinal cord lesions, stroke, Parkinsonism"
 Small hard stools passed irregularly under strain
 Can cause haemorrhoids and anal fissure
 Symptoms and signs of intestinal obstruction or acute abdomen
 Rectal bleeding or haematochesia or rectal mass
 Patients  45 years with no previous history of colon cancer screening
 History of colon cancer in immediate family relatives
- Abdominal mass and tenderness
"- Anorectal examination (faecal impaction, stricture, rectal"
Investigations for patients with alarm features
" Abdominal series (supine, upright, left lateral decubitus)"
" Complete blood count, renal function tests, serum calcium,"
"thyroid function tests, blood sugar"
 Barium enema - CT scan or X-ray
No alarm features or chronic constipation HC2
 Bisacodyl: Adult 10 mg at night. Take until stool is
Child 5-12 years: 5 mg (suppository only) H
- Contraindicated in acute abdomen as it
 Oral or rectal lactulose (osmotic agent). Provides
No alarm features or chronic constipation
 Bisacodyl: Adult 10 mg at night. Take until stool is
Child 5-12 years: 5 mg (suppository only)
- Contraindicated in acute abdomen as it
 Oral or rectal lactulose (osmotic agent). Provides
faster relief than bisacodyl HC2
If alarm features or severe chronic constipation HC2
 Refer to hospital for specialist management HC3
 Diet rich in roughage - plenty of vegetables and fruit
 Plenty of oral fluids with meals
Haemorrhoids (Piles) and Anal Fissures
ICD10 CODE: K64K60.0-K60.1-K60.2
Haemorrhoids are swellings in the upper anal canal and lower rectum
due to engorgement of veins. May be internal or external. Anal fissure
is a tear in the lining of the lower rectum.
 Constipation and straining in defecation
 Portal hypertension from any cause
" Compression of pelvic veins, e.g. abdominal tumours,"
" Visible swelling at the anus or prolapse of the swelling, especially at defecation"
 Blood is usually not mixed with stool but instead coats the
surface of the stool or toiletry
 Mucous discharge and irritation at anus
If alarm features or severe chronic constipation
 Refer to hospital for specialist management HC2
" Rectal polyps, prolapsed rectum"
 Anal tags (harmless growths that hang off the skin around
 Visual inspection and digital rectal examination
" Protoscopy, sigmoidoscopy, colonoscopy"
 Increase fibre and fluid diet intake
 Sitz bath (sitting for 10-15 minutes in lukewarm water
with a spoon of salt) 2 or 3 times a day
 Insert a bismuth subgallate compound rectally every
"12 hours for 5 days (e.g. Anusol, Sediproct cream"
 Give metronidazole 400 mg every 8 hours for 5 days
 Give analgesics as required for the pain
 Increase fibre and fluid diet intake
 Sitz bath (sitting for 10-15 minutes in lukewarm water
with a spoon of salt) 2 or 3 times a day
 Insert a bismuth subgallate compound rectally every
"12 hours for 5 days (e.g. Anusol, Sediproct cream"
 Give metronidazole 400 mg every 8 hours for 5 days
 Give analgesics as required for the pain
 Refer to hospital for surgery HC2
 Maintain high residue (fibre) diet
 Refrain from straining and reading in the toilet
A condition characterised by inflammation of the liver due to hepatitis
"viruses. They may cause acute hepatitis, symptomatic or not. The hepatitis B, D, C virus can cause"
chronic hepatitis. The hepatitis B virus can also give chronic carrier status.
 Hepatitis A and E: orofaecal transmission
" Hepatitis B: sexual, mother to child, transmission by infected body fluids blood"
 Hepatitis C virus: contact with infectious blood (possibly
" Hepatitis D: contact with infectious blood, sexual (possibly"
"6.Acute Hepatitis ICD10 CODES: B15, B16, B17, B19"
" Classic form: fever, fatigue, malaise, abdominal discomfort"
"(right upper quadrant), nausea, diarrhoea, anorexia, followed by jaundice, dark urine and more or less clay coloured stool"
" Fulminant form: acute liver failure due to massive liver necrosis, often fatal. It is more common in HepB patients"
with secondary infection with D virus and pregnant women
who get hepatitis E in their third trimester
" Other causes of hepatitis, e.g. drugs, herbs, tumours, and"
" Gastroenteritis, relapsing fever"
" Malaria, leptospirosis, yellow fever"
" Haemorhagic fevers, e.g. Marburg and Ebola"
 Slide or RDT for malaria parasites
" Viral antigens and antibodies: Hepatitis B, Hepatitis C, and"
 Diet: high in carbohydrates and vitamins and vegetable
proteins. Avoid animal proteins e.g.
 Avoid any drug  they may aggravate symptoms Refer
if patient has features of liver failure or decompensated liver disease
 Avoid drugs generally but especially sedatives and hepatotoxic
 Ensure effective infection control measures e.g. institute
"barrier nursing, personal hygiene"
 Patient isolation is not necessary unless there is high suspicion
 Diet: high in carbohydrates and vitamins and vegetable
proteins. Avoid animal proteins e.g.
 Avoid any drug  they may aggravate symptoms Refer
if patient has features of liver failure or decompensated liver disease HC4
 Avoid drugs generally but especially sedatives and hepatotoxic
 Ensure effective infection control measures e.g. institute
"barrier nursing, personal hygiene"
 Patient isolation is not necessary unless there is high suspicion
 Diet: high in carbohydrates and vitamins and vegetable
proteins. Avoid animal proteins e.g.
 Avoid any drug  they may aggravate symptoms Refer
if patient has features of liver failure or decompensated liver disease
 Avoid drugs generally but especially sedatives and hepatotoxic
 Ensure effective infection control measures e.g. institute
"barrier nursing, personal hygiene"
 Patient isolation is not necessary unless there is high suspicion
" Immunization against hepatitis B (all children, health workers, household contacts of people with chronic hepatitis B,"
sex workers and other populations at risk)
 Infection control in health facilities
 Safe sexual practices (condom use)
6.Chronic Hepatitis ICD10 CODE: B18
"The hepatitis viruses B, C and D can give chronic infection"
with chronic low level inflammation of the liver and progressive
damage which may progress to liver cirrhosis.
 Diet: high in carbohydrates and vitamins and vegetable
proteins. Avoid animal proteins e.g.
 Avoid any drug  they may aggravate symptoms Refer
if patient has features of liver failure or decompensated liver disease HC4
 Avoid drugs generally but especially sedatives and hepatotoxic
 Ensure effective infection control measures e.g. institute
"barrier nursing, personal hygiene"
 Patient isolation is not necessary unless there is high suspicion
"ICD10 CODES: 18.0, 18.1, Clinical features"
Can be symptomatic or asymptomatic:
" Weakness and malaise, low grade fever"
" Nausea, loss of appetite and vomiting"
 Pain or tenderness over the right upper abdomen
" Jaundice, dark urine, severe pruritus"
" Complications: liver cirrhosis, hepatocarcinoma"
 Hepatitis B surface antigen positive for 6 months
 Hepatitis B core antibody: Negative IgM and Positive IgG to
exclude acute hepatitis B infection
" Liver tests, repeated at 6 months"
 HBeAg (can be positive or negative)
 APRI (AST to Platelets Ratio Index): a marker for fibrosis
"(ULN: upper limit of normal, usually 40 IUL)"
 Abdominal ultrasound at 4-6 months
" Screen for HIV: if positive, refer to HIV clinic for ART:"
coninfection is a risk factor for disease progression
and some ARVs are active against Hepatitis B virus
 If HIV negative: refer to a regional hospital for specialist management
 Antiviral treatment is given to prevent complications
and it is usually given for life
 Patients with chronic hepatitis B need periodic
monitoring and follow up for life
 Periodic screening for hepatocarcinoma with alfa
fetoprotein and abdominal ultrasound once a year
Treat with antivirals if the patient has any one of these: RR
- All persons with chronic HBV infections who
have cirrhosis (whether compensated or not)
based on clinical findings andor APRI score
"2, irrespective of liver enzyme levels, HbeAg"
status or hepatitis B viral load)
- HIV co-infection (use a tenofovir based
- Patients with no cirrhosis (APRI score 2) but
- persistently elevated ALT on 3 occasion within
"6-12 months and viral load 20,000 IUL (if"
available) regardless of HbeAg status
Adults and children 12 years or 35 kg: tenofovir
Child 2-11 years (10 kg): Entecavir mgkg
" Screen for HIV: if positive, refer to HIV clinic for ART:"
coninfection is a risk factor for disease progression
and some ARVs are active against Hepatitis B virus
 If HIV negative: refer to a regional hospital for specialist management
 Antiviral treatment is given to prevent complications
and it is usually given for life
 Patients with chronic hepatitis B need periodic
monitoring and follow up for life
 Periodic screening for hepatocarcinoma with alfa
fetoprotein and abdominal ultrasound once a year RR
Treat with antivirals if the patient has any one of these:
- All persons with chronic HBV infections who
have cirrhosis (whether compensated or not)
based on clinical findings andor APRI score
"2, irrespective of liver enzyme levels, HbeAg"
status or hepatitis B viral load)
- HIV co-infection (use a tenofovir based
- Patients with no cirrhosis (APRI score 2) but
- persistently elevated ALT on 3 occasion within
"6-12 months and viral load 20,000 IUL (if"
available) regardless of HbeAg status
Adults and children 12 years or 35 kg: tenofovir
Child 2-11 years (10 kg): Entecavir mgkg RR
The following patients should NOT be treated
 Patients without evidence of cirrhosis (APRI 2) and
with persistently normal ALT level and HBV viral
 Mangement is lifelong because of the need to monitor hepatitis
 Urge patient to avoid alcohol as it worsens disease
 Immunisation of household contacts
 Do not share items that the patient puts in mouth (e.g.
"toothbrushes, cutlery) and razor blades"
6.Inactive Hepatitis B Carriers ICD10 CODE: B18.1
Carriers are patients with chronic but inactive infection:
- HBsAg positive for more than 6 months plus
- Persistently normal liver function (at least 3 times in 12
- No evidence of viral replication (negative HBeAg andor
Patients classified as inactive carriers need to be monitored once a year
"with CBC, renal and liver tests, HBsAg, abdominal ultrasound. If possible,"
They are not highly infectious but close contacts should be immunized
and appropriate precautions should be followed.
6.Pregnant Mother HbsAg Positive ICD10 CODE: B18.1
If a pregnant mother is found HBsAg positive:
The following patients should NOT be treated
 Patients without evidence of cirrhosis (APRI 2) and
with persistently normal ALT level and HBV viral
- Child should receive HepB vaccine at birth
"- She should be referred for further testing (HBeAg, HBDNA) to assess the risk of transmission to the baby and"
eventual need of antiretrovirals
- Child should be immunized at birth
Chronic Hepatitis C Infection ICD10 CODE: B18.2
 Can be symptomatic or asymptomatic
 Anti hepatitis C antibody positive at 0 and 6 months
 Refer to a regional hospital or higher for confirmatory RR
"Liver Cirrhosis CICD10 CODES: K74, K70.3"
Cirrhosis is a chronic disease with necrosis of liver cells followed by
fibrosis and nodule formation. Decompensated cirrhosis is defined by
"the presence of complications such as ascites, variceal bleeding, encephalopathy, or jaundice which result from the portal hypertension and liver"
insufficiency caused by cirrhosis.
" Infections e.g. viral hepatitis B and D, hepatitis C"
" Intoxication with alcohol, drugs, or toxins e.g. methotrexate, isoniazid, methyldopa"
 Refer to a regional hospital or higher for confirmatory
investigations and management RR
" Infiltrative disorders, e.g. non-alcoholic fatty liver disease,"
"Wilsons disease, haemochromatosis"
 Iron overload (e.g. in over transfused SCD patients)
" Immunological, chronic autoimmune hepatitis"
 Congestion with bile e.g. primary biliary cirrhosis (PBC)
" Congestion with blood e.g. chronic cardiac failure, Budd"
" General symptoms: Fatigue, weight loss, features of malnutrition, nausea, vomiting and loss of appetite"
 Initially enlarged liver which later decreases in size
 Distension of blood vessels on the abdomen
 Cirrhosis is decompensated when the following are present:
 Ascites (fluid in abdominal cavity) with or without leg oedema
 Vomiting of blood from ruptured blood vessels in oesophagus (varices)
1 Compensated No varices No ascites 1
cirrhosis No varices No ascites 1
Renal failure Hepatocellular carcinoma Jaundice
 Diffuse hepatic parenchymal disease
 Metastatic or multifocal cancer in the liver
" Blood: Hb, film, WBC, platelets, prothrombin time (INR), serology"
"(hepatitis B, C, and D), HIV serology"
" Liver: Liver function tests, alpha fetoprotein, and biopsy"
Refer to a regional hospital or higher for the attention of specialist
 Treat cause and prevent progression
"- If chronic hepatitis B, start antiviral treatment"
- Specific treatment according to the cause
Renal failure Hepatocellular carcinoma Jaundice
 Treat cause and prevent progression
"- If chronic hepatitis B, start antiviral treatment"
- Specific treatment according to the cause RR
- Avoid herbs and self medication RR
- Use medicines only after prescription from a
 Manage and prevent complications (see below)
 Treat cause and prevent progression
"- If chronic hepatitis B, start antiviral treatment"
- Specific treatment according to the cause
- Avoid herbs and self medication
-  Use medicines only after prescription
 Manage and prevent complications (see below)
"6.Ascites ICD10 CODES: 70.31, 70.11, Pathological accumulation of fluid in the peritoneal cavity."
 Ascites not infected and not associated with hepatorenal
Grade 1 Ascites Only detectable by ultrasound exam-
- Avoid herbs and self medication
- Use medicines only after prescription from a
 Manage and prevent complications (see below)
 Treat cause and prevent progression
"- If chronic hepatitis B, start antiviral treatment"
- Specific treatment according to the cause
- Avoid herbs and self medication
-  Use medicines only after prescription
 Manage and prevent complications (see below)
(mild) Only detectable by ultrasound examination
Grade 2 Ascites Ascites causing moderate symmetrical
(moderate) distension of the abdomen
Grade 3 Ascites Ascites causing marked abdominal dis-
"The main principles of management are: diet modification, daily monitoring, diuretics and drainage"
 Restrict dietary salt to a no-add or low salt diet
 Avoid protein malnutrition (associated with higher
"mortality), so consume plant proteins liberally and"
animal proteins occasionally (titrate to symptoms and
signs of hepatic encephalopathy)
 Restrict water if oedema and hyponatremia are present
" Abstain from alcohol, NSAIDS, herbs"
" Daily weight, BP, pulse, stool for melaena, encephalopathy"
(moderate) Ascites causing moderate symmetrical
(severe) Ascites causing marked abdominal distension
 Restrict dietary salt to a no-add or low salt diet
 Avoid protein malnutrition (associated with higher
"mortality), so consume plant proteins liberally and"
animal proteins occasionally (titrate to symptoms and
signs of hepatic encephalopathy)
 Restrict water if oedema and hyponatremia are present
" Abstain from alcohol, NSAIDS, herbs"
" Daily weight, BP, pulse, stool for melaena, encephalopathy H"
" Use spironolactone 50-100 mgday in the morning,"
to reach goal of weight loss: 300500 g day. If
"needed, doses to be increased every 7 days up to"
maximum of 400 mgday of spironolactone
 Furosemide can be added at a starting dose of 2040
mgday and subsequently increased to 160 mgday
if needed. Best used if pedal oedema is present;
" For maintenance, it is best to titrate to the lowest"
diuretic dose. Most patients do well with
spironolactone 50 mgday if they have no ascites
 Indicated for severe ascites (Grade 3). Paracentesis
is always followed by spironolactone
- Small volume (less than 5 L in 34 hours)
or large volume (510 L) with infusion of a
plasma expander (e.g. 8 g albumin per litre of
- Monitor for hypotension or reduced urine
 Refer if patient has or develops complicated ascites
6.Spontaneous Bacterial Peritonitis (SBP)
SBP is an acute bacterial infection of ascitic fluid. It is a common and
severe complication of advanced liver cirrhosis and it is associated with
" Use spironolactone 50-100 mgday in the morning,"
to reach goal of weight loss: 300500 g day. If
"needed, doses to be increased every 7 days up to"
maximum of 400 mgday of spironolactone
 Furosemide can be added at a starting dose of 2040
mgday and subsequently increased to 160 mgday
if needed. Best used if pedal oedema is present;
" For maintenance, it is best to titrate to the lowest"
diuretic dose. Most patients do well with
spironolactone 50 mgday if they have no ascites
 Indicated for severe ascites (Grade 3). Paracentesis
is always followed by spironolactone 
- Small volume (less than 5 L in 34 hours)
or large volume (510 L) with infusion of a
plasma expander (e.g. 8 g albumin per litre of
- Monitor for hypotension or reduced urine
 Refer if patient has or develops complicated ascites 
Patients must be admitted to hospital and should be suspected of SBP
" Abdominal pain, abdominal tenderness"
" Complications: renal failure, bleeding varices, death"
 Diagnosis is confirmed by an ascitic tap and cell counts. A neutrophil count of  250mm3 in ascitic fluid confirms the diagnosis
 Treat with IV antibiotics for 510 days H
"- If needed, add metronidazole 500 mg IV every"
 Give albumin infusion 1 gkg to prevent hepato- RR
 Consult or refer for specialist care as soon as possible
"ICD10 CODES: 70.41, 71.11, 72.11, Hepatic encephalopathy is a syndrome of neuropsychiatric symptoms and"
"signs, including coma, observed in patients with cirrhosis. It is probably"
due to the accumulation of toxins in the blood.
 Treat with IV antibiotics for 510 days
"- If needed, add metronidazole 500 mg IV every"
 Give albumin infusion 1 gkg to prevent hepatorenal syndrome
 Consult or refer for specialist care as soon as possible RR
"ICD10 CODES: 70.41, 71.11, 72.11, Hepatic encephalopathy is a syndrome of neuropsychiatric symptoms and"
"signs, including coma, observed in patients with cirrhosis. It is probably"
due to the accumulation of toxins in the blood.
" Grade 0: Subclinical  personaity changes, construction"
"apraxia (inability or difficulty to build, assemble, or draw"
" Grade I: Confusion, flap tremor"
" Encephalopathy may be aggravated by surgery, parencentsis, excessive diuretics, sedatives, and opioid analgesics"
 Intracranial hypertension and sepsis are the main causes
Management involves addressing the pathophysiological mechanisms
"related to brain, gut and liver"
 dentify and correct precipitating factors including renal H
"impairment, gastrointestinal bleeding, infections, and"
- Give oral lactulose 15-30 mL every 8 hours until
the condition resolves (aim at 2-3 soft stools
 dentify and correct precipitating factors including renal
"impairment, gastrointestinal bleeding, infections, and"
- Give oral lactulose 15-30 mL every 8 hours until
the condition resolves (aim at 2-3 soft stools
- Lactulose can be administered through a
nasogastric tube (grade 1 and 2) or as an enema
in patients with acute HE (grade 3 and 4)
 Give an antibiotic with a local action on the gut: oral
metronidazole 400800 mg every 8 hours for 5 days
 Or oral paromomycin 1000 mg every 6 hours for 5 days
6.Oesophageal Varices ICD10 CODE: I85.1
"Extremely dilated sub-mucosal veins in the lower third of the esophagus, due to portal hypertension caused by liver cirrhosis. They can"
cause severe upper gastrointestinal bleeding.
 Screen patients with liver cirrhosis with endoscopy to H
" In case of varices, consider the use of beta blockers to"
"- Propranolol 20 mg every 12 hours, titrate to"
keep resting heart rate at 55-60 bpm
- Avoid in refractery ascitis and SBP
 Endoscopic ligation sclerotherapy NR
" If acute bleeding, see section CHAPTER"
- Lactulose can be administered through a
nasogastric tube (grade 1 and 2) or as an enema
in patients with acute HE (grade 3 and 4)
 Give an antibiotic with a local action on the gut: oral
metronidazole 400800 mg every 8 hours for 5 days
 Or oral paromomycin 1000 mg every 6 hours for 5 days RR
 Screen patients with liver cirrhosis with endoscopy to
" In case of varices, consider the use of beta blockers to"
"- Propranolol 20 mg every 12 hours, titrate to"
keep resting heart rate at 55-60 bpm
- Avoid in refractery ascitis and SBP H
 Endoscopic ligation sclerotherapy
" If acute bleeding, see section NR"
6.Hepatorenal Syndrome ICD10 CODE: K76.7
Hepatorenal syndrome (HRS) is the development of renal failure in
patients with advanced chronic liver disease. It
can be precipitated by infection (SBP) and large volume paracentesis
without albumin replacement. It carries a very poor prognosis.
 Reduced urinary output ( 500 ml in 24 hours in adults)
 Abnormal renal function test (progressively raising creatinine)
 Refer for specialised management
6.Hepatocellular Carcinoma ICD10 CODE: C22.0
Liver cancer usually in patients with risk factors such as Hepatitis B and
"C, aflatoxin, alcoholic liver disease and cirrhosis."
" Presents with right upper quadrant pain, hepatomegaly"
" Jaundice, ascites, and lymphadenopathy"
 Refer for specialised management H
 Abdominal ultrasound ( sonogram)
 Refer to a regional hospital or higher RR
Hepatic Schistosomiasis ICD10 CODE: B65.1
Most common cause of liver disease among communities where Schistosoma mansoni is endemic (see section 2)
 Inflammatory and fibrotic reaction to eggs laid by Schistosoma parasites and transported to the liver through the
 Upper gastrointestinal bleeding due to varices or portal hypertensive gastropathy
 Splenomegaly and ruptured spleen
" Bloody diarrhoea, anaemia and stunting"
 Liver ultrasound features: periportal fibrosis patterns and portal vein thickening as described by World Health Organization
 Screen for varices with endoscopy
 Refer to a regional hospital or higher RR
 Praziquantel 40 mgkg single dose if schistosoma eggs
 Surveillance for oesophageal varices with endoscopy
" Primary and secondary prevention of bleeding oesophageal varices with propranolol (see section 6.5.4.4),"
 Treat acute upper gastrointestinal bleeding (see section
Drug-Induced Liver Injury ICD10 CODE: K71
Drugs are an important and common cause of liver injury. Many medicines and herbs are known to cause liver damage. The drug-induced
liver injury can range from asymptomatic elevation of liver enzymes to
severe hepatic failure. Health workers must be vigilant in identifying
drug-related liver injury because early detection can decrease the severity
of hepatotoxicity if the drug is discontinued. Knowledge of the commonly
implicated agents is essential in diagnosis.
" Phenytoin, carbamazepine, anti-tuberculosis drugs, cotrimoxazole, diclofenac, paracetamol, antiretroviral drugs,"
It is a diagnosis of exclusion:
" Any patient with liver enzyme elevation that cannot be attributed to infections, autoimmune disease or malignancy"
 Praziquantel 40 mgkg single dose if schistosoma eggs
 Surveillance for oesophageal varices with endoscopy
" Primary and secondary prevention of bleeding oesophageal varices with propranolol (see section 6.5.4.4),"
 Treat acute upper gastrointestinal bleeding (see section
 Patient exposed to a drug or herbal medication known to
 Patients may present with skin or mucosal drug reactions
 e.g. Stevens-Johnson syndrome or toxic epidermal necrolsis
 Give supportive care: rehydration
 See section for paracetamol poisoning
 Do not give the drug again (do not rechallenge!)
 Refer to a regional hospital or higher for attention of
Jaundice (Hyperbilirubinemia) ICD10 CODE: R17
Yellowish discoloration of sclera and skin due to raised levels of bilirubin
"in the body. Bilirubin is a by-product of red cell breakdown, processed"
in the liver and excreted mainly in bile. Jaundice may be benign or life
" Pre hepatic  haemolysis e.g sepsis, sickle cell disease,"
"pregnancy (HELLP syndrome), disseminated intravascular"
" Hepatic  hepatitis, drugs, tumors, alcohol, toxins, herbs,"
"autoimmune disease, pregnancy, cholangitis"
" Post hepatic  gall stones, strictures, tumors, surgery, pancreatitis, biliary disease"
 Give supportive care: rehydration
 See section for paracetamol poisoning
 Do not give the drug again (do not rechallenge!)
 Refer to a regional hospital or higher for attention of
" Liver function tests (AST, ALT, bilirubin), Coombs tests,"
 Ultrasound shows dilated bile ducts and gall bladder
" CBC, INR, RFTS, LDH, Endoscopic retrograde cholangiopancreatogram (ERCP)"
 Refer andor consult as appropriate H
 Treat the underlying cause f Discontinue offfending
 Use phototherapy with UV light for newborn babies
OR expose the newborn to natural sun
GallstonesBiliary Colic ICD10 CODES: K80
Small hard masses formed in the gallbladder or biliary tree.
" Obesity, diabetes, use of oral contraceptives, dyslipidemia"
 Asymptomatic and often found by chance at an abdominal
 Biliary colic: episodes of intense acute epigastric right hypocondrial pain (due to acute temporary blockage of a bile
"duct) lasting few minutes to few hours, often triggere by a"
high-fat meal. It can occur sporadically. NO fever or jaundice are present.
 Cholecystitis or cholangitis due to blockage and infection
 Pancreatitis due to blockage of the pancreatic duct
 Refer andor consult as appropriate
 Treat the underlying cause f Discontinue offfending
 Use phototherapy with UV light for newborn babies
OR expose the newborn to natural sun H
 Does not require any intervention
 Diclofenac 75 mg IM andor f Pethidine 50-100 mg IM
" Low-fat diet, Weight management"
 Refer for cholecystectomy after acute phase
Acute CholecystitisCholangitis ICD10 CODES: K81
Inflammation of the gall bladder andor of the biliary tract. It often
 Obstruction of gall bladder duct by gall stones (calculi)
" May occur after major trauma, burns, or surgery"
 Occurs in HIV infected persons as acalculous cholecystitis
 Sudden onset of pain and tenderness in the right upper
quadrant of the abdomen; worsens on deep breathing
 Does not require any intervention
 Diclofenac 75 mg IM andor f Pethidine 50-100 mg IM
" Low-fat diet, Weight management"
 Refer for cholecystectomy after acute phase HC4
Severity of acute cholecystitis is classified into:
Grade I (mild acute Associated with no organ dysfunction and limited
"disease in the gallbladder, making cholecystectomy"
"Grade II (moderate Associated with no organ dysfunction, but with"
"acute cholecystitis) extensive disease in the gallbladder, resulting in"
difficulty in safely performing a cholecystectomy
- An elevated white blood cell count
"- A palpable, tender mass in the right"
- Disease duration of more than 72
- Imaging studies indicating significant
Acute cholecystitis with organ dysfunction (shock)
" X-ray, abdominal ultrasound: findings are wall thickening  stone"
" Blood: Haemogram, liver tests, pancreatitis. Findings are: fever,"
 Enzymes and renal function tests
cholecystitis) Associated with no organ dysfunction and limited
"disease in the gallbladder, making cholecystectomy"
"acute cholecystitis) Associated with no organ dysfunction, but with"
"extensive disease in the gallbladder, resulting in"
difficulty in safely performing a cholecystectomy
- An elevated white blood cell count
"- A palpable, tender mass in the right"
- Disease duration of more than 72
- Imaging studies indicating significant
Acute cholecystitis with organ dysfunction (shock)
 Relieve pain: Pethidine 50100 mg IM every 6 hours
 Rehydrate with IV fluids and electrolytes e.g. RR
 Refer to hospital within 23 days for surgery (cholecystectomy)
" In cholangitis, if not better refer for urgent surgical"
 Relieve pain: Pethidine 50100 mg IM every 6 hours
 Rehydrate with IV fluids and electrolytes e.g.
 Refer to hospital within 23 days for surgery (cholecystectomy)
" In cholangitis, if not better refer for urgent surgical"
Acute Renal Failure ICD10 CODE: N17
Acute impairment of renal function
" Compromised renal perfusion e.g. dehydration, heart failure, shock (acute)"
 Damage to renal tissue by infectious and inflammatory
"dieases (e.g. glomerulonephritis), intoxications, nephrotoxic drugs"
 Oliguria (urine flow 1 mlkghour)
" Hypertension, heart failure, dyspnoea"
" Urine analysis: for blood, proteins, leucocytes, casts"
" Urea, creatinine and electrolytes"
 Management of acute kidney condition can be started at
hospital level but the patient should be referred at higher
level for more appropriate management:
 Treat underlying conditions e.g. dehydration HC4
- Daily fluid requirements  10 mlkg  total of
"losses through urine, vomitus and diarrhoea"
 Restrict salt intake (2 g or half teaspoonful daily)
" Restrict potassium intake e.g. oranges, bananas, vegetables, meat, fizzy drinks"
 Ensure adequate calories in diet f Check urine and
electrolytes frequently f Treat any complications (e.g. RR
"hypertension, convulsions), adjusting drug dosages according"
to the clinical response where appropriate
" If oliguria, furosemide IV according to response (high"
"If no response to above general measures, worsening kidney"
function or anuria (urine output less than 100 ml24 hours)
 Treat underlying conditions e.g. dehydration
- Daily fluid requirements  10 mlkg  total of
"losses through urine, vomitus and diarrhoea"
 Restrict salt intake (2 g or half teaspoonful daily)
" Restrict potassium intake e.g. oranges, bananas, vegetables, meat, fizzy drinks"
 Ensure adequate calories in diet f Check urine and
electrolytes frequently f Treat any complications (e.g.
"hypertension, convulsions), adjusting drug dosages according"
to the clinical response where appropriate
" If oliguria, furosemide IV according to response (high"
"If no response to above general measures, worsening kidney"
function or anuria (urine output less than 100 ml24 hours) HC4
 Refer for specialist management including possible HC4
dialysis as soon as possible and before the patients
 Do not give any drugs which may make kidney
damage worse e.g. use gentamicin with caution
Chronic Kidney Disease (CKD) ICD10 CODE: N18
Chronic impairment of kidney function
 Hypertensioncardiovascular disease
" Drugs especially pain killers like diclofenac, ibuprofen and"
 Family history of kidney disease
 Most patients with CKD have no symptoms until the disease is advanced
 May present with features of predisposing risk factor
" Anaemia, lethargy, easy fatigue, appetite loss, nausea,"
"vomiting, skin itching, bone pains"
 Refer for specialist management including possible
dialysis as soon as possible and before the patients
 Do not give any drugs which may make kidney
damage worse e.g. use gentamicin with caution 
 Other causes of chronic anaemia
 Urine dip stick for protein and blood
How to screen for CKD in patient at risk
 Urine dipsticks (for protein and blood) and blood pressure
measurement at least once a year in high risk patients
" In diabetics, urine microalbumin where possible or a spot"
urine for protein: creatinine ratio at least once a year
 Patients with detected abnormalities should have a serum
creatinine test performed and GFR calculated as suggested
Refer the following patients for specialist attention:
 Persistent proteinuria or haematuria beyond 3 months
 GFR 60 mlmin or creatinine mgdl
" Familial kidney disease, e.g. polycystic kidney disease"
"Treatment of end stage renal disease is complex and expensive, and"
available only at national referral hospital
 Establish diagnosis and treat reversible diseases
 Identify co-morbid conditions and manage further complications of CKD
 Slow progression of CKD by optimizing treatment
 Plan renal replacement therapy well before end stage kidney disease is reached
Treatment to preserve kidney function in patients with HC4
" Lifestyle modifications: Weight loss, stop smoking, exercise, healthy balanced diet, lipid control, salt"
 Blood pressure control: Target 13080 mmHg (lower
"in children). Use ACE inhibitors as first line antihypertensives for diabetics and patients with proteinuria,"
 In diabetics: BP control is paramount
 Optimal blood sugar control (HbA1C 7)
 Proteinuria: Reduce using ACE inhibitors andor
" Avoid nephrotoxic medicines, e.g. NSAIDs,"
"celecoxibs, aminoglycosides, contrast agents HR"
 Anaemia: due to multiple causes. Consider iron and
folic supplements. Target Hb 11-12 grdL
 Bone mineral disease: consider adding calcium
Treatment to preserve kidney function in patients with
" Lifestyle modifications: Weight loss, stop smoking, exercise, healthy balanced diet, lipid control, salt"
 Blood pressure control: Target 13080 mmHg (lower
"in children). Use ACE inhibitors as first line antihypertensives for diabetics and patients with proteinuria,"
 In diabetics: BP control is paramount
 Optimal blood sugar control (HbA1C 7)
 Proteinuria: Reduce using ACE inhibitors andor
" Avoid nephrotoxic medicines, e.g. NSAIDs,"
"celecoxibs, aminoglycosides, contrast agents"
 Anaemia: due to multiple causes. Consider iron and
folic supplements. Target Hb 11-12 grdL
 Bone mineral disease: consider adding calcium
" If fluid retentionoliguria, furosemide tablet according"
to response (high doses may be necessary)
 Start ACE inhibitors at low doses and monitor renal function
 Screening of high risk patients
 Optimal treatment of risk factors
 Treatments to slow progression in initial phases
 Be very careful when prescribing any medicine and check
available prescribing information (e.g. in Practical Guidelines for Dispensing 2015) regarding use in renal failure
 Many medicines are excreted through the kidneys and acc
mulate when urinary output is reduced
 Some drugs are presented as sodium or potassium salts
and contribute to accumulation of these electrolytes
" With life-threatening infections (e.g. meningitis), use normal"
"or high doses of antibiotics initially, and then reduce doses"
once the condition has responded
Drugs which are usually safe fDoxycycline
 Benzylpenicillin (max 6 g daily in severe impairment)
" If fluid retentionoliguria, furosemide tablet according"
to response (high doses may be necessary)
 Start ACE inhibitors at low doses and monitor renal function 
Drugs to use with care in reduced doses
ACE inhibitors (e.g. captopril)
 Chloramphenicol (avoid in severe impairment)
 Ciprofloxacin r Cotrimoxazole r Diazepam
" Pethidine (increase dose interval, avoid in severe impairment)"
" Acetylsalicylic acid (aspirin) and other NSAIDS e.g. ibuprofen,"
Glomerulonephritis ICD10 CODE: N00-N01
Acute inflammation of the renal glomeruli (small blood vessels in the kidney)
 Immune reactions often following an infection - usually 1-5
weeks after a streptococcal skin or throat infection
 Common in children 3 years and adolescents
" Haematuria (red, or tea-coloured urine)"
" Oedema: Puffiness of the facearound the eyes, less commonly generalised body swelling"
 Discomfort in the kidney area (abdominal or back pain)
" High blood pressure for age, commonly presenting as"
"headaches, visual disturbances, vomiting, and occasionally"
 Convulsions (in hypertensive crisis)
 Oliguria (passing little urine) as renal failure sets in
 Evidence of primary streptococcal infection:
 Usually as acute tonsillitis with cervical adenitis
" Kidney infections e.g. TB, pyelonephritis"
" Urine: Protein, microscopy for RBCs and casts, WBCs"
" Blood: Urea (uraemia) and creatinine levels, ASOT, electrolytes"
"Inflammatory kidney disease with oedema, hypertension and oliguria"
should be referred to regional hospital for specialised management.
" Monitor urine output, BP, daily weight H"
 Restrict fluid input (in oliguria)
 Restrict salt and regulate protein in the diet (in oliguria)
 Avoid or use with caution any drugs excreted by the
 Treat any continuing hypertension (see section 4.1.6)
 Treat primary streptococcal infection (10-day course):
ph noxymethylpenicillin 500 mg every 6 hours
 Or Amoxicillin 500 mg every 8 hours for 10 days
 Erythromycin 500 mg every 6 hours for 10 days
 Furosemide 80 mg IV (slow bolus)
 Furosemide 80 mg IV (slow bolus)
 Nifedipine 20 mg every 12 hours
" Monitor urine output, BP, daily weight"
 Restrict fluid input (in oliguria)
 Restrict salt and regulate protein in the diet (in oliguria)
 Avoid or use with caution any drugs excreted by the
 Treat any continuing hypertension (see section 4.1.6) H
 Treat primary streptococcal infection (10-day course):
ph noxymethylpenicillin 500 mg every 6 hours
 Or Amoxicillin 500 mg every 8 hours for 10 days
 Erythromycin 500 mg every 6 hours for 10 days
 Furosemide 80 mg IV (slow bolus)
 Furosemide 80 mg IV (slow bolus)
 Nifedipine 20 mg every 12 hours
 Treat throat and skin infections promptly and effectively
 Adequate ventilation in dwellings
Nephrotic Syndrome ICD10 CODE: N04
Disorder characterised by loss of protein in the urine due to damage of
the kidney. It is common in children.
 Idiopathicunknown (majority of cases)
" Secondary: Due to post-streptococcal acute glomerulonephritis, malaria, allergy, UTI, hepatitis B, HClinical features"
 Severe loss of protein in urine (proteinuria)
 Low protein (albumin) levels in the blood serum (hypoalbuminaemia)
 Hyperlipidaemia (high blood cholesterol)
 As for Acute glomerulonephritis plus
 24-hour urine protein quantification or Albumin creatinine ratio
 Malnutrition with oedema e.g. kwashiorkor
 Allergic states causing generalised body swelling
" Restrict salt intake (2 g daily, i.e. less than a half H"
- Both salt and waterfluid intake should be
moderated until diuresis is induced and swelling
"is subsiding, which can take several weeks"
 Furosemide 40-80 mg each morning to induce diuresis
Child: 1-2 mgkg per dose (but see notes below)
 Prednisolone 2 mgkg daily (max: 60 mg)
- Continue until no further proteinuria (around 6
- Gradually reduce the dose after the first 4
"weeks,e.g. reduce by mgkg per day each"
When oedema has subsided and if still hypertensive
 Give appropriate treatment (see section 4.1.6)
If clinical signs ofsuspected streptococcal infection:
 Give antibiotic as in Acute glomerulonephritis
If patient from area of endemic schistosomiasis
 Praziquantel 40 mgkg single dose
If no improvement after 4 weeks or patient relapses
"An infectioninflammation involving the bladder, a part of the lower urinary tract. It is a common manifestation of uncomplicated UTI (Urinary"
Tract Infection) in non- pregnant women.
" Restrict salt intake (2 g daily, i.e. less than a half"
- Both salt and waterfluid intake should be
moderated until diuresis is induced and swelling
"is subsiding, which can take several weeks"
 Furosemide 40-80 mg each morning to induce diuresis
Child: 1-2 mgkg per dose (but see notes below)
 Prednisolone 2 mgkg daily (max: 60 mg)
- Continue until no further proteinuria (around 6
- Gradually reduce the dose after the first 4
"weeks,e.g. reduce by mgkg per day each"
When oedema has subsided and if still hypertensive
 Give appropriate treatment (see section 4.1.6)
If clinical signs ofsuspected streptococcal infection:
 Give antibiotic as in Acute glomerulonephritis
If patient from area of endemic schistosomiasis
 Praziquantel 40 mgkg single dose
If no improvement after 4 weeks or patient relapses
Uncomplicated cystitis is less common in men and needs to be differentiated from prostatitis and urethritis (sexually transmitted).
" Bacterial infection, usually gram negative (from intestinal"
 Dysuria (pain and difficulty in passing urine)
" Urgency of passing urine, frequent passing of small"
 Pyuriahaematuria (pusblood in the urine makingit cloudy)
 There may be retention of urine in severe infection
" Midstream urine: urine analysis for protein, blood, leucocytes,"
 Culture and sensitivity (if resistantrepeated infections)
Symptoms  leucocytes and or nitrates at urine analysis
" Men: urethritis (in young sexually active patients), prostatitis (fever, chills, malaise, perineal pain, confusion, in older"
Note: Asymptomatic bacteriuria or pyuria (leucocytes in urine) does not need
"treatment except in risk groups such as pregnant women, patients undergoing"
urological interventions and post kidney transplant patients
Uncomplicated UTI (cystitis) in non-pregnant women HC2
 Nitrofurantoin 100 mg 6 hourly for 5-7 daysadvise
Child: 3 mgkgday 6 hourly for 7 days
 Ciprofloxacin 500 mg 12 hourly for 7 days (adults)
Children: amoxicillin 125-250 mg 8 hourly for 7 days
If poor response or recurrent infections
 Refer for investigation of culture and sensitivity and
" For urinary tract infection in pregnancy, see section Prevention"
 Improved personalgenital hygiene
Acute Pyelonephritis ICD10 CODE: N10
Upper urinary tract infection involving one or both kidneys (but not
usually involving the glomeruli)
" Bacterial infection, e.g. Escherichia coli, usually due to ascending infection (faecal-perineal-urethral progression of"
Uncomplicated UTI (cystitis) in non-pregnant women
 Nitrofurantoin 100 mg 6 hourly for 5-7 daysadvise
Child: 3 mgkgday 6 hourly for 7 days
 Ciprofloxacin 500 mg 12 hourly for 7 days (adults)
Children: amoxicillin 125-250 mg 8 hourly for 7 days
If poor response or recurrent infections
 Refer for investigation of culture and sensitivity and
" For urinary tract infection in pregnancy, see section Risk factors"
" Loin pain, tenderness in one or both kidney areas (renal"
" Fever, rigors (generalised body tremors)"
" If associated cystitis: dysuria, urgency, frequency"
 Diarrhoea and convulsions (common in children)
 In infants and elderly: may simply present as fever and poor
feedingdisorientation without other signs
 Infection of the fallopian tubes (salpingitis)
 Infection of the gall bladder (cholecystitis)
" Urine: Microscopy for pus cells and organisms, CS of midstream urine"
 Specimen should reach the lab within 2 hours of collection or be
refrigerated at 4C for not 24 hours
" Blood: Full count, CS, urea, electrolytes"
 Ensure adequate intake of fluid (oral or IV) to irrigate HC3
bladder and dilute bacterial concentrations
 Give paracetamol 1 g every 6-8 hours for pain and fever
 Ciprofloxacin 500 mg every 12 hours for 10-14 days
"In severe cases, all children or if no response to above in 48"
Child: 50-80 mgkg IV once a day
Following initial response to parenteral therapy
- Ciprofloxacin 750 mg every 12 hours to
- Or cefixime 200 mg every 12 hours to complete
Child: 16 mgkg the first day then 8 mgkg to complete 10 days
 Gentamicin 5-7 mgkg IV in one or divided doses HC2
with or without ampicillin 2 g IV every 6 hours Child: gentamicin mgkg every 8 hours (or mgkg
once daily on outpatient basis) with or without ampicillin
 Consider referral if there is no response in 72 hours
and for children with recurrent infections (to exclude
 Ensure adequate intake of fluid (oral or IV) to irrigate
bladder and dilute bacterial concentrations
 Give paracetamol 1 g every 6-8 hours for pain and fever
 Ciprofloxacin 500 mg every 12 hours for 10-14 days
"In severe cases, all children or if no response to above in 48"
Child: 50-80 mgkg IV once a day
Following initial response to parenteral therapy
- Ciprofloxacin 750 mg every 12 hours to
- Or cefixime 200 mg every 12 hours to complete
Child: 16 mgkg the first day then 8 mgkg to complete 10 days
 Gentamicin 5-7 mgkg IV in one or divided doses
with or without ampicillin 2 g IV every 6 hours Child: gentamicin mgkg every 8 hours (or mgkg
once daily on outpatient basis) with or without ampicillin
 Consider referral if there is no response in 72 hours
and for children with recurrent infections (to exclude
urinary tract malformations) HC2
 Ensure regular complete emptying of the bladder andor double
voiding (additional attempt to empty bladder after initial urine flow
"Acute inflammationinfection of the prostate, a gland present in the male"
"and located below the bladder, around the proximal urethra."
 Bacterial infection as for UTClinical features
" Rectal, perineal and low back pain"
" Urinary urgency, frequency and dysuria"
 May cause acute urinary retention
 At rectal examination: tender enlarged prostate (avoid vigorous examination)
" IV fluids, antipyretics, bed rest HC4"
 Ciprofloxacin 500 mg 12 hourly for 4-6 weeks
" IV fluids, antipyretics, bed rest"
 Ciprofloxacin 500 mg 12 hourly for 4-6 weeks HC4
Acute severe pain in the loin (kidney area) as a result of obstruction of
" Acute, severe, colicky loin pain often radiating to the iliac"
"fossa, testes, or labia of the same side"
 Lower UT Acute upper UT Other causes of acute abdominal pain
 Plain abdominal X-ray: for radio-opaque stones
 Oral or IV fluids to mantain hydration HC4
 Antiemetics if necessary e.g. metoclopramide 10 mg
IM or  Diclofenac 75 mg IM single dose andor
 Pethidine 50-100 mg IM single dose
Refer if repeated episodesunresolving episode.
 Oral or IV fluids to mantain hydration
 Antiemetics if necessary e.g. metoclopramide 10 mg
IM or  Diclofenac 75 mg IM single dose andor
 Pethidine 50-100 mg IM single dose
Refer if repeated episodesunresolving episode. HC4
 Ensure oral fluid intake of 3-4 Lday
 Reduce salt intake and animal protein
Benign Prostatic Hyperplasia ICD10 CODE: N40
Enlargement of the prostate causing urinary symptoms. Common in
" Benign growth of prostate size, age related"
" Obstructive symptoms: weak urine stream, straining at mi"
"turition, hesitancy, intermittency, sensation of incomplete"
 Irritative symptoms: frequent micturition especially during
"the night, urgency, urge incontinence"
" Complications: acute urinary retention, frequent infections"
" Urine analysis (blood, leucocytes)"
 Treat with antibiotics if infection present (see prostatitis HC2
or acute cystitis in previous section 7.2.3)
 Surgical management if severe symptoms
 Treat with antibiotics if infection present (see prostatitis
or acute cystitis in previous section 7.2.3)
 Surgical management if severe symptoms HC2
"Obstruction of urinary tract anywhere below the bladder, causing distension and incomplete emptying of the bladder. It can be acute (Acute"
 Pelvic masses (rarely pregnancy)
 Infections can precipitate acute retention
 Chronic obstruction can cause hydronephrosis and chronic
" Acute: painful and tender pelvic mass, difficulty in passing"
" Chronic: obstructive and irritative symptoms (see BPH),"
 Other specialised investigations (Cystourethrogram)
 Urethral catheter to relieve obstruction ( 18 F) HC4
 Suprapubic catheter if urethral fails RR
 Refer to specialist for assessmentcare
 Urethral catheter to relieve obstruction ( 18 F)
 Suprapubic catheter if urethral fails
 Refer to specialist for assessmentcare HC4
Urine Incontinence ICD10 CODE: N39.3-4
 Pelvic floor muscles dysfunction (e.g. following pregnancy):
"stress incontinence (at strains like coughing, sneezing)"
 Overactive bladder: urge incontinence (sudden compelling
"need to urinate, difficult to defer)"
" Anatomical problems: continuous incontinence (VVF, ectopic ureter)"
 Chronic bladder outlet obstruction: overflow incontinence
 Careful history and examination
 Stress incontinence: pelvic floor exercises HC2
 Other: specific according to the cause H
 Stress incontinence: pelvic floor exercises
 Other: specific according to the cause HC2
Endocrine and Metabolic Diseases
Addisons Disease ICD10 CODE: E27.1-4
A condition where the adrenal gland produces insufficient glucocorticoid hormones (adrenal insufficiency)
 More common: abrupt cessation of steroid treatment after
 Autoimmune (self destruction of the gland)
" Surgical adrenal removal, cancer affecting adrenal glands,"
"bleeding into the adrenals, necrosis of the adrenals"
 Weakness and fatigability (getting tired easily)
" Mental changes, e.g., irritability and restlessness until coma"
" Fever, hyponatremia (low Na), hyperkalemia (high K), acidosis"
" As above plus weight loss, hair loss"
 Darkening of the skin and mouth
 Menstrual disturbance and infertility
" Symptoms are worse in situations of stress (e.g., infections)"
 Refer at higher level for hormone tests if no clear history of
abrupt withdrawal of steroid treatment
" Hydrocortisone 100 mg IV 6 hourly until stable, then"
 IV fluids and dextrose to maintain normal volume and
 Treat complicationsconcomitant illnesses (e.g. infections)
" If history of abrupt steroid cessation, restart prednisolone"
"treatment, and slowly decrease it by 2.5-5 mg per week"
 Replacement treatment with prednisolone (5-mgday)
" Use doses as in acute regimens in case of stress (e.g.,"
" Avoid self medication with steroids (prednisolone, dexamethasone)"
 Decrease steroids gradually if used for treatment durations
longer than 2 weeks (see above)
" Hydrocortisone 100 mg IV 6 hourly until stable, then"
 IV fluids and dextrose to maintain normal volume and
 Treat complicationsconcomitant illnesses (e.g. infections) H
" If history of abrupt steroid cessation, restart prednisolone"
"treatment, and slowly decrease it by 2.5-5 mg per week"
 Replacement treatment with prednisolone (5-mgday)
" Use doses as in acute regimens in case of stress (e.g.,"
Cushings Syndrome ICD10 CODE: E24
Constellation of signs and symptoms caused by chronic glucocorticoid
"(steroid) excess, from excessive secretion or, more commonly, from"
chronic glucocorticoid therapy.
" Adrenal adenoma, adrenal carcinoma"
" Central (truncal) obesity, moon face, buffalo hump"
" Poor wound healing, muscle weakness and atrophy"
 Hypertension and hyperglycaemia
 Alcoholism (alcohol-induced pseudo-Cushings syndrome)
 Refer to higher level for hormonal tests (dexamethasone suppression test) if no history of steroid overuse
 Slowly decrease steroid dose by 2.5-5 mg every 1 to
 Slowly decrease steroid dose by 2.5-5 mg every 1 to
" Refer non-iatrogenic Cushings, or iatrogenic cases with"
complications to higher level of care
Diabetes Mellitus ICD10 CODE: E08-E13
"Metabolic disease resulting from insulin insufficiency or ineffectiveness,"
"due to decreased insulin secretion, or peripheral resistance to the action"
"of insulin, or a combination of the two."
Type 1: decreased insulin production due to autoimmune destruction
of the pancreas. Usually starts at a young age
"Type 2: insulin resistance, usually combined with insufficient production of insulin as the disease progresses. Usually starts in adulthood"
Gestational Diabetes - any degree of glucose intolerance with onset or
first recognition during pregnancy.
"Secondary diabetes: due to other identifiable causes, e.g.,"
"Cushings syndrome, chronic pancreatitis, etc."
"Type 1: genetic factors, environmental factors (e.g., some viral infections)"
"Non-Modifiable risk factors: Age 40 years, Family history in first degree"
"relatives, Gestational DM, delivery of big baby 4kg"
"Modifiable risk factors; Unhealthy diets, physical inactivity, tobacco use,"
"harmful use of alcohol, hypertension, stress, obesity, high cholesterol"
"levels, impaired glucose tolerance"
" Refer non-iatrogenic Cushings, or iatrogenic cases with"
complications to higher level of care RR
"o Polyuria  frequent urination, night waking to urinate"
"o Polydipsia  frequent thirst, drink a lot of water"
"o Polyphagia  increased appetite, feeling hungry all the time, frequent,"
"o Polyneuropathy-burning pains, pins and needles, numbness"
o Weight loss despite high appetite
"o Frequent skin infections like boils, itchy genitalia (candidiasis), slow"
"o Fatigue  feeling tired all the time, children not wanting to play"
o May present with complications
 Type 2 diabetes often only presents with minor aspecific
"symptoms, and it is diagnosed either by screening or when"
the patient presents with complications
Acute complications of diabetes
"Acute coma due to diabetic ketoacidosis, or hyperosmolar hyperglycaemia (see section 8.1.4), or hypoglycaemia (see section 1.1.6)"
"1.Microvascular complications: affect the small blood vessels, such"
as those supplying blood to the eyes and kidneys. The microvascular
"complications of diabetes are retinopathy, nephropathy and neuropathy."
"2. Macrovasculary complications: affect the larger blood vessels,"
"such as those supplying blood to the heart, brain and legs: stroke, heart"
"attack, peripheral artery disease"
"Stroke, ischaemic heart disease, kidney failure"
"Blindness, impotence, peripheral neuropathy"
Diabetic foot which may lead to amputations
" Diabetes insipidus, HIVAIDS, TB"
" Blood glucose (fasting, random, andor 2 hours after 75mg of"
" Urine: for glucose, and ketones (in type 1)"
"Other baseline tests- RFTs, Lipid profile, ECG, urine protein or microalbuminuria"
1 Fasting blood sugar mmolL (126 mgdl)
2 Two-hour blood sugar after 75 mg of glucose mmolL (200 mgdl)
4 In a patient with classical symptoms of hyperglycaemia:
Random Blood Sugar mmolL (200 mgdl)
 In the absence of unequivocal hyperglycaemia (very high levels
"of blood sugar), criteria 1-3 should be confirmed by repeated"
testing. One single slightly elevated blood sugar in the absence
of symptoms IS NOT DIAGNOSTIC for diabetes
1 Fasting blood sugar mmolL (126 mgdl)
2 Two-hour blood sugar after 75 mg of glucose mmolL (200 mgdl)
4 In a patient with classical symptoms of hyperglycaemia:
Random Blood Sugar mmolL (200 mgdl)
 Treatment of associated risk factors
 Prevention and treatment of acute and chronic complications
Lifestyle modifications f Diabetic diet (see section HC2
19.1.3) Weight loss if overweight
" Assess for other risk factors (hypertension, obesity,"
"smoking, etc.), and manage accordingly"
" Hypertension: target BP 12080, first line medication"
"are ACE inhibitors (renal protection effect), e.g., enalapril"
" Dyslipidaemia: consider statin treatment, e.g. atorvastatin"
20-40 mg once daily or simvastatin 20-40 mg once
"daily in the evening, especially if:"
- Ischaemic heart disease or cerebrovascular
" Do not use beta blockers, e.g., atenolol in diabetes"
Lifestyle modifications f Diabetic diet (see section
19.1.3) Weight loss if overweight
" Assess for other risk factors (hypertension, obesity,"
"smoking, etc.), and manage accordingly"
" Hypertension: target BP 12080, first line medication"
"are ACE inhibitors (renal protection effect), e.g., enalapril"
" Dyslipidaemia: consider statin treatment, e.g. atorvastatin"
20-40 mg once daily or simvastatin 20-40 mg once
"daily in the evening, especially if:"
- Ischaemic heart disease or cerebrovascular
" Do not use beta blockers, e.g., atenolol in diabetes "
Management of complications HC3
" Assess for complications (renal disease, eye problems,"
"diabetic foot, peripheral neuropathy, heart problem,"
"stroke), and refer treat accordingly"
" Aspirin 75-100 mgdaily in ischaemic heart disease, HC3"
 Amitriptyline 10-25 mg at night (max 100 mg in divided
doses) for peripheral neuropathy
 Atorvastatin 20-40 mg once a day in ischaemic heart
"Elderly people are at higher risk of hypoglycaemia. Monitor carefully,"
and do not aim at very strict control of blood sugar.
"Insulin SC: -IUkgday HC4 Children 5 years: start with IUKgday, and refer to a paediatrician"
Insulin Protocol Onset Peak Duration
"acting, regdaily, 30 minutes hours hours"
" Assess for complications (renal disease, eye problems,"
"diabetic foot, peripheral neuropathy, heart problem,"
"stroke), and refer treat accordingly HC3"
" Aspirin 75-100 mgdaily in ischaemic heart disease,"
 Amitriptyline 10-25 mg at night (max 100 mg in divided
doses) for peripheral neuropathy
 Atorvastatin 20-40 mg once a day in ischaemic heart
Insulin Protocol Onset Peak Duration
Insulin As- 3 times daily 10-20mins 45 mins 3-5hours
Insulin in- Once or 13 612 1624
Insulin bi- Once or 30 212 1624
"Preferably, a combination of intermediate and short acting insulin"
"should be used, in the following regimens e.g.,"
Pre-meals short acting insulin (e.g. actrapid) or Rapid acting insulin
analogue (e.g Aspart) and evening intermediate acting insulin (e.g.
Insulatard) or long acting insulin analogues (e.g Glargine). The evening
dose should be 40-50 of the daily dose (basal-bolus therapy)
Twice daily premixed insulin Mixtard: usually 23 of total dose in the
"morning and 13 in the evening, 30 minutes before meals or Biphasic"
Insulin Aspart 23 of total dose in the morning and 13 in the evening
meals 10-20mins 45 mins 3-5hours
"Insulin biphasic, mixture of regular and NPH"
"Preferably, a combination of intermediate and short acting insulin"
"should be used, in the following regimens e.g.,"
Pre-meals short acting insulin (e.g. actrapid) or Rapid acting insulin
analogue (e.g Aspart) and evening intermediate acting insulin (e.g.
Insulatard) or long acting insulin analogues (e.g Glargine). The evening
dose should be 40-50 of the daily dose (basal-bolus therapy)
Twice daily premixed insulin Mixtard: usually 23 of total dose in the
"morning and 13 in the evening, 30 minutes before meals or Biphasic"
Insulin Aspart 23 of total dose in the morning and 13 in the evening
Insulin Protocol Onset Peak Duration
 Patients on insulin should measure their blood glucose level
"at least twice daily (before breakfast, and before dinner), and"
insulin doses adjusted accordingly
 More frequent pre- and post-meals measurements are required
to adjust the doses especially with a basal-bolus therapy.
 Oral antidiabetic medicines are NOT used in type 1.
Metformin can be used but only under specialist advice
"- If sugar levels not very high, and patient is"
"willing, try lifestyle modifications for 3 months,"
"If lifestyle modifications not enough, andor sugar level initially"
 Metformin 1.5-2 g daily in divided doses at meals (start with
"500 mg once a day for one week,then increase by 500 mg"
every week until target control is achieved)
If treatment targets not achieved with lifestyle modifications
"and metformin, add a second line drug."
"If intolerance or contraindication to metformin, start directly"
 0r Glimepiride 1-4 mg once daily before or with the
"- Start with lowest dose, and increase every 1-2 H"
"If control not achieved, add basal insulin (third line)"
 Patients on insulin should measure their blood glucose level
"at least twice daily (before breakfast, and before dinner), and"
insulin doses adjusted accordingly
 More frequent pre- and post-meals measurements are required
to adjust the doses especially with a basal-bolus therapy. 
 Oral antidiabetic medicines are NOT used in type 1.
Metformin can be used but only under specialist advice 
"- If sugar levels not very high, and patient is"
"willing, try lifestyle modifications for 3 months,"
"If lifestyle modifications not enough, andor sugar level initially"
 Metformin 1.5-2 g daily in divided doses at meals (start with
"500 mg once a day for one week,then increase by 500 mg"
every week until target control is achieved)
If treatment targets not achieved with lifestyle modifications
"and metformin, add a second line drug."
"If intolerance or contraindication to metformin, start directly"
 0r Glimepiride 1-4 mg once daily before or with the
"- Start with lowest dose, and increase every 1-2"
"If control not achieved, add basal insulin (third line) HC4"
"8 IU (or IUKg) in the evening, increase by 2-4 IU every"
3-7 days until fasting blood glucose is in range
"If control still not achieved, consider a full insulin regimen. Stop HC4"
"glimepiride, but maintain metformin if possible"
" Biphasic insulin (e.g. Mixtard 3070) twice a day, 23"
"total dose in the morning before breakfast, and 13 in"
"E.g., Starting dose: 10 IU SC morning, 5 IU SC"
"evening, increase by 4-5 IUweekly. Adjust morning dose as"
"per pre-supper blood glucose, and evening dose as per"
" Basal-bolus regimen: 0.4-IUkgday, half is given"
"as basal insulin (e.g. Insulatard) in the evening, and half"
given as rapid insulin 30 minutes before meals
"Adjust basal dose according to fasting blood sugar, and pre-meals"
insulin according to pre- and post- meals blood sugar levels
 Metformin is contraindicated in advanced kidney disease
" Do not use oral anti-diabetics in acute complications, and in"
acutely sick patients: use insulin for initial management
Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycaemic State (HHS) ICD10 CODE: E10.1 AND E11.0
Acute metabolic complications of diabetes mellitus:
"- DKA is characterized by ketosis, acidosis, and hyperglycaemia."
It is more common in type 1 diabetes.
"- HHS is characterized by hyperglycaemia, severe"
"- dehydration and hypovolemia, but no ketosis and acidosis. It"
is more common in type 2 diabetes.
"8 IU (or IUKg) in the evening, increase by 2-4 IU every"
3-7 days until fasting blood glucose is in range HC4
"If control still not achieved, consider a full insulin regimen. Stop"
"glimepiride, but maintain metformin if possible"
" Biphasic insulin (e.g. Mixtard 3070) twice a day, 23"
"total dose in the morning before breakfast, and 13 in"
"E.g., Starting dose: 10 IU SC morning, 5 IU SC"
"evening, increase by 4-5 IUweekly. Adjust morning dose as"
"per pre-supper blood glucose, and evening dose as per"
" Basal-bolus regimen: 0.4-IUkgday, half is given"
"as basal insulin (e.g. Insulatard) in the evening, and half"
given as rapid insulin 30 minutes before meals
"Adjust basal dose according to fasting blood sugar, and pre-meals"
insulin according to pre- and post- meals blood sugar levels HC4
 Metformin is contraindicated in advanced kidney disease
" Do not use oral anti-diabetics in acute complications, and in"
acutely sick patients: use insulin for initial management 
 Poor control of diabetes mellitus
" May be preceded by the typical symptoms of excessive thirst,"
"fluid intake, and passing of urine, weight loss, tiredness"
" Sweet, acetone smell on the breath (from ketosis)"
 Cardiovascular collapse (hypotension)
 More severe dehydration and fluid deficit
 No ketosis and acidosis (nofew ketones in urine)
 Other causes of ketoacidosishyperglycaemia
 Other causes of acute abdominal pain
" Urine analysis (for ketones, positive)"
" Renal function and electrolytes (Na,K)"
" Monitor BP, urine output, and blood sugar hourly"
 Urinary catheter if unconscious
 Treat infections if present (they can be a precipitating factor)
 Enoxaparin 4000 IU SC until patient is able to move (to
- 15-20 mlkg in the first hour (500-1000 ml)
- Continue with 5-15 mlkghour according to
"vital signs, urinary output, and clinical condition"
" If blood sugar 14 mmolL, switch to dextrose 5 if"
"ketones still present, andor clinical condition not yet"
 Soluble insulin 4-6 IU IM every hour until condition stabilises HC4
"- Continue insulin until ketosis resolves, and"
"- Once clinical condition normalises (normal BP,"
"consciousness, urine output, and able to eat),"
start Insulin SC regimen (see section 8.1.3) 1-2
hours before stopping the IM insulin
If potassium level not available
 Add potassium chloride 1 ampoule in every 1 litre of
infusion as soon as the patient has started passing urine
" Monitor BP, urine output, and blood sugar hourly"
 Urinary catheter if unconscious
 Treat infections if present (they can be a precipitating factor)
 Enoxaparin 4000 IU SC until patient is able to move (to
- 15-20 mlkg in the first hour (500-1000 ml)
- Continue with 5-15 mlkghour according to
"vital signs, urinary output, and clinical condition"
" If blood sugar 14 mmolL, switch to dextrose 5 if"
"ketones still present, andor clinical condition not yet"
normal (patient unable to eat) HC4
 Soluble insulin 4-6 IU IM every hour until condition stabilises
"- Continue insulin until ketosis resolves, and"
"- Once clinical condition normalises (normal BP,"
"consciousness, urine output, and able to eat),"
start Insulin SC regimen (see section 8.1.3) 1-2
hours before stopping the IM insulin HC4
If potassium level not available
 Add potassium chloride 1 ampoule in every 1 litre of
infusion as soon as the patient has started passing urine HC4
- K mmolL: add 40 mmol (2 ampoules) per
- K 3.5-mmolL: add 20 mmol (1 ampoule)
- K mmolL: do not add any potassium
"For hypoglycaemia in patients on anti-DM drugs, manage as in section"
"Add Glucagon 1mg (1 unit) IMSC, repeat every 15minutes once or"
twice according to response to treat severe hypoglycemia in diabetes
patients treated with insulin who are unconscious or cannot take some
Visible enlargement of thyroid gland. May be associated with abnormal
"thyroid function (hyper or hypothyroidism), or not."
- K mmolL: add 40 mmol (2 ampoules) per
- K 3.5-mmolL: add 20 mmol (1 ampoule)
- K mmolL: do not add any potassium 
" Physiological (pregnancy, puberty)"
 (Rarely) difficulty in swallowing
 Refer for thyroid hormones and specialist management RR
" If hypo or hyperthyroidism, (see sections 1.1.6)"
" If causing obstruction, surgery is indicated"
Hyperthyroidism ICD10 CODE: E05
"A condition resulting from an excess of thyroid hormones, usually due"
" Graves disease (autoimmune, common in females)"
" Tumours of thyroid gland (adenomas, multinodular toxic"
 Inflammation of the thyroid gland (thyroiditis)
 Iatrogenic causes (side effect of some medications)
 Weight loss with increased appetite
 Refer for thyroid hormones and specialist management
" If hypo or hyperthyroidism, (see sections 1.1.6)"
" If causing obstruction, surgery is indicated RR"
" Irritability, nervousness, inability to rest or sleep"
" Irregular, scanty menstrual periods"
" Profuse sweating, extreme discomfort in hot weather"
 Protruding eyes (exophthalmos) in some forms
 Tumours of the adrenal gland (pheochromocytoma)
 Other causes of protruding eyes
" Blood levels of thyroid hormone (high T3, T4, low TSH)"
 Biopsy of thyroid gland for cytologyhistology
The aim is to restore the euthyroid state
 Use pulse rate and thyroid hormones level to monitor pro
 Carbimazole 15-40 mg (max 60 mg) in 2-3 divided H
Child: 750 microgramskgday in divided doses (max 30 mg)
- Adjust dose according to thyroid hormone levels
(under specialist management only)
 Carbimazole 15-40 mg (max 60 mg) in 2-3 divided
Child: 750 microgramskgday in divided doses (max 30 mg)
- Adjust dose according to thyroid hormone levels
(under specialist management only) H
- To control excessive sympathetic symptoms (e.g. H
 Propranolol 40-80 mg every 12 hours for at least 1
- Child: 250-500 microgramskg 3-4 times daily
" Stop propranolol, and progressively reduce carbimazole to daily maintenance dose of 5-15 mg. Continue"
carbimazole for at least 18 months
" Surgery may be required in certain cases, e.g., obstruction, intolerance, or lack of response to drug treatment"
 Radioactive iodine may also be used especially in
 Patients treated with carbimazole should be advised to report
any sore throat immediately because of the rare complication
of agranulocytosis (low white cell count)
A condition resulting from thyroid hormone deficiency. It is 5 times more
common in females than in males.
" Post-therapeutic, especially after radiotherapy, or surgical"
 Secondary; due to enzyme defects (congenital)
 Iatrogenic (side effects of some medicines)
- To control excessive sympathetic symptoms (e.g.
 Propranolol 40-80 mg every 12 hours for at least 1
- Child: 250-500 microgramskg 3-4 times daily H
" Stop propranolol, and progressively reduce carbimazole to daily maintenance dose of 5-15 mg. Continue"
carbimazole for at least 18 months
" Surgery may be required in certain cases, e.g., obstruction, intolerance, or lack of response to drug treatment"
 Radioactive iodine may also be used especially in
 Patients treated with carbimazole should be advised to report
any sore throat immediately because of the rare complication
of agranulocytosis (low white cell count) 
" Dull facial expression, puffiness, periorbital swelling"
" Hair sparse, coarse, and dry: skin dry, scaly, and thick"
" Forgetfullness, other signs of mental impairment"
" Bradycardia, constipation (often), anaemia (often)"
 Paraesthesia (numbness) of hands and feet
" Blood levels of thyroid hormone (low T3, T4, high TSH)"
- Initial dose 50-100 micrograms once daily before
Elderly: start with 50 micrograms
- Gradually increase by 25-50 micrograms every
4 weeks to maintenance dose of 100-200
"micrograms daily, according to hormonal levels"
"- Once stable, check hormone levels every 6-12"
Child: refer for specialist management
"- In most cases, the treatment is for life"
- Initial dose 50-100 micrograms once daily before
Elderly: start with 50 micrograms
- Gradually increase by 25-50 micrograms every
4 weeks to maintenance dose of 100-200
"micrograms daily, according to hormonal levels"
"- Once stable, check hormone levels every 6-12"
Child: refer for specialist management H
"- In most cases, the treatment is for life "
- Educate patients on the use of iodised salt
8.1.8. Central precocious puberty
Also referred to as gonadotropin dependent precocious puberty is an
endocrine- related developmental disease characterized by the onset of
"pubertal changes, with development of secondary sexual characteristics"
"and accelerated growth and bone maturation, before the normal age of"
puberty (8 years in girls and 9 years in boys).
 Premature activation of the hypothalamic-pituitary-gonadal
" Secondary causes include brain tumors (glioma, astrocytoma), CNS infections (meningitism, encephalitis), brain malformations (hydroceohalus, arachnoid cysts), trauma and"
 Accelerated growth and bone maturation
" Early menarche in girls, and testicular and penile enlargement with development of facial and sexual hair in boys"
" Most cases are sporadic, familiar caese show autosomal"
"dominant mode of transmission with incomplete, gender-dependent penetrance"
 Gonadotropin-independent precocious puberty
 Screening of basal luteinizing hormone (LH) levels or measurement
of gonadotropin levels after stimulation tests using gonadotropin
 Treatment of progressive CPP using GnRH agonists NH
(leuprolide acetate for depot suspension)
 ILeuprolide acetate for depot suspension 7.5mg inj
"The disease has minimal consequences during adulthood, although the"
association of variation of pubertal timing with adult disease or behaviour
 Treatment of progressive CPP using GnRH agonists
(leuprolide acetate for depot suspension)
 ILeuprolide acetate for depot suspension 7.5mg inj
"Mental, Neurological and Substance"
 A chronic condition characterised by recurrent unprovoked
seizures. Seizures are caused by abnormal discharges in the
brain and present in two different forms: convulsive and
 Convulsive epilepsy has features such as sudden muscle
"contraction, causing the person to fall and lie rigidly, followed by the muscles alternating between relaxation and"
rigidity with or without loss of bowel or bladder control
 Non-convulsive epilepsy has features such as change in
"awareness, behaviour, emotions or senses (such as taste,"
"smell, vision or hearing) similar to mental health conditions,"
 Consider a diagnosis of epilepsy if a person has had at least
2 seizures in the last calendar year on two different days.
" Seizures during an acute event (e.g. meningitis, acute traumatic brain injury) are not epilepsy."
" Genetic, congenital malformation, birth asphyxia, brain"
" Brain infections, cysticercosis, trauma (acute or in the past)"
" In some cases, no specific causes can be identified."
 Depending on the type of epilepsy:
"Generalized epilepsy Seizure involves whole brain, consciousness is"
Tonic Clonic (grand- May commence with a warning sensation in the
"mal) or convulsive form of sound, light or abdominal pain (aura)"
epilepsy There may be a sharp cry followed by loss of
Tonic contraction (rigidity) of muscles occurs
followed by jerking movements (clonic phase)
"There may be incontinence of urine or faeces,"
Absence seizures Mainly a disorder of children
(petit mal) The attack is characterized by a brief loss of
consciousness (5-10 seconds) in which posture
is retained but other activities cease
Previous activities are resumed at the end of
Several attacks may occur in a single day
"Atonic or tonic sei- Sudden loss of muscular tone, of brief duration"
"zures (drop attacks) (15 seconds), with consciousness maintained or"
Myoclonus epilepsy Abnormal jerking movements occurring usually
in the limbs but may involve the whole body
"Generalized epilepsy Seizure involves whole brain, consciousness is"
Tonic Clonic (grandmal) or convulsive
epilepsy May commence with a warning sensation in the
"form of sound, light or abdominal pain (aura)"
There may be a sharp cry followed by loss of
Tonic contraction (rigidity) of muscles occurs
followed by jerking movements (clonic phase)
"There may be incontinence of urine or faeces,"
(petit mal) Mainly a disorder of children
The attack is characterized by a brief loss of
consciousness (5-10 seconds) in which posture
is retained but other activities cease
Previous activities are resumed at the end of
Several attacks may occur in a single day
"Atonic or tonic seizures (drop attacks) Sudden loss of muscular tone, of brief duration"
"(15 seconds), with consciousness maintained or"
Myoclonus epilepsy Abnormal jerking movements occurring usually
in the limbs but may involve the whole body
Focal Epilepsy Seizure activity starts in one area of the brain
"Simple Patient remains alert but has abnormal sensory,"
"motor, psychic or autonomic manifestation e.g."
"jerking of a limb, déjà vu, nausea, strange taste"
"or smell, signs of autonomic nerve dysfunction"
"i.e. sweating, flushing, and gastric sensation,"
motor contraction or sensory change in a
"Complex Altered awareness and behaviour e.g. confusion, repetitive movements"
Status epilepticus A convulsive state in which the convulsions
last 30 minutes or several epileptic convulsions occur in succession without recovery
of consciousness in between or convulsions
not responsive to 2 doses of diazepam. It is a
 Hypoglycaemia (low blood sugar)
 Hypocalcaemia (low blood calcium levels)
 Conversion disorder (previously known as hysteria)
 Hyperventilation (fast breathing) and Panic attacks
 A complete medical and mental health assessment
- Useful in petit mal and focal seizures
- To be done at specialist level (RR and NR)
 Other investigations are guided by suspected cause
Focal Epilepsy Seizure activity starts in one area of the brain
"Simple Patient remains alert but has abnormal sensory,"
"motor, psychic or autonomic manifestation e.g."
"jerking of a limb, déjà vu, nausea, strange taste"
"or smell, signs of autonomic nerve dysfunction"
"i.e. sweating, flushing, and gastric sensation,"
motor contraction or sensory change in a
"Complex Altered awareness and behaviour e.g. confusion, repetitive movements"
Status epilepticus A convulsive state in which the convulsions
last 30 minutes or several epileptic convulsions occur in succession without recovery
of consciousness in between or convulsions
not responsive to 2 doses of diazepam. It is a
 All suspected cases of non-convulsive epilepsy should be
confirmed and treated by a specialist
 Convulsive epilepsy can be diagnosed at hospitalHC3
 level but drug refills should be available at lower levels
 One brief isolated seizure does not need further treatment
but review at 3 months and re-assessment. Treat patients
with repeated episodes as per definition
 Treatment can effectively control epilepsy in most cases
 Treatment should include psychological and social support
 Start with a single anti-epileptic medicine
 Start with low doses and increase gradually according to
" If a patient has been seizure free for 2 years, consider gradual stopping of medication"
Commonly used antiepileptics include:
 Generalized tonic-clonic seizures
Children 2 years: phenobarbital or carbamazepine
Children 2 years: carbamazepine or valproate
 Absence seizures: Valproate or ethosuximide
 Caution: Avoid phenobarbital and phenytoin in children
with intellectual disability andor behavioural problems
First aid for acute seizure HC2
DO NOT RESTRAIN or put anything in the mouth
Protect person from injury: make sure they are in a safe
place away from fire or other things that might injure them
DO NOT RESTRAIN or put anything in the mouth
Protect person from injury: make sure they are in a safe
place away from fire or other things that might injure them HC2
DO NOT leave patient alone. Seek help if possible HC2
"After the crisis, check airway, breathing and circulation and,"
"while unconscious, put the person in recovery position (on"
Most seizures resolve spontaneously. HC3
Dextrose 50 1 mLkg adults and Dextrose 10
Give diazepam 10 mg IV or rectal 5 mLkg children
"- Child: mgkg rectally, mgkg repeat dose after 5-10 min if seizures persist"
Phenobarbital 10-15 mgkg slowly IV. Dilute the solution
with 10 times its volume of water for
injections and give VERY SLOWLY (at a rate mgminute)
"- Monitor BP and respiration, be ready to"
administer IV fluids if hypotension develops and
ventilate with Ambu bag in case of respiratory
Or phenytoin 15-18 mgkg over 1 hour
Phenytoin can cause severe tissue damage so use a good IV line
Give another drug (if available) or add phenytoin
- Monitor for respiratory depression
DO NOT leave patient alone. Seek help if possible
"After the crisis, check airway, breathing and circulation and,"
"while unconscious, put the person in recovery position (on"
Most seizures resolve spontaneously. HC3
Dextrose 50 1 mLkg adults and Dextrose 10
Give diazepam 10 mg IV or rectal 5 mLkg children
"- Child: mgkg rectally, mgkg repeat dose after 5-10 min if seizures persist"
Phenobarbital 10-15 mgkg slowly IV. Dilute the solution
with 10 times its volume of water for
injections and give VERY SLOWLY (at a rate mgminute)
"- Monitor BP and respiration, be ready to"
administer IV fluids if hypotension develops and
ventilate with Ambu bag in case of respiratory
Or phenytoin 15-18 mgkg over 1 hour
Phenytoin can cause severe tissue damage so use a good IV line 
Give another drug (if available) or add phenytoin
- Monitor for respiratory depression 
Start with a single anti-epileptic medicine. The effective dose
must be reached progressively and patient monitored for
tolerance and side effects. Aim at the lowest dose able to
If treatment is ineffective (less than 50 reduction in crisis)
try another monotherapy (slowly reduce the current antiepileptic and introduce the new one)
If high doses with side effects are required
"and seizures are anyway infrequent, less than complete control"
"Follow up monthly until stable, then every 3 months"
Warn patient that treatment interruptions can trigger seizures
If no seizure for 2 years and no known cause like head trauma
"or infection, consider possibility of stopping treatment (over"
2 months). Discuss with the patient
"If 2 monotherapy trials fail, refer to specialist"
"Effective in all generalized tonic-clonic seizures, focal seizures"
"- Given twice daily, steady state reached in 8 days"
- Adult: starting dose of 100-200 mg daily and
increased in 100 mg increments every 1-2 weeks
to a maintenance dose of 400 to 1400 mg daily
- Child: starting dose of 5 mgkgday and
maintenance dose of 10-20 mgkgday in
"Side effects: skin rash, diplopia, blurred vision, ataxia (staggering gait), nausea"
Start with a single anti-epileptic medicine. The effective dose
must be reached progressively and patient monitored for
tolerance and side effects. Aim at the lowest dose able to
If treatment is ineffective (less than 50 reduction in crisis)
try another monotherapy (slowly reduce the current antiepileptic and introduce the new one)
If high doses with side effects are required
"and seizures are anyway infrequent, less than complete control"
"Follow up monthly until stable, then every 3 months"
Warn patient that treatment interruptions can trigger seizures
If no seizure for 2 years and no known cause like head trauma
"or infection, consider possibility of stopping treatment (over"
2 months). Discuss with the patient
"If 2 monotherapy trials fail, refer to specialist HC3"
"Effective in all generalized tonic-clonic seizures, focal seizures"
"- Given twice daily, steady state reached in 8 days"
- Adult: starting dose of 100-200 mg daily and
increased in 100 mg increments every 1-2 weeks
to a maintenance dose of 400 to 1400 mg daily
- Child: starting dose of 5 mgkgday and
maintenance dose of 10-20 mgkgday in
"Side effects: skin rash, diplopia, blurred vision, ataxia (staggering gait), nausea HC4"
Effective for tonic-clonic seizures and focal seizures but is
sedative in adults and cause behavioural disturbances and
"hyperkinesia in children. It may be tried for atypical absences,"
- Given once a day in the evening to reduce
- Adult: starting dose of 1 mgkg (60 mg) daily
"- weeks, if not controlled increase to 2 mgkg"
"(120 mg) for 2 months, if not controlled increase"
- Child: starting dose of 2 mgkgday for 2
"- not controlled increase to 3 mgkg for 2 months,"
if not controlled increase until maximum of 6
- It takes 2-3 weeks for the drug to achieve steady
blood levels so assess effect only after this period
"Side effects: drowsiness, lethargy, hyperactivity"
"and irritability in children, skin rash, confusion in elderly,"
Effective in all forms of epilepsy except absences.
- Adult: starting dose of 150-200 mg daily as
single dose or 2 divided doses and maintenance
- Child: starting dose of 3-4 mgkg and
- maintenance dose of 3-8 mgkgday (max 300
- Increase slowly by 25-30 mg every 2 weeks
"Side effects: drowsiness, ataxia, slurred speech, blurred"
"vision, twitching, confusion, gum hyperplasia, blood abnormalities, rash, hepatitis"
Effective for tonic-clonic seizures and focal seizures but is
sedative in adults and cause behavioural disturbances and
"hyperkinesia in children. It may be tried for atypical absences,"
- Given once a day in the evening to reduce
- Adult: starting dose of 1 mgkg (60 mg) daily
"- weeks, if not controlled increase to 2 mgkg"
"(120 mg) for 2 months, if not controlled increase"
- Child: starting dose of 2 mgkgday for 2
"- not controlled increase to 3 mgkg for 2 months,"
if not controlled increase until maximum of 6
- It takes 2-3 weeks for the drug to achieve steady
blood levels so assess effect only after this period
"Side effects: drowsiness, lethargy, hyperactivity"
"and irritability in children, skin rash, confusion in elderly,"
Effective in all forms of epilepsy except absences.
- Adult: starting dose of 150-200 mg daily as
single dose or 2 divided doses and maintenance
- Child: starting dose of 3-4 mgkg and
- maintenance dose of 3-8 mgkgday (max 300
- Increase slowly by 25-30 mg every 2 weeks
"Side effects: drowsiness, ataxia, slurred speech, blurred"
"vision, twitching, confusion, gum hyperplasia, blood abnormalities, rash, hepatitis "
- Child 6 years: initially 500 mg daily in 2 divided
"doses, increase if necessary by 250 mg every"
5-7 days up to a usual daily dose of 1-g in 2
- Child 1 month to 6 years: Initially 250 mg single
- dose at night increased gradually every 5-7 days
as required to usual dose of 20 to 40 mgkg daily
"Side effects: gastrointestinal disorders, blood"
"disorders, gum hyperplasia, drowsiness"
" In children, look for presence of associated intellectual disability"
"or behavioural problems. If present, consider carbamazepine"
or valproate. (avoid phenobarbital and phenytoin) and manage
associated intellectual disability or behavioural problem
 All pregnant women with epilepsy should be referred to
specialist for appropriate management (most
" Healthpsycho-education to patients, carers and community"
 Advice on management of seizures and safety precautions
" In children, look for and manage presence of associated"
intellectual disability or behavioural problems
 Good antenatal care and delivery
- Child 6 years: initially 500 mg daily in 2 divided
"doses, increase if necessary by 250 mg every"
5-7 days up to a usual daily dose of 1-g in 2
- Child 1 month to 6 years: Initially 250 mg single
- dose at night increased gradually every 5-7 days
as required to usual dose of 20 to 40 mgkg daily
"Side effects: gastrointestinal disorders, blood"
"disorders, gum hyperplasia, drowsiness RR"
" In children, look for presence of associated intellectual disability"
"or behavioural problems. If present, consider carbamazepine"
or valproate. (avoid phenobarbital and phenytoin) and manage
associated intellectual disability or behavioural problem
 All pregnant women with epilepsy should be referred to
specialist for appropriate management (most 
Nodding Disease ICD10 CODE: G40.4
An unexplained neurologic condition characterized by episodes of
"repetitive dropping forward of the head, often accompanied by other"
"seizure-like activity, such as convulsions or staring spells."
The condition predominantly affects children aged 515 years and has
been reported in South Sudan from the states of Western and Central
"Equatorial, northern Uganda and southern Tanzania."
Not yet certain but consistent association with onchocerciasis has been
"Other associated factors: malnutrition, pyridoxine deficiency"
 Starts at age 5-7 years in previously normal child
 Early symptoms: problems in concentration and thinking
" Then nodding starts, which is a type of seizure (atonic"
seizures) often triggered by eating or cold temperatures
" Neurological deterioration, delayed puberty and growth"
retardation progresses until the child becomes mentally
 No diagnostic investigations have been identified
Antiepileptic drugs as above (valproate and
Antiepileptic drugs as above (valproate and
Common complaint and cause of disability. Pain can be of varying
intensity and affect different areas of the head.
" Facial and frontal headache: sinusitis, eye problems, oropharyngeal disorders"
" Temporal headache: severe hypertension, stress, ear disorders, subarachnoid haemorrhage"
" Top of the head: stress, tension"
 Unilateral (one sided): migraine
" Whole head: malaria, meningitis, severe hypertension, dehydration"
" Back of the head (occiput and neck): meningitis, malaria,"
"refractive eye problems, neck trauma or sprain, tension"
Recent trauma to the Intracranial bleeding
"Acute onset, severe Intracranial bleeding"
"Chronic worsening Tumours, hypertension"
"Altered consciousness Tumour, intracranial bleeding, intracranial"
andor focal neurolog- infection
"Acute onset, severe Intracranial bleeding"
andor focal neurological symptoms andor
"seizure Tumour, intracranial bleeding, intracranial"
Investigate and treat cause if foundpossible HC2
"If any danger signs, refer to hospital for further assessment"
Follow pain ladder for control of symptoms
"Periodic severe headache, usually unilateral, which may occur with or"
without an aura (neurological warning signs) and associated with nausea
The cause is unknown but thought to be linked to:
" Craniovascular disorders, which can be precipitated by:"
"stress, anxiety, menstruation, flashing lights, hunger, lack"
"of sleep, oestrogens (in COC), perfumes, tyramine- containing foods e.g. red wine, cheese, chocolate"
 Warning signs (aura): visual or sensory sympotms (flashing
lights) preceeding the start of the headache
 Migraine with warning signs is called migraine with aura.
 Moderate to severe episodic unilateral headache throbbing
" Nausea and vomiting, sensitivity to light and sound"
Investigate and treat cause if foundpossible
"If any danger signs, refer to hospital for further assessment"
Follow pain ladder for control of symptoms HC2
 No specific investigations needed except if another cause is
Or Ibuprofen 400 mg every 6-8 hours
Or Acetylsalicilic acid 300-900 mg every 4-6 hours (max
If severe andor not responding to the above treatment HC4
- Plus metoclopramide 10 mg IM IV for the
"Or ergotamine 2 mg sublingual, then 1-2 mg"
hourly to a max of 6 mg in 24 hours
"Or Sumatriptan 50 mg, repeat after 2 hours if necessary,"
Prophylaxis: in case of 3 attacksmonth andor functional HC3
Amitriptyline 10-75 mg nocte or
Propranolol 40-80 mg every 12 hours HC4
A chronic slowly progressive organic mental disorder characterised by
"progressive loss of memory and cognitive function, with difficulty in"
carrying out everyday activities.
Or Ibuprofen 400 mg every 6-8 hours
Or Acetylsalicilic acid 300-900 mg every 4-6 hours (max
If severe andor not responding to the above treatment
- Plus metoclopramide 10 mg IM IV for the
"Or ergotamine 2 mg sublingual, then 1-2 mg"
hourly to a max of 6 mg in 24 hours
"Or Sumatriptan 50 mg, repeat after 2 hours if necessary,"
Prophylaxis: in case of 3 attacksmonth andor functional
Amitriptyline 10-75 mg nocte or
Propranolol 40-80 mg every 12 hours HC3
 Primary degeneration of the brain
" Infections e.g. syphilis, TB, HIVAIDS, meningitis"
 Metabolic disorders e.g. hypothyroidism
 Deficiencies of vitamin B12 and B1
" Brain trauma (chronic subdural haematoma, hydrocephalus)"
" Toxic agents e.g. carbon monoxide, alcohol"
 Impairment of short and long-term memory
" Impaired judgment, poor abstract thinking"
 Language disturbances (aphasia)
" Personality changes: may become apathetic or withdrawn,"
"may have associated anxiety or depression because of failing memory, may become aggressive"
 Wandering and incontinence in later stages
" Delirium, chronic psychosis, depression"
 Guided by history and clinical picture to establish cause
" Thorough physical, neurologic and mental state examination"
" Laboratory: thyroid hormones, RPR and vitamin B12 levels,"
"Where possible, identify and treat the cause HC2"
- psychoeducation of family members about the
illness and about following a regular routine
- provision of regular orientation information
- creation of an environment to support activities
Assess for and treat other co-occurring health problems
"e.g. depression, HDonepezil 5mg once daily initially, can increase to 10mg H"
"Alternatively; Memantine 10mg once daily initially, can"
increase to 20mg after 4-6 weeks
Note: These medicines only slow progression of symptoms
Haloperidol 0.5-1 mg every 8 hours with higher dose at
"Alternatively; Risperidone 0.5-1 mg once daily, preferably"
- Adjust dose according to response and review
"regularly, monitor for and treat extrapyramidal"
side effects with Benzhexol 2 mg every 12 hours
Avoid Diazepam: it can lead to falls and is often not effective
"Where possible, identify and treat the cause"
- psychoeducation of family members about the
illness and about following a regular routine
- provision of regular orientation information
- creation of an environment to support activities
Assess for and treat other co-occurring health problems
"Donepezil 5mg once daily initially, can increase to 10mg"
"Alternatively; Memantine 10mg once daily initially, can"
increase to 20mg after 4-6 weeks
Note: These medicines only slow progression of symptoms
Haloperidol 0.5-1 mg every 8 hours with higher dose at
"Alternatively; Risperidone 0.5-1 mg once daily, preferably"
- Adjust dose according to response and review
"regularly, monitor for and treat extrapyramidal"
side effects with Benzhexol 2 mg every 12 hours
Avoid Diazepam: it can lead to falls and is often not effective 
 Avoid Diazepam: it can lead to falls and is often not effective
 Avoid and treat preventable causes
"Parkinsonism ICD10 CODE: G20, G21"
"A syndrome characterized by tremor, rigidity, bradykinesia (slow movement) and postural disturbances, due to primary degeneration or damage"
to particular areas of the brain
" Infections e.g. sleeping sickness, syphilis"
" Poisoning e.g. manganese, carbon monoxide"
" Drugs e.g. chlorpromazine, haloperidol"
" Vascular disorders, intracranial tumour, trauma"
 Walking with short quick steps (shuffling gait)
 Vacant facial expression (mask face)
 Urinary incontinence (sometimes occurs)
" Essential tremor (isolated intentional tremor, benign)"
 Good history and clinical examination
Levodopa-carbidopa 10100 mg. The dose can increased RR
Start with 1 tablet every 8 hours (specialist only management)
Only for drug-induced parkinsonism
Benzhexol 2-15 mg daily in 1-3 divided doses
- Initially: 1 mgday; increase by 2 mg increments
- Usual dose: 6 to 10 mgday in 3 to 4 divided
doses; doses of 12 to 15 mgday may be required
"Benzhexol side effects: dry mouth, constipation,"
"palpitations, urinary retention, confusion and agitation"
Do not give benzhexol routinely to patients on
antipsychotic medicines in the absence of Parkinsonlike
Levodopa-carbidopa 10100 mg. The dose can increased
Start with 1 tablet every 8 hours (specialist only management)
Only for drug-induced parkinsonism
Benzhexol 2-15 mg daily in 1-3 divided doses
- Initially: 1 mgday; increase by 2 mg increments
- Usual dose: 6 to 10 mgday in 3 to 4 divided
doses; doses of 12 to 15 mgday may be required RR
"Benzhexol side effects: dry mouth, constipation,"
"palpitations, urinary retention, confusion and agitation"
Do not give benzhexol routinely to patients on
antipsychotic medicines in the absence of Parkinsonlike 
Delirium (Acute Confusional State) ICD10 CODE:
"A clinical syndrome usually with acute onset, which involves abnormalities"
in thought and perception and fluctuating level of consciousness. It is
caused by impaired brain function resulting from diffuse physiological
" Infections e.g. malaria, trypanosomiasis, syphilis, meningitis, rabies, typhoid fever, HIVAIDS"
 Pneumonia and urinary tract infections in elderly
 Intoxication with or withdrawal from alcohol or other substances of dependence
 Some medicines e.g. anticonvulsants and neuropsychiatric
" Cerebral pathology e.g. head trauma, tumour"
" Electrolyte imbalances, hyperglycemia"
" Acute onset of mental confusion with associated disorientation, developing within hours or a few days. Attention,"
concentration and memory for recent events is impaired
 Reduced ability to think coherently: reasoning and problem
solving are difficult or impossible
 Illusions and hallucinations are common
 Symptoms tend to fluctuate: patients feel better in the day
 Some patients may present with reduced activity andor
 Guided by history and physical examination: aim at identifying the cause
NB: drug history is very important!
" CBC, blood glucose, RDT, renal function and electrolytes"
"Due to the complexity of underlying conditions, patients with acute confusional state should be referred to hospital for appropriate management"
Identify and treat the cause such as substance H
"and alcohol use disorders, diabetes, head injury or"
"infections e.g. malaria, UTI, pneumonia in older"
"Ensure hydration, control of fever, safe and quiet"
"environment, constant monitoring"
"Withhold any unnecessary medicines, keep the"
use of sedatives and antipsychotics to the minimum
If patient is agitated and acutely disturbed
Haloperidol 5 mg IM: repeat after 60 min if
- Continue with haloperidol 1.25-5 mg every 8
Or chlorpromazine 25-50 mg every 8-12 hours
Trifluoperazine 5-10 mg every 12 hours
Identify and treat the cause such as substance
"and alcohol use disorders, diabetes, head injury or"
"infections e.g. malaria, UTI, pneumonia in older"
"Ensure hydration, control of fever, safe and quiet"
"environment, constant monitoring"
"Withhold any unnecessary medicines, keep the"
use of sedatives and antipsychotics to the minimum
If patient is agitated and acutely disturbed
Haloperidol 5 mg IM: repeat after 60 min if
- Continue with haloperidol 1.25-5 mg every 8
Or chlorpromazine 25-50 mg every 8-12 hours
Trifluoperazine 5-10 mg every 12 hours 
 Early diagnosis and treatment of underlying cause
PSYCHIATRIC AND SUBSTANCE USE DISORDERS
"Anxiety is a normal physiological response, which enables a person to"
take steps to deal with a threat. When anxiety is prolonged or interferes
"individual, it constitutes the clinical condition of an anxiety disorder."
 Not fully understood: possibly external traumatic events
may trigger anxiety in predisposed people
" Association with other mental conditions e.g. depression,"
 Generalized anxiety: Unrealistic and excessive worry about
 Panic attacks: Episodes of sudden onset of intense apprehension or fear; anxiety symptoms usually peak within 1015 minutes and resolve in a few minutes to one hour
 Phobia: An excessive fear of a known stimulus (object or
" situation) e.g. animals, water, confined space) causing the"
person to consciously avoid the object or situation
Each of the above clinical types will have one or more of the
" Sleep, mood and concentration problems"
" Palpitations, dizziness, shortness of breath"
" Shakiness or tremors, excessive sweatiness"
" Other symptoms: urinary frequency, hesitancy, or urgency,"
" Consider organic conditions e.g. hyperthyroidism, hypoglycaemia, phaeochromocytoma"
"Psychosocial interventions: counselling, HC2"
psychotherapy (individual and group psychotherapy)
For an acute episode or intense prolonged anxiety
Benzodiazepines e.g. diazepam 5 mg 1-2 times daily
- Increase if necessary to 15-30 mg daily in
Elderly: Alprazolam 0.25mg -0.5mg twice daily
"initially, Increase if necessary to 3-6 mg daily in"
"If alprazolam is not available, Give half the above dose"
"- Duration of therapy 1-2 weeks, tapering off to"
If poor response: refer to specialist
Fluoxetine 20 mg once a day for long term
management of the anxiety disorder
- Continue antidepressant for 4 to 6 weeks then
"Psychosocial interventions: counselling,"
psychotherapy (individual and group psychotherapy)
For an acute episode or intense prolonged anxiety
Benzodiazepines e.g. diazepam 5 mg 1-2 times daily
- Increase if necessary to 15-30 mg daily in
Elderly: Alprazolam 0.25mg -0.5mg twice daily
"initially, Increase if necessary to 3-6 mg daily in"
"If alprazolam is not available, Give half the above dose"
"- Duration of therapy 1-2 weeks, tapering off to"
If poor response: refer to specialist
Fluoxetine 20 mg once a day for long term
management of the anxiety disorder
- Continue antidepressant for 4 to 6 weeks then
Diazepam is addictive and abrupt cessation can cause
withdrawal symptoms. Use for short periods and gradually
" Diazepam is NOT appropriate for treating depression, phobic"
"or obsessional states, or chronic psychoses (see relevant"
 Antidepressants: May be useful in managing panic disorders
and other anxiety disorders which require long term treatment
"Depression ICD10 CODE: F32, F33"
"A common disorder characterised by low mood, loss of interest and"
enjoyment and reduced energy leading to diminished activity and in
"severe forms, difficult day-to-day functioning."
" Biological, genetic, and environmental factors"
"For at least two weeks, the person had at least two of the symptoms below:"
" Low mood (most of the day, almost every day)"
 Loss of interest or pleasure in activities that are normally
Diazepam is addictive and abrupt cessation can cause
withdrawal symptoms. Use for short periods and gradually
" Diazepam is NOT appropriate for treating depression, phobic"
"or obsessional states, or chronic psychoses (see relevant"
 Antidepressants: May be useful in managing panic disorders
and other anxiety disorders which require long term treatment
" Associated lack of energy, body weakness or easily fatigued"
" During the 2 weeks, the person also has some of the symptoms below:"
" Difficulty in concentrating, reduced attention"
 Reduced self-esteem and self confidence
" Poor sleep, poor appetite, reduced libido"
 Bleak and pessimistic view of the future
 Feeling of guilt and unworthiness
 Multiple body pains or other medically unexplained somatic symptoms
 Ideas or acts of self harm or suicide (occurs in up to 65
" Children and adolescents usually present with irritability,"
"school phobia, truancy, poor academic performance, alcohol and drug abuse"
 Thyroid dysfunction (hypothyroidism)
 Adrenal dysfunction (Addisons disease)
" Parkinsons disease, stroke, dementia"
" Medical, social and personal history"
 Check for bereavement or other major personal loss
 Find out if person has had an episode of mania in the past: if so
consider treatment for bipolar disorder and consult a specialist
 Find out if they have psychotic features e.g. hallucinations (refer
" Assess for co-occurring health conditions (e.g. HIVAIDS),"
 Assess risk of self-harmsuicide
Psychological therapy (Individual or group psychotherapy)
- Psychoeducation (counselling of patient and
"- Addressing current stressors (abuse, neglect)"
- Re activating social networks
- Structured physical activities
Manage concurrent physical medical problems
Address co-existing mental problems e.g.
"If available, consider psychotherapy (cognitive"
"behavioural therapy, interpersonal psychotherapy,"
If bereavement or another major personal loss
- Do not consider drugs or psychotherapy as first
- If not responding to all above HC4
- DO NOT use in children 12 years
- Adolescents: only under specialist supervision RR
Fluoxetine 20 mg once daily in the morning
"- If not better after 4-6 weeks, increase to 40 mg H"
Or Amitriptyline 50 mg at bedtime
- Increase by 25 mg every week aiming at 100-150
mg in divided doses or single bedtime dose by 4-6
Psychological therapy (Individual or group psychotherapy)
- Psychoeducation (counselling of patient and
"- Addressing current stressors (abuse, neglect)"
- Re activating social networks
- Structured physical activities
Manage concurrent physical medical problems
Address co-existing mental problems e.g.
"If available, consider psychotherapy (cognitive"
"behavioural therapy, interpersonal psychotherapy,"
If bereavement or another major personal loss
- Do not consider drugs or psychotherapy as first
- If not responding to all above
- DO NOT use in children 12 years
- Adolescents: only under specialist supervision
Fluoxetine 20 mg once daily in the morning
"- If not better after 4-6 weeks, increase to 40 mg"
Or Amitriptyline 50 mg at bedtime
- Increase by 25 mg every week aiming at 100-150
mg in divided doses or single bedtime dose by 4-6
- Useful in case of associated anxiety
"- Avoid in adolescents, elderly, heart diseases,"
- Or Venflaxine mg given in the morning or
- Increase dose to75mg per day divided 8-12 hourly H
- Maintenance dose is 75 to 225 mg once a day H
- Maximum dose is 375mg; Useful in the patients
with comorbid anxiety disorders.
- Or Sertaline 50mg per day; preferred for patients RR
on other medicines due to its low potential for
"drug interactions and for breast feeding mothers,"
may increase dose by 25mg at weekly intervals RR
"- Or Escitalopram10mg, may increase dose to 20mg"
- Or Bupropion 150 mgday PO for those than
cannot tolerate SSRIs and with comorbid Nicotine
use disorder. Titrate to 150-450 mgday based on
tolerability and efficacy; may administer in divided
If patient responding to medication
Continue for at least 9-12 months
Consider stopping if patient has been without
depressive symptoms and able to carry out normal
activities for at least 9 months
- Counsel the patient about withdrawal symptoms
"- (dizziness, tingling, anxiety, irritability, nausea,"
- Useful in case of associated anxiety
"- Avoid in adolescents, elderly, heart diseases,"
- Or Venflaxine mg given in the morning or
- Increase dose to75mg per day divided 8-12 hourly HC4
- Maintenance dose is 75 to 225 mg once a day
- Maximum dose is 375mg; Useful in the patients
with comorbid anxiety disorders.
- Or Sertaline 50mg per day; preferred for patients
on other medicines due to its low potential for
"drug interactions and for breast feeding mothers,"
may increase dose by 25mg at weekly intervals
"- Or Escitalopram10mg, may increase dose to 20mg"
- Or Bupropion 150 mgday PO for those than
cannot tolerate SSRIs and with comorbid Nicotine
use disorder. Titrate to 150-450 mgday based on
tolerability and efficacy; may administer in divided
If patient responding to medication
Continue for at least 9-12 months
Consider stopping if patient has been without
depressive symptoms and able to carry out normal
activities for at least 9 months
- Counsel the patient about withdrawal symptoms
"- (dizziness, tingling, anxiety, irritability, nausea,"
- Counsel the patient about possibility of relapse
- Reduce slowly over at least 4 weeks even slower
- withdrawal symptoms are significant
- Monitor periodically for re-emergence of
"In case of pregnant woman, child, adolescent,"
patients not responding to treatment with
"antidepressant, psychotic features, history of mania"
Refer for specialist management
SSRI in bipolar depression can trigger a manic
 Promotion of useful social support networks
"Refer to section 9.Suicidal BehaviourSelf Harm ICD10 CODES: T14.91, Z91.5"
Suicidal behaviour is an emergency and requires immediate attention.
"It is an attempted conscious act of self-destruction, which the individual"
concerned views as the best solution. It is usually associated with feelings
"of hopelessness, helplessness and conflicts between survival and death."
"Self-harm is a broader term referring to intentional poisoning or self-inflicted harm, which may or may not have an intent of fatal outcome."
- Counsel the patient about possibility of relapse
- Reduce slowly over at least 4 weeks even slower
- withdrawal symptoms are significant
- Monitor periodically for re-emergence of
"In case of pregnant woman, child, adolescent,"
patients not responding to treatment with
"antidepressant, psychotic features, history of mania"
Refer for specialist management 
SSRI in bipolar depression can trigger a manic 
" Physical illness e.g. HIVAIDS, head injury, malignancies,"
"body disfigurement, chronic pain"
" Psychiatric disorders e.g. depression, chronic psychosis,"
"dementia, alcohol and substance use disorders, personality disorders, epilepsy"
Risk is high in the following cases:
 History of recent loss or disappointment
" Current mental illness e.g. depression, psychosis"
 Evidence of violent behaviour or previous psychiatric admi
 Married or in stable interpersonal relationships
Patients can present in one of the following situations:
 A current suicide attempt or self harm
 A situation of imminent risk of suicidal attempt or self
- Current thoughts or plans of suicideself harm or history of
"thoughts or plans of suicideself harm in the last 1 month,"
or acts of self harmsuicide attempts in the last 1 years plus
"- Person is agitated, violent, emotionally distressed or"
"uncommunicative and socially isolated, hopeless"
 A situation of no imminent risk but
- Thoughts or plans of suicideself harm in the last 1 month
or acts of selfharmsuicide attempt in the last one year in
" Complete medical, social and family history"
 Ask the patient about suicidal or self harm thoughtsplans acts
 Asking about self harm or suicide does not increase the risk of
"those acts. On the contrary, it may help the patient to feel understood and considered. First try to establish a good relationship"
 Always assess risk of suicide and self-harm in patient
" With any other mental illness (depression, mania, psychosis,"
"alcohol and substance abuse, dementia, behavioural or development disorders)"
" Chronic pain, severe emotional distress"
If acute suicidal behaviouract of self harm or HC4
Admit the patient and treat any medical
"complications (bleeding, poisoning etc.)"
Keep in a secure and supportive environment
Offeractivate psychosocial support
Consult mental health specialist
Treat any medical and mental condition present
Offeractivate psychosocial support
Refer to mental health specialist for further
If acute suicidal behaviouract of self harm or
Admit the patient and treat any medical
"complications (bleeding, poisoning etc.)"
Keep in a secure and supportive environment
Offeractivate psychosocial support
Consult mental health specialist
Treat any medical and mental condition present HC4
Offeractivate psychosocial support
Refer to mental health specialist for further
" Suicide is less frequent in children and adolescents, but there"
is increased risk if there is disturbed family background (e.g.
"death of parents, divorce), use of alcohol and other drugs of"
"abuse, physical illness, psychiatric disorder"
"Bipolar Disorder (Mania) ICD10 CODE: F30, F31"
A disorder of mood control characterized by episodes in which the
persons mood and activity level are significantly disturbed: in some
"occasions, there is an elevation of mood and increased energy and"
"activity (mania) and in other occasions, there is a lowering of mood and"
"decreased energy and activity (depression). Characteristically, recovery"
is complete in between the episodes.
" Biological, genetic, environmental factors"
"Patient can present in an acute manic episode, in a depressive episode"
" Elevated, expansive or irritable moods and increased activity or subjective experience of increased energy"
" Increased self-image, self-esteem or grandiosity,"
" Impulsive reckless behavior, extravagancy, partying and,"
" Increased sexual drive, sociability and goal directed behaviour"
" Suicide is less frequent in children and adolescents, but there"
is increased risk if there is disturbed family background (e.g.
"death of parents, divorce), use of alcohol and other drugs of"
"abuse, physical illness, psychiatric disorder "
 Increased appetite but weight loss occurs due to over- activity
 Auditory and visual hallucinations may be present
" As for depression described above, but with a history of"
 High index of suspicion for bipolar in early onset depression with family history of bipolar illness
" Organic mental states e.g. drug or alcohol intoxication, delirium"
" Good medical, social and personal history"
 Assess for acute state of mania
" If depressive symptoms, investigate for previous manic episodes"
 Assess for other medical or mental conditions (alcohol or
"substance abuse, dementia, suicideself harm)"
Patients with suspected bipolar disorder should be referred for specialist
Multiple symptoms as above for  1 week and HC4
severe enough to interfere with worksocial H
activities andor requiring hospitalization
Multiple symptoms as above for  1 week and
severe enough to interfere with worksocial
activities andor requiring hospitalization HC3
Aseess risk to self and others HC3
Discontinue antidepressant if any
Provide counseling and education
Chlorpromazine initially 100-200 mg every 8
"hours, then adjust according to response"
- Daily doses of up to 300 mg may be given as
- Gradually reduce the dose when symptoms
of mania resolve and maintain on doses as
indicated in section on Chronic psychosis
Or haloperidol initially 5-10 mg every 12 hours
then adjust according to response
- Up to 30-40 mg daily may be required in
Or trifluoperazine initially 5-10 mg every
12hours then adjust according to response
- Up to 40 mg or more daily may be required in
- Or Olanzapine 10-15 mgday initially; may
adjust to 20mg according to response
"- Or Risperidone 2-3mg initially, may increase"
to 6mg in over 3 weeks according to response.
If under specialist supervision: initiate a mood stabilizer H
"Carbamazepine initial dose 200 mg at night, increase"
slowly to 600-1000 mgday in divided doses
Or Valproate initial dose of 500 mgday. Usual mainteRR nance dose 1000-2000 mg
Or Lithium 900-1800mgday in in two divided doses (RR)
Discontinue antidepressant if any
Provide counseling and education
Chlorpromazine initially 100-200 mg every 8
"hours, then adjust according to response"
- Daily doses of up to 300 mg may be given as
- Gradually reduce the dose when symptoms
of mania resolve and maintain on doses as
indicated in section on Chronic psychosis
Or haloperidol initially 5-10 mg every 12 hours
then adjust according to response
- Up to 30-40 mg daily may be required in
Or trifluoperazine initially 5-10 mg every
12hours then adjust according to response
- Up to 40 mg or more daily may be required in
- Or Olanzapine 10-15 mgday initially; may
adjust to 20mg according to response
"- Or Risperidone 2-3mg initially, may increase"
to 6mg in over 3 weeks according to response. HC3
If under specialist supervision: initiate a mood stabilizer
"Carbamazepine initial dose 200 mg at night, increase"
slowly to 600-1000 mgday in divided doses
Or Valproate initial dose of 500 mgday. Usual maintenance dose 1000-2000 mg
Or Lithium 900-1800mgday in in two divided doses (RR) H
"Serum lithium should be monitored 12 hours after dose,"
"twice weekly until serum concentration and clinical condition stabilize, and every 3 months thereafter."
Increase dose as tolerated to target serum lithium concentrations of 0.8-mEqL.
"Monitor Wt, BP, PR, Lipid profile and LFTs. Do RFTS,"
TSH and Ca levels for those on Lithium
"If agitationrestlessness, add a benzodiazepine for short HC2"
period (until symptoms improve)
Diazepam 5-10 mg every 12 hours
Zuclopenthixaol acetate 50-100 mg given 48-72 hours
" If extrapyramidal side-effects (muscle rigidity,"
"dripping of saliva, tongue protrusion, tremors)"
are present while on antipsychotic drugs
- Add an anticholinergic: Benzhexol initially 2
mg every 12 hours then reduce gradually to
once daily and eventually give 2 mg only when
DO NOT INITIATE LITHIUM AND VALPROATE AT
LOWER CENTRE EXECEPT AS CONTINUATION
"REFER if poor response, poor adherence, pregnant, side"
"effects, underlying physical or mental comorbidity"
Depressive symptoms but with history of manic episode
"Serum lithium should be monitored 12 hours after dose,"
"twice weekly until serum concentration and clinical condition stabilize, and every 3 months thereafter."
Increase dose as tolerated to target serum lithium concentrations of 0.8-mEqL.
"Monitor Wt, BP, PR, Lipid profile and LFTs. Do RFTS,"
TSH and Ca levels for those on Lithium 
"If agitationrestlessness, add a benzodiazepine for short"
period (until symptoms improve)
Diazepam 5-10 mg every 12 hours
Zuclopenthixaol acetate 50-100 mg given 48-72 hours
" If extrapyramidal side-effects (muscle rigidity,"
"dripping of saliva, tongue protrusion, tremors)"
are present while on antipsychotic drugs
- Add an anticholinergic: Benzhexol initially 2
mg every 12 hours then reduce gradually to
once daily and eventually give 2 mg only when
DO NOT INITIATE LITHIUM AND VALPROATE AT
LOWER CENTRE EXECEPT AS CONTINUATION
"REFER if poor response, poor adherence, pregnant, side"
"effects, underlying physical or mental comorbidity "
Depressive symptoms but with history of manic episode
Psychological support for mild depression otherwise refer
"If on olanzapine, add fluoxetine or give quetiapine alone."
Begin treatment with a mood stabilizer (carbamazepine
Psychoeducation and psychotherapy if available
"If moderatesevere depression, consider treatment with"
antidepressant in addition to mood stabilizer BUT under
specialist supervision (there is risk of triggering a manic
Indication for use of mood stabilizers to prevent both
- 2 or more episodes (2 manic or 1 manic and
- 1 severe manic episode involving significant
Valproate (or carbamazepine) as above or lithium at
Provide psychoeducation and support
Avoid mood stabilizers in pregnant women. Use low dose haloperidol
Refer adolescents for specialist management
Psychological support for mild depression otherwise refer
"If on olanzapine, add fluoxetine or give quetiapine alone."
Begin treatment with a mood stabilizer (carbamazepine
Psychoeducation and psychotherapy if available
"If moderatesevere depression, consider treatment with"
antidepressant in addition to mood stabilizer BUT under
specialist supervision (there is risk of triggering a manic
Indication for use of mood stabilizers to prevent both
- 2 or more episodes (2 manic or 1 manic and
- 1 severe manic episode involving significant
Valproate (or carbamazepine) as above or lithium at
Provide psychoeducation and support 
Avoid mood stabilizers in pregnant women. Use low dose haloperidol
Refer adolescents for specialist management 
"A mental condition characterized by distortions of thinking and perception, as well as inappropriate or narrowed range of emotions."
" Not known, but there are associated biological, genetic and"
Any one or more of these may be diagnostic:
" Delusions (abnormal, fixed, false beliefs) or excessive and"
"unwarranted suspicions (may be multiple, fragmented or"
 Disconnected ideas with vague or incoherent speech and
 Hallucinations: hearing voices or seeing things that are not
 Severe behaviour abnormalities: agitation or disorganised
"behaviour, excitement, inactivity or overactivity"
 Disturbance of emotions such as marked apathy or disconnection between reported emotions and observed effect
 Difficulty in forming and sustaining relationships
 Social withdrawal and neglect of usual responsibilities
Chronic psychosis or schizophrenia
 Symptoms of psychosis lasting for 3 or more months
" Accompanied by deterioration in social, general and occupational"
 Alcohol and drug intoxication or withdrawal
" Organic delirium, dementia, mood disorders"
" Good social, personal and family history"
" Laboratory investigations for infectious diseases e.g. HIV,"
Counsellingpsychoeducation of patient and
Chlorpromazine: starting dose 75-150 mg daily
and maintenance dose of 75-300 mg daily. Up to
1000 mg daily in divided does may be required for H
Or Haloperidol: starting dose 5-10 mg daily
- (Lower in elderly) and maintenance dose of
"- Or Olanzapine 5-10 mg daily, maintenance"
"- Or Risperidone 2 mg initially, may increase to"
- Or Quetiapine 150-750mgday twice daily
"- Or For treatment resistant schizophrenia,"
"Clozapine 25-50mgday initially, if well"
tolerated titrate to 450mg per day in two
Administer orally or IM for those with agitation RR
Only use one antipsychotic at a time
Gradually adjust doses depending on response
Monitor for side effects e.g. extrapyramidal side
Use therapeutic dose for 4-6 weeks to assess
Psychological interventions (family therapy or
social skills therapy) if available
Counsellingpsychoeducation of patient and
Chlorpromazine: starting dose 75-150 mg daily
and maintenance dose of 75-300 mg daily. Up to
1000 mg daily in divided does may be required for
Or Haloperidol: starting dose 5-10 mg daily
- (Lower in elderly) and maintenance dose of
"- Or Olanzapine 5-10 mg daily, maintenance"
"- Or Risperidone 2 mg initially, may increase to"
- Or Quetiapine 150-750mgday twice daily
"- Or For treatment resistant schizophrenia,"
"Clozapine 25-50mgday initially, if well"
tolerated titrate to 450mg per day in two
weeks depending on response HC2
Administer orally or IM for those with agitation
Only use one antipsychotic at a time
Gradually adjust doses depending on response
Monitor for side effects e.g. extrapyramidal side
Use therapeutic dose for 4-6 weeks to assess
Psychological interventions (family therapy or
social skills therapy) if available
"For acute psychosis, continue treatment for at RR"
least 12 months. Discuss discontinuation with
"patient, carergivers and specialist"
If extrapyramidal side-effects HC2
Add an anticholinergic: Benzhexol initially 2
mg every 12 hours then reduce gradually to
once daily and eventually give 2 mg only when
"Treat as above, but if adherence is a problem or"
Fluphenazine decanoate 12.5-50 mg every 2-5
weeks deep IM into gluteal muscle
Or Haloperidol injection (oily) 50-200 mg (300 RR
mg) deep IM into gluteal muscle every 3-4 weeks
OR Zuclopenthixol decanoate 200-500mg every
Psychosocial support for long term care
9.Postnatal Psychosis ICD10 CODE: F53 Postpartum
psychosis is the most severe form of postpartum psychiatric illness.
" Not well known, but hormonal changes may have a role"
 Previous episode of post-natal psychosis
 Previous major psychiatric history
"For acute psychosis, continue treatment for at"
least 12 months. Discuss discontinuation with
"patient, carergivers and specialist RR"
Add an anticholinergic: Benzhexol initially 2
mg every 12 hours then reduce gradually to
once daily and eventually give 2 mg only when
"Treat as above, but if adherence is a problem or"
Fluphenazine decanoate 12.5-50 mg every 2-5
weeks deep IM into gluteal muscle
Or Haloperidol injection (oily) 50-200 mg (300
mg) deep IM into gluteal muscle every 3-4 weeks
OR Zuclopenthixol decanoate 200-500mg every
Psychosocial support for long term care HC4
 Family history of mental illness
 Inadequate psychosocial support during pregnancy
 Symptoms develop within the first 2 postpartum weeks
(sometimes as early as 48-72 hours after delivery)
 The condition resembles a rapidly evolving manic or
mixed episode with symptoms such as restlessness and
"insomnia, irritability, rapidly shifting depressed or elated"
 The mother may have delusional beliefs that relate to the
"infant (e.g. the baby is defective or dying, the infant is"
 Satan or God) or she may have auditory hallucinations
that instruct her to harm herself or her infant
 The risk for infanticide and suicide is high
 Depression with psychotic features
"Good history, physical and psychiatric assessment"
It is a psychiatric emergency: admit to hospital H
Treat any identifiable causeprecipitant e.g.
Haloperidol 10 mg or Chlorpromazine 200 mg
Intramuscular Injection or tablets every 8 or
12 hours. Monitor response to medication and
"If restless and agitated, add rectal or I.523"
It is a psychiatric emergency: admit to hospital
Treat any identifiable causeprecipitant e.g.
Haloperidol 10 mg or Chlorpromazine 200 mg
Intramuscular Injection or tablets every 8 or
12 hours. Monitor response to medication and
"If restless and agitated, add rectal or I.V H"
Diazepam 5-10 mg slow infusion; repeat after H
- Continue with diazepam tablet 5 mg every
 Post-natal psychoses are no different from other similar
"psychoses, give concurrent psychosocial interventions and drug"
" Proper antenatal screening, good psychosocial support"
" Adherence to treatment for a current mental illness e.g depression, bipolar, chronic psychosis"
PSYCHIATRIC AND SUBSTANCE USE DISORDERS
"Anxiety is a normal physiological response, which enables a person to"
take steps to deal with a threat. When anxiety is prolonged or interferes
"individual, it constitutes the clinical condition of an anxiety disorder."
 Not fully understood: possibly external traumatic events
may trigger anxiety in predisposed people
" Association with other mental conditions e.g. depression,"
Diazepam 5-10 mg slow infusion; repeat after
- Continue with diazepam tablet 5 mg every
 Generalized anxiety: Unrealistic and excessive worry
 Panic attacks: Episodes of sudden onset of intense apprehension or fear; anxiety symptoms usually peak within
10-15 minutes and resolve in a few minutes to one hour
 Phobia: An excessive fear of a known stimulus (object or
" situation) e.g. animals, water, confined space) causing the"
person to consciously avoid the object or situation
Each of the above clinical types will have one or more of the
" Sleep, mood and concentration problems"
" Palpitations, dizziness, shortness of breath"
" Shakiness or tremors, excessive sweatiness"
" Other symptoms: urinary frequency, hesitancy, or urgency, diarrhoea"
" Consider organic conditions e.g. hyperthyroidism, hypoglycaemia, phaeochromocytoma"
"Psychosocial interventions: counselling, HC2"
psychotherapy (individual and group psychotherapy)
For an acute episode or intense prolonged anxiety
Benzodiazepines e.g. diazepam 5 mg 1-2 times daily
- Increase if necessary to 15-30 mg daily in
Elderly: Alprazolam 0.25mg -0.5mg twice daily
"initially, Increase if necessary to 3-6 mg daily in"
"If alprazolam is not available, Give half the above dose"
"Psychosocial interventions: counselling,"
psychotherapy (individual and group psychotherapy)
For an acute episode or intense prolonged anxiety
Benzodiazepines e.g. diazepam 5 mg 1-2 times daily
- Increase if necessary to 15-30 mg daily in
Elderly: Alprazolam 0.25mg -0.5mg twice daily
"initially, Increase if necessary to 3-6 mg daily in"
"If alprazolam is not available, Give half the above dose"
"- Duration of therapy 1-2 weeks, tapering off to HC2"
If poor response: refer to specialist
Fluoxetine 20 mg once a day for long term
management of the anxiety disorder
- Continue antidepressant for 4 to 6 weeks then HC4
Diazepam is addictive and abrupt cessation can cause
withdrawal symptoms. Use for short periods and gradually
" Diazepam is NOT appropriate for treating depression, phobic"
"or obsessional states, or chronic psychoses (see relevant"
 Antidepressants: May be useful in managing panic disorders
and other anxiety disorders which require long term treatment
"Depression ICD10 CODE: F32, F33"
"A common disorder characterised by low mood, loss of interest and"
enjoyment and reduced energy leading to diminished activity and in
"severe forms, difficult day-to-day functioning."
"- Duration of therapy 1-2 weeks, tapering off to"
If poor response: refer to specialist
Fluoxetine 20 mg once a day for long term
management of the anxiety disorder
- Continue antidepressant for 4 to 6 weeks then
Diazepam is addictive and abrupt cessation can cause
withdrawal symptoms. Use for short periods and gradually
" Diazepam is NOT appropriate for treating depression, phobic"
"or obsessional states, or chronic psychoses (see relevant"
 Antidepressants: May be useful in managing panic disorders
and other anxiety disorders which require long term treatment 
" Biological, genetic, and environmental factors"
"For at least two weeks, the person had at least two of the symptoms below:"
" Low mood (most of the day, almost every day)"
 Loss of interest or pleasure in activities that are normally
" Associated lack of energy, body weakness or easily fatigued"
" During the 2 weeks, the person also has some of the symptoms below:"
" Difficulty in concentrating, reduced attention"
 Reduced self-esteem and self confidence
" Poor sleep, poor appetite, reduced libido"
 Bleak and pessimistic view of the future
 Feeling of guilt and unworthiness
 Multiple body pains or other medically unexplained somatic symptoms
 Ideas or acts of self harm or suicide (occurs in up to 65
" Children and adolescents usually present with irritability,"
"school phobia, truancy, poor academic performance, alcohol and drug abuse"
 Thyroid dysfunction (hypothyroidism)
 Adrenal dysfunction (Addisons disease)
" Parkinsons disease, stroke, dementia"
" Medical, social and personal history"
 Check for bereavement or other major personal loss
 Find out if person has had an episode of mania in the past: if so
consider treatment for bipolar disorder and consult a specialist
 Find out if they have psychotic features e.g. hallucinations (refer
" Assess for co-occurring health conditions (e.g. HIVAIDS),"
 Assess risk of self-harmsuicide
Psychological therapy (Individual or group psychotherapy) is first line
- Psychoeducation (counselling of patient and family)
"- Addressing current stressors (abuse, neglect)"
- Re activating social networks
- Structured physical activities
Manage concurrent physical medical problems
Address co-existing mental problems e.g. substance abuse
"If available, consider psychotherapy (cognitive behavioural"
"therapy, interpersonal psychotherapy, behavioural activation"
If bereavement or another major personal loss
- Do not consider drugs or psychotherapy as first line
Psychological therapy (Individual or group psychotherapy) is first line
- Psychoeducation (counselling of patient and family) 
"- Addressing current stressors (abuse, neglect)"
- Re activating social networks
- Structured physical activities
Manage concurrent physical medical problems
Address co-existing mental problems e.g. substance abuse
"If available, consider psychotherapy (cognitive behavioural"
"therapy, interpersonal psychotherapy, behavioural activation"
If bereavement or another major personal loss
- Do not consider drugs or psychotherapy as first line 
- If not responding to all above HC4
- DO NOT use in children 12 years
- Adolescents: only under specialist supervision RR
Fluoxetine 20 mg once daily in the morning
"- If not better after 4-6 weeks, increase to 40 mg H"
Or Amitriptyline 50 mg at bedtime
- Increase by 25 mg every week aiming at 100-150
mg in divided doses or single bedtime dose by 4-6
- Useful in case of associated anxiety
"- Avoid in adolescents, elderly, heart diseases,"
- Or Venflaxine mg given in the morning or
- Increase dose to75mg per day divided 8-12 hourly
- Maintenance dose is 75 to 225 mg once a day H
- Maximum dose is 375mg; Useful in the patients
with comorbid anxiety disorders.
- Or Sertaline 50mg per day; preferred for patients RR
on other medicines due to its low potential for
"drug interactions and for breast feeding mothers,"
may increase dose by 25mg at weekly intervals RR
"- Or Escitalopram10mg, may increase dose to 20mg"
- Or Bupropion 150 mgday PO for those than
cannot tolerate SSRIs and with comorbid Nicotine
use disorder. Titrate to 150-450 mgday based on
tolerability and efficacy; may administer in divided
- If not responding to all above
- DO NOT use in children 12 years
- Adolescents: only under specialist supervision
Fluoxetine 20 mg once daily in the morning
"- If not better after 4-6 weeks, increase to 40 mg"
Or Amitriptyline 50 mg at bedtime
- Increase by 25 mg every week aiming at 100-150
mg in divided doses or single bedtime dose by 4-6
- Useful in case of associated anxiety
"- Avoid in adolescents, elderly, heart diseases,"
- Or Venflaxine mg given in the morning or
- Increase dose to75mg per day divided 8-12 hourly HC4
- Maintenance dose is 75 to 225 mg once a day
- Maximum dose is 375mg; Useful in the patients
with comorbid anxiety disorders.
- Or Sertaline 50mg per day; preferred for patients
on other medicines due to its low potential for
"drug interactions and for breast feeding mothers,"
may increase dose by 25mg at weekly intervals
"- Or Escitalopram10mg, may increase dose to 20mg"
- Or Bupropion 150 mgday PO for those than
cannot tolerate SSRIs and with comorbid Nicotine
use disorder. Titrate to 150-450 mgday based on
tolerability and efficacy; may administer in divided
If patient responding to medication
Continue for at least 9-12 months
Consider stopping if patient has been without
depressive symptoms and able to carry out normal
activities for at least 9 months
- Counsel the patient about withdrawal symptoms
"- (dizziness, tingling, anxiety, irritability, nausea,"
- Counsel the patient about possibility of relapse
- Reduce slowly over at least 4 weeks even slower
- withdrawal symptoms are significant
- Monitor periodically for re-emergence of
"In case of pregnant woman, child, adolescent,"
patients not responding to treatment with
"antidepressant, psychotic features, history of mania"
Refer for specialist management
SSRI in bipolar depression can trigger a manic
 Promotion of useful social support networks
If patient responding to medication
Continue for at least 9-12 months
Consider stopping if patient has been without
depressive symptoms and able to carry out normal
activities for at least 9 months
- Counsel the patient about withdrawal symptoms
"- (dizziness, tingling, anxiety, irritability, nausea,"
- Counsel the patient about possibility of relapse
- Reduce slowly over at least 4 weeks even slower
- withdrawal symptoms are significant
- Monitor periodically for re-emergence of
"In case of pregnant woman, child, adolescent,"
patients not responding to treatment with
"antidepressant, psychotic features, history of mania"
Refer for specialist management 
SSRI in bipolar depression can trigger a manic 
"9.Suicidal BehaviourSelf Harm ICD10 CODES: T14.91, Z91.5"
Suicidal behaviour is an emergency and requires immediate attention.
"It is an attempted conscious act of self-destruction, which the individual"
concerned views as the best solution. It is usually associated with feelings
"of hopelessness, helplessness and conflicts between survival and death."
"Self-harm is a broader term referring to intentional poisoning or self-inflicted harm, which may or may not have an intent of fatal outcome."
" Physical illness e.g. HIVAIDS, head injury, malignancies,"
"body disfigurement, chronic pain"
" Psychiatric disorders e.g. depression, chronic psychosis,"
"dementia, alcohol and substance use disorders, personality"
Risk is high in the following cases:
 History of recent loss or disappointment
" Current mental illness e.g. depression, psychosis"
 Evidence of violent behaviour or previous psychiatric admi
 Married or in stable interpersonal relationships
Patients can present in one of the following situations:
 A current suicide attempt or self harm
 A situation of imminent risk of suicidal attempt or self harm:
- Current thoughts or plans of suicideself harm or history of
"thoughts or plans of suicideself harm in the last 1 month,"
or acts of self harmsuicide attempts in the last 1 years plus
"- Person is agitated, violent, emotionally distressed or"
"uncommunicative and socially isolated, hopeless"
 A situation of no imminent risk but
- Thoughts or plans of suicideself harm in the last 1 month
or acts of selfharmsuicide attempt in the last one year in
" Complete medical, social and family history"
 Ask the patient about suicidal or self harm thoughtsplans acts
 Asking about self harm or suicide does not increase the risk of
"those acts. On the contrary, it may help the patient to feel understood and considered. First try to establish a good relationship"
 Always assess risk of suicide and self-harm in patient
" With any other mental illness (depression, mania, psychosis,"
"alcohol and substance abuse, dementia, behavioural or development disorders)"
" Chronic pain, severe emotional distress"
If acute suicidal behaviouract of self harm or HC4
Admit the patient and treat any medical
"complications (bleeding, poisoning etc.)"
Keep in a secure and supportive environment
Offeractivate psychosocial support
Consult mental health specialist
Treat any medical and mental condition present
Offeractivate psychosocial support
Refer to mental health specialist for further
" Suicide is less frequent in children and adolescents, but there"
is increased risk if there is disturbed family background (e.g.
"death of parents, divorce), use of alcohol and other drugs of"
"abuse, physical illness, psychiatric disorder"
"Bipolar Disorder (Mania) ICD10 CODE: F30, F31"
A disorder of mood control characterized by episodes in which the
persons mood and activity level are significantly disturbed: in some
"occasions, there is an elevation of mood and increased energy and"
"activity (mania) and in other occasions, there is a lowering of mood and"
"decreased energy and activity (depression). Characteristically, recovery"
is complete in between the episodes.
If acute suicidal behaviouract of self harm or
Admit the patient and treat any medical
"complications (bleeding, poisoning etc.)"
Keep in a secure and supportive environment
Offeractivate psychosocial support
Consult mental health specialist
Treat any medical and mental condition present HC4
Offeractivate psychosocial support
Refer to mental health specialist for further
" Suicide is less frequent in children and adolescents, but there"
is increased risk if there is disturbed family background (e.g.
"death of parents, divorce), use of alcohol and other drugs of"
"abuse, physical illness, psychiatric disorder "
" Biological, genetic, environmental factors"
"Patient can present in an acute manic episode, in a depressive episode"
" Elevated, expansive or irritable moods and increased activity or subjective experience of increased energy"
" Increased self-image, self-esteem or grandiosity,"
" Impulsive reckless behavior, extravagancy, partying and,"
" Increased sexual drive, sociability and goal directed behaviour"
 Increased appetite but weight loss occurs due to over- activity
 Auditory and visual hallucinations may be present
" As for depression described above, but with a history of"
 High index of suspicion for bipolar in early onset depression with family history of bipolar illness
" Organic mental states e.g. drug or alcohol intoxication, delirium"
" Good medical, social and personal history"
 Assess for acute state of mania
" If depressive symptoms, investigate for previous manic episodes"
 Assess for other medical or mental conditions (alcohol or
"substance abuse, dementia, suicideself harm)"
Patients with suspected bipolar disorder should be referred for specialist
Multiple symptoms as above for  1 week and
severe enough to interfere with worksocial
activities andor requiring hospitalization
Discontinue antidepressant if any
Provide counseling and education HC4
Chlorpromazine initially 100-200 mg every 8
"hours, then adjust according to response"
- Daily doses of up to 300 mg may be given as
- Gradually reduce the dose when symptoms
of mania resolve and maintain on doses as
indicated in section on Chronic psychosis
Or haloperidol initially 5-10 mg every 12 hours
then adjust according to response
- Up to 30-40 mg daily may be required in
Or trifluoperazine initially 5-10 mg every
12hours then adjust according to response
Multiple symptoms as above for  1 week and
severe enough to interfere with worksocial
activities andor requiring hospitalization
Discontinue antidepressant if any
Provide counseling and education
Chlorpromazine initially 100-200 mg every 8
"hours, then adjust according to response"
- Daily doses of up to 300 mg may be given as
- Gradually reduce the dose when symptoms
of mania resolve and maintain on doses as
indicated in section on Chronic psychosis
Or haloperidol initially 5-10 mg every 12 hours
then adjust according to response
- Up to 30-40 mg daily may be required in
Or trifluoperazine initially 5-10 mg every
12hours then adjust according to response HC3
- Or Olanzapine 10-15 mgday initially; may HC3
adjust to 20mg according to response
"- Or Risperidone 2-3mg initially, may increase"
to 6mg in over 3 weeks according to response.
If under specialist supervision: initiate a mood stabilizer H
"Carbamazepine initial dose 200 mg at night, increase"
slowly to 600-1000 mgday in divided doses
Or Valproate initial dose of 500 mgday. Usual maintenance dose 1000-2000 mg
Or Lithium 900-1800mgday in in two divided doses (RR)
"Serum lithium should be monitored 12 hours after dose,"
"twice weekly until serum concentration and clinical condition stabilize, and every 3 months thereafter."
Increase dose as tolerated to target serum lithium concentrations of 0.8-mEqL.
"Monitor Wt, BP, PR, Lipid profile and LFTs. Do RFTS,"
TSH and Ca levels for those on Lithium
"If agitationrestlessness, add a benzodiazepine for short HC2"
period (until symptoms improve)
Diazepam 5-10 mg every 12 hours
Zuclopenthixaol acetate 50-100 mg given 48-72 hours
- Or Olanzapine 10-15 mgday initially; may
adjust to 20mg according to response
"- Or Risperidone 2-3mg initially, may increase"
to 6mg in over 3 weeks according to response. HC3
If under specialist supervision: initiate a mood stabilizer
"Carbamazepine initial dose 200 mg at night, increase"
slowly to 600-1000 mgday in divided doses
Or Valproate initial dose of 500 mgday. Usual maintenance dose 1000-2000 mg
Or Lithium 900-1800mgday in in two divided doses (RR) H
"Serum lithium should be monitored 12 hours after dose,"
"twice weekly until serum concentration and clinical condition stabilize, and every 3 months thereafter."
Increase dose as tolerated to target serum lithium concentrations of 0.8-mEqL.
"Monitor Wt, BP, PR, Lipid profile and LFTs. Do RFTS,"
TSH and Ca levels for those on Lithium 
"If agitationrestlessness, add a benzodiazepine for short"
period (until symptoms improve)
Diazepam 5-10 mg every 12 hours
Zuclopenthixaol acetate 50-100 mg given 48-72 hours
" If extrapyramidal side-effects (muscle rigidity,"
"dripping of saliva, tongue protrusion, tremors)"
are present while on antipsychotic drugs
- Add an anticholinergic: Benzhexol initially 2
mg every 12 hours then reduce gradually to
once daily and eventually give 2 mg only when
DO NOT INITIATE LITHIUM AND VALPROATE AT
LOWER CENTRE EXECEPT AS CONTINUATION
"REFER if poor response, poor adherence, pregnant, side"
"effects, underlying physical or mental comorbidity"
Depressive symptoms but with history of manic episode
Psychological support for mild depression otherwise refer
"If on olanzapine, add fluoxetine or give quetiapine alone."
Begin treatment with a mood stabilizer (carbamazepine
Psychoeducation and psychotherapy if available
"If moderatesevere depression, consider treatment with"
antidepressant in addition to mood stabilizer BUT under
specialist supervision (there is risk of triggering a manic
" If extrapyramidal side-effects (muscle rigidity,"
"dripping of saliva, tongue protrusion, tremors)"
are present while on antipsychotic drugs
- Add an anticholinergic: Benzhexol initially 2
mg every 12 hours then reduce gradually to
once daily and eventually give 2 mg only when
DO NOT INITIATE LITHIUM AND VALPROATE AT
LOWER CENTRE EXECEPT AS CONTINUATION
"REFER if poor response, poor adherence, pregnant, side"
"effects, underlying physical or mental comorbidity "
Depressive symptoms but with history of manic episode
Psychological support for mild depression otherwise refer
"If on olanzapine, add fluoxetine or give quetiapine alone."
Begin treatment with a mood stabilizer (carbamazepine
Psychoeducation and psychotherapy if available
"If moderatesevere depression, consider treatment with"
antidepressant in addition to mood stabilizer BUT under
specialist supervision (there is risk of triggering a manic
Indication for use of mood stabilizers to prevent both
- 2 or more episodes (2 manic or 1 manic and
- 1 severe manic episode involving significant
Valproate (or carbamazepine) as above or lithium at
Provide psychoeducation and support
Avoid mood stabilizers in pregnant women. Use low dose haloperidol
Refer adolescents for specialist management
"A mental condition characterized by distortions of thinking and perception, as well as inappropriate or narrowed range of emotions."
" Not known, but there are associated biological, genetic and"
Indication for use of mood stabilizers to prevent both
- 2 or more episodes (2 manic or 1 manic and
- 1 severe manic episode involving significant
Valproate (or carbamazepine) as above or lithium at
Provide psychoeducation and support 
Avoid mood stabilizers in pregnant women. Use low dose haloperidol
Refer adolescents for specialist management 
Any one or more of these may be diagnostic:
" Delusions (abnormal, fixed, false beliefs) or excessive and"
"unwarranted suspicions (may be multiple, fragmented or"
 Disconnected ideas with vague or incoherent speech and
 Hallucinations: hearing voices or seeing things that are not
 Severe behaviour abnormalities: agitation or disorganised
"behaviour, excitement, inactivity or overactivity"
 Disturbance of emotions such as marked apathy or disconnection between reported emotions and observed effect
 Difficulty in forming and sustaining relationships
 Social withdrawal and neglect of usual responsibilities
Chronic psychosis or schizophrenia
 Symptoms of psychosis lasting for 3 or more months
" Accompanied by deterioration in social, general and occupational functioning"
 Alcohol and drug intoxication or withdrawal
" Organic delirium, dementia, mood disorders"
" Good social, personal and family history"
" Laboratory investigations for infectious diseases e.g. HIV,"
Counsellingpsychoeducation of patient and
Chlorpromazine: starting dose 75-150 mg daily
and maintenance dose of 75-300 mg daily. Up to HC4
1000 mg daily in divided does may be required for
Or Haloperidol: starting dose 5-10 mg daily H
- (Lower in elderly) and maintenance dose of
"- Or Olanzapine 5-10 mg daily, maintenance H"
"- Or Risperidone 2 mg initially, may increase to"
- Or Quetiapine 150-750mgday twice daily
"- Or For treatment resistant schizophrenia,"
"Clozapine 25-50mgday initially, if well NR"
tolerated titrate to 450mg per day in two
Administer orally or IM for those with agitation
Only use one antipsychotic at a time
Gradually adjust doses depending on response
Monitor for side effects e.g. extrapyramidal side
Use therapeutic dose for 4-6 weeks to assess
Psychological interventions (family therapy or
social skills therapy) if available
"For acute psychosis, continue treatment for at"
least 12 months. Discuss discontinuation with
"patient, carergivers and specialist"
Counsellingpsychoeducation of patient and
Chlorpromazine: starting dose 75-150 mg daily
and maintenance dose of 75-300 mg daily. Up to
1000 mg daily in divided does may be required for
Or Haloperidol: starting dose 5-10 mg daily
- (Lower in elderly) and maintenance dose of
"- Or Olanzapine 5-10 mg daily, maintenance"
"- Or Risperidone 2 mg initially, may increase to"
- Or Quetiapine 150-750mgday twice daily
"- Or For treatment resistant schizophrenia,"
"Clozapine 25-50mgday initially, if well"
tolerated titrate to 450mg per day in two
weeks depending on response HC2
Administer orally or IM for those with agitation
Only use one antipsychotic at a time
Gradually adjust doses depending on response
Monitor for side effects e.g. extrapyramidal side
Use therapeutic dose for 4-6 weeks to assess
Psychological interventions (family therapy or
social skills therapy) if available
"For acute psychosis, continue treatment for at"
least 12 months. Discuss discontinuation with
"patient, carergivers and specialist RR"
If extrapyramidal side-effects HC2
Add an anticholinergic: Benzhexol initially 2
mg every 12 hours then reduce gradually to
once daily and eventually give 2 mg only when
"Treat as above, but if adherence is a problem or"
Fluphenazine decanoate 12.5-50 mg every 2-5
weeks deep IM into gluteal muscle
Or Haloperidol injection (oily) 50-200 mg (300 RR
mg) deep IM into gluteal muscle every 3-4 weeks
OR Zuclopenthixol decanoate 200-500mg every
Psychosocial support for long term care
9.Postnatal Psychosis ICD10 CODE: F53 Postpartum
psychosis is the most severe form of postpartum psychiatric illness.
" Not well known, but hormonal changes may have a role"
 Previous episode of post-natal psychosis
 Previous major psychiatric history
 Family history of mental illness
 Inadequate psychosocial support during pregnancy
Add an anticholinergic: Benzhexol initially 2
mg every 12 hours then reduce gradually to
once daily and eventually give 2 mg only when
"Treat as above, but if adherence is a problem or"
Fluphenazine decanoate 12.5-50 mg every 2-5
weeks deep IM into gluteal muscle
Or Haloperidol injection (oily) 50-200 mg (300
mg) deep IM into gluteal muscle every 3-4 weeks
OR Zuclopenthixol decanoate 200-500mg every
Psychosocial support for long term care HC4
 Symptoms develop within the first 2 postpartum weeks
(sometimes as early as 48-72 hours after delivery)
 The condition resembles a rapidly evolving manic or mixed
"episode with symptoms such as restlessness and insomnia,"
"irritability, rapidly shifting depressed or elated mood and"
 The mother may have delusional beliefs that relate to the
"infant (e.g. the baby is defective or dying, the infant is"
 Satan or God) or she may have auditory hallucinations that
instruct her to harm herself or her infant
 The risk for infanticide and suicide is high
 Depression with psychotic features
"Good history, physical and psychiatric assessment"
It is a psychiatric emergency: admit to hospital H
Treat any identifiable causeprecipitant e.g.
Haloperidol 10 mg or Chlorpromazine 200 mg
Intramuscular Injection or tablets every 8 or
12 hours. Monitor response to medication and
"If restless and agitated, add rectal or I.Diazepam 5-10 mg slow infusion; repeat after 10"
- Continue with diazepam tablet 5 mg every
It is a psychiatric emergency: admit to hospital
Treat any identifiable causeprecipitant e.g.
Haloperidol 10 mg or Chlorpromazine 200 mg
Intramuscular Injection or tablets every 8 or
12 hours. Monitor response to medication and
"If restless and agitated, add rectal or I.Diazepam 5-10 mg slow infusion; repeat after 10"
- Continue with diazepam tablet 5 mg every
" Proper antenatal screening, good psychosocial support"
" Adherence to treatment for a current mental illness e.g depression, bipolar, chronic psychosis"
Alcohol Use Disorders ICD10 CODE: F10
"Conditions resulting from different patterns of alcohol consumption,"
"including acute alcohol intoxication, harmful alcohol use, alcohol dependence syndrome and alcohol withdrawal state."
 No single cause; a combination of factors usually leads to
 Social and environmental factors including availability
 Transient condition following intake of alcohol resulting in
"disturbances of consciousness, cognition, perception, affect or behaviour"
 Pattern of alcohol consumption that is causing damage to
"the health, physical (e.g. liver disease) or mental (e.g. depressive disorder)."
" And causing problems to ones social, occupational and"
other important areas of life. Criteria:
- More than five drinks in any given occasion in the last 12
 These patients consume more alcohol than
 Recommended but they do not fulfil (yet) the criteria for
Alcohol consumption during pregnancy is extremely harmful for the
 A disorder characterised by the need to take large daily
amounts of alcohol for adequate functioning. The use of
alcohol takes on a much higher priority for the individual
than other behaviours that once had greater value
" Complications: malnutrition, thiamine deficiency (causing"
"Wernicke encephalopathy), liver disease, chronic pancreatitis, peptic ulcer, cardiomyopathy, neuropathy, head trauma"
 Symptoms occurring upon cessation of alcohol after its
prolonged daily use (6 hours to 6 days after)
" Tremor in hands, sweating, vomiting, tachycardia, hypertension, agitation, anxiety, headache, seizure and confusion"
 A disorder characterised by the need to take large daily
amounts of alcohol for adequate functioning. The use of
alcohol takes on a much higher priority for the individual
than other behaviours that once had greater value
" Complications: malnutrition, thiamine deficiency (causing"
"Wernicke encephalopathy), liver disease, chronic pancreatitis, peptic ulcer, cardiomyopathy, neuropathy, head trauma"
 Symptoms occurring upon cessation of alcohol after its
prolonged daily use (6 hours to 6 days after)
" Tremor in hands, sweating, vomiting, tachycardia, hypertension, agitation, anxiety, headache, seizure and confusion"
Diagnostic criteria for alcohol dependence:
If 3 or more of the features below are present:
 A strong desire to take alcohol
" Difficulties controlling alcohol use in terms of onset, termination or levels of use"
 A physiological withdrawal state when alcohol use has
ceased or been reduced (alcohol withdrawal syndrome)
 Evidence of tolerance: increased doses of alcohol are required to achieve effects originally produced by lower doses
 Progressive neglect of alternative pleasures or interests because of alcohol use
" Alcohol use persists despite clear evidence of harmful consequences e.g. liver damage, depression, cognitive impairment, loss of a job, friends, relationships"
 Abuse of other psychoactive substances
" Depression, chronic psychosis (often co-existing!)"
"Blood: complete blood count, liver enzymes"
- Shows elevated MCV and GGT levels
"Acute intoxication, withdrawal and Wernickes"
see section Harmful alcohol consumption HC3
Investigate and treat concurrent medical or
"psychiatric illness (dementia, depression anxiety,"
Follow up and refer if not better
Counselling and education of the patient
Assess and manage concurrent medical and
Advise thiamine 100 mg daily for at least two
"If patient willing to stop, facilitate alcohol cessation"
"Determine appropriate setting, refer for"
"detoxification, treat withdrawal symptoms with"
"Acute intoxication, withdrawal and Wernickes"
see section Harmful alcohol consumption
Investigate and treat concurrent medical or
"psychiatric illness (dementia, depression anxiety,"
Follow up and refer if not better HC3
Counselling and education of the patient
Assess and manage concurrent medical and
Advise thiamine 100 mg daily for at least two
"If patient willing to stop, facilitate alcohol cessation"
"Determine appropriate setting, refer for"
"detoxification, treat withdrawal symptoms with"
DETOXIFIATION should only be undertaken HC4
Consider referral to self -help groups (AA groups)
"Counsel the family, provide psychosocial"
 Health education on dangers of alcohol abuse
 Reduce accessibility to alcohol
Substance Abuse ICD10 CODE: F11-F19
Conditions resulting from different patterns of drug use including acute
"sedative overdose, acute stimulant intoxication, harmful or hazardous drug"
"use, cannabis dependence, opioid dependence, stimulant dependence,"
benzodiazepine dependence and their corresponding withdrawal states.
- Harmful or hazardous use: causing damage to health
"(physical, mental or social functioning)"
- Dependence: situation in which drug use takes on a much
higher priority for a given individual than other behaviours that once
" Social factors: peer pressure, idlenessunemployment, social pressures, poverty, cultural use, increased availability"
" Psychological factors: other psychiatric disorders e.g. anxiety, depression, stress, adolescent development changes"
" Tobacco (cigarettes, shisha, kuber, mirage, migagi)"
" Cannabis (njaga, bhangi, marijuana)"
DETOXIFIATION should only be undertaken
Consider referral to self -help groups (AA groups)
"Counsel the family, provide psychosocial"
 Petrol fumes and organic solvents (e.g. thinners)
" Opioids: pethidine, morphine, Tramadol"
Presenting features that may point to drug use disorders
 Change in behaviour e.g. excessive irritability
 Change in function e.g. decline in schoolwork performance
" Episodes of intoxication e.g. slurred speech, staggering gait"
" Involvement in illegal activities e.g. rape, theft"
" Change in appearance e.g. weight loss, red eyes, puffy"
"face, untidy, scars from multiple needle pricks"
" Financial difficulties e.g. stealing, unpaid debts"
" Relationship problems e.g. increased conflicts, communication breakdown"
 Find out if person uses illegal or prescribed drugs in a way
that risks damage to their health
" Neonatal Abstinence Syndrome -Symptoms (W ithdrawal, rritability, T remors, Hyperactive, high pitched cry, hypotonia, D iarrhea, disorganized suck, R espiratory distress,"
"rhinorrhea, A pnoeic attacks, W eight loss, A lkalosis (respiratory), L acrimation"
 Ask about use of illicit or non-prescribed drugs
"If yes, assess for features of dependence (3 or more of the following):"
- A strong desire to take drugs
"- Difficulties controlling drug use in terms of onset, termination"
- A physiological withdrawal state when drug use has
- ceased or been reduced (as shown by classic withdrawal
- Evidence of tolerance: increased doses of the drug are
required to achieve effects originally produced by lower doses
- Progressive neglect of alternative pleasures or interests
- Drug use persists despite clear evidence of harmful
"- consequences e.g. depression, loss of a job"
 Investigate concurrent physical or mental illnesses
Assess for and manage co-existing medical HC2
conditions e.g. HAssess for harmful use (substance abuse but not
meeting criteria for dependence) or dependence
Psychoeducation and counselling
Refer to higher LOC for medical treatment of SUD
Treat presenting symptoms (acute intoxication or
Refer to self help groups if possible
Refer to specialist for further management
(detoxification and Medication Assisted Treatment;
Naltrexone for; alcohol and opiods; Methadone
and Buprenophine for opiods use disorder at RRH
and Acamprosate at NRH for alcohol.)
Assess for and manage co-existing medical
conditions e.g. HAssess for harmful use (substance abuse but not
meeting criteria for dependence) or dependence
Psychoeducation and counselling
Refer to higher LOC for medical treatment of SUD
Treat presenting symptoms (acute intoxication or
Refer to self help groups if possible HC2
Refer to specialist for further management
(detoxification and Medication Assisted Treatment;
Naltrexone for; alcohol and opiods; Methadone
and Buprenophine for opiods use disorder at RRH
and Acamprosate at NRH for alcohol.) 
 Health education on dangers of drug use
 Employmentrecreational opportunities
 Encourage social and cultural values
 Attempt to reduce availability of drugs of abuse in communities
Childhood Behavioural Disorders ICD10 CODE: F90-F98
A general term including more specific disorders such as attention deficit
hyperactivity disorder (ADHD) and other behavioural disorders. Only
"children and adolescents with moderate to severe degree of psychological,"
"social, educational or occupational impairment should be"
diagnosed as having behavioural disorders. In some children the problem
Investigate if the childs behavior is a reaction to trauma andor fear
"(child is bullied or harmed at home or outside home). In this case, it is"
"NOT a behavioral disorder; The bullying, and or Abuse must STOP!"
" Medical conditions, alcohol or drug use"
 Attention Deficit Hyperactivity Disorder (ADHD)
 Impaired attention (breaking off from tasks and leaving activities unfinished) so severe as to affect normal functioning
" Excessive restlessness, overactivity especially in situations"
"requiring calm, talkativeness, fidgeting"
 Of early onset (6 years) and lasting 6 months
" Unusually frequent and severe tantrums, persistent severe"
" Repetitive and persistent pattern of dissocial, aggressive or"
"defiant conduct (bullying, cruelty to animals, destructiveness, fire setting etc.), more severe than ordinary mischief,"
"not only in response to severe family or social stressors,"
" Epilepsy, developmental disorders"
 Medical conditions e.g..hyperthyroidism
Family psychoeducation and counselling HC4
"Contact teachers, advise and plan for special"
Psychosocial interventions if available
Refer to specialist for further management
For ADHD not improving with above interventions
Consider methylphenidate under specialist
Family psychoeducation and counselling
"Contact teachers, advise and plan for special"
Psychosocial interventions if available HC4
Refer to specialist for further management
For ADHD not improving with above interventions
Consider methylphenidate under specialist
Childhood Developmental Disorders ICD10 CODE: F80-F89
"A broad spectrum of disorders with childhood onset, characterized by"
"impairment or delay in functions related to central nervous system maturation, and with a steady course rather than remissions and relapses"
as in other mental illnesses. They include intellectual disabilitymental
retardation as well as pervasive developmental disorders such as autism.
 Nutritional deficiencies e.g. iodine deficiencies
" Risk factors: maternal depression, infections in pregnancy"
 Delay in development (using local developmental milestones or comparison with other children)
 Impairment of skills across multiple development areas (i.e.
"cognitive, (thinking), language, motor and skills)"
 Lower intellingence and decreased ability to adapt to daily
Pervasive developmental disorders including autism
" Impaired social behaviour, communication and language"
" Oddities in communication (lack of social use of language skills,"
lack of flexibility of language used)
 Loss of previously acquired skills
 Narrow range of interests and activities that are both unique to
the individual and carried out repetitively originating in infancy
 Some degree of intellectual disability may be present
" Some children may be gifted in specific areas e,g Music, computer"
" Look for other priority mental, neurological or substance use"
"disorder (depression, epilepsy, behavioural disorder)"
 Consider if delay in development could be due to non- stimulating
environment or maternal depression
 Assess for nutritional and other medical conditions e.g. sensory
"impairments (blindness, deafness etc.)"
Address medical issues including visual and HC4
"hearing impairment, nutritional problems"
"Contact teachers, advise and plan for special"
needs education. if their needs are not met in
Provide support to caregiversfamily
Link with community based rehabilitation services
Protect and promote human rights of the child:
THESE CHILDREN ARE VERY VULNERABLE
Refer to specialist for more comprehensive
Address medical issues including visual and
"hearing impairment, nutritional problems"
"Contact teachers, advise and plan for special"
needs education. if their needs are not met in
Provide support to caregiversfamily
Link with community based rehabilitation services
Protect and promote human rights of the child:
THESE CHILDREN ARE VERY VULNERABLE
Refer to specialist for more comprehensive
Pyogenic Arthritis (Septic Arthritis) ICD10 CODE: M00
"Acute infection of a single joint (usually a large joint), commonly affecting"
 Usually haematologenous spread from a primary focus
"following bacteraemia (e.g. septic skin lesions, sinus infections, throat infections, abrasions, wounds, pressure sores,"
" Commonly involved in acute arthritis: Staphylococcus aureus and Gram negative bacilli, e.g., Salmonella spp, Streptococcus spp, Gonococcus"
" In chronic septic arthritis: Brucella, tuberculosis"
" Severe pain, reduced or abolished movement, temporary"
loss of limb function (pseudoparalysis)
 Systemic symptoms: fever (neonates may not show fever
"but refuse to feed), general malaise"
 Complications: irreversible joint damage if immediate treatment is not established
" Intra-articular haemorrhage, e.g., haemophilia and other"
 Osteomyelitis of neighbouring bone
" Blood: Full blood count, CS, ESR (usually elevated)"
 Joint fluid: Aspirate for CS; in case of failure to get pus by
"aspiration, use arthrotomy (in theatre)"
" Provide pain relief, e.g., paracetamol, or ibuprofen HC2"
" Immobilise the involved limb, try splinting"
" REFER URGENTLY to HC4, or hospital"
" Aspirate articular fluid for gram stain, and CS if HC4"
available (use local skin and subcutaneous anaesthesia
- Repeat daily until no further pus is obtained
- Use diazepam mg rectal for sedation in
" Continue pain relief, use paracetamol, ibuprofen HC4"
- Or diclofenac 50 mg every 8 hours Child: mgkg rectally every 6-8 hours (max 150
- Or indomethacin 25-50 mg every 8 hours
" Provide pain relief, e.g., paracetamol, or ibuprofen"
" Immobilise the involved limb, try splinting"
" REFER URGENTLY to HC4, or hospital HC2"
" Aspirate articular fluid for gram stain, and CS if"
available (use local skin and subcutaneous anaesthesia
- Repeat daily until no further pus is obtained
- Use diazepam mg rectal for sedation in
 Or open drainage in theatre HC4
" Continue pain relief, use paracetamol, ibuprofen"
- Or diclofenac 50 mg every 8 hours Child: mgkg rectally every 6-8 hours (max 150
- Or indomethacin 25-50 mg every 8 hours
"Antibiotics: if possible, get guidance from gram HC4"
"stain, and culture and sensitivity results"
"If Gram positive at gram stain, or negative stain but"
 Cloxacillin 500-1 g IV every 6 hours Child: 50
"- Give IV for 2 weeks, then if better, switch to"
 Alternativesecond line: Chloramphenicol 500 mg
IV every 6 hours for at least 2 weeks Child: mg
 Ceftriaxone 1 g IV for 2-4 weeks Alternatives
 Ciprofloxacin 500 mg every 12 hours for 3 weeks
In adults with negative stain and underlying
"conditions (suspect gram negative, e.g. Salmonella"
"in Sickle Cell Disease), and all children with"
"negative stain, or underlying conditions"
If suspicion of gonococcal (e.g. in sexually active
 Ceftriaxone 1 g IV daily for 1 week
"Infection of bone by pus-forming bacteria, mainly affecting older children"
" Any type of bacterium but most commonly S.aureus,"
 following infection elsewhere in the body
"Antibiotics: if possible, get guidance from gram"
"stain, and culture and sensitivity results"
"If Gram positive at gram stain, or negative stain but"
 Cloxacillin 500-1 g IV every 6 hours Child: 50
"- Give IV for 2 weeks, then if better, switch to"
 Alternativesecond line: Chloramphenicol 500 mg
IV every 6 hours for at least 2 weeks Child: mg
 Ceftriaxone 1 g IV for 2-4 weeks Alternatives
 Ciprofloxacin 500 mg every 12 hours for 3 weeks
In adults with negative stain and underlying
"conditions (suspect gram negative, e.g. Salmonella"
"in Sickle Cell Disease), and all children with"
"negative stain, or underlying conditions"
If suspicion of gonococcal (e.g. in sexually active
 Ceftriaxone 1 g IV daily for 1 week HC4
 Risk factor: sickle cell disease (causative agent mostly S.
"Aureus, Salmonella also common)"
 Onset is usually over several days
" Fever, usually high but may be absent, especially in neonates"
" Tenderness and increased heat at the site of infection,"
swelling of the surrounding tissues and joint
 Reduced or complete loss of use of the affected limb
 The patient is usually a child of four years or above with
"reduced immunity, but adults may also be affected"
" History of injury may be given, and may be misleading,"
especially if there is no fever
" May present with pain, erythema, or swelling, sometimes"
in association with a draining sinus tract
 Deep or extensive ulcers that fail to heal after several
"weeks of appropriate ulcer care (e.g. in diabetic foot), and"
"non-healing fractures, should raise suspicion of chronic osteomyelitis"
" Injury (trauma) to a limb, fracture (children)"
" Bone cancer (osteosarcoma, around the knee)"
 Pyomyositis (bacterial infection of muscle)
 Sickle-cell disease (thrombotic crisis)
 Nothing abnormal in first 1-2 weeks
 Loss of bone density (rarefaction) at about 2 weeks
 May show a thin white line on the surface of the infected part of
" Later, may show a piece of dead bone (sequestrum)"
" Blood: CBC, ESR, CS: Type of bacterium may be detected"
" attempt ZN,gene expert, culture if lesion suspect"
Patients with suspected osteomyelitis need to be referred to hospital for
" Immobilize the limb, splint HC3"
" Provide pain and fever relief with paracetamol,"
 Admit and elevate affected limb
 Cloxacillin 500 mg IV every 6 hours for 2 weeks.
Continue orally for at least 4 weeks (but up to 3
months) Child: 50 mgkg every 6 hours RR
 See pyogenic arthritis for other antibiotic treatments
 Osteomyelitis in SCD: see section  Surgical intervention may be indicated in the following
" Provide pain and fever relief with paracetamol,"
 Admit and elevate affected limb
 Cloxacillin 500 mg IV every 6 hours for 2 weeks.
Continue orally for at least 4 weeks (but up to 3
months) Child: 50 mgkg every 6 hours
 See pyogenic arthritis for other antibiotic treatments
 Osteomyelitis in SCD: see section  Surgical intervention may be indicated in the following
" Drainage of subperiosteal and soft tissue abscesses, HC3"
- Debridement of contiguous foci of infection
- (which also require antimicrobial therapy)
- Excision of sequestra (i.e. devitalized bone)
- Failure to improve after 48-72 hours of
"Inflammation of muscle, which may lead to pus formation and deep-seated"
 Bacterial infection (commonly Staphylococcus aureus)
 Most commonly localised in one muscle; usually large striated muscle
" Fever, painful swelling of the involved muscle"
" Affected area is hot, swollen, and tender"
 Peritonitis (in pyomyositis of abdominal muscles)
" Drainage of subperiosteal and soft tissue abscesses,"
- Debridement of contiguous foci of infection
- (which also require antimicrobial therapy)
- Excision of sequestra (i.e. devitalized bone)
- Failure to improve after 48-72 hours of
 Elevate and immobilise affected limb HC3
 Cloxacillin 500 mg IV or oral every 6 hours for 5-10
days Child: 12.5-25 mgkg per dose
" During the early stage, when the muscle is indurated,"
"hot and swollen, antibiotic treatment may be sufficient"
 Surgical drainage is the only effective treatment
"- Leave the wound open, pack and clean daily"
Tuberculosis of the Spine (Potts Disease) ICD10 CODE:
Tuberculous spondylitis (Potts disease) is the most common form of
skeletal TB; it usually affects the lower thoracic and upper lumbar region.
Infection begins with inflammation
of the intervertebral joints and can spread to involve the adjacent vertebral
"body. Once two adjacent vertebrae are involved, infection can involve"
"the adjoining intervertebral disc space, leading to vertebral collapse."
Subsequent kyphosis can lead to cord compression and paraplegia.
 A chronic infection caused by Mycobacteria
 Elevate and immobilise affected limb
 Cloxacillin 500 mg IV or oral every 6 hours for 5-10
days Child: 12.5-25 mgkg per dose
" During the early stage, when the muscle is indurated,"
"hot and swollen, antibiotic treatment may be sufficient"
 Surgical drainage is the only effective treatment
"- Leave the wound open, pack and clean daily HC3"
" Local pain, which increases in severity over weeks to"
"months, sometimes in association with muscle spasm and"
 Constitutional symptoms such as fever and weight loss are
" With the progression and spreading of the disease, anterior collapse of affected vertebrae leads to visible deformity"
"(angular kyphosis or gibbus), and risk of cord compression:"
 Weakness of legs (Potts paraplegia)
 Adequate history and careful examination
" X-ray spine: disc space narrowing, paravertebral shadow, single"
"multiple vertebral involvement, destruction lesions of 2 or more"
"vertebrae without new bone formation, destruction of vertebral"
" Blood: raised ESR, WBC (within normal limits)"
 Fit a spinal corset or plaster jacket for pain relief
 TB treatment as per guidelines (see section for
 Surgical intervention is warranted for patients in the
 Fit a spinal corset or plaster jacket for pain relief
 TB treatment as per guidelines (see section for
 Surgical intervention is warranted for patients in the
- Patients with spinal disease and advanced HC4
- Patients with spinal disease and worsening
"neurological deficits, progressing while on"
- Patients with spinal disease and kyphosis 40 RR
- degrees at the time of presentation
- Patients with chest wall cold abscess
INFLAMMATORYDEGENERATIVE DISORDERS
Rheumatoid Arthritis ICD10 CODE: M05
Most common form of chronic inflammatory joint disease affecting mainly
women. Attacks tend to be bilateral with symmetrical involvement that
" Unknown origin, probably autoimmune"
" Stiffness and pain in the joints (usually 3, symmetrical,"
" Joints are swollen, warm, inflamed, and sensitive to touch"
" Fingers are most affected (metacarpophalangeal, or proximal interpahalangeal), but all small and medium size joints"
can be affected (rarely hips and spine)
" Extra articular manifestations: mild fever, weakness, lethargy, anorexia, weight loss, rheumatoid nodules (20) at"
extensor surface like forearm below joint
" It is a CHRONIC disease with flare-up, remission, and exacerbations"
" In advanced cases, joint deformities may occur"
- Patients with spinal disease and advanced
- Patients with spinal disease and worsening
"neurological deficits, progressing while on"
- Patients with spinal disease and kyphosis 40
- degrees at the time of presentation
- Patients with chest wall cold abscess HC4
" Osteoarthritis, gout arthritis (in males)"
" Blood: Full blood count, ESR, rheumatoid factor, antinuclear factor"
" Suppression of active disease, and slowing progression of"
disease (prevention of structure damage and deformity)
 Maintenance of patients normal lifestyle
Symptomatic treatment can be started at lower level but appropriate
management requires referral for specialist care.
- For pain and inflammation in acute flare HC2
 Any NSAIDS e.g. ibuprofen 400 mg every 8hours
 Or diclofenac 50 mg every 8 hours
 Or indomethacin 50 mg every 8 hours
- Long term treatment is not advised because
"of toxicity, and because NSAIDS do not"
modify the progression of disease
- Consider adding gastroprotection with
- For severe acute inflammation
 Prednisolone 510 mg once daily in the morning
- For pain and inflammation in acute flare
 Any NSAIDS e.g. ibuprofen 400 mg every 8hours
 Or diclofenac 50 mg every 8 hours
 Or indomethacin 50 mg every 8 hours
- Long term treatment is not advised because
"of toxicity, and because NSAIDS do not"
modify the progression of disease
- Consider adding gastroprotection with
- For severe acute inflammation
 Prednisolone 510 mg once daily in the morning HC2
"- They slow disease progression, but should not HC2"
be used for long periods due to side effects
"- Used for treating acute symptoms, and while HC3"
- waiting to start specific medicines
- Refer to specialist for Disease Modifying Anti- RR
- Counselling and health education
 Weight loss and appropriate exercise physiotherapy
Gout Arhthritis ICD10 CODE: M10
An inflammation disorder involving a joint(s) due to deposition of uric
acid crystals; predominant in males.
 Altered urate metabolism with deposition of urate salts in
the joint and other tissues in advanced cases
" Affected joint is hot, red, and swollen"
 Mostly attacks the big toe at the metatarsophalangeal joint
"(podagra), may occasionally start in other joints"
 Sudden severe pain (often at night)
 Repetitive acute attacks are followed by progressive cartilage and bone erosion
" Deposition of tophi in soft tissue, e.g., ear cartilage, bursae, and tendon sheaths"
"- They slow disease progression, but should not"
be used for long periods due to side effects
"- Used for treating acute symptoms, and while"
- waiting to start specific medicines
- Refer to specialist for Disease Modifying Anti-
- Counselling and health education
 Weight loss and appropriate exercise physiotherapy 
 Joint aspiration uric acid crystals viewed by a polarising microscope
 Blood: Serum uric acid (usually elevated)
 Start NSAIDS such as ibuprofen 400 mg every 8 hours
 or Indomethacin 50 mg every 8 hours
 Or Diclofenac 50 mg every 8 hours
- Continue for the duration of the attack
 Prednisolone 40 mg once daily for 5 days
 Or colchicine 0.5-1 mg initially followed by H
"mg every 2-3 hours until relief of pain, or if"
vomiting and diarrhoea occurs (max dose 6 mg).
Do NOT repeat the course within 3 days
" Control diet: healthy diet, limit alcohol consumption,"
 Avoid medicines which may increase uric acid: thiazide diuretics
"If more than 2 attacks per year, andor"
"complications (renal stones, chronic tophaceous"
 Start NSAIDS such as ibuprofen 400 mg every 8 hours
 or Indomethacin 50 mg every 8 hours
 Or Diclofenac 50 mg every 8 hours
- Continue for the duration of the attack
 Prednisolone 40 mg once daily for 5 days
 Or colchicine 0.5-1 mg initially followed by
"mg every 2-3 hours until relief of pain, or if"
vomiting and diarrhoea occurs (max dose 6 mg).
Do NOT repeat the course within 3 days HC2
" Control diet: healthy diet, limit alcohol consumption,"
 Avoid medicines which may increase uric acid: thiazide diuretics
"If more than 2 attacks per year, andor"
"complications (renal stones, chronic tophaceous"
" Allopurinol starting dose 100 mg, increase monthly"
"by 100 mg. Average maintenance dose 300 mg, max H"
900 mg. Titrate to keep uric acid level mmolL
" Do not start during acute attack, but continue with"
 Give prophylactic colchicine mg every 12 hours
for the first 3 months to prevent acute attacks
 DO NOT use allopurinol to treat asymptomatic
Osteoarthritis ICD10 CODE: M15-M19
A degenerative joint disease with damage to articular cartilage usually
caused by inorganic calcium deposit. It is the commonest form of joint
disease. The pathological changes in osteoarthritis are irreversible.
" May involve any joint; most commonly the hip, spine, and"
" Restriction of movement, pain on moving the joint but"
"tends to be absent at rest, limp in case of lower limbs"
" Improvement with rest, deterioration with physical activity,"
and cold and wet weather conditions
 Joints are usually not swollen or warm but there may be
some accumulation of (clear) articular fluid
" Allopurinol starting dose 100 mg, increase monthly"
"by 100 mg. Average maintenance dose 300 mg, max"
900 mg. Titrate to keep uric acid level mmolL H
" Do not start during acute attack, but continue with"
 Give prophylactic colchicine mg every 12 hours
for the first 3 months to prevent acute attacks 
 DO NOT use allopurinol to treat asymptomatic
 Encourage activity and regular exercise HC2
 Use of appropriate foot wear and walking aids
 Paracetamol 1 g every 8 hours HC4
"In acute exacerbation, or severe pain"
" NSAID (ibuprofen, or diclofenac)"
 Intra-articular steroids e.g. triamcinolone
"(specialist only), maximum 4 timesyear"
 Encourage activity and regular exercise
 Use of appropriate foot wear and walking aids
"In acute exacerbation, or severe pain"
" NSAID (ibuprofen, or diclofenac)"
 Intra-articular steroids e.g. triamcinolone
"(specialist only), maximum 4 timesyear HC2"
Conditions characterised by inadequate blood haemoglobin (Hb) levels.
"It is quite common in tropical settings, and often caused by multiple"
factors. Children and young women are particularly at risk.
Normal haemoglobin levels by age
Category Normal Mild Anaemia Moderate Severe
Men 15 years 13 gdL 11-gdL 8-gdL 8 gdL
Women 12 gdL 11-gdL 8-gdL 8 gdL
Pregnant women 11 gdL 10-gdL 7-gdL 7 gdL
Child 12 - 14 years 12 gdL 11-gdL 8-gdL  8 gdL
Child 5  11 years gdL 11-gdL 8-gdL 8 gdL
Child 6 months  5 11 gdL 10-gdL 7-gdL 7 gdL
From WHONMHNHDMNMReference range in newborns and infants
Adapted from Medscape Sept 2016 haemoglobin concentration
Men 15 years 13 gdL 11-gdL 8-gdL 8 gdL
Women 12 gdL 11-gdL 8-gdL 8 gdL
Pregnant women 11 gdL 10-gdL 7-gdL 7 gdL
Child 12 - 14 years 12 gdL 11-gdL 8-gdL  8 gdL
Child 5  11 years gdL 11-gdL 8-gdL 8 gdL
years 11 gdL 10-gdL 7-gdL 7 gdL
Decreased production of red blood cells
" Nutritional iron, andor folic acidvitamin B12 deficiency"
" Depressed bone marrow function (leukaemia, aplasia)"
" Infections (HIV, TB, visceral leishmaniasis)"
Increased destruction of red blood cells (haemolysis)
" Drug side effects (dapsone, cotrimoxazole, AZT)"
" Congenital disorder, e.g. sickle cell anaemia, G6PD"
" Acute and chronic blood loss (e.g. haemorrhage after trauma, hookworm infestation, pregnancy, abortion, heavy"
"menstrual loss, schistosomiasis, massive or chronic Gbleeding)"
" Pallor of conjuctivae, mucous membranes, palms, soles"
" Fatigue, dizziness, palpitations, headache, anorexia,"
"sometimes weight loss, low exercise tolerance"
" Signs of heart failure if severe: oedema in lower limbs,"
"dyspnoea, tachycardia, heart murmurs"
" If due to acute blood loss: postural hypotension, decreased"
"cardiac out put, tachycardia, sweating, restlessness and"
" Look for signs of specific pathology, e.g., splenomegaly,"
"malaria, nutrition deficiency, haemolysis jaundice, etc."
" Complete blood count (CBC) with differentials, Mean"
"Corpuscular Volume (MCV), platelets, and a peripheral"
 Evaluate Hb levels according to the patients age
 Classify anaemia according to MC Microcytic (small RBCs): measure serum ferritin to
"evaluate for iron deficiency, HB electrophoresis for thalassemias, sideroblastic anaemia may be caused by drugs like"
"isoniazid and chloramphenicol, evaluate for chronic blood"
"loss especially gastrointestinal bleeding through stool analysis for parasites, and occult blood."
 Macrocytic: Do vitamin B12 and fasting serum folate
"levels to evaluate for vitamin B12 orfolate deficiency, do"
"TSH to evaluate for thyroid disease, evaluate for chronic"
"alcohol abuse and use of, drugs like zidovudine, methotrexate, hyroxyureaantifolate medications."
" Normocytic: evaluate for acute blood loss loss, chronic"
"diseases, renal failure., Investigate for the cause of hemolysis using peripheral film for schistocytes suggestive of"
"microangiopathic hemolytic anaemia, HB."
 Do bone marrow aspirate and biopsy if patient has bone
"marrow failure for example aplastic anaemia or hematological malignancy for example leukemia, lymphomas and"
" Anaemia is not a final diagnosis: careful history, physical"
examination and laboratory tests are essential to determine
 Determine and treat the cause for example Antithymocyte globulin
(ATG) is used in aplastic anaemia and should be managed by a
 Consider need for blood transfusion according to:
" Clinical condition (haemodynamic status of patient, presence"
"of heart failure, ongoing blood loss)"
11.Iron Deficiency Anaemia ICD10 CODE: D50
 Poor nutritional intake with iron-poor foods.
" Chronic blood loss, e.g., infestation with hook worms,"
"prolongedexcessive menstrual bleeding, chronic gastrointestinal bleeding (e.g., chronic use of NSAIDS, large bowel"
 As per general anaemia symptoms plus:
" Sore tongue, atrophy of lingual papillae"
 Erosions of the corners of the mouth
 Conditions that cause microcytic red cells
" Blood: CBC, Hb, (haematocrit (Hct) rarely 28 unless iron deficiency is present)"
 Low MCV and Mean Corpuscular Hb (MCH)- hypochromia.
This may not be obvious in patients who have already been transfused
 Hypochromic microcytic (small size) red cells
 Investigate the cause of iron deficiency
" Identify, and treat cause of iron deficiency HC2"
 Adjust diet if poor diet is one of underlying causes
 Adult: Oral ferrous sulphate 200 mg (or ferrous
 sulphatefolic acid 200mg) every 8 hours (equivalent
to 180 mg elemental iron per day)
 Child: Oral ferrous sulphate 5 mgkg (max 200 mg)
every 8 hours (equivalent to around 5 mgkg elemental
 Hb rises in 2-3 weeks and returns to normal after 2 months
 Treat for 6 months to 1 year to replenish stores
 Severe symptoms  for blood transfusion
" Identify, and treat cause of iron deficiency"
 Adjust diet if poor diet is one of underlying causes
 Adult: Oral ferrous sulphate 200 mg (or ferrous
 sulphatefolic acid 200mg) every 8 hours (equivalent
to 180 mg elemental iron per day) HC2
 Child: Oral ferrous sulphate 5 mgkg (max 200 mg)
every 8 hours (equivalent to around 5 mgkg elemental
 Hb rises in 2-3 weeks and returns to normal after 2 months
 Treat for 6 months to 1 year to replenish stores
 Severe symptoms  for blood transfusion
" Side effects of oral iron: diarrhoea, abdominal discomfort,"
"constipation, black stools. Warn patient not to worry"
" Parenteral iron is rarely necessary, and can cause"
anaphylaxis.It should only be used by specialists
11.Megaloblastic Anaemia ICD10 CODE: D51-52
Anaemia characterised by large red blood cells. Usually due to folate
"andor vitamin B12 deficiency. Some medicines (hydroxyurea, zidovudine, stavudine can cause macrocytic anaemia without folate andor"
" Low dietary intake of folateincreased need (e.g., children,"
" Low dietary intake of vitamin B12 (in exclusively vegetarian diets, without any animal proteins)"
" Malabsorption of folate and vitamin B12 (severe gastritis,"
"giardia infection, severe intestinal diseases)"
" Medicines e.g., metformin, zidovudine, hydroxyurea,"
" Other causes of macrocytosis: myelodysplasia, hypothyroidism, chronic alcohol use, multiple myeloma"
 Vitamin B12 deficiency: neuropsychiatric abnormalities
"e.g., hyperpigmented palms and feet, smooth beefy"
"tongue, peripheral neuropathy, impaired vibration and position sense, abnormal gait, weakness, decreased muscle"
"strength, spastic motions, memory loss, disorientation,"
"depression, and acute confusional state"
 Elevated MCHMC Pancytopenia in severe cases
" Full blood count: oval macrocytes, hypersegmentation of"
 Decreased serum Vitamin B12 or fasting red cell folate
 Identify and treat underlying cause of anaemia
 Oral B12 may be given at a dose of 1mg (1000µg) daily in
patients who cannot tolerate parenteral therapy.
 There is also a Nasal formulation of vitamin B12 that can be HC2
 Dietary modifications to ensure adequate intake of
"folate and vitamin B12, e.g., eat plenty of green leafy"
"vegetables, andor food of animal origin"
Folic acid and vitamin B12 supplementation
 Folic acid: 5 mg daily until haemoglobin levels
 Vitamin B12: 1 mg IM daily for 5 days; then weekly for
 Follow with 1 mg every second month for life in patients with
 Identify and treat underlying cause of anaemia
 Oral B12 may be given at a dose of 1mg (1000µg) daily in
patients who cannot tolerate parenteral therapy. HC2
 There is also a Nasal formulation of vitamin B12 that can be
 Dietary modifications to ensure adequate intake of
"folate and vitamin B12, e.g., eat plenty of green leafy"
"vegetables, andor food of animal origin"
Folic acid and vitamin B12 supplementation
 Folic acid: 5 mg daily until haemoglobin levels
 Vitamin B12: 1 mg IM daily for 5 days; then weekly for
 Follow with 1 mg every second month for life in patients with
 If vitamin B12 deficiency is suspected: (low leucocytes
"and platelets, neuropsychiatric symptoms, vegan diet) DO"
NOT GIVE folic acid alone but refer for further testing and
treatment. Giving folic acid alone in
 patients with B12 deficiency may precipitate permanent
 Anaemia normally corrects within 1-2 months. White cell
count and thrombocytopenia normalise within 7-10 days
 DO NOT use ferrous-folate combination tablets to treat folic
deficiency because the quantity of folic acid is too low
Anaemia characterised by normal-sized red blood cells
" Haemolysis (destruction of red cells), e.g., auto-immune"
"disorder, hypersplenism, haemoglobin abnormalities (sickle cell disease, thalassemia), drugs (sulphonamides, dapsone, primaquine)"
" Decreased reticulocytosis (formation of new blood cells),"
 e.g. chronic kidney disease and chronic diseases..
 Full blood count smear: spherocytes
 Identify and treat cause of anaemia
" DO NOT treat with iron, folic acid or vitamin B12 unless"
there is clear documented deficiency
 Treat all patients with folic acid 5 mg daily in haemolytic
 Refer to hospital for further management
PreventionHealth Education for Anaemia
" The life long effects of anaemia on health, and cognitive"
 Dietary measures: encourage exclusive breastfeeding for
the first 6 months. Encourage the use of iron-containing
"weaning locally available foods (red meat, beans, peas,"
" Hygiene: avoid walking barefeet to avoid hook worm infestation, use of pit latrines for faecal disposal, and practice"
 Medical: encourage periodic screening for children and
"pregnant mothers, and presumptive iron therapy for either groups in cases of anaemia (see IMCI and pregnancy"
"guidelines, chapters 16 and 17)"
 Routine iron supplementation for all pregnant mothers
" Early treatment of malaria, helminthic infections, etc."
 Identify and treat cause of anaemia 
" DO NOT treat with iron, folic acid or vitamin B12 unless"
there is clear documented deficiency
 Treat all patients with folic acid 5 mg daily in haemolytic
 Refer to hospital for further management HC4
Bleeding Disorders ICD10 CODE: D65-D69
A bleeding disorder is suspected if a patient has unexplained bruising
and bleeding (i.e. no history of trauma). Prolonged bleeding or oozing
"can also occur after injury or surgery (e.g., tooth extraction, small cut)."
" Acquired: age, side effects of steroids, NSAIDS (e.g. easy bruising)"
 Genetic e.g. hereditary telangiectasia
" Decreased platelet numberfunction e.g., blood cancer, viruses,"
" Increased destruction e.g., in hypersplenism, autoimmune disease,"
immune thrombocytopenic purpura (ITP) massive blood transfusion
" Hereditary e.g., haemophilia A or B, von Willebrand disease"
" Acquired e.g., warfarin or heparin, liver disease, alcoholism, acquired factor inhibitors for example in malignancies, autoimmune"
" Infections: meningococcal sepsis, haemorrhagic fevers (causing"
widespread endothelial damage and disseminated intravascular
" Platelet disorder: mucosal bleeding (gingivitis, nose bleeds),"
"superficial ecchymoses, excessive bleeding after minor injury, petechiae, heavy menstrual bleeding"
" Coagulation disorder: large, deep haematomas or haemathrosis"
" Complete blood count, and platelet count (can be estimated using a"
peripheral smear if an auto-analyser is not available)
 A bone marrow aspirate and biopsy is indicated if a haematological
malignancy is suspected to be the cause of the bleeding
 Bleeding time (time required for bleeding to stop). It is normal with
"coagulation factor deficiencies (except Von Willebrand disease), and"
abnormal in thrombocytopenia and qualitative platelet defects
" Prothrombin time (PT): prolonged in factor VII, X, V, deficiencies, liver disease, warfarin treatment"
 International normalised ratio (INR) to monitor anticoagulation
with warfarin (not useful for heparin and direct acting
anticoagulants like rivaroxaban)
" Partial thromboplastin time (aPTT): prolonged in factor VIII,"
"(hemophilia A) XII, XI, IX, (hemophilia B) X, V and I deficiencies"
" If acute, consider if haemorrhagic fevers are the cause"
Patients with acute bleeding disorders should be referred to hospital for appropriate investigations and treatment.
Patients with chronic bleeding disorders should be referred to a specialist.
 Identify and treat root cause of bleeding disorder
 Give phytomenadione (vitamin K) injection to: Newborn: 1
mg for full-term baby; 500 mcg for a pre-term baby IM or
IV. Repeat every 8 hours if necessary
" In patients on warfarin with acute bleeding, give vitamin K"
5 mg slow IV to reverse warfarin effect. If patient has severe
"or active bleeding, give fresh frozen plasma"
" Discontinue any medications that will interfere with coagulation or platelet function, e.g., cephalosporins, dipyridazole,"
"thiazide, alcohol, chloropromazine, sulfonamides, rifampicin,"
"methyldopa, phenytoin, barbiturates, quinidine, isoniazid."
 Identify and treat root cause of bleeding disorder
 Give phytomenadione (vitamin K) injection to: Newborn: 1
mg for full-term baby; 500 mcg for a pre-term baby IM or
IV. Repeat every 8 hours if necessary
" In patients on warfarin with acute bleeding, give vitamin K"
5 mg slow IV to reverse warfarin effect. If patient has severe
"or active bleeding, give fresh frozen plasma"
" Discontinue any medications that will interfere with coagulation or platelet function, e.g., cephalosporins, dipyridazole,"
"thiazide, alcohol, chloropromazine, sulfonamides, rifampicin,"
"methyldopa, phenytoin, barbiturates, quinidine, isoniazid. HC2"
" In patients with ITP, first line treatment is oral prednisolone H"
"(0.5-2mgkgday). Rituximab and Intravenous Immunoglobulin (IVIG) are second line treatments for ITP, however these"
should be given by a specialist.
 Transfuse with platelets if Patient is bleeding (therapeutic
transfusion) or prophylactically when platelet count is less
"than 10,000µL in patients at high risk of bleeding  e.g.,"
 Transfuse with fresh fozenfrozen plasma if bleeding is thought
to be due to disorders related to clotting factors
Refer to a higher level of care if the above options are not viable.
 Refer patient to hospital if any of the following signs
 If cause cannot be determined locally
" Bleeding into muscles or joints, GIT, or CNS"
 Bleeding patients who are on warafrin
 Advise the patient with chronic bleeding disorder to:
 Avoid injections and unnecessary surgery
 Visit the clinic immediately if symptoms occur
 Continue all medication as prescribed
" All haemophiliacs should have prophylactic treatment before traumatic procedures, e.g., tooth extractions, or surgery"
Sickle cell disease (SCD) is a genetic haemoglobin disorder in which
" In patients with ITP, first line treatment is oral prednisolone"
"(0.5-2mgkgday). Rituximab and Intravenous Immunoglobulin (IVIG) are second line treatments for ITP, however these"
should be given by a specialist.
 Transfuse with platelets if Patient is bleeding (therapeutic
transfusion) or prophylactically when platelet count is less
"than 10,000µL in patients at high risk of bleeding  e.g.,"
 Transfuse with fresh fozenfrozen plasma if bleeding is thought
to be due to disorders related to clotting factors
Refer to a higher level of care if the above options are not viable. H
 Refer patient to hospital if any of the following signs
 If cause cannot be determined locally
" Bleeding into muscles or joints, GIT, or CNS"
 Bleeding patients who are on warafrin
red blood cells which carry oxygen around the body change shape
from a smooth doughnut shape into a crescent or half-moon shape. It
is sometimes called Sickle Cell Anaemia (SCA).
 It is caused by a defect in beta chains where a given amino
acid is replaced by another (Substitution of valine for glutamic acid) at position 6 of the chain. This change creates
abnormal haemoglobin called HbS.
 Symptoms usually appear from age of 3 to 6 months:
"anaemia, dactylitis (swelling of fingers), lobar pneumonia,"
recurrent severe bacterial infections. This results from the
"reduction of the foetal haemoglobin F (HbF), and increase"
 Chronic anaemia: Hb 69 gdl with episodes of acute
 Aplastic crisis: sudden transient arrest of blood cells production
"in the bone marrow (low Hb and low reticulocyes), often due to"
 Splenic sequestration: pooling of large amounts of red blood
"cells in the spleen with painful and rapidly enlarging spleen,"
decreasing haemoglobin with high reticulocyte count
 Acute vaso-occlusive phenomenon (occlusion of blood
" Painful crisis (acute, intense) at the back, chest, limbs, abdomen."
"In children 2 years, pain and swelling of hands and feet."
" Stroke: hemiplegia, altered consciousness, seizures."
" Acute chest syndrome: fever, chest pain, difficulty in breathing,"
"low oxygen level, cough, wheezing"
 Acute abdomen or mesenteric crisis (intestinal crisis):
"abdominal pain and distension, reduced or absent bowel"
"sounds, pallor, fever, Abdominal X-ray may show dilated bowel"
"loops. Anaemia, high reticulocyte count, high CRP will be"
" Renal infarction, bone infarction and necrosis, especially at the"
 Chronic organ damage due to anaemia and vasocclusive
 Hyposplenia (spleen undergoes autosplenectomy due to
multiple infarcts and is not functional anymore or has to be
removed because of splenic sequestration)
" Chronic renal and hepatic disease, gallbladder stones"
 Nephropathy and acute kidney injury due to hypovolemia and
 Trans-cranial doppler velocity of 200cmsec predicts high risk
of having a stroke. This is less predictive in adults
 Infections associated with asplenia and hyposplenism like
" Osteomyelitis, pneumonia, septicaemia"
 Family history of sickle cell disease
 Full blood count  peripeharl film comment
 Screening tests for sickling (not fully reliable)
 Haemoglobin electrophoresis (confirms diagnosis)
 Chest radiography (for Acute Chest Syndrome)
 Regular follow up and education of patients and families.
 Give folic acid 5 mg daily for life
" Promptly assess, and treat any fever with antibiotics"
until source of fever is identified
" Ensure complete immunisation using the UNEPI programme, which includes the pneumococcal vaccine"
" Plus, if available, immunisation against"
meningococcus (to be given in regions within the
meningococal belt) and influenza
 Prophylactic penicillin V (up to 5 years of age) HC2
 Child 3 months-3 years: penicillin V 125 mg every
 Child 3-5 years: penicillin V 250 mg every 12 hours
 Malaria prophylaxis with monthly sulphadoxine- pirimet- HC2
 Child 5-10 years: 1 tab monthly
 Child 10-15 years: 2 tabs monthly
 Child 15 years: 3 tablets monthly
For those with sulphur allergy consider use of erythromycin
 Regular follow up and education of patients and families.
 Give folic acid 5 mg daily for life
" Promptly assess, and treat any fever with antibiotics"
until source of fever is identified
" Ensure complete immunisation using the UNEPI programme, which includes the pneumococcal vaccine"
" Plus, if available, immunisation against"
meningococcus (to be given in regions within the
meningococal belt) and influenza HC2
 Prophylactic penicillin V (up to 5 years of age)
 Child 3 months-3 years: penicillin V 125 mg every
 Child 3-5 years: penicillin V 250 mg every 12 hours
 Malaria prophylaxis with monthly sulphadoxine- pirimetamine (SP)
 Child 5-10 years: 1 tab monthly
 Child 10-15 years: 2 tabs monthly
 Child 15 years: 3 tablets monthly
For those with sulphur allergy consider use of erythromycin
Refer to a specialised treatment centre for specialised RR
"management, especially if uncontrolled symptoms"
 Hydroxyurea starting dose 20 mgkg
Children of 9 months and above should be initiated on
 Frequent crises: 3 crises in a year
 Pain interfering with activities of daily living
 Patients with abnormal Transcranial Doppler
(TCD) Ultrasonography velocity 200 cms
 Recurrent or severe acute Chest Syndrome
"Note: However, the decision to give a patient hydroxyurea should"
be done by a senior health worker after full laboratory investigation
Management of acute complications
Painful crisis  home management (mild to moderate pain) HC2
Refer to a specialised treatment centre for specialised
"management, especially if uncontrolled symptoms"
 Hydroxyurea starting dose 20 mgkg
Children of 9 months and above should be initiated on
 Frequent crises: 3 crises in a year
 Pain interfering with activities of daily living
 Patients with abnormal Transcranial Doppler
(TCD) Ultrasonography velocity 200 cms
 Recurrent or severe acute Chest Syndrome
Painful crisis  home management (mild to moderate pain)
 Child: 10-15 mgkg 6-8 hourly HC2
 Andor ibuprofen 400-600 mg every 6-8 hours HC4
 Andor oral diclofenac 50 mg 8 hourly
 Children only 9 years and 35 kg: 2 mgkg in 3
"If pain not controlled, add: RR"
 Codeine 30-60 mg every 6 hours (only in patients
 Or oral tramadol 50-100 mg every 6-8 hours (only in
 Or Oral morphine at 0.2-mgkg every 4 hours and
(see section 13.1.2) for thr WHO analgesic Ladder
"If pain still not controlled, refer to hospital"
Painful crisis  hospital management (severe pain) HC4
" Oxygen, keep oxygen saturation 95"
 Assess for malaria and other infections HC4
 Morphine oral (see section 13.1.2)
 Child and Adult: 0.3-mgkg per dose and reassess
 Or Morphine  Child: 0.1-mgkg per dose
 Adult: 5-10 mg dose and re-assess
 Use of laxative: bisacodyl mg to 5 mg orally to prevent
 Andor ibuprofen 400-600 mg every 6-8 hours
 Andor oral diclofenac 50 mg 8 hourly
 Children only 9 years and 35 kg: 2 mgkg in 3
 Codeine 30-60 mg every 6 hours (only in patients
 Or oral tramadol 50-100 mg every 6-8 hours (only in
 Or Oral morphine at 0.2-mgkg every 4 hours and
(see section 13.1.2) for thr WHO analgesic Ladder
"If pain still not controlled, refer to hospital HC4"
Painful crisis  hospital management (severe pain)
" Oxygen, keep oxygen saturation 95"
 Assess for malaria and other infections
 Morphine oral (see section 13.1.2)
 Child and Adult: 0.3-mgkg per dose and reassess
 Or Morphine  Child: 0.1-mgkg per dose
 Adult: 5-10 mg dose and re-assess HC4
 Use of laxative: bisacodyl mg to 5 mg orally to prevent
"Acute anaemia (acute splenic sequestration, aplastic crisis)"
" Investigate and treat malaria, and infections"
 Avoid splenectomy in acute sequestration (high mortality)
" Restricted IV fluids use, always use calculated required"
amounts of IV fluids. NB: limit in cases of pulmonary
 Salbutamol inhaler (2-4 puffs prn) or nebulisation 5 mg
 Ceftriaxone 1-2 g once daily for 7-10 days
 Plus erythromycin 500 mg every 6 hours for 7-10 days
" Transfuse if no improvement, andor Hb falls 9 gdL."
Start incentive spirometry (or blowing of a balloon) early
 Refer for neuroimaging and advanced management
"Acute anaemia (acute splenic sequestration, aplastic crisis)"
" Investigate and treat malaria, and infections"
 Avoid splenectomy in acute sequestration (high mortality) 
" Restricted IV fluids use, always use calculated required"
amounts of IV fluids. NB: limit in cases of pulmonary
 Salbutamol inhaler (2-4 puffs prn) or nebulisation 5 mg
 Ceftriaxone 1-2 g once daily for 7-10 days
 Plus erythromycin 500 mg every 6 hours for 7-10 days
" Transfuse if no improvement, andor Hb falls 9 gdL."
Start incentive spirometry (or blowing of a balloon) early
 Refer for neuroimaging and advanced management RR
Acute AbdomenMesenteric crisis H
 Ceftriaxone 1-2 g once daily for 7-10 days
 Plus metronidazole 500 mg IV every eight hours
 Child: 10 mgkg IV every 8 hours
 Plain abdominal X-ray to rule out obstruction or
" Prompt assessment and treatment of cause (osteomyelitis, pneumonia, chronic leg ulcers,cellulitis, etc.)"
" Treat according to cause. If no localising focal symptoms, and no malaria, give:"
 Ceftriaxone 1-2 g once daily for 7-10 days
If osteomyelitis or septic arthritis
 Or Cloxacillin 500 mg 6 hourly IV or orally
 Child: 50 mgkg 6 hourly for at least 21 days
 or Ciprofloxacin 500 mg 12 hourly for at least 21 days
 In child: Ceftriaxone 50 mgkg IV once a day for
 Ceftriaxone 1-2 g once daily for 7-10 days
 Plus metronidazole 500 mg IV every eight hours
 Child: 10 mgkg IV every 8 hours
 Plain abdominal X-ray to rule out obstruction or
" Prompt assessment and treatment of cause (osteomyelitis, pneumonia, chronic leg ulcers,cellulitis, etc.)"
" Treat according to cause. If no localising focal symptoms, and no malaria, give:"
 Ceftriaxone 1-2 g once daily for 7-10 days
If osteomyelitis or septic arthritis
 Or Cloxacillin 500 mg 6 hourly IV or orally
 Child: 50 mgkg 6 hourly for at least 21 days
 or Ciprofloxacin 500 mg 12 hourly for at least 21 days
 In child: Ceftriaxone 50 mgkg IV once a day for
Indications for blood transfusion HC4
 Acute exacerbation of baseline anaemia:
 Radiography with ionic contrast
" Patient, family and community education"
 Timely initiation of hydroxyurea
" Periodic comprehensive evaluations, and other diseasespecific health maintenance services"
" Periodic evaluation for sickle cell complications for example urinalysis and renal function for sickle cell nephropathy, cardiac echo for pulmonary hypertension, transcranial doppler in children for early detection of stroke risk."
Patienst with these complications should be referred to a
Indications for blood transfusion
 Acute exacerbation of baseline anaemia:
 Radiography with ionic contrast
 Timely and appropriate treatment of painful crisis and
 Genetic counseling (for couples planning to have children)
 Early recognition screening of children with low Hb
" Vaccination (pneumococcal vaccine, H-influenza vaccine,"
 Antibiotic (oral penicillin twice a day
 Timely and appropriate treatment of acute illness
 Genetic counseling (for couples planning to have children)
 Early recognitionscreening of children with low Hb
"Vaccination (pneumococcal vaccine, H-influenza vaccine, Hepatitis B"
" Antibiotic (oral penicillin twice a day in 5years), and antimalarial chemoprophylaxis"
The Uganda Blood Transfusion Service (UBTS) collects blood and
produces all blood products. Whole blood (WB): unseparated blood
collected inanapprovedcontainerandcontainingapreservative or anticoagulant solution Bloodreferstoany blood component in which the
"main constituentisredbloodcells,e.g.,wholeblood(WB), red cell concentrate,orred cell suspension"
"Unless otherwise specified, others are referred to as blood components"
"or products. Blood components are preparedfrom WB, and contain"
"negligible quantity of red cells,e.g., platelet concentrate, Fresh Frozen"
"Plasma, Cryoprecipitate.(Referto the National Blood Transfusion"
Guidelines for appropriate use of blood formoredetails) UBTS ensures
that all blood and blood products are producedinaway that ensures the
health and safety of both patients and donors andminimisesthe risk
oftransmitting infection through blood.
General Principles of Good Clinical Practice in Transfusion
 Blood is a scarce and expensive resource. Blood transfusion carries risks of adverse reactions and transfusion-transmitted infections
" Use blood appropriately, that is, to treat conditions that"
"can lead to significant morbidity or mortality, which cannot be prevented or effectively managed by other means"
 Minimise the need for transfusion by:
" Early diagnosis, and treatment of anaemia, in particular iron"
" Stop blood loss, through good surgical and anaesthetic"
 Appropriate and timely management of coagulation disorders
" Use of simple alternatives to transfusion when appropriate,"
"e.g., IV fluids as first line treatment of hypovolemic shock"
"Prescribe transfusion according to patients individual needs, using"
"clinical signs and symptoms, and expected outcome, but NOT only"
Do not use blood transfusion to:
" Expand blood volume, unless there has been blood loss of"
 Improve general well-being of the patient in patients with
"on-going fluid losses, e.g. surgical blood loss"
 Blood should not be transfused unless it has been:
 Obtained from appropriately selected donors (voluntary non-remunerated donors)
" Screened for transfusion-transmissible infections (TTIs), namely;"
"HIV, hepatitis B, hepatitis C, and syphilis Tested for compatibility"
(pre-transfusion) between the donors red cells and the antibodies
in the patients plasma in accordance with national guidelines
" The mandate to collect blood from donors, and screen it"
" Guidelines and procedures for requesting, administering,"
and recording blood transfusion should be clearly spelled
"out, and strictly followed to avoid catastrophic mistakes"
 Ensure the transfused patient is closely monitored (during
and after transfusion) and that there is immediate response
Blood and Blood Products: Characteristics and Indications
The following section will present only whole blood and red cells concentrate. Availability and use of other blood components is reserved for
referral hospitals and is beyond the scope of this guideline.
" Whole blood provides red blood cells, plasma volume, stable coagulation factors (VII, XI), and others"
 May not have enough functional platelets and labile coagulation factors (V and VIII)
 It is also used as a raw material from which other blood
 1 unit of whole blood is about 450 ml of donor blood;
obtained from a single donation plus 63 mL of anticoagulantpreservative solution. It is available from HC4 level
 Each unit of blood will raise the HB by about 1gdl
" Red blood cell replacement in acute blood loss (haemorrhage) with significant hypovolaemia such as in trauma, surgery, invasive procedures, GIT haemorrhage"
" Patients in need of red blood cell transfusion, where red"
cell concentrates or suspensions are not available (consider
adding furosemide to avoid fluid overload)
" Only Specialist Use: exchange transfusion in neonates, using less than 5-day old blood units"
 Transfusion must be started within 30 minutes of removal
"from the refrigerator, and completed within 4 hours of"
 Storage is 2-6C in approved blood bank refrigerator with
 WB is contraindicated in severe chronic anaemia and incipient cardiac failure (risk of volume overload)
 Blood should not be warmed (improvised warming method commonly used in health facilities is not necessary)
" The routine use of diuretics (furosemide, or lasix), pre-transfusion is not necessary in most patients. Pre-transfusion"
diuretics are indicated in known cardiac and renal patients
 to prevent circulatory overload.
11.Red Cell Concentrates (packed red cells)
"Red cell concentrates contain red blood cells, suspended in a small"
amount of plasma and additive solutions (which provides nutrients to
"the red cells in storage). It is in a form of two, or three pediatric bags,"
"each containing 80-150 ml, obtained from a single donation. HCT is"
approximately 55. It is available from HC4 level.
 Red blood cell replacement in anaemic patients
" In acute blood loss, together with crystalloid solution if"
 Transfusion must be started within 30 minutes of removal
"from the refrigerator, and completed within 4 hours of starting"
 Storage is 2-6C in approved blood bank refrigerator with
11.Clinical Indications for Blood Transfusion
The indication for blood transfusion (with whole blood or red cell concentrates) depends on:
 The degree of anaemia (estimated by Hb level)
 The clinical conditions (high risk or presence of signs and symptoms
"of tissue hypoxia, or impaired tissue oxygenation resulting from"
"Presence of ongoing blood loss (e.g., internal or external haemorrhage)"
Severe acute anaemia in children and infants
" Hb  4 gdL (or haematocrit  12), whatever the clinical"
" Hb 4  6 gdL (or haematocrit 13-18), in case of life"
"threatening complications, such as, clinical features of hypoxia and cardiac decompensation, acidosis (usually causes respiratory distress, impaired consciousnesscoma, hyperparasitaemia (20) or cerebral malaria, septicaemia,"
Dose: Transfuse 10-15 mLkg of packed red cells (or 20 mLkg of
"Note: In children with chronic anaemia caused by iron deficiency, it"
may be possible to correct with iron therapy alone.
 Consider blood transfusion only in anaemia whose severity is likely to cause has already caused clinical signs of
"hypoxia, or impaired tissue oxygenation. These signs may"
"include; tachycardia, shock, respiratory distress, weakness, dizziness and or unconsciousness."
 Symptomatic anaemia (see above) in adults with 7 gdL
 Haemoglobin 8gdL if with cardiac disease or CNS symptoms
 Give the minimum number of transfusions necessary to
" Transfuse 1 unit at a time, then re-assess"
 If symptoms persist give another unit
" Generally, it is important to screen for iron deficiency"
anaemia early in pregnancy and treating with iron as necessary.
 Hb 5 gdL irrespective of clinical condition
" Hb 5-7 gdL in case of established or incipient heart failureimpaired tissue oxygenation, pneumonia or other serious infection, malaria, pre- existing heart disease"
" Hb 6-8 gdL in case of, established or incipient heart failureimpaired tissue oxygenation, pneumonia or other serious infection,"
"malaria, pre-existing heart disease"
"If history of APH, PPH, previous caesarean section"
" Establishconfirm blood group, and save freshly taken serum for"
 Have 2 units of blood cross-matched and made available
"Pre-operative anaemia should be investigated, and promptly managed"
" Prompt management may include iron supplementation (oral,"
" Where possible, surgery should be delayed or postponed, until"
"anaemia is corrected, since pre-operative anemia is associated"
"with poor surgical outcomes (morbidity and mortality), as well"
as an increased need for blood transfusion.
 Inadequate compensation for the anaemia (symptomatic anaemia)
 Significant co-existing cardiorespiratory disease
 Major surgery or significant blood loss expected
 Pre-surgical correction has not been possible
Management of acute haemorrhagehypovolemia
 IV fluids (crystalloids: Normal saline) is the first line in
treatment of hypovolaemia during acute haemorrhage
 Whole blood (or red blood cells if WB unavailable) are
indicated when blood loss is 20- 30 of blood volume
 The need for blood must be determined by:
 Initial response to IV fluid resuscitation
 Hb level is NOT a reliable indicator for blood need in acute
 Blood transfusion is not necessary for asymptomatic sickle
cell patient with steady Hb 6-8 gdL nor for an uncomplicated painful episode
" In addition to general indications, blood transfusion is indicated if:"
 Acute severe anaemia (Hb 5 gdL or 2 gdL lower than usual
level for the patient) in aplastic and acute sequestration crisis. Aim
 Hb 6 gdL in uncomplicated pregnancy
" Hb 9 gdL in case of acute chest syndrome (ACS), or stroke. For"
"these four patient categories (pregnancy, Csection, ACS, and"
"stroke), the target Hb is 11gdL, and not any higher."
 Use packed cells if available (rather than WB) whole
" Severe anaemia (of any cause (prematurity, sepsis, etc.)"
 Transfusion in neonates should be managed at specialist
Adverse Reactions following Transfusion
Any potentially adverse sign or symptom resulting from a blood transfusion.
Common Acute Transfusion reactions (ATR)include;
 Minor allergic reaction (Urticaria)
 Febrile non-haemolytic transfusion reaction
" Acute haemolytic transfusion reaction (caused by ABO incompatibility): is a severe, and life threatening reaction"
 Transfusion-associated circulatory overload (TACO)
 Transfusion-related acute lung injury (TRALI)
 Severe allergic (Anaphylactic) reaction; relatively rare
" Transfusion-transmitted infections, e.g., HIV, Hepatitis B,"
 Delayed hemolytic transfusion reactions
 Acute transfusion reactions (ATRs) may occur in 1-2 of
 Rapid recognition and management of transfusion reactions may save the patients life
" Accurate patient identification  at bed side, is critical"
 Monitoring transfusion is only way to identify ATRs
 Monitoring transfusion is performed by taking vital
"signs; before, 15 minutes into, whenever a reaction is"
"suspected, and at the end of transfusion"
" Vital signs should always be taken (at a minimum) immediately prior to beginning the transfusion, 15 min after start"
"and at end (see box with Key Points). In addition, a nurse"
or physician should observe the patient for the first 15
"minutes after a new blood unit is started, and vital signs"
 Errors and failure to follow correct procedures are the
most common causes of life threatening acute haemolytic reactions. Such errors include; misidentification of patients  resulting in administering the wrong blood unit to
"the wrong patient, not repeating blood grouping of the"
"blood units received at hospital, not cross-matching, and"
errors in labeling blood samples for pre-transfusion grouping and cross-match. These errors must be avoided.
 ALWAYS store blood used for the compatibility testing for
7 days at 2-8C for possible investigation on transfusion
 In a conscious patient with a severe acute haemolytic
"transfusion reaction, signssymptoms may appear within"
minutes of infusing only 5-10 mL of blood
" In an unconscious or anaesthetised patient, hypotension, hypoxia"
and uncontrolled bleeding may be the only signs of a transfusion
"problem. As such, taking vitals regularly is important."
" Any unexpected change(s) in vitals  a possible ATR,"
If atransfusion reaction is suspected
" Stop the transfusion, and remove the giving set. Prior to disconnecting, the unit must be closed to avoid reflux of patient"
 Check the blood pack labels and patients identity. If there is a
"discrepancy, consult the blood bank"
" Evaluate the patient; take vitals, and manage accordingly (See"
 Obtain a post-transfusion blood sample. Return the implicated
blood unit to the hospital blood bank. Re-grouping and testing
are done on both patient and transfused samples
 Immediately report all suspected acute transfusion reactions to
the hospital blood bank laboratory that works with the clinician
" For category two reactions, record the following in the patients"
"notes: type of reaction, time reaction occurred from start of"
"transfusion, volume, type, and pack numbers of blood products"
" The type of reaction should be diagnosed, and a quick and"
clear investigation should be started in the hospital blood bank
Occurring within 24 hours of transfusion.
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Cancer is an unregulated growth of a previously normal set of body
"cells. Oncology is the study, diagnosis, and management of cancers or"
tumours. It is important to note that any organ or system as well as
affected by cancer. This section will outline major symptoms and signs
"of cancer, key population groups affected, ways to mitigate risk of cancer"
and provide an overview of common cancers in adults and children.
Cancer or malignant neoplasm is collective term for a group of more
than 100 diseases that result from abnormal  uncontrolled growth
of body cells and is able to invade normal tissues and spread to other
parts of the body. The uncontrolled growth causes a lump swelling
called a tumours or neoplasm in many types of cancer or an abnormal
number of abnormal cells in some types of cancer such as blood cancers
"(Leukaemia). Tumours are broadly divided into benign tumors, meaning"
non-cancerous  unable to metastasize (spread to other parts of the body)
or malignant tumors (able to invade normal tissues  spread to other
"parts of the body). Cancers are classified by their type of cell, tissue, or"
"organ of origin. In Uganda, in 2020, it was estimated that there were"
"34,008 new cancer cases, 22,992 cancer deaths, and 62,548 adults"
"living with cancer. The top five causes of cancer morbidity are cervix,"
"Kaposi sarcoma (KS), breast, prostate, and non-Hodgkin lymphoma."
"The top five causes of cancer deaths are cancers of the cervix, KS,"
"esophagus, liver, and non-Hodgkin lymphoma. In Uganda, children aged"
"0  14 years of age, constitute ten percent (10) of cancer patients."
Special Groups at Increased Risk of Cancer
 Consistent occupational exposure to toxins andor radioactive material
Note: Routine screening is recommended for these groups
Cancer should be investigated in an individual with the following symptoms having occurred for 2 weeks:
" Painless or painful swelling, lump, or thickening"
 Persistent indigestion or difficulty in swallowing
 Change in normal bowel or bladder habits
Common Signs and Symptoms of Cancer
Health workers should inform clients  communities that dont wait
"for signs and symptoms of cancer. In most types of cancer, signs and"
symptoms manifest when the disease is advancing or in late stage. Each
"type of cancer manifest with unique signs and symptoms. However,"
many cancer patients report having experienced  noticed some symptoms or signs weeks months  years earlier before they felt very sick.
"Cancer should be investigated in an individual with the following common signs and symptoms of cancer, especially when having occurred"
" Painless or painful swelling, lump, or thickening"
 Persistent indigestion or difficulty in swallowing
 Change in normal bowel or bladder habits
Urgent referral for a possible cancer malignancy might be necessary in
patients with any of the following:
"Haematological Neutropenia, anaemia, infection, bleeding, hyperviscosity, leukocytosis"
"Lung (excluding Coughing blood, superior vena cava obstruction"
"Upper GI Tract Chronic GI bleeding and bowel habit changes, dysphagia, persistent vomiting, unexplained pain and"
"weight loss, abdominal mass without dyspepsia,"
"Lower GI Tract Bleeding and bowel habit changes, palpable rectal"
"mass, unexplained iron deficiency anaemia"
"Haematological Neutropenia, anaemia, infection, bleeding, hyperviscosity, leukocytosis"
"TB) Coughing blood, superior vena cava obstruction"
"Upper GI Tract Chronic GI bleeding and bowel habit changes, dysphagia, persistent vomiting, unexplained pain and"
"weight loss, abdominal mass without dyspepsia,"
"Lower GI Tract Bleeding and bowel habit changes, palpable rectal"
"mass, unexplained iron deficiency anaemia"
"Breast Discrete hard lump with fixation, eczematous skin"
"and nipple changes, unilateral nipple discharge,"
"Gynaecological Postmenopausal bleeding, persistent intramenstrual"
"bleeding, vulval lump and bleeding"
"Urological Hard irregular prostate, urinary symptoms, macroscopic haematuria, swelling or mass in testes, or"
any abdominal mass along urological tract
"Central Nervous Progressive neurological deficit, new onset seizures,"
"System headaches, mental changes, unilateral deafness, and"
"signs of raised intracranial pressure (e.g., vomiting,"
"drowsiness, posture-related headache, tinnitus, and"
"Cancer prevention means activities or actions directed at avoiding,"
"reducing, eliminating, or eradicating the risk of developing cancer or"
the impact of cancer on individuals and populations to promote health.
Approximately 40 of cancers are preventable through interventions
"such as prevention of oncogenic infections (HPV, HIV, HBV, etc),"
"alcohol, tobacco, and, environmental controls, promotion of healthy"
Prevention offers the most cost-effective long-term strategy for
Health workers are responsible for educating the public on:
 Primary Prevention  sustained action to prevent a cancerous process from developing through risk factor reduction
 Secondary Prevention  active discovery and control of
cancerous or pre-cancerous lesions
"Prevention of cancer includes activities or actions directed at avoiding,"
"reducing, eliminating, or eradicating the risk of developing cancer prior"
"Breast Discrete hard lump with fixation, eczematous skin"
"and nipple changes, unilateral nipple discharge,"
"Gynaecological Postmenopausal bleeding, persistent intramenstrual"
"bleeding, vulval lump and bleeding"
"Urological Hard irregular prostate, urinary symptoms, macroscopic haematuria, swelling or mass in testes, or"
any abdominal mass along urological tract
"System Progressive neurological deficit, new onset seizures,"
"headaches, mental changes, unilateral deafness, and"
"signs of raised intracranial pressure (e.g., vomiting,"
"drowsiness, posture-related headache, tinnitus, and"
Primary prevention gives control to the individual in maintaining a
healthy lifestyle and environment to avoid or reduce cancer risk.
" Tobacco use increases the risk of several types of cancer,"
"especially cancer of the lungs, oesophagus, larynx, mouth,"
"throat, kidney, bladder, pancreas, stomach, and cervix"
 Health workers must educate patients  clients  communities
on the dangers of tobacco consumption and smoking; patients
should be advised to avoid tobacco use. For patients clients
"who smoke or use tobacco in any other form, health workers"
must encourage and support them to stop tobacco use.
"Consumption of unhealthy (unbalanced diet, sweetened food and beverages, charred, and unhygienic food) increases the risk of several types"
"of cancer, especially cancer of the colon and rectum, mouth, pharynx,"
"and larynx, corpus uteri, breast, kidney, liver, pancreas, esophagus,"
"thyroid, prostate, multiple myeloma, and gallbladder."
 Health workers must educate patients  clients  communities
" balance their diet with various types of healthy foods,"
" eat plenty of healthy food such as whole grains, pulses, fruits,"
" limit food high in sugar or fat and avoid sugary drinks,"
" limit the amount of salt intake,"
" limit eating red meat and avoid eating processed meat,"
 avoid eating burnt or charred food.
"Being overweight or obese increases the risk of cancer, specifically"
"the oesophageal, colorectal, breast, endometrial, and kidney cancers."
"Heath workers must advise patients to maintain a healthy lifestyle,"
"especially, regular physical activity and a healthy diet."
"Also, inform them to maintain their body weight within the healthy range."
"Sedentary lifestyle increases the risk of colon, endometrial, bladder,"
"breast, lung, esophageal adenocarcinoma, renal, and gastric cancers."
Heath workers must advise patients  clients to be physically active in
everyday life. Limit the time you spend sitting and engage in at least
30 minutes of regularly physical activity per day or on most days of
Excess consumption of alcohol increases the risk of cancer of the oral
"cavity, oesophagus, larynx, liver, colorectal, and breast."
Health workers should educate patients  clients communities of the
dangers of excessive and regular alcohol consumption. The key messages
should include: Not drinking alcohol is better for cancer prevention. If
"you drink alcohol of any type, limit your intake."
Regular exposure to carcinogenic chemicals in the environment can occur
"through unsafe drinking water, air pollution, and food contaminated"
"by aflatoxin or dioxin chemicals, occupational exposure to dangerous"
"Environmental carcinogens (aflatoxins, asbestos, vehicle emissions,"
"lead, ultraviolet light, and ionizing radiation) will lead to increased risk"
"of developing cancer, e.g. lung cancer"
Health workers must educate patients on environmental dangers and
provide suggestions to limit exposure such as:
 Limiting indoor air pollution due to smoke from use of charcoal
and firewood inside a poorly ventilated house
 Avoiding exposure to garbage pollution (burning rubbish)
 Employers should provide employees with a safe working
environment with limited occupational hazards
The following infections are associated with causing certain types of
 Viral Hepatitis BC: cancer of the liver
" Human Papilloma Virus (HPV): cervical, oral, anal, and cancer"
 Helicobacter Pylori: Gastric (stomach) cancer
" HIVAIDS: aggressive lymphoma subtypes, Kaposis sarcoma,"
"anorectal cancer, cervical cancer, etc."
 Schistosomiasis: increases risk of bladder cancer
 Liver Fluke: increases risk of cholangio-carcinoma
 Preventative measures to control oncogenic infection risk
"include vaccination, and preventiontreatment of infection"
 Engage in safe sexual behaviour to avoid sexually transmitted
diseases that can cause or increase the risk of certain types of
"cancer such as cervical, Kaposi sarcoma, lymphoma, and liver"
 HPV Vaccination: vaccinate all girls aged 10 years with 2 doses
of HPV vaccine (for detail see section 18 on immunization)
 Hepatitis B Vaccination: routinely offered in the national
"childhood schedule and populations at risk, in order to prevent"
"infection with hepatitis B, the main risk factor for liver cancer"
(for detail see section 18 on immunization)
" Treatment of HIVAIDS, schistosomiasis, H. pylori, and"
hepatitis BC and other infections is also a preventive measure.
" Ultraviolet (UV) radiation, and in particular solar radiation,"
"is carcinogenic to humans, causing all major types of skin"
"cancer, such as basal cell carcinoma, squamous cell carcinoma and melanoma"
 People with albinism are at a much higher risk of skin cancer
and health workers should encourage them to wear protective
 Ionizing radiation from radioactive isotopes (used in medical diagnostics and treatment) is also associated with leukaemia and other solid tissue tumours. Proper disposal of
highly radioactive isotopes is mandatory to prevent hazardous exposures
The following infections are associated with causing certain types of
 Viral Hepatitis BC: cancer of the liver
 Human Papilloma Virus (HPV): cervical cancer
 Helicobacter Pylori: stomach cancer
"HIVAIDS: aggressive lymphoma subtypes, Kaposis sarcoma, anorectal"
 Schistosomiasis: increases risk of bladder cancer
 Liver Fluke: increases risk of cholangio-carcinoma
 Preventative measures to control infection risk include
"vaccination, and preventiontreatment of infection and"
 HPV Vaccination: immunize all girls from age 10 with 2
doses of HPV vaccine (see section 18.1)
 Hepatitis B Vaccination: routinely offered in the national
"childhood schedule and populations at risk, in order to"
"prevent infection with hepatitis B, the main risk factor for"
liver cancer (see section 18.2.2)
" Treatment of HIVAIDS, schistosomiasis, H. pylori, and"
hepatitis BC and other infections is also a preventive
Secondary prevention of cancer includes activities or actions directed
at halting the progress of cancer at its incipient stage through screen-
"ing, early diagnosis, pre-cancer treatment or cancer management, and"
referral to avoid or reduce complications associated with the cancer.
Secondary prevention strategies relate to the discovery and control of
cancerous or pre-cancerous lesions.
Early detection of cancer greatly increases the chances for successful
treatment and cure. It comprises of:
 Early diagnosis in symptomatic populations
 Screening in asymptomatic high-risk populations
Screening refers to the use of simple tests across a healthy population
"in order to identify individuals who have disease, but do not yet have"
"Based on existing evidence, mass population screening is advocated for"
breast and cervical cancer. Other cancers that are commonly screened
for include prostate and colorectal cancers
Screening  health checkup for breast cancer involves:
"Breast Self-Examination (BSE): a simple, quick examination done by the"
"client herself, aimed at early detection of lumps. Regular (monthly-not"
"during menstruation, at least seven days after ending the menstruation)"
and correct technique of breast examination is important and easy to
teach and administer. Health workers should note that BSE is not a
"standard screening test for breast cancer, but is beneficial for breast"
Clinical Breast Examination (CBE): performed by a trained and skilled
 Take a detailed history and conduct a physical
 All breast quadrants must be examined in detail plus the
" Inspect the skin for changes and swellings, for tethering of"
" the breast on the chest wall, palpate for lumps, check for"
 A suspicious lump or bloody nipple discharge MUST
BE REFERRED for evaluation by mammography or
ultrasonography as well as core needle biopsy
Mammography: a low-dose x-ray of the breast is the test of choice
for screening of early breast cancer but it is available only at national
"Breast Ultrasound: not used as a screening test, but is useful as an"
additional tool in characterizing palpable tumors and taking of image-directed biopsies. It may be used as a screening tool in lactating
"women, small- breasted women and in males, and as diagnostic tests in"
This aims to detect pre-cancerous lesions that are then treated to prevent
progression to invasive cancer. The following methods are recommended:
Visual Inspection with Acetic Acid (VIA): involves applying 3-5 freshly
prepared acetic acid to the cervix and observing results after one minute.
 The VIA results are generally categorized into 3 subsets:
"suspicious for cancer, VIA negative and VIA positive"
" It uses readily available equipment, does not require a"
 laboratory and provides an immediate result.
 Positive cases can be treated with cryotherapy by adequately
Consider the following if using VIA as a screening method:
 Women 25 years of age should be screened only if they are
"at high risk for disease: HIV positive, early sexual exposure,"
"multiple partners, previous abnormal screening results, cervical"
intraepithelial neoplasia (CIN)
 VIA is not appropriate for women 50 years
" Screening is advised every 3-5 years in case of normal results,"
but after 1 years in case of abnormal results and treatment
(cryotherapy) nd every year in HIV positive women.
 Visual Inspection with Lugols Iodine (VILI): it involves looking
at the cervix with the naked eye or low magnification after
swabbing with Lugols iodine. VILI has a sensitivity and
"specificity of about 92 and 85, respectively. Test results"
are available immediately thereby decreasing loss to follow-up.
Recommendations and timings of VIA outlined above also
 Cytology Testing by Pap Smear: it is a microscopic examination
of cells scraped from the opening of the cervix. The PAP
smear is best taken around mid-cycle. It should be postponed
"in case of cervicitis until after treatment; otherwise, the pus"
cells obscure clarity of the smear and affect interpretation. It
requires histocytology services so it is available only at
 HPV DNA testing is currently being piloted as a standard
This section describes the signs and symptoms of common cancers in
"adults and children, and outline some of the investigations required."
Health workers should suspect cancer if they observe any of these clinical features and refer patients to the cancer treatment centers (Uganda
Cancer Institte and regional referral hospitals).
Clinical Features Investigations
Clinical Features Investigations
" Recurrent infections  CBC, peripheral"
" Uric acid, lactate dehydrogenase"
" Usually a jaw or abdomi-  Bone marrow, X-Ray"
nal mass or tumour  Lumbar puncture
 Lymph node enlargement  Lymph node biopsy
 Ultra sound  Abdominal mass in loin
 Fast-growing often crossing midline
"Rhabdosarcoma, rhabdomyosarcoma  Good physical"
 Tumour of muscle  Full Blood Count
" CT scan when availpelvis, bladder, vagina"
 May present with a  Biopsy FNAC
inherited through chromosome 13
 Usually a jaw or abdominal mass or tumour
 Fast-growing often crossing midline
"Rhabdosarcoma, rhabdomyosarcoma"
 May ulcerate and bleed  Good physical
inherited through chromosome 13  Skull XRay
CLINICAL FEATURES INVESTIGATIONS
 May be unilateral or  Fundoscopy
 Weakness or loss of feeling in arms or legs
 Stumblinglack of coordination in walking
 Abnormal eye movements or changesloss in
CLINICAL FEATURES INVESTIGATIONS
 Progressive dysphagia  Endoscopy; visual-
CLINICAL FEATURES INVESTIGATIONS
 Weakness or loss of feeling in arms or legs
 Stumblinglack of coordination in walking
 Abnormal eye movements or changesloss in
CLINICAL FEATURES INVESTIGATIONS
 Endoscopy; visualise and biopsy
CLINICAL FEATURES INVESTIGATIONS
Colorectal  Anal Cancer  Haemogram
 Change in bowel habits; anaemia
"constipation, diarrhoea  Occult blood in stool"
" Anaemia, weight loss  Sigmoidoscopy"
Nephroblastoma (Wilms tumour)  CBC
 UE in normal  Average age 2 years: urography shows
Embryonal tumour displaced calices
Ovarian Cancer  Pelvic ultrasound
"e.g., pressure, poor appetite, nausea, vomiting,"
CLINICAL FEATURES INVESTIGATIONS
 Lower abdominal mass  Haemogram
"e.g., pressure, poor appetite, nausea, vomiting,"
CLINICAL FEATURES INVESTIGATIONS
 Urinary frequency  Ascitic tap for
" to rule out Tuberin 40-69 years, suspect"
Suspect where naevus shows:  CXR
" Vaginal discharge, sometimes foul smeling"
 Post-menopausal bleeding (especially if not
responding to appropriate treatment)
CLINICAL FEATURES INVESTIGATIONS
 Massmasses in abdomen; if mass 15 cm
"cytology, chemistry and microscopy"
 Regional lymph nodes  Wide excision punch
" Vaginal discharge, sometimes foul smeling"
 Post-menopausal bleeding (especially if not
responding to appropriate treatment)  Biopsy
CLINICAL FEATURES INVESTIGATIONS
 Oliguria (due to ureteric obstruction or renal failure)
 A painless lump  Excisional biopsy
(see section  Nipple retraction
 Skin changes such as darkening and dimpling appearing like orange skin
 Symptoms and signs of metastasis
CLINICAL FEATURES INVESTIGATIONS
 Oliguria (due to ureteric obstruction or renal failure)
 Skin changes such as darkening and dimpling appearing like orange skin
 Symptoms and signs of metastasis  Mammography
CLINICAL FEATURES INVESTIGATIONS
Non-Hodgkins Lymphoma (NHL)  Lymph node excision
 Progressive lymph node  Fine needle aspiraenlargement tions (FNA)
 Pallor (anaemia)  Viral serology for H Lymphadenopathy (generalised)
Squamous cell cancer of skin  Wide excision incisional biopsy
 Nonhealing ulcers  XRays of bones
 Indolent KS: nodular skin  HIV screening
"lesions, fungating nod-  CXR: pleural effuules, bone involvement sions"
"nodules, mucous membranes, mouth palate and"
"ENT lesions, lymphadenopathy, paraplegias, any"
CLINICAL FEATURES INVESTIGATIONS
 Hepatomegaly  Lymph node excision
 Viral serology for HSquamous cell cancer of skin
 Lymph nodes  Wide excision incisional biopsy
"lesions, fungating nodules, bone involvement"
"nodules, mucous membranes, mouth palate and"
"ENT lesions, lymphadenopathy, paraplegias, any"
organ can be impacted  Biopsies
CLINICAL FEATURES INVESTIGATIONS
Head and Neck cancers  Chest X-Rays and
Prostate Cancer  Digital Rectal Exam
" Urge to urinate often,  Serum PSA"
especially at night  Ultrasound guided
CLINICAL FEATURES INVESTIGATIONS
 Cranial nerve palsies  Chest X-Rays and
emptying of bladder  Digital Rectal Exam
CLINICAL FEATURES INVESTIGATIONS
 Bleeding or easy bruisabil-  CLL: blood film
 Drenching night sweats basophilia
The following clinical signs require full  CT scan
CLINICAL FEATURES INVESTIGATIONS
The following clinical signs require full
13. PALLIATIVE CARE ICD10 CODE: Z51.5
Palliative care aims to improve the quality of life of patients (and their
"families) who are faced with life-threatening illness, through the prevention and relief of suffering. This is achieved through early identification,"
"ongoing assessment, treatment of pain and other physical, psychosocial"
Pain is what the patient says hurts
Pain is an unpleasant sensory and emotional experience associated
"with actual or potential tissue damage, or described in terms of such"
damage. Pain is the most common symptom of a disease.
"The nature, location and cause of pain will differ in each case. Pain"
"requires a holistic approach as it can be affected by spiritual, psychological, social, and cultural factors, which may need to be addressed"
after physical pain is controlled.
Pain can be divided into two types of causative categories:
 Acute Pain: Caused by a specific action with a definite
"time period, e.g., postoperative, acute infection, or trauma"
" Chronic pain: Ongoing pain with an indefinite time period, for example"
 Constant and usually increasing: cancer
" Recurrent sickle-cell crisis, arthritis, HIVAIDS"
" Drug side-effect or toxicity (e.g., peripheral neuropathy due to"
These factors increase pain perception:
" Anxiety and depression, social abandonment"
 Lack of understanding of the problem
These factors decrease pain perception:
" Explanationunderstanding, venting feelings"
Clinical Features and Investigations
There are 2 types of pain that health workers need to be aware of:
Nociceptive Pain  Somatic Pain (from bones
The pain pathways are intact. aching throbbing
This kind of pain responds to the
analgesic ladder  Visceral Pain: described
"viscera), pressure, cramping and ache for solid"
"Neuropathic Pain  Described as burning,"
"There is damage to nerves or the and needles, insects crawlpathways. The pain responds ing under skin, numbness,"
"only partially hypersensitivity,"
to the analgesic ladder and needs
adjuvants of amitriptyline or phenytoin
This kind of pain responds to the
analgesic ladder  Somatic Pain (from bones
"viscera), pressure, cramping and ache for solid"
There is damage to nerves or the
to the analgesic ladder and needs
"adjuvants of amitriptyline or phenytoin  Described as burning,"
"and needles, insects crawling under skin, numbness,"
It is important for health workers to conduct a thorough investigation
of a patient indicating they are in pain. The following points can be
used to guide the investigation:
" Severity: assess using the Numerical Rating Scale, where"
the patient grades hisher pain on a scale of 0  no pain
" Nature (e.g., stabbing, throbbing, crushing, cramp-like)"
 Periodicity (constant or intermittent)
 Relieving or aggravating factors
" Ask the patient for a detailed history for each pain experienced, as there may be more than one type of pain and"
 A targeted physical examination
There are two goals of pain management:
 Diagnose and treat the disease causing the pain
 Achieve total pain relief with minimal side-effects and enable the patient to live as normal a life as possible
 Pain can be treated through use of medicines andor nondrug treatment
Non pharmacological treatment of pain
 Massage with aromatherapy oils: may be useful for
neuropathic pain and muscular pain
 Application of heat or cold packs
" Distraction (e.g., listening to radio or partaking in a"
 Non-pharmacological treatment of underlying cause
"(e.g., surgery or radiotherapy of cancer)"
The WHO Analgesic Ladder and the following tables describe the use
of medicines to relieve pain based on the type and degree of pain.
 Massage with aromatherapy oils: may be useful for
neuropathic pain and muscular pain
 Application of heat or cold packs
" Distraction (e.g., listening to radio or partaking in a"
 Non-pharmacological treatment of underlying cause
"(e.g., surgery or radiotherapy of cancer)"
STEP 1: MILD PAIN (NON-OPIOID  ADJUVANTS)
 Paracetamol 1 g every 6  Continue with step 1
hours (500 mg in elderly) analgesics when moving to
 Ibuprofen 400 mg every doses of paracetamol may
6- 8 hours (max cause liver toxicity
" 2,400 mgdaily) or  Do not use NSAIDS in"
 Diclofenac 50 mg every  Caution when using
STEP 1: MILD PAIN (NON-OPIOID  ADJUVANTS) 
(WEAK OPIOID  NON-OPIOID  ADJUVANT)
 Morphine 2.5-5 mg  Low dose morphine is
every 4 hours during considered step 2 analgesic
"day, double dose at and recomended first line if"
every 6 hours (max 240  Give Bisacodyl 10-15 mg nocte
mg) to prevent constipation except
 Tramadol 50-100 mg  Add liquid paraffin 10 ml once
a day if Bisacodyl is not enough
(STRONG OPIOID  NON-OPIOID  ADJUVANT
 Morphine 7.5-10 mg  Elderly and renal
every 4 hours during day impairment may require
and double dose at night dose adjustment
 Give additional dose  If modified release tablets are
"30 minutes before an ac- available, use the same 24-hour"
tivity causing pain (e.g. dose but given in 1 or 2 doses
(WEAK OPIOID  NON-OPIOID  ADJUVANT) 
a day if Bisacodyl is not enough
(STRONG OPIOID  NON-OPIOID  ADJUVANT 
30 minutes before an activity causing pain (e.g.
wound dressing)  Elderly and renal
 If modified release tablets are
"available, use the same 24-hour"
 Amitriptyline 12.525 mg nocte for neuropathic pain (max
 Clonazepam 0.5-1 mg nocte for neuropathic pain (second line)
 Dexamethasone 4-8 mg once a day for swelling or oedema
 Hyoscine 20 mg every 6 hours for smooth muscle spasm
 Diazepam 5-20 mg nocte for painful skeletal muscle spasms
 Do not use pethidine for chronic pain; accumulates with severe
side-effects on the gut. Only use as one off-dose for acute severe
" Side effects of NSAIDS: gastritis, renal toxicity, bleeding,"
 Side effects of opioids: see sections 13.13.Pain Management In Children
STEP 1: MILD PAIN (NON-OPIOID  ADJUVANTS)
 Paracetamol 10-15 mgkg w Continue with step 1 analevery 6 hours Andor gesics when moving to step 2
6-8 hours (use only in children
 Amitriptyline 12.525 mg nocte for neuropathic pain (max
 Clonazepam 0.5-1 mg nocte for neuropathic pain (second line)
 Dexamethasone 4-8 mg once a day for swelling or oedema
 Hyoscine 20 mg every 6 hours for smooth muscle spasm
 Diazepam 5-20 mg nocte for painful skeletal muscle spasms 
 Do not use pethidine for chronic pain; accumulates with severe
side-effects on the gut. Only use as one off-dose for acute severe
" Side effects of NSAIDS: gastritis, renal toxicity, bleeding,"
 Side effects of opioids: see sections 13.ANALGESICS COMMENTS
STEP 1: MILD PAIN (NON-OPIOID  ADJUVANTS) 
6-8 hours (use only in children
3 months) w Continue with step 1 analgesics when moving to step 2
STEP 2: MODERATE AND SEVERE PAIN (OPIOID  NON-OPIOID  ADJUVANT)
 Morphine every 4 hours w Codeine and tramadol are
6-12 months: mgkg w Give Bisacodyl
1-2 years: 0.2-mgkg (suppository only) 5
"slowly, until pain is controlled"
 Amitriptyline nocte for neuropathic pain
 Child 2-12 years: 0.2-mgkg (max 1 mgkg or 25
"kg in 2-3 divided doses, increase gradually to avoid side"
STEP 2: MODERATE AND SEVERE PAIN (OPIOID  NON-OPIOID  ADJUVANT) 
"slowly, until pain is controlled"
50 every 24 hours w Codeine and tramadol are
 Amitriptyline nocte for neuropathic pain
 Child 2-12 years: 0.2-mgkg (max 1 mgkg or 25
"kg in 2-3 divided doses, increase gradually to avoid side"
General principles in use of opioids
 Health professionals specially trained in palliative care
should supervise management of chronic pain in advanced
"or incurable conditions (e.g., cancer, AIDS)"
 Morphine is usually the drug of choice for severe pain.
"Liquid morphine is available, easy to dose, and is well absorbed from the oral mucosae and can be dripped in the"
" In continuous pain, analgesics should be given:"
 By the clock (i.e. according to a regular dose schedule)
 By the patient (i.e. self-administered)
 By the mouth (i.e. as oral dose forms)
 Pain is better controlled using regular oral doses which
"control pain. If pain is not controlled, increase the 24-hour"
 Repeated injections are not indicated
 Consider extra doses when painful procedure is planned
and for breakthrough pain. If using breakthrough doses
"regularly, then increase the regular dose!"
 Side effects are minor and well-manageable if careful dosing and titration are done
"Opioids need to be effectively managed and administered, considering"
the associated cautions and side effects below. r Do not use opioids in
severe respiratory depression and
 Use with care in the following conditions
 Advanced liver disease (but can be used in hepatocellular
carcinoma when titrated as above)
 Acute abdominal pain (can use while awaiting diagnostic tests;
never leave the patient in pain)
 Renal failure (reduce starting dose andor reduce dose
 Elderly or severely wasted patient (reduce starting dose
" Use with extreme care (i.e., start with small doses and use"
small incremental increases) in:
 Recurrent or concurrent intake of alcohol or other CNS
Management of Side Effects of Opioids
 Rarely occurs if small oral doses are used and gradually
 Can occur when morphine used parenterally
 Reverse respiratory depression using naloxone 0.4-2 mg slow
2-3 minutes according to response
Child: mgkg slow IV; repeat mgkg if no response
Constipation  Give Bisacodyl 10-15 mg nocte to prevent
constipation except if diarrhoea is present
 Add liquid paraffin 10 ml once a day if bisacodyl
Nausea or  Usually occurs in first 5 days and is self-limiting
 Vomiting later on may be due to another cause
Child 1 yr: 100 micrograms per kg every 12 hours
 Rarely occurs if small oral doses are used and gradually
 Can occur when morphine used parenterally
 Reverse respiratory depression using naloxone 0.4-2 mg slow
2-3 minutes according to response
Child: mgkg slow IV; repeat mgkg if no response 
Constipation  Give Bisacodyl 10-15 mg nocte to prevent
constipation except if diarrhoea is present
 Add liquid paraffin 10 ml once a day if bisacodyl
Vomiting  Usually occurs in first 5 days and is self-limiting
 Vomiting later on may be due to another cause
Child 1 yr: 100 micrograms per kg every 12 hours
"Confusion or  If excessive continuous drowsiness, titrate"
Drowsiness the opioid dose down slowly
" If pain does not respond to above measures, refer to palliative care specialist"
 Refer for radiotherapy at national referral hospital for severe bone pain not responding to above medications
 Refer for surgery if the cause of pain is amenable to surgery
Neuropathic pain occurs as a result of damage to nerve tissue. There are
"two clinical kinds of neuropathic pain, both elements may be combined:"
 Stabbing-type: pain in a nerve distribution with minimal
pain in between (e.g. trigeminal neuralgia) but can occur
with any nerve. Responds to Phenytoin
" Paraesthesia dysaesthesiae, or burning-type pain: (e.g."
post-herpetic neuralgia). Responds well to small doses of
Trigeminal neuralgia or stabbing-type pain
 Carbamazepine initially 100 mg every 12 hours HC3
 Increase gradually by 200 mg every 2-3 days
"according to response, max 1200 mg"
"Burning type pain (post-herpetic neuralgia, diabetic neuropathy)"
 Amitriptyline 12.5-25 mg at night or every
" 12 hours depending on response, max 50-75 mg"
"Drowsiness  If excessive continuous drowsiness, titrate"
Trigeminal neuralgia or stabbing-type pain
 Carbamazepine initially 100 mg every 12 hours
 Increase gradually by 200 mg every 2-3 days
"according to response, max 1200 mg"
 Causes white cell depression HC3
"Burning type pain (post-herpetic neuralgia, diabetic neuropathy)"
 Amitriptyline 12.5-25 mg at night or every
" 12 hours depending on response, max 50-75 mg HC3"
Includes pain in the lumbar region of the spine or bone pain anywhere
Potential causes of back or bone pain:
 Disc degeneration (often has a neuropathic element because of pressure on sciatic or other nerve)
 Osteoporosis (if collapse of vertebrae or fracture)
"Infection (e.g. TB, brucellosis, PID, retroperitoneal)"
" Metastatic cancers, renal disease"
Each situation will differ depending on the cause of the pain
 If an infection is present: throbbing and constant pain
" If sciatica, sciatic nerve roots will be involved"
 Try to establish the cause and type of pain
Management of Back or Bone Pain
 Give a Step 1 drug for 7 days or as long as required
 NSAIDs are the Step 1 drug of choice in bone
" May have to add a Step 2 or 3 drug, especially in"
 Give a Step 1 drug for 7 days or as long as required
 NSAIDs are the Step 1 drug of choice in bone
" May have to add a Step 2 or 3 drug, especially in"
 Rest the back on a firm but not hard surface
 Manage as for neuropathic pain above
OTHER CONDITIONS IN PALLIATIVE CARE
"In palliative care, other conditions that are commonly encountered are"
Due to palliative care conditions or anxiety
 Reassure patient; explore patients fears and anxieties;
 Breathing exercises and relaxation techniques; teach
patient how to slow down breathing by pursing their
lips and breathe with diaphragm rather than chest
 Position patient in most comfortable position in bed
" Ensure good ventilation (e.g., open windows, use fans,"
" Conserve energy (e.g., encourage exertion to breathlessness)"
" Refer if symptoms persist, in airway obstruction, or"
 Oral morphine 2.5-5 mg every 4 hours. Oxygen HC4
if patient is hypoxic. Diazepam if patient is anxious
 Diazepam 2.5-5 mg orally; once a day if
breathlessness is associated with panic attacks
 Rest the back on a firm but not hard surface
 Manage as for neuropathic pain above HC4
 Reassure patient; explore patients fears and anxieties;
 Breathing exercises and relaxation techniques; teach
patient how to slow down breathing by pursing their
lips and breathe with diaphragm rather than chest
 Position patient in most comfortable position in bed
" Ensure good ventilation (e.g., open windows, use fans,"
" Conserve energy (e.g., encourage exertion to breathlessness)"
" Refer if symptoms persist, in airway obstruction, or"
 Oral morphine 2.5-5 mg every 4 hours. Oxygen
if patient is hypoxic. Diazepam if patient is anxious
 Diazepam 2.5-5 mg orally; once a day if
breathlessness is associated with panic attacks HC2
Nausea and Vomiting ICD10 CODE: R11
Can be due to disease or medicines
 Vomiting typically relieves nausea HC4
If due to gastric stasis or delayed bowel transit time
 Give metoclopramide 1020 mg every 8 hours (30 HC4
minutes before meals; same dose SC or IV)
"If due to metabolic disturbance (liverrenal failure, medicines"
 Give haloperidol -mg nocte (PO or SC)
If due to raised intracranial pressure
 If due to visceral stretch or compression f Promethazine 25 mg every 8 hours or f Hyoscine butylblomide
Pressure Ulcer (Decubitus Ulcers) ICD10 CODE: L89
Ulcer of the skin andor subcutaneous tissue caused by ischaemia
secondary to extrinsic pressure or shear
 Non-drug treatment f Debridement of necrotic tissue HC3
" If able, encourage patients to raise themselves off the"
seat and shift their weight every 15-20 minutes or to
 Vomiting typically relieves nausea
If due to gastric stasis or delayed bowel transit time
 Give metoclopramide 1020 mg every 8 hours (30
minutes before meals; same dose SC or IV)
"If due to metabolic disturbance (liverrenal failure, medicines"
 Give haloperidol -mg nocte (PO or SC)
If due to raised intracranial pressure
 If due to visceral stretch or compression f Promethazine 25 mg every 8 hours or f Hyoscine butylblomide
 Non-drug treatment f Debridement of necrotic tissue
" If able, encourage patients to raise themselves off the"
seat and shift their weight every 15-20 minutes or to
 Repositioning of those who cannot move themselves HC3
"frequently, determined by need and skin status"
 Inspect skin every time the patients position is changed
 Maintain optimal hydration and hygiene of skin
" Avoid trauma, by not dragging patient"
 Good nutrition for those with good prognosis to maintain
 Educate patient caretakers on risk factors for developing
"pressure ulcers, how to inspect and care for skin, and"
inform health care professional
 May need skin grafting and flaps; refer to hospital
 Give antibiotics if there is evidence of surrounding cellulitis (see
 Control odour with topical metronidazole
 powder or gel until there is no foul smell
" If patient has sepsis, give parenteral antibiotics (see section for treatment of sepsis)"
 Clean the wound regularly every day with 0.9 saline
(or dissolve 1 teaspoon of salt per pint of cooled boiled HC2
 Protect the normal skin around the wound with barrier
 Repositioning of those who cannot move themselves
"frequently, determined by need and skin status"
 Inspect skin every time the patients position is changed
 Maintain optimal hydration and hygiene of skin
" Avoid trauma, by not dragging patient"
 Good nutrition for those with good prognosis to maintain
 Educate patient caretakers on risk factors for developing
"pressure ulcers, how to inspect and care for skin, and"
inform health care professional
 May need skin grafting and flaps; refer to hospital HC3
 Give antibiotics if there is evidence of surrounding cellulitis (see
 Control odour with topical metronidazole
 powder or gel until there is no foul smell
" If patient has sepsis, give parenteral antibiotics (see section for treatment of sepsis) "
 Clean the wound regularly every day with 0.9 saline
(or dissolve 1 teaspoon of salt per pint of cooled boiled
 Protect the normal skin around the wound with barrier
 If malodourexudate: apply metronidazole powder daily
directly to the wound when changing dressing
" If cellulitis, give appropriate antibiotic"
Anorexia and Cachexia ICD10 CODE: R63.0 AND R64
"Anorexia is loss of desire to eat. Cachexia is a complex metabolic syndrome, characterized by profound loss of lean body mass, in terminal"
" Nausea and vomiting, constipation, gastrointestinal obstruction"
" Sore mouth, mouth tumours, malodour"
" Hypercalcaemia, hyponatraemia, uraemia, liver failure"
 Treat underlying causes if possible. HC4
" In cancer patients, give corticosteroids for one week"
"only, under supervision of specialist"
 Prednisolone 15-40 mg once a day for 7 days
 Or dexamethasone 2-6 mg in the morning for 7
 Small amounts of food frequently
" Give energy-dense food, and limit fat intake"
 Avoid extremes in taste and smell
" Pleasant environment, nice presentation of food"
 If malodourexudate: apply metronidazole powder daily
directly to the wound when changing dressing
" If cellulitis, give appropriate antibiotic "
 Treat underlying causes if possible.
" In cancer patients, give corticosteroids for one week"
"only, under supervision of specialist"
 Prednisolone 15-40 mg once a day for 7 days
 Or dexamethasone 2-6 mg in the morning for 7
 Small amounts of food frequently
" Give energy-dense food, and limit fat intake"
 Avoid extremes in taste and smell
" Pleasant environment, nice presentation of food HC4"
 Eating is a social habit and people eat better with others
" If prognosis 2 months, counsel patient and family to"
understand and adjust to reduced appetite as a normal
" In established cancer and cachexia, aggressive"
parenteral and enteral nutritional supplementation
"Repeated involuntary spasmodic diaphragmatic and inspiratory intercostal muscle contractions. Hiccups up to 48 hours are acute, those"
lasting more than 48 hours are persistent and more than 2 months
" Gastric distension, GERD, gastritis, diaphragmatic irritation by supraphrenic metastasis, phrenic nerve irritation"
" Metabolic: uraemia, hypokalaemia, hypocalcaemia, hyperglycaemia, hypocapnia"
 Infection: oesophageal candidiasis
 Most hiccups are short-lived and self-limiting HC2
 Eating is a social habit and people eat better with others
" If prognosis 2 months, counsel patient and family to"
understand and adjust to reduced appetite as a normal
" In established cancer and cachexia, aggressive"
parenteral and enteral nutritional supplementation
 Most hiccups are short-lived and self-limiting
 Direct stimulation of the pharynx by swallowing dry
 Stimulation of vagus nerve by ingesting crushed ice or
 Rapidly ingest 2 heaped teaspoons of sugar
 Indirect stimulation of the pharynx
  C3-5 dermatome stimulation by tapping or rubbing
 Refer if hiccups persist or are intractable
 For persistent or intractable hiccups use: HC4
 Metoclopramide 10 mg 8 hourly (if the cause is gastric HC3
 Or Haloperidol 25 mg once a day
 Or chlorpromazine 25 mg 6 hourly
Dry or Painful Mouth ICD10 CODE: R68.2
"Dry mouth, painful mouth and mouth ulcers are caused by infections, drugs, chemotherapy, trauma, dryness, radiotherapy, Hand opportunistic infections."
" Mouth wash with salted water (hourly), frequent sipping"
 Brush teeth and tongue at least 3 times a day
 Suck fresh cold pineapple cubes once or twice daily
" Avoid sugary foods and drinks, eat soft food"
" Review medications (dry mouth can be a side effect,"
 Direct stimulation of the pharynx by swallowing dry
 Stimulation of vagus nerve by ingesting crushed ice or
 Rapidly ingest 2 heaped teaspoons of sugar
 Indirect stimulation of the pharynx
  C3-5 dermatome stimulation by tapping or rubbing
 Refer if hiccups persist or are intractable
 For persistent or intractable hiccups use:
 Metoclopramide 10 mg 8 hourly (if the cause is gastric
 Or Haloperidol 25 mg once a day
 Or chlorpromazine 25 mg 6 hourly HC4
" Mouth wash with salted water (hourly), frequent sipping"
 Brush teeth and tongue at least 3 times a day
 Suck fresh cold pineapple cubes once or twice daily
" Avoid sugary foods and drinks, eat soft food"
" Review medications (dry mouth can be a side effect,"
 Candidiasis with fluconazole 200 mg od for 7 days
" Herpes simplex with oral acyclovir 200 mg, 5 times a"
day for 510 days depending on severity
" Anaerobic gingivitis, halitosis, with metronidazole HC3"
mouthwash (mix 50 mL of IV metronidazole with 450
"mL of water, plus 50 mL of juice)"
Severe mucositis or aphtous ulcers
 Consider steroids dexamethasone 8 mg once daily for
" Analgesic gel (Bonjela, Oracure) on ulcers"
" Oral liquid morphine as above (before swallowing, hold"
liquid morphine in the mouth for at least 30 seconds)
" Diazepam 5-10 mg once a day, titrated to three times"
Excessive bronchial secretions HC4
 Hyoscine 20 mg once a day titrated to 3 times a day
 Morphine as above (see section 13.1.2)
 Candidiasis with fluconazole 200 mg od for 7 days
" Herpes simplex with oral acyclovir 200 mg, 5 times a"
day for 510 days depending on severity 
" Anaerobic gingivitis, halitosis, with metronidazole"
mouthwash (mix 50 mL of IV metronidazole with 450
"mL of water, plus 50 mL of juice)"
Severe mucositis or aphtous ulcers
 Consider steroids dexamethasone 8 mg once daily for
" Analgesic gel (Bonjela, Oracure) on ulcers"
" Oral liquid morphine as above (before swallowing, hold"
liquid morphine in the mouth for at least 30 seconds) HC3
" Diazepam 5-10 mg once a day, titrated to three times"
 Hyoscine 20 mg once a day titrated to 3 times a day
 Morphine as above (see section 13.1.2) HC3
Clinical signs at of end of life include (should be considered in those with
terminal conditions who have been gradually deteriorating):
 Patient becomes bed-bound and is increasingly drowsy or
 Minimal oral intake; patient not managing oral medication
and only able to take sips of fluid
 The patients condition is deteriorating rapidly (e.g. day by
 Breathing becomes irregular - noisy (death rattle)
 Changes in skin colour and or temperature
" Exclude reversible problems (e.g. drug toxicity, infections, dehydration, biochemical abnormalities)"
" Before ordering a test, always ask will this test change my"
management plan or the outcome for the patient?
 It is important to weigh the benefit versus the burden in assessing
"an intervention, andor management plan based on the clinical"
features exhibited by the patient
General principles of medicine treatment HC2
 Focus on giving medication that will improve the patients quality of life
 Treat symptoms of discomfort as in sections above
 If the patient is unable to swallow choose an appropriate
"route to give necessary medications (e.g., via NG tube,"
 Subcutaneous (SC) is recommended when the enteral
route is not possible. It is preferred over IV and IM
access due to its reduced trauma and pharmacokinetics
General principles of medicine treatment
 Focus on giving medication that will improve the patients quality of life
 Treat symptoms of discomfort as in sections above
 If the patient is unable to swallow choose an appropriate
"route to give necessary medications (e.g., via NG tube,"
 Subcutaneous (SC) is recommended when the enteral
route is not possible. It is preferred over IV and IM
access due to its reduced trauma and pharmacokinetics HC2
" If repeated injections are anticipated or experienced, a"
butterfly needle can be inserted and used as a route for
 Consider prescribing medications pre-emptively (anticipatory) to combat developing symptoms
 Morphine concentrations can vary depending on the
preparation used; remember that SC morphine has twice
" Patients should eat and drink as they wish, and take"
sips of water as long as they are able
 Families should be educated that it is normal for patients
"to lose their appetite, have a sense of thirst and stop"
feeding towards the end of life.
 They should not feed patients if they are no longer able
to swallow as this may cause choking and distress
 IV fluids at this stage will not prolong life or prevent
thirst. Over-hydration is discouraged as it may contribute to distressing respiratory secretions or generalised
oedema; good regular mouthcare is the best way to keep
 IV dextrose for calorie supplementation is unlikely to
" If there is a reduced level of consciousness, patients"
should not be fed due to the risk of aspiration.
 Artificial nutrition is generally discouraged at the end of life
 Regularly clean the mouth with a moist cloth wrapped
 Prevent and manage pressure sores appropriately
" If repeated injections are anticipated or experienced, a"
butterfly needle can be inserted and used as a route for
 Consider prescribing medications pre-emptively (anticipatory) to combat developing symptoms
 Morphine concentrations can vary depending on the
preparation used; remember that SC morphine has twice
" Patients should eat and drink as they wish, and take"
sips of water as long as they are able
 Families should be educated that it is normal for patients
"to lose their appetite, have a sense of thirst and stop"
feeding towards the end of life.
 They should not feed patients if they are no longer able
to swallow as this may cause choking and distress 
 IV fluids at this stage will not prolong life or prevent
thirst. Over-hydration is discouraged as it may contribute to distressing respiratory secretions or generalised
oedema; good regular mouthcare is the best way to keep
 IV dextrose for calorie supplementation is unlikely to
" If there is a reduced level of consciousness, patients"
should not be fed due to the risk of aspiration.
 Artificial nutrition is generally discouraged at the end of life 
 Regularly clean the mouth with a moist cloth wrapped
 Prevent and manage pressure sores appropriately
 The end of life is an emotional time for all involved and
requires health care professionals to be considerate and
compassionate. Take time to listen to the concerns of
the patient and their family; break bad news sensitively
" Encourage the family to be present, holding a hand"
or talking to the patient even if there is no visible response; the patient may be able to hear even if they
 Consider the best place of death for the patient and their
family; would discharging them to go home be best?
 The end of life is an emotional time for all involved and
requires health care professionals to be considerate and
compassionate. Take time to listen to the concerns of
the patient and their family; break bad news sensitively
" Encourage the family to be present, holding a hand"
or talking to the patient even if there is no visible response; the patient may be able to hear even if they
 Consider the best place of death for the patient and their
family; would discharging them to go home be best? 
DYSMENORRHOEA ICD10 CODE: N94.6
Abdominal pain that occurs just before or during menstruation. Symptoms
begin about 12 hours before onset of menses and last for 13 days.
Primary dysmenorrhoea occurs more commonly among adolescents and
young women. Symptoms usually begin 612 months after menarche
"and occur mainly with ovulatory cycles. Generally, severity of symptoms"
"decreases with age, sexual activity and child birth."
Secondary dysmenorrhoea is usually due to a gynaecological condition
"such as infection or fibroids, and usually occurs in older women above"
Causes of primary dysmenorrheaoa
Causes of secondary dysmenorrhoea
" Nausea, vomiting, diarrhoea, fainting, fever, fatigue, dizziness"
 Other causes of lower abdominal pain
 Encourage the patient to rest or sleep
 Encourage the patient to do some exercises
 Advise the patient to apply a warm compress to the
 Encourage the patient to wear loose fitting clothes
" Advise the patient to have a diet low in fats and supplements such magnesium, vitamin B1, vitamin E and zinc"
 Give NSAIDs e.g. ibuprofen 200400 mg every 8 hours HC4
 Other medications include paracetamol 1 g every 6
hours (in case of mild pain); or diclofenac 50 mg every
 Review the patient after 5 days and if no response or
"if recurrent, refer for specialist management"
" In secondary dysmenorrhoea, treat cause e.g. PID"
Pelvic Inflammatory Disease (PID) ICD10 CODE: N70-N73
"Infection (usually ascending from the vagina) occurring in the uterus, ovary,"
"or uterine tubes and leading to salpingitis, endometritis, pelvic peritonitis"
or formation of tubal ovarian abscess.
 Previous pelvic inflammatory disease infections
 Encourage the patient to rest or sleep
 Encourage the patient to do some exercises
 Advise the patient to apply a warm compress to the
 Encourage the patient to wear loose fitting clothes
" Advise the patient to have a diet low in fats and supplements such magnesium, vitamin B1, vitamin E and zinc"
 Give NSAIDs e.g. ibuprofen 200400 mg every 8 hours
 Other medications include paracetamol 1 g every 6
hours (in case of mild pain); or diclofenac 50 mg every
 Review the patient after 5 days and if no response or
"if recurrent, refer for specialist management"
" In secondary dysmenorrhoea, treat cause e.g. PID"
 Presence of bacterial vaginosis
 Multiple or new sexual partners
History of STIs in the patient or her partner
 Young age of less than 25 years
" Often due to multiple pathogens: Neisseria gonorrhoea,"
"Chlamydia trachomatis, Mycoplasma, Gardnerella, Bacteroids, Gram-negative bacilli, e.g. Escherichia coli"
 Pain in lower abdomen (usually 2 weeks) PLUS
 Vaginal discharge: could be smelly and mixed with pus
 Painful sexual intercourse (dysperunia)
 Cervical motion tenderness: vaginal examination will produce tenderness when the cervix is moved
 Swellings may be felt if there is pus in the tubes or pelvic
 Signs of peritonitis (rebound tenderness)
Do Not Treat Chronic Pelvic Pain With Antibiotics
" Ectopic pregnancy, threated abortion"
 Complicated or twisted ovarian cyst
 Pus swab: For CS. Thespeculum protects the sampling item;
"sample is from endocervix, aspirate from endometrial cavity"
curretings or an aspirate through the posterior pouch
" Ultrasound (if available) for detection of tubo ovarian masses,"
Treatment is based on a combination of medicines that cover
the multiple microorganisms involved.
 Ceftriaxone 250 mg IM (or cefixime 400 mg stat if
 Plus doxycycline 100 mg orally every 12 hours for 14 days
 Plus metronidazole 400 mg twice daily orally for 14 days
 Treat sexual partners as for urethral discharge syndrome
Treatment is based on a combination of medicines that cover
the multiple microorganisms involved.
 Ceftriaxone 250 mg IM (or cefixime 400 mg stat if
 Plus doxycycline 100 mg orally every 12 hours for 14 days
 Plus metronidazole 400 mg twice daily orally for 14 days
 Treat sexual partners as for urethral discharge syndrome
" In pregnancy, use erythromycin 500 mg every 6 hours"
for 14 days instead of doxycycline
 If severe or not improving after 7 days
 Refer for ultrasound scan and parenteral treatment
" Ceftriaxone 1 g IV daily plus metronidazole 500 mg every 8 hours until clinical improvement,"
 then continue oral regimen as above
 All women with PID should be tested for H Abstain from sex or use barrier methods during the
 Do not take alcohol when taking metronidazole
 Avoid sex during menstrual period and for 6 weeks
" In IUD users with PID, the IUD need not be removed."
"However, if there is no clinical improvement within 4872"
"hours of initiating treatment, providers should consider"
removing the IUD and help patient choose an alternative
contraceptive method (see chapter 15)
Abnormal Uterine Bleeding ICD10 CODE: N39.9
Any vaginal bleeding which represents a variation from the normal
pattern of regular menstruation.
 Hormonal abnormalities (ovulatory dysfunction)
" Uterine diseases (fibroids, polyps etc)"
" Cancers (cervical, uterine, rarely vaginal)"
 Others (coagulation disorders etc.)
" Iatrogenic (IUD, hormonal contraceptives)"
" In pregnancy, use erythromycin 500 mg every 6 hours"
for 14 days instead of doxycycline
 If severe or not improving after 7 days
 Refer for ultrasound scan and parenteral treatment
" Ceftriaxone 1 g IV daily plus metronidazole 500 mg every 8 hours until clinical improvement,"
 then continue oral regimen as above HC3
 All women with PID should be tested for H Abstain from sex or use barrier methods during the
 Do not take alcohol when taking metronidazole
 Avoid sex during menstrual period and for 6 weeks
" In IUD users with PID, the IUD need not be removed."
"However, if there is no clinical improvement within 4872"
"hours of initiating treatment, providers should consider"
removing the IUD and help patient choose an alternative
contraceptive method (see chapter 15) 
 Continuous or subcontinuous bleeding
 It can be acute and heavy or light and subcontinuous
 Pregnancy test to exclude abortion and pregnancy
 Vaginal examination (for cervical and vaginal abnormalities
Management is based on the possible cause.
General measures Ferrous sulphate or Fefol 1 HC2
Positive pregnancy See section on abortion and ectop- HC4
Bleeding in postmen- Refer for specialist assessment RR
(possible endometrial pathology)
"Lesion (ulcer, growth) Refer for specialist assessment RR"
"Suspect fibroid (bulky Use analgesics, iron supplement, H"
hard uterus) refer for ultrasound scan
Other signs of infec- Treat as PID and review HC3
Women on family See sections on FP methods and HC2
planning side effects (chapter 15)
General measures Ferrous sulphate or Fefol 1
test See section on abortion and ectopic pregnancy (chapter 16) HC4
Bleeding in postmenopausal woman Refer for specialist assessment
(possible endometrial pathology) RR
in vaginaon cervix Refer for specialist assessment RR
"hard uterus) Use analgesics, iron supplement,"
Other signs of infection Treat as PID and review HC3
planning See sections on FP methods and
Menopause is the cessation of menstruation in a female and usually
spontaneously occurs at the age of 45-55 years. Peri- menopause is the
time around menopause and can last a few years until the menopause
Menopause can also be caused by surgical removal of ovaries.
" Hot flushes (sudden unanticipated, unpleasant wave of"
body heat; can range from mild to intense)
" Night sweats, palpitations, headaches, insomnia, tiredness"
 Irregular menstruation till cessation
" Vaginal atrophy and dryness, loss of libido, painful intercourse"
" Bladder irritability, incontinence, UTIs"
" Skin changes: dryness, thinning, loss of head hair, increase or loss of body hair)"
" Mood swings, emotional changes (e.g. depression, irritability, short temperedness, weepiness)"
" Lack of concentration, failing memory"
 Explain process of menopause to the patient and reassure her it is normal
 Explain process of menopause to the patient and reassure her it is normal
" Diet low in fats, high in fruit and vegetables"
" Food rich supplements such as magnesium, vitamin"
 Calcium-rich food (or supplements) such as milk and
soya beans and vitamin D supplements
" Screen for CVD (hypertension, heart disease) and urine"
" For severe symptoms (severe hot flushes, depression)"
NB: URGENTLY REFER ANY MENOPAUSAL WOMAN WITH VAGINAL BLEEDING FOR FURTHER
" Diet low in fats, high in fruit and vegetables"
" Food rich supplements such as magnesium, vitamin"
 Calcium-rich food (or supplements) such as milk and
soya beans and vitamin D supplements HC2
" Screen for CVD (hypertension, heart disease) and urine"
" For severe symptoms (severe hot flushes, depression)"
NB: URGENTLY REFER ANY MENOPAUSAL WOMAN WITH VAGINAL BLEEDING FOR FURTHER
For further detailed information on Family Planning (FP) and Maternal
"Health, please refer to Procedure Manual for Family Planning and"
"Maternal Health Service Delivery MOH, 2016."
Family planning is a basic human right for an individual and couples
"to exercise control over their fertility, make informed decision on the"
"number of children they want to have, plan pregnancies, and the space"
FP has health benefits for the mother and the children and economic
benefits for the family and the country at large.
Key steps to be followed in provision of fp services
"1. Provide information about FP, including preconception care to"
2. Counsel clients at high risk of unwanted pregnancies to accept
"3. Counsel clients to make informed choice of FP methods, including"
4. Obtain and record client history
5. Perform a physical assessment
6. Perform a pelvic examination
7. Screen for cervical cancer and H8. Manage client according to chosen FP method
Provide Information about FP including Pre-ConceptionCare to Different Groups
The procedures used here are also used in the next step to recruit clients
"for FP and maternal health services in young child, antenatal, labour"
"and delivery wards, outpatients, outreach, and postpartum clinics and"
in providing education on specific chosen FP methods.
 Disseminate correct information to influence people to
"change beliefs, attitudes and practices"
 Recruit new clients and offer several FP methods
Risk factors to look out for in clients include:
" Complicating medical conditions (e.g., diabetes, heart"
 Having children with birth interval 2 years
" Poor obstetric history, which is likely to recur in future"
"pregnancies (e.g., postpartum haemorrhage, pre- eclampsia)"
Identify eligible women (non-pregnant) while conducting clinics such as:
 Young child clinics and paediatric wards
 Maternity and postnatal clinics and wards
 HIVAIDS care centers ART clinics
" Sexual Reproductive Health clinics (e.g. Cervical cancer,"
"Post abortion care, AdolescentYouth clinics)"
 Gender based violence clinics corners
You can also identify the eligible women while:
 Conducting outreaches (Immunisation or Home visits)
Discuss with clients about reproductive choices and risk factors. Give
special consideration to first time parents and adolescents in provision
"of appropriate information on sexuality, family planning and family"
"planning services: types, benefits, availability and procedures."
Pre-Conception Care with Clients Who Desire to Conceive
Pre-conception care discussion topics for clients who desire to conceive
 Pregnancy planning and appropriate contraception
 Folic acid supplementation 3 months preceeding conception
" Good diet, risk assessment and management of pre existing conditions and risk factors"
" Benefits of preconception care (e.g., prevention of unintended pregnancies, good maternal and foetal outcomes)"
" Screening for hereditary diseases e.g., sickle cell disease"
" Screening for STI, including HIV and hepatitis"
Discuss with PLW HIV Special Consideration for HTransmission
Key areas for discussion include:
 Prevention of HIV transmission to spouse and child
 Safer sexual practices and safe conception
 Educationcounseling about perinatal transmission risk
 Initiation or modification of ART considering toxicity
 Evaluation of opportunistic infections and offering ummarizedn
 Some ARV drugs may interact and reduce the effect of
hormonal contraceptives. It is always ummarize to use
"additional barrier methods (condoms), which also prevent"
Educate and Counsel Clients to Make Informed Choice of
9. To dispel any rumours and misconceptions about FP
10. To help the client make a voluntary informed choice
" Prepare the roommaterials needed, ensuring privacy"
 Assess clients knowledge and experience of FP methods
 Explain about different FP methods available
 Mechanism of action and method of use
 Help client choose appropriate method using family
planning medical eligibility criteria wheel (see summary of wheel
Obtain and Record Client History
 To obtain clients personal and social data and information
 To identify abnormalitiesproblems requiring treatment or
"For FP clients, it is important to pay particular attention to information"
Social History  Smoking? How many ummarized per
 Drinking? How much alcohol per day?
"Family Health  Diabetes mellitus, high blood pressure,"
Personal Med-  Excessive weight gainloss (- 5 kg
 Severe headaches (relieved by analgesics?)
 Growth on neck (enlarged thyroid)
" Current or past diseases: asthma, cardiac disease, high BP, diabetes mellitus,"
"mental illness, epilepsy, thrombophlebitis, varicose veins, unilateral pain in"
"thighs or calves, chronic anaemia (e.g."
"sickle-cell anaemia), liver diseasejaundice in the last 6 months or during pregnancy"
Social History  Smoking? How many ummarized per
 Drinking? How much alcohol per day?
"History  Diabetes mellitus, high blood pressure,"
Personal Medical History  Excessive weight gainloss (- 5 kg
 Severe headaches (relieved by analgesics?)
 Growth on neck (enlarged thyroid)
" Current or past diseases: asthma, cardiac disease, high BP, diabetes mellitus,"
"mental illness, epilepsy, thrombophlebitis, varicose veins, unilateral pain in"
"thighs or calves, chronic anaemia (e.g."
"sickle-cell anaemia), liver diseasejaundice in the last 6 months or during pregnancy"
 Any medicines being taken and reason
Surgical History  Any previous or planned operations
" Where and when operation was performed, or is to be performed"
Reproductive  Total pregnancies
 Number and sex of live children
 Number of abortions miscarriages
 Type of delivery for her children
 Any problems in previous pregnancy
 When does she wish to have next
Menstrual  Age at onset of menstruation
 Number of days and amount of blood
 Date and length of last normal period
 Any medicines being taken and reason
Surgical History  Any previous or planned operations
" Where and when operation was performed, or is to be performed"
 Number and sex of live children
 Number of abortions miscarriages
 Type of delivery for her children
 Any problems in previous pregnancy
 When does she wish to have next
History  Age at onset of menstruation
 Number of days and amount of blood
 Date and length of last normal period
Gynaecological  Vulval sores or warts
" PID and STI? If yes, which one, wasit"
 Offensive vaginal odourdischarge
Family Planning  Howwhere first learned about FP
"History  Whether new to FP, or used FP before"
" If used before, which method used"
 Duration of using each FP method
 Reasons for discontinuation of FP
Inform Client  If chosen method seems suitable or
 Explain that physical assessment will
confirm suitability of this method
 Examine client from head to toe
"- Especially, look out for alopecia, acne, chloasma, hirsuitism,"
" PID and STI? If yes, which one, wasit"
 Offensive vaginal odourdischarge
History  Howwhere first learned about FP
" Whether new to FP, or used FP before"
" If used before, which method used"
 Duration of using each FP method
 Reasons for discontinuation of FP
Inform Client  If chosen method seems suitable or
 Explain that physical assessment will
confirm suitability of this method
"jaundice, anaemia, enlarged glands, goitre"
- Pay particular attention to breasts (e.g. lumps) and
"- abdomen (enlarged organs, e.g., liver, uterus)"
The following areas need to be investigated:
" Perform cancer cervix screening (VIA, VILI, Pap smear)"
 Perform bimanual examination to determine size of uterus
 Share findings with the client in simple language
" Advise on when to have next examination (e.g., routine,"
"annual, follow-up, if problems)"
Manage Client for Chosen FP Method
 Take and record clients BP and weight
 Take and record clients history
 Use the table at in the following section to quickly
assess suitability of method considered
" Provide suitable method, and ensure client understands"
"fully how the method works, and how any medicine for"
 Advise client on any potential problems with the chosen
method and when to immediately return
 Discuss management of any serious side-effects and complications
" Arrange for client to return for routine follow-up, and for"
Summary of Medical Eligibility for Contraceptives
The tables below contain a ummarized version of the medical eligibility
"criteria for initiating a patient on contraceptive methods, based on the"
MOH (2016) and WHO (2020) Medical Eligibility Criteria for Contraceptive Use. It guides family planning providers in recommending safe and
effective contraception methods for women with medical conditions or
"medially-relevant characteristics. For more detailed information, consult"
The tables below include recommendations on initiating use of common
types of contraceptive methods:
1. Combined oral contraceptive pills (COC)
2. Progestogen only pills (POP)
"3. Progestogen only injectable (POI) e.g., DMPA- IMSC"
4. Progestogen only implants (POIM)
6. LAM- Lactational amenorrhoea
9. Fertility Awareness Method (FAM) and standard days methods
NNeevviirraappiinnee YY YY YY YY YY
AAttaazzaannaavviirrrr YY YY YY YY YY
Medical Conditions and Patient Characteristics
Condition Coc Pop Poi Poim Cuiud
Reproductive Tract Infections And Disorders
Trophoblastic disease Y Y Y Y N
NNeevviirraappiinnee YY YY YY YY YY
AAttaazzaannaavviirrrr YY YY YY YY YY
Broad spectrum antibiotic Y Y Y Y Y
Reproductive Tract Infections And Disorders 
Trophoblastic disease Y Y Y Y N
Condition Coc Pop Poi Poim Cuiud
Current pelvic inflam- Y Y Y Y Y
"Venous Thromboembolism (Vte E.g Dvt, Pe)"
Major surgery with pro- N N Y Y Y
Ischaemic heart disease N Y N Y Y
Multiple risk factors Y Y Y Y Y
"Hypertension, Obesity And Diabetes"
Current pelvic inflammatory disease Y Y Y Y Y
"Venous Thromboembolism (Vte E.g Dvt, Pe) "
Major surgery with prolonged immobilisation N N Y Y Y
Ischaemic heart disease N Y N Y Y
"Hypertension, Obesity And Diabetes "
adequately controlled N Y Y Y Y
Condition Coc Pop Poi Poim Cuiud
"Diabetes with neuro-, N Y N Y Y"
Increased risk of STIs Y Y Y Y Y
retinal or nephropathy N Y N Y Y
Non-migraine headache Y Y Y Y Y
(neurological symptom) N N Y Y Y
Other STIs and vaginalis Y Y Y Y Y
Increased risk of STIs Y Y Y Y Y
(primary breastfeeding) N Y Y Y Y
Condition Coc Pop Poi Poim Cuiud
Age And Pregnancy History (Parity)
Adolescents (menarche Y Y Y Y Y
 If venous thromboembolism develops while on hormonal
 Recommend another none hormonal family planning method
Conditions where all methods can be used
"Repro- duc- Benign breast disease or undiagnosed mass, benign"
"tive ovarian tumours and cysts, dysmenorrhoea, endometriosis, history of gestational diabetes, history of"
"high blood pressure during pregnancy, history of"
"pelvic surgery including caeserean delivery, irregular,"
"heavy prolonged menstrual bleeding (explained), past"
"ectopic pregnancy, past pelvic inflammatory disease,"
"post-abortion (no sepsis), postpartum (all methods"
except COCs which are given ³6 months)
"Medical Depression, epilepsy, HIV asymptomatic (WHO clinical"
"stage 1 or 2), iron-deficiency anaemia, sickle-cell disease,"
"thalassaemia, malaria, mild cirrhosis, schistosomiasis,"
"superficial venous disorders including varicose veins,"
Age And Pregnancy History (Parity) 
"Repro- ductive Benign breast disease or undiagnosed mass, benign"
"ovarian tumours and cysts, dysmenorrhoea, endometriosis, history of gestational diabetes, history of"
"high blood pressure during pregnancy, history of"
"pelvic surgery including caeserean delivery, irregular,"
"heavy prolonged menstrual bleeding (explained), past"
"ectopic pregnancy, past pelvic inflammatory disease,"
"post-abortion (no sepsis), postpartum (all methods"
except COCs which are given ³6 months)
"Medical Depression, epilepsy, HIV asymptomatic (WHO clinical"
"stage 1 or 2), iron-deficiency anaemia, sickle-cell disease,"
"thalassaemia, malaria, mild cirrhosis, schistosomiasis,"
"superficial venous disorders including varicose veins,"
"thyroid disorders, tuberculosis (non-pelvic), uncomplicated heart disease, viral hepatitis (carrier or chronic),"
"Others Adolescents, breast cancer family history, venous"
"thromboembolism (VTE) family history, high risk for"
"without prolonged immobilisation, taking antibiotics"
(except rifampicin or rifabutin)
Methods all couples (except a few) can safely use
Emergency contraceptive pill (for emergency use only) Bilateral Tubal
"Barrier methods (condoms, diaphragm) Lactational amenorrhoea"
Fertility awareness (FAM) and Standard days methods
Overview Of Key Contraceptive Methods
The following sections contain an overview of mainstream contraceptive
methods and how to manage side effects
of each (in case they occur). Side effects are one of most common reasons
"why women stop using contraception, and the health worker should"
be able to counsel the patient and address her concerns appropriately.
Condom (Male) ICD10 CODE: Z30.018Z30.49
"For example no-logo donation condoms, branded condoms."
 Couples needing an immediately effective method
 Where this is preferred FP method by client
 Couples waiting to rule out suspected pregnancy
 Protection against exposure to STIs including HIVAIDS
" thyroid disorders, tuberculosis (non-pelvic), uncomplicated heart disease, viral hepatitis (carrier or chronic),"
"Others Adolescents, breast cancer family history, venous"
"thromboembolism (VTE) family history, high risk for"
"without prolonged immobilisation, taking antibiotics"
(except rifampicin or rifabutin)
" Where back-up method is needed, e.g. when womanis"
starting or has forgotten to take oral contraceptives
" Couples where one or both partners have HIVAIDS,"
even if using another FP method
 Protects against unwanted pregnancy
 Also protects against STIs and HIV infection
 Some men may have difficulty maintaining an erection
 May cause insensitivity of the penis
 Occasional hypersensitivity to latex or lubricants (may result in a severe allergic reaction)
 Requires correct use with every act of sex for greatest effectiveness
" Ensure client understands correct use, storage, HC2"
 Supply at least 100 condoms to each client for
"three months, and if available, a water or silicone based lubricant"
 Advise client to return for more before they are
" In case of hypersensitivity to latex or lubricants,"
"avoid latex based condoms, and use the female"
" Ensure client understands correct use, storage,"
 Supply at least 100 condoms to each client for
"three months, and if available, a water or silicone based lubricant"
 Advise client to return for more before they are
" In case of hypersensitivity to latex or lubricants,"
"avoid latex based condoms, and use the female"
condom or another FP method HC2
Condom (Female) ICD10 CODE: Z30.018Z30.49
"For example Femidom, Care and FC2."
A soft plastic pre-lubricated sheath with an inner and outer ring which
is inserted into the vagina before sexual intercourse.
 For women whose partners will not use male condom
 Where the man has allergysensitivity to latex condom
 Woman-controlled (but requires partners cooperation)
 Can be inserted hours before intercourse and so does not
 Not dependent on male erection and does not require immediate withdrawal after ejaculation
 Protects against STI and HIV infection
 Requires special training and practice to use correctly
 Relatively new product with limited public awareness
" In some cases, hypersensitivity to polyurethane female"
 Requires correct use with every act of sex for greatest effectiveness
" Ensure client understands correct use, storage, and"
" Ensure client understands correct use, storage, and"
 Supply at least 40 female condoms to each client HC2
 Advise client to return for more before they are finished
" In case of hypersensitivity, avoid use and change to"
Combined Oral Contraceptive Pill (COC)
"Contains an oestrogen plus a progestin, the types and quantities of"
which may vary in different preparations.
 Women 35 years needing highly effective FP method
" Non-breastfeeding clients, or breastfeeding clients after 6"
 Clients with heavy periods or ovulation pain
 Clients concerned by irregular menstrual cycles
 Thromboembolic disease (e.g. deep vein thrombosis)
 Less than 6months after childbirth
 When major surgery is planned within 4 weeks
 Unexplained abnormal vaginal bleeding
Undiagnosed breast lumps or breast cancer
 Supply at least 40 female condoms to each client
 Advise client to return for more before they are finished
" In case of hypersensitivity, avoid use and change to"
"If any 2 of the following, recommend progrestogen-only or non-hormonal FP method"
 Smoking (especially if 10 cigarettesday)
Advantages and other potential health benefitsuses
 Cancer of the ovary or lining of uterus
 Symptomatic pelvic inflammatory disease
 Menstrual cramps and bleeding problems
 Symptoms of polycystic ovarian syndrome
Disadvantages and common side effects
" Spotting, nausea, and vomiting within first few months"
" Changes in bleeding patterns including: fewer days, irregular, lighter, infrequent, or no monthly bleeding"
" May cause headaches, dizziness, weight gain"
 Effectiveness dependent on regular daily dosage
 Medicine interactions reduce effectiveness including:
" Medicines which increase hepatic enzyme activity, e.g., rifampicin"
"(especially), carbamazepine, griseofulvin, nevirapine, phenytoin,"
"- Short courses of some broad spectrum antibiotics, e.g.,"
"ampicillin, amoxicillin, doxycycline"
An additional FP method must be used during course of treatment
with these medicines and for at least 7 days after completion.
Complications and warning signs
" Severe headaches, blurred vision"
 Chest pain plus dyspnoea (pulmonary embolism)
 Swelling or pain in calf muscle (Deep vein thrombosis)
 Give 3 cycles of COC and explain carefully: HC2
 What to do if doses are missed or there are sideeffects or warning signs
If starting COC within 5 days of period
 Supply and show how to use back-up FP method
 Ask client to return when 7 tablets remain in last cycle
MANAGEMENT OF SIDE EFFECTS OF COCS
 Assess for pregnancy and malaria
 Give 3 cycles of COC and explain carefully:
 Strict compliance is essential HC2
 What to do if doses are missed or there are sideeffects or warning signs
If starting COC within 5 days of period
 Supply and show how to use back-up FP method
 Ask client to return when 7 tablets remain in last cycle 
MANAGEMENT OF SIDE EFFECTS OF COCS 
 Assess for pregnancy and malaria 
MANAGEMENT OF SIDE EFFECTS OF COCS
 Suggest taking COCs at bedtime or with food
" Consider locally available remedies (e.g. eating roasted grains,"
"roasted cassava, boiled greens)"
 Recommend that she wears a supportive bra
" Examine for cancer symptoms, such as breast infection,"
"If breastfeeding, examine for breast infection"
" If there is infection, use warm compresses. Refer for appropriate evaluation"
" If the examination shows a suspicious lump or discharge,"
refer for appropriate evaluation
 Counsel her on non-hormonal FP methods
" Suggest ibuprofen, paracetamol, or other pain relievers"
" Take proper history (explore when headaches occur,"
"whether she can continue with her daily tasks, what"
medicines relieve her headaches)
 Give pain relievers such as ibuprofen or paracetamol
" If headaches get worse or occur more often, refer for appropriate"
MANAGEMENT OF SIDE EFFECTS OF COCS
 Suggest taking COCs at bedtime or with food
" Consider locally available remedies (e.g. eating roasted grains,"
"roasted cassava, boiled greens)"
 Recommend that she wears a supportive bra
" Examine for cancer symptoms, such as breast infection,"
"If breastfeeding, examine for breast infection"
" If there is infection, use warm compresses. Refer for appropriate evaluation"
" If the examination shows a suspicious lump or discharge,"
refer for appropriate evaluation
 Counsel her on non-hormonal FP methods
" Suggest ibuprofen, paracetamol, or other pain relievers"
" Take proper history (explore when headaches occur,"
"whether she can continue with her daily tasks, what"
medicines relieve her headaches)
 Give pain relievers such as ibuprofen or paracetamol
" If headaches get worse or occur more often, refer for appropriate"
MANAGEMENT OF SIDE EFFECTS OF COCS
 Rule out anaemia and check blood pressure and weight
" Reassure that this is common in COC users, and usually"
" Evaluate for other causes unrelated to the method, and"
 Evaluate for the cause and refer if necessary
Pills that contain very low doses of a progestin like the natural hormone
"progesterone in a womans body. Since these pills do not contain oestrogen, they are safe to use throughout breastfeeding, and by women"
who cannot use methods with oestrogen.
 Breastfeeding and non-breastfeeding clients immediately
 Women who cannot take COC but prefer to use pills
 Women of all ages with desire to use contraceptive pills
 Breast or genital malignancy (known or suspected)
" Breast cancer 5 years ago, and it has not recurred"
" Severe liver disease, infection, or tumor"
" Taking barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, rifampicin, rifabutin, or"
ritonavir or ritonavir-boosted protease inhibitors. Use a
backup contraceptive method as these medications reduce
MANAGEMENT OF SIDE EFFECTS OF COCS
 Rule out anaemia and check blood pressure and weight
" Reassure that this is common in COC users, and usually"
" Evaluate for other causes unrelated to the method, and"
 Evaluate for the cause and refer if necessary
 Systemic lupus erythematosus with positive (or unknown)
 Current or history of blood clot
Disadvantages and common side effects
 Unpredictable irregular periods
 Medicine interactions: the effectiveness is educed by medicines which increase hepatic enzyme activity
 Give 3 cycles of POP: Explain carefully how to take the HC2
"tablets, and what to do if doses are missed, or if there"
 Supply and show how to use back-up FP method for
"first 14 days of first packet, e.g. condoms or abstinence"
 Ask client to return 11 weeks after starting POP
 Use the last pill packet to show when this will be
MANAGEMENT OF SIDE EFFECTS OF POPS
" If not pregnant andor breast-feeding, reassure that itis"
normal. Some women using POPs stop having monthly
"periods, but this is not harmful"
 Give 3 cycles of POP: Explain carefully how to take the
"tablets, and what to do if doses are missed, or if there"
 Supply and show how to use back-up FP method for
"first 14 days of first packet, e.g. condoms or abstinence"
 Ask client to return 11 weeks after starting POP
 Use the last pill packet to show when this will be HC2
MANAGEMENT OF SIDE EFFECTS OF POPS
" If not pregnant andor breast-feeding, reassure that itis"
normal. Some women using POPs stop having monthly
"periods, but this is not harmful"
MANAGEMENT OF SIDE EFFECTS OF POPS
" If pregnant, reassure that the POPs will not affect her"
"pregnancy, and refer her to ANC"
 Nausea: suggest taking POPs at bedtime or with food
" If symptoms continue, consider locally available remedies"
" Without Aura (e.g. hallucinations, hearing voices): able"
to continue using POPs voluntarily
 With Aura: stop POPs and choose a method without
 Reassure that many women using POPs get irregular
bleeding whether breast-feeding or not. It is not harmful
and should lessen or stop after several months of use
" Counsel on how to reduce irregular bleeding, e.g. making up for missed pills after vomiting or diarrhoea"
 Give 400800 mg ibuprofen every 8 hours after meals
for 5 days when irregular bleeding starts
 Mefenamic acid 500mg three times a day for 5-7days
 Check for anaemia and treat accordingly
If irregular bleeding persists or starts after several months of normal
 Investigate other reasons (unrelated to POPs) and treat
 Change to another pill formulation for at least 3 months
 Or help client choose another method of family planning
MANAGEMENT OF SIDE EFFECTS OF POPS
" If pregnant, reassure that the POPs will not affect her"
"pregnancy, and refer her to ANC"
 Nausea: suggest taking POPs at bedtime or with food
" If symptoms continue, consider locally available remedies"
" Without Aura (e.g. hallucinations, hearing voices): able"
to continue using POPs voluntarily
 With Aura: stop POPs and choose a method without
 Reassure that many women using POPs get irregular
bleeding whether breast-feeding or not. It is not harmful
and should lessen or stop after several months of use
" Counsel on how to reduce irregular bleeding, e.g. making up for missed pills after vomiting or diarrhoea"
 Give 400800 mg ibuprofen every 8 hours after meals
for 5 days when irregular bleeding starts
 Mefenamic acid 500mg three times a day for 5-7days
 Check for anaemia and treat accordingly
If irregular bleeding persists or starts after several months of normal
 Investigate other reasons (unrelated to POPs) and treat
 Change to another pill formulation for at least 3 months
 Or help client choose another method of family planning
Heavy or prolonged bleeding (twice as much as usual or longer than 8
 Give 800 mg ibuprofen every 8 hours after meals for 5 days
 Or other non-steroidal anti-inflammatory drugs (NSAID)
 Ferrous salt tablets (60 mg iron) to prevent anaemia
 Investigate other reasons (unrelated to POPs) and treat
 Change to another pill formulation for at least 3 months
 Or help client choose another method of family planning preferably COC if there is no contra-indication
Injectable Progestogen-Only Contraceptive
"A slowly absorbed depot IM injection or subcutaneous injection, which"
provides contraceptive protection.
 Fertile women requiring contraception
 Knownsuspected HIV positive women who need an effective FP method
 Women who cannot use COC due to oestrogen content
 Women who do not want more children but do not (yet)
want voluntary surgical contraception
 Women awaiting surgical contraception
Advantages and other health benefitsuses
 Do not require daily action (e.g. taking pills)
 Private method: no one else can tell that a woman is using
 Cause no monthly bleeding (for many women)
 Injections can be stopped at anytime
 Cancer of the lining of the uterus (DMPA)
 Reduces heavy flow in Uterine fibroids (DMPA)
 Iron-deficiency anaemia (NET-EN)
Disadvantages and common side-effects
 DOES NOT PROTECT AGAINST ST Amenorrhoea
- Often after 1st injection and after 912 months of use
 Can cause heavy prolonged vaginal bleeding during first
 May delay return to fertility (Up to 12 months after stopping injection)
Complications and warning signs
 Medroxyprogesterone acetate depot injection HC1
 Give 150 mg deep IM into deltoid or buttock
- Do not rub the area as this increases absorption
 Medroxyprogesterone acetate depot injection
- Inject 104 mg in the fatty tissue (subcutaneous) at
"the front of the thigh, the back of the upper arm, or"
- This can be administered at community level
If given after day 17 of menstrual cycle HC1
" To abstain from sex or use a back-up FP method,"
"e.g., condoms, for the first 7 days after injection"
 To return for the next dose on a specific date
 12 weeks after the injection (if client returns
"2-4 weeks later than the date advised, client should be"
certain that she is not pregnant. Rule out pregnancy before
 To return promptly if there are any warning signs
MANAGEMENT OF SIDE EFFECTS OF INJECTABLE POC
" If pregnant, reassure that the injectable POC will not"
affect her pregnancy and refer to ANC
" If not pregnant, reassure her that this contraceptive"
"may stop women having monthly periods, but it is not"
harmful. She can continue with the method or choose
 Medroxyprogesterone acetate depot injection
 Give 150 mg deep IM into deltoid or buttock
- Do not rub the area as this increases absorption
 Medroxyprogesterone acetate depot injection
- Inject 104 mg in the fatty tissue (subcutaneous) at
"the front of the thigh, the back of the upper arm, or"
- This can be administered at community level HC1
If given after day 17 of menstrual cycle
" To abstain from sex or use a back-up FP method,"
"e.g., condoms, for the first 7 days after injection"
 To return for the next dose on a specific date
 12 weeks after the injection (if client returns
"2-4 weeks later than the date advised, client should be"
certain that she is not pregnant. Rule out pregnancy before
 To return promptly if there are any warning signs HC1
MANAGEMENT OF SIDE EFFECTS OF INJECTABLE POC
" If pregnant, reassure that the injectable POC will not"
affect her pregnancy and refer to ANC
" If not pregnant, reassure her that this contraceptive"
"may stop women having monthly periods, but it is not"
harmful. She can continue with the method or choose
MANAGEMENT OF SIDE EFFECTS OF INJECTABLE POC
 Reassure that many women using injectable POC have
irregular bleeding. It is not harmful in the first few
months and should lessen or stop after a few months
"If irregular bleeding continues, immediately:"
 Give 400800 mg ibuprofen 8 hourly when irregular bleeding starts
 Or 500 mg mefenamic acid eight hourly after meals for five days
Avoid Tranexamic acid for treatment of bleeding as a result of using
contraceptives for fear of blood clots.
 If irregular bleeding continues or starts after several
months of normal or no monthly bleeding:
 Investigate other reasons (unrelated to the contraceptive)
 Help client choose another FP method if necessary
"Blood clots, flow interfears with client daily routine, should not be"
"more than 7days, feel of thirst all the time."
If heavy bleeding is between 812 weeks of first injection:
 Reassure (as for irregular bleeding)
 Repeat progestogen-only injection and change return
date to 3 months after the latest injection
Heavy bleeding after 2nd injection:
 Give 1 COC pill daily for 21 days (1 cycle)
Heavy bleeding after 3rd or later injection:
MANAGEMENT OF SIDE EFFECTS OF INJECTABLE POC
 Reassure that many women using injectable POC have
irregular bleeding. It is not harmful in the first few
months and should lessen or stop after a few months
"If irregular bleeding continues, immediately:"
 Give 400800 mg ibuprofen 8 hourly when irregular bleeding starts
 Or 500 mg mefenamic acid eight hourly after meals for five days
Avoid Tranexamic acid for treatment of bleeding as a result of using
contraceptives for fear of blood clots.
 If irregular bleeding continues or starts after several
months of normal or no monthly bleeding:
 Investigate other reasons (unrelated to the contraceptive)
 Help client choose another FP method if necessary
"Blood clots, flow interfears with client daily routine, should not be"
"more than 7days, feel of thirst all the time."
If heavy bleeding is between 812 weeks of first injection:
 Reassure (as for irregular bleeding)
 Repeat progestogen-only injection and change return
date to 3 months after the latest injection
Heavy bleeding after 2nd injection:
 Give 1 COC pill daily for 21 days (1 cycle)
Heavy bleeding after 3rd or later injection:
MANAGEMENT OF SIDE EFFECTS OF INJECTABLE POC
 Give 1 COC pill daily for 21 days (1 cycle) when irregular
 Or 50 µg ethinyl estradiol daily for 21 days
 Or 500 mg mefenamic acid eight hourly after meals for 5 days
 Ferrous salt tablets (60 mg iron) to prevent anaemia
 Investigate other reasons (unrelated to injectable POC)
 Help client choose another FP method if necessary
 A woman should not be worried if she has not become
pregnant even after stopping use for 12 months
 Reassure and counsel her about the fertile days; ovulation normally occurs 14 days before the next menstrual period (if womans cycle is 28 days and has regular
 Rule out weight gain due to pregnancy
" Interview client on diet, exercises, and eating habits promoting weight gain; counsel as needed. Explain to client"
that all hormonal contraceptives may have a slight effect
" If weight gain is more than 2 kg, instruct her on diet and"
" Find out if she has stress, fatigue, anxiety, depression,"
and if she is on new medication. Explore if this is due to
dry vagina andor painful intercourse
MANAGEMENT OF SIDE EFFECTS OF INJECTABLE POC
 Give 1 COC pill daily for 21 days (1 cycle) when irregular
 Or 50 µg ethinyl estradiol daily for 21 days
 Or 500 mg mefenamic acid eight hourly after meals for 5 days
 Ferrous salt tablets (60 mg iron) to prevent anaemia
 Investigate other reasons (unrelated to injectable POC)
 Help client choose another FP method if necessary
 A woman should not be worried if she has not become
pregnant even after stopping use for 12 months
 Reassure and counsel her about the fertile days; ovulation normally occurs 14 days before the next menstrual period (if womans cycle is 28 days and has regular
 Rule out weight gain due to pregnancy
" Interview client on diet, exercises, and eating habits promoting weight gain; counsel as needed. Explain to client"
that all hormonal contraceptives may have a slight effect
" If weight gain is more than 2 kg, instruct her on diet and"
" Find out if she has stress, fatigue, anxiety, depression,"
and if she is on new medication. Explore if this is due to
dry vagina andor painful intercourse
MANAGEMENT OF SIDE EFFECTS OF INJECTABLE POC
 Explore lifestyle and suggest changes where needed.
"Advise on foreplay and if possible, involve spouse"
 Help client choose another FP method if necessary
" Explore possible social, financial, health, or physical"
causes of headaches. Ask her to keep a record of the
timing and number of headaches for the next 2 weeks
and ask her to come for follow-up
 Evaluate cause of headache (Is blood pressure raised?
Does she have sinus infection purulent nasal discharge
and tenderness in the area of sinuses?)
" Give pain relievers such as acetylsalicylic acid, ibuprofen, or"
" Regardless of age, a woman who develops migraine"
headaches with aura or whose migraine headaches becomes worse while using monthly injections should stop
"using injectable. If migraine headaches are without aura,"
she can continue using the method if she wishes
Progestogen-Only Sub-Dermal Implant
Flexible progestogen-releasing plastic rods surgically inserted under the
skin of the womans upper arm which provide contraceptive protection
for 37 years depending on the type of implant (Implanon: 3 years;
"Jadelle: 5 years; Femplant: 4 years, Norplant: 5 years: implanon NXT:"
" Women wanting long-term, highly-effective but not permanent contraception where alternative FP methods are"
MANAGEMENT OF SIDE EFFECTS OF INJECTABLE POC
 Explore lifestyle and suggest changes where needed.
"Advise on foreplay and if possible, involve spouse"
 Help client choose another FP method if necessary
" Explore possible social, financial, health, or physical"
causes of headaches. Ask her to keep a record of the
timing and number of headaches for the next 2 weeks
and ask her to come for follow-up
 Evaluate cause of headache (Is blood pressure raised?
Does she have sinus infection purulent nasal discharge
and tenderness in the area of sinuses?)
" Give pain relievers such as acetylsalicylic acid, ibuprofen, or"
" Regardless of age, a woman who develops migraine"
headaches with aura or whose migraine headaches becomes worse while using monthly injections should stop
"using injectable. If migraine headaches are without aura,"
she can continue using the method if she wishes
 Highly effective (only 1-3 failure rate)
 No delay in return to fertility after removal
 Low user-responsibility (no need for daily action)
 Protects against symptomatic pelvic inflammatory disease
Disadvantages and Common Side Effects
" DOES NOT PROTECT AGAINST ST Irregular bleeding, spotting, or heavy bleeding in first few"
Possibility of local infection at insertion site
 Must be surgically inserted and removed by specially
 May not be as effective in women 70kg
 Warning signs (require urgent return to clinic)
" Pus, bleeding, or pain at insertion site on arm"
 Insert the implant subdermally under the skin of the HC2
upper arm following recommended procedures
 Insert the implant subdermally under the skin of the
upper arm following recommended procedures HC2
 Carefully explain warning signs and need to return if HC2
 After two weeks: To examine implant site
 After three months: For first routine follow-up
 Annually until implant removed: routine follow- up
MANAGEMENT OF SIDE EFFECTS OF IMPLANTS
" If pregnant, reassure that the implant will not affect her"
" If not pregnant, reassure that implants may stop women"
"from having monthly periods, but this is not harmful."
She can continue with the method
If irregular bleeding continues:
 Give 400800 mg ibuprofen eight hourly when irregular bleeding starts
 Or 500 mg mefenamic acid eight hourly after meals for 5 days
 Check for anaemia and treat accordingly
 Give 1 COC pill daily for 21 days (1 cycle)
 Or 50 µg ethinyl estradiol daily for 21 days
 Investigate other reasons (unrelated to implants) and treat accordingly
 Help client choose another method of family planning
Heavy or prolonged bleeding (twice as much as usual or longer than 8
 Carefully explain warning signs and need to return if
 After two weeks: To examine implant site
 After three months: For first routine follow-up
 Annually until implant removed: routine follow- up HC2
MANAGEMENT OF SIDE EFFECTS OF IMPLANTS
" If pregnant, reassure that the implant will not affect her"
" If not pregnant, reassure that implants may stop women"
"from having monthly periods, but this is not harmful."
She can continue with the method
If irregular bleeding continues:
 Give 400800 mg ibuprofen eight hourly when irregular bleeding starts
 Or 500 mg mefenamic acid eight hourly after meals for 5 days
 Check for anaemia and treat accordingly
 Give 1 COC pill daily for 21 days (1 cycle)
 Or 50 µg ethinyl estradiol daily for 21 days
 Investigate other reasons (unrelated to implants) and treat accordingly
 Help client choose another method of family planning
Heavy or prolonged bleeding (twice as much as usual or longer than 8
MANAGEMENT OF SIDE EFFECTS OF IMPLANTS
 Give ibuprofen 800 mg eight hourly when irregular bleeding starts
 Or 500 mg mefenamic acid eight hourly after meals for five days
 Give 1 COC pill daily for 21 days (one cycle)
 Give ferrous salt tablets (60 mg iron) to prevent anaemia
 Investigate other reasons (unrelated to implants) and treat accordingly
 Help client choose another method of family planning
 Manage the same as for Injectable POC
 Manage the same as for Injectable POC
Infection at the Insertion Site
 Clean the infected area with soap and water or antiseptic
 Give oral antibiotics for 710 days like Amoxycillin 500mg 8 hourly
If no improvement after the 10days refer
 Ask the client to return after taking all antibiotics if the
"infection does not clear. If infection has not cleared, remove the implant or refer for removal"
 Expulsion or partial expulsion often follows infection.
Ask the client to return if she notices an implant coming
" If she has migraine headaches without aura, she can"
continue to use implant if she wishes
" If she has migraine aura, remove the implant. Help her"
choose a method without hormones
MANAGEMENT OF SIDE EFFECTS OF IMPLANTS
 Give ibuprofen 800 mg eight hourly when irregular bleeding starts
 Or 500 mg mefenamic acid eight hourly after meals for five days
 Give 1 COC pill daily for 21 days (one cycle)
 Give ferrous salt tablets (60 mg iron) to prevent anaemia
 Investigate other reasons (unrelated to implants) and treat accordingly
 Help client choose another method of family planning
 Manage the same as for Injectable POC
 Manage the same as for Injectable POC
Infection at the Insertion Site
 Clean the infected area with soap and water or antiseptic
 Give oral antibiotics for 710 days like Amoxycillin 500mg 8 hourly
If no improvement after the 10days refer
 Ask the client to return after taking all antibiotics if the
"infection does not clear. If infection has not cleared, remove the implant or refer for removal"
 Expulsion or partial expulsion often follows infection.
Ask the client to return if she notices an implant coming
" If she has migraine headaches without aura, she can"
continue to use implant if she wishes
" If she has migraine aura, remove the implant. Help her"
choose a method without hormones
Emergency Contraception (Pill and IUD)
Emergency Contraception can be used to prevent unwanted pregnancy
"after unprotected sex, rape, defilement or contraceptive method failure."
Methods available include Emergency Contraceptive Pills and IUDs.
Caution: Emergency contraceptive methods do not cause abortion.
Regular Emergency Contraceptive Pill users should be counselled to use
Emergency  The ECP contains a special dose of
Contraceptive progestin (Levonorgestrel or LNG):
Pill (ECP) may come as one pill (mg) or two
 The dose (mg) should be taken as
"soon as possible within 72 hours, but"
"can be taken up to five days after unprotected sex, or in case of contraceptive method failure, e.g.,"
" condom burst, failure to take regular FP"
 ECPs are NOT regular contraceptive
pills and should not be used as a family planning method
Emergency  This IUD should be inserted as soon as
Contraceptive possible after penetrative sexual interIUD course but within 5 days
 It is important to monitor side-effects
"that may occur, as outlined below"
Pill (ECP)  The ECP contains a special dose of
progestin (Levonorgestrel or LNG):
may come as one pill (mg) or two
  The dose (mg) should be taken as
"soon as possible within 72 hours, but"
"can be taken up to five days after unprotected sex, or in case of contraceptive method failure, e.g.,"
" condom burst, failure to take regular FP"
  ECPs are NOT regular contraceptive
pills and should not be used as a family planning method
IUD  This IUD should be inserted as soon as
possible after penetrative sexual intercourse but within 5 days
 It is important to monitor side-effects
"that may occur, as outlined below"
 All women and adolescents at risk of becoming pregnant
 Prevents unplanned pregnancy after penetrative sexual
 Safe for all women and have no long-term side effects
 Able to have on hand in case of emergency
 DOES NOT PROTECT AGAINST ST Potential misuse as a regular contraceptive method
" Minor, short-term side effects: nausea and vomiting, altered menstrual bleeding, headaches, abdominal pain"
"breast tenderness, dizziness and fatigue"
 Should be taken as soon as possible after unprotected HC2
sex where pregnancy is not desired
 Can prevent pregnancy if taken anytime within 5 days
after unprotected sex (decreasing efficacy over this 5
 Safe and suitable for all women at risk of an unplanned
 Women on ARVs have to take double dose (levonorgestrel
 Should be taken as soon as possible after unprotected
sex where pregnancy is not desired
 Can prevent pregnancy if taken anytime within 5 days
after unprotected sex (decreasing efficacy over this 5
 Safe and suitable for all women at risk of an unplanned
 Women on ARVs have to take double dose (levonorgestrel
3 mg  e.g. Postinor 4 tablets) HC2
 Warn women against regularfrequent use of
emergency contraceptive. Advise them to consider
Intrauterine Device (IUD) ICD10 CODE: Z30.014
"Easily reversible long-term FP method effective for up to 10 years,"
which can be inserted as soon as 6 weeks postpartum:
 Hormonal: Levonorgestrel loaded
 Women desiring long-term contraception
 When hormonal FP methods are contraindicated
 Treatment of heavy periods- menorrhagia (for levonorgestrel)
 PID or history of this in last 3 months
 Undiagnosed abnormal uterine bleeding
"Reduced immunity, e.g., diabetes mellitus, terminal AIDS"
 Known or suspected cancer of pelvic organs
 Severe anaemia or heavy menstrual bleeding
 Prevents unplanned pregnancy after penetrative sexual
 Warn women against regularfrequent use of
emergency contraceptive. Advise them to consider
 Safe for all women including breast feeding mothers
 Does not affect libido (copper)
 Reduces chances of getting STIs (Lenovorgestrel)
" Its recommended for women with NCDs like diabetes,"
 Does not increase the risk of STIs
Disadvantages and common side effects
 Mild cramps during first 3-5 days after insertion
 Longer and heavier menstrual blood loss in first 3 months
 Vaginal discharge in first 3 months
 Spotting or bleeding between periods
 Increased cramping pains during menstruation
 Threads might prick the spose during sex (cut the treads
Complications and warning signs
 Foul-smelling vaginal discharge
 Insert the IUD closely following recommended proce- HC3
dures; explain each step to the client (ensure the thread
is cut short not to cause discomfort)
 Carefully explain possible side-effects and what to do
 Not to have more than 1 sexual partner
 To check each sanitary pad before disposal to ensure
"the IUD has not been expelled, in which case to use"
an alternative FP method and return to the clinic
 How to check that the IUD is still in place after each
" To report to the clinic promptly if: Late period or pregnancy,"
abdominal pain during intercourse
" Exposure to STI, feeling unwell with chillsfever,"
" shorterlongermissing strings, feeling hard part of IUD in"
 To use condoms if any risk of STIs including H Recommendation for a follow-up visit after 3-6 weeks
MANAGEMENT OF SIDE EFFECTS OF IUD
" If pregnant, reassure that IUD will not affect her pregnancy and refer her to ANC"
" If not pregnant, investigate other reasons for amenorrhea"
 If no pregnancy reassure the client
 Insert the IUD closely following recommended procedures; explain each step to the client (ensure the thread
is cut short not to cause discomfort)
 Carefully explain possible side-effects and what to do
 Not to have more than 1 sexual partner
 To check each sanitary pad before disposal to ensure
"the IUD has not been expelled, in which case to use"
an alternative FP method and return to the clinic
 How to check that the IUD is still in place after each
" To report to the clinic promptly if: Late period or pregnancy,"
abdominal pain during intercourse
" Exposure to STI, feeling unwell with chillsfever,"
" shorterlongermissing strings, feeling hard part of IUD in"
 To use condoms if any risk of STIs including H Recommendation for a follow-up visit after 3-6 weeks
MANAGEMENT OF SIDE EFFECTS OF IUD
" If pregnant, reassure that IUD will not affect her pregnancy and refer her to ANC"
" If not pregnant, investigate other reasons for amenorrhea"
 If no pregnancy reassure the client
MANAGEMENT OF SIDE EFFECTS OF IUD
 Reassure that many women using IUD get irregular
bleeding. It is not harmful and should lessen or stop after
 Give 400-800 mg ibuprofen eight hourly after meals for 5 days
 Tranexamic acid 500mg 8hourly 5-7days
 Check for anaemia and treat accordingly
If irregular bleeding persists:
 Investigate other reasons (unrelated to IUD) and treat accordingly
 Help client choose another FP method if necessary
 Give ibuprofen 400-800 mg every eight hours after meals for
" Or tranexamic acid 1500 mg every eight hours for 3 days, then"
1000 mg once daily for two days
 Give ferrous salt tablets (60 mg iron) to prevent anaemia
 Investigate other reasons (unrelated to IUD) and treat accordingly
 Help client choose another FP method if necessary
Natural FP: Cervical Mucus Method (CMM) and Moon
CMM is a fertility awareness-based method of FP which relies on the
change in the nature of vaginal mucus during the menstrual cycle in order
"to detect the fertile time. During this time, the couple avoids pregnancy by"
changing sexual behaviour as follows:
MANAGEMENT OF SIDE EFFECTS OF IUD
 Reassure that many women using IUD get irregular
bleeding. It is not harmful and should lessen or stop after
 Give 400-800 mg ibuprofen eight hourly after meals for 5 days
 Tranexamic acid 500mg 8hourly 5-7days
 Check for anaemia and treat accordingly
If irregular bleeding persists:
 Investigate other reasons (unrelated to IUD) and treat accordingly
 Help client choose another FP method if necessary
 Give ibuprofen 400-800 mg every eight hours after meals for
" Or tranexamic acid 1500 mg every eight hours for 3 days, then"
1000 mg once daily for two days
 Give ferrous salt tablets (60 mg iron) to prevent anaemia
 Investigate other reasons (unrelated to IUD) and treat accordingly
 Help client choose another FP method if necessary
 Abstaining from sexual intercourse: Avoiding vaginal sex
completely (also called periodic abstinence)
" Using barriers methods, e.g., condoms, cervical caps"
 Guidance on correct use of the method is only available at
centres with specially trained service providers.
 Ensure client understands how the method works HC1
 Explain how to distinguish the different types of mucus
" Show client how to complete the CMM chart, can be used"
 Carry out a practicetrial period of at least 3 cycles
 Confirm that the chart is correctly filled
 Always use condoms as well as CMM if there is any risk of
exposure to STIsH Return on a specific follow-up date after one
Natural FP: Lactational Amenorrhoea Method (LAM)
LAM relies on the suppression of ovulation through exclusive breastfeeding as a means of contraception. Guidance on correct use of the method
is only available at centres with trained service providers. LAM requires 3
conditions which must ALL be met:
 The mothers monthly bleeding has not returned
" The baby is fully or nearly fully breastfed; and is fed often, day"
 The baby is less than 6 months old
 Ensure client understands how the method works HC1
 Explain how to distinguish the different types of mucus
" Show client how to complete the CMM chart, can be used"
 Carry out a practicetrial period of at least 3 cycles
 Confirm that the chart is correctly filled
 Always use condoms as well as CMM if there is any risk of
exposure to STIsH Return on a specific follow-up date after one
 DOES NOT PROTECT AGAINST ST Low couple years of protection
 Ensure client understands how the method works
 Ensure client understands how the method works HC1
 She must breastfeed her child on demand on both
breasts at least 10-12 times during day and night
(including at least once nightly in the first months)
" Daytime feedings should be no 4 hours apart, and"
night-time feedings no 6 hours apart
 She must not give the child any solid foods or
 other liquids apart from breast milk
 Advise the client that LAM will no longer be an effective
 The baby does not feed regularly on demand
 Menstruation resumes; she will then need to use
 To use condoms as well as LAM if there is any risk of
exposure to STIsH To return after 3 months for a routine follow-up
 or earlier if she has any problem
 If she wants to change to another FP method
Surgical Contraception for Men: Vasectomy
This permanent FP method involves a minor operation carried out
under local anaesthetic to cut and tie the two sperm-carrying tubes (vas
deferens). It is only available at centres with specially trained service
providers. There is need to dispel the myths of impotence following
 Ensure client understands how the method works
 Ensure client understands how the method works
 She must breastfeed her child on demand on both
breasts at least 10-12 times during day and night
(including at least once nightly in the first months)
" Daytime feedings should be no 4 hours apart, and"
night-time feedings no 6 hours apart
 She must not give the child any solid foods or
 other liquids apart from breast milk
 Advise the client that LAM will no longer be an effective
 The baby does not feed regularly on demand
 Menstruation resumes; she will then need to use
 To use condoms as well as LAM if there is any risk of
exposure to STIsH To return after 3 months for a routine follow-up
 or earlier if she has any problem
 If she wants to change to another FP method HC1
" Fully aware, counselled clients who have voluntarily signed"
 Who have definitely reached their desired family size and want
 Where the woman cannot risk another pregnancy due to
 Ensure client understands how the method works and HC4
"that it is permanent, not reversible, and highly effective"
 Vasectomy is not castration and sexual ability
 The procedure is not immediately effective and that
the client will need to use a condom for at least 15
ejaculations after the operation (or three months)
" After the operation, advise client:"
 To return for routine follow-up after days days or
"earlier if there is fever, excessive swelling, pus, or"
tenderness at the site of operation
 To continue using condoms or other
 contraceptive devices for three-months following
 To use condoms if there is any risk of HIVSTIs
Surgical Contraception for Women: Tubal Ligation
This permanent FP method involves a minor 15-minute operation
carried out under local anaesthetic to cut and tie the two egg-carrying
 Ensure client understands how the method works and
"that it is permanent, not reversible, and highly effective"
 Vasectomy is not castration and sexual ability
 The procedure is not immediately effective and that
the client will need to use a condom for at least 15
ejaculations after the operation (or three months)
" After the operation, advise client:"
 To return for routine follow-up after days days or
"earlier if there is fever, excessive swelling, pus, or"
tenderness at the site of operation
 To continue using condoms or other
 contraceptive devices for three-months following
 To use condoms if there is any risk of HIVSTIs HC4
fallopian tubes. It is only available at centres with specially trained
 As for vasectomy (above) but for females
 Ensure client understands how the method works and HC4
"that it is permanent, irreversible, and highly and immediately effective"
 There may be some discomfortpain over the small
 To use condoms if there is any risk of exposure to
STIsH To return after 7 days for routine follow-up or
" earlier if there is fever, excessive swelling, pus, or"
tenderness at the site of operation
 Ensure client understands how the method works and
"that it is permanent, irreversible, and highly and immediately effective"
 There may be some discomfortpain over the small
 To use condoms if there is any risk of exposure to
STIsH To return after 7 days for routine follow-up or
" earlier if there is fever, excessive swelling, pus, or"
tenderness at the site of operation HC4
ANTENATAL CARE (ANC) ICD10 CODE: Z36
Antenatal care is a planned programme of medical care offered to
"pregnant women by a skilled birth attendant, from the time of conception to delivery, aimed at ensuring a safe and satisfying pregnancy"
The main objective of antenatal care is to give information on:
" Screening, prevention, and treatment of complications"
" Satisfying any unmet nutritional, social, emotional, and"
physical needs of the pregnant woman
" Provision of patient education, including successful care"
 Identification of high-risk pregnancy
 Encouragement of male partner involvement in antenatal
Goal-Oriented Antenatal Care Protocol
Important: Goals are different depending on the timing of the visit.
4 visits are aimed for in an uncomplicated pregnancy.
"If a woman books later than in first trimester, preceding goals should be"
"combined and attended to. At all visits address any identified problems,"
check the BP and measure the Symphysio-Fundal Height (SFH). All
"women must receive Hb, HIV testing and Syphilis testing (RPR) routinely."
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"no lesnuoC eht ssucsiD ni VBGS esisahpmE,eneigyh tnemtaert no esivdA strofmocsid ycnangerp"
- - - - devresbo -borp sessenlli dna sngis -nuoc esu nommoc fo regnad ycnangerp noitirtun ot
"yna sserddA dereetnulov dna htrib etadpU nalp ycnegreme regnad weiveR ycnangerp,evitisop-VIH TCTMe no NTI no lesnuoC no esivdA fo strofmocsid ycnangerp eht ssucsiD ni VBGS no esisahpmE,eneigyh ecnerehda tnemtaert"
"yrotarobaL revef Co5.73,evitisop rof srehtom evitageN,09041 rof senilediug tset 4DCdaol itna gnineercs"
"eniru bH TGGO sah rehtoM evoba SB TDR SBTDR VIH evitisop susehR od,srehtom"
 PB fI kcehc nietorp kcehC oD fI pmeT( od fI wollof taepeR lariV VIH roF ydob
noitanimaxE dna amedeO:maxe elpitlum VBGS
PB erusaeM thgiew rof kcehC rollaP HFS erusaeM lanimodbA tuo ycnangerp lateof kcehC taebtraeh rof sseccA
"yrotsiH gnikaT:laicoS,gnikoms lohocla sgurd laicoS troppus"
- - rof ksA laicos yna smelborp dna sessenlli etad ksA tsrif lateof -evom stnem fi ksA si ereht yna saw lanigav gnideelb -sid egrahc
slaoG TT eviG edulcxE elpitlum ycnangerp rof kcehC -nangerp decudni-yc noisnetrepyh )HIP( enimreteD htworg lateof -evom dna tnem edulcxE aimeana rof neercS eht fi MDG ta si rehtom.ksir
"devresbo yna sserddA,09041  PB fPB erusaeM"
ni sn ru g o is b r a e l g y n c a n d a h n c g a e e r T p
C o r 5 ev.7 e 3 f s e a v h o b re a h p to m M eT fI (
"-nuoc,evitisop-VIH fI TCTMe no les"
eht fo erac hcaeT -xe ylrae:nrobwen gnideef-tsaerb evisulc
"droc,erac lamreht sngis regnad,erac fo regnad eht ssucsiD ycnangerp ni VBGS"
"no esisahpmE noitirtun,eneigyh ot ecnerehda dna"
snoitcA dica cilofnori 1 fi PS-pTPI dessap esod suoiverp smelborp TCTMe laud esu PF rof namow no etacude dna erac ecnanetniam
"sah yna ot noitcetorp,esu,VIH lesnuoC lesnuoC"
llifeR eviG htnom ecnis taerT VIH htlaeH sNILL
htlaeH devresbo -borp sessenlli ni sngis ruobalycnangerp etadpu ycnegreme -nuoc esu -raptsop eht -xe gnideef-tsaerb droc sngis fo regnad ycnangerp noitirtun ot
"yna sserddA dereetnulov ro dna smel regnad hcaeT ruobal ssucsiD dna ssucsiD dna htrib nalp ylimaf ssucsiD gninnalp,evitisop-VIH fI TCTMe no les NTI lesnuoC tuoba hcaeT erac mut fo erac hcaeT ylrae:nrobwen evisulc,erac lamreht regnad,erac eht ssucsiD ni VBGS no esisahpmE,eneigyh ecnerehda dna tnemtaert"
"yrotarobaL revef Co5.73,evitisop,09041 senilediug"
eniru bH sah rehtoM evoba SB TDR SBTDR
 PB kcehc nietorp kcehC pmeT( wollof
PB erusaeM rof HFS erusaeM lanimodbA lateof taebtraeh
yrotsiH gnikaT rof ksA laicos yna smelborp dna sessenlli fi ksA si ereht yna saw lanigav gnideelb -sid dna egrahc
lateof edulcxE aimeana kcehC etadpU nalp
d n n a a l p h t y r c ib n e e g t r a e d m pu e
C o r 5 ev.7 e 3 f s e a v h o b re a h p to m M eT fI (
"-tsop,htrib,ruobal,evitisop SBTDR feil"
-raptsop tuob e a ra h c c m ae u T t
"evisulcxe dna ylrae lamreht,gnideeftsaerb"
fo regnad eht ssucsiD ycnangerp ni VBGS
"no esisahpmE noitirtun,eneigyh ot ecnerehda dna"
snoitcA dica cilofnori 1 fi PS-pTPI dessap esod suoiverp smelborp TCTMe laud esu PF rof noitneverp namow no etacude dna erac ecnanetniam
"sah yna ot noitcetorp,esu,VIH lesnuoC lesnuoC"
llifeR eviG htnom ecnis taerT VIH htlaeH sNILL
"htlaeH devresbo yna sserddA -borp dereetnulov sessenlli dna smel ruobal ssucsiD dna htrib etadpu nalp ycnegreme ni TCTMe hcaeT -tsop,htrib,ruobal mutrap esu NTI no lesnuoC dna PF ssucsid-eR noitneverp VIH -raptsop tuoba hcaeT erac mut fo erac hcaeT regnad:nrobwen,nrobwen ni sngis evisulcxe dna ylrae lamreht,gnideeftsaerb erac droc,erac fo regnad eht ssucsiD ycnangerp ni VBGS no esisahpmE noitirtun,eneigyh ot ecnerehda dna tnemtaert"
"yrotarobaL kcehc revef Co5.73,evitisop"
noitanimaxE traeh maxe -atneserp
yrotsiH gnikaT rof smelborp yna fi lanigav gnideelb
"slaoG htworg aispmalceerp civlepolahpec,noitroporpsid fo htrib -negreme"
enimreteD lateof edulcxE aimeana rof kcehC rof kcehC edulcxE lamronba -atneserp eilnoit nialpxE smotpmys ruobal etadpU nalp
Management of Common Complaints during Pregnancy
Low back  Exclude urinary Avoid unnecessary
"ache, and tract infection medication"
"passing urine If none, reassure"
Morning sick-  Reassure; usually Avoid anti- emetics
ness (nausea lasts only up to 3 in the first trimes-
advice (frequent be necessary ONLY
"small dry meals, in severe forms (see"
" If severe with dehydration, admit"
Swelling of  Check for Advise mother to
"the feet anaemia, blood elevate feet if findpressure, urine ings are normal"
Indigestion  High roughage Avoid strong laxa-
"(flatulence  diet, increase flu- tives  enemas"
"If none, reassure Avoid unnecessary"
" If severe with dehydration, admit"
2-3 times daily Avoid anti- emetics
manage appropriately Advise mother to
elevate feet if findings are normal
"diet, increase fluids. Avoid strong laxatives  enemas"
Excessive  Reassure Avoid anticholinersalivation gic drugs
Food craving  Ensure balanced Discourage harmful
"(pica) diet materials, e.g. soil"
"sign of iron deficiency anaemia,"
Generalised  Reassure. Avoid steroids
Vulval  Treat as for Avoid douching
pruritus with abnormal vaginal with antiseptics
 Avoid repeat doses or prolonged
Cramps  Give calcium Avoid giving
"Fatigue  Reassure, bed rest Avoid drugs"
use ginger Avoid anticholinergic drugs
"sign of iron deficiency anaemia,"
 Avoid repeat doses or prolonged
"Fatigue  Reassure, bed rest Avoid drugs"
High Risk Pregnancy (HRP) ICD10 CODE: O09
"This is a pregnancy with a higher than average risk of an adverse outcome for the mother or baby, e.g., abortion, intrauterine death, still"
"birth, prematurity, other morbidity or mortality."
High risk criteria: if a woman has history of or current
 Extremes of reproductive age: 18 and 35 years
" Primigravida: Especially if too young (18 years), short"
 High parity: 5 or short birth-to-pregnancy interval below
 Prematurity and Low birth weight (LBW) 2.5kg
 Obstructed and difficult labours
" Poor obstetric history, e.g., stillbirths, neonatal deaths,"
" History of reproductive tract surgery, e.g., VVF repair, repaired (ruptured uterus), surgery on the cervix, myomectomy"
" Genetic or familial diseases, such as sickle cell disease"
" Medical conditions: Diabetes, HIV, cardiac, renal, hypertension, rhesus, those with disabilities"
" Obstetrical conditions, e.g. multiple pregnancy, malpresentations, APH, PPH, DVT, IUGR,(FGR), IVF, PROM, post dates,"
 Early identification of high risk pregnant women and HC4
 Preconception care and folic acid supplementation
 Prophylaxis and antenatal counselling will prevent
 Close medical supervision during pregnancy
 Special investigations to evaluate foetal development
 Timely intervention for therapy and delivery
 Early referral to higher level as appropriate
Note: Skilled attendance at birth remains the most important component of comprehensive emergency obstetric and new-born care.
MANAGEMENT OF SELECTED CONDITIONS IN
Anaemia in Pregnancy ICD10 CODE: Anaemia is the most frequent and major complication of pregnancy.
It may be defined as haemoglobin level below the normal (11 gdL for
pregnant women). For second trimester the cut off is 10.5gdL.
 Early identification of high risk pregnant women and
 Preconception care and folic acid supplementation
 Prophylaxis and antenatal counselling will prevent
 Close medical supervision during pregnancy
 Special investigations to evaluate foetal development
 Timely intervention for therapy and delivery
 Early referral to higher level as appropriate HC3
" Nutritional causes; iron deficiency, folic acid deficiency"
" Infections and infestations; hookworm infestation, malaria, UTI, HIVAIDS"
" Haemorrhagic causes: bleeding in pregnancy, trauma"
" Haemoglopathies eg. Sickle cell anaemia, thalassemias"
 Due to medications from HIV Cancer treatment
 Gradual onset of exhaustion or weakness
" Dyspnoea, dizziness, and palpitations"
" Pallor of the conjunctiva, tongue, palm, vagina, etc., of"
"varying degree, depending on the severity of anaemia"
" In very severe cases: evidence of heart failure such as engorged neck veins, dyspnoea, hepatomegally, ascites, gallop rhythm, and oedema"
 Untreated anaemia may increase the risk of premature
"labour, poor intrauterine foetal growth, weak uterine contractions, foetal hypoxia, postpartum haemorrhage, poor"
 Hb (11 gdL is considered abnormal)
 Peripheral smear to determine the type of anaemia and presence
 Stool: ova and cysts of hookworm infestation
 All pregnant women should receive ferrous and folic
acid daily from 12 weeks. Continue supplementation
If severe anaemia(Hb 7 gdL) or patient has heart failure HC4
 Refer patient to a well-equipped facility for further
 Give combination of ferrous and folic acid
 Review the mother every 2 weeks (Hb should rise by
" Emphasise a realistic balanced diet rich in proteins, HC2"
"iron, and vitamins, e.g. beans, peas, millet, sorghum,"
"peanuts, red meat, liver, dark green vegetables, fortified"
 Treat malaria presumptively with SP and follow up
 De-worm the patient with mebendazole 500 mg single
 Treat any other cause as found from investigations
 Advise child spacing with an interval of at least 2 years
"If not improving, refer to hospital"
"If mother still anaemic at 36 weeks of gestation, or at time HC4"
 Refer to a well-equipped facility for further management
If patient has sickle-cell disease HC4
 Refer to higher level for ANC and delivery
 All pregnant women should receive ferrous and folic
acid daily from 12 weeks. Continue supplementation
until 6months after delivery. HC2
If severe anaemia(Hb 7 gdL) or patient has heart failure
 Refer patient to a well-equipped facility for further
 Give combination of ferrous and folic acid
 Review the mother every 2 weeks (Hb should rise by
" Emphasise a realistic balanced diet rich in proteins,"
"iron, and vitamins, e.g. beans, peas, millet, sorghum,"
"peanuts, red meat, liver, dark green vegetables, fortified"
 Treat malaria presumptively with SP and follow up
 De-worm the patient with mebendazole 500 mg single
 Treat any other cause as found from investigations
 Advise child spacing with an interval of at least 2 years
"If not improving, refer to hospital HC2"
"If mother still anaemic at 36 weeks of gestation, or at time"
 Refer to a well-equipped facility for further management
If patient has sickle-cell disease
 Refer to higher level for ANC and delivery HC4
PreventionHealth Education  mother selfcare
 Explain the possible causes of anaemia
 Advise on nutrition and diet: mother should increase consumption of foods rich in iron and vitamins
" Instruct patient to use medication as prescribed, and the"
 Advise on side effects of iron medicines (e.g. darkened
 Instruct patient to come every 2 weeks for follow-up
All HIV services for pregnant mothers are offered in the MCH clinic.
"After delivery, mother and baby will remain in the MCH postnatal clinic"
until HIV status of the child is
"confirmed, then they will be transferred to the general ART clinic."
All pregnant mothers and partners should receive routine counselling
 Repeat test in third trimesterduring labour and delivery
If mother tests positive or is already known positive but not yet on ART
If mother is already positive and already on ART:
 Continue on their existing regimen; may not be switched
 Perform viral load at first contact
"For more information on HIV, including clinical diagnosis, management,"
"and psychosocial support, refer to specific HIVAIDS guidelines (see"
16.Care for HIV Positive Women (eMTCT)
"ICD10 CODE: Ensure the following care is provided during pregnancy, labour, delivery,"
and postpartum period for all HIV women
" Find out what she has told her partner (degree of disclosure), labour companion, and family support. Respect her"
choice and desired confidentiality
During labour: safe obstetric practices
 Avoid artifical rupture of membranes
 Avoid instrumental delivery (vacuum)
 Avoid frequent vaginal examination
 Do not milk umbilical cord before cutting
 Actively manage third stage of labour
 Give infants daily Nevirapine (NVP) for for 6 weeks
(12 weeks for high risk infants)
" Give Cotrimoxazole beginning at 6 weeks, continue"
until final HIV status is confirmed negative
" Offer DNA PCR test at 6 weeks, and again 6"
weeks after cessation of breastfeeding
 TDF and EFV are now considered safe in pregnancy
 Those newly diagnosed during labour will receive
 sdNVP tablet and begin HAART for life after delivery
" In case of low body weight, high creatinine, diabetes,"
"hypertension, chronic renal disease, and concomitant"
nephrotoxic medications: perform renal investigation before
During labour: safe obstetric practices
 Avoid artifical rupture of membranes
 Avoid instrumental delivery (vacuum)
 Avoid frequent vaginal examination
 Do not milk umbilical cord before cutting
 Actively manage third stage of labour 
 Give infants daily Nevirapine (NVP) for for 6 weeks
(12 weeks for high risk infants)
" Give Cotrimoxazole beginning at 6 weeks, continue"
until final HIV status is confirmed negative
" Offer DNA PCR test at 6 weeks, and again 6"
weeks after cessation of breastfeeding HC3
 TDF and EFV are now considered safe in pregnancy
 Those newly diagnosed during labour will receive
 sdNVP tablet and begin HAART for life after delivery 
" In case of low body weight, high creatinine, diabetes,"
"hypertension, chronic renal disease, and concomitant"
nephrotoxic medications: perform renal investigation before
 TDF is contraindicated in advanced chronic renal disease
" Reduction of new HIV infection in children, by minimizing"
the risk of HIV transmission from infected pregnant
" and lactating women, to less than 5 in breastfeeding"
"populations, and to less than 2 in non-breastfeeding"
" Improved health, and reduced maternal mortality and"
morbidity of HIV-infected mothers through lifelong ART
 Reduction of the risk of HIV transmission to non-HIV- infected sexual partner in discordant relationship
 Reduction in the number of HIVAIDS orphans
 Contribution to the achievement of the 909090 goals
 Contributes to achievement of the Sustainable Development Goals by 2030
16.Counselling for HIV Positive Mothers
 Encourage mothers to enroll in Family Support Groups
 Advise on the importance of good nutrition
 Talk to family members to encourage the woman to eat enough
and help her avoid hard physical work
 Micronutrient supplementation during pregnancy and
 breastfeeding; iron  folic acid and multivitamins
" Advise her that she is more liable to infections, and to seek"
medical help as soon as possible
 Advise her to continue attending ANC
 Advise her to deliver in a health facility where appropriate care
can be provided for her and the baby
 Advise her to go to the health facility as soon as labour
 Advise on the infectiousness of lochia and blood- stained
"sanitary pads, and how to dispose them off safely according to local facilities"
" If not breastfeeding exclusively, advise her to use a family"
planning method immediately to prevent unwanted pregnancy
" Linkage of mother-baby pair and her family, for on-going"
" Breast care: If not breastfeeding, advise that:"
 The breasts may be uncomfortable for a while
 She should avoid expressing the breast to remove milk (the more
" She should support her breasts with a firm, well-fitting"
" bra or cloth, and give her paracetamol for painful breasts"
" Advise her to seek care if breasts become painful,"
" swollen, red; if she feels ill; or has fever"
Counselling on infant feeding choice
 Begin infant feeding counselling before birth when the
pregnant mother has been identified to be HIV positive.
 The decision on how she will feed the baby should be
made before delivery. The mother should then be supported to implement the feeding option she has chosen
 All mothers are encouraged to breastfeed their babies exclusively for 6 months and then introduce complimentary
 The mother has to continue her ARVs all through breastfeeding
" The child should continue cotrimoxazole prophylaxis, until status confirmed negative with a PCR at 6 weeks after"
 If a mother chooses to feed the newborn on replacement
"feeding from the beginning, the choice of replacement"
"feeds should fulfil the AFASS Criteria (Affordable, Feasible, Available, Sustainable and Safe)."
Chronic Hypertension in Pregnancy
Blood pressure 14090 present before the pregnancy or starting
Pregnant women with chronic hypertension should continue to follow
the lifestyle modifications for controlling hypertension such as:
" Regular moderate exercise, brisk walking for 30 minutes at"
 Ask mother about foetal movements at each visit
" Consider labour if BP is persistently ³16090 mmHg,"
"pregnancy ³37 weeks gestation, and if there is maternal or"
"foetal compromise, e.g. poor SFH growth"
Switch chronic antihypertensive medication to or start HC3
" Methyldopa 250 mg 8 hourly, increase as necessary,"
 Nifedipine 20-40 mg every 12 hours
If not controlled or any sign of pre eclampsia: refer to hospital
Switch chronic antihypertensive medication to or start
" Methyldopa 250 mg 8 hourly, increase as necessary,"
 Nifedipine 20-40 mg every 12 hours
If not controlled or any sign of pre eclampsia: refer to hospital HC3
" ACE inhibitors, ARBs are contraindicated in"
 Avoid beta blockers and diuretics
Malaria in Pregnancy ICD10 CODE: B54
"Malaria can contribute to pregnancy complications such as abortion,"
"poor foetal mental development, premature labour, intrauterine growth"
"retardation and foetal death, severe maternal anaemia due to haemolysis, and death."
Complications are more common in mothers of low gravidity (primi- and
"secundigravidae), HIV positivity, adolescent age, sickle-cell disease, and"
"those from areas of low endemicity,e.g. in Kisoro and Kabale.. see section for more information on features and diagnosis of"
Management of Malaria in Pregnancy
Prophylaxis All  Intermittent Preventive Treatment HC2
pregnant mothers (IPTp) with Sulphadoxine pyrimethWexcept those amine (SP) once a month starting
with HIV on at 13 weeks until delivery
Treatment of  Quinine oral 600 mg 8 hourly for 7 HC2
"Uncomplicated days (if Quinine not available, ACT"
" ACE inhibitors, ARBs are contraindicated in"
 Avoid beta blockers and diuretics 
prophylaxis  Intermittent Preventive Treatment
(IPTp) with Sulphadoxine pyrimethamine (SP) once a month starting
trimester  Quinine oral 600 mg 8 hourly for 7
"days (if Quinine not available, ACT"
trimesters First line alternative
3 tablets (1080 mg) once daily for
" Quinine, oral 600 mg 8 hourly for"
Severe malaria  IMIV Artesunate mgkg at HC3
"All trimesters and 0, 12 and 24 hours, then once a"
lactation day until mother can tolerate oral
until mother can tolerate oral medication. Complete treatment with 3
"If artesunate or arthemeter not available, use"
 Quinine 10 mgKg IV every 8 hours
 Quinine is associated with an increased risk of hypoglycaemia
Prevention and control of malaria in pregnancy
" Use insecticide-treated mosquito nets (ITN) before, during,"
3 tablets (1080 mg) once daily for
" Quinine, oral 600 mg 8 hourly for"
lactation  IMIV Artesunate mgkg at
"0, 12 and 24 hours, then once a"
day until mother can tolerate oral
until mother can tolerate oral medication. Complete treatment with 3
"If artesunate or arthemeter not available, use"
 Quinine 10 mgKg IV every 8 hours
 Quinine is associated with an increased risk of hypoglycaemia
 Give all pregnant women intermittent preventive treatment (IPTp) with sulfadoxine pyrimethamine (SP)  Except
 Prompt diagnosis and effective treatment of malaria in
Education messages to mothers and the community
 Malaria is transmitted by female anopheles mosquitoes
 Pregnant women and children are at particular risk of malaria
" If untreated, malaria can cause severe anaemia and death"
" Malaria can lead to anaemia, miscarriage, stillbirth, mentally-retarded children, or low birth weight children, who"
are more prone to infantchildhood mortality compared
 It is better and cheaper to prevent than to treat malaria
" The individual, family, and the community can control malaria by taking appropriate actions"
 Sleeping under an insecticide-treated mosquito netis the
 It is very important to complete the course of treatment in
" Severe complicated malaria needs special management,"
Diabetes in Pregnancy ICD10 CODE: O24
Diabetes can be pre-existent or presenting during pregnancy: the latter
is called gestational diabetes (GDM).
Risk factors (and indication for screening)
 Family history (8 first degree relatives) of diabetes
" Previous unexplained third trimester death, macrosomic"
 Foetus large for gestational age
Diagnostic criteria for gestational diabetes
 Plasma glucose mmolL 2 hours after 75 g glucose tolerance test
 Pre prandial blood glucose mmolL
 1-hour postprandial glucose mmolL
 2-hour postprandial glucose mmolL
" Stop smoking, moderate exercise, dietary advice (see HC3"
If obese and mild diabetes consider
" Metformin 500 mg (start with one tablet a day, increase"
by 500 mg per week up to max 2 g per day in divided
 Insulin (see section 8.1.3) HC4
 Mothers with diabetes should be advised to deliver in hospital
" Stop smoking, moderate exercise, dietary advice (see"
If obese and mild diabetes consider
" Metformin 500 mg (start with one tablet a day, increase"
by 500 mg per week up to max 2 g per day in divided
 Insulin (see section 8.1.3) HC4
 Mothers with diabetes should be advised to deliver in hospital 
Urinary Tract Infections in Pregnancy
"Urinary tract infections are common in pregnancy, and maybe associated"
 Frequency and urgency of micturition
" Urine dipstick (for nitrate andor leucocytes, also protein and"
 Full blood count (raised in pyelonephritis)
 Encourage increased oral fluid intake
 Nitrofurantoin 100 mg twice a day for 5 days (avoid in HC2
 Or Amoxicillin 500 mg every 8 hours for 5 days
 Encourage increased oral fluid intake
 Nitrofurantoin 100 mg twice a day for 5 days (avoid in
 Or Amoxicillin 500 mg every 8 hours for 5 days HC2
 Ceftriaxone 1 g IV daily for 48 hours or until fever
 Cefixime 200 mg every 12 hours for 10 days
If ceftriaxone not available HC3
 Ampicillin 500 mg IV every 6 hours  gentamicin 5-7
mgkg in 2-3 divided doses IM (max 80 mgdose) for
Hyperemesis Gravidarum ICD10 CODE: O21
"Excessive vomiting during pregnancy, associated with ketosis, dehydration and weight loss (5 of pre-pregnancy weight)."
Not known but may be common in multiple and molar pregnancy
 May occur from the 4th week of pregnancy and can continu
 Defining symptoms are nausea and vomiting so severe that
" Patient may develop complications of excessive vomiting,"
such as vomiting blood and dehydration
 Ceftriaxone 1 g IV daily for 48 hours or until fever
 Cefixime 200 mg every 12 hours for 10 days HC4
 Ampicillin 500 mg IV every 6 hours  gentamicin 5-7
mgkg in 2-3 divided doses IM (max 80 mgdose) for
" Blood: complete count, RDT for malaria parasites"
 Urinalysis: to exclude urinary tract infection
 Ultrasound scan: to detect molar or multiple pregnancies
 IV fluids to correct dehydration (see section 1.1.3)
and ketosis (give Ringers lactate or Normal saline and
 Promethazine 25 mg IM or orally every 8 hours prn
 Vitamin B6 (Pyridoxine) 1 tablet every 12 hours for 7 days
 Or Metoclopramide 10 mg IM or IV or orally every 6-8
 Chlorpromazine 25 mg IM or orally every 6 hours prn
Vaginal Bleeding in Early Pregnancy Abortion
"This is almost always abnormal, and patients may need to be admitted"
or referred. The most common causes of bleeding in the first six months
(26 weeks gestation) are abortion and ectopic pregnancy
Abortion (miscarriage) occurs when the foetus is lost before 28 weeks
 IV fluids to correct dehydration (see section 1.1.3)
and ketosis (give Ringers lactate or Normal saline and
 Promethazine 25 mg IM or orally every 8 hours prn
 Vitamin B6 (Pyridoxine) 1 tablet every 12 hours for 7 days
 Or Metoclopramide 10 mg IM or IV or orally every 6-8
 Chlorpromazine 25 mg IM or orally every 6 hours prn
 Not known in the majority of patients
 May be intentional (induced abortion)
 May be spontaneous (often as a result of fever)
" If mother has more than 2 miscarriages, refer for assessment"
 Pregnancy outside the uterus (ectopic pregnancy)
" Other causes of bleeding from the vagina, e.g. cancer"
" Other causes of lower abdominal pain, e.g. PID"
"Clinical features, terminology and management"
 Depend on the stage of the abortion See table below.
Threatened  Medical treatment is usually not HC2
abortion necessary (hormones and tocolytics will not prevent a miscarriage)
bleeding  Observe for 4-6 hours
No or moderate  Paracetamol 1 g every 6-8 hours
 Avoid strenuous activity and abexpected size by
stain from sex for at least 14 days
 Follow up in 2 days in ANC clinic
"If bleeding persists, refer to HC3"
still continue  Medical treatment is usually not
necessary (hormones and tocolytics will not prevent a miscarriage)
 Paracetamol 1 g every 6-8 hours
 Avoid strenuous activity and abstain from sex for at least 14 days
 Follow up in 2 days in ANC clinic
"If bleeding persists, refer to HC3 HC2"
 History of prior ectopic pregnancy
 Prior abdominal or tubal surgery
" History of PID, endometriosis, history of infertility"
 There may be a period of amenorrhoea as in normal
" Lower abdominal pain, often acute and followed by slight"
" If the tube ruptures, the patient may suddenly become"
 Abdomen may be very tender with rebound tenderness and
 Abdomen may not be moving with normal breathing
 Tenderness of moving cervix during vaginal examination
 There may be features of free fluid in the abdomen
" Other causes of acute abdominal pain and vaginal bleeding,"
" Appendicitis, pelvic inflammatory disease"
"- If the tube ruptures, there may be little time for investigations"
but ultrasound could be useful (if the patient is not in shock)
 Pregnancy test (to exclude other causes)
" Complete blood count, blood grouping and cross-matching"
 Set up IV drip with normal saline and run very slowly HC3
" DO NOT RUN A LOT OF FLUIDS BEFORE SURGERY, as"
"this raises blood pressure, which may worsen the patients"
"bleeding, and worsen state of shock."
Premature Rupture of Membranes (PROM  PPROM)
PROM is a rupture of membranes before the start of labour. It can
- When foetus is matureterm at or after 37 weeks (PROM)
- Or when foetus is immaturepreterm between 24-37
weeks of gestation. This is referred to as Pre-term PROM
"In all cases of PPROM, prematurity and its attendant problems are"
"the principal concerns for the foetus, while infection morbidity and its"
complications are the primary concerns for the mother.
Risk factors associated with PPROM
"Low socioeconomic status, tobacco use"
 Prior history of PV bleeding during pregnancy
" Urinary tract infection, chorioamnionitis"
" Cervical cerclage, amniocentesis"
Clinical features associated with PROM
 Leakage of fluid or vaginal discharge
 Set up IV drip with normal saline and run very slowly
 Refer to hospital for surgery HC3
" DO NOT RUN A LOT OF FLUIDS BEFORE SURGERY, as"
"this raises blood pressure, which may worsen the patients"
"bleeding, and worsen state of shock. "
 May be with or without vaginal bleeding
 Pelvic pressure but no contractions
" If ROM has been prolonged, the patient may present with fever,"
"abdominal pain, and a foul smelling vaginal discharge"
 The typical odour of amniotic fluid is diagnostic
 Place a vaginal pad over the vulva; examine visually and by smell
 Use a high-level disinfected or sterile speculum for vagina
 examination: fluid may be seen coming from the cervix or forming
 Ask patient to cough: this may cause a gush of fluid
" If membrane rupture is not recent or leakage is gradual, confirming"
 Abdominal US scan may show absence of or very low
" If available, do Nitrazine test and Ferning test"
 Do NOT do digital vaginal examination  it does not help
diagnosis and may cause infection
 Over 90 of patients with PROM go into spontaneous
 Expectant management carries a risk of infection
 Induction of labour decreases the risk of infection without
increasing the CS delivery rate
" Expectant management also carries a risk of neonatal issues,"
"e.g., infection, abruptio placenta, foetal distress, foetal restriction deformities, and death"
 Refer all patients to hospital and keep in hospital until HC4
If the membranes have been ruptured for 18 hours
 Give prophylactic antibiotics until delivery to help reduce
neonatal group B streptococcus infection: Ampicillin 2
g IV every 6 hours or benzylpenicillin 2 MU IV every
 Refer to HC4 or above (with facilities for emergency
obstetric management) for induction with oxytocin (see
 The primary determinant of neonatal morbidity and mortality
"is gestational age at delivery, hence stressing the need for"
conservative management whenever possible for Pre-PROM
 All patients with Pre-PROM should receive antenatal steroids
 All patients with PPROM should receive prophylactic antibiotics since there is a high risk of infection
 Administration of tocolytics for 48 hours may allow administration of steroids to accelerate lung maturity
" In general, prognosis is good after 34 weeks of gestation"
 All patients with PPROM should be cared for in a facility
where a Neonatal Intensive Care Unit (NICU) is available
 Refer all patients to hospital and keep in hospital until
If the membranes have been ruptured for 18 hours
 Give prophylactic antibiotics until delivery to help reduce
neonatal group B streptococcus infection: Ampicillin 2
g IV every 6 hours or benzylpenicillin 2 MU IV every
 Refer to HC4 or above (with facilities for emergency
obstetric management) for induction with oxytocin (see
" Refer all patients to hospital, and keep in hospital H"
If no signs of infection and pregnancy 24-34 weeks (if
 Give dexamethasone 6 mg IM every 12 hours for a
"total of 4 doses (or betamethasone 12 mg IM, 2 doses"
 Routine antibiotics: Erythromycin 250 mg every 8 H
hours plus amoxicillin 500 mg every 8 hours
- Stop them after delivery if no signs of
If palpable contractions and blood- stained mucus
 Hydrate with IV fluids before administering nifedipine
 Consider administration of tocolytics
- Tocolytics: Nifedipine 10 mg sublingual tablet
placed under the tongue every 15 minutes
"if necessary, up to a maximum of 40 mg in"
the first hour. Then 60-160 mg daily in 3-4
"divided doses, adjusted to uterine activity, for"
If vaginal bleeding with abdominal pain (intermittent or constant)
 Suspect and treat as abruptio placentae (see section
"If signs of infection (fever, foul-smelling vaginal discharge)"
 Give antibiotics as for Amnionitis (section 16.3.5)
 Do not use steroids in presence of infection
" Refer all patients to hospital, and keep in hospital"
If no signs of infection and pregnancy 24-34 weeks (if
 Give dexamethasone 6 mg IM every 12 hours for a
"total of 4 doses (or betamethasone 12 mg IM, 2 doses"
 Routine antibiotics: Erythromycin 250 mg every 8
hours plus amoxicillin 500 mg every 8 hours
- Stop them after delivery if no signs of
If palpable contractions and blood- stained mucus
 Hydrate with IV fluids before administering nifedipine
 Consider administration of tocolytics
- Tocolytics: Nifedipine 10 mg sublingual tablet
placed under the tongue every 15 minutes
"if necessary, up to a maximum of 40 mg in"
the first hour. Then 60-160 mg daily in 3-4
"divided doses, adjusted to uterine activity, for"
If vaginal bleeding with abdominal pain (intermittent or constant)
 Suspect and treat as abruptio placentae (see section
"If signs of infection (fever, foul-smelling vaginal discharge)"
 Give antibiotics as for Amnionitis (section 16.3.5)
 Do not use steroids in presence of infection 
Chorioamnionitis ICD10 CODE: O41.1
Infection of the chorionic and amniotic membranesfluid before delivery.
 History of vaginal draining of liquor
 Foul-smelling or purulent vaginal discharge
" Acute complications: postpartum haemorrhage, puerperal"
" Chronic complications: infertility due to salpingitis, and or"
 Urinalysis to rule out UT Swab (vaginal discharge) for gram stain
Care for mother and neonate includes early delivery and antibiotic
administration. The risk of neonatal sepsis is increased.
 Start antibiotics and refer to hospital H
- Ampicillin 2 g IV every 6 hours
- Plus gentamicin 5 mgkg IV every 24 hours
"For penicillin allergic patients, give"
 Clindamycin 300-600 mg IV 12 hourly
 Continue parenteral antibiotics until woman is afebrile
for 48 hours and no foul-smelling discharge
" If the mother comes back with complications, refer H"
If the woman has a Caesarean section
" Continue the above antibiotics, and add metronidazole"
- Continue until 48 hours after fever has gone
 Examine the neonate for suspected sepsis before
 If newborn sepsis is suspected manage as in section
2. Advise the mother on how to recognize danger signs
Antepartum Haemorrhage (APH)  Abruptio Placentae
and Placenta Praevia ICD10 CODE: O44-O46
"Vaginal bleeding occurring after 28 weeks of pregnancy, and up to"
 Start antibiotics and refer to hospital
- Ampicillin 2 g IV every 6 hours
- Plus gentamicin 5 mgkg IV every 24 hours
"For penicillin allergic patients, give"
 Clindamycin 300-600 mg IV 12 hourly
 Continue parenteral antibiotics until woman is afebrile
for 48 hours and no foul-smelling discharge H
" If the mother comes back with complications, refer"
If the woman has a Caesarean section
" Continue the above antibiotics, and add metronidazole"
- Continue until 48 hours after fever has gone H
 Examine the neonate for suspected sepsis before
 If newborn sepsis is suspected manage as in section
2. Advise the mother on how to recognize danger signs
 Local causes from genital tract
 Placenta praevia: All or part of the placenta is found in the
 Abruptio placentae: Premature separation of a normally
Comparison of Clinical features
SIGNSYMPTOM PLACENTA PRAEVIA ABRUPTIO PLACENTAE
Abdominal pain Painless Severe pain
Foetal movements Foetal movements usu- Loss of foetal moveally present ments common
Amount of vaginal Significant bleeding from Significant bleeding
bleeding the vagina may be absent; only
"Maternal general Shock and anaemia if Shock and anaemia,"
condition bleeding is heavy even when no frank
Uterine consistency Uterus soft and not Uterus hard and
Position of foetal High presenting part Foetal parts difficult
presenting part (head) or malpresenta- to feel because of
tion (the part in the hard uterus
Foetal heart sounds Foetal heart sounds Foetal heart sounds
SIGNSYMPTOM PLACENTA PRAEVIA ABRUPTIO PLACENTAE
Abdominal pain Painless Severe pain
Foetal movements Foetal movements usually present Loss of foetal movements common
bleeding Significant bleeding from
the vagina Significant bleeding
"bleeding is heavy Shock and anaemia,"
Uterine consistency Uterus soft and not
presenting part High presenting part
(head) or malpresentation (the part in the
lower uterus not head) Foetal parts difficult
Foetal heart sounds Foetal heart sounds
usually heard Foetal heart sounds
 Ruptured uterus especially in a patient with previous caesarean section or grand multipara
" Local causes, e.g. cervical cancer"
 Ultrasound: To find the site of the placenta and viability of the
"baby, this may not be conclusive for AP (take note of clinical"
 Clotting time and bleeding time
 Any bleeding in late pregnancy needs immediate referral H
" Admit, inspect the vulva to ascertain colour and amount"
of bleeding but DO NOT perform a digital vaginal examination if you suspect placenta praevia
 Correct anaemia and coagulation defects (transfuse
 In case of confirmed Abruptio Placentae where the baby
"is dead, and facilities for theatre and blood transfusion"
"are available, with no contraindication to vaginal delivery:"
- Rupture membranes and start oxytocin 10 IU
in 500 mL of Normal saline to induce labour
 Any bleeding in late pregnancy needs immediate referral
" Admit, inspect the vulva to ascertain colour and amount"
of bleeding but DO NOT perform a digital vaginal examination if you suspect placenta praevia
 Correct anaemia and coagulation defects (transfuse
 In case of confirmed Abruptio Placentae where the baby
"is dead, and facilities for theatre and blood transfusion"
"are available, with no contraindication to vaginal delivery:"
- Rupture membranes and start oxytocin 10 IU
in 500 mL of Normal saline to induce labour H
 In case of Abruptio Placentae where the baby is alive H
- Deliver by emergency caesarean section (ensure
- Give steroids (as for PPROM) if 34 weeks
- Emergency cesarean section if bleeding is
"uncontrolled, mothers or babys life in danger or"
"- If bleeding resolves, keep mother in hospital and"
Pre-eclampsia is a hypertensive condition of pregnancy usually diagnosed after 20 weeks of gestation and can present as late as 4-6 weeks
"It is haracterized with hypertension, proteinuria with or without oedema"
"and, may result into maternal fits if not managed appropriately."
It may also be superimposed on chronic hypertension. It is classified as
Mild to moderate pre-ec- A diastolic BP of 90-109 mmHg and or
"lampsia systolic BP of 140-159 mmHg, with ³1"
proteinuria; and no organ dysfunction
Severe pre- eclampsia acute severe hypertension (160110
mmHg) and ³1 proteinuria OR any
degree of hypertension with evidence of
"organ dysfunction (e.g., renal dysfunction,"
"raised liver enzymes, thrombocytopaenia)"
Clinical features of severe pre-eclampsia
" Headache, blurring of vision of new onset"
" Epigastric or right upper quadrant pain, vomiting"
 In case of Abruptio Placentae where the baby is alive
- Deliver by emergency caesarean section (ensure
- Give steroids (as for PPROM) if 34 weeks
- Emergency cesarean section if bleeding is
"uncontrolled, mothers or babys life in danger or"
"- If bleeding resolves, keep mother in hospital and"
Mild to moderate pre-eclampsia A diastolic BP of 90-109 mmHg and or
"systolic BP of 140-159 mmHg, with ³1"
proteinuria; and no organ dysfunction
Severe pre- eclampsia acute severe hypertension (160110
mmHg) and ³1 proteinuria OR any
degree of hypertension with evidence of
"organ dysfunction (e.g., renal dysfunction,"
"raised liver enzymes, thrombocytopaenia)"
" Dyspnoea, weakness or general malaise"
" Oedema (swelling of hands, face, legs and other parts of the"
 Systolic BP 160 mmHg and Diastolic BP 110 mmHg
 Pre-elampsia related hypertension usually resolves spontaneously after delivery and almost always within 12 weeks
" Other causes of oedema and hypertension, e.g., renal diease)"
- Clotting time if platelet count is less than 100 X 109
 Ultrasound Scan for foetal Estimated Gestational Age and viability
"Any case of pre-eclampsia has to be referred to hospital, lower facilities"
"can give emergency care (Magnesium sulphate, antihypertensive as"
" Bed rest, preferably in hospital"
" Monitor BP, urine output, renal and liver function tests,"
"platelet count, foetal condition"
 Mother may be hypovolaemic; careful (slow) infusion of
 Consider delivery if risks to mother outweigh risks of
" Methyldopa, oral, 250 mg every 8 hours as a starting"
"dose, increase to 500 mg 6 hourly according to response,"
 Nifedipine 20-40 mg every 12 hours
Severe pre-eclampsia (hypertensive emergency)
 Give IV fluids (Normal saline) very slowly (1 L in 6-8
 Give IV loading dose of magnesium sulphate injection
- Draw 8 mL of a 50 MgSO4 and add 12 mL
of water for injection or Normal saline: this is
- Give the solution as a slow IV bolus over 20
" Then give 5 g MgSO4 (10 mL of MgSO4 50, undiluted)"
in each buttock deep IM (total 10 g) with 1 mL of 2
" If unable to give IV loading dose, give only the 10 g"
" Bed rest, preferably in hospital"
" Monitor BP, urine output, renal and liver function tests,"
"platelet count, foetal condition"
 Mother may be hypovolaemic; careful (slow) infusion of
 Consider delivery if risks to mother outweigh risks of
" Methyldopa, oral, 250 mg every 8 hours as a starting"
"dose, increase to 500 mg 6 hourly according to response,"
 Nifedipine 20-40 mg every 12 hours HC3
Severe pre-eclampsia (hypertensive emergency)
 Give IV fluids (Normal saline) very slowly (1 L in 6-8
 Give IV loading dose of magnesium sulphate injection
- Draw 8 mL of a 50 MgSO4 and add 12 mL
of water for injection or Normal saline: this is
- Give the solution as a slow IV bolus over 20
" Then give 5 g MgSO4 (10 mL of MgSO4 50, undiluted)"
in each buttock deep IM (total 10 g) with 1 mL of 2
" If unable to give IV loading dose, give only the 10 g"
If BP is 95 mmHg diastolic or 160 mmHg systolic
 Give hydralazine 5 mg IV bolus every 30 minutes until
diastolic is BP is down to 100 mmHg
- Alternative if hydralazine not available:
Nifedipine 20-40 mg orally every 12 hours until delivery
"- Or Labetalol 20 mg IV over 2 minutes, double RR"
the dose every 30 minutes until diastolic is 100
mmHg (total dose not to exceed 160 mghour)
 Maintenance antihypertensive therapy is necessary after
controlling the BP. Maintain the patient on Nifedipine
 Monitor BP every 15 minutes until stable (when systolic
 Women with severe pre-eclampsia should be delivered
urgently (vaginally or CS) regardless of gestational age
- Headache that is persistent and severe
 Monitor BP every 15 minutes for 2 hours
" Continue to monitor vital signs (BP, urine protein, etc)"
very carefully for at least 48 hours
 Continue antihypertensive to mantain diastolic BP less
 Send home when BP is stable and no urine protein
 Continue antihypertensive according to clinical monitoring
- Hypertension usually resolves with the birth
of the baby but may persist (e.g. in case of
undiagnosed pre existent hypertension)
If BP is 95 mmHg diastolic or 160 mmHg systolic
 Give hydralazine 5 mg IV bolus every 30 minutes until
diastolic is BP is down to 100 mmHg
- Alternative if hydralazine not available:
Nifedipine 20-40 mg orally every 12 hours until delivery HC4
"- Or Labetalol 20 mg IV over 2 minutes, double"
the dose every 30 minutes until diastolic is 100
mmHg (total dose not to exceed 160 mghour)
 Maintenance antihypertensive therapy is necessary after
controlling the BP. Maintain the patient on Nifedipine
 Monitor BP every 15 minutes until stable (when systolic
BP 160 and Diastolic 100 mmHg RR
 Women with severe pre-eclampsia should be delivered
urgently (vaginally or CS) regardless of gestational age
- Headache that is persistent and severe
 Monitor BP every 15 minutes for 2 hours
" Continue to monitor vital signs (BP, urine protein, etc)"
very carefully for at least 48 hours
 Continue antihypertensive to mantain diastolic BP less
 Send home when BP is stable and no urine protein
 Continue antihypertensive according to clinical monitoring
- Hypertension usually resolves with the birth
of the baby but may persist (e.g. in case of
undiagnosed pre existent hypertension) H
 Do not use ergot-containing medicines
 Do not use diuretics or ACE inhibitors
"Occurrence of generalised tonic-clonic seizures after 20 weeks of pregnancy, associated with hypertension"
"and proteinuria, without any other neurological cause of seizures."
 Patient may or may not have had previous clinical features of
" Headache that is usually frontal, blurring of vision, aura"
 Generalized tonic-clonic seizures
 Right upper quadrant abdominal pain with nausea
 Oedema of legs and sometimes face and body
 Unconsciousness if condition not treated
 Amnesia and other mental changes
" Other causes of fits, e.g. cerebral malaria, meningitis, epilesy,"
 Clotting time if platelet count 100x109
Eclampsia is a medical emergency and should be referred to hospital
"urgently, after first aid measures as available."
 Controllingpreventing convulsions
 Delivering the baby as soon as possible
 Protect the airway by placing the patient on her left side
- Prevent patient from hurting herself
 Place padded tongue blade between her teeth to prevent
"tongue bite, and secure it to prevent aspiration  DO"
NOT attempt this during a convulsion
 Do not restrictrestrain the patient while fitting
 Refer to hospital as soon as possible
Stop and control convulsions HC3
 Give IV loading dose of magnesium sulphate
 Draw 8 mL of a 50 MgSO4 and add 12 mL of water
for injection or Normal saline: this is equal to 4 g of
 Give the solution as slow IV bolus over 20 minutes (the
 Then give 5 g of magnesium sulphate (10 mL of MgSO4
"50 solution, undiluted) in each buttock deep IM (total"
10 g) with 1 mL of 2 lignocaine in the same syringe
 Give IV fluids (Normal saline) very slowly (1 L in 6-8
" Monitor BP, pulse, and respiration every 30 minutes;"
pass indwelling Foleys catheter for continuous bladder
 Protect the airway by placing the patient on her left side
- Prevent patient from hurting herself
 Place padded tongue blade between her teeth to prevent
"tongue bite, and secure it to prevent aspiration  DO"
NOT attempt this during a convulsion
 Do not restrictrestrain the patient while fitting
 Refer to hospital as soon as possible HC2
 Give IV loading dose of magnesium sulphate
 Draw 8 mL of a 50 MgSO4 and add 12 mL of water
for injection or Normal saline: this is equal to 4 g of
 Give the solution as slow IV bolus over 20 minutes (the
 Then give 5 g of magnesium sulphate (10 mL of MgSO4
"50 solution, undiluted) in each buttock deep IM (total"
10 g) with 1 mL of 2 lignocaine in the same syringe HC3
 Give IV fluids (Normal saline) very slowly (1 L in 6-8
" Monitor BP, pulse, and respiration every 30 minutes;"
pass indwelling Foleys catheter for continuous bladder
"If the facility has capacity, continue with maintenance H"
"dose after 4 hours from the loading dose, ONLY IF:"
 Urine output 100 mL in 4 hours f Respiratory rate is
16 per minute f Patellar reflexes (knee jerk) are present
Signs of magnesium sulphate toxicity
" Respiratory depression, rate 16 breaths per minute"
Antidote for magnesium sulphate
" Give calcium gluconate 1 g (10 mL of 10) slow IV, not"
exceeding 5 mL per minute. Repeat prn until respiratoty
rate gets back to normal (rate 16 breaths per minute)
 Magnesium sulphate 5 g IM (10 mL of MgSO4 50
solution) every 4 hours in alternate buttocks for 24
hours from the time of loading dose or after the last
convulsion; whichever comes first. Add 1 mL of lignocaine 2 in the same syringe
If there are further convulsions
 Repeat ½ of the loading dose of magnesium sulphate
"(2 g of 20 solution given IV, slowly)"
ONLY IF magnesium sulphate is not available use
" Diazepam 10 mg slow IV over 2 minutes loading dose,"
(repeat once if convulsions recur)
 Diazepam 40 mg in 500 mL of normal saline IV infusion
"to run slowly, keeping the patient sedated but rousable"
 Notify the person who will resuscitate the newborn
that a benzodiazepine andor magnesium sulphate
Control blood pressure: if BP is 110 mmHg diastolic H
 Give hydralazine 5 mg IV bolus every 30 minutes until
"If the facility has capacity, continue with maintenance"
"dose after 4 hours from the loading dose, ONLY IF:"
 Urine output 100 mL in 4 hours f Respiratory rate is
16 per minute f Patellar reflexes (knee jerk) are present
Signs of magnesium sulphate toxicity
" Respiratory depression, rate 16 breaths per minute"
Antidote for magnesium sulphate
" Give calcium gluconate 1 g (10 mL of 10) slow IV, not"
exceeding 5 mL per minute. Repeat prn until respiratoty
rate gets back to normal (rate 16 breaths per minute)
 Magnesium sulphate 5 g IM (10 mL of MgSO4 50
solution) every 4 hours in alternate buttocks for 24
hours from the time of loading dose or after the last
convulsion; whichever comes first. Add 1 mL of lignocaine 2 in the same syringe H
If there are further convulsions
 Repeat ½ of the loading dose of magnesium sulphate
"(2 g of 20 solution given IV, slowly) "
ONLY IF magnesium sulphate is not available use
" Diazepam 10 mg slow IV over 2 minutes loading dose,"
(repeat once if convulsions recur)
 Diazepam 40 mg in 500 mL of normal saline IV infusion
"to run slowly, keeping the patient sedated but rousable "
 Notify the person who will resuscitate the newborn
that a benzodiazepine andor magnesium sulphate
Control blood pressure: if BP is 110 mmHg diastolic
 Give hydralazine 5 mg IV bolus every 30 minutes until H
diastolic is BP is down to 100 mmHg H
" Alternative, if hydralazine not available: Nifedipine 20"
mg orally every 12 hours until delivery
" Or Labetalol 20 mg IV over 2 minutes, double the dose"
every 30 minutes until diastolic is 100 mmHg (total
 Maintenance antihypertensive therapy is necessary after
controlling the BP. Maintain the patient on Nifedipine
retard 20 mg 12 hourly until delivery H
 Monitor BP every 15 minutes until stable (when systolic RR
Deliver the baby by the safest and fastest means available H
 Augment labour if mother is approaching second
stage with nor contraindication to vaginal delivery and
 Perform vacuum extraction if mother is in second stage
and there is no contraindication
 Deliver by emergency caesarian section if facilities are
 Monitor BP every 15 minutes for 2 hours
" Continue to monitor vital signs (BP, urine protein, etc)"
very carefully for at least 48 hours
 Continue antihypertensive to mantain BP diastolic
 Send home when BP is stable and no urine protein
 Continue antihypertensive according to clinical monitoring
 Hypertension usually resolves with birth of the
"baby, but may persist (e.g. in case of undiagnosed"
diastolic is BP is down to 100 mmHg
" Alternative, if hydralazine not available: Nifedipine 20"
mg orally every 12 hours until delivery
" Or Labetalol 20 mg IV over 2 minutes, double the dose"
every 30 minutes until diastolic is 100 mmHg (total
dose not to exceed 160 mghour) H
 Maintenance antihypertensive therapy is necessary after
controlling the BP. Maintain the patient on Nifedipine
retard 20 mg 12 hourly until delivery
 Monitor BP every 15 minutes until stable (when systolic
BP 170 and Diastolic 100 mmHg) H
Deliver the baby by the safest and fastest means available
 Augment labour if mother is approaching second
stage with nor contraindication to vaginal delivery and
 Perform vacuum extraction if mother is in second stage
and there is no contraindication
 Deliver by emergency caesarian section if facilities are
 Monitor BP every 15 minutes for 2 hours
" Continue to monitor vital signs (BP, urine protein, etc)"
very carefully for at least 48 hours
 Continue antihypertensive to mantain BP diastolic
 Send home when BP is stable and no urine protein
 Continue antihypertensive according to clinical monitoring 
 Hypertension usually resolves with birth of the
"baby, but may persist (e.g. in case of undiagnosed"
"LABOUR, DELIVERY AND ACUTE COMPLICATIONS"
Normal Labour and Delivery ICD10 CODE: O80
Labour is a physiological process by which the uterus expels the foetus
 Regular attendance of good antenatal care with a skilled
"birth attendant, and checking of blood pressure and urine"
and other products of conception. Labour can last from between 6 to
18 hours; being longer for first pregnancies.
Normal labour is characterized by:
 Onset of regular uterine contractions at term
 Progressive cervical dilatation
 From onset of labour to full dilation of the cervix
 The presenting part descends well into the midpelvis
 Provide rapid counselling and testing for HIV if it was not done
 Make correct diagnosis of labour
 Open a partogram for the patient and monitor progress of labour
 Vaginal examinations every 2 to 4 hours. Expected rate of cervical dilatation is at least 1 cmhour. Examine every hour once
an 8 cm dilatation has been reached
" Observe change of shape of foetal head (moulding), foetal position,"
and caput. Descent is assessed by abdominal palpation noting
how much of the head you can feel above the pelvis
" Hourly monitoring of mothers BP, temperature, pulse and respiration. Check ketones and proteins in urine, and Hb"
 From onset of labour to full dilation of the cervix
 The presenting part descends well into the midpelvis
 Provide rapid counselling and testing for HIV if it was not done
 Make correct diagnosis of labour
 Open a partogram for the patient and monitor progress of labour
 Vaginal examinations every 2 to 4 hours. Expected rate of cervical dilatation is at least 1 cmhour. Examine every hour once
an 8 cm dilatation has been reached
" Observe change of shape of foetal head (moulding), foetal position,"
and caput. Descent is assessed by abdominal palpation noting
how much of the head you can feel above the pelvis
" Hourly monitoring of mothers BP, temperature, pulse and respiration. Check ketones and proteins in urine, and Hb"
 Check foetal heart rate (FHR) for 1 minute every 30 minutes.
A normal FHR is 120 to 160 beats per minute; FHR 160 or
120 beats per minute indicates foetal distress
 Observe state of membranes and colour of amniotic fluid if
" Ensure oral or IV fluid intake especially in prolonged labour, to"
 Give normal saline and Dextrose solution as required
 Provide appropriate analgesia if desired by the patient e.g.
morphine 10 mg IM stat at 4-6 cm dilatation
 From full dilatation to expulsion of the foetus
 Contractions become strong and frequent
 Perineum bulges and overlying skin becomes tense and
 Ensure full dilatation of the cervix by vaginal examination
" Encourage the mother to bear down with contractions, and"
 Protect the perineum from tearing by supporting with fingers
 Do an epsiotomy under local anaesthesia if required
 Allow the babys head to rest when it is born and loose cord from
"around the neck if present. If cord is too tight, clamp it with two"
 Support the head during delivery. Anterior shoulder is delivered
" Place the baby on mothers abdomen or arms. Dry the baby,"
" If baby not crying, assess breathing. Rub the back 2-3 times. If"
not breathing resuscitate (see section 16.5.1)
 Check foetal heart rate (FHR) for 1 minute every 30 minutes.
A normal FHR is 120 to 160 beats per minute; FHR 160 or
120 beats per minute indicates foetal distress
 Observe state of membranes and colour of amniotic fluid if
" Ensure oral or IV fluid intake especially in prolonged labour, to"
 Give normal saline and Dextrose solution as required
 Provide appropriate analgesia if desired by the patient e.g.
morphine 10 mg IM stat at 4-6 cm dilatation
 From full dilatation to expulsion of the foetus
 Contractions become strong and frequent
 Perineum bulges and overlying skin becomes tense and
 Ensure full dilatation of the cervix by vaginal examination
" Encourage the mother to bear down with contractions, and"
 Protect the perineum from tearing by supporting with fingers
 Do an epsiotomy under local anaesthesia if required
 Allow the babys head to rest when it is born and loose cord from
"around the neck if present. If cord is too tight, clamp it with two"
 Support the head during delivery. Anterior shoulder is delivered
" Place the baby on mothers abdomen or arms. Dry the baby,"
" If baby not crying, assess breathing. Rub the back 2-3 times. If"
not breathing resuscitate (see section 16.5.1)
" After the baby is born, palpate mothers abdomen to exclude"
 Then give Oxytocin 10 IU IM to the mother
 Clamp the cord and cut it (1-3 minutes after birth)
 From delivery of the baby to delivery of the placenta
" Evaluate babys condition using APGAR (Appearance, Pulse,"
"Grimace, Activity, Respiration) score, and record in the babys"
chart. Resuscitate if necessary
 Give 1 mg IM stat of phytomenadione (Vitamin K) to baby
 Clean the eyes with sterile warm water and apply tetracycline
eye ointment to babys eyes as prophylaxis against ophthalmia
" Give identification tag to baby, wrap in warm towels and give to"
the mother to introduce breast feeding
 Weigh the baby and compare with chart
 Give a full physical examination to the baby f Immunize the baby
 Examine fundal height and palpate uterus lightly to determine
whether it has contracted well and to exclude undiagnosed twins
 Ensure oxytocin 10 IU IM was given
 Await strong contraction (2-3 minutes) and deliver the placenta
by controlled cord traction. Deliver the
 placenta and examine it for completeness and normalcy. Weigh
"the placenta. If placenta is not delivered within 30 minutes, see"
Retained Placenta section  Massage lower abdomen lightly to stimulate contraction and
" Examine the perineum, vagina, and cervix for tears."
 Repair episiotomy and any tears immediately
" Observe for 1 to 2 hours. Monitor BP, temperature, and pulse"
"rate hourly. Also do uterine palpation, vulva inspection and"
estimation of degree of blood loss
" After the baby is born, palpate mothers abdomen to exclude"
 Then give Oxytocin 10 IU IM to the mother
 Clamp the cord and cut it (1-3 minutes after birth)
 From delivery of the baby to delivery of the placenta
" Evaluate babys condition using APGAR (Appearance, Pulse,"
"Grimace, Activity, Respiration) score, and record in the babys"
chart. Resuscitate if necessary
 Give 1 mg IM stat of phytomenadione (Vitamin K) to baby
 Clean the eyes with sterile warm water and apply tetracycline
eye ointment to babys eyes as prophylaxis against ophthalmia
" Give identification tag to baby, wrap in warm towels and give to"
the mother to introduce breast feeding
 Weigh the baby and compare with chart
 Give a full physical examination to the baby f Immunize the baby
 Examine fundal height and palpate uterus lightly to determine
whether it has contracted well and to exclude undiagnosed twins
 Ensure oxytocin 10 IU IM was given
 Await strong contraction (2-3 minutes) and deliver the placenta
by controlled cord traction. Deliver the
 placenta and examine it for completeness and normalcy. Weigh
"the placenta. If placenta is not delivered within 30 minutes, see"
Retained Placenta section  Massage lower abdomen lightly to stimulate contraction and
" Examine the perineum, vagina, and cervix for tears."
 Repair episiotomy and any tears immediately
" Observe for 1 to 2 hours. Monitor BP, temperature, and pulse"
"rate hourly. Also do uterine palpation, vulva inspection and"
estimation of degree of blood loss
"Induction of labour may be indicated for medical reasons, like, pre-eclampsia, diabetes, post-term pregnancy."
"However, possible risks of induction are:"
" Hyperstimulation syndrome, requiring emergency caesarean section."
Induction is contraindicated in para 5 and above and in patients with a
previous scar. In these cases there is indication for caesarean section.
Cervix favourable in HIV and Hep B negative mothers H
 Artifically rupture the membranes (with amniotic hook
or Kocher clamp) followed 2 hours later by
 Oxytocin IV IU in 500 mL of Normal saline.
 Increase infusion rate by 10 drops every 30 minutes
(max 60 minutes) until good contraction pattern is
"established (3-5 contractions in 10 minutes each lasting 40 secs), and maintain until delivery is complete"
" If no good contraction pattern with 60 drops minute,"
increase oxytocin concentration to 5 IU in 500 mL of
"Dextrose or Normal saline at 30 dropsminute, increase"
by 10 drops every 30 minutes until maximum of 60
 ONLY IN PRIMIGRAVIDA: if no good contraction
"pattern established, increase concentration of oxytocin"
to 10 IU in 500 mL and repeat as above (from 30 to
 DO NOT USE 10 IU in 500 mL in MULTIGRAVIDA or
WOMEN WITH PREVIOUS CAESAREAN SECTION
 Refer other cases or primigravida not responding to the
higher concentration for surgical management
Cervix favourable in HIV and Hep B negative mothers
 Artifically rupture the membranes (with amniotic hook
or Kocher clamp) followed 2 hours later by
 Oxytocin IV IU in 500 mL of Normal saline.
 Increase infusion rate by 10 drops every 30 minutes
(max 60 minutes) until good contraction pattern is
"established (3-5 contractions in 10 minutes each lasting 40 secs), and maintain until delivery is complete"
" If no good contraction pattern with 60 drops minute,"
increase oxytocin concentration to 5 IU in 500 mL of
"Dextrose or Normal saline at 30 dropsminute, increase"
by 10 drops every 30 minutes until maximum of 60
 ONLY IN PRIMIGRAVIDA: if no good contraction
"pattern established, increase concentration of oxytocin"
to 10 IU in 500 mL and repeat as above (from 30 to
 DO NOT USE 10 IU in 500 mL in MULTIGRAVIDA or
WOMEN WITH PREVIOUS CAESAREAN SECTION
 Refer other cases or primigravida not responding to the
higher concentration for surgical management
"If 4 contractions in 10 minutes, or contraction H"
longer than 60 secs or foetal distress:
 Give salbutamol 5 mg in RL or NS 500 mL IV infusion
 Misoprostol 25 micrograms inserted vaginally every
"6 hours for 2 doses, if no response increase to 50"
"micrograms every 6 hours, max 200 micrograms in"
24 hours  stop when in established labour
 Or misoprostol 20 micrograms orally (dissolve 1 200
microgram tablet in 200 mL of water and give 20 mL)
every 2 hours until labour starts or max 24 hours
 Or Foley catheter: insert Foley catheter through internal
"cervical os under sterile technique, inflate bulb with 50"
"mL of water, and tape catheter under light traction, leave"
it until contraction begins or up to 12 hours
" If cervical ripening, proceed to cesarean section"
" If cervix ripens but labour does no start, start oxytocin"
 Do not start oxytocin within 8 hours of using
 Carefully control oxytocin infusion  do not give
 Monitor uterine contractions and foetal heart
" If foetal distress, do emergency cesarean section"
"If 4 contractions in 10 minutes, or contraction"
longer than 60 secs or foetal distress:
 Give salbutamol 5 mg in RL or NS 500 mL IV infusion
 Misoprostol 25 micrograms inserted vaginally every
"6 hours for 2 doses, if no response increase to 50"
"micrograms every 6 hours, max 200 micrograms in"
24 hours  stop when in established labour
 Or misoprostol 20 micrograms orally (dissolve 1 200
microgram tablet in 200 mL of water and give 20 mL)
every 2 hours until labour starts or max 24 hours H
 Or Foley catheter: insert Foley catheter through internal
"cervical os under sterile technique, inflate bulb with 50"
"mL of water, and tape catheter under light traction, leave"
it until contraction begins or up to 12 hours
" If cervical ripening, proceed to cesarean section"
" If cervix ripens but labour does no start, start oxytocin"
 Do not start oxytocin within 8 hours of using
 Carefully control oxytocin infusion  do not give
 Monitor uterine contractions and foetal heart
" If foetal distress, do emergency cesarean section "
 Cephalopelvic disproportion (CPD)
" Foetal abnormalities: hydrocephalus, conjoined twins"
 Malpresentation: the presenting part of the foetus is not the
"head, e.g. breech presentation, shoulder presentation, face,"
 Malposition: an abnormal position of the foetal head when
"this is the presenting part, e.g. occipito-posterior"
 Any barrier that prevents the babys descent down the birth
 Contractions are strong but no evidence of descent of the
 Malposition or malpresentation may be felt on abdominal
" In a first delivery, the pains will just stop spontaneously"
 Foetal distress with meconium stained liqour
 Fever and dehydration with maternal exhaustion
" In late stages, the regular colicky strong pains may stop when"
"the uterus is ruptured, and be replaced by a dull continuous"
 Signs of shock if the uterus has ruptured
" Physical examination reveals signs of shock, tender uterus,"
"formation of a Bandls ring, vulva may be oedematous, vagi16.Obstructed Labour ICD10 CODE: O64-O66"
Failure of labour to progress despite good uterine contractions.
"na is hot and dry, theres usually a large caput"
 Set up an IV normal saline line and rehydrate the HC3
patient to maintain plasma volume and treat dehyHC4
 Start 5-day course of antibiotics: Amoxicillin 500 mg HC3
every 8 hours or erythromycin 500 mg every 6 hours
 Plus metronidazole 400 mg every 8 hours
 Refer urgently to HC4Hospital for further management
 Every woman with prolongedobstructed labour should receive
the management protocol for prevention of obstetric fistula
 Careful monitoring of labour using a partogram for early
Ruptured Uterus ICD10 CODE: O71.1
"Partial or complete tearing of the uterus, common in:"
 Multiparous women (i.e. have had 1 live babies)
 Women with previous caesarean section
 Assisted deliveriesobstetric procedures
 Tearing of a poorly-healed uterine scar during labour
 Short interpregnancy interval of less than 18 months after
" Previous history of uterine surgery, e.g. myomectomy"
 Set up an IV normal saline line and rehydrate the
patient to maintain plasma volume and treat dehydration and ketosis HC3
 Start 5-day course of antibiotics: Amoxicillin 500 mg
every 8 hours or erythromycin 500 mg every 6 hours
 Plus metronidazole 400 mg every 8 hours
 Refer urgently to HC4Hospital for further management HC3
 Every woman with prolongedobstructed labour should receive
the management protocol for prevention of obstetric fistula
" Damage to uterus due to a blow, e.g. kick or accident"
 Cessation of regular uterine contractions (labour pains)
 Foetal parts easily felt under the skin if the foetusis outside
uterus and foetal heart is not heard
 Other causes of acute abdomen in late pregnancy
" Blood: CBC, grouping and cross-matching"
Mothers with a suspicion of ruptured uterus should be referred immediately to hospital for blood transfusion and surgical management.
 Set up IV normal saline infusion HC3
 Give IV ceftriaxone 2 g and IV metronidazole 500 mg H
 Refer to hospital immediately for surgical management
(cesarean section  hysterectomy)
 Set up IV normal saline infusion
 Give IV ceftriaxone 2 g and IV metronidazole 500 mg
 Refer to hospital immediately for surgical management
(cesarean section  hysterectomy) HC3
 Good ANC and education on early arrival to the facility for
 Skilled birth attendance at all deliveries
 Careful monitoring of labour using a partogram
 Minimise the use of oxytocin in multiparous women
 Do not attempt fundal pressure during labour
 DO NOT use misoprostol for induction of labor
Retained Placenta ICD10 CODE: O73
Failure of delivery of placenta within 30 minutes of delivery of the baby.
 Poor management of 3rd stage of labour
 Failure of the uterus to contract
" Failure of the placenta to separate, e.g. if it is stuck in uterine"
 Closing of the cervix before the placenta is expelled
 The umbilical cord protrudes from the vagina
 Bleeding may be present (in partial separation)
 Uterus may be poorly contracted and high in the abdomen
" May be signs of infection, e.g. fever, unpleasant bloody discharge if the placenta is retained for long"
" Blood: Hb, grouping and cross-matching"
"If woman is bleeding, manage as PPH (section 16.4.6)"
 Set up IV normal saline infusion
 Empty the bladder (voluntarily or catheterise)
 Repeat controlled cord contraction
If placenta is not delivered in another 30 minutes
 Perform manual removal of placenta (use
 Repeat Oxytocin 10 IU IM or slow IV injection after
 If no signs of infection and no obstructed labour Give
" If signs of infection, give antibiotics as in amnionitis"
" If obstructed labour, give antibiotic prophylaxis as indicated in section If unable to remove placenta manually HC4"
 Give oxytocin 20 IU in Normal saline 500 cc at 30
drops per minute during transfer
Postpartum Haemorrhage (PPH) ICD10 CODE: O72
Vaginal bleeding of more than 500 mL after vaginal delivery or 1000
"If woman is bleeding, manage as PPH (section 16.4.6) "
 Set up IV normal saline infusion
 Empty the bladder (voluntarily or catheterise)
 Repeat controlled cord contraction
If placenta is not delivered in another 30 minutes
 Perform manual removal of placenta (use
 Repeat Oxytocin 10 IU IM or slow IV injection after
 If no signs of infection and no obstructed labour Give
" If signs of infection, give antibiotics as in amnionitis"
" If obstructed labour, give antibiotic prophylaxis as indicated in section HC3"
If unable to remove placenta manually
 Give oxytocin 20 IU in Normal saline 500 cc at 30
drops per minute during transfer
- Primary PPH occurs in the first 24 hours after delivery
- Secondary PPH occurs between 24 hours and six weeks
PPH is an EMERGENCY. It can occur in any woman and needs prompt
" Tone: failure of uterus to contract, precipitated labour"
 Tissues: such as retained placenta (in part or whole) or
membranes which may lead to atony as well as infection in
" Tears (e.g. damage torupture of the perineum, vagina,"
 Thrombotic disorders which may be due to DIC following
abruptio placenta or severe APH
" History of previous PPH, multiple previous CS, multiple"
" Placenta praevia, abruptio placenta"
" Precipitated labour, prolonged labour, large baby"
 Patients with hypertensive disorders
 Bleeding from the genital tract which may be a gush of blood
or a small but persistent trickle of blood (1 pad soaked in
" The uterus may still be large, soft, and not contracted escially"
" If uterus is well contracted, look for tears on the perineum, vagina,"
" Signs of shock may be present: tachycardia, low BP, cold and"
" In secondary PPH, there may be signs of infection, e.g.,"
 Hb and blood group should have been already done and recorded
"during ANC; if not, do them urgently"
 Women at high risk of PPH should have blood cross- matched
" If time allows (e.g. in secondary PPH), check blood for Hb,"
The principles of management include two major components:
1. Resuscitation and management of obstetric haemorrhage and
2. Identification and management of underlying causes
 Check uterus to see if contracted f Massage uterus (to
expel clots) f Give oxytocin 10 IU IM or IV slowly Give
tranexamic acid 1gm IV slowly over 10 mins but within
3 hours after delivery of the baby
 Start IV fluids (normal saline) using 2 IV lines using
"large bore canulae, run 2L as fast as possible then give"
40drops perminute according to patient BP
 Check uterus to see if contracted f Massage uterus (to
expel clots) f Give oxytocin 10 IU IM or IV slowly Give
tranexamic acid 1gm IV slowly over 10 mins but within
3 hours after delivery of the baby
 Start IV fluids (normal saline) using 2 IV lines using
"large bore canulae, run 2L as fast as possible then give"
40drops perminute according to patient BP HC3
" If oxytocin not available, give misoprostol 800 mi- HC3"
crograms sublingually or ergometrine 0.2mg IM (if a
"Check if placenta has been expelled, and is complete"
" If yes, expel any clots in the birth canal"
" If not, perform manual removal or refer"
 Prophylatic antibiotic: ampicillin 2 g IV stat plus
" metronidazole 500 mg  If signs of infection, give antibiotics as in puerperal fever"
If uterus contracted and placenta expelled
 Check for local causes if bleeding continues
- Inspect carefully the lower genital tract for
"perineal lacerations, haematomas, vaginal and"
 Repeat oxytocin 10 IUin 0.5L of normal saline run at HC3
 Give misoprostol sublingual 800 micrograms or ergometrine 0.2mg IM (if not given before)
 Repeat tranexamic acid 1gm after 30 mins of the first dose
" If bleeding persists, insert Uterine balloon tamponade"
(UBT) and apply Non-pneumonic anti-shock garment
 Restore blood volume with IV fluids
 Refer to higher level for further management with UBT
 Do not give heat stable carbetocin for treatment of
PPH. It is used for prevention of PPH.
 Do not give ergomentrine in hypertensive mothers
 Ensure active management of 3rd stage of labour for all
"women in labour, and delivery by skilled staff"
" If oxytocin not available, give misoprostol 800 micrograms sublingually or ergometrine 0.2mg IM (if a"
"Check if placenta has been expelled, and is complete"
" If yes, expel any clots in the birth canal"
" If not, perform manual removal or refer"
 Prophylatic antibiotic: ampicillin 2 g IV stat plus
" metronidazole 500 mg  If signs of infection, give antibiotics as in puerperal fever HC3"
If uterus contracted and placenta expelled
 Check for local causes if bleeding continues
- Inspect carefully the lower genital tract for
"perineal lacerations, haematomas, vaginal and"
 Repeat oxytocin 10 IUin 0.5L of normal saline run at
 Give misoprostol sublingual 800 micrograms or ergometrine 0.2mg IM (if not given before)
 Repeat tranexamic acid 1gm after 30 mins of the first dose
" If bleeding persists, insert Uterine balloon tamponade"
(UBT) and apply Non-pneumonic anti-shock garment
 Restore blood volume with IV fluids
 Refer to higher level for further management with UBT
 Check for coagulation problems HC3
 Do not give heat stable carbetocin for treatment of
PPH. It is used for prevention of PPH.
 Do not give ergomentrine in hypertensive mothers 
 Give heat stable Carbetocin 100mcg IVIM (single dose) or
oxytocin 10 IU IM or misoprostol 600mcg orally to the
"mother within 1 minute of delivery, after ruling out presence"
 Clamp the cord and cut it (3-5 minutes after birth) or when
 Controlled cord traction during a contraction with counter-traction to deliver the placenta
 Massage the uterus immediately after delivery of the placenta
to ensure the uterus is contracted
 Identify mothers at risk and manage accordingly
" Give 5 days prophylactic antibiotics in prolonged or obstructed labour, or in presence of other risk factors, e.g."
"rupture of membranes, birth before arrival at health facility,"
NOTE: Carbetocin should be given as a single dose
Puerperal FeverSepsis ICD10 CODE: O85
Infection of the female internal genital tract within 6 weeks of childbirth.
"Signs and symptoms usually occur after 24 hours, although the disease"
may manifest earlier in settings of prolonged rupture of membranes
and prolonged labour without prophylactic antibiotics.
 Ascending infection from contamination during delivery or
 Bacteria include: Staphylococcus aureus and Gram- negative
"bacteria from the gut, e.g. Escherichia coli, Bacteroides,"
"Streptococcus pyogenes, clostridium spp, chlamydia, gonococci"
" In peurperal sepsis, multiple organisms are likely"
" Persistent bloodypus discharge (lochia) from genital tract,"
which may have an unpleasant smell
 Tenderness on palpating the uterus
" Anaemia, malnutrition in pregnancy"
" Prolonged labour, prolonged rupture of membranes"
" Traumatic delivery (instrumental deliveries, tears)"
" Other causes of fever after childbirth, e.g. malaria, UTI,"
"DVT, wound sepsis, mastitisbreast abscess, RTInvestigations"
" Blood: CBC, CS, BS for malaria parasites  RDT"
" Urine: For protein, sugar, microscopy, CS"
"Puerperal fever carries a high risk of sepsis with a high mortality, and"
Parenteral antibiotic therapy HC3
 Ampicillin 500 mg IV or IM every 6 hours
 Plus gentamicin 5-7 mgkg IV or IM daily in 2 divided
 Plus metronidazole 500 mg IV every 8 hours for at
 Clindamycin 150 mg IVIM every 6 hours  gentamicin
" If anaemic, transfuse with blood"
 Look for retained products and evacuate uterus if
" Use of clean delivery kits and ensuring clean deliveries,"
 Prophylactic antibiotic when indicated (prolonged labour
"and premature rupture of membranes, manual removal of"
Care of Mother and Baby Immediately After Delivery
Provide the following care for the first two hours after complete delivery
 Constant attention; Never leave mother and baby alone
 Request the mother or attendant to report any unusual
changes in the mother and baby to the health worker
" Record any findings, treatment, and procedures in the Postpartum Record"
 Ampicillin 500 mg IV or IM every 6 hours
 Plus gentamicin 5-7 mgkg IV or IM daily in 2 divided
 Plus metronidazole 500 mg IV every 8 hours for at
 Clindamycin 150 mg IVIM every 6 hours  gentamicin
" If anaemic, transfuse with blood"
 Look for retained products and evacuate uterus if
"For additional information on care of the HIV positive mother, refer to"
16.Care of Mother Immediately After Delivery
- Rapid assessment for danger signs such as
"excessive PV bleeding, difficulty in breathing,"
- Feel if uterus is hard and round
" Check every 15 minutes for 2 hours, then at 3"
"and 4 hours, then every 4 hours until discharge"
 Raised diastolic blood pressure
- 110 mmHg with proteinuria 3 and signs
sympotms of eclampsia: manage as severe
- If 90-110 mmHg with proteinuria: manage as pre
- If 90 mmHg with no proteinuria and no
symptoms of eclampsia: monitor and treat as
hypertension (section 16.6.1.2)
 Fever with chills or uterine tenderness or foul
"smelling discharge, treat as puerperal fever (section 16.4.7)"
"- If isolated raised temperature, monitor, hydrate"
- and observe for 12 hours. Treat for pueperal fever
if it persists (section 16.4.7)
- Suture if trained or refer for further management
 If bleeding (If pad soaked in 5 minutes or constant trickle of blood) and uterus not hard and
- Treat as PPH (section 16.4.6)
- Rapid assessment for danger signs such as
"excessive PV bleeding, difficulty in breathing,"
- Feel if uterus is hard and round HC3
" Check every 15 minutes for 2 hours, then at 3"
"and 4 hours, then every 4 hours until discharge"
 Raised diastolic blood pressure
- 110 mmHg with proteinuria 3 and signs
sympotms of eclampsia: manage as severe
- If 90-110 mmHg with proteinuria: manage as pre
- If 90 mmHg with no proteinuria and no
symptoms of eclampsia: monitor and treat as
hypertension (section 16.6.1.2)
 Fever with chills or uterine tenderness or foul
"smelling discharge, treat as puerperal fever (section 16.4.7)"
"- If isolated raised temperature, monitor, hydrate"
- and observe for 12 hours. Treat for pueperal fever
if it persists (section 16.4.7)
- Suture if trained or refer for further management
 If bleeding (If pad soaked in 5 minutes or constant trickle of blood) and uterus not hard and
- Treat as PPH (section 16.4.6) HC3
" Anaemia: monitor for bleeding and look for conjunctival or palmar pallor, check Hb if indicated,"
" Encourage mother to pass urine, eat, and drink"
 Ask the companion to stay with her
16.Care of Baby Immediately After Delivery
"- Breathing, warmth,pulse, SpO2"
- Umbilical cord stump should be well ligatured
 Wipe off blood or meconium with wet cloth
- Do not remove vernix or bathe the baby within
 Apply an eye antimicrobial e.g. tetracycline eye ointment
- Leave in place and do not wash it away
 Apply chlorhexidine digluconate gel to the cord stump
"daily after every bath, until the cord falls off. Provide"
the gel to the mother and teach her how to use it while
 Keep baby warm with skin to skin contact
If feet are cold or mother and baby are separated
Cover baby with blanket; cover babys toes and fingers as
well as the head with warm clothing
" Anaemia: monitor for bleeding and look for conjunctival or palmar pallor, check Hb if indicated,"
" Encourage mother to pass urine, eat, and drink"
 Ask the companion to stay with her 
"- Breathing, warmth,pulse, SpO2"
- Umbilical cord stump should be well ligatured HC3
 Wipe off blood or meconium with wet cloth
- Do not remove vernix or bathe the baby within
 Apply an eye antimicrobial e.g. tetracycline eye ointment
- Leave in place and do not wash it away
 Apply chlorhexidine digluconate gel to the cord stump
"daily after every bath, until the cord falls off. Provide"
the gel to the mother and teach her how to use it while
 Keep baby warm with skin to skin contact
If feet are cold or mother and baby are separated
Cover baby with blanket; cover babys toes and fingers as
well as the head with warm clothing
 Examine the baby according to first newborn examination
"requirements, classify the condition, and treat accordingly (see section and section 17.1) Section 17.1)"
Ensure the mother starts breastfeeding as soon as possible (preferably
 Offer mother help to position (attach) the baby correctly onto
the breast to avoid cracked nipples
If unable to start breastfeeding:
 Plan for alternative feeding method
"- Ensure that alternative method is Affordable, Feasible,"
"Acceptable, Sustainable and Safe"
"- Do not give artificial feeds, sugar water or local feeds"
- before baby has attempted to initiate natural breastfeeding
- Consider referral to a higher level
In case the baby dies or is stillborn
 Give supportive care to the mother
 Respect local customs; find out if the motherfamily would
like to look at or hold the stillborn baby
" Check, identity and give wrapped body to family for disposalburial according to local customs"
 Provide death certificate and complete required reporting
 Examine the baby according to first newborn examination
"requirements, classify the condition, and treat accordingly (see section and section 17.1) Section 17.1) "
 Advise on postpartum care and hygiene HC3
" Advise mother on breast care; wear a firm bra, do not"
 Give paracetamol if breasts are painful
 You may give lactation suppression drugs such as
 bromocriptine mg once a day for 2 weeks
 Counsel on appropriate family planning
Newborn Resuscitation ICD10 CODE: P22
Start resuscitation within one minute of birth if baby is not breathing
 Observe universal hygiene precautions to prevent infection
 Prepare for resuscitation at each delivery even where there
"are no signs of foetal distress, just in case the baby requires it"
Minimum preparation for every birth
Ensure that the following equipment is available and in good working
 Two warm cotton cloths and a small one to position the head
 Heat source to keep the baby warm
 Mucus extractor such as a penguin sucker (or bulb syringe)
" Ambu bag and new-born masks of varying sizes (0 and 1),"
 A birth attendant skilled in new-born resuscitation
 Advise on postpartum care and hygiene
" Advise mother on breast care; wear a firm bra, do not"
 Give paracetamol if breasts are painful
 You may give lactation suppression drugs such as
 bromocriptine mg once a day for 2 weeks
 Counsel on appropriate family planning HC3
 Keep the baby warm by drying the baby using the first cotton HC3
cloth and change to the second dry cotton cloth. Rub the back
- Clamp and cut the cord if necessary
- Transfer the baby to a dry clean warm surface
- Tell the mother that the baby is having difficulty
starting to breathe and that you will help the baby
- Position the head so that it is slightly extended
- Place a folded towel 2 cm thick under babys shoulders
- Suction if secretions in mouth or nose and if baby
- born through meconium stained amniotic fluid:
"suction 5 cm in the mouth, 3 cm in the nose while"
"withdrawing, for max 10 seconds in total."
- Do not suction too deep into the throat as this may
cause the heart to slow down or breathing to stop
" If still not breathing, SELECT APPROPRIATE MASK SIZE"
"TO COVER CHIN, MOUTH AND NOSE, AND VENTILATE"
"- Form a seal with mask covering chin, mouth and nose"
"- Reposition head, check mask seal, squeeze bag harder"
" Once good seal and chest rising, ventilate for one minute at 40"
squeezes per minute then stop and look for breathing
If breathing 30minute and no severe chest in- drawing
 Put baby skin-to-skin on mothers chest
 Observe every 15 minutes for breathing and warmth:
"take temperature, count breaths, observe for chest-indrawing or grunting respiration."
 Keep the baby warm by drying the baby using the first cotton
cloth and change to the second dry cotton cloth. Rub the back
- Clamp and cut the cord if necessary
- Transfer the baby to a dry clean warm surface
- Tell the mother that the baby is having difficulty
starting to breathe and that you will help the baby
- Position the head so that it is slightly extended
- Place a folded towel 2 cm thick under babys shoulders
- Suction if secretions in mouth or nose and if baby
- born through meconium stained amniotic fluid: HC3
"suction 5 cm in the mouth, 3 cm in the nose while"
"withdrawing, for max 10 seconds in total."
- Do not suction too deep into the throat as this may
cause the heart to slow down or breathing to stop
" If still not breathing, SELECT APPROPRIATE MASK SIZE"
"TO COVER CHIN, MOUTH AND NOSE, AND VENTILATE"
"- Form a seal with mask covering chin, mouth and nose"
"- Reposition head, check mask seal, squeeze bag harder"
" Once good seal and chest rising, ventilate for one minute at 40"
squeezes per minute then stop and look for breathing 
If breathing 30minute and no severe chest in- drawing
 Put baby skin-to-skin on mothers chest
 Observe every 15 minutes for breathing and warmth:
"take temperature, count breaths, observe for chest-indrawing or grunting respiration."
If breathing 30minute and no severe chest in- drawing
 Put baby skin-to-skin on mothers chest
 Observe every 15 minutes for breathing and warmth:
"take temperature, count breaths, observe for chest-indrawing or grunting respiration."
 Encourage mother to breastfeed within one hour
If breathing 30minute or severe chest in-drawing
 Continue ventilating f Arrange for immediate referral
 Give oxygen if available f Reassess every 1-2 minutes
 Continue to ventilate during referral
If not gasping or breathing at all after 20 minutes of
" Stop ventilation, the baby is dead"
 Room air is sufficient in the absence of oxygen
 Cardiac massage is RARELY required; it is dangerous when
done incorrectly. A slow heart rate almost always responds
to good breathing assistance only
" Usually, there is no need for drugs if prompt and sufficient"
Harmful and ineffective resuscitation practices
 Routine suction of new-borns mouth and nose as soon as the
 Stimulation of the new-born by slapping or flicking the soles
If breathing 30minute and no severe chest in- drawing
 Put baby skin-to-skin on mothers chest
 Observe every 15 minutes for breathing and warmth:
"take temperature, count breaths, observe for chest-indrawing or grunting respiration."
 Encourage mother to breastfeed within one hour
If breathing 30minute or severe chest in-drawing
 Continue ventilating f Arrange for immediate referral
 Give oxygen if available f Reassess every 1-2 minutes
 Continue to ventilate during referral
If not gasping or breathing at all after 20 minutes of
" Stop ventilation, the baby is dead "
 Room air is sufficient in the absence of oxygen
 Cardiac massage is RARELY required; it is dangerous when
done incorrectly. A slow heart rate almost always responds
to good breathing assistance only
" Usually, there is no need for drugs if prompt and sufficient"
 Postural drainage (putting the baby upside down) and slapping
 Squeezing the back to remove secretions from airway
 Routine giving of sodium bicarbonate to new-borns who are
 Intubation by an unskilled person
General Care of Newborn After Delivery
Provide the following care up to the time of discharge:
TYPE OF CARE AND MONITORING NOTES
"Keep baby with mother If baby is in a cot, ensure baby is"
dressed or well-wrapped: covered
"within easy reach with blanket, head is covered and"
- Under mosquito net the feet and hands have socks
Ensure room is warm Do NOT put baby in direct sun or
(25C) and has no cold on any cold surface or directly in
breeze (draughts) the line of a cold breeze
Adviseteach mother how to: - If mother is unable
Support exclusive breast- If breastfeeding difficult:
"on demand, day and night, attach the baby"
Advise on safe replacement feeding (AFASS)
TYPE OF CARE AND MONITORING NOTES
"- Under mosquito net If baby is in a cot, ensure baby is"
dressed or well-wrapped: covered
"with blanket, head is covered and"
breeze (draughts) Do NOT put baby in direct sun or
on any cold surface or directly in
- Ensure hygiene - If mother is unable
Support exclusive breastfeeding
whenever baby wants If breastfeeding difficult:
Advise on safe replacement feeding (AFASS)
TYPE OF CARE AND MONITORING NOTES
Ask mother and companion If feet cold-this is a sign of
Watch the baby Teach mother how to rewarm the
baby; apply one to two layers of
"clothes more than adults, and use"
"bleeding Reassess in 1 hour; if no improvement, take"
hours then daily for: temperature and manage accordingly
If cord tie loosecord bleeding:
"If bleeding persists, refer urgently"
Check any baby with warning Refer urgently if:
and 12 hours: worsens or persists for
- Listen for grunting - Temperature 36.5C
- Look for chest in - persists or decreases
drawing - Not able to feed at 8
"Give prescribed treatments If referring the baby, write treataccording to dosage schedule ments given, when, and why"
TYPE OF CARE AND MONITORING NOTES
Breathing problems If feet cold-this is a sign of
baby; apply one to two layers of
"clothes more than adults, and use"
"Reassess in 1 hour; if no improvement, take"
temperature and manage accordingly
If cord tie loosecord bleeding:
"If bleeding persists, refer urgently"
breastfeeding Refer urgently if:
"according to dosage schedule If referring the baby, write treatments given, when, and why"
Assess breastfeeding in every Do not discharge if baby is not
baby before planning discharge feeding well
Do not discharge baby  24 hours old
Advise mother: Do NOT plan early discharge if:
- When to seek care - Baby small (LBW or
if danger signs - Not feeding well
Give BCG and polio 0 before Counsel mother on next routine
discharge check in 3-7 days and next immunization in 6 weeks
Extra Care of Small Babies or Twins in the First Days of
Provide the following care for small babies:
 Refer very small babies for specialized attention:
TYPE OF CARE AND MONITORING NOTES
Ensure room is warm: Teach Provide extra blanket for mother and
mother how to keep baby warm baby if needed
baby before planning discharge Do not discharge if baby is not
Do not discharge baby  24 hours old 
respiration) Do NOT plan early discharge if:
discharge Counsel mother on next routine
check in 3-7 days and next immunization in 6 weeks
TYPE OF CARE AND MONITORING NOTES
mother how to keep baby warm Provide extra blanket for mother and
TYPE OF CARE AND MONITORING NOTES
Teach mother how to ensure hy- Do not bathe the baby
"Give special support for breast- If not breastfeeding well, teach mother"
feeding and assess daily alternative feeding methods
Assess small baby daily: - If breathing or
twins) longer before discharge.
- Body temperature - If mother  baby not
"- normal for 3 able to stay, ensure"
consecutive days daily (home) visits or
- Mother confident send to hospital
TYPE OF CARE AND MONITORING NOTES
Teach mother how to ensure hygiene for baby Do not bathe the baby
"Give special support for breastfeeding and assess daily If not breastfeeding well, teach mother"
twins) longer before discharge.
- caring for baby - If mother  baby not
Eye care  Explain to mother to seek care if eyes drain
"pus, and not to apply anything into the eyes"
Cord care  Wash hands before and after cord care
 Put chlorhexidine gel daily (if not available
- Keep stump loosely covered with
"- If stump soiled, wash with clean"
"water and soap, dry completely with"
- Do not apply anything else to the
If umbilicus red or draining pus or blood
 Examine the baby and manage accordingly
"General baby  Wash the face, neck, and under arms daily"
 Wash the buttocks when soiled and dry
- Dispose as for sanitary towelspads
- f Bathe when necessary using warm
- Ensure room is warm with no cold
"- Dry completely, then dress and"
Eye care  Explain to mother to seek care if eyes drain
"pus, and not to apply anything into the eyes"
Cord care  Wash hands before and after cord care
 Put chlorhexidine gel daily (if not available
- Keep stump loosely covered with
"- If stump soiled, wash with clean"
"water and soap, dry completely with"
- Do not apply anything else to the
If umbilicus red or draining pus or blood
 Examine the baby and manage accordingly
"care hygiene  Wash the face, neck, and under arms daily"
 Wash the buttocks when soiled and dry
- Dispose as for sanitary towelspads
- f Bathe when necessary using warm
- Ensure room is warm with no cold
"- Dry completely, then dress and"
 Small babies need specially careful attention
 Wash hands before and after baby care
Postpartum Care ICD10 CODE: Z39
"The postpartum period, also known as the puerperium, begins with"
"the delivery of the baby and placenta, up to six weeks after delivery."
Healthcare providers should be aware of the medical and psychological
"needs of the postpartum mother, and sensitive to cultural differences"
"that surround childbirth, which"
may involve eating particular foods and restricting certain activities.
The mother and baby should be seen at 6 hours after birth and again
before discharge if in a health facility (and anytime the mother reports
concern about herself and her baby) or approximately 6 hours after
"The routine follow-up visits are at 6 days and 6 weeks, and have the"
" Assessment and management of observed or reported problems. Check for hypertension, anaemia, vaginal bleeding and"
"discharge, uterine infection, puerperal fever, malaria, UTI,"
"urine dribbling, pus or perineal pain, postpartum depression,"
"breast problems, HIV and any other complaint"
Provide the following counselling at all postpartum visits.
" Nutrition, ferrous and folic acid supplements, avoid alcohol"
Complications and danger signs for the mother
 Readiness plan in case of an emergency
- Advise her to have someone near for at least 24 hours
after delivery to respond to any change in condition
- Discuss emergency issues with her and partnerfamily:
"- Where to go if danger signs appear, how to get there,"
"costs involved, familycommunity support"
- Advise her to seek help from the community if needed
- Advise her to bring any home-based maternal record to
"the health facility, even for an emergency visit"
" Self care and other good health practices, personal hygiene, handwashing, genital hygiene (care of the episiotomy or repaired tears)"
 Postpartum checks (6 days and 6 weeks)
" Provide information on bonding by encouraging the mother to hold, touch, explore her baby as well as rooming-in"
(mother and baby sleeping in the same bedHIV testing
 Discuss with the couple the need for shared care of the
 Help build confidence by providing reassurance that the
woman is capable of caring for the newborn
" Nutrition, ferrous and folic acid supplements, avoid alcohol"
Complications and danger signs for the mother
 Readiness plan in case of an emergency
- Advise her to have someone near for at least 24 hours
after delivery to respond to any change in condition
- Discuss emergency issues with her and partnerfamily:
"- Where to go if danger signs appear, how to get there,"
"costs involved, familycommunity support"
- Advise her to seek help from the community if needed
- Advise her to bring any home-based maternal record to
"the health facility, even for an emergency visit"
" Self care and other good health practices, personal hygiene, handwashing, genital hygiene (care of the episiotomy or repaired tears)"
 Postpartum checks (6 days and 6 weeks)
" Provide information on bonding by encouraging the mother to hold, touch, explore her baby as well as rooming-in"
(mother and baby sleeping in the same bedHIV testing
 Discuss with the couple the need for shared care of the
 Help build confidence by providing reassurance that the
woman is capable of caring for the newborn
" Hygiene and care of the baby, (see previous sections)"
 Let baby sleep on the back or side
 Ensure the baby is kept warm without overcovering
 Apply chlorhexidine digluconate gel to the cord stump daily
after every bath until the cord falls off. Provide the gel to
"the mother, and teach her how to use it while at home"
 Keep baby away from smoke and smokers
 Keep baby (especially if small) away from anyone whois ill
" Do not share supplies (for example, clothing, feeding utensils) with other babies"
Advise mother on danger signs as follows:
TYPE OF DANGER SIGN ACTION TO TAKE
 Vaginal bleeding (2 pads soaked Go to health facility
in 30 minutes after delivery or immediately
 Pain in the calf (ankle) muscles
" Hygiene and care of the baby, (see previous sections)"
 Let baby sleep on the back or side
 Ensure the baby is kept warm without overcovering
 Apply chlorhexidine digluconate gel to the cord stump daily
after every bath until the cord falls off. Provide the gel to
"the mother, and teach her how to use it while at home"
 Keep baby away from smoke and smokers
 Keep baby (especially if small) away from anyone whois ill
" Do not share supplies (for example, clothing, feeding utensils) with other babies"
TYPE OF DANGER SIGN ACTION TO TAKE
 Vaginal bleeding (2 pads soaked
in 30 minutes after delivery or
 Too weak to get out of bed Go to health facility
 Pain in the calf (ankle) muscles 
TYPE OF DANGER SIGN ACTION TO TAKE
 Fever; abdominal pain; feels ill; Go to health facility as
"breasts red, tender, swollen; sore soon as possible"
nipple; urine dribbling or pain on
urination; perineal pain or draining pus; foul-smelling lochia
16.Postpartum Examination of the Mother Up to 6 Weeks
 When and where did you deliver?
 Any pain or fever or bleeding since delivery?
 Do you have any problem with passing urine?
 Ask if the woman has started having sex with her partner
 Have you decided on any contraception?
 Do you have any other concerns?
" Check records fo any complications during delivery, any"
"treatments she is receiving, HIV status?"
 Ask about tobacco use and exposure to second-hand
 Measure blood pressure and temperature
 Feel uterus. Is it hard and round?
" Look at vulva and perineum for tear, swelling or pus"
 Look at pad for bleeding and lochia
- Does it smell or is the bleeding profuse?
TYPE OF DANGER SIGN ACTION TO TAKE
 Fever; abdominal pain; feels ill;
"breasts red, tender, swollen; sore"
nipple; urine dribbling or pain on
urination; perineal pain or draining pus; foul-smelling lochia Go to health facility as
 Measure blood pressure and temperature
 Feel uterus. Is it hard and round?
" Look at vulva and perineum for tear, swelling or pus"
 Look at pad for bleeding and lochia
- Does it smell or is the bleeding profuse?
Use the table on the next page to examine mother at any postpartum visit
TAERT -pmalce-erp -nocevig -netrepyhitna nemow
f   -nitnocevig evisnetrepyhitna )ees(
"aispmalce-erp,aispmalce-erp tnangerp-non keew"
"TNEMSSESSA erusserp PB,gHmm retfa"
eviG 1: )lof yliad refeR wolloF kcehc dna
ramlap lavitcujnoc yna ssensselhtaerB
7 ereveS rollap rollap seriT tser
gnideelb -nangerp yreviled -deelb erit -uor -esuoh bH
retfa yreviled yna ecnis?yreviled uoy uoy erusaeM
rof kcehC yvaeh?ylisae gnirud?krow
"kcehC rof ni,yc ro ksA gni oD erA enit"
YFISSALC etaredoM aimeanA -eanA
SNGIS 11-7 ro ramlaP -noc -lavitcuj
nicotyxo etairporppa ot noitces
Signs Classify As Treat And Advise
 Mother Normal  Make sure woman and
feeling well family know what to
 No breast counsel on compliance
Signs Classify As Treat And Advise
Postpartum  Make sure woman and
yna kaew lanimodbA ssenrednet -llems-luoF aihcol ton lanimodba fo -gav
dna esuforP aihcol suretU detcart rewoL yrotsiH yvaeh
"TNEMSSESSA uoy evaH?revef dah rof ksA fo ecneserp gnillems-luof -nrub,aihcol -aniru no gni yvaeh ro noit gnideelb rewol leeF dna nemodba dna sknalf ssenrednet rof kooL lamronba ffits,aihcol dna kcen ygrahtel erusaeM erutarepme"
TNEMTAERT laro namow -itna xes -noc
YFISSALC -naC noitcefnaeohrronoG noitces noitces
SNGIS lamronbA -sid dna sah larhteru egrahcsid gninrub gnissap
mih?melborp tneserp gnissap ton -xe fo tnemssessa
"4 egrahcsid eht rentrap ksa larhteru,sup dluoc,dehcaorppa ecnatropmi ot noitcefnier"
"gnihcti si,cinilc ro no,yreviled ruoy yraniru rentrap:sah egrahcsid rentrap"
lanigav ynA?avluv saH eht eh eniru nialp dna diova
TNEMSSESSA TDR doolb rof airalam
TNEMTAERT ot gninoitisop ot morf
"rehtom gnideeftsaerb sdeef,retteb woh dna dna gnideeftsaerb"
eht tcerroc retfa tsaerb yhtlaeh
egaruocnE eunitnoc ssessaeR.)yad eht ybab eunitnoc
hcaeT dna 1 ro( hcaet eht deef eht no
TNEMSSESSA ruoy?leef eht rof eht:rof -inihs ssender rof yltneg fo trap tsaerb -met a fi deeftsaerb enod
"od ta ta,gnillews erusaeM erutarep evresbO"
stsaerb elppin erussif stsaerb lufniap tey
"2 gnitsisrep noitces,lesnuoC erussaer ni"
"wol elbanu erac,smelborp gnileef,flesreh ton"
elbissoP lairetcaB noitcefnnoitces
eht kool ruodo egrahcsid enimaxe regnif eht no
"etarapeS dna lamronba:egrahcsid devolg kool egrahcsid,ruoloc"
Postnatal Depression ICD10 CODE: F53
Condition characterized by persistent low mood developing during the
"puerperium period, usually 1 or 2 weeks following delivery. It needs"
specialized assessment and treatment.
"Mild depressive symptoms (sadness, tearfulness, irritability, anxiety)"
develop commonly during the first week after
the delivery but resolve within 2 weeks (baby blues): it usually needs
" Young age, first baby (primigravida) and associated fear of the"
responsibility for the new baby
" Poor marital relationship, poor social support"
 Starts soon after delivery and may continue for a year or
" Feelings of sadness with episodes of crying, anxiety, marked"
"irritability, tension, confusion"
 Guilty feeling of not loving baby enough
 Loss of positive feeling towards loved ones
" Distortions of thinking and perception, as well as inappropriate or narrowed range of emotions (see section 9.1.1.1)"
 Routine assessment for depressive symptoms during post HC3
natal visits or at least once at 6 weeks
 Counselling and reassurance at first contact and review
" If persisting, refer for specialized treatment"
- Antidepressant (see section 9.2.2)
" If suicidal thoghts, or any risk for mother andor baby,"
" Postpartum counselling, support, and follow up"
 Identification of patients at risk
MastitisBreast Abscess ICD10 CODE: O91
Infection of the breast usually in a breastfeeding mother. Causes
 Usually Staphylococcus aureus enters from the babys mouth
through a cracked nipple into an engorged breast. Less
" Pain in the breast, which is swollen, often shiny, and tender"
 May proceed to become an abscess; a collection of pus within the breast tissue
 There may be localised erythema (shinny red skin)
" Firm lump, felt initially but may later become fluctuant"
 Routine assessment for depressive symptoms during post
natal visits or at least once at 6 weeks
 Counselling and reassurance at first contact and review
" If persisting, refer for specialized treatment"
- Antidepressant (see section 9.2.2)
" If suicidal thoghts, or any risk for mother andor baby,"
" Loss of breast size, noticeable breast asymmetry"
 Mammary duct fistula formation due to reccurrence
 Breast engorgement (for mastitis)
 Breast lumpcancer (for abscess)
 US scan to rule out breast abscess in patients with recurrent
 Stop breastfeeding on the affected breast but express HC2
milk and discard to avoid breast engorgement
 Give analagesics such as paracetamol 1 g every 8
 Apply warm compresses to relieve pain in affected breast
 Continue breastfeeding on the normal breast
 Give cloxacillin 500 mg 6 hourly for 10 days or
- (If not available use amoxicillin 500 mg every
 If penicillin allergies: erythromycin 500 mg every 6
- Or cephalexin 500 mg PO every six hours for
 Refer to hospital for utrasound scan and further management
 If clinical or US scan features of breast abscess: incise
 Stop breastfeeding on the affected breast but express
milk and discard to avoid breast engorgement
 Give analagesics such as paracetamol 1 g every 8
 Apply warm compresses to relieve pain in affected breast
 Continue breastfeeding on the normal breast
 Give cloxacillin 500 mg 6 hourly for 10 days or
- (If not available use amoxicillin 500 mg every
 If penicillin allergies: erythromycin 500 mg every 6
- Or cephalexin 500 mg PO every six hours for
 Refer to hospital for utrasound scan and further management
 If clinical or US scan features of breast abscess: incise
 Proper attachment of baby on the breast
 Frequent emptying of the breast
 Ensure the baby is sucking on the areolar and not the nipple
" Manage breast engorgement if not breastfeeding, or lost baby"
(Refer to section on care of the mother and baby immediately
Obstetric Fistula ICD10 CODE: 071
"Obstetric fistula is an abnormal communication between the birth canal,"
"and either the bladder, ureters, or rectum. It is one of the major causes"
of maternal morbidity making the women with the condition suffer from
"constant urinary incontinence which can lead to skin infections, kidney"
disorder or death if left untreated.
 Obstructed labour (main cause): most fistula develops in 2
"weeks after an obstructed labour, causing an often expansive"
crush injury to the vaginal tissues
 Sexual abuse and rape (Gender-based violence)
 Complication of unsafe abortion
 Surgical trauma usually following a caesarean section
 Gynaecological cancers and radiotheraphy
 Lack of access to maternity care
 Lack ofinadequate skilled care at birth
 Lack of facilities for ANC and childbirth
 Lack of knowledge to identify danger signs and promptly
 Poverty and lack of women empowerment
 Inadequate family planning access
 Harmful traditional practices such as Female Genital Mutilation
 Unncontrolled leakage of urine or faeces from vagina
" Stress, urge or overflow incontinence"
" Speculum examination to visualise leakage; site, size and amount"
" Confirm by dye test on pelvic examinationspeculum examination, andor examination under anaesthesia (EUA)"
A fundamental part of the management of obstetric fistula is the appropriate standard management of ALL women who have survived
"prolonged or obstructed labour, since it can prevent fistula formation"
 Make the woman continent and able to resume a full and
Principles of immediate care of women who have survived prolonged
"obstructed labour, or who present immediately after delivery with"
 Insert appropriate sized (Foley size 16-18) catheter and
- The vagina should be examined by speculum
as soon as possible and necrotic tissue gently
excised under aseptic conditions
- Repeat this until vagina is clean
 The mother can be discharged with the catheter and
advised on care and to come back for review andor
 Recommend increase in fluid intake up to 5 litres a day
 Perineal Sitz or salt baths twice daily to help the perineum to heal
 Treat any intercurrent infection and give prophylaxis
- Nitrofurantoin 100 mg 1 tablet in the evening HC3
"- After 2 weeks, only if no damage is shown to"
- After 4-6 weeks in case of small fistula
" After removing the catheter, if there is no evidence of"
"fistula, discharge with the following advice:"
- Avoid sexual intercourse for 3 months. Once
"it has resumed, it should be gentle and with"
- Avoid pregnancy for about 6 months to one
- Advise on family planningcontraception and
"spacing of children, and the importance of"
good ANC during her next pregnancy
- All future babies should be delivered in a unit
equipped to undertake caesarean section
 Insert appropriate sized (Foley size 16-18) catheter and
- The vagina should be examined by speculum
as soon as possible and necrotic tissue gently
excised under aseptic conditions
- Repeat this until vagina is clean
 The mother can be discharged with the catheter and
advised on care and to come back for review andor
 Recommend increase in fluid intake up to 5 litres a day
 Perineal Sitz or salt baths twice daily to help the perineum to heal
 Treat any intercurrent infection and give prophylaxis
- Nitrofurantoin 100 mg 1 tablet in the evening
"- After 2 weeks, only if no damage is shown to"
- After 4-6 weeks in case of small fistula
" After removing the catheter, if there is no evidence of"
"fistula, discharge with the following advice:"
- Avoid sexual intercourse for 3 months. Once
"it has resumed, it should be gentle and with"
- Avoid pregnancy for about 6 months to one
- Advise on family planningcontraception and
"spacing of children, and the importance of"
good ANC during her next pregnancy
- All future babies should be delivered in a unit
equipped to undertake caesarean section 
Management of women who presents with an established obstetric fistula
These are women in whom the conservative management described
above failed or they presented with an established fistula.
 Refer to regional level for assessment and appropriate RR
 Each woman who has been successfully repaired should
"receive a card with details of her history, a diagram of"
the injury and a summary of the operation done which
should be presented to every health worker wherever
 Fistula repair has to be performed by a trained doctor
 Provide skilled attendance at births and improve on emergency obstetric care at all levels
" Increase access to accurate and quality family planning information and services, especially for adolescents"
 Establish appropriate and effective referral system at all levels
ENSURE ALL WOMEN WHO HAVE SUFFERED OBSTRUCTED
LABOUR ARE MANAGED ACCORDING TO THE STANDARD
MANAGEMENT PROTOCOL FOR FISTULA PREVENTION
 Refer to regional level for assessment and appropriate
 Each woman who has been successfully repaired should
"receive a card with details of her history, a diagram of"
the injury and a summary of the operation done which
should be presented to every health worker wherever
 Fistula repair has to be performed by a trained doctor 
 Absence or cessation of fetal movementsthe usual reason
" A uterus that is significantly smaller than the expected size i.e.,"
fundal height too small for gestational age or decrease in fundal
 Absence of fetal heart sounds on electronic auscultation
" Sometimes, breast engorgement, indicating the end of the"
 The above signs suggest fetal death but are not sufficiently
"sensitive to justify a hasty, rash decision. Errors are common."
 Ultrasonography paired with indicative clinical findings is essential for the accurate diagnosis confirmation of Intra-uterine
Common etiologies of IUFD 28weeks gestation:
 Infection or other medical conditions
 Placental abruption or insufficiencyIntrauterine growth restriction
 Congenital malformations of the fetus
 Umbilical cord accidents or other complications
Medical management of IUFD ( 14 to  28 weeks)
 IUFD may be managed expectantly or treated surgically (DE)
or medically (with medications).
 Discussions aim to foster shared decision making about the plan
for care and support maternalparental choice.
 Supportive social and psychological care should be made available to all bereaved parents
 a combination of mifepristone and misoprostol should be the
 Mifepristone (200mg) administered orally followed 12 days later by repeat doses of 400 µg misoprostol administered sublingually or vaginally
every 46 hours. The minimum recommended interval between use of
mifepristone and misoprostol is 24 hours. Between 24 and 48 hours of
"mifepristone (200mg), the four tablets of misoprostol should be given"
"vaginally, sublingually and can be administered by physician, midwife or"
 Alternative regimens: repeat doses of 400 µg misoprostol administered
"sublingually or vaginally every 46 hours. However, research shows that"
"the combination regimen, above is more effective than misoprostol alone."
 Expectant Management of IUFD involves awaiting spontaneous
labour (may take up to 3 weeks).
 Recommendations about labour and birth should take into
"account the mothers preferences, her medical condition and"
 Vaginal birth is the recommended mode of delivery for most
"women, but caesarean birth may need to be considered in"
 Pregnancy tissue should be treated in the same way as other
biological material unless the individual expresses a desire for
" If a woman has had a previous caesarean section, a discussion"
as to the safety and benefits of induction of labour needs to be
undertaken by a consultant obstetrician.
" Clinical assessment and evaluation are recommended to assess maternal wellbeing and to determine the cause of death,"
"the chance of recurrence, and of avoiding future pregnancy"
 Laboratory tests are recommended to rule out any maternal
disease or risk factor that may have contributed to the IUFD
 Fetal karyotyping should be considered in all cases.
 Parents should be offered a full postmortem examination of
 Postmortem examination should include external examination
"with birth weight, histology of relevant tissues and plain radiography (skeletal survey)"
" Pathological examination of the cord, membranes and placenta"
is recommended in all cases of IUFD
 Standardized checklists should be used to ensure that all
appropriate care options are offered and that each response
 A standardized dataset should be collected for all IUFDs.
 All IUFDs should be reviewed in a multi-professional meeting
 All term intra-partum deaths with no evidence of a major congenital anomaly should be investigated locally.
 Staff working with bereaved parents should be provided with
an opportunity to develop their knowledge and understanding
"of perinatal loss, together with the development of skills in"
 A system should be in place to give clinical and psychological
support to staff involved with an IUFD.
 A follow-up appointment with the consultant obstetrician should
be arranged and it should be clear who is responsible for making
 Women with a history of IUFD should attend a consultant-led
hospital-based antenatal clinic in their next pregnancy and
undergo increased antenatal surveillance.
Medical management of IUFD with mifepristone and misoprostol
combined is contraindicated in any person with a known allergy to
"either medication, ectopic pregnancy, chronic adrenal failure, or inherited porphyria, and used with caution in women with life-threatening"
"un-stabilized conditions such as uncontrolled cardiac disease, severe"
"anemia, or hemorrhagic disorders, uncontrolled serious asthma or in"
Medical management of induced abortion
Medical management of induced abortion (for both viable and non-viable pregnancies) at early or later gestational ages involves the use of
a single-drug regimen or a combination regimen of medicines used in
"sequence, with specific dosages and routes of administration."
"In Uganda, the following categories of people who can get services"
 severe maternal illnesses threatening the health of a pregnant
"woman e.g. severe cardiac disease, renal disease, severe pre-eclampsia and eclampsia;"
" severe foetal abnormalities which are not compatible with extra-uterine life e.g. molar pregnancy, anencephaly; cancer cervix."
 HIV-positive women requesting for a termination.
Medical termination of pregnancy services can be provided at;
"By a medical officer, or gynaesurgeon"
For medical management of induced abortion at gestation ages
" Two-medication regimen: First, the use of 200 mg mifepristone"
"is administered orally, followed 12 days later by 800 µg of"
"misoprostol administered vaginally, sublingually, or buccally. The"
minimum recommended interval between use of mifepristone
and misoprostol is 24 hours. These medications can be taken
"by the person herself, or administered on an outpatient basis"
 Single-medication regimen: 800 µg misoprostol administered
"buccally, sublingually, or vaginally."
Evidence from clinical studies demonstrates that the combination
regimen is more effective than misoprostol alone.
 Repeat doses of misoprostol can be considered when needed to
achieve success of the abortion process. In this guideline we do
not provide a maximum number of doses of misoprostol.
" All routes are included as options for misoprostol administration,"
in consideration of patient and provider preference
Medical management of induced abortion at gestational
 Two-medication regimen: 200 mg mifepristone is administered
"orally, followed 12 days later by repeat doses of 400 µg misoprostol administered buccally, sublingually or vaginally every 3"
hours. The minimum recommended interval between use of
mifepristone and misoprostol is 24 hours.
 Single-medication regimen: When using misoprostol alone:
recommend the use of repeat doses of 400 µg misoprostol
"administered vaginally, sublingually or buccally every 3 hours."
Should be proactive for medical management of induced abortion at
any gestational age. Pain medication should be offered routinely (e.g.
non-steroidal anti-inflammatory drugs NSAIDs). It should be provided
for the individual to use if and when wanted. Acetominophen can be
used for pain control when NSAIDS are unavailable. Other methods of
"pain control, such as certain anti-emetics and epidural anaesthesia can"
"be considered as necessary, with the goal of proactive, patient-centered"
" Ectopic pregnancy should be excluded, and intra-uterine"
gestation confirmed before the medical abortion. The medical
abortion regimen will not terminate the ectopic pregnancy
 Fertility can return within two weeks therefore all patients
should be given post-abortion contraception where eligible
 Access to appropriate medical care must be assured in case an
emergency develops; the patient should be given clear verbal
and written instructions on whom she should contact and
where to go in case of concerns or suspected complications
This chapter presents the management of sick infant and child up to
"age 5, following the WHO syndromic approach IMNCI."
Additional information about management of childhood illnesses can
Care of the new born See chapter 16
Immunisable diseases and See chapter 1 INFECTIONS and
other infectious diseases BODY SYSTEM CHAPTERS
HIV care in children See chapter 3 HIVAIDS
Care of the new born See chapter 16
other infectious diseases See chapter 1 INFECTIONS and
HIV care in children See chapter 3 HIVAIDS
Manutrition rehabilitation See chapter 19
Sickle cell disease See chapter 11 BLOOD DISORDERS
IMNCI (Integrated Management of Newborn and Childhood Illnesses)
The following guidelines use a syndromic approach to the management
of common childhood conditions at Primary Health Care Level and
should be followed page-by-page.
The general approach used involves 5 main steps:
- Identify and provide the required treatment
"There are 3 sections, based on age:"
- Sick newborn (1st week of life)
- Sick child (2 months to 5 years)
Manutrition rehabilitation See chapter 19
Sickle cell disease See chapter 11 BLOOD DISORDERS
Newborn ExaminationDanger Signs
"Use the following procedures to examine all newborn babies after delivery,"
"before discharge or if baby is seen as an outpatient for routine, FOLLOW"
"UP, or sick newborn visit during first week of life."
"Ask If first visit Look, listen, feel"
 How old is the baby? Where  Assess breathing (baby
was the baby born? must be calm)
 Who delivered the baby? - Count breaths (normal: 30-60
Check infant record for risk min)
factors - Assess for gruntingchest
 What was birth weight? - Check SpO2 if available
LBW? Preterm?Twin?  Look at the movements:
 Any problem at birth? normal and symmetrical?
Breech? Difficult birth? Was  Look at the presenting
Ask the mother  Check abdomen for pallor
- Has the baby had any and distetion
heavy vomiting?  Feel the tone: nomal?
feeding problems?  Feel for warmth and check
- How many times has baby temperature
breastfed in last 24 hours?  Weigh the baby
- Is baby satisfied with feeds?
Have you fed baby any other  Observe a breastfeed: Is
food or drinks? the baby able to attach?
- Has baby breastfed in previous Suckling effectively? Wellhour? positioned?
- Do you have any other  Look for ulcers and white
- Is baby satisfied with feeds?
- Has baby breastfed in previous
Suckling effectively? Wellpositioned?
"If danger signs present, treat as below"
TAERT MI nicimatneg 4( eunitnoc dna naitneG -cefni gm dna yreve
sucilibmu succocolyhpats 05 sruoh gKgm
42 elbissop syad ylppa nillicaxolc
nillicipma sruoh yreve ot 7 rof detcefni dna yreve 7-5
21 gkgm fi larrefer tnemtaert selutsup fo evig MIVI sruoh
"eviG yreve refeR peeK naelC teloiV ksir,noit"
"YFISSALC -eS ssenllI -oen -nem 1.noitces,sispes"
SNGIS ro staeb -atnops Cssender niks
"ro ro noisnetsidrevo  ro ro,sup niks ro"
 gnipsag yltnatsnoc ydob stnemevom gniniard ot dednetxe ro 01 ssenrah pmuts
gniwollof etar yrotaripseR ro tsehc llew gnideef snoisluvnoC lanimodbA etar setunim ffits ro  erutarepmeT gnimraw sucilibmU selutsup dna morf
gnitnurg gnillews gnillews gnideelB
eht ereveS traeH yppolF suoen rollaP
"If no danger signs present, classify and treat as below"
"evisulcxe noitazinummi ton M,htmraw desab-emoh ybab( gm eye"
"SNGIS llew gnideeF gnilkcus( 8 ylevitceffe 42 ni semit )sruoh thgieW ro g 005,2 ybab llams gnitae gniniag llew thgiew regnad sngis laiceps tnemtaert sdeen"
YFISSALC gnideeF melborP gnideeF melborP ybaB
"Assess for Special Treatment Needs, Local Infection, and"
Ask (check records) Look Listen and feel
 Has the mother had  Eyes: Swollen and
(within 2 days of draining pus?
treated with antibiotic?  Skin: Many or severe
delivery?  Jaundice: check face
 Has the mother testcheck palms and
" Has anything been Swelling, bruising?"
 Has the mother tested RPR positive?
 Is the mother Hpositive? is she on
applied to the umbilicus? Look Listen and feel
SNGIS enarbmem  revef no scitoibitna
noitcefni enilcycartet rof )2.2.3-latipsoh
rehtom tew aidymalhc PU:tnemevorpmi
ksiR noitcefnlaccoconoG )noitcefnioC noitces
wolleY 42( ro wolleY smlap selos sruoh
sesiurB gnillews skcottub nellowS no
  etalap gnikool ecnaraeppa eussit daeh ro
bulC tfelC pil ddO nepO eht kcab
SICK YOUNG INFANT AGE UP TO 2 MONTHS
 Ask the mother what the childs problems are
 Check if this is an initial or FOLLOW UP visit for this
 If FOLLOW UP visit: Check up on previous treatments
 If initial visit: Continue as below
"Assess, classify and treat for the following:"
 Severe disease and local bacterial infection
 Nutrition and breastfeeding of the child
 To return for FOLLOW UP as scheduled
 To return immediately at the clinic if the danger signs in the table
 Breastfeeding or drinking poorly Immediately
 Breastfeeding or drinking poorly
Check for Very Severe Disease and Local Bacterial
"Ask Ask if the infant Look, listen, feel"
feeding?  Count the number of breaths
had any - Repeat the count if this is 
convulsions? 60 breaths per minute
 Look for severe chest indrawing
 Look and feel for a bulging fontanel
 Look for pus draining from the ear
 Look at the umbilicus. Is it red or
(or feel for fever or low body temperature)
" Look for skin pustules, if present,"
 See if the young infant is lethargic
 Observe the young infants movements
"convulsions? Look, listen, feel"
 Look for severe chest indrawing
 Look and feel for a bulging fontanel
 Look for pus draining from the ear
 Look at the umbilicus. Is it red or
(or feel for fever or low body temperature)
" Look for skin pustules, if present,"
 See if the young infant is lethargic
 Observe the young infants movements
Classify and treat possible infection as in the table below:
TNEMTAERT 05 ro MI ro yb eht ecirht
nillicipma )syad gKUI deeftsaerb( retaw no
"fi( 000,05 7 5:scitoibitna gkgm ragus tnafni  tsael"
"MI wol woh ot YLTNEGRU,elbissop nillicipma"
fo 7 larrefer tneverp )syad ecno
"sulp fi( gkgm,2CH )TGN 7 nicimatneG"
ts1 gk erp ot ro esivdA ot ton eunitnoC  fi
eviG gm fi rO elgnis taerT evig puc yaw refeR larrefer yliad
yreSNGIS:gniwollof ro gnihtaerb shtaerb ni C5.73( C5.53( loots
gnideef snoisluvnoC tsehc ro )toh ydob )dloc tnemevoM -mits on stnemevom
eht toN ro llew tsaF 06( ro )nim ereveS reveF sleef woL pmet sleef nehw detalu lla doolB
ot:citoibitna 1 )gk yliad rof esivda latipsoh
"6-4 eciwt,rehtom,shtnom taert emoh owt ot"
¼ rehtom teloiV rehtom PU:esrow
eviG gm 052 fi( bat 5 hcaeT ylppa( naitneG esivdA:retteb etelpmoc tnemtaer ro emas
noitcefnlacoL esaesiD -cefnylekinU
"If jaundice present, Ask Look and feel"
 When did the  Look for jaundice (yellow
Classify jaundice as in the following table
 Any Severe Jaudice  Treat to prevent low
jaundice blood sugar (breastif age less feed or give expressed
 yellow  Refer urgently to hospalms pital
and soles  Advise mother to keep
 Advise mother to return immediately if
age Severe Jaudice  Treat to prevent low
blood sugar (breastfeed or give expressed
 Advise mother to return immediately if
 Jaundice Jaundice  FOLLOW UP in one day:
 No No  Advise mother to give home
jaundice Jaundice care for the young infant
 If child has  Infants movements
how long it has - Does the infant move
been present when stimulated but then
yellow Jaundice  FOLLOW UP in one day:
Jaundice  Advise mother to give home
"been present If yes, Look and feel"
Classify and treat the dehydration and diarrhoea as in the table below
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
For dehydration (see also section 1.1.3.1)
Two of these signs: Severe If infant has no other seDehydration vere classification:
 Movement  Give fluid for severe deonly hydration (Plan C) OR
stimulated or no If infant also has another
movement at all severe classification:
Two of these signs: Some Dehy-  Give Plan B (Give fluid
dration and breast milk for some
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
For dehydration (see also section 1.1.3.1) 
Dehydration If infant has no other severe classification:
 Give fluid for severe dehydration (Plan C) OR
slowly. If infant also has another
irritable Some Dehydration  Give Plan B (Give fluid
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
"ot gnideef PU,retteb ylgnidrocca"
eht laceaf dilos-imes?tnafni fi
 Has the mother andor young infant had an HIV test?
 What is the mothers HIV status?
- Serological test POSITIVE or NEGATIVE
 What is the young infants HIV status?
- Virological test POSITIVE or NEGATIVE
- Serological test POSITIVE or NEGATIVE
If mother is HIV positive (or serological test of the child is positive) and NO positive virological test in child ASK:
 Is the young infant breastfeeding now?
 Was the young infant breastfeeding at the time of test or
 Is the mother and young infant on PMTCT ARV prophylaxis?
IF NO test: Mother and young infant status unknown
 Perform serological HIV test for the mother (or serological test
"for the child if the mother is not present); if positive, perform"
virological test for the young infant
Classify and treat HIV status (see also section 3.1.4)
elozaxomirtoc rep snoitadnemmocer tset rehtom senilediug
ega sa lacigoloriv skeew gnideeftsaerb PU
evitisop tnafni 6 tey lacigolores
VIH gnuoy gnideeftsaerb ssel VIH tnafni
rehtoM deppots rehtoM evitisoP tnafni
Check for Feeding Problem or Low Weight-for-Age
17.All Young Infants Except HIV-exposed Infants Not
If an infant has no indications to Look listen and feel
 Is there any difficulty feed- - Weigh the child
"- If yes, how many times in to determine if"
a 24-hour period? the child is low
 Does the infant usually weight for its
receive any other foods or age in months
"drinks, including water?  Look for ulcers"
 Has the infant breastfed in the previous hour?
"- If no, ask the mother to put the infant to the breast."
"- If yes, ask the mother if she can wait and tell you when"
the infant is willing to feed again
 Observe breastfeeding for 4 minutes: is the infant able to
"attach properly to the breast? For good attachment, the"
- More areola visible above than below the mouth
" Is the infant able to suckle effectively? This means slow,"
deep sucks with occasional pauses
- Clear a blocked nose if it interferes with breastfeeding
If an infant has no indications to
 Is there any difficulty feeding?
the infant? Look listen and feel
 Has the infant breastfed in the previous hour?
"- If no, ask the mother to put the infant to the breast."
"- If yes, ask the mother if she can wait and tell you when"
the infant is willing to feed again
 Observe breastfeeding for 4 minutes: is the infant able to
"attach properly to the breast? For good attachment, the"
- More areola visible above than below the mouth
" Is the infant able to suckle effectively? This means slow,"
deep sucks with occasional pauses
- Clear a blocked nose if it interferes with breastfeeding 
"TNEMEGANAM,ylevitceffe,sruoh esivdA gnol eht ta yliad )htolc"
"peek,yletaidemmi 42.gnideef sa dna semit tfos"
gnilkcus ni thgin dna taert 4 a
semit netfo deef emoh tniap esu
8 ycneuqerf sa ot ta rehtom teloiv
ton gninoitisop llew puc naht deeftsaerb yad lla woh mraw
"ro dehcatta hcatta ot rehtom a yb ssel esaercni,stnaw ta gnideeftsaerb rehtom tnafni eht naitneg naelc"
"llew elba eht dna ot rehtom eht thgiew,hsurht syad"
ton hcaet ton hcaet klim esivda eht ton esivdA emoh 7
fo gnideeF llew naht sruoh sevieceR ro hsurhT ni sehctap
"ro,thgiew,retteb 41 ot gnideef syad"
melborp ni egaruocne 41 gnideef
emoh gnisool taht fI tub ni refer
llit.yltcerroc.tnemtaert rof rof PU
gnideef PU kcehc thgiew ega llits
"evig.ssessaer fI thgiew dna WOLLOF:thgiew,ega"
"ot rehtom yna,esrow nevig yad-7 wol wol rehtom thgiew eht rof tsol"
tnafni yrotcafsitas si si regnol esiarp dna ro
WOLLOF syad eunitnoC hsurht tnemtaert etelpmoc WOLLOF eht.eunitnoc wol rehtom melborp latipsoh
"esivdA gnuoy.refer on esiarp llits,llew wol"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Not No Feeding  Advise mother on home
low Problem care for young infant
17.HIV-exposed Non Breastfeeding Infants
 What milk are you giving?  Determine
 How are you preparing the (thrush)
"explain how a feed is prepared, and how it is given"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
"explain how a feed is prepared, and how it is given"
"feeding utensils? Look, listen and feel"
Classify and treat feeding problems
TNEMEGANAM tnemecalper dna a rehtom emoh ta yliad )htolc eht hsurht
efas fo si rehtom eht esivdA mraw taert 4 tniap a esu erac emoh melborp
eht tuoba hcaet deef ylppa( tnafni
"lesnuoC nialpxE gnideef ylimaf,elttob ot emoh esivdA gnuoy"
-rocni -nu yllacineigyh ro tnemecalper tneiciffusni tnemecalper rehtom
wol wol rehtom thgiew eht syad rof tsol
thgiew ega hsurhT sreclu( etihw sehctap )htuom
wol thgiew dna rehto fo gnideef
Check Young Infants Immunization Status
Check immunization card and classify
 Imuniza- Infant Not  Give all missed
tion not Immunized doses on this
up to date as per visit (Include sick
according Schedule infants unless
 Immuniza- Infant Im-  Advise caretaker
tion upto munized as when to return
date as per Per Sched- for the next
"Assess any other presenting problems (e.g. eye problems, rashes) and"
 Check for current health problems
 Check nutritional status and anaemia
 Check whether family planning help is required
 Check on tetanus immunization status
Summary of IMNCI Medicines Used for Young Infants
Ampicillin 50 mgkg Pre referral IM dose in HC3
Ampicillin 50 mgkg Pre referral IM dose in
Gentamicin Age  7 days 5 Pre referral IM dose in HC3
"Benzyl peni- 50,000 IU Pre referral IM dose in HC2"
cillin Kg IM very severe disease if
Amoxicillin Birth-1 In local bacterial infec- HC1
250 mg dispersible tablets ¼ tab every 12
Gentian Violet Apply in the In oral thrush HC2
Apply on skin Local bacterial infection
Cotrimoxazole 1 tab once daily Prophylaxis in HIV in- HC2
Teach correct positioning and attachment for breast feeding
 Show mother how to hold the infant:
 With the infants head and body straight
days In local bacterial infection HC1
a day for 7 days In oral thrush HC2
5 days Local bacterial infection
pediatric tablet 1 tab once daily Prophylaxis in HIV infected or HIV exposed
 Facing her breast with infants nose opposite the nipple
 With infants body close to hers
" Supporting the infants whole body, not just the neck and shoulders"
" Show her how to help the infant attach, she should:"
 Touch her infants lips with her nipple
 Wait until her infants mouth opens wide
 Move her infant quickly onto her breast aiming the infants lower
 Look for signs of good attachment and effective suckling
" If either is not good, try again"
Advise mother on home care for the young infant
" Food and fluids: Breastfeed frequently on demand (as often and for as long as the infant wants) day and night,"
 Warmth: Ensure the young infant is always warm
SICK CHILD AGE 2 MONTHS TO 5 YEARS
 Ask the mother what the childs problems are
 Check if this is an initial or FOLLOW UP
"- If FOLLOW UP visit: Check up on previous problems,"
check that the treatment has been given correctly and
 If initial visit: Continue as below
"In assessing a sick child, assess for the following:"
- General danger signs: URGENT ATTENTION and
- Malnutrition and feeding problems
"- H- Immunization, deworming and vitamin A"
- Extra fluids for any sick child
- Nutrition and breastfeeding of the child
- To return for FOLLOW UP as scheduled
 To return immediately if any danger sign appear
 Breastfeeding or drinking poorly
 Is the child unable to  See if the child
drink or breastfeed lethargic or unconscious
everything  Is the child convulsing now
 Breastfeeding or drinking poorly
 Any Very  Give diazepam if convulsing
danger  Quickly complete the assesssign ment
 Give any pre referral treatment
 Treat to prevent low blood sugar
breast milk breastmilk substitute
Check for Cough or Difficult Breathing
" If child Ensure the child is calm, then"
breathing  Look for chest indrawing
"If yes, ask  Looklisten for stridor (stridor"
pitched sound caused by oblong child
" If pulse oximeter is available,"
If wheezing with either fast breathing
Disease  Give diazepam if convulsing
 Quickly complete the assessment
 Give any pre referral treatment
 Treat to prevent low blood sugar
breast milk breastmilk substitute
 Looklisten for stridor (stridor
"is an abnormal harsh, highpitched sound caused by obstructed airflow, usually more"
" If pulse oximeter is available,"
If wheezing with either fast breathing
 Give a trial of rapid acting inhaled broncodilator (with spacer) for up to 3 times
15-20 min apart. Count the breaths
"and look for chest indrawing again,"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Any Severe Pneu-  Give 1st dose of appropriate antigeneral monia or Very biotic: ampicillin 50 mg Kg IM
danger Severe Disease and gentamicin mgKg IM
 SpO2  antibiotics not available
 Continue ampicillin 6 hourly and
gentamicin once daily for 5 days
 Chest Pneumonia  Give amoxicillin DT 40 mgkg
indrawing for 5 days as first line treatment
  Give a trial of rapid acting inhaled broncodilator (with spacer) for up to 3 times
15-20 min apart. Count the breaths
"and look for chest indrawing again,"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
Severe Disease  Give 1st dose of appropriate antibiotic: ampicillin 50 mg Kg IM
 Continue ampicillin 6 hourly and
gentamicin once daily for 5 days
indrawing Pneumonia  Give amoxicillin DT 40 mgkg
for 5 days as first line treatment
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Fast  If wheezing give an inhaled bronbreathing chodilator for 5 days (salbutamol
 Child inhaler every 3-4 hours as nec2-12 essary)t
 If coughing for more than 14 days
"or recurrent wheeze, refer for posbreaths"
" If chest in drawing in HIV exposedinfected child, give first"
- Children  Soothe throatrelieve
- 1-5 years: cough with safe remedy
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
minute  If wheezing give an inhaled bronchodilator for 5 days (salbutamol
inhaler every 3-4 hours as necessary)t
 If coughing for more than 14 days
"or recurrent wheeze, refer for possible TB or asthma assessmen"
"  If chest in drawing in HIV exposedinfected child, give first"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
No signs of Cough or  If wheezing give an inhaled
severe disease Cold (No bronchodilator (salbutamol
or pneumonia pneumo- inhaler every 3-4 hours as
 Use age-appropriate spacers to administer salbutamol inhaler
 Does the  Look at the childs general condition.
diarrhoea?  Lethargic or unconscious?
child has had  Offer the child fluid. Is the child:
this  Unable to drink or drinks poorly?
" Using appro-  Thirsty, drinks eagerly?"
priate local  Pinch the skin of the abdomen. Does
there is blood  Very slowly? (2 seconds)
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
needed  If wheezing give an inhaled
 Use age-appropriate spacers to administer salbutamol inhaler 
 Look at the childs general condition.
 Offer the child fluid. Is the child:
 Unable to drink or drinks poorly?
 Pinch the skin of the abdomen. Does
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
"Any 2 of these Severe Dehy-  If child has no other sesigns: dration vere classification, give"
 Lethar- dehydration Plan C (see
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
poorly  If child is 2 years or older
returns  Give 1st dose of erythrovery mycin 125 mg (if child 
slowly 2 years) or 250 mg (child
(2 sec- 2-5 years) every 6 hours
 Educate mother on hygiene and sanitation
"Any 2 of these Some Dehy-  Give fluid, zinc supplesigns: dration ments, and food if possible"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
"eyes Severe Dehydration  If child has no other severe classification, give"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Give 1st dose of erythromycin 125 mg (if child 
 Educate mother on hygiene and sanitation
"irritable Some Dehydration  Give fluid, zinc supplements, and food if possible"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Educate mother on hygiene and sanitation
" Not No Dehydra-  Give fluid, zinc suppleenough tion ments, and food to treat"
signs to diarrhoea at home (Plan
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Educate mother on hygiene and sanitation
"dehydration No Dehydration  Give fluid, zinc supplements, and food to treat"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Blood in Dysentery  Give ciprofloxacin 15 mg
stool kg for 3 days for Shigella
Dehydration Severe  Give vitamin A
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
stool Dysentery  Give ciprofloxacin 15 mg
CLINICAL FEA- CLASSIFY MANAGEMENT
If diarrhoea for 14 days or more:
No dehydra- Persistent  Advise mother on feeding child
tion Diarrhoea with PERSISTENT DIARRHOEA
 Give vitamin A; multivitamins and
minerals (including zinc) for 14 days
 The current recommendation for treatment of diarrhoea is
"oral rehydration salts (ORS) and zinc salts (Zn sulphate, Zn"
- Give zinc for 10 days: Child  6 months: 10 mg per day;
 If the child has fever  Lookfeel for stiff
or temperature 37.5C  Look for runny nose
If diarrhoea for 14 days or more: 
Diarrhoea  Advise mother on feeding child
 Give vitamin A; multivitamins and
minerals (including zinc) for 14 days
 The current recommendation for treatment of diarrhoea is
"oral rehydration salts (ORS) and zinc salts (Zn sulphate, Zn"
- Give zinc for 10 days: Child  6 months: 10 mg per day;
"- If 7 days, ask if  tenderness, oral"
"fever has been sores, refusal to use"
"present every day a limb, hot tender"
"- Ask if the child has swelling, red tender"
"had measles in the skin or boils, lower"
last 3 months abdominal pain or
TEST in all fever urine in older
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Any Very Severe Fe-  Give 1st dose of rectal argeneral brile Disease tesunate (10 mgkg) or IM
danger IV artesunate (3 mgkg if
 Stiff 20 kg) (see section 2.5.2)
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
neck Very Severe Febrile Disease  Give 1st dose of rectal artesunate (10 mgkg) or IM
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Give 1st dose of appropriate antibiotic for serious bacterial infection:
 Give one dose of paracetamol 10 mgkg for high
" Malaria Malaria  Give 1st line malaria treattest ment (oral ACT, see section"
 Give one dose of paracetamol 10 mgkg for high
"also identified, give appropriate antibiotic treatment"
"return immediately, counsel on use of insecticide"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
  Give 1st dose of appropriate antibiotic for serious bacterial infection:
 Give one dose of paracetamol 10 mgkg for high
"positive Malaria  Give 1st line malaria treatment (oral ACT, see section"
 Give one dose of paracetamol 10 mgkg for high
"also identified, give appropriate antibiotic treatment"
"return immediately, counsel on use of insecticide"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Malaria Fever  Give one dose of paracetatest mol 10 mgKg in child with
" If no bacterial infection identified, reassure, give paracetamol, advise to come"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
No Malaria  Give one dose of paracetamol 10 mgKg in child with
" If no bacterial infection identified, reassure, give paracetamol, advise to come"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
counsel on use of insecticide treated mosquito
net and educate on environmental sanitation.
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
counsel on use of insecticide treated mosquito
net and educate on environmental sanitation.
TNEMEGANAM tnemtnio neeb -moc -noc melborp
ylppA naitneg syad sup seye era
esrow:eye gnigrahcsid fI hsurhtsreclu
"morf fA,sreclu ni,yltcerroc tnemtaert.tnemtaert refer"
 Does the child have  Look for pus drainan ear problem? ing from the ear
" If yes,  Feel for tender swelling behind the ear"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Tender Mastoiditis  Give 1st dose of approswelling priate antibiotic ampibehind cillin 50 mg Kg IM and
 Ear pain Acute Ear  Give amoxicillin DT 40
 Look for pus draining from the ear
 Feel for tender swelling behind the ear
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
the ear Mastoiditis  Give 1st dose of appropriate antibiotic ampicillin 50 mg Kg IM and
Infection  Give amoxicillin DT 40
Check for Malnutrition and Feeding Problems
" If child  6 m,  Look for signs of acute malask if the child nutrition like"
has breasfeeding problem - Oedema on both feet
(how many - Determine weight for height
"times a day, length (WFHL) using WHO"
etc) growth charts standards (see
 If child ³ 6 end of this chapter)
"months, ask if - As an alternative, determine"
 Ask about children ³ 6 months using
habits If WFHL is less than -3 z-scores or
 How many - Pneumonia or chest indrawing
"times a day If no medical complication presents,"
 Does the child  Child ³ 6 months: assess
 Look for signs of acute malnutrition like
If WFHL is less than -3 z-scores or
 Check for any medical complication present
"If no medical complication presents,"
Classify and treat as directed below
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Oedema of Complicat-  Give first dose approboth feet OR ed Severe priate antibiotic (am-
 WFHL less Acute Mal- picillin 50 mgKg IM
nutrition and gentamicin scores
cated Severe - Benzylpenicillin
- not able to amoxicillin DT for 5
finish RUTF days (40 mgkg twice
- Breastfeeding  Give ready-to-use therproblem
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
Acute Malnutrition  Give first dose appropriate antibiotic (ampicillin 50 mgKg IM
 Treat the child to prevent low blood
 Give ready-to-use therapeutic food (RUTF)
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Or very (SAM)  a child aged 6 months
weight See section 19. Counsel the mother on
AND Moderate Acute  Assess for possible TB
finish See section 19. Advise mother when to
RUTF for more details return immediately
for age feeding and counsel the
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
See section 19.for more details
See section 19.for more details  a child aged 6 months
Clinical Features Classify As Management
 WF- no acute Mal-  If child is  2 years
"HL - 2 nutrition old, assess the childs"
z-scores feeding and counsel the
or more mother on feeding according to the feeding  OR
 If you advise the mother to make significant
 WFHL is Weight-for-Height or Weight-for-Length
determined by using the WHO growth standards charts
 MUAC is Mid-Upper Arm Circumference measured using
MUAC tape in all children ³ 6 months
Clinical Features Classify As Management
or more no acute Malnutrition  If child is  2 years
mother on feeding according to the feeding
 If you advise the mother to make significant
 RUTF is Ready-to-Use Therapeutic Food for conducting
the appetite test and feeding children with severe acute
malnutrition. For doses and more information see chapter
 RUTF already contains all the necessary vitamins and
"minerals (folic acid, iron etc) so there is no need of additional"
" In appropriate local  Look for palmar pallanguage, ask if lor. Is it"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Severe Severe  Refer URGENTLY to
 Some Anaemia  Give ferrous sulphate ½ tab
"palmar day if 1-5 years, 1 ml of syrup"
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
pallor Anaemia  Give ferrous sulphate ½ tab
"day if 1-5 years, 1 ml of syrup"
CLINICAL FEA- CLASSIFY AS MANAGEMENT
 Advise mother when to return immediately
" If child still has palmar pallor after two months, refer"
 N o No Anaemia  If child is less than two years
"pal- old, assess the childs feedmar ing and counsel the mother"
 Is the child already enrolled in HIV care?
 Has the mother or child had an HIV test?
CLINICAL FEATURES CLASSIFY AS MANAGEMENT
 Advise mother when to return immediately
" If child still has palmar pallor after two months, refer"
pallor No Anaemia  If child is less than two years
"old, assess the childs feeding and counsel the mother"
 Is the child already enrolled in HIV care?
 Has the mother or child had an HIV test? 
"If yes: decide HIV status If no, then test"
 Mother: POSI-  Mother and child status
TIVE or NEGA- unknown: TEST mothTIVE er.
NEGATIVE - If below 18 months: do
- Serological test virological testing
"POSITIVE or - If above 18 months, do"
"If mother is HIV positive and child is negative or unknown,"
 Was the child breastfeeding at the time or 6 weeks before the test?
 Is the child breastfeeding now?
 If breastfeeding ASK: Is the mother and child on ARprophylaxis?
" For HIV testing algorithm and result interpretation in children,"
see section FEATURES CLASSIFY AS MANAGEMENT
 Positive Confirmed  Initiate ART treatment
virologi- HIV Infection and HIV care
(see section  Give cotrimoxazole prophchild
and child status unknown: TEST child
"If mother is HIV positive and child is negative or unknown,"
 Was the child breastfeeding at the time or 6 weeks before the test?
 Is the child breastfeeding now?
 If breastfeeding ASK: Is the mother and child on ARprophylaxis? 
" For HIV testing algorithm and result interpretation in children,"
see section FEATURES CLASSIFY AS MANAGEMENT
FEATURES CLASSIFY AS MANAGEMENT
 Assess or refer for TB asserosessment and Isoniazid
or older as per national guidelines
 Mother HIV Exposed  Give cotrimoxazole
HIV- prophylaxis till infection
positive can be excluded by H3.1.4)
negative breastfeeding for at least
 Start or continue ARa breastprophylaxis as recomfeeding
" Do virological test to conor only stopped less firm HIV status: if negathan 6 weeks tive, repeat 6 weeks after"
ago OR cessation of breastfeeding
 Mother  Assess the childs feeding
"positive, counselling to the mother"
yet tested  Advise the mother on
sero- as per national guidelines
" Negative HIV Infection  Treat, counsel and FOLHIV Unlikely LOW UP on existing intest in fections"
FEATURES CLASSIFY AS MANAGEMENT
 Assess or refer for TB assessment and Isoniazid
can be excluded by Htesting after cessation of
 Start or continue ARprophylaxis as recommended
" Do virological test to confirm HIV status: if negative, repeat 6 weeks after"
months  Assess the childs feeding
"Unlikely  Treat, counsel and FOLLOW UP on existing infections"
"Check Immunization, Vitamin A, Deworming"
Check immunization card and classify
 Imuni- Child Not  Give all missed
zation Immunized as doses on this visit
schedule (see  Give mebendazole
 Immu- Child Immu-  Praise the mother
"Assess any other presenting problems (e.g. eye problems, rashes) and"
 Explain to the mother why the medicine is needed
 Calculate the correct dose for the childs weight or age
 Use a sterile needle and syringe for injections
 Accurately measure and administer the dose
" If referral is not possible, follow the instructions given"
schedule Child Immunized as Per
 Advise the caretaker when to return for the next
17.Medicines Used Only in Health Centers
Ampicillin 50 mgkg Pre referral IM dose in very HC3
Gentamicin mgkg Pre referral IM dose in very HC3
Diazepam mgkg Pre referral treatment of HC2
"Benzyl peni- 50,000 IUkg Pre referral IM dose in very HC2"
cillin severe disease or severe
Rectal ar- 10 mgkg Pre referral dose for very HC1
tesunate (see section severe febrile disease
Artesunate 3 mgkg if Pre referral IM dose for HC3
parenteral very severe febrile disease
Salbutamol 2 puff For acute wheezing HC3
Teach mothercaretaker how to give oral medicines at home
 Determine the correct medicine and dose for the childs
Ampicillin 50 mgkg Pre referral IM dose in very
Gentamicin mgkg Pre referral IM dose in very
diluted ampoule) mgkg Pre referral treatment of
"Benzyl penicillin 50,000 IUkg Pre referral IM dose in very"
2.5.2.2) Pre referral dose for very
very severe febrile disease HC3
inhaler 2 puff For acute wheezing HC3
 Explain the reason for giving the medicine
- Ask the mother to give the first dose to her child
- Explain carefully how to give the medicine
" Include dose, frequency, and duration"
Stress the need to compete the full course of treatment even if the
"If child vomits the medicine within one hour from taking it, REPEAT"
" Collect, measurecount, pack, and label it separately"
 Check the mothers understanding before she leaves
Amoxicillin Every 12 hours Pneumonia Acute ear HC1
Artemether Every 12 hours Un-complicated malaria HC1
3-5 years: 2 tab Un-complicated malaria HC1
Erythromicin Every 6 hours Cholera HC3
Ciprofloxa- 15 mgkg every Dysentery HC2
Folic acid mgdaily Anaemia in child with HC2
Iron ferrous Once daily for 14 Anaemia in non sick- HC2
Cotri- moxa-  6 months: Prophylaxis in HIV HC2
zole 120 mg positive and H1 tablet
Folic acid mgdaily Anaemia in child with
1 ml Anaemia in non sicklers HC2
day Prophylaxis in Hpositive and Hexposed HC2
Meben- dazole Child 1-2 Routine deworming HC2
Albendazole Child 1-2 Routine deworming HC1
Paracetamol Every 6 hours Fever  oC or HC1
Vitamin A Up to 6 Routine every 6 HC2
"612 months: three doses for persistent diarrhoea, measles"
"three doses for persistent diarrhoea, measles"
ORS As per plan Rehydration HC1
Zinc Daily for 10 Treatment of HC1
Nystatin syrup 1 ml 4 times Oral thrush HC2
Tetracycline 5 mm of oint- Eye infection HC2
Ciprofloxacin 1-2 drops Chronic otitis
Ready To Use See chapter Severe malnutrition HC1
eye ointment 5 mm of ointment inside
ARVs See section HIV prophylaxis HC3
17.Treatment of Local Infections at Home
Teach mother caretaker how to treat local infections
 Explain what the treatment is and why it is needed
 Describe the treatment steps as detailed below
 Watch the mother do the first treatment in the clinic (except coughsore throat remedy)
 Explain how often to do the treatment and for how long
 Provide the required medication for home treatment
 Check that she understands completely before leaving the
Eye infection  Clean both eyes 4 times daily:
- Use clean cloth with clean water to
- Use a different part of the cloth for
- Clean each eye from nose-side
to ear-side to avoid passing the
infection from one eye to the other
 Apply tetracycline eye ointment 1 to each
eye 4 times daily after cleaning the eyes
- Squirt a small amount (5 mm length)
on the inside of the lower eyelid
 Continue application until the redness
 Do not put anything else into the eye
Eye infection  Clean both eyes 4 times daily:
- Use clean cloth with clean water to
- Use a different part of the cloth for
- Clean each eye from nose-side
to ear-side to avoid passing the
infection from one eye to the other
 Apply tetracycline eye ointment 1 to each
eye 4 times daily after cleaning the eyes
- Squirt a small amount (5 mm length)
on the inside of the lower eyelid
 Continue application until the redness
 Do not put anything else into the eye
Ear infection  Dry the ear at least 3 times daily
- Roll clean absorbent cloth or soft
- Place this in the ear and remove
- Replace wick with a clean one
- Repeat this process until the ear is
- Instill ciprofloxacin ear drops 3
 Do not put anything else into the ear
Mouth ulcers  Treat these twice daily
 Wash childs mouth with clean soft cloth
moistened with salt water and wrapped
" Paint the mouth with gentian violet aqueous paint 0.5 (if necessary, dilute 1 with"
an equal volume of water and provide this
 Continue giving gentian violet for 48 hours
 Give paracetamol for pain relief
Oral thrush  Treat for thrush four times daily for seven
 Wash a clean soft cloth with water and
 Instill nystatin 1 ml every six hours
 Avoid feeding for 20 minutes after medication
Ear infection  Dry the ear at least 3 times daily
- Roll clean absorbent cloth or soft
 - Place this in the ear and remove
- Replace wick with a clean one
- Repeat this process until the ear is
- Instill ciprofloxacin ear drops 3
 Do not put anything else into the ear
Mouth ulcers  Treat these twice daily
 Wash childs mouth with clean soft cloth
moistened with salt water and wrapped
" Paint the mouth with gentian violet aqueous paint 0.5 (if necessary, dilute 1 with"
an equal volume of water and provide this
 Continue giving gentian violet for 48 hours
 Give paracetamol for pain relief
Oral thrush  Treat for thrush four times daily for seven
 Wash a clean soft cloth with water and
 Instill nystatin 1 ml every six hours
 Avoid feeding for 20 minutes after medication
" If breastfed, check mothers breasts for"
thrush and if present treat with nystatin
 Advice mother to wash breast after feeds
 If baby unable to breastfeed advise mother
to feed baby with a cup and spoon.
 Give paracetamol of needed for pain
Sore throat or cough  Use a safe remedy to soothe the throat
- Breastmilk (for exclusively breastfed
codeine or antihistamines (e.g.
17.Feeding Recommendation during Illness
 Breastfeed more often and for longer at each feed
" Increase fluid intake, e.g. give soup, rice water, yoghurt"
 Giving extra fluid can be lifesaving
" Give fluid according to Plan A or B, depending on the"
state of dehydration of the child
17.Assessing Appetite and Feeding
 Ask about the childs usual feeding habits during the current illness
 Compare the answers given with the feeding recommendations for the childs age
"  If breastfed, check mothers breasts for"
thrush and if present treat with nystatin
 Advice mother to wash breast after feeds
 If baby unable to breastfeed advise mother
to feed baby with a cup and spoon.
 Give paracetamol of needed for pain
Sore throat or cough  Use a safe remedy to soothe the throat
- Breastmilk (for exclusively breastfed
codeine or antihistamines (e.g.
Breastfeeding - Do you breastfeed the child?
Other food or fluids - What food or fluids?
If severe or moderate - What foods are available at
special concern about - What foods does the child
- Does the child receive hisher
During this illness - Has the childs feeding
"If HIV exposed child - If mother and child on ARVs,"
"preparation of substitute milk,"
Breastfeeding - Do you breastfeed the child?
Other food or fluids - What food or fluids?
growth (e.g. HIV) - What foods are available at
- Does the child receive hisher
During this illness - Has the childs feeding
"If HIV exposed child - If mother and child on ARVs,"
"preparation of substitute milk,"
These recommendations are for both sick and healthy children
AGE OF CHILD FEEDING RECOMMENDATIONS
Birth up to 6  Breastfeed as often as your child wants
" Look for signs of hunger, such as beginning to fuss, sucking fingers, or"
 Breastfeed day and night whenever
"your baby wants, at least 8 times in 24"
 Frequent feeding produces more milk
 Do not give other foods or fluids
 Breast milk is all your baby needs
6-9 months  Breastfeed as often as your child wants
"Also give thick porridge made with maize, cassava, millet,"
"soya flour, or any mix of these. Add sugar and oil, and"
mix with milk or pounded groundnuts or mixtures of well
"matooke, potatoes, cassava, posho (maize or millet), rice."
"Mix these with fish, beans, or pounded groundnuts. Add"
" Give a nutritious snack, e.g. egg, banana, bread: 3 timesday if breastfed"
 Including animal source foods and vitamin A-rich fruits and vegetables
 Start by giving 2 to 3 tablespoons of
food. Gradually increase to ½ cups (1
 Offer 1 or 2 snacks each day between
meals when the child seems hungry
AGE OF CHILD FEEDING RECOMMENDATIONS
months  Breastfeed as often as your child wants
" Look for signs of hunger, such as beginning to fuss, sucking fingers, or"
 Breastfeed day and night whenever
"your baby wants, at least 8 times in 24"
 Frequent feeding produces more milk
 Do not give other foods or fluids
 Breast milk is all your baby needs
6-9 months  Breastfeed as often as your child wants
"Also give thick porridge made with maize, cassava, millet,"
"soya flour, or any mix of these. Add sugar and oil, and"
mix with milk or pounded groundnuts or mixtures of well
"matooke, potatoes, cassava, posho (maize or millet), rice."
"Mix these with fish, beans, or pounded groundnuts. Add"
" Give a nutritious snack, e.g. egg, banana, bread: 3 timesday if breastfed"
 Including animal source foods and vitamin A-rich fruits and vegetables
 Start by giving 2 to 3 tablespoons of
food. Gradually increase to ½ cups (1
 Offer 1 or 2 snacks each day between
meals when the child seems hungry
AGE OF CHILD FEEDING RECOMMENDATIONS
9 to 12 months  Breastfeed as often as your child
" Also give a variety of mashed or finely chopped family food, including animal source foods and vitamin A-rich"
 Give 12 cup at each meal (1 cup
 Offer 1 or 2 snacks between meals.
" For snacks, give small chewable items"
that the child can hold. Let your child
"try to eat the snack, but provide help"
12-24  Breastfeed as often as your child wants
months  Also give a variety of mashed or finely
"chopped family food,including animal"
source foods and vitamin A-rich fruits
 Give 34 cup at each meal (1 cup
 Offer 1 to 2 snacks between meals
" Continue to feed your child slowly, patiently. Encourage but do not force your"
" Breastfeed on demand, day and night"
 Give adequate servings of complementary foods as above except that you may
AGE OF CHILD FEEDING RECOMMENDATIONS 
9 to 12 months  Breastfeed as often as your child
" Also give a variety of mashed or finely chopped family food, including animal source foods and vitamin A-rich"
 Give 12 cup at each meal (1 cup
 Offer 1 or 2 snacks between meals.
" For snacks, give small chewable items"
that the child can hold. Let your child
"try to eat the snack, but provide help"
months  Breastfeed as often as your child wants
 Also give a variety of mashed or finely
"chopped family food,including animal"
source foods and vitamin A-rich fruits
 Give 34 cup at each meal (1 cup
 Offer 1 to 2 snacks between meals
" Continue to feed your child slowly, patiently. Encourage but do not force your"
" Breastfeed on demand, day and night"
 Give adequate servings of complementary foods as above except that you may
AGE OF CHILD FEEDING RECOMMENDATIONS
Age 2 years and  Give a variety of family foods to your
"over child, including animal source foods and"
vitamin A-rich fruits and vegetables
 Give at least 1 full cup (250 ml) at each
 Offer 1 or 2 snacks between meals
" If your child refuses a new food, offer"
tastes several times. Show that you
 Be patient. Talk with your child during a
 A good daily diet should be adequate in
quantity and include an energy-rich food
"(for example, thick cereal with added oil);"
"meat, fish, eggs, or pulses; and fruits and"
Stopping breast STOPPING BREASTFEEDING means
changing from all breast milk to no breast milk. This
should happen gradually over one month. Plan in
" Mother should discuss and plan in advance with her family, if possible"
 Find a regular supply of formula or milk
 Learn how to prepare and store milk
AGE OF CHILD FEEDING RECOMMENDATIONS
over  Give a variety of family foods to your
"child, including animal source foods and"
vitamin A-rich fruits and vegetables
 Give at least 1 full cup (250 ml) at each
 Offer 1 or 2 snacks between meals
" If your child refuses a new food, offer"
tastes several times. Show that you
 Be patient. Talk with your child during a
 A good daily diet should be adequate in
quantity and include an energy-rich food
"(for example, thick cereal with added oil);"
"meat, fish, eggs, or pulses; and fruits and"
feeding STOPPING BREASTFEEDING means
changing from all breast milk to no breast milk. This
should happen gradually over one month. Plan in
" Mother should discuss and plan in advance with her family, if possible"
 Find a regular supply of formula or milk
 Learn how to prepare and store milk
AGE OF CHILD FEEDING RECOMMENDATIONS
 Teach mother to cup feed (See Counsel
 Clean all utensils with soap and water
 Start giving only formula or cows milk
 Express and discard enough breast milk
to keep comfortable until lactation stops
Child with persis- If still breastfeeding
tent diarrhoea  Give more frequent and longer
" With fermented milk products, e.g."
17.Counselling for Feeding Problems
If the child is not being fed as above
AGE OF CHILD FEEDING RECOMMENDATIONS
 Teach mother to cup feed (See Counsel
 Clean all utensils with soap and water
 Start giving only formula or cows milk
 Express and discard enough breast milk
to keep comfortable until lactation stops
Child with persistent diarrhoea If still breastfeeding
" With fermented milk products, e.g."
PROBLEM COUNSELLING AND FOLLOW UP
Breastfeeding  Assess breastfeeding
"problems  As required, show mother correct positioning and attachment"
If child 6 months  Build the mothers confidence that she
old and taking oth- can provide all the breast milk needed
"er milk or foods  Suggest giving more frequent, longer"
"feeds day and night, and gradually reduce"
If mother is away  Suggest she expresses breast milk to
from the child due leave for the baby
"If other milk needs  Breastfeed as much as possible, including"
 Make sure that any other milk usedis an
"appropriate breastmilk substitute,"
 Correctly and hygienically prepared given
 Finish any prepared milk within 1 hour
If the child is being  Remind mother that thick foods rich in
given diluted milk energy and nutrients are needed by inor thin porridge fants and young children
 Advise her not to dilute the milk
 Advise her to make thicker porridge
If the mother is  Recommend using a cup instead of a botusing a bottle to tle
 Show the mother how to feed the child
with a cup: press cup on infants lower
"lip and allow him to take the milk himself,"
do not pour the milk into infants mouth)
PROBLEM COUNSELLING AND FOLLOW UP
" As required, show mother correct positioning and attachment"
old and taking other milk or foods  Build the mothers confidence that she
can provide all the breast milk needed
" Suggest giving more frequent, longer"
"feeds day and night, and gradually reduce"
"to work, etc.  Suggest she expresses breast milk to"
"to be continued  Breastfeed as much as possible, including"
 Make sure that any other milk usedis an
"appropriate breastmilk substitute,"
 Correctly and hygienically prepared given
 Finish any prepared milk within 1 hour
or thin porridge  Remind mother that thick foods rich in
energy and nutrients are needed by infants and young children
 Advise her not to dilute the milk
 Advise her to make thicker porridge
feed the child  Recommend using a cup instead of a bottle
 Show the mother how to feed the child
with a cup: press cup on infants lower
"lip and allow him to take the milk himself,"
do not pour the milk into infants mouth)
PROBLEM COUNSELLING AND FOLLOW UP
If the child is not  Counsel the mother to
- Sit with the child and encourage eating
- Give the child an adequate serving in a
"If the mother is  Encourage her to provide these regularly,"
"not giving foods e.g. eggs, green leafy vegetables, carrots,"
"rich in vitamin A liver, mangoes, yellow sweet potatoes,"
If the child is 6  Gradually introduce thick porridge mixed
months and appro- with available protein (e.g. milk); add sugpriate ar and fat
complementary  Gradually introduce mashed foods mixed
not been intro-  Add green leafy vegetables and fat to this
 Give nutritious snacks 3-5 times daily as
in feeding recommendations above
If child eats solid  Give a variety of mashed food mixtures
food with insuf- made with local staples and mixed with
ficient nutrient animal or plant protein relish
 Add green leafy vegetables and fat to this
 Give nutritious snacks 3 - 5 times daily as
in feeding recommendations above
 Counsel mother about her own health
" If she is sick, provide care for her or refer for further management"
" If she has a breast problem (e.g. engorgement, sore nipples,"
"infection), provide care for her or refer for further help"
 Advise her to eat well to keep up her own strength and health
PROBLEM COUNSELLING AND FOLLOW UP
being fed actively  Counsel the mother to
- Sit with the child and encourage eating
- Give the child an adequate serving in a
"rich in vitamin A  Encourage her to provide these regularly,"
"e.g. eggs, green leafy vegetables, carrots,"
"liver, mangoes, yellow sweet potatoes,"
not been introduced  Gradually introduce thick porridge mixed
with available protein (e.g. milk); add sugar and fat
 Gradually introduce mashed foods mixed
 Add green leafy vegetables and fat to this
 Give nutritious snacks 3-5 times daily as
in feeding recommendations above
food with insufficient nutrient
density or variety  Give a variety of mashed food mixtures
made with local staples and mixed with
 Add green leafy vegetables and fat to this
 Give nutritious snacks 3 - 5 times daily as
in feeding recommendations above
 Check immunization status and give Tetanus Toxoid (TT) if
 Make sure each mother has access to:
" Counselling on prevention of STIs, HIVAIDS"
 Give additional counselling if the mother is HIV-positive
 Reassure her that with regular FOLLOW UP much can be
"done to prevent serious illness, and maintain her and the"
" Emphasize good hygiene, and early treatment of illnesses"
INTEGRATED COMMUNITY CASE MANAGEMENT
"Integrated Community Case Management (iCCM) of malaria, pneumonia and diarrhoea is a recently adopted strategy for the treatment of"
common childhood illness at community level by trained Community
Health Workers since 2010. It addresses a gap in delivery of curative
services to children below 5 years allowing:
" prompt and accessible treatment of uncomplicated malaria, pneumonia and diarrhoea"
" identification of danger signs (convulsions, chest in-"
" drawing, unable to feed, vomiting everything, lethargy unconsciousness) and pre-referral treatment"
" monitoring of newborns during the first week of life,"
 counselling and referral if any problem identified.
Community health workers work in close collaboration with the health
"unit, to which they report and refer cases and from which they receive"
Supplies provided to trained community health workers
 Respiratory timers and Amoxicillin dispersible tablets for
diagnosis and treatment of pneumonia
 ORS sachets and Zinc tablets for treatment of diarrhoea
 RDTs and ACTs for diagnosis and treatment of uncomplicated malaria
 Rectal artesunate for pre referral treatment of complicated
" Registers, referral notes and sick job aids"
Other commodities for community health workers
" Other preventive treatments: used in prevention and treatment of common conditions and neglected topical diseases like albendazole, azithromycin syrup and tablets, ivermectin, tetracycline eye ointment, praziquantel, COC."
Amoxicillin DT 250 Pneumonia (cough 2-11 months: 1 tab every
21 days  in1-5 years: 2 tab every
creased respiratory rate) 12 hours for 5 days GREEN
Zinc Tablets and Diarrhoea Zinc
 14 days without 2-6 months: ½ tab once a day
at least ½ cup after each loose
21 days  increased respiratory rate) 2-11 months: 1 tab every
at least ½ cup after each loose
ACT Fever 4 months-2 years: 1 tab
7 days every 12 hours for 3 days (YELLOW PACK)
2-5 years: 2 tab every 12 hours
"Rectal Ar- Fever and danger signs, 4-11 months: 1 capsule"
CHILD GROWTH WEIGHT STANDARDS CHARTS
The WHO Child Growth Standards charts are used to identify normal
"growth for children under 5 years, as well as growth problems or trends"
that suggest that a child is at risk of a problem.
r Used to show if a child is normal weight or underweight for their
age. It should not be used to assess obesity and overweight.
" If a childs age is unknown, it is of limited use"
 It cannot distinguish between chronic malnutrition (stunting) and acute
" Also, if a child has oedema of both feet, fluid retention increases the"
"childs weight, masking what may actually be very low weight."
r Used to diagnose acute malnutrition
"r The cut-off for severe acute malnutrition is -3 z-scores and below. These children are at a high risk of mortality, but respond"
quickly and safely to re-feeding using therapeutic foods following
r The cut-off for moderate acute malnutrition is -2 to -3 z-scores
positive 4 months-2 years: 1 tab
every 12 hours for 3 days (YELLOW PACK)
2-5 years: 2 tab every 12 hours
"Rectal Artesunate Fever and danger signs,"
prereferral 4-11 months: 1 capsule
Mean Upper Arm circumference (MUAC)
r Used to diagnose acute malnutrition
r The cut off for severe acute malnutrition is 115 mm (cm)
Arm circumference-for-age GIRLS
"Adapted from the UNEPIMOH Immunization Schedule, 2022"
Vaccine Or Age Dose  Mode Of Mode Of Ad- Site Of AdAntigen Administration ministration ministration
BCG At birth 0-11 months: Intradermally Right Up-
Hepatitis At ml IM Intramus- Outer
Oral Polio 4 doses: 2 drops Orally Mouth
Inactivat- 2 doses: mL Intramus- Outer
ed Polio At 6 and cular aspect of
Administration Mode Of Administration Site Of Administration
mL Intradermally Right Upper Arm
life) ml IM Intramuscular Outer
Vaccine Or Age Dose  Mode Of Mode Of Ad- Site Of AdAntigen Administration ministration ministration
DPT- 3 doses: mL Intramus- Outer
PCV 3 doses: mL Intramus- Outer
Rota 2 doses: at 2 drops orally Slow admin
Measles 2 doses:At mL Subcutaneous Left Upper
Yellow fever At 9 months ml Subcutaneous Right Upper
All girls in HPV Give 2 doses IM 6 Intramuscular Left Upper
General principles of routine childhood immunization
 The aim is to ensure that all target age groups complete
their immunization schedule as above
" Age for vaccinations: Give each vaccine at the recommended age or if this is not possible, at any first contact"
"- Give this as early as possible in life, preferably at birth"
- Do NOT give BCG vaccine to any child with clinical signs
"and symptoms of immunosuppression, e.g. AIDS"
Administration Mode Of Administration Site Of Administration
14 weeks mL Intramuscular Outer
14 weeks mL Intramuscular Outer
10 weeks 2 drops orally Slow admin
months mL Subcutaneous Left Upper
Yellow fever At 9 months ml Subcutaneous Right Upper
months apart Intramuscular Left Upper
 Use each vaccine with its corresponding pre-cooled diluent
 Polio vaccination ( birth dose): This is a primer dose of
"oral polio vaccine (OPV), which should be given ideally at"
birth but otherwise in the first 2 weeks of life
- Is a combination of DPT vaccine  hepatitis B vaccine (HepB)
 haemophilus influenzae type b (Hib) vaccine
- Minimum interval between each of the doses is 4 weeks
 Given at 9 and 18 months of age or first contact after this age
 Can also be given to any unimmunised child of 6-9 months
 old who has been exposed to measles patients. Children vaccinated
in this way must have the vaccination repeated at 9 months of age
" Admit and treat any child who is severely ill, and vaccinate at the"
 Minor illness is not a contraindication to vaccination
 Screen clients at points of care and administer the due vaccines
 Screen clients for vaccine preventable diseases for investigation
Administration and storage of vaccines
" At health units, vaccines should be stored between 2C to"
 At the district and central vaccine stores (static units) where
"freezers exist, polio and measles rubella vaccines may be"
stored for prolonged periods at -20C
" Do not freeze DPT-HepB-Hib, PCV, IPV, HPV, hepatitis B,"
" Never freeze the diluents for BCG,yellow fever and measles"
 Use conditioned ice packs and sponge method for transport
Carefully follow recommended procedures to maintain the cold chain
 Ensure continuous supply of powergas
" Record fridge temperature twice daily (morning and evening,"
including weekendspublic holidays)
 Use sponge method during each immunization session
Reconstitution and administration
 Never use the diluents provided for vaccines to mix other
 Never use water for injection as a diluent for vaccine reconstitution
Do not vaccinate in direct sunlight (always carry out immunization in a building or under a shade)
 Record every vaccination in the child register and on a
tally sheet until child has completed all the antigens
 Use the child register and child health card for tracking
 A child who received any immunization dose during national immunization campaigns should still get the routine
- When the vaccine vial monitor (VVM) has changed to
"- If there has been contamination, or contamination is"
"- DPT-HepB-Hib, HebB, PCV,rotavirus vaccine, IPV, HPV,"
Adhere to the WHO recommended Multi-Dose Vial Policy
OPV and IPV Do not use vaccine if:
The VVM at or beyond discard point (stage 3 
Vials have been opened for 4 weeks
Vaccines have not been stored under cold chain
DPT-HepB- Do not use vaccine if:
"Hib, Hep B, Contaminated or has no label"
"TT,PCThe VVM is at or beyond discard point"
Vials have been opened for 4 weeks or more
Vaccines have not been stored under cold chain
"BCG,yellow  Discard remaining doses in the"
fever opened vials of these vaccines after 6
Rubella  of reconstitution or at the end of the
"immunization session, whichever"
Common non-serious side effects of vaccines and patient advice
VACCINE AND SIDE EFFECTS PATIENT ADVICE
BCG  The ulcer that forms at the
 Pain at injecexpected reaction that heals
by itself and leaves a permanent scar. It should not be
OPV and IPV Do not use vaccine if:
The VVM at or beyond discard point (stage 3 
Vials have been opened for 4 weeks
Vaccines have not been stored under cold chain
The VVM is at or beyond discard point
Vials have been opened for 4 weeks or more
Vaccines have not been stored under cold chain
Rubella  Discard remaining doses in the
opened vials of these vaccines after 6
 of reconstitution or at the end of the
"immunization session, whichever"
VACCINE AND SIDE EFFECTS PATIENT ADVICE
 Pain at injection site  The ulcer that forms at the
by itself and leaves a permanent scar. It should not be
VACCINE AND SIDE EFFECTS PATIENT ADVICE
"DPT-HepB-Hib, PCV  Do not apply anything to the"
at injection site:  Take paracetamol if necessary.
"swelling, pain,  If fever continues after 2 doses of"
"paracetamol, report to health facility"
24 hours of the  Wiping the child with a cool sponge or cloth
injection (with water at room temperature) is also good
"reactions  If seizures or severe rash difficulty in breathing occurs, return"
 Seizures to health facilty immediately
Oral Polio and Rotavirus  Dispose of the childs faeces
 Short-lived gasthrough the oral-faecal route
"symptoms (pain,  Wash hands thoroughly after"
"diarrhoea, irrita- changing the babys nappies"
InactivatedInjectable Polio  Side effects usually mild and
and swelling at  Take paracetamol if necessary
 If fever continues after 2 doses
" Fever, headache, of paracetamol, report to health"
 Irritability in  Report any severe reaction to
infants health worker immediately
Measles rubella  Child may get a mild skin
injection site  Do not apply anything to
VACCINE AND SIDE EFFECTS PATIENT ADVICE
"DPT-HepB-Hib, PC Mild reactions"
 Seizures  Do not apply anything to the
 If fever continues after 2 doses of
"paracetamol, report to health facility"
 Wiping the child with a cool sponge or cloth
(with water at room temperature) is also good
" If seizures or severe rash difficulty in breathing occurs, return"
"diarrhoea, irritation)  Dispose of the childs faeces"
 vomiting  Side effects usually mild and
 If fever continues after 2 doses
"of paracetamol, report to health"
vaccine  Child may get a mild skin
VACCINE AND SIDE EFFECTS PATIENT ADVICE
Yellow fever  Side effects may occur
munization; they are usuredness at injecally mild and should not
"redness, itch-  Report to health worker"
"ing, bruising or immediately any severe"
Tetanus Toxoid (TT)  Side effects may occur
 Irritation at injecmunization; they are usution site
"Hep B Vaccine  If fever develops, give"
" Since 2005, children are immunised against Hepatitis B in"
"the routine childhood immunization using the DPT-HepBHib vaccine at 6, 10, and 14 weeks of age"
VACCINE AND SIDE EFFECTS PATIENT ADVICE
after the vaccine  Side effects may occur
within 12 days of immunization; they are usually mild and should not
"aches, nausea  Side effects usually mild"
" Fever, malaise  Side effects may occur"
within 12 days of immunization; they are usually mild and should not
" For adolescents and adults, it is recommended that the"
hepatitis B vaccination is given preferably after testing for
hepatitis B infection (HBsAg and Anti-HBs). Patients with
HIV and pregnant women should be handled on a case by
" Vaccination is recommended for high risk groups, e.g:"
- Health workers in clinical settings and training
- Persons who frequently receive blood transfusions
- Recipients of solid organ transplantation
- Partners and household contacts of HBsAg positive patients
- Support staff in health facilities
" The schedule has three doses: at 0, 1 month after 1st"
"dose, and 6 months after first dose (0, 1, 6 months)"
 The storage temperature for the vaccine is 2C to 8C
 Dose: mL given intramuscularly on the deltoid muscle (upper arm)
 Do NOT give vaccine on the buttocks because of low immune
response (decreased protective antibody response) and risks of
"The yellow fever vaccine is live attenuated, and it is reconstituted before"
"use. Ideally, it should be used within 6 hours after reconstitution."
 Dose: mL given intramuscularly on the upper arm as
 The storage temperature for the vaccine is 2C to 8C
 Immunity is life-long and international travel certificateis
issued once and valid for life.
 All children should be vaccinated against tetanus during
routine childhood immunization using the DPT-HepB-Hib
"vaccine at 6, 10, and 14 weeks of age (see above)"
 Neonatal tetanus is prevented by routinely immunising all
pregnant womenwomen of child- bearing age (1545
years) against tetanus with Tetanus Toxoid vaccine (see
18.Prophylaxis Against Neonatal Tetanus
" Ensure hygienic deliveries, including proper cutting and"
care of umbilical cords through the use of skilled birth
 Immunise all pregnant womenwomen of child- bearing
age (15  45 years) against tetanus with Tetanus Toxoid
 Give TT vaccine mL IM into the upper arm as per the
RoutineT Tv accine schedule and the period of protection
TT DOSE WHEN GIVEN DURATION AND
Td1 At first contact with woman of childbearing None
age or as early as possible during pregnancy
Td2 At least 4 weeks after Td1 3 years;
At least 6 months after Td2 5 years;
Td4 At least 1 year after Td3 10 years;
Td5 At least 1 year after Td4 30 years;
Vaccination Against Adult Tetanus
" High risk groups such as farm workers, military personnel, miners, safe male circumcision clients, should be vaccinated as in the table above (if not fully immunized) and"
given regular boosters every 10 years
TT DOSE WHEN GIVEN DURATION AND
Td1 At first contact with woman of childbearing
age or as early as possible during pregnancy None
Td2 At least 4 weeks after Td1 3 years;
Td3 At least 6 months after Td2 5 years;
Td4 At least 1 year after Td3 10 years;
Td5 At least 1 year after Td4 30 years;
 Patients at risk of tetanus as a result of contaminated
"wounds, bites, burns, and victims of road traffic accidents"
be given Antitetanus Immunoglobulin (TIG) and then be
vaccinated as indicated in the table below
 Ensure adequate surgical toilet and proper care of wounds
"Passive immunization: give to any patient at risk, except if"
fully immunized and having had a booster within the last 10
 Give IM tetanus immunoglobulin human (TIG):
 Double the dose if heavy contamination suspected or if 24 hours
Alternative - only if TIG not available:
" Antitetanus serum (tetanus antitoxin) 1,500 IU deep SC or IM"
Unimmunised or partially immunised patients:
 Give a full course of vaccination for those who are not immunized at
all (3 doses mL IM at intervals of 4 weeks)
Fully immunized patients with booster 10 years before:
 Give one booster dose of TT mL intramuscularly
Fully immunised patients who have had a booster dose within
 Giving TIG or TT to a fully immunised person may cause
"an unpleasant reaction, e.g., redness, itching, swelling, and"
"fever, but with a severe injury this is justified"
 Ensure adequate surgical toilet and proper care of wounds
"Passive immunization: give to any patient at risk, except if"
fully immunized and having had a booster within the last 10
 Give IM tetanus immunoglobulin human (TIG):
 Double the dose if heavy contamination suspected or if 24 hours
Alternative - only if TIG not available:
" Antitetanus serum (tetanus antitoxin) 1,500 IU deep SC or IM HC3"
Unimmunised or partially immunised patients:
 Give a full course of vaccination for those who are not immunized at
all (3 doses mL IM at intervals of 4 weeks)
Fully immunized patients with booster 10 years before:
 Give one booster dose of TT mL intramuscularly
Fully immunised patients who have had a booster dose within
 Giving TIG or TT to a fully immunised person may cause
"an unpleasant reaction, e.g., redness, itching, swelling, and"
"fever, but with a severe injury this is justified "
 for children 5years -12 with parental consent
Table showing vaccines and respective dosing and schedules
 A booster dose that can be administered at least 6 months
after completion of the primary series is recommended for
"all those aged 50 years and above, health workers, teachers both in pre-primary, primary, secondary, and tertiary"
"institutions, religious leaders, cultural leaders, security personnel, media personnel, drivers and conductors of public"
"transport vehicles, boda boda riders, bar and night club"
"workers, market workers and vendors"
Table: COVID Vaccine Matching and mixing (heterologous
primary schedules) Booster dosing
First Dose Second Dose OR Booster
1 AstraZeneca Pfizer or Moderna
4 Sinopharm AstraZeneca or Pfizer or Moderna
 First Dose Second Dose OR Booster
1 AstraZeneca Pfizer or Moderna
4 Sinopharm AstraZeneca or Pfizer or Moderna
First Dose Second Dose OR Booster
5 Sinovac AstraZeneca or Pfizer or Moderna
6 Johnson  Johnson Pfizer or Moderna
"Nutrition is the intake of food, considered in relation to the bodys"
"dietary needs. Good nutrition  an adequate, well balanced diet combined with regular physical activity  is a cornerstone of good health."
"Poor nutrition can lead to reduced immunity, increased susceptibility"
"to disease, impaired physical and mental development, and reduced"
"Optimal nutrition means obtaining a balance of macronutrients (carbohydrates, proteins and fats) and micronutrients (vitamins and minerals)."
"Macronutrients provide energy for organ and tissue functions and growth,"
and micronutrients are needed in small amounts for chemical processes in
"the body such as metabolism, growth, and protection against infections."
"In addition, plenty of water is needed to build cells and regulate body"
 First Dose Second Dose OR Booster
5 Sinovac AstraZeneca or Pfizer or Moderna
6 Johnson  Johnson Pfizer or Moderna
NUTRITION GUIDELINES IN SPECIAL POPULATIONS
Infant and Young Child Feeding (IYCF)
1. Counsel and support all mothers to initiate breastfeeding within an
hour of delivery and exclusively breastfeed their infants for the first
"six months of life, unless medically contraindicated."
"2. Teach mother correct positioning and attachment for breastfeeding,"
"how to express and store breast milk hygienically, and how to feed"
"3. Counsel and support parents to introduce adequate, safe, and appropriate complementary foods at 6 months of age, and to continue"
breast feeding until the child is 2 years.
4. A good diet should be adequate in quantity and include an energy-rich
"food (e.g. thick cereal with added oil, meat, fish, eggs, legumes,"
5. Pregnant women and lactating mothers should consume adequate
6. Recommend exclusive breastfeeding for infants of HIV-infected
"women for the first 6 months unless the replacement is acceptable,"
"feasible, affordable, sustainable, and safe (AFASS)."
7. Malnourished children should be provided with appropriate medical
"care, nutritional rehabilitation, and follow-up."
8. Encourage mothers of low birth weight infants who can suckle to
breastfeed. Assist those who cannot breastfeed to express breast
"9. During illness, children should take increased fluids: breastfeed"
"more often, increase amount of milk given, increase fluid intake"
"(e.g. soups, yoghurt, and drinking water). Extra fluid in diarrhoea"
10. For more information on feeding recommendations in infants and
"young children, see IMCI section 17.888"
Good nutrition in HIVAIDS is important as it helps to:
 Prevent malnutrition and wasting
 Delay the progress of HIV to AIDS
 Enhance the bodys ability to fight opportunistic infections
 Achieve and maintain optimal body weight and strength
"Relieve complications, e.g., diarrhoea, nausea, vomiting, thrush"
 Improve effectiveness and tolerance of medication
Severe malnutrition is diagnosed when:
 Weight loss 10 in past 2 months
 MUAC 185 mm (210 mm if pregnant or postpartum)
If patient has other complications HC4
 Admit patient and treat infections and rehydrate
If patient has no other medical complications
" Promote weight gain with high-energy foods, protein,"
" If ready-to-use therapeutic food is available, give 3 sachets Supplement the patients diet with multivitamins"
"and minerals, 1-2 tablets per day e.g, a combination of"
selenium and molinga has been proven to be beneficial
"per day in adults, in addition to normal food"
- See next section for malnutrition in children
" Follow up in 2 weeks, at 1 month, then every 2 months"
If patient has other complications
 Admit patient and treat infections and rehydrate
If patient has no other medical complications
" Promote weight gain with high-energy foods, protein,"
" If ready-to-use therapeutic food is available, give 3 sachets Supplement the patients diet with multivitamins"
"and minerals, 1-2 tablets per day e.g, a combination of"
selenium and molinga has been proven to be beneficial
"per day in adults, in addition to normal food"
- See next section for malnutrition in children
" Follow up in 2 weeks, at 1 month, then every 2 months"
People with diabetes should follow normal nutritional guidelines for the
"general population, and can eat the same foods as the whole family since"
everyone benefits from healthy eating.
Healthy eating and exercise in diabetics help to:
 Maintain the blood glucose close to normal to prevent complications
" Control blood pressure, and reduce the risk of complications such"
"In addition, diabetics have to take care to balance their food with insulin"
and oral antidiabetic medications to help manage their blood glucose levels.
"Healthy diet involves eating a variety of foods including vegetables, whole"
"grains, fruits, non-fat dairy products, beans, lean meat, poultry, and fish."
"These are rich in vitamins, minerals and fibre. Avoid processed foods."
" Eat three meals a day. Avoid skipping meals, and space out"
"breakfast, lunch, and evening meal over the day"
" At each meal, include moderate amount (around 13 of"
"the plate) of starchy carbohydrate foods, e.g., bread, pasta,"
"chapatis, potatoes, yams, noodles, rice, and cereals. Eat"
"more slowly absorbed (low glycaemic index) foods, e.g.,"
"pasta, rice, sweet potato and yam, porridge oats, bran, and"
" Reduce fat in the diet, especially saturated fats. Use unsaturated fats or oils e.g. olive oil, sunflower oil"
 Eat more fruit and vegetables. Aim for at least five portions
a day. Eat more beans and lentils.
 Reduce salt in the diet to 6 g or less per day
 Drink alcohol only in moderation: 1 drink (one beer or one
small glass of wine or one shot of spirit) for women and
2 for men as a maximum amount daily. Alcohol has some cardioprotective effect. It should be consumed with food to prevent hypoglycaemia
" Dont use products marketed as diabetic foods, drinks or"
herbs (they are expensive and of no benefit)
" Routine supplementation with vitamins and minerals without underlying actual deficiency is not beneficial, patients"
"should eat lots of fruits and vegetables e.g, a combination"
of selenium and molinga has been proven to be beneficial
 Obese and overweight patients need to be encouraged to
reduce weight using exercise and diet modifications
MALNUTRITION ICD10 CODE: E40-43
Malnutrition is the cellular imbalance between the supply of nutrients
"and energy and the bodys demand for them to ensure growth, maintenance, and specific functions. It includes both under- and over nutrition."
"However, the term malnutrition commonly refers to"
"undernutrition, and is used as such in these guidelines."
"Although malnutrition can affect all ages, however, the early stages,"
"including, foetus, infants and children, are most vulnerable to the effects"
of undernutrition during the period of their most rapid physical growth
and development during the first two years of life.
Malnutrition is a significant contributor to morbidity and mortality
among children under 5 years in Uganda. It also makes the prognosis
" Previously, malnutrition was classified into two types: 1) ProteinEnergy Malnutrition (PEM) due to lack of adequate protein and"
energy in the diet and 2) Micronutrient malnutrition-due to
deficiencies in specific micronutrients (vitamins and minerals).
 These causal names are now avoided because protein and
energy deficits are likely to be accompanied by deficiencies of
"other nutrients, and management of malnutrition takes this"
Causescontributing factors to malnutrition
 Immediate causes: diet and disease
 Inadequate quantity and quality of food
" Lack of knowledge on appropriate foods provided to children,"
"poor food preparation, food taboos"
" Infections: reduce appetite, increase energy and nutrient utilisation,"
"and limit the ability to absorb or retain nutrients e.g. in diarrhoea,"
" Root causes: food insecurity, poor health services, poor"
"environmental sanitation, natural disasters, excessive"
"workload for women, poor weaning practices, culture, inadequate water supply, low literacy levels, low nutrition"
" Underlying causes: poverty, corruption, poor governance,"
" Impaired growth, physical and mental and development"
 Impaired body resistanceimmune system
 Increased risk of adult chronic diseases
 Increased risk for the cycle of inter-generational malnutrition
 Poor economic well-being for the individual and country
" Malignancy (e.g., gastrointestinal tract cancer, liver cancerhepatocellular carcinoma)"
19.Classification of Malnutrition
"Acute  Is an indicator of current nutritional status,"
reflecting recent weight changes or disruption in nutrient intake
 Most appropriate indicator to use in an
emergency setting (e.g. due to sudden
 Associated with loss of body fat and severe
 Children are thinner than their comparable
 Classified as Moderate or Severe based on
"anthropometry (measurement of the size,"
"weight and proportions of the human body),"
biochemistry and clinical assessment
Chronic  Is an indicator of the nutritional status overtime; chronically malnourished children are
shorter (stunted) than their comparable age
Clinical features of malnutrition
" Marasmus: severe wasting, old mans face, excess skin"
"hangs around the buttocks, ribs and zygoma bones are"
"prominent, scapular blades and extremities (limbs), eyes"
"- Apathetic or irritable, appetite is fairly good, skin is almost"
"normal, hair demonstrates some changes but not as dramatic"
"as in Kwashiorkor, organomegaly is rare (liver and spleen"
" Kwashiakor: pitting feet oedema, skin desquamation, hair"
"changes, presence of bilateral pitting oedema (oedema of"
"Acute  Is an indicator of current nutritional status,"
reflecting recent weight changes or disruption in nutrient intake
 Most appropriate indicator to use in an
emergency setting (e.g. due to sudden
 Associated with loss of body fat and severe
 Children are thinner than their comparable
 Classified as Moderate or Severe based on
"anthropometry (measurement of the size,"
"weight and proportions of the human body),"
biochemistry and clinical assessment
Chronic  Is an indicator of the nutritional status overtime; chronically malnourished children are
shorter (stunted) than their comparable age
" Appears adequately nourished due to excess extra cellular fluid,"
"but is very miserable, apathetic"
" Skin changes (dermatosis, flacky paint dermatitis)"
" Hair changes: Silky, straight, sparsely distributed; easily, painlessly"
" Severe pallor of the conjunctiva, mucous membranes, palms, and"
"soles, loss of skin turgor (dehydration)"
" Organomegaly (liver, spleen) is common"
" Marasmus-kwashiakor: most common form, presents with"
features of both Marasmus and Kwashiorkor
19.Assessing Malnutrition in Children 6 months to 5 years
The 4 key features used to diagnose acute malnutrition are:
 Weight-for-HeightLength (WFHL) using WHO growth standards
charts (see section 15.5). It is the best indicator for diagnosing
 Mean Upper Arm Circumference (MUAC) in mm using a measuring
 Oedema of both feet (kwashiorkor with or without severe wasting)
 Appetite test: ability to finish portion of ready-to-use therapeutic
WEIGHT FOR AGE (WFA) reflects both long term (stunting) and
"short term (wasting) nutritional status, so it is not very useful for"
diagnosis of acute malnutrition.
"It can also miss out oedematous children, who are very malnourished"
but may have a near-normal weight because of fluid retention.
Moderate Acute  WFHL between -3 and -2 z-scores
Severe Acute Without complications
 Oedema of both feet (kwashiorkor
with or without severe wasting) OR
- Medical complication present OR
Specific micronu-  Vitamin A: xerophthalmia
 Vitamin B12 and folic acid: megaloblastic anaemia (see section
 Iron: iron-deficiency anaemia (see
Malnutrition  WFHL between -3 and -2 z-scores
Malnutrition Without complications
 Oedema of both feet (kwashiorkor
with or without severe wasting) OR
- Medical complication present OR
Specific micronutrient deficiencies  Vitamin A: xerophthalmia
 Vitamin B12 and folic acid: megaloblastic anaemia (see section
 Iron: iron-deficiency anaemia (see
Children with SAM should always be first assessed with a full clinical
"examination to confirm presence of any danger sign, medical complications, and tested for appetite."
" Recent intake of food, loss of appetite, breastfeeding"
 Usual diet before current illness (compare the answers to the Feeding
Recommendations for the Childs age (section 17.3.12.3)
" Duration, frequency and type of diarrhoea and vomiting"
 Cough 2 weeks and contact with TB
 Known or suspected HIV infectionexposure
 Initial examination for danger signs and medical complications:
" Shock: lethargy or unconscious, cold hands, slow capillary refill (3"
"seconds), weak pulse, low blood pressure"
" Eye signs of vitamin A deficiency: dry conjunctiva, corneal ulceration,"
" Local signs of infection: ear, throat, skin, pneumonia"
 Signs of HIV (see WHO Clinical Staging section 3.1.1)
 Fever (³37.5C) or hypothermia (rectal temp 35.5C)
" Skin changes of kwashiorkor: hypo- or hyperpigmentation, desquamation, ulcerations all over the body, exudative lesions (resembling"
burns) with secondary infection (including candida)
"- Complete blood count or Hb, malaria, HIV, electrolytes"
"- Stool microscopy for ova and cysts, occult blood, and"
 Chest X-ray: Look for evidence of tuberculosis or other chest
- Assess all children ³6 months for appetite at the initial visit
and at every follow up visit to the health facility
 Arrange a quiet corner where the child and mother can take
their time to eat RUTF. Usually the child eats the RUTF portion
 The purpose of assessing the childs appetite
- Wash hands before giving RUTF
- Sit with child and gently offer RUTF
- Encourage child to eat without feeding by force
- Offer plenty of water to drink from a cup during RUTF feeding
Offer appropriate amount of RUTF to child to eat:
" After 30 minutes, check if the child was able to finish or not able"
to finish the amount of RUTF given and decide:
- Child ABLE to finish at least one third of a packet of RUTF portion
(92 g) or 3 teaspoons from a pot within 30 minutes
- Child NOT ABLE to eat one-third of a packet of RUTF portion (92 g)
or 3 teaspoons from a pot within 30 minutes
 Determine WFHL: Measure the childs height and weight and
plot the score on the appropriate chart (boy or girl). Match the
value to the z-score on the right y-axis to determine the childs
" Measure MUAC: Using a MUAC tape, measure the circumference"
 Arrange a quiet corner where the child and mother can take
their time to eat RUTF. Usually the child eats the RUTF portion
 The purpose of assessing the childs appetite
- Wash hands before giving RUTF
- Sit with child and gently offer RUTF
- Encourage child to eat without feeding by force
- Offer plenty of water to drink from a cup during RUTF feeding
Offer appropriate amount of RUTF to child to eat:
" After 30 minutes, check if the child was able to finish or not able"
to finish the amount of RUTF given and decide:
- Child ABLE to finish at least one third of a packet of RUTF portion
(92 g) or 3 teaspoons from a pot within 30 minutes
- Child NOT ABLE to eat one-third of a packet of RUTF portion (92 g)
or 3 teaspoons from a pot within 30 minutes
of the childs upper arm and plot the score on the appropriate
"chart (boy or girl, section 17.5). Please note: 1 cm10 mm, so"
Management of Acute Malnutrition in Children
General principles of management
" Admit all children with any danger sign, medical complications, pitting oedema or those who fail appetite tests for"
inpatient care and treatment for complicated SAM.
" Keep them in a warm area separated from infectious children, or"
 Children with good appetite and no medical complications
can be managed as outpatients for uncomplicated SAM.
 Adequate facilities and staff to ensure correct preparation
"of therapeutic foods, and to feed child regularly day and"
 Accurate weighing machines and MUAC tapes should be
 Proper records of feeds given and childs measurements
should be kept so that progress can be monitored
 Explain to patientcare-giver to handle the child gently
19.Management of Moderate Acute Malnutrition
 Assess the childs feeding and counsel the mother on HC3
" If child has any feeding problem, counsel and follow up"
in 7 days (see section 17.3.12.4)
 Assess for possible TB infection
 Advise mother when to return immediately (danger signs)
 Assess the childs feeding and counsel the mother on
" If child has any feeding problem, counsel and follow up"
in 7 days (see section 17.3.12.4) HC3
 Assess for possible TB infection
 Advise mother when to return immediately (danger signs) 
"- If better, praise mother and counsel on nutrition"
"- If still moderate malnutrition, counsel and follow"
"- If worse, loosing weight, or feeding problem:"
19.Management of Uncomplicated Severe Acute
 Give oral antibiotics: amoxicillin DT 40 mgkg twice HC3
 Give ready-to-use therapeutic food (RUTF) for a child
"aged ³ 6 months (for doses, see next section)"
 Counsel the mother on how to feed the child (see
 Assess for possible TB infection
 Advise mother when to return immediately (danger signs)
" Reassess child and feeding. If no new problem,"
After 14 days or during regular follow up:
" Do a full reassessment of the child: check WFHL,"
"MUAC, oedema of both feet and do another appetite test"
If the child has complicated SAM
If the child has uncomplicated SAM
"- If better, praise mother and counsel on nutrition"
"- If still moderate malnutrition, counsel and follow"
"- If worse, loosing weight, or feeding problem:"
 Give oral antibiotics: amoxicillin DT 40 mgkg twice
 Give ready-to-use therapeutic food (RUTF) for a child
"aged ³ 6 months (for doses, see next section)"
 Counsel the mother on how to feed the child (see
 Assess for possible TB infection
 Advise mother when to return immediately (danger signs) HC3
" Reassess child and feeding. If no new problem,"
After 14 days or during regular follow up:
" Do a full reassessment of the child: check WFHL,"
"MUAC, oedema of both feet and do another appetite test"
If the child has complicated SAM
If the child has uncomplicated SAM 
 Counsel the mother and encourage her to continue
with appropriate RUTF feeding. Ask mother to return
If the child has moderate acute malnutrition:
 Advise the mother to continue RUTF. Counsel her
to start other foods according to the age appropriate
feeding recommendations (see section 17.3.12.3)
 Tell her to return in 14 days. Continue to see the
child every 14 days until the child has no more acute
If the child has no acute malnutrition (WFHL is -2
"z-scores or more, or MUAC is 125 mm or more)"
" Praise the mother, STOP RUTF and counsel her about"
age appropriate feeding recommendations
19.Management of Complicated Severe Acute Malnutrition
 Refer child to hospital: prevent hypoglycaemia by giving
"small sips of sugar water, keep the child warm, first dose"
of antibiotics (ampicillin  gentamicin)
 Triage the children to fast-track seriously ill patients for
"assessment and care: treat shock, hypoglycaemia, and"
"corneal ulceration, immediately"
 General treatment involves 10 steps in two phases: initial
stabilisation for 1 week and rehabilitation (for weeks 2-6)
ISSUE STABILISATION REHABILITATION
 Counsel the mother and encourage her to continue
with appropriate RUTF feeding. Ask mother to return
If the child has moderate acute malnutrition:
 Advise the mother to continue RUTF. Counsel her
to start other foods according to the age appropriate
feeding recommendations (see section 17.3.12.3)
 Tell her to return in 14 days. Continue to see the
child every 14 days until the child has no more acute
If the child has no acute malnutrition (WFHL is -2
"z-scores or more, or MUAC is 125 mm or more)"
" Praise the mother, STOP RUTF and counsel her about"
age appropriate feeding recommendations 
ISSUE STABILISATION REHABILITATION
ISSUE STABILISATION REHABILITATION
Micronutrients No iron With iron
" Iron is given after 2 days on F-100; if patient is taking RUTF,"
Management of Complications in SAM
Hypoglycaemia (Blood sugar 3 mmolL or 54 mgdL)
" All severly malnourished children are at a risk of hypoglycaemia, and should be given a feed or 10 glucose or"
"sucrose, immediately on admission"
 Frequent 2 hour feeding is important
 Give 50 ml of glucose or sugar water (one rounded teaspoon of
"sugar in 3 tablespoons of water) orally or by NGT, followed by"
" Give first feed of F-75 therapeutic milk, if available, every 30 minutes for 2 hours, then continue with feeds"
"- Then give feeds every 2 or 3 hours, day and night"
 Treat with IV 10 glucose at 5 mlkg
" If IV access cannot be quickly established, give 10 glucose or"
"sucrose solution by NGT tube. To make 10 solution, dilute 1"
part of 50 glucose with 4 parts of water OR 1 part of glucose
ISSUE STABILISATION REHABILITATION
Micronutrients No iron With iron
" Iron is given after 2 days on F-100; if patient is taking RUTF,"
 Give 50 ml of glucose or sugar water (one rounded teaspoon of
"sugar in 3 tablespoons of water) orally or by NGT, followed by"
" Give first feed of F-75 therapeutic milk, if available, every 30 minutes for 2 hours, then continue with feeds"
"- Then give feeds every 2 or 3 hours, day and night"
 Treat with IV 10 glucose at 5 mlkg
" If IV access cannot be quickly established, give 10 glucose or"
"sucrose solution by NGT tube. To make 10 solution, dilute 1"
part of 50 glucose with 4 parts of water OR 1 part of glucose
"- If IV glucose not available, give 1 teaspoon of sugar"
"moistened with 1-2 drops of water sublingually, and"
repeat every 20 minutes to prevent relapse
- Monitor children for early swallowing which delays
"- absorption; if it happens, give another dose of sugar"
- Start on appropriate IVIM antibiotics
"If initial blood glucose was low, repeat measurement after 30 minutes"
" If blood glucose falls to 3 mmolL (54 mgdL), repeat the"
"10 glucose or oral sugar solution, and ensure antibiotics have"
"- If it is higher, change to 3 hourly feeds of F-75"
" If rectal tempearture falls to 35.5C, or if level of consciousness"
"deteriorates, repeat the blood glucose measurement and treat"
" Feed every 2 hours, starting immediately (see below), or if child is"
"dehydrated, rehydrate first. Continue feeding throught the night"
" Encourage mothers to watch for any deterioration, help feed"
Hypothermia (Axillary temperature 35C and rectal temperature 35.5C)
 Often associated with hypoglycaemia or serious infection
 Feed child immediately as in hypoglycaemia above
" Warm the child: make sure the child is well covered, especially"
"the head, with cloths, hats, and blankets"
"- If available, use a heater but not pointing directly at the"
child. DO NOT use hot water bottles or flourescent lamps
 Encourage caretakermother to sleep next to her child and
"kangaroo technique for infants (skin-to-skin contact, direct heat"
warmth transfer from mother to child)
"- If IV glucose not available, give 1 teaspoon of sugar"
"moistened with 1-2 drops of water sublingually, and"
repeat every 20 minutes to prevent relapse
- Monitor children for early swallowing which delays
"- absorption; if it happens, give another dose of sugar"
- Start on appropriate IVIM antibiotics
"If initial blood glucose was low, repeat measurement after 30 minutes"
" If blood glucose falls to 3 mmolL (54 mgdL), repeat the"
"10 glucose or oral sugar solution, and ensure antibiotics have"
"- If it is higher, change to 3 hourly feeds of F-75"
" If rectal tempearture falls to 35.5C, or if level of consciousness"
"deteriorates, repeat the blood glucose measurement and treat"
" Feed every 2 hours, starting immediately (see below), or if child is"
"dehydrated, rehydrate first. Continue feeding throught the night"
" Encourage mothers to watch for any deterioration, help feed"
 Feed child immediately as in hypoglycaemia above
" Warm the child: make sure the child is well covered, especially"
"the head, with cloths, hats, and blankets"
"- If available, use a heater but not pointing directly at the"
child. DO NOT use hot water bottles or flourescent lamps
 Encourage caretakermother to sleep next to her child and
"kangaroo technique for infants (skin-to-skin contact, direct heat"
warmth transfer from mother to child)
 Keep the ward closed during the night and avoid wind drafts inside
 Give appropriate IV or IM antibiotics
" Change wet nappies, clothes and bedding to keep child and"
 Quickly clean the patient with a warm wet towel and dry immediately. Avoid washing the baby directly in the first few weeks
 Take childs rectal temperature every 2 hours until it rises to
"36.5C, If using a heater, take it every 30 minutes"
" Cover the child at all times, especially at night. Keep head covered with hat to prevent heat loss"
" In both oedema and non-oedematous SAM, the margin"
of safety between dehydration and over-hydration is very
narrow. Exercise care and caution to avoid over-hydration
 Assume that all children with watery diarrhoea or reduced urine
" Do NOT use IV route for rehydration, except in cases of shock"
" Rehydrate slowly, either orally or by NGT using ReSoMal, a specially prepared"
"rehydration solution for malnutrition, The standard ORS has a high sodium"
"and low potassium content, which is not suitable for SAM, except if profuse"
 Give ReSoMal more slowly than you would when rehydrating a
- Give 5 mlkg every 30 minutes for the first 2 hours
"- Then give 5-10 mlkg per hour for the next 4-10 hours, with F-75"
"formula. Exact amount depends on how much the child wants, the"
volume of stool loss and whether the child is vomiting
"- Give half strength standard ORS, with added potassium and glucose as"
"per the ReSoMal recipe below, unless the child has cholera or profuse"
 Keep the ward closed during the night and avoid wind drafts inside
 Give appropriate IV or IM antibiotics
" Change wet nappies, clothes and bedding to keep child and"
 Quickly clean the patient with a warm wet towel and dry immediately. Avoid washing the baby directly in the first few weeks
 Take childs rectal temperature every 2 hours until it rises to
"36.5C, If using a heater, take it every 30 minutes"
" Cover the child at all times, especially at night. Keep head covered with hat to prevent heat loss"
" Do NOT use IV route for rehydration, except in cases of shock"
" Rehydrate slowly, either orally or by NGT using ReSoMal, a specially prepared"
"rehydration solution for malnutrition, The standard ORS has a high sodium"
"and low potassium content, which is not suitable for SAM, except if profuse"
 Give ReSoMal more slowly than you would when rehydrating a
- Give 5 mlkg every 30 minutes for the first 2 hours
"- Then give 5-10 mlkg per hour for the next 4-10 hours, with F-75"
"formula. Exact amount depends on how much the child wants, the"
volume of stool loss and whether the child is vomiting
"- Give half strength standard ORS, with added potassium and glucose as"
"per the ReSoMal recipe below, unless the child has cholera or profuse"
"- If rehydration still required at 10 hours, give starter F-75"
"- Instead of ReSoMal, at the same times. Give the same volume of"
"If child is unconscious, in shock or severe dehydration"
" Give IV fluid Darrows solution or Ringers lactate and 5 glucose (or if not available, ½ saline and 5 glucose at 15 mLkg the first hour and reassess"
"- If improving, give 15 mLkg in second hour"
"- If conscious, give NGT ReSoMal"
"- If not improving, treat for septic shock"
 ONLY rehydrate until the weight deficit is corrected and then
"STOP, DO NOT give extra fluid to prevent recurrence (from"
" During rehydration, respiration and pulse rate should fall and"
" Return of tears, moist mouth, improved skin tugor and less sunken eyes and fontanelle are a sign of rehydration. SAM children"
will not show these and so weight gain should be measured
" Monitor progress of rehydration every 30 minutes for 2 hours,"
then every hour for the next 4-10 hours
"Be alert for signs of overhydration, which is dangerous and can lead to"
- Weight gain (make sure it is not quick or excessive)
"- If increase in pulse rate by 25minute, respiratory rate by 5minute is"
"present, stop ReSoMal. Reassess after 1 hour"
- Urine frequency (if child urinated since last check)
- Enlarging liver size on palpation
- Frequency of stools and vomit
" Same as in dehydration in well-nourished child, except that ReSoMal is used"
instead of standard ORS. Give 30-50 ml of ReSoMal (for child 2 years) and 100
ml (for child ³2 years) after each watery stool.
"- Small, frequent, unformed stools are common in SAM and should"
"not be confused with profuse watery stools, and they do not require"
"- If rehydration still required at 10 hours, give starter F-75"
"- Instead of ReSoMal, at the same times. Give the same volume of"
"If child is unconscious, in shock or severe dehydration"
" Give IV fluid Darrows solution or Ringers lactate and 5 glucose (or if not available, ½ saline and 5 glucose at 15 mLkg the first hour and reassess"
"- If improving, give 15 mLkg in second hour"
"- If conscious, give NGT ReSoMal"
"- If not improving, treat for septic shock"
 ONLY rehydrate until the weight deficit is corrected and then
"STOP, DO NOT give extra fluid to prevent recurrence (from"
" During rehydration, respiration and pulse rate should fall and"
" Return of tears, moist mouth, improved skin tugor and less sunken eyes and fontanelle are a sign of rehydration. SAM children"
will not show these and so weight gain should be measured
" Monitor progress of rehydration every 30 minutes for 2 hours,"
then every hour for the next 4-10 hours
"Be alert for signs of overhydration, which is dangerous and can lead to"
- Weight gain (make sure it is not quick or excessive)
"- If increase in pulse rate by 25minute, respiratory rate by 5minute is"
"present, stop ReSoMal. Reassess after 1 hour"
- Urine frequency (if child urinated since last check)
- Enlarging liver size on palpation
- Frequency of stools and vomit
" Same as in dehydration in well-nourished child, except that ReSoMal is used"
instead of standard ORS. Give 30-50 ml of ReSoMal (for child 2 years) and 100
ml (for child ³2 years) after each watery stool.
"- Small, frequent, unformed stools are common in SAM and should"
"not be confused with profuse watery stools, and they do not require"
 Initiate re-feeding with starter F-75
 Give ReSoMal between feeds to replace stool lossess.
Give 50-100 ml after each watery stool
Recipe for ReSoMal using the standard WHO ORS
Electrolytemineral solution 40 ml
" All SAM children have deficiencies of potassium and magnesium, which may take up to 2 weeks to correct"
 Oedema is partly due to potassium deficiency and sodium
 Do not treat oedema with diuretics
 Giving high sodium doses could kill the child
 Give extra potassium (3-4 mmolkg per day) f Give extra magnesium (0.4-mmolkg per day) f Add extra potassium and
"magnesium to the feeds. If not already pre-mixed, add 20 ml of"
"the combined electrolytemineral solution to 1 litre of feed, or"
 Prepare food without added salt
" In SAM, usual signs of bacterial infection, e.g. fever, are"
"usually absent, yet multiple infections are common."
" Assume all SAM cases have an infection, and treat with"
Electrolytemineral solution 40 ml
 Give extra potassium (3-4 mmolkg per day) f Give extra magnesium (0.4-mmolkg per day) f Add extra potassium and
"magnesium to the feeds. If not already pre-mixed, add 20 ml of"
"the combined electrolytemineral solution to 1 litre of feed, or"
 Prepare food without added salt
antibiotics immediately. Hypoglycaemia and hypothermia
are often signs of severe infection
" Benzylpenicillin 50,000 IUkg IM or IV every 6 hours Or ampicillin 50 mgkg every 6 hours for 2 days f Then, oral amoxicillin"
 Gentamicin mgkg once a day for 7 days
" If child is ³ 6 months and not vaccinated, or was vaccinated"
before 9 months of age. Delay vaccination if child is in shock
" Treat other specific infections if diagnosed as appropriate, e.g.,"
"malaria, pneumonia, dysentery, soft- tissue infections, mengingitis, TB, H If parasitic worms are diagnosed, delay treatment until the rehabilitation phase. Give albendazole 200-400 mg single dose"
"- In endemic areas, give mebendazole orally twice a day"
- for 3 days to all SAM children 7 days after admission
"- If HIV diagnosed, start ART as soon as possible after"
stabilisation of metabolic compilcations
" If child is still anorexic after 7 days of antibiotic treatment, continue"
"for a full 10-day course. If anorexia persists, reassess child fully"
 All SAM children have vitamin and mineral deficiencies
" Anaemia is common, but DO NOT give iron initially, instead wait until the child has a good appetite and has started gaining weight, usually in the second week, because iron"
 RUTF already contains adequate iron so do not add. F-100 does
"not contain iron, so iron supplements are needed"
" Benzylpenicillin 50,000 IUkg IM or IV every 6 hours Or ampicillin 50 mgkg every 6 hours for 2 days f Then, oral amoxicillin"
 Gentamicin mgkg once a day for 7 days
" If child is ³ 6 months and not vaccinated, or was vaccinated"
before 9 months of age. Delay vaccination if child is in shock
" Treat other specific infections if diagnosed as appropriate, e.g.,"
"malaria, pneumonia, dysentery, soft- tissue infections, mengingitis, TB, H If parasitic worms are diagnosed, delay treatment until the rehabilitation phase. Give albendazole 200-400 mg single dose"
"- In endemic areas, give mebendazole orally twice a day"
- for 3 days to all SAM children 7 days after admission
"- If HIV diagnosed, start ART as soon as possible after"
stabilisation of metabolic compilcations
" If child is still anorexic after 7 days of antibiotic treatment, continue"
"for a full 10-day course. If anorexia persists, reassess child fully"
" F-75, F-100 and RUTF already contain multivitamins (including vitamin A and folic acid) zinc and copper. Additional doses are not needed"
" If there are no eye signs or history of measles, then do not"
give a high dose of vitamin A as therapeutic foods already
ONLY IF child has signs of vitamin A deficiency like corneal ulceration
" Give Vitamin A on day 1, and repeat on days 2 and 14"
"Note: If a first dose was given in the referring centre, treat on days 1 and 14 only"
 Give iron in the second week of nutritional rehabilitation
- Do not give in the stabilization phase
- Do not give in children receiving RUTF
 Start iron at 3 mgkg per day after 2 days on F-100 catch- up formula
"If child is not on any pre-mixed therapeutic foods, give the following micronutrients"
 Folic acid at 5 mg on day 1; then 1 mg daily Multivitamin syrup 5 ml
" Other vitamins and minerals e.g, a combination of selenium and moringa has"
Initial Re-Feeding during Stabilisation Phase
"In the initial phase, feeding should be gradual."
The essential features of initial feeding are:
ONLY IF child has signs of vitamin A deficiency like corneal ulceration
" Give Vitamin A on day 1, and repeat on days 2 and 14"
"Note: If a first dose was given in the referring centre, treat on days 1 and 14 only"
 Give iron in the second week of nutritional rehabilitation
- Do not give in the stabilization phase
- Do not give in children receiving RUTF
 Start iron at 3 mgkg per day after 2 days on F-100 catch- up formula
"If child is not on any pre-mixed therapeutic foods, give the following micronutrients"
 Folic acid at 5 mg on day 1; then 1 mg daily Multivitamin syrup 5 ml
" Other vitamins and minerals e.g, a combination of selenium and moringa has"
 Frequent (every 2-3 hours) oral small feeds of low osmolality and low lactose. Never leave the child alone or forcefeed
"the child, as this can cause aspiration pneumonia"
 Nasogastric tube feeding if the child is eating  80 of the
amount offered at two consecutive feeds
 Calories at 100 kcalkg per day (do not exceed)
 Liquid at 130 mlkg per day or 100 mlkg per day if child
" Milk-based formulas, such as F-75 (with 75 kcal and g"
"protein100 ml), will be satisfactory for most children"
- Starter F-75 formula can be commercially supplied or
- locally prepared from basic ingredients
- In children who get osmotic diarrhoea with commercial
"preparation, prepare a cereal based F75 as in the table"
" If child is breastfeeding, continue breastfeeding but add the prescribed"
amounts of the starter formula as in the table below:
Days Frequency Volume kg feed Volume kg per
" Feed from a cup or bowl. Use a spoon, dropper or syringe to feed"
 Teach the mother or caregiver to help with the feeding
" Night feeds are essential, since long periods without a feed may"
lead to hypoglycaemia and death
" If child is vomiting, during or after a feed, estimate amount vomited"
"and offer that amount again. If child keeps vomiting, offer half the"
amount of feed twice as often (e.g. every 1 hour) until vomiting stops
- Amounts of feed offered and left over
- Stool frequency and consistency
Recipe for refeeding formula F-75 and F-100
"If pre-mixed formulas are not available, prepare as below"
Ingredient F-75 (Starter) Cereal-Based F-100 (Catch-Up)
Water: make up to 1000 ml 1000 ml
 Cook cereal-based formula for 4 minutes and add mineral
This phase is designed to prepare the child for phase 2 or outpatient
Signs that a child is ready for transition:
 No episodes of hypoglycaemia (metabolically stable)
 Reduction in or disappearance of all oedema
Ingredient F-75 (Starter) Cereal-Based F-100 (Catch-Up)
 Cook cereal-based formula for 4 minutes and add mineral
"Make a transition from starter formula to catch-up formula, gradually over 23 days. DO NOT switch at once."
 Make a gradual transition from starter F-75 to catch-up formula
"F-100 or RUTF over 2-3 days, as tolerated"
" Give RUTF or a milk-based formula, e.g, F-100 containing 100"
kcal100 mL and g of protein per 100 ml. Replace starter
F-75 with an equal amount of catch- up F-100 for 2 days.
 Start with small but regular meals of RUTF and encourage child
"to eat often (first, 8 meals per day, and later, 5-6 meals per day)"
 If child cannot eat whole amount of RUTF per meal in the
"transition phase, top-up with F-75 to complete the feed, until"
child is able to eat a whole RUTF meal
" If child cannot take at least half of the RUTF in 12 hours, stop"
RUTF and give F-75. Try introducing RUTF again in 1-2 days
until the child is able to take adequate amount
" If still breastfeeding, offer breast milk first before each RUTF feed"
"If RUTF is not available or child does not accept it, give"
" In the first 2 days, give F-100 every 3-4 hours (the same"
amount of F-75 that they were being given). Do not
" On the 3rd day, increase each successive feed by 10 ml"
" If the child does not finish the meal, offer the same"
 Keep adding 10 ml until the child leaves a bit of most
of his meals (i.e. point at which intake is likely to have
 Make a gradual transition from starter F-75 to catch-up formula
"F-100 or RUTF over 2-3 days, as tolerated"
" Give RUTF or a milk-based formula, e.g, F-100 containing 100"
kcal100 mL and g of protein per 100 ml. Replace starter
F-75 with an equal amount of catch- up F-100 for 2 days.
 Start with small but regular meals of RUTF and encourage child
"to eat often (first, 8 meals per day, and later, 5-6 meals per day)"
 If child cannot eat whole amount of RUTF per meal in the
"transition phase, top-up with F-75 to complete the feed, until"
child is able to eat a whole RUTF meal
" If child cannot take at least half of the RUTF in 12 hours, stop"
RUTF and give F-75. Try introducing RUTF again in 1-2 days
until the child is able to take adequate amount
" If still breastfeeding, offer breast milk first before each RUTF feed"
"If RUTF is not available or child does not accept it, give"
" In the first 2 days, give F-100 every 3-4 hours (the same"
amount of F-75 that they were being given). Do not
" On the 3rd day, increase each successive feed by 10 ml"
" If the child does not finish the meal, offer the same"
 Keep adding 10 ml until the child leaves a bit of most
of his meals (i.e. point at which intake is likely to have
" If child is being breasfed, encourage mother to breastfeed in"
" After a gradual transition, give:"
"- Frequent feeds, unlimited amounts"
 F-100 should never be given to take home. Transition to
 Monitor the child at least every 4 hours during transition
 Return child to stabilization phase if:
"- Child develops loss of appetite, cannot take 80 of the"
"feeds, develops or increased oedema, medical conditions"
"not improving, any signs of fluid overload, significant refeeding diarrhoea"
"Early signs of congestive heart failure (e.g. rapid pulse, fast breathing, basal lung crepitations, enlarging liver, gallop heart rhythm,"
If pulse is increased by 25 beatsminute and breathing rate by 5
"breathsminute, and the increase is sustained for two successive"
- Reduce volume fed to 100 mlkg per day for 24 hours
 Then gradually increase as follows:
- 115 mlkg per day for next 24 hours
- 130 mlkg per day for the following 48 hours
" Then, increase each feed by 10 ml as described earlier"
" If child is being breasfed, encourage mother to breastfeed in"
" After a gradual transition, give:"
"- Frequent feeds, unlimited amounts"
 F-100 should never be given to take home. Transition to
 Monitor the child at least every 4 hours during transition
 Return child to stabilization phase if:
"- Child develops loss of appetite, cannot take 80 of the"
"feeds, develops or increased oedema, medical conditions"
"not improving, any signs of fluid overload, significant refeeding diarrhoea"
"Early signs of congestive heart failure (e.g. rapid pulse, fast breathing, basal lung crepitations, enlarging liver, gallop heart rhythm,"
If pulse is increased by 25 beatsminute and breathing rate by 5
"breathsminute, and the increase is sustained for two successive"
- Reduce volume fed to 100 mlkg per day for 24 hours
 Then gradually increase as follows:
- 115 mlkg per day for next 24 hours
- 130 mlkg per day for the following 48 hours
" Then, increase each feed by 10 ml as described earlier"
Childs Weight Transition Rehabilitation Phase
Packets Per Packets Per Packets
Patient instructions on how to give RUTF
 Wash hands before giving the RUTF
 Sit with child on the lap and gently offer RUTF
 Encourage child to eat RUTF without force-feeding
" Give small, regular meals of RUTF and encourage child to"
" If still breastfeeding, continue offering breast milk first before every RUTF feed"
" Give only the RUTF for 2 weeks, if breastfeeding continue"
to breastfeed and gradually introduce foods recommended
for the age (see section 17.3.12.3)
" When introducing recommended foods, ensure that the"
child completes his daily ration of RUTF before giving other foods
" Offer plenty of clean water, to drink from a cup, when the"
Catch-up growth or rehabilitation phase
Criteria for transfer from transition phase
 Good appetite (child takes 80 of daily ration of RUTF)
 Significantly reduced oedema or no oedema
 Resolved medical complications and completed parenteral
Children with complicated SAM can be transferred to outpatient care
during rehabilitation phase. The child will require continuing care as an
outpatient to complete rehabilitation and prevent relapse.
 Carefully assess the child and the available commuinty support
 Refer the child for rehabilitation in outpatient care or to a
"community feeding programme if possible, otherwise keep"
If the child cannot be managed as outpatient (e.g. no easily
accessible nutritional rehabilitation services where the child
 Keep the child admitted until full discharge from nutritional
" Continue with RUTF or F-100, but increase amount as the"
If the child can be managed as outpatient
 Discharge the mother with 2-week supply of RUTF according
If the child cannot be managed as outpatient (e.g. no easily
accessible nutritional rehabilitation services where the child
 Keep the child admitted until full discharge from nutritional
" Continue with RUTF or F-100, but increase amount as the"
If the child can be managed as outpatient
 Discharge the mother with 2-week supply of RUTF according
 Counsel caregivers on outpatient treatment and link them to
a community nutritional programme if available. Ensure that
- Brings back the child for weekly supplements
Has received specific counselling on appropriate child feeding practices
"(types, amount, frequency) and basic hygiene"
"- Has resources to feed child (if not, give advice on available"
Monitoring (by rate of weight gain)
" Weigh child every morning before feeding, and plot the"
 Calculate and record weight gain every 3 days as gkg per
Current weight of child  6300 g Weight 3 days ago  6000 g
Weight gain in grams: 6300-6000  300 g Average daily weight
Childs average weight: (6000  6300)  2  6150 g
Divide by childs average weight in kg: 100 gday  kg 
"- Poor (5 gkg per day), child needs a full reassessment"
"- Moderate (5-10 gkg per day), check if intake targets are"
being met or if infection has been overlooked
- Good (10 gkgday): continue rehabilitation
" A cheerful, stimulating environment"
 Counsel caregivers on outpatient treatment and link them to
a community nutritional programme if available. Ensure that
- Brings back the child for weekly supplements
 Structured play therapy for 15-30 minutesday
 Physical activity as soon as the child is well enough
" As much maternal involvement as possible (e.g., comforting, feeding, bathing, playing)"
 Provide suitable toys and play activities for the child
19.Treatment of Associated Conditions
If child has signs of vitamin A deficiency like corneal ulceration
" Give vitamin A on day 1, repeat on days 2 and 14"
"If a first dose was given in the referring centre, treat on days 1 and 14"
"If eyes show corneal clouding or ulceration, give care below"
to prevent corneal rupture and lens extrusion
" Instil chloramphenicol or tetracycline eye drops 4 times a day,"
" Instil atropine eye drops, 1 drop 3 times a day for 3-5 days"
Usually due to zinc deficiency. The childs skin quickly improves with
zinc supplementation. In addition:
 Bathe or soak affected areas for 10 minutes per day in
 0.01 potassium permanganate solution
If child has signs of vitamin A deficiency like corneal ulceration
" Give vitamin A on day 1, repeat on days 2 and 14"
"If a first dose was given in the referring centre, treat on days 1 and 14"
"If eyes show corneal clouding or ulceration, give care below"
to prevent corneal rupture and lens extrusion
" Instil chloramphenicol or tetracycline eye drops 4 times a day,"
" Instil atropine eye drops, 1 drop 3 times a day for 3-5 days"
 Bathe or soak affected areas for 10 minutes per day in
 0.01 potassium permanganate solution
 Apply barrier cream (zinc and castor oil ointment or petroleum
"jelly) to the raw areas, and gentian violet or nystatin cream to"
 Avoid using nappies so that the perinuem can stay dry
 Give blood transfusion in the first 24 hours ONLY IF:
"- Hb is 4-6 gdl, and the child has respiratory distress"
 Use smaller volumes and slower transfusion than for a well-nourished child. Give:
"- Whole blood, 10 mlkg over 3 hours"
"- Furosemide, 1 mgkg at the start of the transfusion"
If child has signs of heart failure
" Give 10 mLkg of packed cells, as whole blood may worsen"
 Children with SAM and oedema may have redistribution
"of fluid leading to apparent low Hb, which does not require"
" Monitor pulse and breathing rates, listen to lung fields,"
"examine adbomen for liver size, check jugular venous"
pressure every 15 minutes during transfusion
- If either breathing rate increases by 5 breathsminute or
"heart rate increases by 25 beatsminute, transfuse more"
"- If there are basal lung crepitations or an enlarging liver,"
stop transfusion and give IV furosemide IV at 1 mgkg
 Apply barrier cream (zinc and castor oil ointment or petroleum
"jelly) to the raw areas, and gentian violet or nystatin cream to"
 Avoid using nappies so that the perinuem can stay dry
 Give blood transfusion in the first 24 hours ONLY IF:
"- Hb is 4-6 gdl, and the child has respiratory distress"
 Use smaller volumes and slower transfusion than for a well-nourished child. Give:
"- Whole blood, 10 mlkg over 3 hours"
"- Furosemide, 1 mgkg at the start of the transfusion"
If child has signs of heart failure
" Give 10 mLkg of packed cells, as whole blood may worsen"
 Children with SAM and oedema may have redistribution
"of fluid leading to apparent low Hb, which does not require"
" Monitor pulse and breathing rates, listen to lung fields,"
"examine adbomen for liver size, check jugular venous"
pressure every 15 minutes during transfusion
- If either breathing rate increases by 5 breathsminute or
"heart rate increases by 25 beatsminute, transfuse more"
"- If there are basal lung crepitations or an enlarging liver,"
stop transfusion and give IV furosemide IV at 1 mgkg
If Giardiasis suspected or confirmed by stool microscopy
 Give metronidazole mgkg every 8 hours for 7 days
If due to lactose intolerance (very rare)
Diagnosed if profuse watery diarrhoea only occurs after milk-based
feeds are begun and stops when they are withdrawn or reduced
 Replace feeds with yoghurt or a lactose free infant formula
 Reintroduce milk feeds gradually in the rehabilitation phase
Suspect if diarrhoea worsens substantially with hyperosmolar F-75
and ceases when sugar and osmolality are reduced
" Use a cereal-based starter F-75, or if necessary, a commercially"
 Introduce catch-up F-100 or RUTF gradually
19.Discharge from Nutritional Programme
Discharge children with SAM from nutritional treatment ONLY IF:
 Weight-for-height or length is at least ³-2 z score and they
"have no oedema for at least 2 weeks, or"
 Mid-upper-arm circumference is ³125 mm and they have
 The indicator used at admission should be the same one
used during follow-up. If only pitting oedema was used at
"diagnosis, then either WFHL or MUAC can be used for"
 Percentage weight gain should not be used as a criterion
Feeding after discharge from nutritional programme Counsel the mother
on feeding and other issues as in the table below
If Giardiasis suspected or confirmed by stool microscopy
 Give metronidazole mgkg every 8 hours for 7 days
If due to lactose intolerance (very rare)
Diagnosed if profuse watery diarrhoea only occurs after milk-based
feeds are begun and stops when they are withdrawn or reduced
 Replace feeds with yoghurt or a lactose free infant formula
 Reintroduce milk feeds gradually in the rehabilitation phase
Suspect if diarrhoea worsens substantially with hyperosmolar F-75
and ceases when sugar and osmolality are reduced
" Use a cereal-based starter F-75, or if necessary, a commercially"
 Introduce catch-up F-100 or RUTF gradually
 Feed child at least 5 times a day with meals that contain high
energy and high protein content (100 kcal and 2-3 g protein per
" Give high energy snacks between meals (e.g., milk, banana,"
 Assist and encourage child to complete each meal
 Give food separately to child so their intake can be checked
 Breastfeed as often as the child wants
 How to continue any needed medications at home
 Danger signs to bring child back for immediate care
" When and where to go for planned follow-up: at 1 week, 2"
"weeks, 1 month, 3 months, and 6 months; then twice a year"
until when the child is 3 years old
 Where and when to take child for growth monitoring and promotion on monthly basis up to 2 years
" When to return for next immunisation, vitamin A, and deworing"
 How to continue stimulating the child at home with play acti
"PlanWhen child is discharged, make a follow-up plan until full recovery,"
"with the appropriate clinic (e.g., OPD, nutrition clinic or local health"
 Weigh the child weekly after discharge
" If child fails to gain weight over 2 weeks, loses weight between 2 measurements, develops loss of appetite or oedema, refer child back to hospital for a full reassessment"
Monitor child periodically after discharge from the nutritional programme
"to prevent relapse: at 1 week, 2 weeks, 1 month, 3 months, and 6"
months; then twice a year until when the child is 3 years old
 Feed child at least 5 times a day with meals that contain high
energy and high protein content (100 kcal and 2-3 g protein per
" Give high energy snacks between meals (e.g., milk, banana,"
 Assist and encourage child to complete each meal
 Give food separately to child so their intake can be checked
 Breastfeed as often as the child wants
 How to continue any needed medications at home
 Danger signs to bring child back for immediate care
" When and where to go for planned follow-up: at 1 week, 2"
"weeks, 1 month, 3 months, and 6 months; then twice a year"
until when the child is 3 years old
 Where and when to take child for growth monitoring and promotion on monthly basis up to 2 years
" When to return for next immunisation, vitamin A, and deworing"
 How to continue stimulating the child at home with play acti
SAM in Infants Less than 6 Months
SAM in infants 6 months is rare. An organic cause or failure to thrive
should be considered and treated. Admit the infant with SAM if any of
 General danger signs or serious condition
 Recent weight loss or failure to gain weight
" Ineffective breastfeeding (attachment, positioning, or suckling) directly observed for 15-20 minutes"
Any pitting bilateral oedema of feet
 Any medical problem needing more assessment
 Any social issue needing detailed assesssment or intensive
support e.g depression of caretaker
 Give parenteral antibiotics to treat possible sepsis and appropriate
treatment for other medical complications
 Re-establish effective breastfeeding by mother or give infant
"formula, safely prepared and used"
" In infants with SAM and oedema, give infant formula (preferably)"
"or if not available, F-75 or diluted F-100 (use litres instead"
" For infants with SAM and NO oedema, give expressed breast"
"milk; if not possible, give commercial infant formula, F-75 or"
diluted F-100 in this order of preference
 Assess the physical and mental health of mothers or caretakers.
Provide relevant treatment and support
 Give parenteral antibiotics to treat possible sepsis and appropriate
treatment for other medical complications
 Re-establish effective breastfeeding by mother or give infant
"formula, safely prepared and used"
" In infants with SAM and oedema, give infant formula (preferably)"
"or if not available, F-75 or diluted F-100 (use litres instead"
" For infants with SAM and NO oedema, give expressed breast"
"milk; if not possible, give commercial infant formula, F-75 or"
diluted F-100 in this order of preference
 Assess the physical and mental health of mothers or caretakers.
Provide relevant treatment and support
 Infants can be transferred to outpatient care if:
"- All clinical conditions, medical complications and oedema"
"are resolved, or if child is clinically well and alert"
- Child is breastfeeding effectively or feeding well
"- Weight gain is satisfactory, e.g., above median WHO"
growth velocity standards or 5 gkg per day for 3
" Before discharge, verify immunisation status, link mothers and caregivers with community follow-on support"
"and ensure that child is breastfeeding well, has an adequate weight gain and has WFL ³-2 Z scores"
Obesity and Overweight ICD10 CODE: E66
Overweight and obesity are an abnormal or excessive fat accumulation
that presents a risk to health. It is a risk factor for many diseases and
is linked to many deaths. Body mass index (BMI) is a simple index of
weight-for-height used to classify overweight and obesity in adults.
Height (in metres) squared (m2)
Interpretation of BMI values in adults
waist circumference 88 cm (F) or
 Infants can be transferred to outpatient care if:
"- All clinical conditions, medical complications and oedema"
"are resolved, or if child is clinically well and alert"
- Child is breastfeeding effectively or feeding well
"- Weight gain is satisfactory, e.g., above median WHO"
growth velocity standards or 5 gkg per day for 3
" Before discharge, verify immunisation status, link mothers and caregivers with community follow-on support"
"and ensure that child is breastfeeding well, has an adequate weight gain and has WFL ³-2 Z scores"
waist circumference 88 cm (F) or
waist circumference 88 cm (F) or
"In children, age needs to be considered when defining overweight and"
Overweight WFH 2 standard deviations above WHO
Obesity WFH 2 standard deviations above WHO
"For WHO Child Growth Standards Charts, see Causes"
" High energy (i.e. calorie) intake: eating too much, eating"
" Low expenditure of energy: sedentary lifestyle, no exercise"
" Disease: hypothyroidism, diabetes mellitus, pituitary cancer"
Raised BMI is a major risk factor for:
 Cardiovascular disease: heart disease and stroke
 Musculoskeletal disorders: osteoarthritis
" Some cancers: endometrial, breast, ovarian, prostate, liver, kidney, gallbladder, kidney"
waist circumference 88 cm (F) or
Overweight WFH 2 standard deviations above WHO
Obesity WFH 2 standard deviations above WHO
"For WHO Child Growth Standards Charts, see 921"
" Poor self-image, antisocial, depression"
" In children, also increased risk of fractures, hypertension, cardiovascular disease, insulin resistance"
 Advise patient to reduce carbohydrate and fat intake HC2
"and increase fruit, fibre and vegetable intake"
 Refer patient to a nutritionist for individualised diet
"counselling, and to compile a diet plan"
" Advise patient to control appetite, participate in"
 Advise patient to increase physical activty and exercise
daily. Advise to start slowly and build up gradually
" Warn the patient of their high risk of diabetes, heart"
"disease, hypertension, stroke, and general poor health"
Encourage patient not to give up even when the weight
Prevention and health education
 Society and community choices: make healthier food the
"most accessible, available, and affordable food, and regular"
 Advise patient to reduce carbohydrate and fat intake
"and increase fruit, fibre and vegetable intake"
 Refer patient to a nutritionist for individualised diet
"counselling, and to compile a diet plan"
" Advise patient to control appetite, participate in"
 Advise patient to increase physical activty and exercise
daily. Advise to start slowly and build up gradually
" Warn the patient of their high risk of diabetes, heart"
"disease, hypertension, stroke, and general poor health"
Encourage patient not to give up even when the weight
- Limit energy intake from total fats and sugars: reduce fatty
"meat, palm cooking oil (replace with sunflower, olive, corn"
"- Increase consumption of fruits and vegetables, as well as"
"- legumes, whole grains and nuts"
- Engage in regular physical activity (60 minutes a day for
children and 150 minutes spread through the week for adults)
- Stop other habits that increase risk of non-communicable
"- diseases, e.g., tobacco smoking, alcohol abuse"
INFECTIONS AND INFLAMMATORY EYE CONDITIONS
Notes on Use of Eye Preparations
 Eye drops: Apply 1 drop every 2 hours until the condition
"is controlled, then reduce frequency"
" Eye ointment: If used alone, apply 3-4 times daily; if used"
"with drops, apply at night only"
 Continue treatment for 48 hours after healing
Conjunctivitis (Red Eye) ICD10 CODE: H10
Inflammation of the conjunctiva of the eye.
" Trauma: Chemicals, foreign bodies"
 Watery discharge (viral or chemicals)
 Cornea is clear and does not stain with fluorescein
 Redness (usually both eyes but may startbe worse in one;
usually reddest at outer edge of the eye)
 Swelling and itching (may be present)
" Corneal ulcer (tends to be in one eye only, rednessis greatest near the cornea, pain is often great)"
 Clinical features are diagnostic
 Pus swab for culture and sensitivity
 Apply chloramphenicol or gentamicin eye drops 2
or 3 hourly for 2 days then reduce to 1 drop every 6
 Change treatment as indicated by results of culture
NB. Gonococcal conjunctivitis should be treated aggressively and in line with management of Sexually Transmitted Infections (see section 3.2.9)
 Cold compresses and facial hygiene
 Betamethasone or hydrocortisone eye drops every
1-2 hours until inflammation is controlled then apply
 Limit use of steroid eye drops to short durations
r Do not use steroid preparations unless you are sure of the
diagnosis as they may mask infections
 Apply chloramphenicol or gentamicin eye drops 2
or 3 hourly for 2 days then reduce to 1 drop every 6
 Change treatment as indicated by results of culture
NB. Gonococcal conjunctivitis should be treated aggressively and in line with management of Sexually Transmitted Infections (see section 3.2.9)
 Cold compresses and facial hygiene
 Betamethasone or hydrocortisone eye drops every
1-2 hours until inflammation is controlled then apply
 Limit use of steroid eye drops to short durations HC2
r Do not use steroid preparations unless you are sure of the
diagnosis as they may mask infections 
 Personal hygiene; daily face washing
Stye (Hordeolum) ICD10 CODE: H00
A localized infection of the hair follicle of the eyelids
 Other infections of the eyelids
" Usually, the stye will heal spontaneously HC2"
 Avoid rubbing eye as this might spread the infection
 Apply a warmhot compress to the eye
 Apply tetracycline eye ointment 1 2-4 times daily
until 2 days after symptoms have disappeared
 Remove the eye lash when it is loose
" Usually, the stye will heal spontaneously"
 Avoid rubbing eye as this might spread the infection
 Apply a warmhot compress to the eye
 Apply tetracycline eye ointment 1 2-4 times daily
until 2 days after symptoms have disappeared
 Remove the eye lash when it is loose HC2
"A chronic infection of the outer eye caused by Chlamydia trachomatis,"
"transmitted though direct personal contact, shared towels and cloths,"
and flies that have come into contacat with the eyes or nose of an
infected person. It is a common cause of blindness.
" Early stages: reddening of eye, itching, follicles (grain-like"
 If repeated untreated infections: scar formation on eyelids
causing the upper eyelid to turn inwards (entropion) and
the eyelashes to scratch the cornea
 Scarring of the cornea leading to blindness
 Allergic conjunctivitis (chronic)
 Other chronic infections of the eye
 Tetracycline eye ointment 1 twice daily for
 4-6 weeks (until the infectioninflammation has disappeared) HC4
 Or erythromycin 500 mg every 6 hours for 14 days
 Or azithromycin 1 g stat; child 20 mgkg stat
 Tetracycline eye ointment 1 twice daily for
 4-6 weeks (until the infectioninflammation has disappeared)
 Or erythromycin 500 mg every 6 hours for 14 days
 Or azithromycin 1 g stat; child 20 mgkg stat
" Good personal hygiene, regular face washing"
" Education of public on trachoma, and environmental control"
" Infection: Bacterial, viral, or fungal; leading to corneal ulceration"
" Trauma: Chemical, foreign bodies"
 Cornea is not clear and will stain with fluorescein in the
case of corneal ulcer (pattern of staining depends on the
"causative agent, for example dendritic in viral keratitis)"
 Visual acuity is usually reduced
Investigations (where facilities are available)
 Fluorescein stain to confirm diagnosis
" Pus swab for gram stain, culture and sensitivity"
" Corneal scraping for microscopy, culture and sensitivity"
" Admission is mandatory for young children, one- eyed H"
"patients, non-improvement after 72 hours of treatment,"
"large ulcers (4 mm diameter), associated occular complications such as hypopion or scleritis"
" If bacterial, apply gentamicin eye drops alternately with"
chloramphenicol eye drops 12 hourly until infection HC2
" If viral, acyclovir eye ointment 5 times daily for herpes RR"
" If fungal, natamycin ophthalmic suspension 5 HC4"
 Atropine eye drops to relieve pain
 Vitamin A capsules for children
 Surgery may be necessary in some circumstancesi.e.
conjunctival flap and tarsorrhaphy
 Debridement (chemicalmechanical)
r DO NOT use topical corticosteroids in patients with infective
Inflammation of the uvea of the eye. It is classified as either anterior
(involves iris and ciliary body) or posterior (involves choroid which is
the posterior part of the uvea).
" Systemic diseases (TB, HIV, lymphoma, autoimmune"
"diease, leprosy, toxoplasmosis)"
" Admission is mandatory for young children, one- eyed"
"patients, non-improvement after 72 hours of treatment,"
"large ulcers (4 mm diameter), associated occular complications such as hypopion or scleritis"
" If bacterial, apply gentamicin eye drops alternately with"
chloramphenicol eye drops 12 hourly until infection
" If viral, acyclovir eye ointment 5 times daily for herpes"
" If fungal, natamycin ophthalmic suspension 5"
 Atropine eye drops to relieve pain
 Vitamin A capsules for children
 Surgery may be necessary in some circumstancesi.e.
conjunctival flap and tarsorrhaphy
 Debridement (chemicalmechanical) H
r DO NOT use topical corticosteroids in patients with infective
" Anterior uveitis: Involves the iris and ciliary body, pain,"
"photophobia, ciliary infection, poor vision, small and irregular pupil, cells and flare in the anterior chamber, and"
" Posterior uveitis: Involves choroid, poor vision, cells in the"
 Investigation of uveitis is broad and requires a high index of
 Diagnosis of uveitis requires expertise and can only be confirmed
 Explain seriousness of the condition to the patient HC4
 Refer urgently to a qualified eye health worker
 Periocular steroids may be used in severe anterior uveitis
 Atropine eye drops to relieve pain
" Refer bilateral cases, and where there is poor vision"
and associated ocular complications
 Treat the primary condition if any
" Topical, periocular and systemic steroids"
 AtropineCyclopegics to relieve pain in anterior uveitis
" Wear protective goggles when hammering, sawing, chopping, grinding etc."
 Explain seriousness of the condition to the patient
 Refer urgently to a qualified eye health worker
 Periocular steroids may be used in severe anterior uveitis
 Atropine eye drops to relieve pain
" Refer bilateral cases, and where there is poor vision"
and associated ocular complications HC2
 Treat the primary condition if any
" Topical, periocular and systemic steroids"
 AtropineCyclopegics to relieve pain in anterior uveitis 
 Warn children playing with sticks about risk of eye injuries
Orbital Cellulitis ICD10 CODE: H05.01
Orbital cellulitis is a sudden acute inflammation of the tissues around
 Children- most common cause is post sinus infection by
" Adults- common causes are Staphylococcus aureus, Streptococcus pneumonia and beta-haemolytic streptococcus"
" Sinus infection, tooth extraction, orbital trauma"
 Pain in the eye especially on eye movements
 Infection - Cavernous sinus thrombosis
 Endocrine dysfunction - Dysthyroid exophthalmos
" Idiopathic inflammation - Orbital myositis, orbital pseudotumour, Wegeners granulomatosis"
" Neoplasm with inflammation, e.g. Burkitts lymphoma"
 Good history taking and examination
 This is an emergency and needs immediate referral to H
 This is an emergency and needs immediate referral to
 Prompt treatment of sinus and dental infections
" Complete immunization schedule for children, more especially Hib vaccine (included in the pentavalent DPT"
Postoperative Endophthalmitis ICD10 CODE: H44.0
Postoperative endophthalmitis is the severe inflammation involving
both the anterior and posterior segments of the eye after intraocular
 Perioperative introduction of microbial organisms into the
" Decreased vision, and permanent loss of vision"
" Bacterial endophthalmitis: pain, redness, lid swelling, and"
" Fungal endophthalmitis: blurred vision, pain, and decreased visual acuity"
 It is a medical emergency and treatment should be H
"instituted within an hour of presentation, especially"
 Refer to an ophthalmologist immediately
 Admit patients with severe endophthalmitis and treat
"aggressively with topical, periocular and where possible"
 It is a medical emergency and treatment should be
"instituted within an hour of presentation, especially"
 Refer to an ophthalmologist immediately
 Admit patients with severe endophthalmitis and treat
"aggressively with topical, periocular and where possible"
 Antibiotics: vancomycin or ceftriaxone H
 Apply povidone iodine 5 in the conjunctival sac for a
minimum of 3 minutes prior to surgery and 10 povidone
iodine painting of the periocular skin
Dryness of the part of the eye ball exposed to air and light Cause
 Followed by dryness of the conjunctiva and cornea
" Eventually the cornea melts away, the eye perforates, and"
" Give vitamin A on day 1, repeat on days 2 and 14 HC2"
"Adult and child 1 year: 200,000 IU"
"If eyes show corneal clouding or ulceration, give care below"
to prevent corneal rupture and lens extrusion
 Instil chloramphenicol or tetracycline eye drops 4 times
" Instil atropine eye drops, one drop 3 times a day for"
 Antibiotics: vancomycin or ceftriaxone
" Give vitamin A on day 1, repeat on days 2 and 14"
"Adult and child 1 year: 200,000 IU"
"If eyes show corneal clouding or ulceration, give care below"
to prevent corneal rupture and lens extrusion
 Instil chloramphenicol or tetracycline eye drops 4 times
" Instil atropine eye drops, one drop 3 times a day for"
" Good balanced diet especially for children, women, and"
"institutionalised persons, e.g., prisoners, long-term hospital in-patients, boarding school students, etc."
 Routine Vitamin A supplementation
" Child 5 years with measles or malnutrition: 100,000 IU"
" All mothers after delivery: 200,000 IU"
" A child above one year: 200,000 IU every 6 months"
DECREASED OR REDUCED VISION CONDITIONS
Opacity of the lens inside the eye. It is the most common cause of
 Certain drugs e.g. corticosteroids
" Pupil is not the normal black colour but is grey, white,"
 Condition is not painful unless caused by trauma
 Eye is not red unless condition is caused by trauma
20.Paediatric Cataract ICD10 CODE: H26.0
Cataract in children is unique as it may interfere with the normal
development of vision resulting in lazy eye (amblyopia).
 Intrauterine infections (TORCHES)
" Drugs, trauma, metabolic diseases, e.g. Diabetes"
 Older children may complain of poor vision
" Dancing eyes (nystagmus), squints"
" If at HC2 or HC3, reassure patient and refer to hospital"
 Condition is managed surgically under general an- RR
 Surgery can be done as early as one month of age
 Patchingocclusion therapy in case of lazy eyes
 Aphakic children those less than one year who are
not implanted should be given aphakic glasses or
" Wear protective goggles when hammering, sawing, chopping, grinding, etc."
 Caution children playing with sticks about risk of eye injuries
 Condition is managed surgically under general anaesthesia
 Surgery can be done as early as one month of age
 Patchingocclusion therapy in case of lazy eyes
 Aphakic children those less than one year who are
not implanted should be given aphakic glasses or
Glaucoma is a group of disorders characterised by a loss of visual
field associated with cupping of the optic disc and optic nerve
damage. Although glaucoma is associated with raised intra-ocular
"pressure (IOP), it can also occur when this pressure is within the"
Glaucoma is classified as either open-angle or angle-closure glaucoma. Primary open-angle glaucoma is the most common.
Risk factors for open-angle glaucoma
" Older age, black people, family history, genetics"
" Vascular dys-regulation (migraine, vasospasm, abnormalities in ocular blood flow), low ocular perfusion pressure,"
" Ocular factors: Raised intra-ocular pressure, myopia, central corneal thickness  thinner corneas associated with"
 History of gradual loss of vision in affected eye or loss of
 Often suspected after seeing cupping of optic disc on routine fundoscopy or finding elevated intra-ocular pressure
" Sudden onset of severe eye pain and redness, associated"
"with nausea, vomiting and headache"
 Loss of vision in the affected eye
 Coloured halos or bright rings around lights
" Severely elevated IOP. When palpated with a finger, the"
"affected eye feels hard, compared to the other eye"
" If IOP rises more slowly, the patient may be asymptomatic"
" Goal of treatment is to arrestdelay progress of the disease, not for visual improvement. Therapy is usually life"
 Angle-closure glaucoma is a medical emergency that requires urgent reduction of intra ocular pressure
Refer all suspects to specialist
 Timolol 0.5 eye drops given 1 drop 12 hourly
" For urgent reduction of IOP, give mannitol 20 by"
slow IV infusion until IOP is reduced
 Reduce intracocular pressure with acetazolamide tablets
500 mg single dose followed by 250 mg every 6 hours
 Plus timolol 0.5 drops 1 drop 12 hourly
" Avoid timolol eye drops in patients with asthma, heart"
block and uncontrolled heart failure
"Diabetic Retinopathy ICD10 CODE: E10.31, E11.31"
A disease in which small blood vessels are damaged due elevated
blood sugar over a prolonged period of time.
 Timolol 0.5 eye drops given 1 drop 12 hourly
" For urgent reduction of IOP, give mannitol 20 by"
slow IV infusion until IOP is reduced
 Reduce intracocular pressure with acetazolamide tablets
500 mg single dose followed by 250 mg every 6 hours
 Plus timolol 0.5 drops 1 drop 12 hourly RR
" Avoid timolol eye drops in patients with asthma, heart"
block and uncontrolled heart failure 
Risk factors for Diabetic Retinopathy
 Longer duration and poor control of diabetes
 Pregnancy (associated with rapid disease progression)
" High Body mass index (BMI), sedentary lifestyle"
 Patients can present either with a sudden painless loss of
vision or gradual and progressive loss of vision. It may also
be discovered on routine examination
 Conduct a thorough eye examination
" Other investigations: fundus photography, optical coherence"
"tomography, fluorescein angiography"
Involves any or a combination of: RR
 Pan retinal photocoagulation (PRP)
 Anti-Vascular Endothelial growth factor (VEGF) eye
 Control of diabetes and other risk factors
Refractive Errors ICD10 CODE: H52
This is the inability of images to be focused properly on the retina. The
"most common refractive errors are long sightedness, short sightedness,"
Involves any or a combination of:
 Pan retinal photocoagulation (PRP)
 Anti-Vascular Endothelial growth factor (VEGF) eye
Refractive Error Causes Clinical Features
"Hyperopia,  Axial etiology  Blurred"
"long-sightedness (length of the vision, eye"
"or far-sightedness, eye, small strain"
or pathological of the eye)  crossed eye
"(mal-development,  Trauma  Headaches"
drug-induced) in  Paralysis of acnature. commodation
"Myopia,  Axial etiolo-  Blurred"
short-sightedness gy (length of distance
"or near-sightedness the eye, big vision"
It can be simple eyeball)  Flashes
pathologicaldeetiology (power (high myogenerative (mal-deof the eye) pia)
"anatomical) in  Ocular disease,  Asthenopia"
"nature, induced or e.g. keratocon- (eyestrain,"
It is an age-related  Age (35- 40
It results from the  Difficulty
(accommodain accommodation usual near
and quality of life. easetrauma
Refractive Error Causes Clinical Features
 Paralysis of accommodation  Blurred
pathologicaldegenerative (mal-development or
and quality of life.  Axial etiology (length of
REFRACTIVE ERROR CAUSES CLINICAL FEATURES
" Systemic dis-  Drowsieases (diabetes, ness"
" History (blurred vision, asthenopia, etc.)"
" Visual Acuity (distance, near and pinhole)"
" Ocular motility, Binocular Vision and Accommodation"
" Ocular health assessment (slit lamp, fundus assessment)"
 Optical correction with spectacles or contact lenses HC4
 Vision therapyorthoptics (for pseudomyopia) f For presbyopia:
multifocal lenses f Refractive Surgery
This is a loss of eyesight that makes everyday tasks difficult. A person
with low vision finds it difficult or impossible to accomplish activities
"such as reading, watching television, driving a car or recognizing faces."
"When vision cannot be improved with regular eyeglasses, medicine"
"or surgery, people with low vision need rehabilitation to learn how to"
make the most of their remaining sight and keep their independence.
Classification patterns of vision loss include:
REFRACTIVE ERROR CAUSES CLINICAL FEATURES
 Optical correction with spectacles or contact lenses
 Vision therapyorthoptics (for pseudomyopia) f For presbyopia:
multifocal lenses f Refractive Surgery HC4
Central vision This is the detailed vision we use when we look directly at
something. Age-related Macular degeneration (AMD) affects
central vision. Diabetic retinopathy can affect central or
Peripheral vision This is the less detailed vision we use to see everything
around the edges. Glaucoma affects peripheral vision first.
Strokes can affect one side of the peripheral vision
Contrast sensi- This is the ability to distinguish between objects of similar
a white cup or to distinguish facial features. All eye problems
can decrease contrast sensitivity
Depth perception This is the ability to judge the position of objects. New vision
"loss in one eye can affect depth perception, such as the"
Visual processing The lens in our eye focuses light rays onto our retina. The
retina converts these light rays into signals that are sent
"through the optic nerve to our brain, where they are interpreted as the images we see. A problem with any of these"
processes affects our vision in various ways
" Congenital (e.g., prenatal or postnatal trauma, genetic or"
" Hereditary (e.g., retinitis pigmentosa or Stargardts macular"
" Acquired conditions (e.g., ocular infection or disease, trauma,"
"age-related changes, or systemic disease)"
 Loss of the ability to read standard-sized print
 Difficulty performing work-related tasks or leisure activities
 Inability to recognise faces or familiar people
Central vision This is the detailed vision we use when we look directly at
something. Age-related Macular degeneration (AMD) affects
central vision. Diabetic retinopathy can affect central or
Peripheral vision This is the less detailed vision we use to see everything
around the edges. Glaucoma affects peripheral vision first.
Strokes can affect one side of the peripheral vision
Contrast sensitivity This is the ability to distinguish between objects of similar
a white cup or to distinguish facial features. All eye problems
can decrease contrast sensitivity
Depth perception This is the ability to judge the position of objects. New vision
"loss in one eye can affect depth perception, such as the"
Visual processing The lens in our eye focuses light rays onto our retina. The
retina converts these light rays into signals that are sent
"through the optic nerve to our brain, where they are interpreted as the images we see. A problem with any of these"
processes affects our vision in various ways
" Ocular Health Assessment: external examination, Slit lamp"
"exam, tonometry, fundoscopy with dilated pupil"
 Mobility instruction and community-based rehabilitation
" Co-management with optometrist, low vision worker,"
community rehabilitation worker
" Counselling services (psychiatric, psychological and"
A common cause of blindness in Uganda.
Foreign Body in the Eye ICD10 CODE: T15
Presence of an external object or substance in the eye.
" Solids: dust, insects, metal or wood particles"
 Liquids: Splashes of irritating fluids
 Foreign body (FB) may be visible
" Make a thin finger of moistened cotton wool, move HC2"
"eyelid out of the way, and gently remove FB HC4"
 Mobility instruction and community-based rehabilitation
" Co-management with optometrist, low vision worker,"
community rehabilitation worker
" Counselling services (psychiatric, psychological and"
" Make a thin finger of moistened cotton wool, move"
"eyelid out of the way, and gently remove FB HC2"
" If this fails, refer to an Eye Specialist HC2"
For irritating fluids in the eye HC4
 Wash the eye with plenty of clean water or normal
" Apply tetracycline eye ointment 1, cover the eye,"
An injury to the eye may result in vision loss. It is important to recognize serious eye injuries and give appropriate treatment or refer to a
 Blunt injury from a blunt object like a ball or a fist
" A perforating injury from a sharp object, like, a knife, high"
velocity projectiles from explosives
20.Blunt Injuries ICD10 CODE: S05.1
A blunt object striking the eye with great force may result in minor or
Different structures of the eye maybe involved.
ANATOMINAL STRUCTURE CLINICAL FEATURES
"Lids, cornea, and the Eyelid swelling and subcutaneous bleedconjunctiva ing. The degree of swelling may be mild"
to severe. There may be corneal abrasions
and conjunctival swelling and sub conjunctival haemorrhages
" If this fails, refer to an Eye Specialist"
For irritating fluids in the eye
 Wash the eye with plenty of clean water or normal
" Apply tetracycline eye ointment 1, cover the eye,"
and refer to an Eye Specialist HC2
conjunctiva Eyelid swelling and subcutaneous bleeding. The degree of swelling may be mild
to severe. There may be corneal abrasions
and conjunctival swelling and sub conjunctival haemorrhages
ANATOMINAL STRUCTURE CLINICAL FEATURES
"Anterior chamber, Decreased visual acuity is an indication"
"lens, vitreous or that the injury involved either the anterior"
"retina chamber, lens, vitreous, or retina."
All the above will result in poor vision and
are potentially blinding conditions.
Orbital bones A blunt injury may cause orbital bone
fractures. The commonest is a fracture of
The patient may present with swelling of
the eye and proptosis if there is haemorrhage in the orbit or a sunken or retracted
depending on the site of the fracture.
The patient may also complain of double
" Assess the visual acuity, and if this is normal and there HC2"
are no signssymptoms of orbital bone fracture give:
- Gentamicin or chloramphenicol eye drops or
- A cold compress maybe helpful in lid swelling
" If the visual acuity is poor, pad the eye, give a pan"
reliever and REFER URGENTLY THE PATIENT HC4
TO A SPECIALIST as this is an indication of injury
20.Penetrating Eye Injuries ICD10 CODE: S05.2-6
Penetrating eye injuries are common in children and adults and result
retina Decreased visual acuity is an indication
that the injury involved either the anterior
"chamber, lens, vitreous, or retina."
All the above will result in poor vision and
are potentially blinding conditions.
Orbital bones A blunt injury may cause orbital bone
fractures. The commonest is a fracture of
The patient may present with swelling of
the eye and proptosis if there is haemorrhage in the orbit or a sunken or retracted
depending on the site of the fracture.
The patient may also complain of double
" Assess the visual acuity, and if this is normal and there"
are no signssymptoms of orbital bone fracture give:
- Gentamicin or chloramphenicol eye drops or
- tetracycline eye ointment HC2
- A cold compress maybe helpful in lid swelling
" If the visual acuity is poor, pad the eye, give a pan"
reliever and REFER URGENTLY THE PATIENT
TO A SPECIALIST as this is an indication of injury
 A cut involving the lid margin needs to be repaired HC4
"under magnification so that the margin is well approximated, otherwise, if not well repaired, it will heal with"
- A cut involving the eye lids may injure the lacrimal
system if located in the medial aspect of the lid
Corneal and Scleral Perforations
All perforations of the cornea or sclera are serious injuries HC2
" Apply an eye shield to protect the eye, give a pain reliever"
and refer the patient immediately to an Ophthalmologist
 At the secondary or tertiary level the treatment of
cornealscleral lacerations is immediate repair with RR
"100 sutures under an operating microscope, or if the"
"laceration is extensive, an immediate evisceration of the"
20.Chemical Injuries to the Eye ICD10 CODE: S05.8
Various chemicals may injure the eye when they come into contact
with the eyes or face. The commonest are acidic or alkaline chemical
"Acids and Alkaline products will cause serious injuries to the lids,"
" On exposure to acid or chemical products, the eyes"
should be immediately irrigated with copious amounts
of water as a first aid treatment
 A cut involving the lid margin needs to be repaired
"under magnification so that the margin is well approximated, otherwise, if not well repaired, it will heal with"
- A cut involving the eye lids may injure the lacrimal
system if located in the medial aspect of the lid HC4
Corneal and Scleral Perforations
All perforations of the cornea or sclera are serious injuries
" Apply an eye shield to protect the eye, give a pain reliever"
and refer the patient immediately to an Ophthalmologist
 At the secondary or tertiary level the treatment of
cornealscleral lacerations is immediate repair with
"100 sutures under an operating microscope, or if the"
"laceration is extensive, an immediate evisceration of the"
" On exposure to acid or chemical products, the eyes"
should be immediately irrigated with copious amounts
of water as a first aid treatment HC2
" On arrival at a medical centre, continue irrigation with HC2"
normal saline to wash out the entire chemical
" After irrigation of the eye, apply tetracycline eye ointment and pad the eye, and refer to an ophthalmologist"
" Tear gas, which is used in crowd dispersion can cause"
the eyes to sting and tear copiously. The individual
should irrigate the eyes with plenty of water
- Tear gas injury is usually short lived and does not
Retinoblastoma ICD10 CODE: C69.2
It is the most common primary cancer of the retina and affects young
children mostly under 5 years. It is curable if detected and treated early.
 Redness and swelling of the eye
 Glowing in the dark or cats eye reflex
 Ocular examination by midwives immediately after HC3
 Refer urgently (within 72 hours) all children suspected
to have retinoblastoma to an ophthalmologist
" On arrival at a medical centre, continue irrigation with"
normal saline to wash out the entire chemical
" After irrigation of the eye, apply tetracycline eye ointment and pad the eye, and refer to an ophthalmologist"
" Tear gas, which is used in crowd dispersion can cause"
the eyes to sting and tear copiously. The individual
should irrigate the eyes with plenty of water
- Tear gas injury is usually short lived and does not
 Ocular examination by midwives immediately after
 Refer urgently (within 72 hours) all children suspected
to have retinoblastoma to an ophthalmologist HC3
Squamous Cell Carcinoma of Conjunctiva
Squamous cell carcinoma (SCC) of the conjunctiva is a cancer on the
surface of the eye that tends to occur in older people (average age of
"diagnosis is 60 years), and young adults (30-40 years) with HIVAIDS."
" Eye irritation, discomfort or foreign body sensation"
 Growthtumour on eyeball that may exhibit the following
" Leucoplakic (white), flesh-coloured or red patch"
"- Rounded, elevated growth with a gel-like appearance"
- Large dilated blood vessels leading to the tumour
"- In early disease, the tumour often appears in the bulbar"
"conjunctiva nasally, temporally or at the limbus"
NB: Squamous cell carcinoma should be suspected in cases of
chronic conjunctivitis that lasts longer than 3 months.
 Excision (total) biopsy for histopathological examination
" Pterygium, solar keratosis, pinguecula"
 Refer patient to ophalmologist and eventually to cancer RR
 Refer patient to ophalmologist and eventually to cancer
Foreign Body in the Ear ICD10 CODE: T16
Fungal infection usually confined to the mucous membranes and external
layers of skin. Severe forms are usually associated with immunosuppressive
"conditions, such as HIVAIDS, diabetes, pregnancy, cancer, prolonged"
Common foreign bodies (FB) include:
" Insects (flies, cockroaches, ants), seeds, beads, stones"
" Children: Usually insert the FB themselves, or their peers may"
" Adults: Usually insects, cotton buds"
 Occasionally the FB may penetrate adjacent parts and lodge in
 Noise in the ear if it is a live FB like an insect
If attempts have been made to remove the FB:
 Syringe the ear with clean lukewarm water
" If FB cannot be removed by syringing, remove with a"
- General anaesthesia may be essential in children
"- Do NOT use forceps to try to grasp round objects,"
as this will only push them further in the ear
" If there is an edge to grab, remove with Hartmann (crocodile) forceps"
 Kill these by inserting clean cooking oil or water into the
"ear, then syringe out with warm water"
 Cockroaches are better removed by a crocodile forcep
since they have hooks on their legs that make removal
 Do NOT use syringing with water as the seed may swell
- Refer immediately to ENT specialist if you cannot
 Suction may be useful for certain FBs
Wax in the Ear ICD10 CODE: H61.2
An accumulation of wax in the external ear. Wax in the ear is normal
and usually comes out naturally from time to time. It may accumulate
to form a wax plug and cause a problem for the patient.
 Syringe the ear with clean lukewarm water
" If FB cannot be removed by syringing, remove with a"
- General anaesthesia may be essential in children
"- Do NOT use forceps to try to grasp round objects,"
as this will only push them further in the ear HC3
" If there is an edge to grab, remove with Hartmann (crocodile) forceps "
 Kill these by inserting clean cooking oil or water into the
"ear, then syringe out with warm water"
 Cockroaches are better removed by a crocodile forcep
since they have hooks on their legs that make removal
 Do NOT use syringing with water as the seed may swell
- Refer immediately to ENT specialist if you cannot
 Suction may be useful for certain FBs 
 Excessive andor thick wax production
" Small, tortuous andor hairy ear canal"
 Soften the wax by inserting drops of Vegetable oil or
Glycerine or Sodium bicarbonate into the ear 3 times
a day for a few days. After this the wax may fall out on
 Syringe the ear carefully with clean warm water when
 Advise the patient not to poke anything into the ear in an attempt
"to clean it, as this may damage the eardrums"
 Do not syringe if (a) there is history of discharge and (b) if there
Otitis External ICD10 CODE: H60
"Infection of the external ear canal, which may be localised (furunculosis)"
 Soften the wax by inserting drops of Vegetable oil or
Glycerine or Sodium bicarbonate into the ear 3 times
a day for a few days. After this the wax may fall out on
 Syringe the ear carefully with clean warm water when
 Advise the patient not to poke anything into the ear in an attempt
"to clean it, as this may damage the eardrums"
 Do not syringe if (a) there is history of discharge and (b) if there
"Bacterial, fungal, viral infections"
" Pain, tenderness on pulling the pinna (external ear)"
 Itching (especially for fungal infections)
 Otitis media (especially with pus discharge)
 Good history and physical examination are important in making
" If there is a discharge: Pus swab for microscopy, CS"
"- If discharge is white or black, it is fungal"
"- If discharge is yellow, it is bacterial"
 Thoroughly clean external ear canal HC2
" Apply antibiotic drops, e.g., Chloramphenicol ear drops"
0.5 2 drops into the ear every 8 hours for 14 days
" Give analgesics e.g., Paracetamol"
 Cloxacillin 250-500 mg every 6 hours for 5-7 days
 Thoroughly clean external ear canal
" Apply antibiotic drops, e.g., Chloramphenicol ear drops"
0.5 2 drops into the ear every 8 hours for 14 days
" Give analgesics e.g., Paracetamol HC2"
 Cloxacillin 250-500 mg every 6 hours for 5-7 days
 Child: 12.5-25 mgkg per dose HC4
If fungal infection is suspected HC3
 Remove any crusting by syringing
 Apply Clotrimazole solution once a week for 4-8 weeks
 Or fluconazole 200 mg once a day for 10 days
Otitis Media (Suppurative) ICD10 CODE: H66
An acute or chronic infection of the middle ear occurring mostly in
" Bacterial infection, e.g., Streptococcus pneumoniae, Haemophilus influenzae"
 Commonly follows an acute infection of the upper respiratory
" Acute onset of pain in the ear, redness of the ear drum"
 On and off pus discharge from one or both ears for 14 days
 Otitis externa and media with effusion
" Referred ear pain, e.g., from toothache"
If fungal infection is suspected
 Remove any crusting by syringing
 Apply Clotrimazole solution once a week for 4-8 weeks
 Or fluconazole 200 mg once a day for 10 days HC3
 Good history and physical examination are important in making
 Amoxicillin 500 mg every 8 hours for 5 days
 Or erythromycin 500 mg every 6 hours in penicillin allergy
" Give analgesics, e.g., Paracetamol as required"
 Systemic antibiotics are NOT recommended: they are
not useful and can create resistance
 Aural irrigation 2-3 times a day
- 1 spoon of hydrogen peroxide in 12 glass of
- Gently irrigate ear using a syringe without needle
- Avoid directing the flow towards the tympanic
- Gently irrigate ear using a syringe without needle
- Avoid directing the flow towards the tympanic
" Dry by wicking 3 times daily for several weeks, until the HC3"
" Each time after drying, apply 2-4 drops of ciprofloxacin"
 Amoxicillin 500 mg every 8 hours for 5 days
 Or erythromycin 500 mg every 6 hours in penicillin allergy
" Give analgesics, e.g., Paracetamol as required"
 Systemic antibiotics are NOT recommended: they are
not useful and can create resistance
 Aural irrigation 2-3 times a day
- 1 spoon of hydrogen peroxide in 12 glass of
- Gently irrigate ear using a syringe without needle
- Avoid directing the flow towards the tympanic
- Gently irrigate ear using a syringe without needle
- Avoid directing the flow towards the tympanic
" Dry by wicking 3 times daily for several weeks, until the"
" Each time after drying, apply 2-4 drops of ciprofloxacin"
 Do NOT allow water to enter the ear HC3
" Refer if complications occur, e.g., meningitis, mastoid abscess"
"(behind the ear), infection in adjacent areas, e.g., tonsils, nose"
" Health education, e.g., advising patients on recognizing the discharge of otitis media (believed by some to be milk in the ear)"
 Early diagnosis and treatment of acute otitis media and upper
" Treat infections in adjacent area, e.g., tonsillitis"
Glue Ear (Otitis Media with Effusion) ICD10 CODE: H65
" Blockage of the Eustachian tube by: adenoids, infection in the"
"tube, thick mucoid fluid and tumours of the postnasal space"
 Viral infection of the middle ear
 Hearing impairment (the main feature)
" Often fluctuant, e.g., in children: this child hears when s he wants"
 Presence of non-purulent fluid in middle ear
 Loss of usual colour of ear drum (dull eardrum)
 Do NOT allow water to enter the ear HC3
" Refer if complications occur, e.g., meningitis, mastoid abscess"
"(behind the ear), infection in adjacent areas, e.g., tonsils, nose "
 Eliminate known or predisposing causes HC4
 Chlorphenamine 4 mg every 12 hours for 10 days
- Child 1-2 years: 1 mg every 12 hours
- Child 2-5 years: 1 mg every 6 hours (max: 6 mg
- Child 6-12 years: 2 mg every 6 hours (max: 12
 Plus xylometazoline nasal drops 0.1 or ephedrine 2
drops every 8 hours for 2 weeks Child: Use 0.05 drops
" Exercises: Chewing, blowing against closed nose tends"
If effusion persists 6 weeks in spite of the above:
Inflammation of the mastoid bone behind the ear
 Usually a complication of suppurative otitis media
 Severe pain felt over the mastoid bone
 Swelling in post auricular area (pinna is pushed down and forward)
 Current or history of pus discharge from the ear
 Mental confusion is a grave sign of intracranial spread of infection (Refer to ENT surgeon immediately)
 Eliminate known or predisposing causes
 Chlorphenamine 4 mg every 12 hours for 10 days
- Child 1-2 years: 1 mg every 12 hours
- Child 2-5 years: 1 mg every 6 hours (max: 6 mg
- Child 6-12 years: 2 mg every 6 hours (max: 12
 Plus xylometazoline nasal drops 0.1 or ephedrine 2
drops every 8 hours for 2 weeks Child: Use 0.05 drops
" Exercises: Chewing, blowing against closed nose tends"
If effusion persists 6 weeks in spite of the above:
 Diagnosis mainly by clinical features
 X-ray: Useful in chronic mastoiditis
" Blood: Full blood count, shows leucocytosis"
 Admit urgently; give emergency treatment HC4
 Ceftriaxone 2-4 g by IV or deep IM once daily for 1014 days
- Divide IM doses over 1 g between 2 sites
 Plus metronidazole 400 mg every 8 hours for 10-14 days
 Surgical drainage may be necessary to remove pus if an
 Refer urgently for specialist care
Foreign Body in the Nose ICD10 CODE: T17.0
Usually occurs in children 5 years
" Seeds, e.g., bean, peas, ground nut"
 Admit urgently; give emergency treatment
 Ceftriaxone 2-4 g by IV or deep IM once daily for 1014 days
- Divide IM doses over 1 g between 2 sites
 Plus metronidazole 400 mg every 8 hours for 10-14 days
 Surgical drainage may be necessary to remove pus if an
 Refer urgently for specialist care HC4
" Paper, foam rubber (e.g., mattress foam)"
" Usually inserted by the child, and therefore mostly found in the"
 Foreign body noticed by childparent
 Sharp object may cause bleeding
 Unilateral foul-smelling discharge from the nose
" Infection in the nose, sinuses, or adenoids"
 Usually not required (Clinical diagnosis is enough)
 X-rays may be helpful in case of metallic objects like wires or
 Sit the child up or wrap in a blanket HC2
 Blow through the mouth while blocking the unaffected
" Grasp firmly and remove with a fine forceps, e.g., Tilleys"
 Sit the child up or wrap in a blanket
 Blow through the mouth while blocking the unaffected
" Grasp firmly and remove with a fine forceps, e.g., Tilleys"
" Carefully pass a blunt hook behind the object, and then HC2"
" Caution children about placing objects in mouth, nose, and ears"
Epistaxis (Nose Bleeding) ICD10 CODE: R04.0
"Bleeding from the nostrils, which may be arterial or venous"
" Local: nose-picking, trauma, nose infections, tumours"
" General: hypertension, bleeding disorders, pertussis, Sickle-cell"
"traitdisease, renal failure, often familial"
" Can also be a symptom of serious disease, e.g., typhoid, malaria,"
" On examination, site of bleeding from nose may be seen"
 Signs and symptoms of shock if bleeding is severe
 Signs and symptoms of predisposing cause
 Clinical assessment to exclude any of above causes
" Blood: Full blood count, platelet count"
" Carefully pass a blunt hook behind the object, and then"
 Sit the patient up (if the patient is not in shock) and tilt
head forward not backwards to avoid pooling of blood
 Instruct patient to pinch the nose between the finger and
"the thumb for 15 minutes, breathe through the mouth,"
 Impregnate a gauze strip with Soft paraffin or Tetracycline eye ointment and pack into the nose using forceps
 Leave gauze in place for 24-48 hours
If bleeding still does not stop after this period
 Refer to hospital for further management
 Treatcontrol predisposing conditions
"An abnormal reaction of the nasal tissues to certain allergens, which"
tends to start in childhood. Vasomotor rhinitis starts in the 20s and 30s.
 Hereditary: Family history of similar or allied complaints
 Infections may alter tissue permeability
 Psychological and emotional factors in vasomotor rhinitis
 Sit the patient up (if the patient is not in shock) and tilt
head forward not backwards to avoid pooling of blood
 Instruct patient to pinch the nose between the finger and
"the thumb for 15 minutes, breathe through the mouth,"
 Impregnate a gauze strip with Soft paraffin or Tetracycline eye ointment and pack into the nose using forceps
 Leave gauze in place for 24-48 hours
If bleeding still does not stop after this period
 Refer to hospital for further management 
 Changes in humidity and temperature
" Certain foods; drugs, e.g. acetylsalicylic acid"
 Often present in school age children
 Sometimes preceded or followed by eczema or asthma. Less
" Nasal obstruction, variable in intensity and may alternate from"
 Postnasal drip (mucus dripping to the back of the nose)
 Careful history is most important
 Large turbinates on examining the nose
 Avoid precipitating factors (most important) HC2
 Avoid precipitating factors (most important)
" Antihistamines, e.g., Chlorphenamine 4 mg every 12 hours HC2"
"for up to 21 days, then as required thereafter if it recurs"
" Nasal decongestants, e.g., Pseudoephedrine or"
 Surgery may be required if there is obstruction of the nose
" Do NOT use vasoconstrictor nasal drops, e.g. Pseudoephedrine"
"and Xylometazoline for 7 days or repeatedly, since they can"
cause rebound congestion and alter the nasal environment making
Sinusitis (Acute) ICD10 CODE: J01
Inflammation of air sinuses of the skull
" Viruses, e.g., rhinovirus, often as a complication of URT Dental focal infection"
" Bacteria, e.g., Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes"
" Pain over cheek and radiating to frontal region or teeth, increasing with straining or bending down"
" Redness of nose, cheeks, or eyelids"
 Tenderness to pressure over the floor of the frontal sinus immediately above the inner canthus
" Antihistamines, e.g., Chlorphenamine 4 mg every 12 hours"
"for up to 21 days, then as required thereafter if it recurs"
" Nasal decongestants, e.g., Pseudoephedrine or"
 Surgery may be required if there is obstruction of the nose HC2
" Do NOT use vasoconstrictor nasal drops, e.g. Pseudoephedrine"
"and Xylometazoline for 7 days or repeatedly, since they can"
cause rebound congestion and alter the nasal environment making
" Referred pain to the vertex, temple, or occiput"
 Persistent coughing or pharyngeal irritation
" Nasal polyps, adenoids rhinitis"
 Steam inhalation may help clear blocked nose
 Nasal irrigation with normal saline
If there are signs of bacterial infection (symptoms persisting 
"1 week, unilateral facial pain, worsening of symptoms after an"
 Amoxicillin 500 mg every 8 hours for 7-10 days
 Steam inhalation may help clear blocked nose
 Nasal irrigation with normal saline
If there are signs of bacterial infection (symptoms persisting 
"1 week, unilateral facial pain, worsening of symptoms after an"
 Amoxicillin 500 mg every 8 hours for 7-10 days HC2
If there is a dental focus of infection
 Give antibiotics e.g. Amoxicillin plus
"Metronidazole (see Gingivitis, section 23.2.5)"
 If there is a foreign body in the nose
" Do NOT use antibiotics except if there are clear features of bacterial sinusitis, e.g., persistent ( 1 week) purulent nasal discharge,"
"sinus tenderness, facial or periorbital swelling, persistent fever"
Chronic infection of the nasal mucosa in which various components
become thinner (atrophy) due to fibrosis of the terminal blood vessels.
" Unknown but associated with: HIVAIDS, poor socio- economic"
"status, syphilis, rhinoscleroma (early stages)"
 Tends to affect both nasal cavities
 Affects females more than males
 Foul stench not noticed by patient who cannot smell
 Crusts and bleeding points in the nose
 Sensation of obstruction in the nose
If there is a dental focus of infection
 Give antibiotics e.g. Amoxicillin plus
"Metronidazole (see Gingivitis, section 23.2.5)"
 If there is a foreign body in the nose
 Refer to hospital for removal HC2
" Do NOT use antibiotics except if there are clear features of bacterial sinusitis, e.g., persistent ( 1 week) purulent nasal discharge,"
"sinus tenderness, facial or periorbital swelling, persistent fever "
 Clean nasal cavities twice daily to remove crusts (most HC3
 Syringe nose or douche it with warm normal saline
 Or sodium bicarbonate solution 5 (dissolve 1 teaspoon
of powder in 100 ml cup of warm water)
 Then apply tetracycline eye ointment 1 inside the nose
- Give amoxicillin 500 mg every 8 hours for 14 HC4
daysFor rhinoscleroma: Give 1 g every 8 hours
If atrophic rhinitis not better or is worse after 2 weeks
" Treateliminate known causes, such as syphilis"
"Adenoid Disease ICD10 CODE: J35.02, J35.2"
Enlargementinflammation of nasopharyngeal tonsil. Common in small
 Clean nasal cavities twice daily to remove crusts (most
 Syringe nose or douche it with warm normal saline
 Or sodium bicarbonate solution 5 (dissolve 1 teaspoon
of powder in 100 ml cup of warm water)
 Then apply tetracycline eye ointment 1 inside the nose
- Give amoxicillin 500 mg every 8 hours for 14
daysFor rhinoscleroma: Give 1 g every 8 hours
If atrophic rhinitis not better or is worse after 2 weeks
"May be due to enlargement, inflammation, or both"
" Obstruction of the nose leading to mouth breathing, difficulty"
"eating, snoring, jaw deformities"
" Obstruction of Eustachian tube leading to hearing loss, which"
fluctuates due to fluid in middle ear (Glue ear)
" Physical and other developmental retardation, e.g. small size for"
 Diagnosis is usually based on history
 X-ray for neck soft tissue: lateral view shows narrowing of the
" Other causes of nasal obstruction and discharge, e.g., rhinitis,"
 Dental and jaw diseases or abnormalities
Mild (If symptoms are not marked)
 Give conservative treatment with chlorpheniramine 1-2
mg daily (depending on age) for 7 days HC2
 Topical nasal steroids if available
Mild (If symptoms are not marked)
 Give conservative treatment with chlorpheniramine 1-2 
mg daily (depending on age) for 7 days
 Topical nasal steroids if available HC2
Moderate and Severe (If symptoms are marked or do not improve on treatment)
 Refer to ENT surgeon for surgery
Foreign Body (FB) in the Airway ICD10 CODE: T17
Mostly occurs in children 5 years
" Types of FBs include seeds (groundnuts, beans, maize) plastics,"
"rubber, metal wires, ball bearings"
" Child is chewing, laughing, or crying or there is a sudden disturbance, which opens the vocal cords so the object is inhaled"
 Sudden onset of choking followed by stridor (noisy breathing) or
" Cough, difficulty in breathing, wheezing"
 Hoarseness of voice if FB stuck at the vocal cords
" Symptoms start suddenly, some symptoms may be transient (may"
"disappear after a short period), but complications may present"
"few days later (sudden death, intractable pneumonia)"
" Upper airway obstruction as shown by: flaring of the nostrils,"
"recession of the chest inlet andor below the ribs, rapid chest"
movements and reduced air entry (usually on the right side)
" Once the history and examination are suggestive, investigations"
Moderate and Severe (If symptoms are marked or do not improve on treatment)
 Refer to ENT surgeon for surgery 
" Chest x-ray may show lung collapse, hyperinflation, mediastinal"
" If chocking, attempt to dislodge it by 3 cycles of 5 back"
slaps5 chest compressions (for infants) or Heimlich
 Do not do blind finger sweeps. If a foreign body is visible
"in the mouth, remove it with a Magill forceps"
" If severe respiratory distress, refer to higher level for"
airway visualization. Give oxygen if necessary
" Dislodge large FB, e.g. chunk of meat, from the pharynx by cycles of 5 back slaps and Heimlich manoeuvre"
(standing behind the patient with both arms around the
upper abdomen and giving 5 thrusts)
- If patient pregnant or very obese: Perform 6-10
chest thrusts with patient lying on the back
" If still suspect of FB, refer for airway visualization"
 Do not give groundnuts or other small hard food items to children 2 years
" If a child is found with objects in the mouth, leave the child alone"
to chew and swallow or gently persuade the child to spit out the
 Do not struggle withforce the child
" If chocking, attempt to dislodge it by 3 cycles of 5 back"
slaps5 chest compressions (for infants) or Heimlich
 Do not do blind finger sweeps. If a foreign body is visible
"in the mouth, remove it with a Magill forceps"
" If severe respiratory distress, refer to higher level for"
airway visualization. Give oxygen if necessary HC2
" Dislodge large FB, e.g. chunk of meat, from the pharynx by cycles of 5 back slaps and Heimlich manoeuvre"
(standing behind the patient with both arms around the
upper abdomen and giving 5 thrusts)
- If patient pregnant or very obese: Perform 6-10
chest thrusts with patient lying on the back
" If still suspect of FB, refer for airway visualization "
Foreign Body in the Food Passage ICD10 CODE: T18
 Types of FBs commonly involved include:
" Fish or chicken bones, often lodging in the tonsils, behind the"
"tongue, or in the pharynx, occasionally in the oesophagus"
" Coins, especally in children. Coins are particularly likely to be"
ingested. Disc battery is particularly dangerous and requires immediate referral
 Difficulty and pain in swallowing
 Patient winces as he attempts to swallow
 Patient may point to where foreign body is stuck with a finger
" FB may be seen, e.g., in tonsil, pharynx"
 Medication ulcer (e.g. doxycycline)
 X-ray may reveal radio-opaque FB
 Coins may appear on X-rays done for other reasons
 Look for a gas shadow if in the oesophagus
" The approach depends upon the type of object ingested, the"
"location of the object, and the patients clinical status."
" If negative radiographs, no symptoms and the FB does not belong to a dangerous category (magnets, disc batteries, sharp long"
"objects, superabsorbent polymer), expectant management is advised."
" If patient is symptomatic andor the object is dangerous, immediate referral for further management."
 Do NOT try to dislodgemove the FB with solid food
- This may push it into the wall of the oesophagus
causing infection and sometimes death
 Give IV infusion if unable to swallow liquids or if oral
If FB is invisible on X-ray or symptoms persist 24 hours from
 Refer to hospital with ENT facility
"If FB is visible in the pharynx, tonsil, etc."
 Grasp and remove it with long forceps
If patient tried to push FB with solid food:
 Give broad-spectrum antibiotic cover with amoxicillin
500 mg every 8 hours for 5 days
 Keep potential FBs out of childrens reach
" Advise on care in eating, i.e., not taking in too large pieces of"
"food, chewing thoroughly before swallowing"
 Advise once a FB is stuck to avoid trying to push it down with
solid food as this may sometimes be fatal
 Do NOT try to dislodgemove the FB with solid food
- This may push it into the wall of the oesophagus
causing infection and sometimes death
 Give IV infusion if unable to swallow liquids or if oral
If FB is invisible on X-ray or symptoms persist 24 hours from
 Refer to hospital with ENT facility
"If FB is visible in the pharynx, tonsil, etc."
 Grasp and remove it with long forceps
If patient tried to push FB with solid food:
 Give broad-spectrum antibiotic cover with amoxicillin
500 mg every 8 hours for 5 days 
Pharyngitis (Sore Throat) ICD10 CODE: J02
" Bacterial: commonly Group A haemolytic Streptococci, diphtheria in non-immunized children"
 Gonorrhoea (usually from oral sex)
 May also follow ingestion of undiluted spirits
 Candida albicans in the immunosuppressed
" Mild fever, loss of appetite, general malaise"
" In children: nausea, vomiting, and diarrhoea"
" The presence of runny nose, hoarseness, cough, conjunctivitis,"
"viral rash, diarrhea suggests viral infection"
" The presence of tonsilar exudates, tender neck glands, high fever, and absence of cough suggest a bacterial pharyngotonsillitis"
" Tonsillitis, epiglottitis, laryngitis"
 Otitis media if there is referred pain
 Throat examination with torch and tongue depressor
 Serological test for haemolytic streptococci (ASOT)
Most cases are viral and do not require antibiotics
" Give plenty of (warm) oral fluids e.g., tea"
" Give analgesics, e.g., Paracetamol for 3 days"
 Review the patient for progress
For Streptococcal pharyngitis: see section Notes
" If not properly treated, streptococcal pharyngitis may"
lead to acute rheumatic fever and retropharyngeal or
- Therefore ensure that the full 10-day courses of
antibiotics are completed where applicable
Pharyngo-Tonsillitis ICD10 CODE: J03
 Streptococcal infection (most common)
" Sudden onset, most common in children"
" Fever, shivering, headache, vomiting"
 Tonsils enlarged and with exudate and cervical lymph nodes
" Local: peritonsillar cellulitis and abscess (quinsy),"
Most cases are viral and do not require antibiotics
" Give plenty of (warm) oral fluids e.g., tea"
" Give analgesics, e.g., Paracetamol for 3 days"
 Review the patient for progress
For Streptococcal pharyngitis: see section HC2
" If not properly treated, streptococcal pharyngitis may"
lead to acute rheumatic fever and retropharyngeal or
- Therefore ensure that the full 10-day courses of
antibiotics are completed where applicable 
" Systemic complications: bacterial endocarditis, glomerulonephritis, rheumatic fever (see section 4.1.9)"
Bacterial pharyngotonsillitis HC2
 Phenoxymethylpenicillin 500 mg every 6 hours for 10 days
 Or Benzathine penicillin MU IM single dose
 Erythromycin 500 mg every 6 hours for 10 days
 Treat symptomatically with analgesics and increased
Peritonsillar Abscess (Quinsy) ICD10 CODE: J36
An abscess between the tonsil capsule and the lateral wall of the pharynx
 Follows (often mild) tonsillitis attack
" Fever, headache, malaise, rigors may occur"
 Inability to open the mouth; salivation and dribbling
 Phenoxymethylpenicillin 500 mg every 6 hours for 10 days
 Or Benzathine penicillin MU IM single dose
 Erythromycin 500 mg every 6 hours for 10 days
 Treat symptomatically with analgesics and increased
 Thickened muffled (unclear) speech
 Tonsil and soft palate reddish and oedematous
 Swelling pushing the uvula to opposite side
  May be pointing (bulging collection of pus)
 Carry out CS on pus if present or after drainage
Early stages: Disease of adolescents and adults
 Adult: Benzylpenicillin 2 MU IV or IM every 6 hours
for 48 hours then switch to amoxicillin 500 mg every 8
hours to complete a total of 7 days
 Ceftriaxone 1 g IV once daily for 7 days Child: 50 mg
kg  Plus metronidazole 500 mg IV every 8 hours Child: 10 HC2
Early stages: Disease of adolescents and adults
 Adult: Benzylpenicillin 2 MU IV or IM every 6 hours
for 48 hours then switch to amoxicillin 500 mg every 8
hours to complete a total of 7 days
 Ceftriaxone 1 g IV once daily for 7 days Child: 50 mg
kg  Plus metronidazole 500 mg IV every 8 hours Child: 10
 Set up an IV drip e.g. Normal saline
 Surgery (which should be done by a trained person)
- Suction facility will be needed
- Carry out incision and drainage at the most
pointing area with the protected tip of no.11
 6 weeks later: Refer for tonsillectomy as this condition
 Prompt and adequate treatment of tonsillitis
 Set up an IV drip e.g. Normal saline
 Surgery (which should be done by a trained person)
- Suction facility will be needed
- Carry out incision and drainage at the most
pointing area with the protected tip of no.11
 6 weeks later: Refer for tonsillectomy as this condition
A very superficial bacterial infection of the epidermis (upperouter layer
"of skin), bullous and non bullous impetigo"
" Streptococcus or staphylococcus infection, or both"
" Common in children, although it can also occur in adults."
" Lesions usually on face, head, and hands as bullae, or small"
brown crusts on an erythematous base
" In some cases, large flaccid bullae containing pus and serum are"
formed commonly in the axilla and groin
 Culture and sensitivity (exudate from unroofed lesion)
 Clean affected area with chlorhexidine solution 0.05
Antiseptic: if infection mild and localised (5 lesions)
 Apply gentian violet aqueous paint 0.5 every 12 hours
 OR apply silver sulphadiazine 1 cream 12 hourly for
5 days OR apply Mupirocin(supirocin) 2 8 hourly for
Antiseptic: if infection mild and localised (5 lesions)
 Apply gentian violet aqueous paint 0.5 every 12 hours
 OR apply silver sulphadiazine 1 cream 12 hourly for
 Keep skin clean by frequent washing and drying
" Use soap and water to soften, and gently remove any"
"Systemic antibacterial: if signs of regional or systemic spread,"
 Cloxacillin 250500 mg every 6 hours before food for
7 days Child: 12.525 mgkg per dose
" Or in penicillin allergy, erythromycin 250-500 mg every"
6 hours for 7 days Child: mgkg per dose
 Impetigo is contagious until the lesions have dried up
 Isolate separate from other patients  in case of admission
 Clean affected area with chlorhexidine solution 0.05
Antiseptic: if infection mild and localised (5 lesions)
 Apply gentian violet aqueous paint 0.5 every 12 hours
 OR apply silver sulphadiazine 1 cream 12 hourly for
5 days OR apply Mupirocin(supirocin) 2 8 hourly for
Antiseptic: if infection mild and localised (5 lesions)
 Apply gentian violet aqueous paint 0.5 every 12 hours
 OR apply silver sulphadiazine 1 cream 12 hourly for
 Keep skin clean by frequent washing and drying
" Use soap and water to soften, and gently remove any"
"Systemic antibacterial: if signs of regional or systemic spread,"
 Cloxacillin 250500 mg every 6 hours before food for
7 days Child: 12.525 mgkg per dose
" Or in penicillin allergy, erythromycin 250-500 mg every"
6 hours for 7 days Child: mgkg per dose HC2
 Impetigo is contagious until the lesions have dried up
 Isolate separate from other patients  in case of admission 
 Proper hygiene with use of antiseptic soap
Boils (Furuncle)Carbuncle ICD CODE: L02
A boil or furuncle is a deep-seated infection of the hair follicles with a
walled-off collection of pus. A carbuncle is a cluster of interconnected
" Bacterial infection with Staphylococcus aureus, leading to to the"
" Common in people with poor general health, diabetes, to or the"
" Swelling becomes fluctuant, may point after 3 days"
 Pus swab for Gram staining and CS
" If recurrent, check for diabetes mellitus and HIV infection"
 Intermittent warm compresses to allow lesion to point
" Incise and drain when ready (most fluctuant point), then"
cover with dressing (pack cavity)
" May be useful if instituted early and in carbuncles, lesions"
on face and in immunocompromised patients
 Cloxacillin 250-500 mg every 6 hours before food for
" OR in penicillin allergy patients, erythromycin"
 Personal hygiene with use of antiseptic soap
Cellulitis and Erysipelas ICD10 CODE: L03
Cellulitis is an acute inflammation of the skin involving the dermis and
"subcutaneous tissues, caused mainly by streptococci and staphylococci."
"Erysipelas has a raised demarcated border, whereas the border is not"
" Streptococcus and S. Aureus, in adults"
 Haemophilus influenza type b in children under 3 years
 Intermittent warm compresses to allow lesion to point
" Incise and drain when ready (most fluctuant point), then"
cover with dressing (pack cavity)
" May be useful if instituted early and in carbuncles, lesions"
on face and in immunocompromised patients
 Cloxacillin 250-500 mg every 6 hours before food for
" OR in penicillin allergy patients, erythromycin"
" Cellulitis is sometimes caused by other organisms e.g, pseudomonas picked from bath tubs to a lesser extent"
 Pre-existing lesion such as ulcer or erosion
" Iatrogenic, via intra venous therapy (cannulation) and prolonged"
" Pain, swelling - loss of function, tenderness"
 Acute localised swelling and oedema
" In erysipelas, lesions are more superficial and have a defined"
 Skin becomes tense and shiny in advanced stages
 Regional lymphadentiis may be present
 Pus swab for Gram staining and culture and sensitivity
"NB; Investigations depend on differential diagnosis list, e.g. Xray,"
" Give an analgesic e.g., paracetamol 1 g every 6-8 hours"
 Antibiotics: cloxacillin 250-500 mg every 6 hours before
" OR in penicillin allergy, erythromycin 500 mg every 6"
- Adult: 1 g every 12 hours for 3 days
 Then oral antibiotics to complete 1 week of antibiotics
"A viral infection transmitted by direct contact, and characterized by a"
"localized primary lesion, latency, and recurrence. Lesions can be oral"
"lips, oral mucosae  (HSV 1) or genital- (HSV 2)."
 Herpes simplex virus types 1 and 2
Herpes simplex: Primary  May be asymptomatic
" Give an analgesic e.g., paracetamol 1 g every 6-8 hours"
 Antibiotics: cloxacillin 250-500 mg every 6 hours before
" OR in penicillin allergy, erythromycin 500 mg every 6"
- Adult: 1 g every 12 hours for 3 days
 Then oral antibiotics to complete 1 week of antibiotics HC3
"Herpes simplex: Primary  In some cases, there may be feinfection ver, malaise, gingivostomatitis,"
"and vesicular lesions in the oropharynx, commonly on lips."
" If genital infection, painful vescicular eruption in the genital area"
 Meningoencephalitis and eczema herpeticum in patients with
"atopic eczema, may be the complications"
Herpes simplex Reactivation  Recurrent Herpes labialis and
" Other causes of genital sores, e.g., syphilis"
 Other causes of meningoencephalitis
 No routine investigation necessary. Diagnosis is clinical
" Clean lesions with antiseptic, e.g. chlorhexidine solution"
 Or diluted hydrogen peroxide solution 6 f In severe or
"extensive infection, acyclovir 400 mg every 8 hours by"
- Child: 100-200 mg 5 times a day for 5-7 days
"infection  In some cases, there may be fever, malaise, gingivostomatitis,"
"and vesicular lesions in the oropharynx, commonly on lips."
" If genital infection, painful vescicular eruption in the genital area"
 Meningoencephalitis and eczema herpeticum in patients with
"atopic eczema, may be the complications"
of primary infection  Recurrent Herpes labialis and
" Clean lesions with antiseptic, e.g. chlorhexidine solution"
 Or diluted hydrogen peroxide solution 6 f In severe or
"extensive infection, acyclovir 400 mg every 8 hours by"
- Child: 100-200 mg 5 times a day for 5-7 days HC2
 Acyclovir only works if it is started within 48 hours of the first
 Avoiding direct contact with infected people
 Use of gloves and condoms as applicable
Herpes Zoster (Shingles) ICD10 CODE: B02
"An acute cutaneous infection involving primarily the dorsal root ganglia,"
usually of a single dermatome. It is characterised by a vesicular eruption
in areas supplied by peripheral sensory nerves in the affected root ganglia.
" Varicella zoster virus, usually reactivated from the virus that entered"
the cutaneous nerves during an earlier episode of chicken pox and
remained in a latent form. This usually occurs during low immunity.
"- For chickenpox, see section Clinical features"
" Pre-eruptive pain, itching or burning: generally localized to the"
"dermatome, precedes the eruption by 4-5 days"
 The above are followed by characteristic crops of very painful
vesicles on the side supplied by affected nerve
 Acyclovir only works if it is started within 48 hours of the first
 Clinical diagnosis is sufficient
" Serology test for HIV, if sero-status not known"
Symptomatic and supportive treatment HC2
" Clean lesions with antiseptic, e.g. chlorhexidine solution"
 Or diluted hydrogen peroxide solution 6
 Apply calamine lotion 23 times daily
 Analgesics for neuropathic pain e.g. amitriptyline 25 mg
"nocte, or carbamazepine 200 mg nocte as necessary"
 Oral aciclovir 800 mg 5 times a day for 7 days can be
"given, especially if the disease is diagnosed very early or"
 Refer to an ophthalmologist (Eye Specialist)
" Protect high-risk individuals (e.g., the immuno-suppressed) from"
direct contact with the disease
"Superficial infection caused by dermatophytes or malassetia fungi, which"
"invade dead tissue of the skin and its appendages (stratum corneum,"
nails and hair). They are not very infectious but are usually recurrent.
"Common in children, 4  14 years of age"
Symptomatic and supportive treatment
" Clean lesions with antiseptic, e.g. chlorhexidine solution"
 Or diluted hydrogen peroxide solution 6
 Apply calamine lotion 23 times daily
 Analgesics for neuropathic pain e.g. amitriptyline 25 mg
"nocte, or carbamazepine 200 mg nocte as necessary"
 Oral aciclovir 800 mg 5 times a day for 7 days can be
"given, especially if the disease is diagnosed very early or"
 Refer to an ophthalmologist (Eye Specialist) HC2
 Microsporum canis- from animal to human (commonest cause
 Features (and name of the infection) depend on the body part
"Tinea capitis  Alopecia, scaly patches with hairs broken"
 The lesion may sometimes be inflamed
"with multiple pustules-Kerion, (pockets of"
 Especially in children (4- 14 years and immuno-suppressed
Tinea corporis  Single or multiple plaques on hairless skin
"(ringworm) except, palm, sole and groin, especially"
" Well-demarcated, scaly and raised border"
Tinea (or pityriasis)  A chronic yeast infection caused by malasversicolor sezia fur fur- a normal flora.
 Well-defined roundoval patches on the
"chest, upper back, face and arms."
" Not scaly, but peels off when scratched"
" Rare in children, onset usually around puberty."
"Tinea capitis  Alopecia, scaly patches with hairs broken"
 The lesion may sometimes be inflamed
"with multiple pustules-Kerion, (pockets of"
 Especially in children (4- 14 years and immuno-suppressed
(ringworm)  Single or multiple plaques on hairless skin
"except, palm, sole and groin, especially"
" Well-demarcated, scaly and raised border"
versicolor  A chronic yeast infection caused by malassezia fur fur- a normal flora.
 Well-defined roundoval patches on the
"chest, upper back, face and arms."
" Not scaly, but peels off when scratched"
" Rare in children, onset usually around puberty."
"Tinea (or pityriasis)  Treatment; topical application or shamversicolor poo; ketoconazole, clotrimazole, miconazole. In severe form, parental application may be used."
 NB: griseofulvin SHOULD not be used
cause p. versicolor is an yeast infection 
not by dermatophyte hence not effective.
"Nails (Onycho- my-  Thickened, discolored nails; can be white,"
 Brittle nails that break easily
"Tinea capitis  Bald, scaly patches with hairs broken off"
 The lesion may sometimes be inflamed
with multiple pustules (pockets of pus)
 Especially in children and mmune- suppressed
"Tinea corporis  Single or multiple plaques on the face,"
" Well demarcated, scaly and raised border"
Tinea (or pityriasis)  A chronic fungal infection of large areas
" Pale or discolored spots on the skin, e.g.,"
" Not scaly, but peels off when scratched"
" Rare in children, onset usually around puberty"
"versicolor  Treatment; topical application or shampoo; ketoconazole, clotrimazole, miconazole. In severe form, parental application may be used."
 NB: griseofulvin SHOULD not be used
cause p. versicolor is an yeast infection 
not by dermatophyte hence not effective.
"Nails (Onycho- mycosis)  Thickened, discolored nails; can be white,"
 Brittle nails that break easily
"Tinea capitis  Bald, scaly patches with hairs broken off"
 The lesion may sometimes be inflamed
with multiple pustules (pockets of pus)
 Especially in children and mmune- suppressed
"(ringworm)  Single or multiple plaques on the face,"
" Well demarcated, scaly and raised border"
versicolor  A chronic fungal infection of large areas
" Pale or discolored spots on the skin, e.g.,"
" Not scaly, but peels off when scratched"
" Rare in children, onset usually around puberty"
"Nails (Onycho- my-  Thickened, discolored nails, can be white,"
 Brittle nails that break easily
Tinea pedis (Ath-  White scaling usually between the 4th and
letes foot) 5th toes or between the 3rd and 4th toes
" Scales, vesicles, cracks, erosion"
 Burning or itching between toes and under foot especially when shoes and socks
 May be secondary bacterial infection
" Seborrhoeic dermatitis, eczema, contact dermatitis"
" Scales from the active edge of the lesions are scraped off, placed"
"in 10-20 potassium hydroxide (KOH) for 30 minutes, and"
examined microscopically for mycelia
 Culture of specimen on Sabourauds agar
"Nails (Onycho- mycosis)  Thickened, discolored nails, can be white,"
 Brittle nails that break easily
Tinea pedis (Athletes foot)  White scaling usually between the 4th and
5th toes or between the 3rd and 4th toes
" Scales, vesicles, cracks, erosion"
 Burning or itching between toes and under foot especially when shoes and socks
 May be secondary bacterial infection
 Oral griseofulvin 10 mgkg day as single dose once HC2
 Do NOT treat with topical antifungal agents; they cannot
 Apply Whitfields ointment (benzoic acid  salicylic acid)
12 hourly until 2 weeks after lesions clear
 Clotrimazole 1 cream twice a day
 Or miconazole 2 cream 12 hourly for 2-3 weeks
 Griseofulvin 10 mgkg for 3 weeks
 Apply clotrimazole cream 12 hourly until lesions disappear
 Or miconazole 2 cream 12 hourly for 2-3 weeks
 Fluconazole 300 mg once weekly for 2 weeks
NB; Griseofulvin should not be used
 Oral griseofulvin 10 mgkg per day as single dose once
daily after meals for 6-12 months
" Apply clotrimazole cream 12 hourly, continue for 14"
days after the lesions have healed
 Apply powder (not necessarily medicated) to the feet
 Oral griseofulvin 10 mgkg day as single dose once
 Do NOT treat with topical antifungal agents; they cannot
 Apply Whitfields ointment (benzoic acid  salicylic acid)
12 hourly until 2 weeks after lesions clear
 Clotrimazole 1 cream twice a day
 Or miconazole 2 cream 12 hourly for 2-3 weeks
 Griseofulvin 10 mgkg for 3 weeks HC2
 Apply clotrimazole cream 12 hourly until lesions disappear
 Or miconazole 2 cream 12 hourly for 2-3 weeks
 Fluconazole 300 mg once weekly for 2 weeks
NB; Griseofulvin should not be used HC3
 Oral griseofulvin 10 mgkg per day as single dose once
daily after meals for 6-12 months
" Apply clotrimazole cream 12 hourly, continue for 14"
days after the lesions have healed
 Apply powder (not necessarily medicated) to the feet
" For persistent or non-responsive infection, oral griseoful- HC3"
vin 10 mgkg day as single dose once daily after meals
 Double the dose in severe infections
 Do NOT use for tinea versicolor (pityriasis)
 Advise female patient to not get pregnant while on treatment
 Men should avoid fathering children while on treatment
Prevention and health education
" Clean all contaminated objects, e.g., combs, brushes"
" Avoid sharing contaminated combs, towels, clothes, etc."
 Advise patient on the need to persist with the long durations of
treatment to completely clear infection
 Personal foot hygiene is important. Keep feet clean and dry.
" If patient has repeat fungal infections, refer himher for HIV,"
diabetes counselling and testing.
Contagious skin disease associated with severe itch
" A parasitic mite, Sarcopterus scabiei hominis"
 Transmitted by direct skin contact with infected person
" For persistent or non-responsive infection, oral griseofulvin 10 mgkg day as single dose once daily after meals"
 Double the dose in severe infections
 Do NOT use for tinea versicolor (pityriasis)
 Advise female patient to not get pregnant while on treatment
 Men should avoid fathering children while on treatment 
" Intense itching, especially at night"
" Wheals, papules, vesicles, and thread-like burrows"
" Common in flexural areas, i.e., wrists and inter-digital creases,"
"axillae, nipples, buttocks, and genitalia"
" Scratching spreads mites to other areas leading to widespread,"
" Papular urticaria, atopic or seborrhoeic dermatitis"
" Microscopic identification of mites - diagnosis is largely clinical,"
their eggs or faeces obtained from the vesicles or mite burrows.
" Close contacts and all family members in the household-symptomatic and asymptomatic, should be treated"
 Wash with hot water and iron all linen which has touched
" Close contacts and all family members in the household-symptomatic and asymptomatic, should be treated"
 Wash with hot water and iron all linen which has touched
 Apply benzyl benzoate lotion 25 to the whole body from HC2
the scalp to the soles of the feet but taking care to avoid
contact with the eyes. apply at bed time and wash off in
the morning. Repeat 2 times except in pregnant women
 Give an antihistamine to relieve itching: tablet chorpheniramine 4 mg every 8 hours for 3 days
- Cetirizine 10mg at bed time for 5  7 days-in
If treatment ineffective or unsuitable
 Ivermectin 200 micrograms single dose (avoid in preg- HC3
"nancy, and in children 15 kg or belosw 12 years)"
" For complete eradication of mites, repeat the dose after"
If secondary infection is present
 Give an antibiotic as in boils (see section 22.1.2)
 Personal hygiene (washing clothes and regular bathing)
 Avoid close contact with infected people
PediculosisLice ICD10 CODE: B85
"Infestation by lice, usually in the hairy parts of the body. Usually found"
"on the scalp, armpits, chest or pubic area."
" Pediculosis humanus (capitis, corporis, pubis)"
 Usually transmitted directly by person-to-person contact but may
"also be transmitted indirectly via the clothing, towels, and bedding of infested persons"
 Apply benzyl benzoate lotion 25 to the whole body from
the scalp to the soles of the feet but taking care to avoid
contact with the eyes. apply at bed time and wash off in
the morning. Repeat 2 times except in pregnant women
 Give an antihistamine to relieve itching: tablet chorpheniramine 4 mg every 8 hours for 3 days
- Cetirizine 10mg at bed time for 5  7 days-in
If treatment ineffective or unsuitable
" Ivermectin 200 micrograms single dose (avoid in pregnancy, and in children 15 kg or belosw 12 years)"
" For complete eradication of mites, repeat the dose after"
If secondary infection is present
 Give an antibiotic as in boils (see section 22.1.2) HC2
" Severe itching of affected areas, scratch marks"
 Nits (white eggs) attached to hairs
 Continued scratching may lead to secondary bacterial infection
 Apply pediculocide to kill lice
- Apply benzyl benzoate lotion 25 and leave on
- Child 2-12 years: dilute the lotion with an equal
part of water before application
- Child 2 years: dilute 1 part of lotion with 3 parts
"of water, leave on for 12 hours. Apply ONLY once"
- Comb with a fine toothed comb if not shaved
 Do not use undiluted Benxyl Benzoate A in children 2 years. It
" If the head is not shaved, ensure that the BBA is massaged well"
 Soak all brushes and combs in BBA for at least 2 hours
 Apply pediculocide to kill lice
- Apply benzyl benzoate lotion 25 and leave on
- Child 2-12 years: dilute the lotion with an equal
part of water before application
- Child 2 years: dilute 1 part of lotion with 3 parts
"of water, leave on for 12 hours. Apply ONLY once"
- Comb with a fine toothed comb if not shaved HC2
 Do not use undiluted Benxyl Benzoate A in children 2 years. It
" If the head is not shaved, ensure that the BBA is massaged well"
 Soak all brushes and combs in BBA for at least 2 hours 
 Treat all sexual partners at the same time
 Personal hygiene (washing clothes and regular bathing)
 Avoid close contact with infected people
" Avoid sharing combs, towels, etc"
Tungiasis (Jiggers) ICD10 CODE: B88.1
An infestation by the burrowing flea Tunga penetrans. Commonly affects
"the feet, hands, elbows, and sometimes buttocks."
" A burrowing sand flea, Tunga penetrans"
 Travel to areas with T. penetrans
" Living in same house with domestic animals such as pigs, dogs"
" Punctum or ulceration, often described as a white patch with a"
 There may be redness and swelling around affected site
" A serosanguineous exudate may ooze from the central opening,"
and eggs may be seen with the naked eye
 Lesions can be painful and very itchy
 Treat all sexual partners at the same time 
" Tissue necrosis, suppuration, gangrene"
 Creeping eruption (ancylostoma species)
 Clinical features are diagnostic
 In many cases tungiasis will heal on its own as the
"burrowed flea dies within 25 weeks, and naturally"
" Physical removal of the flea using sterile forceps, or"
Medicine treatment and suffocation of flea Apply Dimethicone
 Wash the feet or the affected part of the body thoroughly
 Apply a few drops on the black dot of the identified jiggers
 In many cases tungiasis will heal on its own as the
"burrowed flea dies within 25 weeks, and naturally"
" Physical removal of the flea using sterile forceps, or"
Medicine treatment and suffocation of flea Apply Dimethicone
 Wash the feet or the affected part of the body thoroughly
 Apply a few drops on the black dot of the identified jiggers
 For severe cases you may require to rubrubbing the oil HC2
 A single treatment as above is enough but can be repeated
after two weeks in situations of severe infestation
" Avoid contact with eyes. In case of contact, wash the"
 The oil is highly inflammable. Avoid sitting near open
fires after applying Dimeticone.
 Store the unused oil away from open fire and children
 Do not use dimeticone on people with known hypersensitivity reactions to any of the Dimeticone oils
 Apply benzyl benzoate 25 emulsion twice daily to the
 Immerse affected area in potassium permanganate 0.05
once a day for 10 minutes for 10 days
 Then follow with application of thickpetroleum jelly or
20 salicylated petrolleum jelly vaseline) daily for 7 days
If secondary bacterial infection
 Treat as per boils (see section 22.1.2)
 Health education to prevent secondary bacterial infections such
 For severe cases you may require to rubrubbing the oil
 A single treatment as above is enough but can be repeated
after two weeks in situations of severe infestation
" Avoid contact with eyes. In case of contact, wash the"
 The oil is highly inflammable. Avoid sitting near open
fires after applying Dimeticone.
 Store the unused oil away from open fire and children
 Do not use dimeticone on people with known hypersensitivity reactions to any of the Dimeticone oils
 Apply benzyl benzoate 25 emulsion twice daily to the
 Immerse affected area in potassium permanganate 0.05
once a day for 10 minutes for 10 days
 Then follow with application of thickpetroleum jelly or
20 salicylated petrolleum jelly vaseline) daily for 7 days
If secondary bacterial infection
 Treat as per boils (see section 22.1.2) HC2
 Health education to prevent secondary bacterial infections such
 Spray the ground with insecticide such as malathion
 Protect feet with socks and shoes
 Dry laundry on a line instead of the ground
" Do not share housing with animals. Animals such as goats, pigs,"
cows can all be infested with jiggers
 Keep floors clean and dust free
INFLAMMATORY AND ALLERGIC SKIN CONDITIONS
Acne is a common chronic skin disease caused by blockage andor
inflammation of hair follicles and sebaceous glands. It commonly occurs
in puberty and adolescence and is associated with hormonal changes.
Acne develops as a result of the following four factors:
 Release of inflammatory mediators into the skin
 Follicular hyperkeratinization with subsequent plugging ofof the
 Acne develops as a result of the following four factors:
 Release of inflammatory mediators into the skin
 Follicular hyperkeratinization with subsequent plugging of the
 Propionibacterium acnes follicular colonization
" Typically affects face, and upper part of chest and back"
" Inflammatory papules, pustules and nodules"
 Cysts and scars in severe cases
 Clinical features are largely diagnostic
 Reassure patient. Inform him or her that diet plays no
 Clean face twice daily with mild soap and water
 Commercial facial wash cleansers can decrease skin oiliness
" Do not use oil, cream or petroleum jelly"
" Sunshine is helpful, but avoid sunburn"
" If acne is getting worse or pustular, refer to a dermatologist"
 Reassure patient. Inform him or her that diet plays no
 Clean face twice daily with mild soap and water
 Commercial facial wash cleansers can decrease skin oiliness
" Do not use oil, cream or petroleum jelly"
" Sunshine is helpful, but avoid sunburn"
" If acne is getting worse or pustular, refer to a dermatologist HC2"
" Benzoyl peroxide 2.5 to 10, applied at night for not"
 Only use if acne is severe and creams are unavailable
 Duration of treatment depends on response. May last 6
 Doxycycline 100 mg once daily for 6-12 months.
 Review treatment monthly to ascertain response
" OR erythromycin 500 mg every 6 hours for 1 month,"
during pregnancy or breast feeding
 Refer to dermatologist if no response occurs
" Combined oral contraceptive (see Family Planning,"
UrticariaPapular Urticari ICD10 CODE: L50
"An acute, sub-acute or chronic inflammation of the skin, caused by"
endogenous or exogenous agents. Urticaria is an itchy skin rash.
" Endogenous: familial, also associated with other allergic diseases"
" Exogenous: agents include sunlight, chemicals, certain foods,"
 Inflammation of skin: transient itching hives and wheals
" Papular urticaria: vesicles, redness, oedema, oozing in case of"
" Benzoyl peroxide 2.5 to 10, applied at night for not"
 Only use if acne is severe and creams are unavailable
 Duration of treatment depends on response. May last 6
 Doxycycline 100 mg once daily for 6-12 months.
 Review treatment monthly to ascertain response
" OR erythromycin 500 mg every 6 hours for 1 month,"
during pregnancy or breast feeding
 Refer to dermatologist if no response occurs HC2
" Combined oral contraceptive (see Family Planning,"
 Fungal and bacterial infections of the skin
 No satisfactory investigations for skin allergy
 Blood: haemogram to demonstrate eosinophilia
 Stool: microscopy to exclude worms
Establish the cause and treat accordingly. Identify what the HC2
" Give an analgesic e.g., paracetamol for any pain or"
 Give an antihistamine to relieve itching; chlorphenamine
4 mg every 8 hours Child: 1-2 mg per dose
 Or promethazine 25 mg at night. Increase to every 12
 Child: 1 mgkg daily in 1-2 divided doses
 Prednisolone 1 mgkg orally once a day for 3-5 days
 Avoid contact with known allergens
"Eczema (Dermatitis) ICD10 CODE: L20, L23"
Acute or chronic superficial inflammation of the skin
Establish the cause and treat accordingly. Identify what the
" Give an analgesic e.g., paracetamol for any pain or"
 Give an antihistamine to relieve itching; chlorphenamine
4 mg every 8 hours Child: 1-2 mg per dose
 Or promethazine 25 mg at night. Increase to every 12
 Child: 1 mgkg daily in 1-2 divided doses
 Prednisolone 1 mgkg orally once a day for 3-5 days HC2
" Allergic dermatitis: reaction to food, chemicals, plants, jewellery"
 Atopic dermatitis: unknown cause
 Itchy rash with dry rough scaly skin especially in flexural areas-(
" Oozing due to secondary bacterial infection, causing regional"
 Apply betamethasone cream 0.1 every 12 hours for 2
"weeks on affected parts, EXCEPT the face and genital areas"
" If face or genitalia affected, apply hydrocortisone cream"
 Give an antihistamine to relieve itching; chlorphenamine
4 mg every 8 hours Child: 1-2 mg per dose
 OR promethazine 25 mg at night; increase frequency
to every 12 hours if necessary Child: 1 mgkg daily in
 Apply betamethasone cream 0.1 every 12 hours for 2
"weeks on affected parts, EXCEPT the face and genital areas"
" If face or genitalia affected, apply hydrocortisone cream"
 Give an antihistamine to relieve itching; chlorphenamine
4 mg every 8 hours Child: 1-2 mg per dose
 OR promethazine 25 mg at night; increase frequency
to every 12 hours if necessary Child: 1 mgkg daily in
 Moisturizers (eg; Vaseline petroleum jelly) twice daily HC2
after bath to keep the body moist.
"If evidence of secondary infection, treat according to cause."
 Give a systemic antibiotic as in impetigo (section 22.1.1)
"If viral or fungal infection, treat as shown in respective"
" Avoid contact with allergens, Advise on light dressing in hot"
"weather to avoid sweating, advise on bathing habits like; reduce"
"on frequency of bathing  at most twice daily, use soft sponge."
"A chronic recurrent skin disease characterized by scaling, reddened papules or plaques on the scalp, back of the elbows and front of the knees."
Psoriasis commonly affects skin and joints plus nails.
The lesions tend to appear at sites of trauma (Koebners reaction).
" Unknown, but usually genetically transmitted"
 About 30 of cases have a family history
 Usually in patients 25-40 years old
" Gradual onset of distinct, red scaling papules which coalesce to"
" Adherent, silvery white scales, which reveal bleeding points"
 Worsening psoriasis may lead to total erythroderma
" Extra articular feature, e.g., pitting or thickening of nail plate"
with accumulation of debris under the nail plate
 Moisturizers (eg; Vaseline petroleum jelly) twice daily
after bath to keep the body moist.
"If evidence of secondary infection, treat according to cause."
 Give a systemic antibiotic as in impetigo (section 22.1.1)
"If viral or fungal infection, treat as shown in respective"
" Fungal infection, lichen planus"
 KOH microscopy to exclude fungal infection
" Blood: Serum uric acid, rheumatoid factor, and anti- nuclear"
factor and histology to rule out other diseases like rheumatoid
"arthritis, SLE, skin malignancies etc."
" Remove scales, then apply medicine as below HC4"
Mild cases (lesions 10 of the body)
" Give high potent topical steroids, e.g. clobetasolo proponate 0.05 cream applied on the lesions twice a"
 Apply crude coal tar ointment 1 at night for 2 weeks
Severe cases (lesions 20 of the body surface area)
 Refer for specialist management
" Remove scales, then apply medicine as below"
Mild cases (lesions 20 of the body)
" Give topical steroids, e.g. betamethasone cream applied"
on the lesions once in the morning
" Remove scales, then apply medicine as below"
Mild cases (lesions 10 of the body)
" Give high potent topical steroids, e.g. clobetasolo proponate 0.05 cream applied on the lesions twice a"
 Apply crude coal tar ointment 1 at night for 2 weeks
Severe cases (lesions 20 of the body surface area)
 Refer for specialist management
" Remove scales, then apply medicine as below"
Mild cases (lesions 20 of the body)
" Give topical steroids, e.g. betamethasone cream applied"
on the lesions once in the morning HC4
 Apply crude coal tar ointment 1 at night for 2 weeks HC4
Severe cases (lesions 20 of the body surface area) RR
 Refer for specialist management
" Drugs that precipitateexacerbate psoriasis include lithium, beta-blockers, antimalarials and systemic steroids"
Chronic ulcerative skin lesion caused by various aetiologies and often
" Vascular, e.g. venousarterial insufficiency"
" Bacterial: leprosy, Buruli ulcer (by Parasites: guinea worm, leishmaniasis, jiggers"
" Parasites: guinea worm, leishmaniasis"
" Diabetes, sickle cell disease, malnutrition"
 Often in lower third of the leg
" Ulcerated lesion with necrotic tissue, slough, discharge, oedema"
 Features of cellulitis due to secondary infection may be present
 Apply crude coal tar ointment 1 at night for 2 weeks
Severe cases (lesions 20 of the body surface area)
 Refer for specialist management HC4
" Drugs that precipitateexacerbate psoriasis include lithium, beta-blockers, antimalarials and systemic steroids "
- If exudatingdirty lesions: use chlorhexidine
solution 0.05 or hydrogen peroxide solution 6
- If clean wound: use clean water or normal saline
 Apply silver sulphadiazine or povidone iodine if the
- Otherwise use gauze moistened with normal saline
 Treat as per guidelines (see section 22.1.3)
Steven-Johnson Syndrome (SJS) and Toxic Epidermal
Necrolysis (TEN) ICD10 CODE: L51
A life threatening hypersensitivity reaction that affects the skin and the
"mucous membranes: SJS affects up to 10 of the body surface area, while"
"TEN affects 30. If it is between 10 and 30, it is SJSTEN overlap."
- If exudatingdirty lesions: use chlorhexidine
solution 0.05 or hydrogen peroxide solution 6
- If clean wound: use clean water or normal saline
 Apply silver sulphadiazine or povidone iodine if the
- Otherwise use gauze moistened with normal saline
 Treat as per guidelines (see section 22.1.3) HC2
" Certain medications such as: HIV medication (nevirapine), Anti-TB medications, anticonvulsants, e.g., carbamazepine, lamotrigine, sulpha-containg drugs (e.g., co-trimoxazole, allopurinol)"
" Infections, especially in immunocompromised persons"
" Dark macular skin rash, progressing to confluence with epidermal necrosis and large flaccid blisters which rupture, leaving"
" Usually sparing the scalp but involving mucosa (genitalia, mouth,"
"anal area, eyes) with multiple erosions"
" General lanning: fever, malaise"
" Complications: dehydration, electrolyte imbalances, hypoalbuminemia, secondary infection and sepsis"
" Serology for HIV, if status unknown"
" RFTs, pus swab, CS if indicated"
" Remove offending medicine or agent, possibly stop all H"
 Management is multi disciplinary and supportively (as in
" Remove offending medicine or agent, possibly stop all"
 Management is multi disciplinary and supportively (as in
" If eyes are involved, consult eye specialist f Treat if there"
is secondary bacterial infection
" There is no strong evidence to support the use of corticosteroids, which also increase risk of infection and catabolism"
"NB; Avoid unnecessary medication, this may worsen the condition"
 Advise patients to avoid self-medication
A disorder characterized by complete or partial absence of melanin
pigment in the skin hair and eyes- (albinos)
 due to absence of defect of tyrosinase enzyme involved in the
production of melanin (skin pigment)
 Apply sun screen whenever moving under the sun. Stay as much
 Do annual skin assessment to screen skin for cancer or leisons
" If eyes are involved, consult eye specialist f Treat if there"
is secondary bacterial infection
" There is no strong evidence to support the use of corticosteroids, which also increase risk of infection and catabolism"
"NB; Avoid unnecessary medication, this may worsen the condition H"
23.1.1. HalitosisBad Breath ICD 10 CODE: R19.6
Unpleasant odour from the oral cavity
 Gum disease due to infections in the mouth
" Systemic conditions or illnesses, such as liver disease, kidney"
 Drink plenty of water every day to encourage saliva
" Dietary changes, like use of raw carrots, as recommended"
by your dentist or nutritionist
 Advise on brushing teeth thoroughly at least twice daily
 Drink plenty of water every day to encourage saliva
" Dietary changes, like use of raw carrots, as recommended"
by your dentist or nutritionist
 Advise on brushing teeth thoroughly at least twice daily
23.1.2. Dentin Hypersensitivity ICD10 CODE: K03.9
"This condition is due to wearing off of the enamel, making it thinner"
leading to exposure of the dentin
 Gum recession due to age or improper tooth brushing
 Acidic beverages that cause enamel erosion and dentin exposure
 Chipped or fractured tooth may also expose the dentine
" Eating disorders, e.g. bulimia nervosa and anorexia nervosa (exposure to vomitus)"
" Sensitivity to hot, cold, sweet or very acidic foods and drinks,"
 Topical application of fluoride in form of toothpaste HC2
" In severe conditions, refer for root canal therapy"
 Professional cleaning of teeth HC4
23.1.3. Malocclusion ICD10 CODE: M26.4
Malocclusion is any deviation from the normal relation of the teeth in
"the same arch to each other, and to the teeth in the opposite arch"
 Aetiology is usually multifactorial
" Discrepancies in the craniofacial skeleton, dentition, or both"
 Topical application of fluoride in form of toothpaste
" In severe conditions, refer for root canal therapy"
 Professional cleaning of teeth HC2
 The main indications for orthodontic treatment are aesthetics
 Crossbites (as associated occlusal interferences may predispose
to Temporomandibular Pain Dysfunction Syndrome)
 Deep traumatic overbite with palatal impingement of the mandibular incisors
" Large overjets (increased risk of trauma), severe crowding (as this"
reduces periodontal support for teeth)
" While severe malocclusion can have a psychologically debilitating effect, it is often influenced by social and cultural factors"
 Removable appliance orthodontic therapy in the mixed
 Fixed appliance orthodontic therapy in adolescents and
 Cases with discrepancies in the craniofacial skeleton may
require orthognathic surgery by an oral and maxillofacial
23.1.4. Fluorosis (Mottling) ICD10 CODE: K003
 Occurs due to long-term excess of fluoride. Endemic in areas of
high fluoride occurring naturally in the water.
 Removable appliance orthodontic therapy in the mixed
 Fixed appliance orthodontic therapy in adolescents and
 Cases with discrepancies in the craniofacial skeleton may
require orthognathic surgery by an oral and maxillofacial
 Varies from white opacities to severe pitting and discolouration
due to incorporation of the excess fluoride in the enamel structure
" Tooth coloured (composite) fillings, veneers RR"
 Monitoring of fluoride levels in drinking water
 Use of fluoride-free toothpastes in endemic areas
"Traditional beliefs in many Ugandan communities attribute diarrhoea,"
"fever, and vomiting in children to the developing dentition with the belief"
"that if the offending teeth or ebinnyo are not removed, the child will die."
 The practice of extraction of ebinnyofalse teeth is based on
the belief that rubbing of herbs on the gum (in the region of
"the canine), or the removal of the primary and or permanent"
canine tooth buds will lead to the relief of childhood fevers and
The procedure is done as early as 1 month and up to 3 years of age.
Most studies report a peak age of 4-18 months
" Whereas infant illnesses may be attributed to the teething period, they are in fact a result of the poor health conditions in"
which these children are raised
" The term ebinyo encompasses both the childs ailment, as well"
as the treatment offered by traditional healers
Consequences of traditional treatment of ebinyo
" Tooth coloured (composite) fillings, veneers RR"
" The procedure is aimed at removal of the primary canine, but"
damage to the surrounding tissues occurs
" The incisions in the mouth and the herbs can lead to oral sepsis,"
"bacteraemia, anaemia, and death"
" If initial cause of diarrhoea, fever, and vomiting is not addressed,"
dehydration and death can occur
" Depending on the extent of damage, malocclusion can result"
"because the permanent canine maybe missing, impacted, or malformed"
 Counsel the parentcaretaker HC2
 Treat the condition causing the symptoms
 Sensitise community on dangers of ebinnyo beliefs
 Appropriate treatment of childhood illnesses
 Provision of proper nutrition to children
23.2.1. Prevention of Dental Caries and Other Conditions Due to
" Advise patient to reduce sugary foods and soft drinks, and to"
have adequate fresh fruit and vegetables in their diet
 Advise patient to brush their teeth at least twice a day (morning and evening) or preferably after every meal (wait at least 30
"minutes if you have consumed acidic food like lemon, oranges,"
 Treat the condition causing the symptoms HC2
 Dental flossing at least once a day
 Tooth strengthening and protection by rinsing with fluoride rinses and applying sealants to susceptible sites on teeth
 Prevention and early management of dental caries
 Advise patient to have a dental check-up every six months
Sugar-dependent disease resulting into cavities or holes in the teeth.
 Poor oral hygiene results in bacteria accumulation in a plaque on
the tooth surface. Acid produced as a by-product of metabolism
of dietary carbohydrate by the plaque bacteria causes demineralization and disintegration of the tooth surface forming a cavity
 Tooth sensitivity to hot and cold stimuli
" Susceptible sites include pits and fissures of the posterior teeth,"
"interproximal surfaces, and teeth in malocclusion"
" Referred pain from ENT infections, commonly sinusitis"
 Paracetamol 1 g every 8 hours HC2
- Child: 10-15 mgkg every 8 hours
- Child: 10-15 mgkg every 8 hours HC2
 Or ibuprofen 400 mg every 8 hours
- Child: 7-13 mgkg every 8 hours HC4
 Refer to specialist for filling or extraction
"These are anterior caries in the pre-school child, due to prolonged and"
" Frequent and prolonged consumption of fluid containing fermentable carbohydrates from a bottle, feeder cup, or on- demand nightly breast feeding after 15 months of age"
 Rapid progression of decay commencing labially and quickly encircling the teeth
 Teeth are affected in order of eruption
 Lower incisors are rarely affected as they are protected by the
tongue during suckling and directly cleansed by secretions from
sublingual and submandibular salivary glands
 Gently brush teeth with a toothpaste approved for children
 Build-up of the teeth should be done using composites
to restore shape and function HC4
 Disc affected teeth interproximally to create self- cleansing areas
 Or ibuprofen 400 mg every 8 hours
- Child: 7-13 mgkg every 8 hours
 Refer to specialist for filling or extraction HC4
 Gently brush teeth with a toothpaste approved for children
 Build-up of the teeth should be done using composites
 Disc affected teeth interproximally to create self- cleansing areas
 Regular fluoride applications HC2
 Educate care taker to avoid frequent on-demand liquids at night
"including breastfeeding, after 15 months"
23.Rampant and Radiation Caries
Rapid carious attack involving several teeth including those surfaces that
are usually caries-free (e.g. the smooth surface of a tooth)
 Frequent ingestion of sugary foods and drinks in individuals with
 Prolonged and frequent intake of sugar-based syrup medications
 Radiation caries: Radiation for head and neck cancer may result
in fibrosis of salivary glands and subsequent reduction in saliva
flow. Patients often resort to sucking sweets to alleviate their dry
"mouth, which further exacerbates the problem"
 Removal of causative factors as mentioned above HC4
" Education, fluoride treatment, tooth restoration, endodontic therapy, extractions"
Inflammation of the pulp of a tooth
 Commonly presents as a complication of dental caries
" Thermal, chemical, or traumatic insult to the pulp"
 Removal of causative factors as mentioned above
" Education, fluoride treatment, tooth restoration, endodontic therapy, extractions HC4"
 Pulsatile pain that lasts for several hours and worsens at night
 Tooth is very tender to percussion
" Referred pain of ENT origin, e.g. sinusitis"
" Pain due to temporomandibular joint pain dysfunction syndrome,"
or erupting mandibular wisdom teeth
" Dentine sensitivity due to thermal, tactile, or osmotic stimulus"
 Give an analgesic for pain relief HC2
- Child: 10-15 mgkg every 8 hours
 Or ibuprofen 400 mg every 8 hours
- Child: 7-13 mgkg every 8 hours
" Refer to dentist pulpotomy, endodontic (root canal)"
Acute Periapical Abscess or Dental Abscess ICD10 CODE:
Infection with pus formation at the root of a tooth as a sequel to pulpitis
caused by dental caries or trauma
 Mixed bacterial flora but mainly Staphylococcus spp
 Severe pain that disturbs sleep
 Facial swelling may be localized in the gum or extend to adjacent
 Give an analgesic for pain relief
- Child: 10-15 mgkg every 8 hours
 Or ibuprofen 400 mg every 8 hours
- Child: 7-13 mgkg every 8 hours
" Refer to dentist pulpotomy, endodontic (root canal)"
 Abscesses of the mandibular incisors or molars may discharge
 Affected tooth is mobile and tender to percussion
 Fever and headache may be present if infection has spread
" Pain due to sinusitis, temporomandibular joint pain dysfunction"
"syndrome, or erupting wisdom teeth"
" Dentine sensitivity due to thermal, tactile, or osmotic stimulus"
Infections localized to a tooth and its surroundings (swelling lim- HC4
"ited to the gum and no signs of infection extending to anatomical structures, or general signs of infection)"
 Pain relief (paracetamol andor ibuprofen)
 Root canal therapy if possible or extraction of tooth
- NO NEED of antibiotics since they cannot reach
If infection is spreading to local adjacent structures (painful
gingival and buccal swelling) or systemic signs and symptoms
 Then amoxicillin 500 mg every 8 hours
- Child: amoxicillin dispersible tablets 25 mgkg
"Infections localized to a tooth and its surroundings (swelling limited to the gum and no signs of infection extending to anatomical structures, or general signs of infection)"
 Pain relief (paracetamol andor ibuprofen)
 Root canal therapy if possible or extraction of tooth
- NO NEED of antibiotics since they cannot reach
If infection is spreading to local adjacent structures (painful
gingival and buccal swelling) or systemic signs and symptoms
 Then amoxicillin 500 mg every 8 hours
- Child: amoxicillin dispersible tablets 25 mgkg
 Plus metronidazole 400 mg every 8 hours
- Child: 10-mgkg (max 200 mg per dose)
- Child: 10-15 mgkg every 8 hours
 Or Ibuprofen 400 mg every 8 hours
- Child: 7-13 mgkg every 8 hours
Bleeding socket can be primary (occurring within first 24 hours post
extraction) or secondary (occurring beyond 24 hours post- extraction)
 Disturbing the blood clot by the patient through rinsing or inadequate compression on the gauze
 Physical exercise following extraction
 Medication (e.g. aspirin or anticoagulants)
 Active bleeding from the socket
 The socket may or may not have a blood clot
 If patient has lost significant amount of blood; decreased pulse
"rate, hypotension, dehydration may be present Traumatic area of"
 Features of infection or trauma in secondary bleeding
 Plus metronidazole 400 mg every 8 hours
- Child: 10-mgkg (max 200 mg per dose)
- Child: 10-15 mgkg every 8 hours
 Or Ibuprofen 400 mg every 8 hours
- Child: 7-13 mgkg every 8 hours 
" Restore airway, breathing and circulation if necessary"
 Clear any clot present and examine the socket to identify
 If the bleeding is from soft tissue (which is common)
"remove any foreign body like bone spicule if found,"
 Suture the wound only if necessary
 Check and repack the socket with gauze
"- Tell patient to bite on gauze pack for 30 minutes,"
not to rinse or eat hot foods on that day; at least
"for 12 hours, and avoid touching the wound"
 Consider blood transfusion if Hb decreases to 7 gdL
in an otherwise healthy patient before extraction
If bleeding continues after 24 hours
 Consult a haematologist or physician for further management
23.2.5. Gingivitis ICD10 CODE: K05.0
"Inflammation of the gum, usually as a result of plaque accumulation."
" Increased tendency of the gingiva to bleed on gentle probing,"
during tooth brushing or even on touch
" Restore airway, breathing and circulation if necessary"
 Clear any clot present and examine the socket to identify
 If the bleeding is from soft tissue (which is common)
"remove any foreign body like bone spicule if found,"
 Suture the wound only if necessary
 Check and repack the socket with gauze
"- Tell patient to bite on gauze pack for 30 minutes,"
not to rinse or eat hot foods on that day; at least
"for 12 hours, and avoid touching the wound HC4"
 Consider blood transfusion if Hb decreases to 7 gdL
in an otherwise healthy patient before extraction
If bleeding continues after 24 hours
 Consult a haematologist or physician for further management 
 See following sections for specific types of gingivitis
23.Chronic Gingivitis ICD 10 CODE: K05.1
Inflammatory infiltrate in response to the accumulation of undisturbed
dental plaque next to the gingival margin
" Mixed anaerobic and aerobic oral flora, e.g., Streptococcus viridans, facultative streptococci; fusiform bacteria, spirochaetes,"
 Poor oral hygiene with increase in plaque accumulation
Swelling and erythema of the gingival margins which bleed on brushing
Plaque and calculus (tartar) deposits adjacent to the gingival margins
Rinse mouth with mouthwash 3 times a day
 Warm salt solution (5 ml spoonful of salt in 200 ml
 See following sections for specific types of gingivitis HC4
Rinse mouth with mouthwash 3 times a day
 Warm salt solution (5 ml spoonful of salt in 200 ml
" Or hydrogen peroxide solution 6, (add 15 ml to a 200"
- Child: 10-15 mgkg every 8 hours
 Or Ibuprofen 400 mg every 8 hours
- Child: 7-13 mgkg every 8 hours
"If systemic signs and symptoms present, give a 5-day course"
 Metronidazole 400 mg every 8 hours
- Child: 10-mgkg (max 200 mg per dose)
 Or Amoxicillin 500 mg every 8 hours
- Child: Amoxicillin Dispersible tablets 25 mgkg
" Refer to a dentist for scaling, root planing lanning and"
"polishing, to remove plaque and calculus deposits"
 Avoid metronidazole in 1st trimester of pregnancy
23.2.6. Acute Necrotizing Ulcerative Gingivitis (ANUG)PeriodontitisStomatitis ICD10 CODE: A69.0-1
Also known as Vincents gingivitis or Vincents gingivostomatitis. They
are infections characterized by oral ulcerations and necrosis.
"Gingivitis only affects the gums, periodontitis involves the surrounding"
tissue and attaching the teeth.
"In stomatitis, there is widespread involvement of mucosa and bone loss,"
"until the most severe form known as noma or cancrum oris, leading to"
" Or hydrogen peroxide solution 6, (add 15 ml to a 200"
- Child: 10-15 mgkg every 8 hours
 Or Ibuprofen 400 mg every 8 hours
- Child: 7-13 mgkg every 8 hours
"If systemic signs and symptoms present, give a 5-day course"
 Metronidazole 400 mg every 8 hours
- Child: 10-mgkg (max 200 mg per dose)
 Or Amoxicillin 500 mg every 8 hours
- Child: Amoxicillin Dispersible tablets 25 mgkg
" Refer to a dentist for scaling, root planing lanning and"
"polishing, to remove plaque and calculus deposits HC2"
 Avoid metronidazole in 1st trimester of pregnancy 
extensive destruction of facial tissues and bones.
Inadequately treated ANUG will lapse into a less symptomatic form
known as chronic ulcerative gingivitis.
 Fusospirochaetal complex together with gram negative anaerobic organisms
" Associated with poor oral hygiene, stress and smoking"
" Uncontrolled diabetes mellitus, and debilitated patients with"
" Swelling and erythema of the gingival margins, which bleed easily when touched, causing difficulty drinking and eating"
 Painful papillary yellowish-white ulcers
 Necrosis and sloughing of gum margins
 Loss of gingiva and support bone around teeth
 Patient complains of metallic taste and the sensation of their
" Fever, malaise, and regional lymphadenitis may be present"
 Extensive destruction of the face and jaws in the severe form of
Cancrum Oris or noma (in malnourished patients)
 Rinse mouth with mouthwash 3 times a day
 Warm salt solution (5 ml spoonful of salt in 200 ml
" Or hydrogen peroxide solution 6, (add 15 ml to a 200"
 Or chlorhexidine solution 0.2 f Surgical debridement
 Metronidazole 400 mg every 8 hours
 Child: 10-mgkg (max 200 mg per dose) every
23.2.7. Periodontitis ICD10 CODE: K05.2-3
Periodontitis occurs when inflammation or infection of the gums (gingivitis)
occurs and is not treated. Infection and inflammation spreads from the
gums (gingiva) to the ligaments and bone that support the teeth. Loss
of support causes the teeth to become loose and eventually fall out.
" Mixed microbial flora commonly B. gingivalis, B. forsythus, B."
"intermedius, Wolinella sp, and Fusobacter"
 Bleeding of gums on probing and brushing
 Rinse mouth with mouthwash 3 times a day
 Warm salt solution (5 ml spoonful of salt in 200 ml
" Or hydrogen peroxide solution 6, (add 15 ml to a 200"
 Or chlorhexidine solution 0.2 f Surgical debridement
 Metronidazole 400 mg every 8 hours
 Child: 10-mgkg (max 200 mg per dose) every
 Presence of periodontal pockets due to apical migration of the
junctional epithelium beyond the enamel-cemental junction of
 Tooth sensitivity to thermal changes
 Presence of sub-gingival calculus with increased tooth mobility
 Give instructions on oral hygiene HC2
 Oral rinses with mouthwash consisting of
 chlorhexidine solution 0.2 3 times a day HC4
" Refer to a dentist for scaling, root lanning, and polishing,"
to remove plaque and calculus deposits
23.2.8. Periodontal Abscess ICD10 CODE: K05.21
Localised collection of pus within a periodontal pocket
 Entry of virulent organisms into an existing pocket
" Impact of a foreign body, e.g., a fishbone into healthy periodontal membrane"
" Localised, red and tender swelling of gum"
 Need to differentiate it from a dental abscess
 Give instructions on oral hygiene
 Oral rinses with mouthwash consisting of
 chlorhexidine solution 0.2 3 times a day
" Refer to a dentist for scaling, root lanning, and polishing,"
to remove plaque and calculus deposits HC2
DENTAL ABSCESS-PERI- PERIODONTAL ABSCESS
Associated tooth is non-vital  Associated tooth is vital
Tooth is tender to vertical  Tooth is tender to lateral movepercussion ments
 Incision and drainage under a local anaesthetic HC4
 Debridement of the pocket with a scaler
- Child: 10-15 mgkg every 8 hours
 Or ibuprofen 400 mg every 8 hours
- Child: 7-13 mgkg every 8 hours
 Or diclofenac 50 mg every 8 hours
 Amoxicillin 500 mg every 8 hours
 Plus Metronidazole 400 mg every 8 hours
23.2.9. Stomatitis ICD10 CODE: K12
Inflammation of the epithelial lining of the oral mucosa
" Nutritional deficiency, e.g. vitamin A"
" Infections: Spirochaetes, Bacilli, Candida, Measles virus, Herpes"
DENTAL ABSCESS-PERIAPICAL ABSCESS PERIODONTAL ABSCESS
Associated tooth is non-vital  Associated tooth is vital
percussion  Tooth is tender to lateral movements
 Incision and drainage under a local anaesthetic
 Debridement of the pocket with a scaler
- Child: 10-15 mgkg every 8 hours
 Or ibuprofen 400 mg every 8 hours
- Child: 7-13 mgkg every 8 hours
 Or diclofenac 50 mg every 8 hours
 Amoxicillin 500 mg every 8 hours
 Plus Metronidazole 400 mg every 8 hours HC4
" Inflammation of the tongue and lining of mouth - tongueis red,"
" Ulcers on the gum, palate, lips"
 Thrush (in babies and HIVdebilitated patients)
" Allergic reactions, erythema multiforme, pemphigus"
" Swab mouth for microscopy, and culture and sensitivity of bacteria and fungi (though normal oral flora may give false positives)"
" Blood: For Rapid Plasma Reagin (RPR) test, HIV serology"
 Rinse mouth 3 times a day with Salt solution (dissolve 1 HC2
teaspoon of salt in a cup of warm water)
 Or Hydrogen peroxide solution 6 (add 15 ml to a
 Or chlorhexidine mouth wash 0.2
- Child: 10-15 mgkg every 8 hours
 Continue treatment until healing takes place
 Rinse mouth 3 times a day with Salt solution (dissolve 1
teaspoon of salt in a cup of warm water)
 Or Hydrogen peroxide solution 6 (add 15 ml to a
 Or chlorhexidine mouth wash 0.2
- Child: 10-15 mgkg every 8 hours
 Continue treatment until healing takes place HC2
Redness of the palate under a denture with petechial and whitish areas
" 90 of cases due to Candida albicans, 9 other Candida"
 Increased intake of sugary foods
 Mild inflammation and redness under denture
 Petechial and whitish areas in severe cases
 Burning sensation but no pain or tenderness
" Exclude diabetes, i.e. blood glucose"
 Improve denture hygiene by soaking in hypochlorite
cleanser (10 drops of household bleach in a denture cup
or container filled with tap water) and brushing fitting
" Nystatin suspension 100,000 IUml 6 hourly"
23.2.10. Aphthous Ulceration ICD10 CODE: K12.0
Aphthous ulcers or recurrent aphthous stomatitis (RAS) are painful recurrent mucous membrane ulcerations. Usually affect the non-keratinized
There are 3 types of aphthous ulcers
 Improve denture hygiene by soaking in hypochlorite
cleanser (10 drops of household bleach in a denture cup
or container filled with tap water) and brushing fitting
" Nystatin suspension 100,000 IUml 6 hourly HC2"
Minor aphthous ulcers  Small roundoval ulcers (2-4 mm)
 Surrounded by erythematous ulcers
" Occur in groups of only a few ulcers (i.e., 1-6) at a time"
"cheeks, floor of the mouth, sulci,"
 Heal spontaneously in 7-10 days
Major aphthous ulcers  Painful ulcers on non-keratinized
 Several may be present simultaneously
" Marked tissue destruction, sometimes constantly present"
 Healing is prolonged often with
Herpetiform ulcers  Occur in a group of small (1-5
"Goal of treatment: to offer symptomatic treatment for pain and discomfort,"
especially when ulcers are causing problems with eating.
Minor aphthous ulcers  Small roundoval ulcers (2-4 mm)
 Surrounded by erythematous ulcers
" Occur in groups of only a few ulcers (i.e., 1-6) at a time"
"cheeks, floor of the mouth, sulci,"
 Heal spontaneously in 7-10 days
Major aphthous ulcers  Painful ulcers on non-keratinized
 Several may be present simultaneously
" Marked tissue destruction, sometimes constantly present"
 Healing is prolonged often with
Herpetiform ulcers  Occur in a group of small (1-5
 Salt mouth wash for cleansing HC4
 Prednisolone 20 mg every 8 hours for 3 days; then taper
dose to 10 mg every 8 hours for 2 days; then 5 mg every
 Or topical triamcinolone paste applied twice a day
 Paracetamol 1 g every 8 hours for 3 days
 Refer to specialist if ulcers persist for more than 3 weeks
 Oral gel containing an anti-inflammatory agent combined with
analgesic and antiseptic is ideal treatment
Pericoronitis ICD10 CODE: K05.30
Inflammation of the operculum covering an erupting tooth occurs more
commonly in association with the mandibular wisdom teeth.
 Usually associated with partially erupted andor impacted third
 Associated trauma from a tooth in the opposing archis usually
" The operculum is swollen, red, and often ulcerated"
 Fever and regional lymphadenitis may be present
 Prednisolone 20 mg every 8 hours for 3 days; then taper
dose to 10 mg every 8 hours for 2 days; then 5 mg every
 Or topical triamcinolone paste applied twice a day
 Paracetamol 1 g every 8 hours for 3 days
 Refer to specialist if ulcers persist for more than 3 weeks
 Oral gel containing an anti-inflammatory agent combined with
analgesic and antiseptic is ideal treatment 
 Operculectomy done under local anaesthesia
 Extraction of the third molar associated with the condition
 Grinding or extraction of the opposing tooth
 Apply caustic agents (trichloracetic acid and glycerine)
Treat with analgesic and antibiotic for 5-7 days
 Paracetamol 500 mg every 8 hours Child: 10-15 mg
- Or ibuprofen 400 mg every 8 hours Child: 7-13
- Or diclofenac 50 mg every 8 hours
 Amoxicillin 500 mg every 8 hours Child: 25 mgkg
 Add metronidazole 400 mg every 8 hours if necessary
23.2.12. Osteomyelitis of the Jaw ICD10 CODE: M27.2
Inflammation of the medullary portion of the jaw bone which extends to
involve the periosteum of the affected area. Infection in the bone ends up
"with pus formation in the medullary cavity or beneath the periosteum,"
and obstructs the blood supply. The infected bone becomes necrotic
 Malaise and fever; there is no swelling
 Enlargement of regional lymphnodes
" Teeth in affected area become painful and loose, thus causing"
 Operculectomy done under local anaesthesia
 Extraction of the third molar associated with the condition
 Grinding or extraction of the opposing tooth
 Apply caustic agents (trichloracetic acid and glycerine)
Treat with analgesic and antibiotic for 5-7 days
 Paracetamol 500 mg every 8 hours Child: 10-15 mg
- Or ibuprofen 400 mg every 8 hours Child: 7-13
- Or diclofenac 50 mg every 8 hours
 Amoxicillin 500 mg every 8 hours Child: 25 mgkg
 Add metronidazole 400 mg every 8 hours if necessary
 Bone undergoes necrosis and area becomes very painful and
 Pus ruptures through the periosteum into the muscular and subcutaneous fascia. Eventually it is discharged on to the skin surface through a sinus
 X-ray- Orthopantomograph (OPG) will show characteristic
"features (e.g., widening of periodontal spaces, changes in bone"
"trabeculation, areas of radiolucency and sequestra formation in"
 Incision and adequate drainage of confirmed pus accu- H
 Amoxicillin 500 mg every 8 hours for 7-10 days
 Or cloxacillin 500 mg every 6 hours
 Plus metronidazole 400 mg every 8 hours
 Removal of the sequestrum by surgical intervention
 Change medication according to the results of culture and sensitivity testing
 Refer to regional referral hospital in case of long- standing pus
discharge and sinuses from the jaws
 Incision and adequate drainage of confirmed pus accumulation which is accessible
 Amoxicillin 500 mg every 8 hours for 7-10 days
 Or cloxacillin 500 mg every 6 hours
 Plus metronidazole 400 mg every 8 hours
 Removal of the sequestrum by surgical intervention H
 Change medication according to the results of culture and sensitivity testing
 Refer to regional referral hospital in case of long- standing pus
discharge and sinuses from the jaws 
Oral Candidiasis ICD10 CODE: B37.0
 Caused primarily by Candida albicans
" Common in immunosuppressed, infants, and after prolonged"
 In advanced HIV it can present as intractable oral and oesophageal candidiasis. Angular cheilitis is also common
" Nystatin tablets 500,000-1,000,000 IU every 6 hours for"
10 days (chewed then swallowed) Child 5 years: Nystatin
"oral suspension 100,000 IU every 6 hours for 10 days"
"- Child 5-12years: 200,000 IU per dose every 6"
" Fluconazole loading dose 400 mg, then 150-200 mg"
"- Child: loading dose 6 mgkg, then 3 mgkg daily"
Herpes Infections ICD10 CODE: B00
Infections caused by virus herpes (simplex and zoster)
 Both simplex and zoster infections can affect the face and oral
" Nystatin tablets 500,000-1,000,000 IU every 6 hours for"
10 days (chewed then swallowed) Child 5 years: Nystatin
"oral suspension 100,000 IU every 6 hours for 10 days"
"- Child 5-12years: 200,000 IU per dose every 6"
" Fluconazole loading dose 400 mg, then 150-200 mg"
"- Child: loading dose 6 mgkg, then 3 mgkg daily HC3"
 Herpes simplex: cluster of painful vesicles around the mouth
(cold sores or fever blisters). Can be recurrent
 Herpes zoster: multiple small vesicles (2-3 mm) that ulcerate and
coalesce to form larger ulcers on the oral mucosa
"- Commonly on the vermillion border, gingiva, dorsal tongue,"
- Always present as a unilateral lesion and never cross the
- Pre-eruption pain followed by the development of painful
vesicles on the skin or oral mucosa that rupture to give rise to
ulcers or encrusting skin wounds in the distribution outlined
- Post herpetic neuralgia may continue for years
" Reassure, it will resolve in most cases"
 For severe forms consider acyclovir 400 mg every 8
 Acyclovir 800 mg 5 times daily for 5 days
 May require antibiotic therapy if the area becomes secondarily infected
" Analgesics, topical anaesthetic (e.g. lidocaine)"
Kaposis Sarcoma ICD10 CODE: C46
"A malignancy of vascular endothelium that, until the advent of AIDS,"
was seen only occasionally in Jews and immune suppressed patients
" Reassure, it will resolve in most cases"
 For severe forms consider acyclovir 400 mg every 8
 Acyclovir 800 mg 5 times daily for 5 days
 May require antibiotic therapy if the area becomes secondarily infected
" Analgesics, topical anaesthetic (e.g. lidocaine) HC2"
 Painless purplish swelling on the skin
" In the mouth, the palate is the most frequent site"
"Benign lesion, usually asymptomatic, associated with HIV immunosuppression, and linked to Epstein Barr Virus infection"
" Adherent white, corrugated plaque, usually found bilaterally on"
 Podophyllin resin 25: Apply to lesion once weekly if RR
 Manage HIV infection as per national guidelines
Injury to the oral or dental tissues as a result of trauma.
Traumatic lesions I ICD10 CODE: S00.5
 Podophyllin resin 25: Apply to lesion once weekly if
 Manage HIV infection as per national guidelines RR
Fibroepithelial polyp  Well-localized sessile or
"pedunculated lump, usuOver-vigorous response to low grade"
recurrent trauma resulting in fibrous
Mucocele  History of trauma and
characteristic appearSaliva extravasation into the tissues
from damage to minor salivary gland
ducts. They are commonly seen in
the lower labial and ventral lingual
"Ranula  Blue, transparent sublingual swelling"
A mucocele that occurs from the
 Excision biopsy and histological confirmation
 Surgical removal (recurrence may occur if there is regular
 Excision of the sublingual gland
Traumatic lesions These simple lesions are often confused for more severe conditions like
"lichen planus, oral candidiasis, pemphigus, erythema multiforme."
Over-vigorous response to low grade
recurrent trauma resulting in fibrous
hyperplasia  Well-localized sessile or
"pedunculated lump, usually located on the palate"
Saliva extravasation into the tissues
from damage to minor salivary gland
ducts. They are commonly seen in
the lower labial and ventral lingual
A mucocele that occurs from the
"sublingual gland  Blue, transparent sublingual swelling"
 Excision biopsy and histological confirmation
 Surgical removal (recurrence may occur if there is regular
 Excision of the sublingual gland RR
Burns  Burns in the palate located in characteristic
"of hot foods, and particularly seen"
on the palate or tongue. Chemical
burns are usually due to analgesics
positioned next to a painful tooth or
chemicals used in restorative dentistry
Sharp teeth and restorations  Lesion is site specific and
Trauma from sharp teeth or restorations is often worsened in patients
with physical or intellectual disability
Ulceration due to local anaesthetic  Ulcer confined to the
lceration due to biting the area of
 Reassurance that healing will occur without scarring
 Topical anaesthetic lidocaine 2 may help
 Smooth the edge andor apply a restorative material
 Smooth the edge andor apply a restorative material
"of hot foods, and particularly seen"
on the palate or tongue. Chemical
burns are usually due to analgesics
positioned next to a painful tooth or
chemicals used in restorative dentistry  Burns in the palate located in characteristic
Trauma from sharp teeth or restorations is often worsened in patients
with physical or intellectual disability
Whats this?  Lesion is site specific and
Ulceration due to local anaesthetic
lceration due to biting the area of
anaesthetised mucosa  Ulcer confined to the
 Reassurance that healing will occur without scarring
 Topical anaesthetic lidocaine 2 may help
 Smooth the edge andor apply a restorative material
 Smooth the edge andor apply a restorative material
Ulceration due to local anaesthetic RR
 May require antibiotic therapy if the area becomes secondarily infected
- Amoxicillin 500 mg every 8 hours for 5-7 days if
"Traumatic lesions Trauma due to physical injury, e.g., a fall, sports, road traffic accident"
 Give tetanus booster if needed (see section 18.1.4)
 Check for facial fractures andor lacerations
" If evidence of head injury (amnesia, loss of consciousness,"
"neurological signs), transfer patient to hospital immediately"
"(see Trauma and Head injuries, section 1.2.5)"
" Intra-oral check: for soft-tissue lacerations, dento-alveolar"
" Check for the whereabouts of tooth fragments, which"
are commonly embedded in the lip
 Examine traumatized teeth for mobility
" Check occlusion, especially if any teeth have been displaced"
 Refer for radiographs of affected teeth to check for root HC4
 Avulsed permanent teeth should be re-planted immediately.
"Prognosis is good with immediate treatment, therefore"
refer the patient to a dentist as soon as possible
Ulceration due to local anaesthetic
 May require antibiotic therapy if the area becomes secondarily infected
- Amoxicillin 500 mg every 8 hours for 5-7 days if
 Give tetanus booster if needed (see section 18.1.4)
 Check for facial fractures andor lacerations
" If evidence of head injury (amnesia, loss of consciousness,"
"neurological signs), transfer patient to hospital immediately"
"(see Trauma and Head injuries, section 1.2.5)"
" Intra-oral check: for soft-tissue lacerations, dento-alveolar"
" Check for the whereabouts of tooth fragments, which"
are commonly embedded in the lip
 Examine traumatized teeth for mobility
" Check occlusion, especially if any teeth have been displaced RR"
 Refer for radiographs of affected teeth to check for root
 Avulsed permanent teeth should be re-planted immediately.
"Prognosis is good with immediate treatment, therefore"
refer the patient to a dentist as soon as possible HC4
 Suture soft tissue lacerations in 30 resorbable suture HC4
 Refer to an oral surgeon for reduction and immobilization
of mobile teeth and alveolar fragments
 Wash mouth with warm salt solution (dissolve a 5 ml
spoonful of salt in 200 ml of warm water) f Or hydrogen
peroxide solution 6 (add 15 ml to
 a cup 200 ml of warm water) f Repeat mouth wash 3
times daily f Paracetamol 1 g every 8 hours f Or ibuprofen
Give prophylactic antibiotics if indicated
 Amoxicillin 500 mg every 8 hours for 5-7 days f Refer
"to a dentist for orthodontics, endodontic"
" (root canal) treatment, or protection of pulp"
 Early orthodontic treatment in children with large overjets that
 Provision of a mouth guard (made of vacuum formed thermoplastic vinyl) for sports
 Be alert for evidence of child abuse and notify relevant authorities if any.
Burkitts Lymphoma ICD10 CODE: C83.7
"Burkitts lymphoma (or Burkitts tumour or Malignant lymphoma,"
"Burkitts type) is a cancer of the lymphatic system (in particular, B"
lymphocytes). It is a non-Hodgkins lymphoma and recognised as the
fastest growing human tumour. Of all cancers involving the same class
"of blood cell, 2 of cases are Burkitts lymphoma."
 Suture soft tissue lacerations in 30 resorbable suture
 Refer to an oral surgeon for reduction and immobilization
of mobile teeth and alveolar fragments HC4
 Wash mouth with warm salt solution (dissolve a 5 ml
spoonful of salt in 200 ml of warm water) f Or hydrogen
peroxide solution 6 (add 15 ml to
 a cup 200 ml of warm water) f Repeat mouth wash 3
times daily f Paracetamol 1 g every 8 hours f Or ibuprofen
Give prophylactic antibiotics if indicated
 Amoxicillin 500 mg every 8 hours for 5-7 days f Refer
"to a dentist for orthodontics, endodontic"
" (root canal) treatment, or protection of pulp HC2"
 Associated with Epstein-Barr virus (EBV)
Often presents as a tooth ache in the maxilla
Extractions do not relieve the swelling
Peak incidence at 4-7 years of age and more common among boys
Burkitts lymphoma is divided into 3 main clinical variants:
" Endemic variant: occurs in malaria endemic areas. Chronic malaria is believed to reduce resistance to Epstein-Barr virus (EBV),"
"which is usually linked with the disease. The disease characteristically involves the jaw or other facial bone, distal ileum, caecum,"
"ovaries, kidney, or the breast."
 Sporadic type: (also known as non-African) is usually found
 Immunodeficiency-associated Burkitts lymphoma: usually associated with HIV infection or in post- transplant patients taking
immunosuppressive drugs. Burkitts lymphoma can be the initial
 Refer to cancer treatment specialist centres for appropriate management
 Refer to cancer treatment specialist centres for appropriate management 
" Treatment options include: chemotherapy, immuno- RR"
"therapy, bone marrow transplants, surgery, radiotherapy."
" Treatment options include: chemotherapy, immunotherapy, bone marrow transplants, surgery, radiotherapy. RR"
Intestinal Obstruction ICD10 CODE: K56
"Interruption of the normal flow of intestinal content, due to mechanical"
"obstruction (at small or large bowel level), or due to functional paralysis."
" Small bowel mechanical obstruction: tumours, adhesions from"
previous surgeries or infections
" Large bowel obstructions: tumours, volvolus, adhesions, inflammatory strictures (e.g. diverticulosis, etc.)"
" Small bowel obstruction: cramping abdominal pain, nausea,"
"vomiting, abdominal distention. Due to the accumulation of fuids"
"into the dilated intestinal loops, there is usually a varying degree"
" Large bowel obstruction: bloating, abdominal pain, constipation,"
vomiting and nausea less frequent and mainly in proximal colon
obstruction; signs of dehydration and shock come later.
" Abdominal X-ray (erect or left lateral decubitus, for air- fluid level),"
" Paralytic ileus (diffuse functional paralysis of small and large bowel due to drugs, biochemical abnormalities, abdominal infections"
" IV fluids (normal saline, Ringers Lactate)"
- To correct fluids deficit and replace ongoing losses
"- Monitor haemodynamic status (pulse, blood"
"- pressure, skin turgor, level of consciousness,"
"hydration of mucosae, urine output at least 0.5"
- It may take up to 6 hours to re-hydrate
"- If not responding to IV fluids, suspect septic shock"
- Insert urinary catheter to monitor urinary output
- Pass NGT and connect with a drainage bag to
empty the stomach in small bowel obstruction or
- Ceftriaxone 2 g IV once a day
- Plus metronidazole 500 mg IV every 8 hours
" If the patient is in severe colicky pain, administer pethidine"
 If surgery is indicated and the patients parameters are
"near normal after resuscitation, take the patient to the"
operating theatre for an appropriate surgical relief of
"- Blood loss, fluid aspirated from the gut and other"
- Maintenance fluid should be given: 5 mlkghour
" IV fluids (normal saline, Ringers Lactate)"
- To correct fluids deficit and replace ongoing losses
"- Monitor haemodynamic status (pulse, blood"
"- pressure, skin turgor, level of consciousness,"
"hydration of mucosae, urine output at least 0.5"
- It may take up to 6 hours to re-hydrate
"- If not responding to IV fluids, suspect septic shock"
- Insert urinary catheter to monitor urinary output
- Pass NGT and connect with a drainage bag to
empty the stomach in small bowel obstruction or
- Ceftriaxone 2 g IV once a day
- Plus metronidazole 500 mg IV every 8 hours
" If the patient is in severe colicky pain, administer pethidine"
 If surgery is indicated and the patients parameters are
"near normal after resuscitation, take the patient to the"
operating theatre for an appropriate surgical relief of
"- Blood loss, fluid aspirated from the gut and other"
- Maintenance fluid should be given: 5 mlkghour 
- Use normal saline or Ringers lactate solution and
5 dextrose in the ratio 1:2 for the first 24-48
- Monitor for adequate rehydration
Post-operative antibiotics and analgesics
 Continue with analgesics in the postoperative period.
"(Tramadol, pethidine, diclofenac, paracetamol; morphine"
 Continue with antibiotic treatment where
- clinically indicated (metronidazole  ceftriaxone
"In selective cases, non-operative treatment of intestinal obstruc- RR"
tion (in particular small bowel obstructions) can be tried
" Indicated in appendicular mass, acute pyosalpingitis (PID),"
"some patients with adheisions, pseudo obstruction, plastic"
"peritonitis of TB, acute pancreatitis"
" Involves NGT decompression, intravenous fluid therapy"
and antibiotic therapy if indicated
" Monitor clinical progression of obstruction using parameters of: abdominal pain, abdominal girth, amount and"
"colour of NG aspirate, temperature, pulse"
 If no improvement after 72 hours or the NG content
"becomes fecolent, operate the patient"
Internal bleeding (also called internal haemorrhage) is a loss of blood
that occurs from the vascular system into a body cavity or space. It is
- Use normal saline or Ringers lactate solution and
5 dextrose in the ratio 1:2 for the first 24-48
- Monitor for adequate rehydration 
Post-operative antibiotics and analgesics
 Continue with analgesics in the postoperative period.
"(Tramadol, pethidine, diclofenac, paracetamol; morphine"
 Continue with antibiotic treatment where
- clinically indicated (metronidazole  ceftriaxone
"In selective cases, non-operative treatment of intestinal obstruction (in particular small bowel obstructions) can be tried"
" Indicated in appendicular mass, acute pyosalpingitis (PID),"
"some patients with adheisions, pseudo obstruction, plastic"
"peritonitis of TB, acute pancreatitis"
" Involves NGT decompression, intravenous fluid therapy"
and antibiotic therapy if indicated
" Monitor clinical progression of obstruction using parameters of: abdominal pain, abdominal girth, amount and"
"colour of NG aspirate, temperature, pulse"
 If no improvement after 72 hours or the NG content
"becomes fecolent, operate the patient RR"
a serious medical emergency and the extent of severity depends on:
 Bleeding rate (hypovolaemic shock)
" Location of the bleeding (damage to organs, even with relatively"
limited amounts: see specific chapters)
Severe bleeding in a body cavityspace is an emergency condition with
"unstable vital signs (e.g., ruptured spleen, ruptured tubal pregnancy)"
Invasive surgical intervention to control bleeding is life saving RR
 Do not delay operation in attempt to stabilise the patient
 Establish IV line and give fluids rapidly
 Draw blood for grouping and cross matching for volume
replacement after surgical haemostasis
- Rapid sequence induction of general anaesthesia
- Use drugs with minimal or no cardiac depression
- Laparotomy to achieve surgical haemostasis
Management of Medical Conditions in Surgical Patient
The medical condition must be stabilised as much as possible before
 Establish whether condition is stable or unstable
" If unstable, control or correct the condition"
Invasive surgical intervention to control bleeding is life saving
 Do not delay operation in attempt to stabilise the patient
 Establish IV line and give fluids rapidly
 Draw blood for grouping and cross matching for volume
replacement after surgical haemostasis
- Rapid sequence induction of general anaesthesia
- Use drugs with minimal or no cardiac depression
- Laparotomy to achieve surgical haemostasis RR
Operative and post-operative management
 Anaesthesia technique based on condition and nature of surgery
- Diastolic of 90 mmHg and systolic of 140 mmHg
"- If hypertension not adequately controlled,"
"there is risk of vasoconstriction, hypovolaemia,"
exaggerated vasoactive response to stress
"leading to hypo or hypertension, hypertensive"
complications during anaesthesia
 Control hypertension pre-operatively
 Patient should take antihypertensive medicines on schedule
 General anaesthesia technique is preferred
 Ensure adequate depth of anaesthesia and analgesia
Condition of reduced oxygen carrying capacity; patient prone
- Hypotension or hypoxia can cause cardiac arrest
 Correct anaemia to acceptable level depending on urgency
of surgery (see section of anaemia 11.2.2)
 Regional anaesthesia is the preferred method
" If general anaesthesia is used, avoid myocardial depressant, e.g. thiopental"
 Use small doses of anaesthetics
- Intubate and ventilate except for very short
- Diastolic of 90 mmHg and systolic of 140 mmHg
"- If hypertension not adequately controlled,"
"there is risk of vasoconstriction, hypovolaemia,"
exaggerated vasoactive response to stress
"leading to hypo or hypertension, hypertensive"
complications during anaesthesia
 Control hypertension pre-operatively
 Patient should take antihypertensive medicines on schedule
 General anaesthesia technique is preferred
 Ensure adequate depth of anaesthesia and analgesia
Condition of reduced oxygen carrying capacity; patient prone
- Hypotension or hypoxia can cause cardiac arrest
 Correct anaemia to acceptable level depending on urgency
of surgery (see section of anaemia 11.2.2)
 Regional anaesthesia is the preferred method
" If general anaesthesia is used, avoid myocardial depressant, e.g. thiopental"
 Use small doses of anaesthetics
- Intubate and ventilate except for very short
- Replace blood very carefully HC4
- Extubate patient when fully awake
- Give oxygen in the post-operative period
"For sickle cell anaemia, the above also applies, as well as avoiding use of tourniquet"
" Avoid drugs and other factors likely to trigger bronchospasms, e.g., thiopental"
 Regional anaesthesia is the preferred method
 Achieve blood glucose control using standard treatment
- Delay surgery even in emergency for 8-12 hours
- Correct and control all associated disturbances
 Hyperglycaemia under general anaesthesia is safer than
 Patient should be operated on early in the morning and
 fRegional anaesthesia is the method of choice where
 Stop usual antidiabetic dose on the morning of surgery
 Start infusion of 5 glucose infusion rate of 2 ml
 Usual medication is resumed as soon as the patient is
- Extubate patient when fully awake
- Give oxygen in the post-operative period
"For sickle cell anaemia, the above also applies, as well as avoiding use of tourniquet HC4"
" Avoid drugs and other factors likely to trigger bronchospasms, e.g., thiopental"
 Regional anaesthesia is the preferred method
 Achieve blood glucose control using standard treatment
- Delay surgery even in emergency for 8-12 hours
- Correct and control all associated disturbances
 Hyperglycaemia under general anaesthesia is safer than
 Patient should be operated on early in the morning and
 fRegional anaesthesia is the method of choice where
 Stop usual antidiabetic dose on the morning of surgery
 Start infusion of 5 glucose infusion rate of 2 ml
 Usual medication is resumed as soon as the patient is
 Control on sliding scale of insulin
" Infusion of 5 glucose started on the morning of surgery,"
or glucose insulin potassium infusion
Newborn with Surgical Emergencies
Babies may be born at lower health facilities with congenital defects that
require emergency surgical intervention at tertiary levels:
- The common surgical emergencies in neonates include:
gastroschisis (defect of abdominal wall with intestine sticking
"outside the body), tracheoesophageal fistula, imperforate"
"- If diagnosed in lower level health facilities (HCII, HCIII, HCIV,"
"District Hospital), apply general principles of supportive"
" The aim should be to avoid hypothermia, inimize risk of infection,"
"ensure adequate hydration, and inimize risk of aspiration and"
 Use sterile or clean gauze if available to properly cover HC2
the defects which are externally visible.
" For gastroschisis, moisten the gauze using warm saline"
and use it to properly wrap the exposed intestines
 Properly cover the newborn using a clean thick linen to
 Insert IV cannula gauge 24 and administer prophylactic
antibiotics preferably IV antibiotics (ampicillin  gentamicin)
 Control on sliding scale of insulin
" Infusion of 5 glucose started on the morning of surgery,"
or glucose insulin potassium infusion
 Monitor blood sugar 200 mgdl HC4
 Use sterile or clean gauze if available to properly cover
the defects which are externally visible.
" For gastroschisis, moisten the gauze using warm saline"
and use it to properly wrap the exposed intestines
 Properly cover the newborn using a clean thick linen to
 Insert IV cannula gauge 24 and administer prophylactic
antibiotics preferably IV antibiotics (ampicillin  gentamicin) HC2
Prophylaxis is not recommended for most uncomplicated clean procedures
One single dose prior to the procedure is usually sufficient
"Routine post-operative antimicrobial administration is NOT recommended for most surgeries as it causes wastage of limited resources,"
causes unnecessary side effects to the patient and can lead to antimicrobial resistance.
Diagnostic Imaging: A Clinical Perspective
Medical imaging is an essential part of the diagnosis of many diseases.
A diagnostic imaging procedure is indicated when the management of a
"patient depends on the findings of the procedure. Therefore, before any"
"diagnostic imaging procedure is requested, the question of how the results"
will influence patient management and care should always be asked.
" Prior to requesting a procedure, it is useful to determine if the"
"required information is already available from recent procedures,"
"and if the relevant clinical, laboratory, diagnostic imaging, and"
treatment information is provided.
" When indicated and available, alternative diagnostic imaging"
"procedures which do not use ionising radiation, e.g. ultrasound,"
"should be chosen first, especially in children."
Questions to be answered to prevent unnecessary use of procedure and
 Has this procedure been done already?
 Are all the investigations I am requesting necessary?
 Have you provided appropriate clinical information and questions that the procedure should answer?
No procedure should ever be requested in lieu of a thorough clinical
assessment or as a means of satisfying a difficult patient.
Basic Diagnostic Imaging Modalities
 Ultrasound scan (HC4 and Hospital)
- Ultrasound is non-invasive and does not use ionising radiation.
"Therefore, when indicated, it is the most appropriate imaging"
modality for children and pregnant women.
Other imaging modalities (at RR and NR)
"In the following table, a summary of the clinical indication, the suggested investigation modality and the possible findings are presented, as a"
guide to request the correct investigation based on the clinical suspicion.
 CT scan is the investigation of choice for intracranial pathological
"processes (severe head trauma, stroke, etc.) but it is only available"
D E D IV O R P N O IT A M R s e r u tc a r F s n o ita c o ls iD )c illa te m ( s e id o b n g ie r o F n o itc u r ts e d  s n o is e l e n o B s itile y m o e ts O
e n p o h c n o r b.g.e s n o itc e fn i ts e h C
"r e tn i,a in o m u e n p r a b o l,a in o m a in o m u e n p la it )n o is u ffe la r u e lp ( y s ir u e lP"
i y lla ic e p s e s e ta r tlifn i g n u L ( B T
"a c,n o is u ffe la r u e lp,e b o l r e p p u"
"p m y l r a lih  la n its a id e m,s e iti )s e d o n"
m u e n p ( s n o ita c ilp m o c a m u a rT
"tn o c g n u l,s b ir d e r u tc a r f,x a r o h t )x a r o h to m e a h,n o is s e s s a m g n u L"
r e d r o s id la ih c n o r b  g n u l r e h tO )D P O C (
"Y T IL A D O M s y a r - X n ia lP th g ir ta n e k a t s w e iv 2 e h t e d u lc n i, s e lg n a w o le b d n a e v o b a tn io j e r u tc a r f a fo e s a c n i y a r -X ts e h C"
"n ip s,llu k s y n o b fo s e itim e r tx e d n a"
itile y m o e ts o ( s n o it ).c te
t g n id n o p s e r to n tn e m ta e r t s is y tp o m e a H a m u a r t ts e h c tn u lB
"o r p  y c n e ic iffu s n i a m h ts a,s m e l s e id o b n g ie r o F )s n io c,c illa te m ("
 M E T S Y S E R A Y D O B -o lu c s u M la te le k s  ts e h C r a n o m lu p
NOITAMROFNI ylagemoidrac( -ed )senil
YDOB -oidraC ralucsav lasanaraP
"NOITAMROFNI -gerp caidrac,suteofoyrbme"
"eniretuartnnoitatseg,ytivitca,ycnan"
"citoinma dna cimotana,ytivitca,yrtemoib eht"
"lateof droc,rebmun,noitisop lacilibmU,emulov"
dr3 thgieh-odnuF naht gnideelb lateof
"     slevel ni eht -wob fo sislatsirep,desaercni -lrihw"
"dna gnireffid rehtona dellif-diulf,mc si lewob"
"pool tnemges,lewob,slevel,mc 3 01"
llams diulf-ria naht slevel morf llams eht tnemges detalid yb fo noitom
yaR-lanimodba tnedneped ro )sutibuced
"yfitnedi yam,noitpecsussutni,sraozeb.g.e"
"NOITAMROFNI noitisnart lewob snoitidnoc,noitpecsussutni -ut"
lamixorp a latsid ni thgirpu esuac etuca ton eb
"dna,mc eht noitcurtsbo sag.shpargoidar eht erom sah hguone"
6 ni rebilac retemaid ecnesba.noitcurtsbo era noloc si cinoloc gnol
detalid noloC mc 9 ton cinoloc tsegral si noloc fo etis ro yticuap slevel diulf-riA detalid sutibuced stseggus noitcurtsbo eht tneserp debrosba
yaR-X laretal dnuosartlU dnuosartlU dnuosartlU
Main objectives of anaesthesia during surgery are to:
 Support physiological functions
 Provide favourable conditions for the operation
Equipment  Available and in a state of readiness at all
 Appropriate in quality and quantity
Staff  Qualified anaesthesia provider
 An assistant for the anaesthesia provider
 Adequate assistance in positioning the patient
 Adequate technical assistance to ensure
proper functioning and servicing of all
Before anaesthesia  Read the notesmedical records of the patient
 Assess the patient very carefully
" The drugs, equipment, instruments and"
materials to be used must be known
 Properly prepare workplace and patient
Equipment  Available and in a state of readiness at all
 Appropriate in quality and quantity
Staff  Qualified anaesthesia provider
 An assistant for the anaesthesia provider
 Adequate assistance in positioning the patient
 Adequate technical assistance to ensure
proper functioning and servicing of all
Before anaesthesia  Read the notesmedical records of the patient
 Assess the patient very carefully
" The drugs, equipment, instruments and"
materials to be used must be known
 Properly prepare workplace and patient
Before anaesthesia  Anaesthesia is administered (induction and
 The patient must be monitored meticulously to:
 Detect dangerous signs as soon as they
arise and appropriately treat them
 Expertise in resuscitation is obligatory. If
 Keep an accurate and legible record of the
anaesthetic and all measured vital signs on
After anaesthesia  The patient:
- Recovers from effects of anaesthesia
- Is returned to the ward in the fully
 Follow-up patient for next 24 hours
Anaesthesia may be produced in a number of ways
" Basic elements: Loss of consciousness, analgesia, prevention of"
"undesirable reflexes, and muscle relaxation"
 Sensation of pain is blocked without loss of consciousness. The
conduction of stimulus from a painful site to the brain can be
interrupted at one of the many points:
Before anaesthesia  Anaesthesia is administered (induction and
 The patient must be monitored meticulously to:
 Detect dangerous signs as soon as they
arise and appropriately treat them
 Expertise in resuscitation is obligatory. If
 Keep an accurate and legible record of the
anaesthetic and all measured vital signs on
After anaesthesia  The patient:
- Recovers from effects of anaesthesia
- Is returned to the ward in the fully
 Follow-up patient for next 24 hours
 Intravenous regional anaesthesia
PREPARATION IN THE OPERATING THEATRE
Should be in a constant state of preparedness for anaesthesia
"The following should be available, checked, and ready"
 Operating table that is adjustable and with its accessories
 Anaesthesia machine with accessories
 Self inflating bag for inflating the lungs with oxygen
 Appropriate range of face masks
 Suction machine with range of suction catheters
" Appropriate range of oropharyngeal airways, endotracheal"
"tubes, and other airways, e.g., laryngeal mask airway"
 Laryngoscope with suitable range of blades
" Intravenous infusion equipment, appropriate range of cannulae"
 Equipment for regional anaesthesia
" Safe disposal of items contaminated with body fluids, sharps,"
" Refrigeration for storage of fluids, drugs, and blood"
 Anaesthetic drugs: General and local anaesthetic agents
 Appropriate range of sizes of syringes
" Monitors: stethoscope, sphygmomanometer, pulse oximeter"
" Appropriate protection of staff against biological contaminants. This includes: caps, gowns, gloves, masks, footwear"
and eye shields (personal protective equipment)
" Drugs necessary for management of conditions, which may"
complicate or co-exist with anaesthesia
PREPARATION IN THE OPERATING THEATRE
Should be in a constant state of preparedness for anaesthesia
"The following should be available, checked, and ready"
 Operating table that is adjustable and with its accessories
 Anaesthesia machine with accessories
 Self inflating bag for inflating the lungs with oxygen
 Appropriate range of face masks
 Suction machine with range of suction catheters
" Appropriate range of oropharyngeal airways, endotracheal"
"tubes, and other airways, e.g., laryngeal mask airway"
 Laryngoscope with suitable range of blades
" Intravenous infusion equipment, appropriate range of cannulae"
 Equipment for regional anaesthesia
" Safe disposal of items contaminated with body fluids, sharps,"
" Refrigeration for storage of fluids, drugs, and blood"
 Anaesthetic drugs: General and local anaesthetic agents
 Appropriate range of sizes of syringes
" Monitors: stethoscope, sphygmomanometer, pulse oximeter"
" Appropriate protection of staff against biological contaminants. This includes: caps, gowns, gloves, masks, footwear"
and eye shields (personal protective equipment)
" Drugs necessary for management of conditions, which may"
complicate or co-exist with anaesthesia
PREPARATION IN THE OPERATING THEATRE
The aim is to make the patient as fit as possible before surgical operation
- Identify the patient and establish rapport
- A standard history is obtained and an examination done
- Emphasis is on the cardio-respiratory systems
"- Investigations appropriately interpreted e.g., Hb"
- Health statuscondition of the patient
- Classify physical status of the patient according to A.S.A.
(ASA classification 1-5 with or without E)
- Make a plan for anaesthesia based on the information
- Explain the procedure to the patient and ensure that he
- Ensure informed consent form is signed
- Weight of patient should be taken
- Check site and side of the operation
- Remove: Ornamentsprosthesesdentures that may injure
the patient and make-up that may interfere with monitoring
- Any other necessary preparation based on patients
condition and nature of the operation (condition of deficits
"imbalances should be corrected, control chronic conditions)"
- Ability of the patient to withstand the stresses and adverse
effects of anaesthesia and the surgical procedure will
depend on how well prepared heshe is
Most anaesthetic agents are included in the specialist essential medicines
list meaning that use is restricted to specialised health workers
PREPARATION IN THE OPERATING THEATRE
The aim is to make the patient as fit as possible before surgical operation
- Identify the patient and establish rapport
- A standard history is obtained and an examination done
- Emphasis is on the cardio-respiratory systems
"- Investigations appropriately interpreted e.g., Hb"
- Health statuscondition of the patient
- Classify physical status of the patient according to A.S.A.
(ASA classification 1-5 with or without E)
- Make a plan for anaesthesia based on the information
- Explain the procedure to the patient and ensure that he
- Ensure informed consent form is signed
- Weight of patient should be taken
- Check site and side of the operation
- Remove: Ornamentsprosthesesdentures that may injure
the patient and make-up that may interfere with monitoring
- Any other necessary preparation based on patients
condition and nature of the operation (condition of deficits
"imbalances should be corrected, control chronic conditions)"
- Ability of the patient to withstand the stresses and adverse
effects of anaesthesia and the surgical procedure will
depend on how well prepared heshe is
"Ketamine  Indication: Induction of anaesthesia, maintenance of anaes-"
" Contraindication: Hypertension,"
"epilepsy,raised intracranial pres-"
- IV 1-2 mgkg  Side effects: Emergency delir-
"- IM. 5-7 mgkg ium, hallucinations, increased"
"salivation, increased muscle tone"
"Propofol  Indications: Induction of anaesthesia, maintenance of anaes-"
 Route:  Side effects: Pain at site of in-
Inhalational anaesthetic agents
Halothane is included in the general essential medicines list but should
only be used by health workers confident with the use of this anaesthetic
MEDICINE CHARACTERISTICS AND USE
Halothane  A volatile liquid at room temperature
"- Induction of anaesthesia (in children,"
patients with airway obstruction)
"- IM. 5-7 mgkg  Indication: Induction of anaesthesia, maintenance of anaesthesia (infusion), analgesia"
" Contraindication: Hypertension,"
"epilepsy,raised intracranial pressure, e.g., head injury"
" Side effects: Emergency delirium, hallucinations, increased"
"salivation, increased muscle tone"
"ml per second  Indications: Induction of anaesthesia, maintenance of anaesthesia"
 Side effects: Pain at site of injection
MEDICINE CHARACTERISTICS AND USE
Halothane  A volatile liquid at room temperature
"- Induction of anaesthesia (in children,"
patients with airway obstruction)
MEDICINE CHARACTERISTICS AND USE
Halothane  Precaution: Always use at least 30 oxygen with halothane
 It is safe to avoid use of adrenaline to prevent high incidence of arrhythmias
 Adverse effects which may occur include:
- Severe cardiopulmonary depression
"They are used to provide muscle relaxation to facilitate a procedure, and"
"used in a patient who is unconscious, e.g. general anaesthesia, or sedated."
 Precaution before using a muscle relaxant: always have means of
supporting the airway and respiration
Selection of Type of Anaesthesia for the Patient
Consider the following factors:
" Patient factors: medical state, time of last meal, mental state,"
" Surgical factors: nature of surgery, site of operation, estimated"
"duration of surgery, position in which the surgery is to be performed"
" Anaesthetic factors: availability of drugs, experience and competence of the anaesthetic provider"
24.Techniques of General Anaesthesia
- Take and record baseline vital signs
- Establish intravenous line and commence infusion
MEDICINE CHARACTERISTICS AND USE
Halothane  Precaution: Always use at least 30 oxygen with halothane
 It is safe to avoid use of adrenaline to prevent high incidence of arrhythmias
 Adverse effects which may occur include:
- Severe cardiopulmonary depression
RAPID SEQUENCE INDUCTION OF GENERAL ANAESTHESIA
" Inhalation route (children, patient with difficult airway)"
 Secure a clear airway using an oropharyngeal airway
 Titrate concentration of inhalation against response of the patient
" Monitor, record every 5 minutes or more frequently, BP, pulse,"
" This technique may be used for operations on limbs, perineum, superficial wall of chest, and abdomen"
 Suitable for operations lasting less than 30 minutes
 Intravenousinhalation (see above)
- When spontaneously breathing for anticipated difficult
- Under relaxation by suxamethonium and laryngoscopy
- Confirm correct tube placement by presence of breath
- Connect the breathingdelivery system to the endotracheal
 Titrate concentration of inhalation agent against response of
"- A selected, long acting muscle relaxant is given"
- Intermittent positive pressure ventilation is done
RAPID SEQUENCE INDUCTION OF GENERAL ANAESTHESIA
" Inhalation route (children, patient with difficult airway)"
 Secure a clear airway using an oropharyngeal airway
 Titrate concentration of inhalation against response of the patient
" Monitor, record every 5 minutes or more frequently, BP, pulse,"
" This technique may be used for operations on limbs, perineum, superficial wall of chest, and abdomen"
 Suitable for operations lasting less than 30 minutes
 Intravenousinhalation (see above)
- When spontaneously breathing for anticipated difficult
- Under relaxation by suxamethonium and laryngoscopy
- Confirm correct tube placement by presence of breath
- Connect the breathingdelivery system to the endotracheal
 Titrate concentration of inhalation agent against response of
"- A selected, long acting muscle relaxant is given"
- Intermittent positive pressure ventilation is done
RAPID SEQUENCE INDUCTION OF GENERAL ANAESTHESIA
- Monitor vital signs (as above)
 At the end of the operation when the patient shows signs of
- IV. Neostigmine to mgkg to reverse the
- effects of the long acting muscle relaxant
 All operations that require a protected airway and controlled
"ventilation, e.g, intraabdominal, intrathoracic, and intracranial"
(Also called crash induction) For patients with full stomach and at
"risk of regurgitation, e.g., emergency surgery, distended abdomen"
 Establish an intravenous line and commence infusions
 Induce with selected intravenous anaesthetic agent
 Assistant applies cricoid pressure
 Trachea is intubated and correct tube placement confirmed
" The cuff of the endotracheal tube is inflated, then cricoid pressure released"
 The position of the tube is fixed by strapping and an airway
 Then connect to breathing circuitsystem to maintain anaesthesia
24.Techniques for Regional Anaesthesia
" Detailed knowledge of anatomy, technique, and possible complications is important for correct injection placement"
RAPID SEQUENCE INDUCTION OF GENERAL ANAESTHESIA
- Monitor vital signs (as above)
 At the end of the operation when the patient shows signs of
- IV. Neostigmine to mgkg to reverse the
- effects of the long acting muscle relaxant
 All operations that require a protected airway and controlled
"ventilation, e.g, intraabdominal, intrathoracic, and intracranial"
(Also called crash induction) For patients with full stomach and at
"risk of regurgitation, e.g., emergency surgery, distended abdomen"
 Establish an intravenous line and commence infusions
 Induce with selected intravenous anaesthetic agent
 Assistant applies cricoid pressure
 Trachea is intubated and correct tube placement confirmed
" The cuff of the endotracheal tube is inflated, then cricoid pressure released"
 The position of the tube is fixed by strapping and an airway
 Then connect to breathing circuitsystem to maintain anaesthesia
 Preoperative assessment and preparation of the patient should
 Patient refusal and local sepsis are the only absolute contraindications
 Select the appropriate technique for operation
 Discuss the procedure with the patient
 Identify the injection site using appropriate landmarks
" Use small bore needle, which causes less pain during injection"
 Select concentration and volume of drug according to the technique
 Aspirate before injection to avoid accidental intravascular injection
 Inject slowly and allow 5-10 minutes for onset of drug action
 Confirm desired block effect before surgery commences
 The patient must be monitored throughout the procedure
 Supplemental agents should be available for analgesia or anaesthesia if technique is inadequate
" Resuscitative equipment, drugs, and oxygen must be at hand"
before administration of any anaesthetic
 Discuss the procedure with the patient
 Identify the injection site using appropriate landmarks
" Use small bore needle, which causes less pain during injection"
 Select concentration and volume of drug according to the technique
 Aspirate before injection to avoid accidental intravascular injection
 Inject slowly and allow 5-10 minutes for onset of drug action
 Confirm desired block effect before surgery commences
 The patient must be monitored throughout the procedure
 Supplemental agents should be available for analgesia or anaesthesia if technique is inadequate
" Resuscitative equipment, drugs, and oxygen must be at hand"
before administration of any anaesthetic
Standard Infection Control Precautions
Transmission of infections in health care facilities can be prevented and
controlled through the application of basic infection control precautions
 Standard precautions: basic infection control measures which
"must be applied to all patients at all times, regardless of diagnosis or infectious status. They are designed to reduce the risk"
of transmission of micro-organisms from both recognized and
 Additional (transmission-based) precautions: measures that are
used for patients known or suspected to be infected or colonized
with highly transmissible or epidemiological important pathogens for which additional precautions are needed to interrupt
transmission in health care facilities.
For more details please refer to Uganda National Infection Prevention
and Control Guidelines December 2013.
Personal Hygiene involves the general cleanliness and care of the whole
"body: short and clean nails, short or pinned up hair, appropriate clean"
"clothing (uniforms), no jewels on the hands, closed shoes."
Hand washing is a major component of standard precautions and
one of the most effective methods to prevent transmission of pathogens associated with health care.
APPEND Before and after any direct patient contact and between patients
 When any skin area is contaminated with body fluids
 Before handling an invasive device or doing any procedures (even
" During patient care, when moving from contaminated to a clean"
 After contact with inanimate objects in the immediate
" Hand wash (40-60 sec) with water and soap, rub all surfacs, dry"
" Hand rub (wtih an alcohol based rub) for 20-30 sec, apply enough"
product to cover all areas of the hands and rub hands until dry
Respiratory hygiene and cough etiquette
 Patients with respiratory symptoms should cover their mouth
"and nose with tissue or mask while coughing sneezing, dispose"
of used tissues and masks and perform hand hygiene after contact with respiratory secretions
 Patients with respiratory symptoms should be placed 1 metre
"away from others in waiting areas and hand hygiene, tissues and"
masks made available in common areas
Instrument hygiene (decontamination)
"Decontamination is the combination of processes, including cleaning,"
APPENDdisinfection andor sterilisation used to render a re- useable medical
device safe for further episodes of use. The level of decontamination
depends on the situation involved and the type and use of equipment.
" Cleaning is the single most important step in making a medicaldevicereadyforre-use:byremovingorganicmaterial and reducing the number of micro-organisms present, it is an essential"
prerequisite of equipment decontamination to ensure effective
disinfection or sterilization can be subsequently carried out. It
" Disinfection is a process used to reduce the number of viable micro-organisms, which may not necessarily inactivate some viruses and bacterial spores. Disinfection will not achieve the same"
reduction in microbial contamination levels as sterilization. It can
be carried out by heat (boiling) or by chemical disinfectants.
" Sterilization is a process used to render the object free from viable micro-organisms, including spores and viruses. Moist Heat"
via clean steam (autoclaving) is the method of choice. Chemical
disinfection may only be used when autoclaving is not possible.
A clean environment forms the basis of sound infection prevention and
control practices. This is because there is an important link between
cleaning of health care facilities and persistence of nosocomial pathogens.
 The purpose of cleaning the environment is toremove visible
"dirt, reduce the level of microorganisms and to minimize the dissemination of infectious agents in the facility, thereby providing"
"an aesthetically pleasing, sanitary and relatively contamination"
"free environment for patients, staff and visitors"
 Ensure proper handling of linenlaundry
 Collect clothingsheets stained with bloodbody-fluids while wearing
gloves or using a plastic bag and keep separate from other laundry
APPEND Disinfect with hypochlorite if contaminated with body fluids
 Wash with soap and boil for 20 minutes
Personal Protective equipment (PPE)
Personal Protective Equipment is specialised clothing or equipment
worn to protect someone against a hazard or infection. PPE is indicated
when health worker-patient interaction indicates that exposure to blood
or body fluids is anticipated. They provide a physical barrier between
micro- organism and the person.
" Wear clean protective gloves when handling body fluidssecretions, mucous membranes, nonintact skin contaminated waste,-"
"soiled bedding or linen instruments, and for when cleaning body"
 Change between tasks and procedures on the same patients after contact with potentially infectious material
" Remove after use, before touching any other surface, and wash"
 Wear sterile or high-level disinfected gloves when performing
 Wear a surgical or procedure mask and eye protection (googles
or glasses) or a face shield when performing activities which are
"likely to generate splashes or sprays of blood, body fluids, secretions or excretions"
 Wear a gown to protect skin and prevent soiling of clothing in
 Use a waterproof bandage to cover wounds
" Wear protective boots and gloves and where possible, wear a"
"water-proof apron when working in a heavily contaminated area,"
APPEND Avoid mouth-to-mouth resuscitation and pipetting by mouth
" In surgical procedures, use a needle holder and appropriate sized"
"needle, wear double gloves and eye shield"
 Ensure safe sharps handling and disposal
" Avoid accidental pricks and cuts with contaminated sharp instruments (e.g., needles) by careful handling and proper disposal"
 Use hands-free technique for passing sharp instruments
 Keep a puncture-resistant container nearby
- Use a sterile needle and syringe for every injection
"- Do not recap, bend, or break needles after use"
" Drop all used disposable needles, plastic syringes, and blades"
directly into the sharps container without recapping or passing
 Empty or send for incineration when container is full
 Separate hazardous (potentially dangerous) from non- hazardous
- Hazardous waste includes: infectious waste (e.g. soiled
"bandages), anatomical waste (placenta), sharps, chemical and"
 Use adequate personal protective equipment when handling
"hazardous waste (boots, gown, water proof apron, gloves, face"
" Practice safe waste disposal as per guidelines (incineration, burying)"
These are necessary for patients who are known or suspected to be
APPENDinfected or colonized with specific pathogens that are transmitted by
"airborn, droplet or contact route of transmission."
Airborn precautions are designed to prevent transmission of particles
" 5 micron in size (e.g. some viruses like measles or chickenpox, M."
 Placement of a patient in a well ventilated room with door closed
 Use of appropriate respirators (masks with high filtration power)
 Limitation of contacts (visitors)
 Use of surgical mask for the patient if leaving the room
 Adherence to cough etiquette by the patient
" In particular settings, negative air pressure an be created"
They are designed to prevent transmission of pathogens transmitted
"by droplets, released by talking, sneezing and coughing: H. Influenza,"
"N.meningitis, some viruses, pertussis, influenza etc."
 Place patient in well ventilated room or at least 1 metre distance
 Wear a mask if within 1 metre from the patient
 Patient to wear a mask when moving.
 Closed door and negatve air pressure are not necessary
These precautions are designed to reduce the transmission of organism
from an infected or colonized patient through direct or indirect contact.
"It applies to microorganisms like HIV, hepatitis B, multi-drug resistant"
"APPENDbacteria like MRSA, herpes simplex, varicella and haemorrhagic fevers"
"viruses, skin staphylococcal infections, scabies, lice, other wound infections."
 Appropriate barrier method must be used
" Isolate patient, use dedicated equipment if possible"
" Wear gloves before entering the room, change gloves after contact with potentially infected material"
 Remove gloves as soon as leaving the room and wash hands with
 Minimize patients movements outside the room
"In case of blood borne pathogens (HIV, hepatitis B)"
 Use particular precautions in taking blood samples
 Decontaminate any body fluidblood spillage with 0.51 hypochlorite solutions
Patients suspected of having hemorrhagic fevers require the strictest
"infection control procedures (see WHO, 2016. Clinical management of"
patients with viral hemorrhagic fever. http:www.who.intcsrresources
publicationsclinical- management-patientsen)
Accidental exposure to blood during medical procedures (needle or
"other sharp injury, splashes of blood on mucosae) carries the risk of"
transmission of HIV andor hepatitis B.
Immunization against hepatitis B is recommended in health workers as
an effective protection measure.
Steps for post exposure prophylaxis are described in section 3.1072
Pharmacovigilance and Adverse Drug Reaction Reporting
Pharmacovigilance and Adverse Drug Reaction Reporting
Pharmacovigilance is defined as the science and activities relating to the
"detection, assessment, understanding and prevention of adverse effects"
or any other drug-related problem.
The aims of pharmacovigilance are to enhance patient care and patient
safety in relation to the use of medicines; and to support public health
"programmes by providing reliable, balanced information for the effective"
assessment of the risk- benefit profile of medicines.
"Any medicine may cause unwanted or unexpected adverse reactions,"
"some of which may be life threatening, for example anaphylactic shock"
Rapid detection and recording of adverse drug reactions (ADR) is of
vital importance so that unrecognised hazards are identified promptly
and appropriate regulatory action is taken to ensure medicines are used
safely and future events are prevented.
"Suspected adverse events to any medicine, vaccines and herbal products"
should be reported (including self- medication medicines).
Report all adverse drug reactions such as:
 ADRs to to any medicine (whether new or old)
 Serious reactions and interactions
 ADRs which are not clearly stated in the package insert
 Unusual or interesting adverse drug reactions
APPEND All adverse reactions or poisonings to traditional or herbal remedies
Report Product Quality Problems such as:
 Non-adherence (may be due to product characteristic)
Report medication errors such as:
" Pharmaceutical Companies, Distributors, Wholesalers and Retailers"
Health workers are urged to immediately report suspected ADRs
directly to the National Drug Authority Pharmacovigilance Centre using
the ADR forms (see example at the end of this section). The forms can
APPENDalso be obtained from the regional pharmacovigilance centres. Encourage
your patients to report suspected ADRs to you.
ADRs can also be reported directly online using the following links:
 https:primaryreporting.who-umc.orgReporting Reporter?OrganizationIDUG
 All regional referral hospitals have pharmacovigilance coordinators
The following NDA offices can also be contacted for further information:
Plot 4648 Lumumba Avenue Kampala
Tel. 041425566504143473910414344052
"House No. 29, Mbaguta Estates Kamukuzi Tel. 0485-421088"
South Bukedi Cooperative Building Plot No. 6 Busia Road
TelFax 045-45185 TORORO  UGANDA
Tel.Fax 0473-420652 LIRA  UGANDA
"South-Eastern Regional Office Stanley Road, Jinja Municipality Tel."
Central Regional Office Premier Complex Building Tel. 0312-261548
Tel. 0465-440688 HOIMA - UGANDA
Plot 4648 Lumumba Avenue Kampala
Tel. 041425566504143473910414344052
"House No. 29, Mbaguta Estates Kamukuzi Tel. 0485-421088"
South Bukedi Cooperative Building Plot No. 6 Busia Road
TelFax 045-45185 TORORO  UGANDA
Tel.Fax 0473-420652 LIRA  UGANDA
"South-Eastern Regional Office Stanley Road, Jinja Municipality Tel."
Central Regional Office Premier Complex Building Tel. 0312-261548
Tel. 0465-440688 HOIMA - UGANDA
APPENDWhat Will Happen When I Report?
"When NDA receives your report, they will assess the likelihood that the"
"suspected adverse reaction is actually due to the medicine, using the"
WHO causality assessment criteria for deciding on the contribution of
the medicine towards the adverse event.
"Depending on the outcome of the causality assessment, NDA will give"
"feedback in any of the following ways: medicine alerts, media statements,"
"patient information leaflets, newsletters and personal feedback to reporters."
Prevention of Adverse Drug Reactions (ADRs)
 Never use any medicine without a clear indication
" If a patient is pregnant, do not use a medicine unless it is absolutely necessary"
" Ask the patient if they have any allergies, hypersensitivity or"
previous reactions to the medicine or to similar medicines
" Reduce doses when necessary, for example, in the young, the"
"elderly, and if liver or renal disease is present"
 Always prescribe as few medicines as possible
" Carefully explain dose regimes to patients, especially those on"
"multiple medicines, the elderly, and anyone likely to misunderstand. Check for understanding before patient goes away."
 Age and liver or kidney disease may affect the way medicines behave in the body so that smaller than usual amounts are needed
 Ask if patient is taking other medicines including self medication
"medicines, health supplements, herbal products as interactions"
" If possible, always use medicines with which you are familiar"
 Look out for ADRs when using new or unfamiliar drugs
 Warn patients about likely adverse effects and advise them on
"APPEND Give patients on certain prolonged treatments, for example anticoagulants, corticosteroids, and insulin, a small card which they"
can carry with them giving information about the treatment
"Note: Please attach additional pages to the ADR reporting form if necessary. Even if you do not know some details in the form, do not be put off"
reporting the suspected adverse event
The test menu was developed by Uganda National
Health Laboratory Services (UNHLS). It is a list of tests that are available
at the specified level of health care. The laboratory system of Uganda is
designed to support the minimum health care package for each level of
"care, with complexity of tests increasing with the level of care."
"The laboratory test menu has been included in UCG 2023, in order to"
guide clinicians about the laboratory services available at each level of
"health care, and where to refer a patient in need of a particular test."
The National Laboratory Test Menu
HEALTH CENTER Serology Pregnancy Test
ADDITIONAL TESTS FOR HEALTH CENTER Haematology Urobilinogen
Blood film comments Ketones (Acetoacetic acid)
Sickle cell test Protein (Albumin)
Sickle cell screening test Nitrite
Plasmin Inhibitor Leukocytes in urine
Erythrocyte sedimentation rate Microbiology
The National Laboratory Test Menu 
HEALTH CENTER Serology Pregnancy Test
ADDITIONAL TESTS FOR HEALTH CENTER Haematology Urobilinogen
Blood film comments Ketones (Acetoacetic acid)
Sickle cell test Protein (Albumin)
Sickle cell screening test Nitrite
Plasmin Inhibitor Leukocytes in urine
Erythrocyte sedimentation rate Microbiology
APPENDADDITIONAL TESTS FOR HEALTH CENTER Blood Transfusion AFB test
Cryptoccocal Antigen test Malaria test
Brucella agglutinin test Filaria test
Rheumatoid factor Leishmania test
TB LAM Rapid Test Trypanosoma test
Helicobacter pylori IgG Immunology Molecular
"Hepatitis B rapid test CD4,CD3,CD8 Counts and Ratios"
Rapid Blood Sugar DNA PCR EID (Emerging Infectious Diseases)
ADDITIONAL TESTS FOR HC Haematology Indirect bilirubin
Thrombin clotting time (TT) Urea
Prothrombin time (PT) Creatinine
ADDITIONAL TESTS FOR HEALTH CENTER Blood Transfusion AFB test
Cryptoccocal Antigen test Malaria test
Brucella agglutinin test Filaria test
Rheumatoid factor Leishmania test
TB LAM Rapid Test Trypanosoma test
Helicobacter pylori IgG Immunology Molecular
"Hepatitis B rapid test CD4,CD3,CD8 Counts and Ratios"
Rapid Blood Sugar DNA PCR EID (Emerging Infectious Diseases)
ADDITIONAL TESTS FOR HC Haematology Indirect bilirubin
Thrombin clotting time (TT) Urea
Prothrombin time (PT) Creatinine
APPENDADDITIONAL TESTS FOR HC Infectious Disease Chloride
Biochemistry High Vaginal Swab (HVS) analysis
ADDITIONAL TESTS FOR GENERAL DISTRICT HOSPITALS
Thrombin time in the presence of TSH (Thyroid Stimulating HorProtamine Sulphate mone)
Activated partial Thromboplastin Fertility Hormones
Fibrinogen test (Modified Clauss Follicle Stimulating Hormone (FSH)
Plasmin Inhibitor Luteinizing Hormone (LH)
Platelet function tests Progesterone
Blood Transfusion Services Tumour Markers
Direct Coombs test Alpha fetoprotein
ADDITIONAL TESTS FOR HC Infectious Disease Chloride
Biochemistry High Vaginal Swab (HVS) analysis
ADDITIONAL TESTS FOR GENERAL DISTRICT HOSPITALS 
Thrombin time in the presence of
Protamine Sulphate TSH (Thyroid Stimulating Hormone)
Activated partial Thromboplastin
Fibrinogen test (Modified Clauss
Assay) Follicle Stimulating Hormone (FSH)
Plasmin Inhibitor Luteinizing Hormone (LH)
Platelet function tests Progesterone
Blood Transfusion Services Tumour Markers
Direct Coombs test Alpha fetoprotein
APPENDADDITIONAL TESTS FOR GENERAL DISTRICT HOSPITALS
Indirect Coombs test Pancreatic function tests
Immediate Spin Cross Match (ISCM) Amylase
Anti Streptolysin O-Test (ASOT) Lipase
Toxoplasma IgG and IgM Metabolic Profile
Infectious Disease Lactic acidLactate
Creatinine Clearance Occult blood Test
Total Cholesterol Eye Swab analysis
Low Density Lipoproteins (LDL) LDLc Nasal swab analysis
High Density Lipoproteins (HDL) HDLc Ear swab
Cardiac Profile HistologyCytology
Creatine Kinase (CK-MB) test PAP Smear
Lactate dehydrogenase (LDH Biopsy Tissue
Free T3 Lactophenol cotton blue
ADDITIONAL TESTS FOR GENERAL DISTRICT HOSPITALS 
Indirect Coombs test Pancreatic function tests
Immediate Spin Cross Match (ISCM) Amylase
Anti Streptolysin O-Test (ASOT) Lipase
Toxoplasma IgG and IgM Metabolic Profile
Infectious Disease Lactic acidLactate
Creatinine Clearance Occult blood Test
Total Cholesterol Eye Swab analysis
Low Density Lipoproteins (LDL) LDLc Nasal swab analysis
High Density Lipoproteins (HDL) HDLc Ear swab
Cardiac Profile HistologyCytology
Creatine Kinase (CK-MB) test PAP Smear
Lactate dehydrogenase (LDH Biopsy Tissue
Free T3 Lactophenol cotton blue
APPENDADDITIONAL TESTS FOR HC Haematology Iron
Reticulocyte count(count (RET) G6PD
Immature RBC haemoglobin (RBC Tumour Markers
Plasmin Inhibitor Prostate antigen (PSA)
Erythrocyte sedimentation rate CA 19-9 Ag
Peripheral Film Comment Fertility Hormones
Blood Transfusion Services Bacteriology
Measles IgM test Gastric Aspirate
Rubella IgG and IgM Test Nasopharyngeal oropharyngeal
Biochemistry CervicalEndo-cervical swab
Extended Electrolytes UrethralRectal Swab
Calcium Bacterial identification tests
Magnesium Bacterial susceptibility testing
Cardiac Profile Lymph Node Aspirate
ADDITIONAL TESTS FOR HC Haematology Iron
Reticulocyte count(count (RET) G6PD
Plasmin Inhibitor Prostate antigen (PSA)
Erythrocyte sedimentation rate CA 19-9 Ag
Peripheral Film Comment Fertility Hormones
Blood Transfusion Services Bacteriology
Measles IgM test Gastric Aspirate
Rubella IgG and IgM Test Nasopharyngeal oropharyngeal
Biochemistry CervicalEndo-cervical swab
Extended Electrolytes UrethralRectal Swab
Calcium Bacterial identification tests
Magnesium Bacterial susceptibility testing
Cardiac Profile Lymph Node Aspirate
APPENDADDITIONAL TESTS FOR HC ASO (RHD) Mycology
NT Pro BNP Mycology Culture and sensitivity
Myoglobin Fungal Identification Tests
Blood gases ABG ImmunologyMolecular
Metabolic Tests Viral load for HEPATITIS B Virus
Glycosylated Haemoglobin TB DNA PCR
ADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
Haematology Extended Electrolytes
Low Fluorescence Ratio (LFR) Phosphate
Medium Fluorescence Ratio (MFR) Cardiac Profile
High Fluorescence Ratio (HFR) hs-CRP
Reticulocyte haemoglobin (RET-HE) ASO (RHD)
"Immature RBC haemoglobin (RBC Troponins (C,T,I)"
Mono Nuclear cell count(MN) Myoglobin
ADDITIONAL TESTS FOR HC ASO (RHD) Mycology
NT Pro BNP Mycology Culture and sensitivity
Myoglobin Fungal Identification Tests
Blood gases ABG ImmunologyMolecular
Metabolic Tests Viral load for HEPATITIS B Virus
Glycosylated Haemoglobin TB DNA PCR
ADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
Haematology Extended Electrolytes
Low Fluorescence Ratio (LFR) Phosphate
Medium Fluorescence Ratio (MFR) Cardiac Profile
High Fluorescence Ratio (HFR) hs-CRP
Reticulocyte haemoglobin (RET-HE) ASO (RHD)
Mono Nuclear cell count(MN) Myoglobin
APPENDADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
Polymorph nuclear cell count (PMN) Arterial Blood gases (ABG)
HB electrophoresis test (Sickle cell) Metabolic Tests
Immunotyping (light and heavy PTHH
Platelet function tests Fertility Hormones
Clot retraction test Oestrone (E1)
Thromboerythrogram Oestradiol (E2)
Coagulation Tests Oestriol (E3)
Fibrinogen Antigen Assay by RIA DHEA
Factor Assays(II) Tumour Markers
Factor Assays(V) CEA (Carcino Embryonic Antigen)
Factor Assays(VIII) -FP (alpha fetoprotein)
Factor Assays(IX) NSE (Neuro Specific Enolase)
ADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
Polymorph nuclear cell count (PMN) Arterial Blood gases (ABG)
HB electrophoresis test (Sickle cell) Metabolic Tests
Platelet function tests Fertility Hormones
Clot retraction test Oestrone (E1)
Thromboerythrogram Oestradiol (E2)
Coagulation Tests Oestriol (E3)
Fibrinogen Antigen Assay by RIA DHEA
Factor Assays(II) Tumour Markers
Factor Assays(V) CEA (Carcino Embryonic Antigen)
Factor Assays(VIII) -FP (alpha fetoprotein)
Factor Assays(IX) NSE (Neuro Specific Enolase)
APPENDADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
One- stage Intrinsic Assay of prek- Cyfra 21-1
"allikren(PKK), and High Molecular"
Peripheral Film Comment Gastric Aspirate
Lupus erythromatous test Nasopharyngeal oropharyngeal
ANT THROMBIN(AT) Cervical Endo-cervical swab
Anti-Thrombin Liquid (AT) Urethral Rectal Swab
Plasmin Inhibitor (PI) Lymph Node Aspirate
Blood Transfusion Corneal scraping
Blood Transfusion services SkinNailHair Scrapping
Du test Special staining identification tests
Immediate Spin Cross Match Toluidine Blue-O for pneumocystis
Weak D Typing Mycology Culture and sensitivity
Serology Fungal Identification Tests
Infectious Disease Fungal susceptibility tests
Rubella IgGIgM Lactophenol cotton blue
Measles IgGIgM Mycology Grocotts silver stain
Mumps IgGIgM Toluidine Blue-O for pneumocystis
ADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
"One- stage Intrinsic Assay of prekallikren(PKK), and High Molecular"
Weight Kininogen (HMWK) Cyfra 21-1
Peripheral Film Comment Gastric Aspirate
Lupus erythromatous test Nasopharyngeal oropharyngeal
ANT THROMBIN(AT) Cervical Endo-cervical swab
Anti-Thrombin Liquid (AT) Urethral Rectal Swab
Plasmin Inhibitor (PI) Lymph Node Aspirate
Blood Transfusion Corneal scraping
Blood Transfusion services SkinNailHair Scrapping
Du test Special staining identification tests
(ISCM) Toluidine Blue-O for pneumocystis
Weak D Typing Mycology Culture and sensitivity
Serology Fungal Identification Tests
Infectious Disease Fungal susceptibility tests
Rubella IgGIgM Lactophenol cotton blue
Measles IgGIgM Mycology Grocotts silver stain
Mumps IgGIgM Toluidine Blue-O for pneumocystis
APPENDADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
HSV 2 IgGIgM Histology  Cytology
Inulin Clearance Histological test
"ADDITIONAL TESTS FOR SPECIALISED LABS (NTRL, UBTS,"
Inhibitor Screening Benzodiazepines
Clotting factor inhibitor screening Cannabinoides
Ristocetin cofactor Activityvon Cocaine
willebrand factor Activity (VWF:RCo or VWF: Act)
Von willebrand factor Antigen(VW- Ethanol
Von willebrand factor Collagen Methadone
Factor VIII binding Assay( VWD Methaqualone
F VIII inhibitor test Propoxyphene
F IX inhibitor test Tricyclic antidepressants
ADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
HSV 2 IgGIgM Histology  Cytology
Inulin Clearance Histological test
"ADDITIONAL TESTS FOR SPECIALISED LABS (NTRL, UBTS,"
Inhibitor Screening Benzodiazepines
Clotting factor inhibitor screening
Ristocetin cofactor Activityvon
willebrand factor Activity (VWF:RCo or VWF: Act) Cocaine
Von willebrand factor Antigen(VWF:Ag) Ethanol
binding assay (VWF:CB) Methadone
F VIII inhibitor test Propoxyphene
F IX inhibitor test Tricyclic antidepressants
APPENDADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
F XIII activity assay Lysergic Acid Diethylamide
Lupus anti-coagulant(LAC) and ImmunoHistoChemistry
Phospholipid anti- body(APA) tests
Dilute Russells Viper Venom Time A Foeto protein
ANTI THROMBIN III (AT3) A1 anti chymotrypsin
Other Specialized Tests ACE mono
Free Protein S (Free PS) Actine muscle
Protein S Activity Actine muscle lisse
Plasminogen (PLG) Actine muscle spé
Activated Protein C Resistance Adenovirus
α2-Antiplasmin (APL) Androgen Receptor
Chromogenic VIII High (F-VIII Chr B Catenin
"Silica Clotting Time (SCT-S, SCT BCL2"
ADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
F XIII activity assay Lysergic Acid Diethylamide
Phospholipid anti- body(APA) tests ImmunoHistoChemistry
Dilute Russells Viper Venom Time
ANTI THROMBIN III (AT3) A1 anti chymotrypsin
Other Specialized Tests ACE mono
Free Protein S (Free PS) Actine muscle
Protein S Activity Actine muscle lisse
Plasminogen (PLG) Actine muscle spé
Factor test (APCR-V) Adenovirus
α2-Antiplasmin (APL) Androgen Receptor
Chromogenic VIII High (F-VIII Chr
"Silica Clotting Time (SCT-S, SCT"
APPENDADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
Blood Transfusion services (NBTS) BerEP4
"Serological Testing (Ab, Ag, PCR) BOB.1"
"IgG Phenotyping: Fya, Fyb, Jka, BRAF V600E"
"IgM Rh-Kell C, c, E, e, K - Vertical CDX2"
"High Titer CD1a,2,3,4,5,7,8,10,13,14,15, 16,20..68"
Direct Anti globulin Test(DAT) CA125
"Antibody screen, commonly known CA19.9"
as Antibody detection test (ADT)
Anti globulin cross match Calcitonin
Platelet Compatibility Test Calcitonin
"Serological Testing (CMIA, Ab, Caldesmon"
Helicobacter pylori IgGIgM Caveolin-1
"HBsAg IgG CD1a, 2,3,4,5,7,8,10,13,14,15,16,20..68"
ADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
Blood Transfusion services (NBTS) BerEP4
"Serological Testing (Ab, Ag, PCR) BOB.1"
"IgG Phenotyping: Fya, Fyb, Jka,"
"IgM Rh-Kell C, c, E, e, K - Vertical CDX2"
"High Titer CD1a,2,3,4,5,7,8,10,13,14,15, 16,20..68"
Direct Anti globulin Test(DAT) CA125
"Antibody screen, commonly known"
as Antibody detection test (ADT) CA19.9
Anti globulin cross match Calcitonin
Platelet Compatibility Test Calcitonin
Helicobacter pylori IgGIgM Caveolin-1
"HBsAg IgG CD1a, 2,3,4,5,7,8,10,13,14,15,16,20..68 "
APPENDADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
HIV confirmatory SPECIFIC PROTEINS
GnRH (Gonadotropin Realesing Ferritin
ADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
HIV confirmatory SPECIFIC PROTEINS
APPENDADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
Bone Profile Soluble Transferrin
PTH (Parathyroid Hormone) Kappa
N-MID-Oesteocalcin Antithrombin
ADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
Bone Profile Soluble Transferrin
PTH (Parathyroid Hormone) Kappa
N-MID-Oesteocalcin Antithrombin
APPENDADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
Cortisol ANA (antinuclear antibodies)
GnRH ANCA (anti neutrophil cytoplasmic
- h CG-free Identification of Mycobacteria tuberculosis complex (MTC)
Cyfra-21-1 Drug susceptibility testing (DST)
ADDITIONAL TESTS FOR MULAGO BUTABIKA NATIONAL
Cortisol ANA (antinuclear antibodies)
GnRH ANCA (anti neutrophil cytoplasmic
- h CG-free Identification of Mycobacteria tuberculosis complex (MTC)
Cyfra-21-1 Drug susceptibility testing (DST)
" Uganda, National Tuberculosis and Leprosy Programme, 2016. Tuberculosis and Leprosy Manual, 3rd Edition"
" Uganda, Makerere Palliative Care Unit, 2014."
"World Health Organisation, 2010. WHO guide for Rabies Pre and"
Post-Exposure Prophylaxis in Humans. http:www. who.intrabies
PEP_prophylaxis_guidelines_June10.pdf Accessed on 25112016
" Uganda, 2013. Uganda National Infection Prevention and Control Guidelines 2013. http:library. health.go.ug"
publicationsleadership-and-governance- governanceguidelines
uganda-national-infection- prevention Accessed on 25112016
" Uganda, 2010. Guidelines for the Syndromic Management of Sexually Transmitted Infections in Uganda."
" Uganda, 2022. Essential Maternal and Newborn"
Clinical Care Guidelines for Uganda.
"Uganda Guidelines for Prevention, Testing, Care and Treatment of"
"Hepatitis B and C Virus Infection, May 2019"
" Uganda, 2016. The Uganda Medical Eligibity"
"Criteria for Contraceptive Use, MEC Wheel"
" Uganda, 2015. Integrated Community Case Management"
" Uganda, 2015. Integrated Management of Malaria"
"Training, 2nd Edition. Facilitators Guide"
" Uganda, 2015. Practical Guideline for Dispensing"
"for Higher Level Health Centres, 2015."
" Uganda, AIDS Control Programme, 2016. Consolidated Guidelines for Prevention and Treatment of HIV in Uganda."
"APPEND Uganda, 2016. Guidelines for Integrated Management of Nutrition in Uganda."
"Uganda Gastroenterology Society, 2016. Pocket Guide: Care and"
Treatment for Hepatitis B Virus Infection for Clinicains in Uganda
"UNAS, CDDEP, GARP-Uganda, Mpairwe, Y.,  Wamala"
S. (2015). Antibiotic Resistance in Uganda: Situation Anaysis and
"Recommendations. Kampala, Uganda: Uganda National Academy of"
"Sciences; Center for Disease Dynamics, Economics  Policy."
"World Health Organisation, 2015. Integrated Management of Pregnancy and Childbirth. 3rd Edition. http:apps.who."
intirisbitstream1066524958019789241549356-eng. pdf
"World Health Organisation, 2002. The Clinical Use of Blood. http:"
www.who.intbloodsafetyclinical_useen Handbook_EN.pdf Accessed on 25112016
"World Health Organisation, 2013. Pocket Book of Hospital"
"Care for Children, 2nd Edition. http:apps.who.intiris bitstr"
eam106658117019789241548373_eng.pdf Accessed on
"World Health Organisation, 2007. Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors."
World Health Organisation and UNICEF 2009. WHO child growth
standards and the identification of severe acute malnutrition in infants
"World Health Organisation, 2016. WHO Guidelines for the treatment"
of Treponema Pallidum (syphilis). http:www. who.int
"World Health Organisation, 2016. WHO Guidelines for the treatment"
of Neisseria Gonorrhoeae. http:www.who.int
"World Health Organisation, 2016. WHO Guidelines for the treatment"
of Chlamydia Trachomatis. http:www.who.int
APPENDWorld Health Organisation 2015. Medical Eligibility Criteria for
Contraceptive Use. 5th edition (2015). http:www.who. intreproductivehealthen
"World Health Organisation, 2014. Integrated Management of"
Childhood Illness Chart Booklet. http:apps.who.int irisbitstre
am10665104772169789241506823_ Chartbook_eng.pdf
"World Health Organisation, 2015. Guidelines for the Treatment"
"of Malaria, 3rd Edition, 2015. http:apps.who. intirisbitstre"
am1066516244119789241549127_eng. pdf Accessed on
"World Health Organisation, 2010. mhGAP Intervention"
Guide. http:apps.who.intiris bitstream10665444061
9789241548069_eng.pdf Accessed on 25112016
Medecins Sans Frontieres. Clinical Guidelines - Diagnosis and treatment manual. 2016 edition. http:refbooks.msf. orgmsf_docsen
"Dowell, S. F., Sejvar, J. J., Riek, L., Vandemaele, K. A. H.,"
"Lamunu, M., Kuesel, A. C.,  Mbonye, A. K. (2013). Nodding Syndrome. Emerging Infectious Diseases, 19(9), 13741373. http:doi."
"Global Inititative for Chronic Obstructive Lung disease, 2015. Pocket"
"Guide to COPD diagnosis, management and prevention. http:"
goldcopd.orgpocket-guide-copd- diagnosis-management-prevention-2016 Accessed on 25112016
"BMJ Group and the Royal Pharmaceutical Society of Great Britain,"
"2014. British National Formulary 66, 2013-2014. London, UK"
"BMJ Group and the Royal Pharmaceutical Society of Great Britain,"
"2014. British National Formulary for Children 2013-2014. London,"
"APPENDRepublic of Namibia. and Social Services, 2011."
Namibia Standard Treatment Guidelines. http:apps.who.int
medicinedocsdocumentss19260en s19260en.pdf Accessed on
Republic of South Africa. Essential Drugs Programme. Hospital
(Adults) Standard Treatment Guidelines and Essential Medicines List.
4th ed. Republic of South Africa: National Department of Health;
2015. http:www. health.gov.zaindex.phpcomponentphocadownload category197
Republic of South Africa. Essential Drugs Programme. Hospital (Paediatrics) Standard Treatment Guidelines and Essential Medicines List.
3rd ed. Republic of South Africa: National Department of Health;
2013. http:www. health.gov.zaindex.phpcomponentphocadownload category197
Republic of South Africa. Essential Drugs Programme. Primary
Health Care Level. Standard Treatment Guidelines and Essential
Medicines List. 5th ed. Republic of South Africa: National Department of Health; 2014. http:www.health.gov.zaindex.phpcomponent phocadownloadcategory197
Medscape. http:www.medscape.com
"SIAPS. 2015. Developing, Implementing, and Monitoring the Use of"
Standard Treatment Guidelines: A SIAPS How-to Manual. Submitted
to the US Agency for International Development by the Systems for
"to Pharmaceuticals and Services (SIAPS) Program. Arlington, VA:"
Management Sciences for Health. http: www.siapsprogram.org
African Snakebite Institute. https:www.africansnakebiteinstitute.
abstract mosquitotransmitted arbovirus constitute a large proportion of emerging infectious disease that are both a public health problem and a threat to animal population many such virus were identified in east africa a region where they remain important and from where new arbovirus may emerge we set out to describe and review the relevant mosquitoborne virus that have been identified specifically in uganda we focused on the discovery burden mode of transmission animal host and clinical manifestation of those previously involved in disease outbreak a search for mosquitoborne arbovirus detected in uganda wa conducted using search term arbovirus in uganda and mosquito and virus in uganda in pubmed and google scholar in twentyfour mosquitoborne virus from different animal host human and mosquito were documented the majority of these were from family peribunyaviridae followed by flaviviridae togaviridae phenuiviridae and only one each from family rhabdoviridae and reoviridae sixteen of the virus were associated with febrile illness ten of them were first described locally in uganda six of these are a public threat a they have been previously associated with disease outbreak either within or outside uganda historically there is a high burden and endemicity of arbovirus in uganda given the many diverse mosquito specie known in the country there is also a likelihood of many undescribed mosquitoborne virus next generation diagnostic platform have great potential to identify new virus indeed four novel virus two of which were from human ntwetwe and nyangole virus and two from mosquito kibale and mburo virus were identified in the last decade using next generation sequencing given the unbiased approach of detection of virus by this technology it use will undoubtedly be critically important in the characterization of mosquito viromes which in turn will inform other diagnostic effort keywords uganda history mosquitoborne arbovirus outbreak abstract background there is a critical need to identify the driver of willingness to receive new vaccine against emerging and epidemic disease a discrete choice experiment is the ideal approach to evaluating how individual weigh multiple attribute simultaneously we assessed the degree to which six attribute were associated with willingness to be vaccinated among university student in uganda method we conducted a singleprofile discrete choice experiment at makerere university in participant were asked whether or not they would be vaccinated in unique scenario where attribute varied by disease risk disease severity advice for or against vaccination from trusted individual recommendation from influential figure whether the vaccine induced indirect protection and side effect we calculated predicted probability of vaccination willingness using mixed logistic regression model comparing health professional student with all other discipline finding of the participant were health professional student and were female vaccination willingness wa high and higher among health student than other student we observed the highest vaccination willingness for the most severe disease outcome and the greatest exposure risk along with the minister of health recommendation or a vaccine that extended secondary protection to others mild side effect and recommendation against vaccination diminished vaccination willingness interpretation our result can be used to develop evidencebased messaging to encourage uptake for new vaccine future vaccination campaign such a for covid vaccine in development should consider acknowledging individual risk of exposure and disease severity and incorporate recommendation from key health leader abstract background the burden of malaria infection in subsaharan africa among schoolaged child aged year is underappreciated and represents an important source of humantomosquito transmission of plasmodium falciparum additional intervention are needed to control and eliminate malaria we aimed to assess whether preventive treatment of malaria might be an effective mean of reducing p falciparum infection and anaemia in schoolaged child and lowering parasite transmission method in this systematic review and two metaanalyses we searched the online database pubmed embase cochrane central and clinicaltrialsgov for intervention study published between jan and dec we included randomised study that assessed the effect of antimalarial treatment among asymptomatic schoolaged child aged year in subsaharan africa on prevalence of p falciparum infection and anaemia clinical malaria and cognitive function we first extracted data for a studylevel metaanalysis then contacted research group to request data for an individual participant data metaanalysis outcome of interest included prevalence of p falciparum infection detected by microscopy anaemia study defined value or haemoglobin less than ageadjusted and sexadjusted value clinical malaria infection and symptom on the basis of studyspecific definition during followup and code transmission test score we assessed effect by treatment type and duration of time protected and explored effect modification by transmission setting for studylevel metaanalysis we calculated risk ratio for binary outcome and standardised mean difference for continuous outcome and pooled outcome using fixedeffect and randomeffects model we used a hierarchical generalised linear model for metaanalysis of individual participant data this study is registered with prospero crd finding of study identified were eligible for the studylevel metaanalysis n researcher from study contributed data on at least one outcome n for an individual participant data metaanalysis intervention and study design were highly heterogeneous overall risk of bias wa low in the studylevel metaanalysis treatment wa associated with reduction in p falciparum prevalence risk ratio rr ci anaemia and clinical malaria result for cognitive outcome are not presented because data were only available for three trial in our individual participant data metaanalysis we found treatment significantly decreased p falciparum prevalence adjusted rr arr ci p individual study anaemia arr p individual study and subsequent clinical malaria arr p individual four study across transmission setting we detected a marginal effect on cognitive function in child older than year adjusted mean difference in standardised test score p individual five study although we found no significant effect when combined across all age interpretation preventive treatment of malaria among schoolaged child significantly decrease p falciparum prevalence anaemia and risk of subsequent clinical malaria across transmission setting policy maker and programme manager should consider preventive treatment of malaria to protect this age group and advance the goal of malaria elimination while weighing these benefit against potential risk of chemoprevention funding u national institute of health and burroughs wellcome fundastmh fellowship abstract introduction in india contributed for of malaria case and of death in the south east asia region here we systematically and critically analyzed data published on malaria in pregnancy mip in india method epidemiological clinical parasitological preventive and therapeutic aspect of mip and it consequence on both mother and child were reviewed and critically analyzed knowledge gap and solution way are also presented and discussed several electronic database including google scholar google pubmed scopus wiley online library the malaria in pregnancy consortium library the world malaria report the who regional website and clinicaltrialsgov were used to identify article dealing with mip in india the archive of local scientific associationsjournals and website of national program were also consulted result malaria in pregnancy is mainly due to plasmodium falciparum pf and p vivax pv and on rare occasion to p ovale spp and p malariae too the overall prevalence of mip is for peripheral malaria and for placental malaria peripheral pf infection at antenatal care anc visit decreased from in to in in madhya pradesh while placental pf infection at delivery unit slightly decreased from in to in in jharkhand in contrast the prevalence of peripheral pv infection at anc increased from in to in in jharkhand and from in to in in chhattisgarh clinical presentation of mip is diverse ranging from asymptomatic carriage of parasite to severe malaria and associated with comorbidities and concurrent infection such a malnutrition covid dengue and cardiovascular disorder severe anemia cerebral malaria severe thrombocytopenia and hypoglycemia are commonly seen in severe mip and are strongly associated with tragic consequence such a abortion and stillbirth congenital malaria is seen at prevalence of infected baby are generally smallforgestational age premature with low birthweight and suffer mainly from anemia thrombocytopenia leucopenia and clinical jaundice main challenge and knowledge gap to mip control included diagnosis relapsing malaria mixed plasmodium infection treatment selfmedication low density infection and utility of artemisininbased combination therapy conclusion all taken together the finding could be immensely helpful to control mip in malaria endemic area keywords india epidemiology malaria outcome pregnancy prevention treatment abstract purpose of review malaria case and death decreased from to but remain increased since several new development and strategy could help reverse this trend the purpose of this review is to discus new world health organization who guideline and recent research on malaria prevention in child recent finding fifteen country have now rolled out seasonal malaria chemoprophylaxis smc in child at highest risk for severe malaria and new who recommendation provide more flexibility for smc implementation in term of target age group geographic region and number of cycle recent study confirm that malaria burden in school aged child and their contribution to transmission is high new guideline permit expanded chemoprevention option for these child two vaccine have been approved for use in malaria endemic country rtssas e and rmatrixm additionally pyrethroidchlorfenapyr bed net are being deployed to combat resistant mosquito summary while challenge remain in malaria control towards elimination new guideline and recently approved vaccine offer hope monitoring for continued vaccine and chemoprevention effectiveness and for possible epidemiologic shift in severe malaria presentation and death a additional prevention effort roll out will be paramount abstract background lao pdr ha made significant progress in malaria control the national strategic plan outline ambitious target aiming for the elimination of plasmodium falciparum and p vivax malaria from all northern province by and national elimination by this article present an overview of malaria epidemiology surveillance and response system in lao pdr emphasizing experience and achievement in transmission reduction method data on surveillance monitoring and evaluation system human resource infrastructure and community malaria knowledge during were systematically gathered from the national program and relevant document the collected information wa synthesized and discussion on challenge and future prospect were provided result malaria control and elimination activity in lao pdr were implemented at various level with a focus on health facility catchment area there ha been significant progress in reducing malaria transmission throughout the country targeted intervention such a case management vector control and community engagement using stratification of control intervention by catchment area have contributed to the decline in malaria case in elimination area active surveillance strategy including case and focus investigation are implemented to identify and stop transmission the surveillance system ha facilitated timely detection and response to malaria case enabling these targeted intervention in higherrisk area conclusion the malaria surveillance and response system in lao pdr ha played a crucial role in reducing transmission and advancing the country towards elimination challenge such a importation drug resistance and sustaining support require ongoing effort further strengthening surveillance improving access to service and addressing transmission determinant are key area of focus to achieve malaria elimination and enhance population health in lao pdr keywords elimination epidemiology lao pdr malaria surveillance abstract background plasmodium falciparum is the dominant malaria specie in the subsaharan africa and the main cause of severe disease and death notwithstanding severe malaria and death due to nonfalciparum infection have been reported but at much lower rate than p falciparum infection following increasing use of molecular detection technique in epidemiological study a higher prevalence of nonfalciparum specie ha been reported in the region than previously thought this article review the literature on the prevalence of nonfalciparum malaria specie in uganda and the clinical figure of their severe disease it aim to elucidate the extent to which mono nonfalciparum malaria infection in a highly malariaendemic country contribute to malaria mortality and outline it policy implication on malaria case management method the available englishlanguage published peerreviewed literature up to march wa sought via pubmed and google scholar the keywords used were severe malaria and p falciparum p malariae p vivax p ovale spp mixed infection and uganda the review encompassed article article using molecular diagnosis method were accounted for analysis result the literature reported a substantial prevalence of nonfalciparum infection in uganda plasmodium malariae and plasmodium ovale spp were the second and third most prevalent reported malaria specie respectively after p falciparum a dominant specie nonfalciparum malaria infection often occur a mixed infection rather than monoinfections besides molecular diagnostics revealed that of initially reported monoinfections of p falciparum were in fact mixed infection no article wa found on the prevalence of severe malaria or case fatality rate due to mixed or nonfalciparum infection conclusion a critical knowledge gap exists regarding the impact of mixed and nonfalciparum specie on severe malaria and death in uganda robust evidence on prevalence recurrent parasitaemia and severe clinical manifestation of mixed and nonfalciparum malaria infection is crucial for evidencebased and effective policymaking regarding malaria case management keywords p falciprum p malariae p ovale spp p vivax mixed infection nonfalciparum severe malaria uganda abstract introduction map of malaria risk are important tool for allocating resource and tracking progress most map rely on crosssectional survey of parasite prevalence but health facility represent an underused and powerful data source we aimed to model and map malaria incidence using health facility data in uganda method using month of individuallevel outpatient data collected from surveillance health facility located in district across uganda n laboratoryconfirmed case we estimated monthly malaria incidence for parish within facility catchment area n by estimating careseeking population denominator we fit spatiotemporal model to the incidence estimate to predict incidence rate for the rest of uganda informed by environmental sociodemographic and intervention variable we mapped estimated malaria incidence and it uncertainty at the parish level and compared estimate to other metric of malaria to quantify the impact that indoor residual spraying irs may have had we modelled counterfactual scenario of malaria incidence in the absence of irs result over parishmonths malaria incidence averaged case per personyears map indicated high burden in the north and northeast of uganda with lower incidence in the district receiving irs districtlevel estimate of case correlated with case reported by the spearmans r p but were considerably higher case estimated compared with case reported indicating the potential for underreporting by the routine surveillance system modelling of counterfactual scenario suggest that approximately million case were averted due to irs across the study period in the district receiving irs estimated population conclusion outpatient information routinely collected by health system can be a valuable source of data for mapping malaria burden national malaria control programme may consider investing in robust surveillance system within public health facility a a lowcost high benefit tool to identify vulnerable region and track the impact of intervention keywords epidemiology geographic information system malaria abstract background while of million global malaria case are reported in uganda it is also a top refugee hosting country in africa with over million refugee despite malaria being an emerging challenge for humanitarian response in refugee settlement little is known about it risk factor this study aimed to investigate the risk factor for malaria infection among child under year of age in refugee settlement in uganda method we utilized data from uganda malaria indicator survey which wa conducted between december and february at the peak of malaria season in this national survey household level information wa obtained using standardized questionnaire and a total of child under year of age were tested for malaria using mainly the rapid diagnostic test we focused on malaria tested child under five in refugee settlement located in yumbe arua adjumani moyo lamwo kiryadongo kyegegwa kamwenge and isingiro district the extracted variable included prevalence of malaria demographic socialeconomic and environmental information multivariable logistic regression wa used to identify and define the malaria associated risk factor result overall malaria prevalence in all refugee settlement across the nine hosting district wa malaria infection were higher in refugee settlement located in isingiro kyegegwa and arua district several risk factor were significantly associated with acquisition of malaria including fetching water from open water source adjusted odds ratio aor ci p boreholes aor ci p and water tank aor ci p other factor included pitlatrines aor ci p open defecation aor ci p lack of insecticide treated bed net aor ci p and knowledge on the cause of malaria aor ci p conclusion the persistence of the malaria infection were mainly due to open water source poor hygiene and lack of preventive measure that enhanced mosquito survival and infection malaria elimination in refugee settlement requires an integrated control approach that combine environmental management with other complementary measure like insecticide treated bed net indoor residual spraying and awareness keywords child household malaria refugee risk factor settlement uganda abstract background understanding the relationship between malaria infection risk and disease outcome represents a fundamental component of morbidity and mortality burden estimation contemporary data on severe malaria risk among population of different parasite exposure are scarce using surveillance data we compared rate of paediatric malaria hospitalisation in area of varying parasite exposure level method surveillance data at five public hospital jinja mubende kabale tororo and apac were assembled among admission aged month to year between and the address of each admission wa used to define a local catchment population where national census data wa used to define personyearexposure to risk within each catchment historical infection prevalence wa assembled from previously published data and current infection prevalence defined using populationbased school survey among child poisson regression wa used to compute the overall and sitespecific incidence with confidence interval result both current and historical plasmodium falciparum prevalence varied across the five site current prevalence ranged from in kabale to in apac overall the malaria admission incidence rate ir wa per person year among child aged month to year of age ci the lowest rate wa described at kabale ir ci and highest at apac ir ci there wa a correlation between ir across the five site and the current parasite prevalence in school child though finding were not statistically significant across all site except kabale malaria admission were concentrated among young child were under year the median age of malaria admission at kabale hospital wa month iqr and at apac hospital wa month iqr overall severe anaemia wa the most common presentation and unconsciousness the least common conclusion malaria hospitalisation rate remain high in uganda particularly among young child the incidence of hospitalized malaria in different location in uganda appears to be influenced by past parasite exposure immune acquisition and current risk of infection interruption of transmission through vector control could influence agespecific severe malaria risk keywords age hospitalized incidence malaria uganda abstract background malaria is a critical global health issue particularly for child in endemic region however factor associated with recurrent severe malaria in child under year of age in northern uganda are poorly understood this study aimed to identify factor associated with readmission due to severe malaria within six month postdischarge among child in this age group method a crosssectional study wa conducted in otuke district encompassing twelve health facility a total of caregiver of child admitted with severe malaria were interviewed and hospital record were reviewed to verify the readmission data the primary outcome assessed wa readmission with severe malaria within six month after initial discharge data analysis wa performed via stata version result the prevalence of readmission with severe malaria among child under year of age wa factor significantly associated with readmission included having sickle cell anaemia adjusted prevalence ratio apr confidence interval ci living in house constructed with straw and thatch wall apr ci and seeking care after h when the child ha a fever apr ci conclusion the finding indicate a high proportion of severe malaria readmission in child under year of age sickle cell anaemia living in house built using straw and thatch wall and seeking care after h when a child ha fever were the key risk factor for readmission with severe malaria this study highlight the importance of targeted postdischarge intervention such a prophylactic antimalarial in addition to bed net to prevent recurrent infection especially among child with sickle cell disease in addition improvement in housing quality and timely treatment of child with malaria are essential for reducing the burden of malaria particularly in endemic region keywords associated factor child child under year of age readmission severe malaria uganda abstract background routine malaria surveillance data in africa primarily come from public health facility reporting to national health management information system although information on gender is routinely collected from patient presenting to these health facility stratification of malaria surveillance data by gender is rarely done this study evaluated gender difference among patient diagnosed with parasitological confirmed malaria at public health facility in uganda method this study utilized individual level patient data collected from january through april at public health facility in uganda and crosssectional survey conducted in target area around these facility in april association between gender and the incidence of malaria and nonmalarial visit captured at the health facility from patient residing within the target area were estimated using poisson regression model controlling for seasonality association between gender and data on healthseeking behaviour from the crosssectional survey were estimated using poisson regression model controlling for seasonality result overall incidence of malaria diagnosed per person year wa among female and among male irr ci p with larger difference among those year irr ci p and over year irr ci p compared to those under year irr ci p female gender wa also associated with a higher incidence of visit where malaria wa not suspected irr ci p with a similar pattern across age stratum these association were consistent across the individual health centre from the crosssectional survey female were more likely than male to report fever in the past week and seek care at the local health centre v p with these association significant for those year rr ci p and over year rr ci p conclusion female disproportionately contribute to the burden of malaria diagnosed at public health facility in uganda especially once they reach childbearing age contributing factor included more frequent visit to these facility independent of malaria and a higher reported risk of seeking care at these facility for febrile illness keywords age difference gender incidence malaria routine surveillance abstract background globally nearly half of all death among child under the age of year can be attributed to malaria diarrhoea and pneumonia a significant proportion of these death occur in subsaharan africa despite several programme implemented in subsaharan africa the burden of these illness remains persistently high to mobilise resource for such programme it is necessary to evaluate their cost costseffectiveness and affordability this study aimed to estimate the provider cost of treating malaria diarrhoea and pneumonia among child under the age of year in routine setting at the health facility level in rural uganda and mozambique method service and cost data wa collected from health facility in midwestern uganda and inhambane province mozambique from private and public health facility financial and economic cost of providing care for childhood illness were investigated from the provider perspective by combining a topdown and bottomup approach to estimate unit cost and annual total cost for different type of visit for these illness all cost were collected in ugandan shilling and mozambican meticais cost are presented in u dollar result in uganda the highest number of outpatient visit were for child with uncomplicated malaria and of inpatient admission were for respiratory infection including pneumonia the highest unit cost for outpatient visit wa for pneumonia and other respiratory infection and ranged from to while the highest unit cost for inpatient admission wa for malaria in mozambique the highest number of outpatient and inpatient admission visit were for malaria the highest unit cost were for malaria too ranging from to for outpatient visit and for inpatient admission the greatest contributor to cost in both country were drug and diagnostics followed by staff conclusion the finding highlighted the intensive resource use in the treatment of malaria and pneumonia for outpatient and inpatient case particularly at higher level health facility timely treatment to prevent severe complication associated with these illness can also avoid high cost to health provider and household trial registration clinicaltrialsgov identifier nct keywords cost diarrhoea malaria mozambique pneumonia uganda abstract background few recent description of severe childhood malaria have been published from hightransmission region in the current study the clinical epidemiology of severe malaria in mbale eastern uganda is described where the entomological inoculation rate exceeds infective bite per year method a prospective descriptive study wa conducted to determine the prevalence clinical spectrum and outcome of severe plasmodium falciparum malaria at mbale regional referral hospital in eastern uganda all child aged month year who presented on monday to friday between am and pm from th may until th april were screened for parasitaemia clinical and laboratory data were then collected from all p falciparum positive child with feature of whodefined severe malaria by use of a standardized proforma result a total of child were screened of which had a positive blood film of these child had clinical feature of severe malaria and were consented for the current study respiratory distress wa the most common severity feature while had hyperparasitaemia had clinical jaundice had severe anaemia had hyperlactataemia lactate mmoll had passed dark red or black urine had impaired consciousness and had hypoxaemia oxygen saturation inhospital mortality wa overall but wa higher in child with either cerebral malaria or severe anaemia factor that were independently associated with mortality on multivariate analysis included severe anaemia odds ratio or p hyperlactataemia or p hypoxaemia or ci p and hepatomegaly or p no independent association wa found between mortality and either coma or hyperparasitaemia conclusion severe childhood malaria remains common in eastern uganda where it continues to be associated with high mortality an unusually high proportion of child with severe malaria had jaundice or gave a history of having recently passed dark red or black urine an issue worthy of further investigation keywords child dark red or black urine p falciparum malaria severe anaemia severe malaria uganda abstract background accurate measure of malaria incidence are essential to track progress and target highrisk population while health management information system hmis data provide count of malaria case quantifying the denominator for incidence using these data is challenging because catchment area and careseeking behaviour are not well defined this study aim wa to estimate malaria incidence using hmis data by adjusting the population denominator accounting for travel time to the health facility method outpatient data from two public health facility in uganda kihihi and nagongera over a year period were used to model the relationship between travel time from patient village of residence available for each individual to the facility and the relative probability of attendance using poisson generalized additive model output from the model were used to generate a weighted population denominator for each health facility and estimate malaria incidence among child aged month to year monthly hmisderived incidence estimate with and without population denominator weighted by probability of attendance were compared with gold standard measure of malaria incidence measured in prospective cohort result a total of outpatient visit were recorded across the two site over the study period hmis incidence correlated with cohort incidence over time at both study site correlation in kihihi p correlation in nagongera p hmis incidence measure with denominator unweighted by probability of attendance underestimated cohort incidence aggregated over the year in kihihi case per personyear ppy v case ppy and nagongera case ppy v case ppy hmis incidence measure with denominator weighted by probability of attendance were closer to cohort incidence but remained underestimate case ppy in kihihi and case ppy in nagongera conclusion although malaria incidence measured using hmis underestimated incidence measured in cohort even when adjusting for probability of attendance hmis surveillance data are a promising and scalable source for tracking relative change in malaria incidence over time particularly when the population denominator can be estimated by incorporating information on village of residence keywords health facility health management information system incidence malaria surveillance uganda abstract background in subsaharan africa ssa malaria remains a public health problem despite recent report of declining incidence severe malaria is a multiorgan disease with wideranging clinical spectrum and outcome that have been reported to vary by age geographical location transmission intensity over time there are report of recent malaria epidemic or resurgence but few data if any focus on the clinical spectrum of severe malaria during epidemic this describes the clinical spectrum and outcome of childhood severe malaria during the disease epidemic in eastern uganda method this prospective cohort study from october to september wa nested within the malaria epidemiological pathophysiological and intervention study in highly endemic eastern uganda tmasfmepie study at mbale regional referral hospital uganda child aged day to year who at admission tested positive for malaria and fulfilled the clinical who criterion for surveillance of severe malaria were enrolled on the study followup wa performed until day data were collected using a customized proforma on social demographic characteristic clinical presentation treatment and outcome laboratory analysis included complete blood count malaria rdt sd bioline malaria ag pfpan ref fk and blood slide lactate glucose blood gas and electrolyte in addition urinalysis using dipstick multistix sg siemens ref at the bedside wa done data were analysed using stata v the study had prior ethical approval result a total of participant were recruited the median age wa year mean of month and iqr of month many child were under year and were male the common clinical feature were prostration jaundice in severe malarial anaemia in black water fever and multiple convulsion impaired consciousness acidosis respiratory distress and coma in prolonged hospitalization wa found in and wa associated with acidosis p the overall mortality wa day followup wa achieved in conclusion during the malaria epidemic in eastern uganda severe malaria affected much older child and the spectrum had more of prostration jaundice severe malarial anaemia black water fever and multiple convulsion with less of earlier reported respiratory distress and cerebral malaria keywords child clinical spectrum prolonged hospitalization and mortality severe malaria abstract background the risk of widespread resistance to artemisininbased combination therapy act remains high in uganda following detection of plasmodium falciparum parasite with delayed artemisinin clearance genotype and phenotype establishment of context specific intervention to mitigate emergence and spread of artemisinin resistance is thus key in the fight against malaria in the country the aim of this study wa to explore the experience of healthcare personnel on malaria diagnosis and selfreported efficacy of act in the management of malaria symptomatic patient in hospital in low and high malaria transmission setting in uganda method this wa a qualitative study in which data wa collected from healthcare personnel in hospital using key informant interview the key informant interview guide wa developed pretested prior to use and covered the following area i sociodemographic characteristic ii malaria diagnosis clinical and parasite based iii qualityassured artemisininbased combination therapy iv malaria patient followup v artemisinin resistance vi antimalarial selfmedication data wa entered in atlasti ver and analysis done following a framework criterion result a total of respondent were interviewed of which were clinician majority of the respondent were male the following theme were developed from the analysis malaria diagnosis procedure and challenge use of malaria laboratory test result malaria treatment in hospital use of quality assured act qaact in malaria treatment and efficacy of act in malaria treatment conclusion most healthcare personnelinitiated malaria treatment after a positive laboratory test case of malaria patient who report remaining symptomatic after prior use of act exist especially in high malaria transmission setting in uganda there is need for regular monitoring of artemisinin resistance emergence and spread in the country keywords malaria microscopy policy rapid diagnostic test testandtreat abstract background malaria in pregnancy contributes to substantial morbidity and mortality among woman in uganda however there is limited information on the prevalence and factor associated with malaria in pregnancy among woman in arua district northwestern uganda we therefore assessed the prevalence and factor associated with malaria in pregnancy among woman attending routine antenatal care anc clinic at arua regional referral hospital in northwestern uganda method we conducted an analytic crosssectional study between october and december we used a paperbased structured questionnaire to collect data on maternal sociodemographic and obstetric factor and malaria preventive measure malaria in pregnancy wa defined a a positive rapid malarial antigen test during anc visit we performed a modified poisson regression analysis with robust standard error to determine factor independently associated with malaria in pregnancy reported a adjusted prevalence ratio apr and confidence interval ci result we studied pregnant woman with a mean age of year that attended the anc clinic all without symptomatic malaria of the participant were in their second or third trimester were first or secondtime pregnant woman and reported sleeping under insecticidetreated bednets itns every day the prevalence of malaria in pregnancy wa by rapid diagnostic testing rdt with the independently associated factor being daily use of insecticidetreated bednets apr ci first anc visit after week of gestation apr ci and being in the second or third trimester apr ci conclusion the prevalence of malaria in pregnancy among woman attending anc in this setting is high we recommend the provision of insecticidetreated bednets to all pregnant woman and early anc attendance to enable access to malaria preventive therapy and related intervention abstract background appropriate malaria management is a key malaria control strategy the objective of this study wa to determine health care worker adherence level to malaria case management guideline in the busoga subregion uganda method health facility assessment health care worker hcw and patient exit interview pei survey were conducted at government and private health facility in the subregion all health centre hc iv iii and a sample of hc ii representative of the tiered structure of outpatient service delivery at the district level were targeted hcws at these facility were eligible for participation in the study for pei patient of all age presenting with a history of fever for outpatient care at selected facility in each district were targeted patient outcome measure included testing rate adherence to treatment dispensing and counselling service a per national guideline the primary outcome wa appropriate malaria case management defined a the proportion of patient tested and only prescribed artemetherlumefantrine al if positive hcw readiness eg training supervision and health facility capacity eg availability of diagnostics and antimalarial to provide malaria case management were also assessed data were weighted to cater for the disproportionate representation of hc ii in the study sample result a total of patient and hcw from facility were considered in the analysis the median age of patient wa year majority female most facility were hciis and were owned by the government malaria testing service were available at of facility al wa in stock at facility of those with a positive result nearly all were prescribed an antimalarial with al accounting for most prescription among those prescribed al were given al at the facility lowest at hc iv and government owned facility corresponding to al stock level overall ci of all enrolled patient received appropriate malaria case management however only of patient seen at pfps received appropriate malaria management conclusion adherence level to malaria case management guideline were good but with gap noted mainly in the private sector the supply chain for al need to be strengthened intervention to improve practise at pfp facility should be intensified keywords adherence malaria case management uganda abstract background few study have explored how vector control intervention may modify association between environmental factor and malaria method we used weekly malaria case reported from six public health facility in uganda environmental variable temperature rainfall humidity and vegetation were extracted from remote sensing source the nonlinearity of environmental variable wa investigated and negative binomial regression model were used to explore the influence of indoor residual spraying irs and longlasting insecticidal net llins on association between environmental factor and malaria incident case for each site a well a pooled across the facility with or without considering the interaction between environmental variable and vector control intervention result an average of weekly malaria case per site range occurred between and from the pooled model malaria risk related to environmental variable wa reduced by about with llins and with irs significant interaction were observed between some environmental variable and vector control intervention there wa sitespecific variability in the shape of the environmentmalaria risk relationship and in the influence of intervention to reduction in case with llins and to with irs conclusion the influence of vector control intervention on the malariaenvironment relationship need to be considered at a local scale in order to efficiently guide control program keywords bednets control environment epidemiology indoor residual spraying malaria prevention abstract background malaria risk factor at household level are known to be complex uncertain stochastic nonlinear and multidimensional the interplay among these factor make targeted intervention and resource allocation for malaria control challenging however few study have demonstrated malaria transmission complexity control and integrated modelling with no available evidence on uganda refugee settlement using the uganda malaria indicator survey umis data an alternative bayesian belief network bbn modelling approach wa used to analyse predict rank and illustrate the conceptual reasoning and complex causal relationship among the risk factor for malaria infection among child underfive in refugee settlement of uganda method in the umis household level information wa obtained using standardized questionnaire and a total of child under year were tested for malaria from the dataset a casefile containing malaria test result demographic socialeconomic and environmental information wa created the casefile wa divided into a training n and testing n datasets the training dataset wa used to develop the bbn model following well established guideline the testing dataset wa used to evaluate model performance result model accuracy wa with an area under the receiveroperating characteristic curve of the model spherical payoff wa with the logarithmic and quadratic loss of and respectively indicating a strong predictive and classification ability of the model the probability of refugee child testing positive and negative for malaria wa and respectively the top ranked malaria risk factor based on the sensitivity analysis included age of child roof material ie thatch roof wall material ie pole with mud and thatch wall whether child sleep under insecticidetreated net type of toilet facility used ie no toilet facility and pit latrine with slab walk time distance to water source between and min drinking water source ie open water source and piped water on premise conclusion ranking rather than the statistical significance of the malaria risk factor is crucial a an approach to applied research a it help stakeholder determine how to allocate resource for targeted malaria intervention within the constraint of limited funding in the refugee settlement keywords bayesian belief network child malaria ranking refugee risk factor settlement uganda abstract background village health worker vhws in uganda provide treatment for the childhood illness of malaria pneumonia and diarrhoea through the integrated community case management iccm strategy under the strategy child under five year receive treatment for these illness within h of onset of illness this study examined promptness in seeking treatment from vhws by child under five year with malaria pneumonia and diarrhoea in rural southwestern uganda method in august a database containing information from the vhws patient register over a year study period wa reviewed a total of child record drawn from village of bugoye subcounty kasese district were included in the study promptness wa defined a caregiver seeking treatment for a child from a vhw within h of onset of illness result sixtyfour percent of the child included in the study sought treatment promptly child with fever had the highest likelihood of seeking prompt treatment aor ci p a compared to those with diarrhoea aor ci p and pneumonia aor ci p conclusion the finding provide further evidence that vhws play a critical role in the treatment of childhood illness in rural context however the proportion of child seeking prompt treatment remains below the target set at the inception of the iccm strategy in uganda there is a need to continually engage rural community to promote modification of healthseeking behaviour particularly for child with danger sign evidence to inform the design of service and behaviour change communication can be provided through undertaking qualitative study to understand the underlying reason for decision about careseeking in rural setting codesign with community in these setting may increase the acceptability of these service keywords childhood illness community health worker promptness treatment abstract background the potential effect of sarscov and plasmodium falciparum coinfection on host susceptibility and pathogenesis remain unknown we aimed to establish the prevalence of malaria and describe the clinical characteristic of sarscov and p falciparum coinfection in a highburden malaria setting method this wa an exploratory prospective cohort study of patient with covid who were admitted to hospital in uganda patient of all age with a pcrconfirmed diagnosis of sarscov infection who had provided informed consent or assent were consecutively enrolled from treatment centre in eight hospital across the country and followed up until discharge or death clinical assessment and blood sampling were done at admission for all patient malaria diagnosis in all patient wa done by rapid diagnostic test microscopy and molecular method previous p falciparum exposure wa determined with serological response to a panel of p falciparum antigen assessed using a multiplex bead assay additional evaluation included complete blood count marker of inflammation and serum biochemistry the main outcome wa overall prevalence of malaria infection and malaria prevalence by age including age category of year year year and year the frequency of symptom wa compared between patient with covid with p falciparum infection versus those without p falciparum infection the frequency of comorbidities and covid clinical severity and outcome wa compared between patient with low previous exposure to p falciparum versus those with high previous exposure to p falciparum the effect of previous exposure to p falciparum on covid clinical severity and outcome wa also assessed among patient with and those without comorbidities finding of people with pcrconfirmed sarscov infection enrolled from april to oct had complete information and were included in our analysis the majority of were male individual with a median age of year iqr overall prevalence of p falciparum infection wa ci of participant with highest prevalence in the age group of year five of patient and older than year nine of patient confusion four of patient v eight of patient p and vomiting four of patient v five of patient p were more frequent among patient with p falciparum infection than those without patient with low versus those with high previous p falciparum exposure had a increased frequency of severe or critical covid clinical presentation of patient v three of patient p and a higher burden of comorbidities including diabetes of patient v two of patient p and heart disease seven of patient v zero of patient p among patient with no comorbidities those with low previous p falciparum exposure still had a higher proportion of case of severe or critical covid than did those with high p falciparum exposure six of patient v one of patient p multivariate analysis showed higher odds of unfavourable outcome in patient who were older than year adjusted or ci p interpretation although patient with covid with p falciparum coinfection had a higher frequency of confusion and vomiting coinfection did not seem deleterious the association between low previous malaria exposure and severe or critical covid and other adverse outcome will require further study these preliminary descriptive observation highlight the importance of understanding the potential clinical and therapeutic implication of overlapping coinfections funding malaria consortium usa abstract background the yield of tuberculosis tb contact tracing is historically low in uganda we determined factor associated with a positive contact tracing yield at an urban public tb clinic in kampala uganda method we reviewed contact tracing register of index tb case registered between and at kitebi health center a primary level facility contact who had symptom of tb were designated a having presumptive tb a contact investigation that yielded a new tb case wa designated a a positive yield we used logistic regression to determine factor associated with a positive yield of contact tracing result of index tb case had a contact investigation conducted index case with a telephone contact in the unit tb register adjusted odds ratio aor ci p were more likely to have a contact investigation conducted than those who did not of contact had presumptive tb of these were further evaluated for active tb and contact had active tb the contact tracing yield for active tb wa therefore the odds of a positive yield increased tenfold with each additional presumptive contact evaluated for active tb aor ci p also retreatment index tb case were more likely to yield a positive contact aor ci p than to new case conclusion tb contact tracing should aim to evaluate all contact with presumptive tb and contact of retreatment case to maximise the yield of contact tracing keywords active contact tracing presumptive tuberculosis uganda yield abstract background mycobacterium tuberculosis a bacterium that relies on it human host to achieve airborne transmission and existence is the primary cause of tuberculosis tb a disease that is vital to public health aim to update the society on tuberculosis diagnostic and treatment delay among patient in uganda material and method the review paper utilized different search engine such a pubmed central scopus web of science google scholar and so forth to conduct this review paper result delay in diagnosis could cause disease to spread throughout the community progress more quickly and increase mortality with many population experiencing tb diagnostic delay and less than a third of the population experiencing tb treatment delay the rate of tuberculosis diagnosis and treatment delay are high conclusion the delay in diagnosing and treating tuberculosis in men is positively correlated with knowledge of the disease symptom and the regular use of a handkerchief or both hand to cover the mouth and nose while coughing or sneezing keywords diagnosis patient treatment delay tuberculosis abstract background globally tuberculosis disease tb is more common among male than female recent research proposes that difference in social mixing by sex could alter infection pattern in tb we examine evidence for two mechanism by which socialmixing could increase men contact rate with tb case first men could be positioned in social network such that they contact more people or social group second preferential mixing by sex could prime men to have more exposure to tb case method we compared the network of male and female tb case and healthy matched control living in kampala uganda specifically we estimated their position in social network network distance to tb case degree betweenness and closeness and assortativity pattern mixing with adult men woman and child inside and outside the household result the observed network consisted of individual there were few difference in estimate of node position by sex we found distinct mixing pattern by sex and tb disease status including that tb case have proportionally more adult male contact and fewer contact with child conclusion this analysis used a network approach to study how social mixing pattern are associated with tb disease understanding these mechanism may have implication for designing targeted intervention strategy in highburden population keywords contact pattern malebias social network tuberculosis abstract background decentralised molecular testing for tuberculosis could reduce missed diagnosis and loss to followup in highburden setting the aim of this study wa to evaluate the cost and costeffectiveness of the xpert performance evaluation for linkage to tuberculosis care xpeltb study strategy a multicomponent strategy including decentralised molecular testing for tuberculosis in uganda method we conducted a costing and costeffectiveness analysis nested in a pragmatic clusterrandomised trial of onsite decentralised versus hubandspoke centralised testing for tuberculosis with xpert mtbrif ultra xpert in community health centre in uganda we collected empirical data on the cost of the xpeltb strategy decentralised xpert testing workflow redesign and performance feedback and routine tuberculosis testing onsite smear microscopy with specimen transport for centralised xpert testing from the health system perspective timeandmotion study were performed to estimate activitybased service cost costeffectiveness wa assessed a the incremental cost u per tuberculosis diagnosis and per day treatment initiation finding the xpeltb study ran from oct to march effectiveness and costeffectiveness outcome were assessed from dec to nov and included woman and men on a pertest basis the cost of decentralised range and centralised range xpert testing wa similar however decentralised testing resulted in more patient receiving appropriate xpert testing so the perpatient cost of decentralised testing wa higher range versus range the xpeltb strategy wa estimated to cost uncertainty range per incremental tuberculosis diagnosis and per incremental patient initiating tuberculosis treatment within day costeffectiveness wa reduced in site performing fewer than test annually interpretation the xpeltb strategy facilitated higher rate of xpert testing for tuberculosis at a similar pertest cost and modest incremental cost per tuberculosis diagnosis and treatment initiation decentralised xpert testing with appropriate implementation support should be scaled up to clinic with sufficient testing volume to support a singlemodule device funding the national heart lung and blood institute abstract background alcohol use is common among people with hiv and is a risk factor for tuberculosis disease and nonadherence to isoniazid preventive therapy ipt few intervention exist to reduce alcohol use and increase ipt adherence in subsaharan africa the aim of this study wa to test the hypothesis that financial incentive conditional on pointofcare negative urine alcohol biomarker testing and positive urine isoniazid testing would reduce alcohol use and increase isoniazid adherence respectively in people with hiv who have latent tuberculosis infection and hazardous alcohol use method we conducted an openlabel factorial randomised controlled trial in uganda eligible for the study were nonpregnant hivpositive adult aged year prescribed antiretroviral therapy for at least month with current heavy alcohol use confirmed by urine ethyl glucuronide biomarker of recent alcohol use and a positive alcohol use disorder identification testconsumption auditc for woman for men for the past month drinking no history of active tuberculosis tuberculosis treatment or tuberculosis preventive therapy and a positive tuberculin skin test we randomly assigned participant initiating month of ipt to no incentive group or incentive for recent alcohol abstinence group isoniazid adherence group or both group escalating incentive were contingent on monthly pointofcare urine test negative for ethyl glucuronide group and or positive on isoscreen biomarker of recent isoniazid use group and the primary alcohol outcome wa nonhazardous use by selfreport auditc for woman for men and phosphatidylethanol peth pastmonth alcohol biomarker ngml at month and month the primary isoniazid adherence outcome wa more than bottle opening of day prescribed we performed intentiontotreat analysis this trial is registered with clinicaltrialsgov nct and is complete finding from april to aug people were screened of whom were randomly assigned to group to group to group and to group the median age of participant wa year iqr were male of had hiv rna viral load of less than copy per ml median auditc score wa iqr and median peth wa ngml iqr among participant who completed the trial with alcohol use endpoint measure group group group group nonhazardous alcohol use wa more likely in the group with incentive for alcohol abstinence group and versus no alcohol incentive group and of versus of respectively adjusted risk difference ard ci to p among participant who completed the trial with isoniazid adherence endpoint measure group group group group incentive for isoniazid adherence did not increase adherence of in the isoniazid incentive group group and versus of in the no isoniazid incentive group group and ard ci to p overall of participant discontinued isoniazid due to grade or higher adverse event there wa no significant association between randomisation group and hepatotoxicity resulting in isoniazid discontinuation after adjusting for sex and site interpretation escalating financial incentive contingent on recent alcohol abstinence led to significantly lower biomarkerconfirmed alcohol use versus control but incentive for recent isoniazid adherence did not lead to change in adherence the alcohol intervention wa efficacious despite less intensive frequency of incentive and clinic visit than traditional programme for substance use suggesting that pragmatic modification of contingency management for resourcelimited setting can have efficacy and that further evaluation of implementation is merited funding national institute on alcohol abuse and alcoholism translation for the runyankole translation of the abstract see supplementary material section abstract background bcg vaccine are given to more than million child every year but there is considerable debate regarding the effectiveness of bcg vaccination in preventing tuberculosis and death particularly among older child and adult we therefore aimed to investigate the agespecific impact of infant bcg vaccination on tuberculosis pulmonary and extrapulmonary development and mortality method in this systematic review and individual participant data metaanalysis we searched medline web of science biosis and embase without language restriction for casecontact cohort study of tuberculosis contact published between jan and april search term included mycobacterium tuberculosis tb tuberculosis and contact we excluded cohort study that did not provide information on bcg vaccination or were done in country that did not recommend bcg vaccination at birth individuallevel participant data for a prespecified list of variable including the characteristic of the exposed participant contact the index case and the environment were requested from author of all eligible study our primary outcome wa a composite of prevalent diagnosed at or within day of baseline and incident diagnosed more than day after baseline tuberculosis in contact exposed to tuberculosis secondary outcome were pulmonary tuberculosis extrapulmonary tuberculosis and mortality we derived adjusted odds ratio aors using mixedeffects binary multivariable logistic regression analysis with studylevel random effect adjusting for the variable of interest baseline age sex previous tuberculosis and whether data were collected prospectively or retrospectively we stratified our result by contact age and mycobacterium tuberculosis infection status this study is registered with prospero crd finding we identified original record from our database search we included participantlevel data from cohort study done in country in our metaanalysis among participant developed tuberculosis of bcgvaccinated participant v of unvaccinated participant the overall effectiveness of bcg vaccination against all tuberculosis wa aor ci when stratified by age bcg vaccination only significantly protected against all tuberculosis in child younger than year aor ci among contact with a positive tuberculin skin test or ifn release assay bcg vaccination significantly protected against tuberculosis among all participant aor ci participant younger than year and participant aged year there wa no protective effect among those with negative test unless they were younger than year cohort reported on whether tuberculosis wa pulmonary or extrapulmonary n bcg vaccination significantly protected against pulmonary tuberculosis among all participant in vaccinated participant v in unvaccinated participant aor but not against extrapulmonary tuberculosis in vaccinated participant v in unvaccinated participant in the four study with mortality data bcg vaccination wa significantly protective against death interpretation our result suggest that bcg vaccination at birth is effective at preventing tuberculosis in young child but is ineffective in adolescent and adult immunoprotection therefore need to be boosted in older population funding national institute of health abstract introduction the involvement of private hospital in tuberculosis care in uganda is still limited there is a lack of literature about the barrier and motivator to private hospital engagement in tuberculosis care in uganda objective to explore the barrier to and motivator of private hospital engagement in tuberculosis care method the study employed a qualitative study design that utilized indepth interview with private healthcare worker purposively selected in june due to their active involvement in tuberculosis care from four urban private hospital in mbarara municipality an inductive content analytic approach framed by the consolidated framework for implementation research wa used for analysis the interview were transcribed and coded to identify key theme using content analysis result focusing through the consolidated framework for implementation research barrier to private hospital engagement were related to cost external policy and incentive structure characteristic network and communication and knowledge and belief about the intervention these include concern regarding the payment of care by patient indirect incomegenerating nature of tuberculosis management lack of drug register and diagnostic tool lack of accreditation from the ugandan limited space for keeping tuberculosis patient lack of proper followup mechanism lack of training and qualified human resource and delayed seeking of health care by the patient perceived high quality of care in the private hospital privacy and confidentiality concern proximity of private hospital to patient and formalization of partnership between private hospital and the government were the motivator that arose from the three construct relative advantage patient need and resource and engaging conclusion the engagement of private hospital in tuberculosis care requires commitment from key stakeholder supplemented with the organizational shared belief towards this change there is a need for ensuring mechanism for lessening these barrier to ensure full engagement of private hospital in tuberculosis care keywords implementation framework public private mix tuberculosis challenge enablers abstract background in the tuberculosis molecular bacterial load assay tbmbla a ribosomal rnabased test wa acknowledged by who a a molecular assay that could replace smear microscopy and culture for monitoring tuberculosis treatment response in this study we evaluated the accuracy of tbmbla for diagnosis and monitoring of treatment response in comparison with standardofcare test method for this longitudinal prospective study patient aged year or older with presumptive tuberculosis coughing for at least week night sweat and weight loss were enrolled at chinauganda friendship hospital naguru kampala uganda participant were evaluated for tuberculosis by tbmbla in comparison with xpert mtbrif ultra xpertultra and smear microscopy with mycobacteria growth indicator tube mgit culture a a reference test participant who were positive on xpertultra were enrolled on a standard month antituberculosis regimen and monitored for treatment response at week and after initiation of treatment and then month after treatment finding between nov and june participant median age year iqr were enrolled participant were male and were hiv positive the pretreatment diagnostic sensitivity of tbmbla and xpertultra were similar both ci but the specificity wa higher for tbmbla than for xpertultra ten participant were xpertultra trace positive eight of whom were negative by tbmbla and mgit culture smear microscopy had lower diagnostic sensitivity but higher specificity than tbmbla and xpertultra among participant who were smear microscopy negative the sensitivity of tbmbla wa ci and wa ci in those who were hiv positive participant were identified a tuberculosis positive by xpertultra and these individual were enrolled in the treatment group and monitored for treatment response according to tbmbla of these patient cleared bacillary load to zero by week of treatment and remained negative throughout the month treatment followup positivity for tuberculosis decreased with treatment a measured by all test but the rate wa slower with xpertultra consequently of participant were still xpertultra positive at the end of treatment but were clinically well and negative on tbmbla and culture at month of treatment two patient were still xpertultra positive with a further month of posttreatment followup the rate of conversion to negative of the dnabased xpertultra wa time slower than that of the rrnabased tbmbla consequently for the same patient it would take week and week to reach complete tuberculosis negativity by tbmbla and xpertultra respectively participant who were positive on smear microscopy at week who received an extra month of intensive treatment had a similar tbmblameasured bacillary load at week to those who were smear microscopy negative interpretation tbmbla ha a similar performance to xpertultra for pretreatment diagnosis of tuberculosis but is more accurate at detecting and characterising the response to treatment than xpertultra and standardofcare smear microscopy funding european and developing country clinical trial partnership makerere university research and innovation fund u national institute of health abstract background globally displaced population face an increased burden of tuberculosis tb uganda is currently hosting unprecedented big number of refugee from the east african region recent evidence show increased spread of multidrug resistant tb mdrtb across east africa a a result of migrant from somalia a high mdrtb prevalent country calling for urgent identification and management of case for the country in the region one of the strategy recommended is optimization of diagnosis treatment and prevention of tb in refugee this study aimed at exploring the barrier to and facilitator for tb case finding and retention in care among urban slum refugee and suggestion on how to improve this wa to guide the development of intervention to improve tb case finding and retention in care among the said population method a crosssectional study utilizing qualitative method wa conducted among refugee in an urban slum in kampala city uganda key informant interview with health care worker and community leader and indepths interview with refugee tb patient and care taker of tb patient were conducted interview in total interview question were based on construct from the combb model capability opportunity and motivation model of behaviour change manual content analysis wa performed and identified targeted intervention strategy guided by the related behavior change wheel implementation framework result key barrier included physical capability availability of and easily accessible private facility in the community with no capacity to diagnose and treat tb psychological capability lack of knowledge about tb among refugee social opportunity wide spread tb stigma and language barrier physical opportunity poor living condition mobility of refugee reflective motivation lack of facilitation for health worker automatic motivation discrimination and rejection of tb patient facilitator were physical capability availability of free tb service in the public health facility social opportunity availability of translator we identified education incentivization training enablement and restructuring of the service environment a relevant intervention function with potential to address barrier to and enhance facilitator of tb case finding and retention among refugee in urban slum conclusion the key barrier to tb control among refugee living urban slum in kampala uganda included poor access to health service limited knowledge about tb tb stigma language barrier and lack of facilitation of community health worker identified intervention strategy included education training enablement environmental restructuring and persuasion the finding could serve a a guide for the design and implementation of intervention for improving the same keywords behaviour change wheel comb model refugee tb case finding and retention in care abstract background the occurrence of chronic pulmonary aspergillosis cpa among drug sensitive pulmonary tuberculosis ptb patient on optimal therapy with persistent symptom wa investigated method we consecutively enrolled participant with ptb with persistent pulmonary symptom after month of antitb treatment at mulago hospital kampala uganda between july and june cpa wa defined a a positive aspergillusspecific iggigm immunochromatographic test ict a cavity with or without a fungal ball on chest xray cxr and compatible symptom month result we enrolled participant median age year iqr were male were hivinfected and had prior ptb thirtyeight sputum sample grew a niger and a fumigatus specie complex six participant had intracavitary fungal ball and had cavity overall participant had cpa cpa wa associated with prior ptb adjusted odds ratio aor ci p and far advanced cxr change aor ci p the aspergillus iggigm ict wa positive in participant with cpa conclusion chronic pulmonary aspergillosis may cause persistent respiratory symptom in up to onefifth of patient after intensive treatment for ptb the aspergillus iggigm ict positivity rate wa very low and may not be used alone for the diagnosis of cpa in uganda keywords uganda chronic pulmonary aspergillosis persistent symptom pulmonary tuberculosis abstract background people with bacteriologically confirmed pulmonary tuberculosis require sputum smear monitoring at and month to establish treatment outcome however there is limited information about sputum smear monitoring in uganda similar to other developing country we examined factor associated with complete sputum smear monitoring among person with bacteriologically confirmed pulmonary tb aged year in central uganda method we retrospectively reviewed and abstracted data for person with bacteriologically confirmed pulmonary tb initiated on treatment between january and december across large tb unit in masaka district in central uganda complete sputum smear monitoring wa measured a the receipt of three sputum smear microscopy test at and month of tb treatment the data were summarized descriptively and the difference in the outcome with independent variable were examined using test of statistical significance namely the chisquare or fisher exact test and the student ttest the factor independently associated with the outcome were established using the modified poisson regression analysis with robust standard error reported a adjusted risk ratio arr along with the confidence interval ci result a total of participant were enrolled with a mean age of year of the participant were male were rural resident and had complete sputum smear monitoring urban residence arr ci and treatment under the communitybased directly observed therapy shortcourse strategy dot arr ci were associated with a higher likelihood of complete sputum smear monitoring while tb and human immunodeficiency virus tbhiv comorbidity arr ci wa associated with a lower likelihood of complete sputum smear monitoring conclusion we found a low magnitude of complete sputum smear monitoring among person with bacteriologically confirmed pulmonary tb aged year in central uganda strategy to enhance the performance of sputum smear monitoring should target rural health facility strengthen tbhiv collaboration and the implementation of communitybased dot keywords bacteriologically confirmed pulmonary tuberculosis smearpositive tuberculosis sputum smear monitoring uganda abstract background before the use of parallel tuberculosis tb reporting system wa resource intensive with duplication of effort and hence the need to select one that contributed to better tb case notification at the national tb and leprosy program nltp in uganda we sought to analyse the difference in reporting rate between the two system in order to improve ntlp tb case notification rate logistics management and planning for better health service delivery initiative method we conducted a comparative study to assess tb case notification between the webbased dhis and the district tb supervisorled health management information system between january to december we used poisson regression analysis to assess the statistical difference in reporting rate between the two reporting system result the association between tb case notification and the type of reporting system wa statistically significant prob chi the incident rate ratio irr for the webenabled dhis system versus the district tb supervisorled health management information system wa conclusion the webbased integrated dhis system wa more effective in reporting missing tb case it present an opportunity for better planning and allocation of resource for improved service delivery in a lowincome setting keywords dhis uganda case notification tuberculosis webbased reporting abstract background tuberculosistb is among the leading cause of infectious death worldwide contact investigation is an evidencebased world health organisationendorsed intervention for timely tb diagnosis treatment and prevention but ha not been widely and effectively implemented method we are conducting a steppedwedge clusterrandomised hybrid type iii implementationeffectiveness trial comparing a usercentred to a standard strategy for implementing tb contact investigation in healthcare facility in uganda the usercentred strategy consists of several clientfocused component including a tbeducation booklet a contactidentification algorithm an instructional sputumcollection video and a communityhealthrider service to transport client chws and sputum sample along with several healthcareworkerfocused component including collaborative improvement meeting regular auditandfeedback report and a digital groupchat application designed to develop a community of practice site will crossover from the standard to the usercentred strategy in six eightweek transition step following a randomly determined sitepairing scheme and timeline the primary implementation outcome is the proportion of symptomatic close contact completing tb evaluation within day of tb treatment initiation by the index person with tb the primary clinical effectiveness outcome are the proportion of contact diagnosed with and initiating active tb disease treatment and the proportion initiating tb preventative therapy within day we will assess outcome from routine source document using intentiontotreat analysis we will also conduct nested mixedmethods study of implementation fidelity and context and perform costeffectiveness and impact modelling the makerere school of public health irb the uganda national council for science and technologyhses and the yale institutional review board approved the study and waived informed consent for the main trial implementationeffectiveness outcome we will submit result for publication in peerreviewed journal and disseminate finding to local policymakers and representative of affected community discussion this pragmatic quasiexperimental implementation trial will inform effort to find and prevent undiagnosed person with tb in highburden setting using contact investigation it will also help assess the suitability of humancentred design and community of practice for tailoring implementation strategy and sustaining evidencebased intervention in lowandmiddleincome country trial registration the trial wa registeredclinicaltrialsgov identifier nct on november after the trial launch on march keywords contact investigation implementation science steppedwedge trial tuberculosis uganda abstract background the high casefatality rate among child with tuberculosis tb are reportedly driven by inhospital mortality and severe form of tb therefore there is need to better understand the predictor of mortality among child hospitalised with tb we examined the patient clinical profile length of hospital stay from date of admission to date of final admission outcome and predictor of mortality among child hospitalised with tb at two tertiary hospital in uganda method we conducted a caseseries study of child below year of age hospitalised with tb from january st to december st convenience sampling wa done to select tb case from paperbased medical record at mulago national referral hospital mnrh in urban kampala and fort portal regional referral hospital frrh in rural fort portal we fitted linear and logistic regression model with length of stay and inhospital mortality a key outcome result out of the child hospitalised with tb were at frrh and at mnrh the male to female ratio wa with median age of year interquartile rangeiqr there wa a high prevalence of hiv severe malnutrition reported a weightforage zscore sd among child with pulmonary tb who initiated antituberculosis therapy att either during hospitalisation or within seven day prior to hospitalisation cough fever and dyspnoea were common symptom child with tb meningitis commonly presented with fever convulsion and cough the median length of hospital stay wa day iqr of the child with known inhospital outcome died during hospitalisation tb meningitis wa associated with inhospital mortality aor ci p while male sex wa associated with reduced mortality aor ci p hospitalisation in the urban hospital predicted a day increase in natural logtransformed length of hospital stay lnlength of stay ci p but not age sex hiv malnutrition or tb meningitis conclusion inhospital mortality wa high and significantly driven almost four time higher by tb meningitis with longer hospital stay among child in urban hospital the high inhospital mortality and long hospital stay may be reduced by timely tb diagnosis and treatment initiation among child abstract objective this sequential prospective metaanalysis sought to identify risk factor among pregnant and postpartum woman with covid for adverse outcome related to disease severity maternal morbidity neonatal mortality and morbidity and adverse birth outcome data source we prospectively invited study investigator to join the sequential prospective metaanalysis via professional research network beginning in march study eligibility criterion eligible study included those recruiting at least consecutive case of covid in pregnancy within a defined catchment area method we included individual patient data from participating study data quality wa assessed and harmonized variable for risk factor and outcome were constructed duplicate case were removed pooled estimate for the absolute and relative risk of adverse outcome comparing those with and without each risk factor were generated using a stage metaanalysis result we collected data from country and territory including case of sarscov infection in pregnancy or postpartum we found that woman with comorbidities preexisting diabetes mellitus hypertension cardiovascular disease v those without were at higher risk for covid severity and adverse pregnancy outcome fetal death preterm birth low birthweight participant with covid and hiv were time confidence interval more likely to be admitted to the intensive care unit pregnant woman who were underweight before pregnancy were at higher risk of intensive care unit admission relative risk confidence interval ventilation relative risk confidence interval and pregnancyrelated death relative risk confidence interval prepregnancy obesity wa also a risk factor for severe covid outcome including intensive care unit admission relative risk confidence interval ventilation relative risk confidence interval any critical care relative risk confidence interval and pneumonia relative risk confidence interval anemic pregnant woman with covid also had increased risk of intensive care unit admission relative risk confidence interval and death relative risk confidence interval conclusion we found that pregnant woman with comorbidities including diabetes mellitus hypertension and cardiovascular disease were at increased risk for severe covidrelated outcome maternal morbidity and adverse birth outcome we also identified several less commonly known risk factor including hiv infection prepregnancy underweight and anemia although pregnant woman are already considered a highrisk population special priority for prevention and treatment should be given to pregnant woman with these additional risk factor keywords covid sarscov maternal mortality neonatal mortality pneumonia pregnancy preterm birth smallforgestationalage abstract background despite being a priority population for covid vaccination limited data are available regarding acceptability of covid vaccine among people living with hiv plwh in subsaharan africa we described covid vaccine acceptability and factor associated with vaccine acceptability among plwh in uganda method this wa a crosssectional study conducted among plwh aged year enrolled participant who were seeking hiv care from six purposely selected accredited art clinic in kampala we obtained data on vaccine acceptability defined a willingness to accept any of the available covid vaccine using intervieweradministered questionnaire in addition we assessed vaccination status complacency regarding covid disease vaccine confidence and vaccine convenience factor associated with covid vaccine acceptability were evaluated using modified poisson regression with robust standard error result we enrolled participant of whom were woman the median age wa year interquartile range iqr for woman and year iqr for men of the respondent confidence interval ci reported receiving at least one vaccine dose with woman significantly more likely than men to have been vaccinated v p among the unvaccinated ci were willing to accept vaccination had greater vaccine confidence had strong belief that the vaccine were effective that they were beneficial and safe for plwh had trust in health care professional or top government official and believed that it would be easy to obtain a vaccine if one decided to be vaccinated vaccine acceptability wa positively associated with greater vaccine confidence adjusted prevalence ratio apr ci and positive perception that it would be easy to obtain a vaccine apr ci conclusion vaccine acceptance wa high among this cohort of plwh and wa positively associated with greater vaccine confidence and perceived easiness convince to obtained the vaccine building vaccine confidence and making vaccine easily accessible should be a priority for vaccination program targeting plwh abstract background quarantine ha been adopted a a key public health measure to support the control of the coronavirus disease covid pandemic in many country uganda adopted institutional quarantine for individual suspected of exposure to severe acute respiratory syndrome coronavirus sarscov to be placed in institution like hotel andor hostel of institution for at least day this study explored experience of individual who underwent institutional quarantine in uganda to inform measure to increase it effectiveness and reduce it associated negative impact method we conducted a qualitative description study using indepth interview with purposively selected individual who had spent time in institutional quarantine facility these were mainly phonebased interview that were audio recorded and transcribed verbatim electronic data coding wa conducted using atlasti software thematic content analysis wa used to synthesize the finding with similar code grouped to form subthemes and ultimately study theme the finding are presented thematically with typical participant quote result study participant spent between to day in institutional quarantine four theme emerged describing the experience of study participant during institutional quarantine which determined whether participant experience were positive or negative these theme were quarantine environment including facility related factor and compliance with covid measure quarantine management factor of entity paying the cost communication and day spent in quarantine individual factor comprising attitude towards quarantine fear during and postquarantine and coping mechanism and linkage to other service such a health care and postquarantine followup conclusion the planning management and implementation of the quarantine process is a key determinant of the experience of individual who undergo the measure to improve the experience of quarantined individual and reduce it associated negative impact the prequarantine process should be managed to comply with standard quarantined person should be provided a much information a possible their quarantine duration should kept short and cost of the process ought to be minimised furthermore quarantine facility should be assessed for suitability and monitored to comply with guideline while avenue for access to healthcare for the quarantined need to be arranged and any potential stigma associated with quarantine thoroughly addressed keywords covid challenge coping experience institutional quarantine sarscov abstract background despite the discovery of vaccine the control and prevention of coronavirus disease covid relied on nonpharmaceutical intervention npis this article describes the development and application of the public health act to implement npis for covid pandemic control in uganda method this is a case study of uganda experience with enacting covid rule under the public health act cap the study assessed how and what rule were developed their influence on the outbreak progress and litigation the data source reviewed were applicable law and policy presidential speech cabinet resolution statutory instrument covid situation report and the registry of court case that contributed to a triangulated analysis result uganda applied four covid broad rule for the period march to october the minister of health enacted the rule which response team enforcement agency and the general population followed the presidential speech their expiry period and progress of the pandemic curve led to amendment of the rule twenty one time the uganda people defense force act no of the public finance management act no of and the national policy for disaster preparedness and management supplemented the enacted covid rule however these rule attracted specific litigation due to perceived infringement on certain human right provision conclusion country can enact supportive legislation within the course of an outbreak the balance of enforcing public health intervention and human right infringement is an important consideration in future we recommend public sensitization about legislative provision and reform to guide public health response in future outbreak or pandemic keywords covid nonpharmaceutical intervention pandemic public health law rule uganda abstract background between march and december due to cholera and coronavirus disease covid pandemic there were cholera case with death and covid case with death reported respectively in uganda this study investigated mass vaccination campaign for the prevention of the two pandemic namely oral cholera vaccine ocv and covid vaccine coverage adverse event following immunization aefi barrier and enablers for the vaccine uptake and assessed water sanitation and hygiene wash condition in the six cholera and covid hotspot district of uganda method a household survey wa conducted between january and february in the six cholera hotspot district of uganda which had recently conducted ocv mass vaccination campaign and had ongoing covid mass vaccination campaign the survey randomly enrolled household with person of whom were above year data were collected using a data entry application designed in kobotoolbox and analysed using stata version frequency percentage odds ratio mean confidence interval and map were generated and interpreted result the ocv coverage for dose one and two were ci and ci respectively among the ocv recipient reported mild aefi reported moderate aefi and none reported severe aefi the covid vaccination coverage for dose one and two were ci and ci respectively approximately of covid vaccine recipient reported aefi most were mild were moderate and case were severe the commonest reason for missing covid vaccine wa fear of the side effect for most district sanitation latrinetoilet coverage were low at conclusion there is high ocv coverage but low covid vaccine and sanitation coverage with high number of moderate case of aefi recorded due to covid vaccine the low covid vaccine coverage could indicate vaccine hesitancy for covid vaccine furthermore incorporation of wash condition assessment in the ocv coverage survey is recommended for similar setting to generate data for better planning however more study are required on covid vaccine hesitancy keywords adverse event following immunization africa covid cholera coronavirus pandemic sanitation uganda vaccine coverage vaccine hesitancy wash water coverage abstract objective to evaluate the impact of the coronavirus disease covid pandemic on the disease course life and psychosocial wellbeing of person with epilepsy pwe in uganda method from april till may we carried out a descriptive crosssectional study at four hospital located in four region of uganda pwe presenting at the study site were offered a structured questionnaire in the local language we used the phq questionnaire to screen for depression and the gad to screen for anxiety univariate and multivariable logistic regression wa used to investigate factor associated with anxiety and depression result a total of response were collected the median age of the respondent wa year iqr and were male during the lockdown period the seizure frequency increased in pwe various form of physical and psychological violence were inflicted upon pwe fiftyeight screened positive for anxiety and positive for depression both increased seizure frequency and experienced violence were associated with experiencing depression and anxiety conclusion the covid pandemic and lockdown impacted seizure frequency and the psychosocial wellbeing of pwe in uganda increased seizure frequency wa associated with higher rate of anxiety and depression this underline the importance of continued followup of pwe and a low threshold to screen for depression anxiety and domestic violence keywords anxiety covid depression epilepsy lockdown uganda abstract background identifying preventable cause of covid death is key to reducing mortality we investigated possible preventable cause of covid death over a sixmonth period in uganda method a casepatient wa a person testing reverse transcription polymerase chain reactionpositive for sarscov who died in kampala metropolitan area hospital from august to february we reviewed record and interviewed health worker and casepatient caretaker result we investigated of reported covid death during the investigation period were male and the median age wa year a total of had underlying medical condition most had advanced disease at admission to the hospital where they died a total of did not receive a covid test at their first presentation to a health facility despite having consistent symptom a total of needed intensive care unit admission of whom received it needed mechanical ventilation of whom received it conclusion among hospitalized patient with covid who died in this investigation early opportunity for diagnosis were frequently missed and there wa inadequate intensive care unit capacity emphasis is needed on covid a a differential diagnosis early testing and careseeking at specialized facility before the illness reach a critical stage increased capacity for intensive care is needed keywords covid coronavirus disease death pandemic uganda abstract background violence towards hiv positive men is one of the silent barrier to utilization of hiv care service hiv positive men are potential victim of violence from other people including woman and violence may interfere with treatment outcome this study determined the prevalence of violence towards hiv positive men in rural community of southwestern uganda method a crosssectional study wa conducted among hiv positive men at selected health center using an interviewer administered questionnaire data were analyzed in spss version using chisquare and multivariate regression at level of significance and a precision of result of the participant had experienced violence of these n had experienced kicking or slapping while reported sexual violence factor associated with violence were using alcohol and drug aor ci p knowledge of support structure or ci p and owning land for farming aor ci p conclusion the prevalence of violence at is quite high especially since violence against men is rarely talked about this should not be ignored there should be strategy to support this vulnerable group keywords hiv positive men uganda prevalence rural community violence abstract background interaction between substance use violence hiv and aid known a the sava syndemic are understudied among refugee youth we assessed the synergistic effect of frequent alcohol use depression and violence on hiv vulnerability among urban refugee youth aged year in kampala uganda method we conducted a crosssectional survey between january and april with a convenience sample of refugee youth aged year living in informal settlement in kampala kabalagala rubaga kansanga katwe nsambya we assessed noncommunicable health condition frequent time per week alcohol use fau depression violence young adulthood violence yav at age year intimate partner violence ipv and hiv vulnerability past month transactional sex recent past month multiple sex partner we calculated the prevalence and cooccurrence of noncommunicable health condition violence and hiv vulnerability variable we then conducted multivariable logistic regression analysis to first create unique profile of fau depression yav and ipv exposure and second to assess for interaction between exposure on hiv vulnerability outcome result most participant n mean age sd woman n men n reported at least one noncommunicable health condition or violence exposure n and over half n reported cooccurring exposure onefifth reported fau n and onetenth n major depression in logistic regression model including all twoway product term adjusted for sociodemographics we found a multiplicative interaction for joint effect of fau and ipv adjusted or aor ci to on multiple sex partner and b multiplicative interaction for joint effect of fau and ipv aor ci to and yav and depression aor ci to on transactional sex conclusion finding signal the importance of addressing the sava syndemic among urban refugee youth in uganda synergistic interaction indicate that addressing fau depression or violence may concomitantly reduce hiv vulnerability with urban refugee youth keywords child health communitybased survey hiv mental health psychiatry abstract background globally hivaids continues to rise among adolescent ugandan study have examined knowledge and attitude regarding hivaids among adult population this study specifically paid attention to this particular age group of adolescent year aim to explore hiv knowledge and attitude among adolescent attending secondary school mbarara uganda method a qualitative descriptive study wa conducted in three secondary school in south western uganda forty eight adolescent with age range between year were purposively recruited in the study data were collected from six focus group and analyzed thematically ethical approval received from must and unsct s review committee result four theme emerged knowledge about hiv source of information attitude towards person with hiv and prevention strategy most adolescent had the basic knowledge of hiv from multiple source like social medium health worker peer and parent their attitude toward individual with hiv included compassion shock and uneasiness participant suggested prevention program to be implemented in the school emphasizing hiv education life skill sex education and the formation of peer group conclusion the finding showed that most participant had knowledge about hiv and how it can be prevented however few had knowledge gap thinking that hiv doe not exist keywords adolescent hivaids attitude knowledge prevention abstract background young people year bear the highest burden of new infection and are particularly vulnerable because of their highly risky behavior such a early sexual activity there is paucity of information on the role of religious leader in the multisectoral fight against hivaids we examined the role of religious leader in the use of hiv prevention strategy among young people method a cross sectional study wa conducted between march and april among randomly selected young people in lira district uganda an interviewer administered a questionnaire to the young people in order to collect quantitative data a total key informant were purposively sampled and interview were conducted with religious leader using a key informant interview guide data wa collected on social demographic hiv prevention message and awareness about hiv prevention strategy data wa analyzed using stata version using proportion mean percentage frequency and logistic regression analysis at a level of significance qualitative data wa analyzed using thematic content analysis and the major theme were generated from the participant response result about of the respondent were female the prevalence of use of hiv prevention strategy among young people wa factor significantly associated with the use of hiv prevention included completing the primary level aor p completing at least a level aor p awareness of hiv prevention strategy advocated for by religious leader aor p religious leader provided targeted hiv prevention message aor p advocacy for abstinence outside marriage and fidelity in marriage aor p religious leader preaching about hiv prevention aor p qualitative data indicated that a section of religious leader recommended abstinencefaithfulness condom use wa the most discouraged hiv prevention strategy however most religious leader agree with the fact that they have a role to play in hiv prevention which includes sensitization teaching and organizing sermon about hiv prevention conclusion the use of hiv prevention strategy advocated for by religious leader among young people wa nearly this finding indicates that religious leader have a role to play in hivaids prevention among young people in the lira district this call for the involvement of religious leader in hiv prevention program tailored to prevent new infection of hiv among young people abstract background the prevalence of hypertension is increasing among people living with hivaids plwha in low and middleincome country lmics however knowledge of the complication and management of hypertension among plwha in uganda remains low we explored the acceptability of implementing hypertension htn specific health education by community health worker chws among plwha in rural uganda method we conducted a qualitative study consisting of indepth interview plwhahtn and chws focus group discussion fgds with plwhahtn and with chws from nakaseke district uganda participant were interviewed after a single session interaction with the chw data were transcribed from luganda local language into english and analyzed using thematic analysis we used sekhons model of acceptability of health intervention to explore participant perception result participant believed chws utilized easytounderstand colloquial nontechnical language during education delivery had a preexisting rapport with the chws that aided faster communication and had more time to explain illness than medical doctor had participant found the educational material pocketdoktor to be simple and easy to understand and perceived that the education would lead to improved health outcome participant stated their health wa a priority and sought further diseasespecific information we also found that chws were highly motivated to carry out the patientcentered education while delivering the education chws experienced difficulty in keeping up with the technical detail regarding hypertension in the pocketdoktor financial stress and patient question beyond their selfperceived skill level and experience plwhahtn had challenge accessing the health facility where the intervention wa delivered and preferred a household setting conclusion hypertension patientcentered education delivered by chws using the pocketdoktor wa acceptable to plwha and hypertension in nakaseke area in rural uganda there is need for further study to determine the cost implication of delivering this intervention among plwha across lmic setting keywords acceptability hypertension plwha patient education pocketdoktor abstract background although school have been identified a significant setting in the response to the hivaids pandemic limited research is available on how they can accommodate youth living with hivaids ylwha especially in resource limited country in this study we explored strategy by school stakeholder school staff parentscaretakers and student in western uganda to care for and support ylwha in their school method the article utilizes data collected between may and october from a qualitative inquiry based on focus group discussion and interview with school stakeholder purposively selected from secondary school in western uganda textual data wa analyzed thematically involving both inductive and deductive coding result we identified overarching interrelated theme in which participant reported strategy to care for and support ylwha counselling and guidance social support network and linkage knowledge and skill antistigma and antidiscrimination measure disclosure of hiv status treatment and management of hivaids and affirmative action for ylwha stakeholder strategy often differed regarding what wa considered appropriate the approach and who to take lead in supporting ylwha conclusion despite the limited care and support strategy specific for ylwha currently available in school our study point to optimism and high potential given stakeholder identified avenue for improvement we posit that promoting hivaidscare and support in school is a gradual process requiring each school to develop a strong knowledge base about hivaids and support need of ylwha develop a coherent and schoolwide approach and collaborate extensively with external stakeholder who are significant in supporting ylwha keywords hivaids hivaidscompetence qualitative social support youth abstract background who revised their hiv drug resistance hivdr monitoring strategy in enabling country to generate nationally representative hivdr prevalence estimate from survey conducted using this methodology in we adopted this strategy in uganda and conducted an hivdr survey among adult initiating or reinitiating art method a crosssectional survey of adult aged year initiating or reinitiating art wa conducted at site using a twostage cluster design sampling method participant provided written informed consent prior to enrolment whole blood collected in edta vacutainer tube wa used for preparation of dried blood spot db specimen or plasma sample were shipped from the site to the central public health laboratory cphl for temporary storage before transfer to the uganda virus research institute uvri for genotyping prevalence of hivdr among adult initiating or reinitiating art wa determined result specimen from participant median age year and female were collected between august and december specimen from participant were successfully genotyped fortynine had drug resistance mutation yielding an overall weighted hivdr prevalence of with the highest noted for nnrti at conclusion we observed a high hivdr prevalence for nnrti among adult prior to initiating or reinitiating art in uganda this is above who recommended threshold of when country should consider changing from nnrti to dolutegravirbased firstline regimen this recommendation wa adopted in the revised ugandan art guideline dolutegravircontaining art regimen are preferred for first and secondline art regimen abstract background we evaluated the efficacy of a community health worker chwled intervention in supporting disclosure among adult living with hiv in heterosexual relationship method we conducted a quasiexperimental study with arm allocated by geographically determined cluster and adjusted for betweengroup difference among adult living with hiv in the greater luwero region of uganda who had never disclosed their status to their current primary sexual partner cluster were allocated to either a chwled intervention or a control arm in both arm participant were consecutively recruited a opposed to receiving routine care for the control arm participant in the intervention arm received additional chw disclosure support the overall followup wa month and the primary outcome wa disclosure to the sexual partner data were analyzed using a clustered modified poisson regression model with robust standard error to determine independent factor associated with disclosure result of the participant who enrolled completed the study and of those were in the intervention arm the median age wa interquartile range year the majority were woman and most did not know their partner hiv status at study entry at the end of followup the overall disclosure prevalence wa confidence interval ci and participant in the intervention arm were more likely to disclose compared to those in the control adjusted relative ratio arr ci men were arr ci more likely to disclose compared to woman and membership in an hivaids association increased disclosure by arr ci conclusion chw support improved disclosure among adult living with hiv in heterosexual relationship when compared to routine care therefore chwled mechanism may be utilized in increasing disclosure among adult living with hiv in heterosexual relationship in rural setting abstract introduction with effective antiretroviral therapy art many person living with hiv plhiv live to old age caring for aged plhiv necessitates the engagement of caregiver and patient to establish agreedupon goal of treatment however there is limited literature on friendly and centered model of care for elderly plhiv we explored strategy to improve care in hiv clinic among plhiv aged year and above in uganda method we conducted indepth interview in two hospital with elderly plhiv aged year and above who had lived with hiv for more than ten year we explored strategy for improving care of elderly plhiv at both health facility and community level the indepth interview were audiorecorded and transcribed verbatim the thematic approach guided data analysis result the elderly plhiv suggested the following strategy to improve their care creating geriatric clinic increasing screening test for noncommunicable disease in the art clinic community and homebased art delivery workshop at health facility to provide health education on aging effectively creating community support group financial assistance for the elderly plhiv and advance in science conclusion there is need to improve community hiv care especially for the elderly and social and economic support in the community involving the elderly plhiv in developing strategy to improve their health go a long way to improve the patient quality of care there is a need to incorporate the raised strategy in hiv care or older adult keywords elderly plhiv improved care strategy uganda
tuberculosis treatment both inactive tuberculosis tb also called latent tb infection and active tb disease can be treatednit is important to take and finish all tb medicine exactly a your health care provider recommendsncompleting treatment for inactive tb and active tb disease can protect yourself your family and friend and your communitynnot everyone infected with tb germ becomessick a a result two tbrelated condition existinactive tbandactive tb disease both inactive tb and active tb disease can be treatedneven though you may not feel sick inactive tb can develop into active tb disease at any time and make you sick if you haveinactive tbtreating itis the best way to protect you from getting sick with active tb diseasenif you haveactive tb disease you can betreatedwith medicinentb germ are strong and it can take a long time for them to die it is important to take and finish all tb medicinesexactlyas your health care provider recommendsnthere are several safe and effective treatment plan recommended in the united state forinactive tbandactive tb disease atreatment planalso called treatment regimen for inactive tb or active tb disease is a schedule to take tb medicine to kill all the tb germ your treatment plan for inactive tb or active tb disease will includenthetypesof tb medicine to takenhow muchtb medicine to takenhow oftento take the tb medicinesnhow longto take the medicinesnhow to monitoryourself for any side effect of your tb medicine andnthe health care providerswho will support youthrough the treatment processnyou and your health care provider will discus which treatment plan is best for yountreatment for inactive tb can take three four six or nine month depending on the treatment plannthe treatment plan for inactive tb use different combination of medicine that may includenisoniazidnrifampinnrifapentinentreatment for active tb disease can take four six or nine month depending on the treatment plannthe treatment plan for active tb disease use different combination of medicine that may includenethambutolnisoniazidnmoxifloxacinnrifampinnrifapentinenpyrazinamidenthere are several treatment plan fordrugresistant tb diseasedepending on what medicine the tb germ are resistant to treating and curing drugresistant tb disease is complicated it should be treated by a tb medical expertnpeople with drugresistant tb disease must be treated with special medicine treatment may take a long time sometimes month or year and the medicine can cause side effectsnsome medicine can interact with the tb medicine and cause a possible side effect or reaction after taking medicinensome oral contraceptive birth control pill may not work a well when you take them with medicine for inactive tb or active tb diseasetb medicine can sometimes interfere with birth control pill and possibly make the birth control pill less effectiveif you are taking birth control pill talk with your health care provider before beginning any new medicinesntb medicine can sometimes interfere with birth control pill and possibly make the birth control pill less effectivenif you are taking birth control pill talk with your health care provider before beginning any new medicinesnyour health care provider can recommend a treatment plannalcoholic beverage include wine beer or liquor ask your health care provider about thing to avoid while taking medicine for inactive tb or active tb diseasenmost people can take their tb medicine without any problem however like all medicine the medicine you take for inactive tb or active tb disease can have side effectsnpeople react differently to medicine tell your health care provider about anything you think is wrongnfor example any tb medicine can cause a skin rash other tb medicine may cause an upset stomach or nausea taking your tb medicine with food can help your body absorb the medicine betternthe rifampin or rifapentine medicine may cause some body fluid to turn an orange color such asnurine peensalivantearsnsweat andnbreast milknthis is normal and harmless the color may fade over time also your health care provider may tell you not to wear soft contact lens because they may get permanently stainednif you have any of these side effect you can continue taking your medicinenif you have a serious side effect call your health care provider immediately your health care provider may tell you to stop taking your medicine or to return to the clinic for test serious side effect includenliver injuryabdominal painnausea and vomitingskin and eye turning yellow also called jaundicenabdominal painnnausea and vomitingnskin and eye turning yellow also called jaundicendizziness or lightheadednessnloss of appetitenflulike symptomsntingling or numbness in your hand or feetnif you are taking isoniazid you may have tingling or numbness in your hand and foot your health care provider may ad about tuberculosis tb is caused by a bacterium calledmycobacterium tuberculosisntwo tbrelated condition exist inactive tb and active tb diseasengetting tested and treated for tb can protect yourself your family and friend and your communityntuberculosis tb is caused by a bacterium or germ calledmycobacterium tuberculosis in the united state the majority of tb disease case in people are caused bymycobacterium tuberculosisother mycobacteria such asmycobacterium boviscan also cause tb disease in peoplentb usually affect the lung tb can also affect other part of the body such a the brain the kidney or the spine tb can also affect multiple part of the body at the same time for example tb can affect both the lung and lymph nodesnnot everyone infected with tb germ becomes sick a a result two tbrelated condition existinactive tbor latent tb infection andactive tb diseasenif not treated properly tb disease can be fatalntb germ can live in the body without making you sick this is calledinactive tb or latent tb infection people with inactive tb are infected with tb germ but they do not have active tb disease they do not feel sick do not have any symptom and can not spread tb to othersnwithouttreatment people with inactive tb can develop active tb disease at any time and become sickntb germ become active if the immune system canut stop them from growing when tb germ are active multiplying in your body this is calledactive tb disease people with active tb disease feel sick they may also be able to spread the germ to people they spend time with every day withouttreatment active tb disease can be fatalna cough that last three week or longernchest painncoughing up blood or sputum phlegm from deep inside the lungsnweakness or fatiguenweight lossnloss of appetitenchillsnfevernnight sweatsnpeople with inactive tb donothave symptom however without treatment they can develop active tb disease and become sicknanyone can get tb but you might have a higher risk for tb if younwere born in or frequently travel to country where tb is common including some country in asia africa and latin americanlive or used to live in large group setting where tb is more common such ashomeless sheltersprisons orjailsnrecently spent time with someone who hasactive tb diseasenhave a weaker immune system because of certain medication or health condition such asdiabetes cancer andhivnwork in place where tb is more likely to spread such ashospitals homeless shelter correctional facility and nursing homesntb is spread through the air from one person to another the tb germ are put into the air when a person with active tb disease of the lung or throat cough speaks or singsnthese germ can stay in the air for several hour depending on the environment tb germ are more likely to spread in indoor area or other place with poor air circulation such a a closed vehicle than in outdoor area people who breathe in the air become infected with tbnpeople with active tb disease are most likely to spread tb germ to people they spend time with every daynif you are diagnosed with inactive tb there aretreatmentsavailable that can help protect you from getting sick with active tb diseasentb disease is one of the world leading infectious disease killersncdc estimate up to million peoplein the united state live with inactive tbnwithout treatment in peoplewith inactive tb will get sick with active tb disease tb disease can spread to others and be deadlynin there were case of tb diseasereported in the united statesncdc recommends that people that are at increased risk should be tested for tb there are two type of test that can find tb infectionnthetb blood testis also called an interferongamma release assay or igra the tb blood test measure how your immune system reacts to the germ that cause tbnif you have ever received avaccine for tb your health care provider should recommend the tb blood test unlike the tb skin test tb blood test are not affected by the tb vaccine bcg vaccinenfor thetb skin test a health care provider us a small needle to put some testing material under the skin you will need to return to your health care provider in two to three day to see if there is a reactionnyou have tb germ in your body your health care provider will doother teststo determine if you have inactive tb or active tb diseasenthese test may include a chest xray and a test of the sputum phlegm you cough upnif you have inactive tb treating it is the best way to protect you from getting sick with active tb diseasenif you have active tb disease you can be treated with medicine you will need to take and finish all of your tb medicine a directed by your health care provider this is to help you feel better and prevent other people from getting sicknbacille calmetteguuerin bcgis a vaccine for tb disease the va symptom most individual with tuberculosis tb disease have one or more symptomsnsymptoms of tb disease may vary depending on the part of the body affectednusually tb disease is diagnosed when someone with symptom seek medical carenin a few instance tb disease can be diagnosed when someone is receiving care for an unrelated problem such a when trauma is evaluated with a chest radiograph that unexpectedly indicates tb in the lung in other instance tb disease can be diagnosed after recent infection a part of a tb contact investigationnthe onset of tb disease is usually gradual a rapid onset is rare and may be related to an immune deficiencynusually the symptom are mild at first developing slowly a patient might blame the symptom on something common like allergy for cough or daily stress for low energy the symptom might be present for week or month before reaching a tipping point that convinces the patient to seek medical carentb disease is not a common in the united state a it wa many year ago health care provider might not consider the possibility of tb disease when evaluating patient who have symptom a a result the diagnosis of tb disease may be delayed or even overlooked and the patient may remain ill and possibly infectious for a prolonged periodnsome symptom of tb disease like cough or weight loss can be the same a the symptom of other disease these symptom should prompt heath care provider to consider tb disease especially after more common problem are ruled outnsymptoms of tb disease may vary depending on the part of the body affectednsome general systemic symptom are common to tb in any part of the bodynfevernnight sweatsnweight lossnloss of appetitensense of illness or loss of energyntb disease most commonly affect the lung pulmonary tb disease most case of tb disease are pulmonarynsymptoms of pulmonary disease includencough especially lasting for week or longerncoughing up sputum or blood hemoptysisnchest painnshortness of breathnextrapulmonary tb disease affect organ in addition to or instead of the lung it may cause symptom related to the part of the body that is affectednsymptoms of extrapulmonary tb disease includenblood in the urine may indicate tb disease of the kidneynheadache or confusion may indicate tb meningitisnback pain may indicate tb disease of the spinenhoarseness may indicate tb disease of the larynxnswollen gland may indicate tb disease of the lymph nodesnswollen painful joint may indicate tb disease of the bone or cartilagenextrapulmonary tb disease should be considered in the differential diagnosis of ill person who have systemic symptom and who are at highriskfor tb diseasencore curriculum on tuberculosis what the clinician should knownselfstudy module on tuberculosisnwhy tb patient seek medical carencommon symptomsnresources diagnosis prevention people with inactive tuberculosis tb also called latent tb infection can take treatment to prevent the development of active tb diseasenpeople with active tb disease of the lung or throat may need to take step to prevent spreading tb germ to othersnit is important for people to take all tb medicine exactly a prescribedninfection control plan can minimize the risk for exposure to and spread of tb in health care settingsntbis spread through the air from one person to another the tb germ are put into the air when a person with tb disease of the lung or throat cough speaks or singsnthese germ can stay in the air for several hour depending on the environment tb germ are more likely to spread in indoor area or other place with poor air circulation such a a closed vehicle than in outdoor areasnpeople who breathe in the air become infected with tb not everyone infected with tb germ becomes sick a a result two tbrelated condition existninactive tbandnactive tb diseasenpeople with active tb disease are most likely to spread tb germ to people they spend time with every day such asnfamily membersnfriendsncoworkers ornschoolmatesncontact your health care provider or health department if you think you have beenexposedto someone with active tb disease be sure to tell the health care provider when you spent time with the person who ha active tb diseasenpeople at higher risk of being exposed to tb germ andnpeople at higher risk of developing active tb disease once infected with tb germsnwereborn in or frequently travel to country where tb is common including some country in asia africa and latin americanlive or used to live in large group setting where tb is more common such ashomeless sheltersprisons orjailsnrecently spent time with someone who ha active tb diseasenwork in place where tb is more likely to spread such a hospital homeless shelter correctional facility and nursing homesnwere recently infected with tb germsnhave a weaker immune system because of certain medication or health condition such asdiabetes cancer orhivnactive tb disease in the lung may causesymptomsincludingna cough that last week or longernchest painncoughing up blood or sputum phlegmnweakness or fatiguenweight lossnloss of appetitenchillsnfevernnight sweatsnpeople with inactive tb donothavesymptoms of tb disease however without treatment they can develop active tb disease and become sicknwithout treatment people with inactive tb can develop active tb diseasensome people with weakened immune system due tocertain medication or health condition are at veryhigh riskof developing active tb disease once infected with tb germ it is very important that they receive treatment for inactive tb to prevent the development of active tb diseasenif you have tb disease of the lung or throat you could be infectious this mean you could spread tb germ to others you and your health care provider will discus how to prevent the spread of tb germ to other peoplenthe most important way you can prevent the spread of tb is to take all medicine exactly a directed by your health care providernkeep all your clinic appointment your health care provider need to see how you are doing this often requires another chest xray or a test of the sputum or phlegm you may cough up these test will shownif the tb medicine are workingnif you can still spread tb germ to othersnbe sure to tell your health care provider about anything you think is wrongndo not miss any dos and do not stop treatment early it can be very dangerous to stop taking your medicine or not to take all your medicine regularlyntell your health care provider if you are having trouble taking the medicinesnif you are sick enough with tb disease to go to a hospital you may stay in a special room these room use air vent that keep tb germ from spreading to other room people who work in these special room must wear a special face mask to protect themselves from tb germ you must stay in the room so that you will not spread tb germ to other peoplentake your medicine a directed this is very importantnalways cover your mouth with a tissue when you cough or laugh put the tissue in a closed bag and throw it awayndo not go to work or school until your health care provider tell you it is safeseparate yourself from others and avoid close contact with anyonesleep in a bedroom away from other family membersnseparate yourself from others and avoid close contact with anyonensleep in a bedroom away from other family membersnair out your room often to the outside of the building if it is not too cold outsidetb germ spread in small closed space where air doe not moveput a fan in your window to blow air to the outside if you open other window in the room the fan also will pull in fresh air this will reduce the chance that tb germ will stay in the room and infect someone who breat cause tuberculosis tb germ spread through the air from one person to anotherntb germ can get into the air when someone with active tb disease cough speaks or singsnpeople nearby may breathe in these germ and become infectednpeople with inactive tb also called latent tb infection can not spread tb germ to othersntuberculosis tb is caused by a bacterium or germ calledmycobacterium tuberculosis when a person breathes in tb germ the germ can settle in the lung and begin to grow from there they can move through the blood to other part of the body such a the kidney spine and brainntb bacteria can live in the body without making you sick this is calledinactive tb or latent tb infection people with inactive tb are infected with tb germ but they do not haveactive tb disease they do not feel sick do not have symptom of tb disease and can not spread tb germ to othersnwithouttreatment people with inactive tb can develop active tb disease at any time and become sickntb germ become active if the immune system cant stop them from multiplying and growing in the body when tb germ are active multiplying in your body this is calledactive tb disease people with active tb disease feel sick they may also be able to spread the germ to people they spend time with every day withouttreatment active tb disease can be fatalntb germ can get into the air when a person withactive tb diseaseof the lung or throat cough speaks or sings these germ can stay in the air for several hour depending on the environmentntb germ are more likely to spread in indoor area or other place with poor air circulation such a a closed vehicle than in outdoor area people nearby may breathe in these germ and become infectedntb germ arenotspread bynshaking someone handnsharing food or drinkntouching bed linen or toilet seatsnsharing toothbrushesnkissingnwithout treatment people with inactive tb can develop active tb diseasenpeople with weakened immune system are at veryhigh riskof developing active tb disease once infected with tb germ it is very important that these people receive treatment for inactive tb to prevent the development of active tb diseasenif you have tb disease of the lung or throat you could be infectious this mean you could spread tb germ to othersnyour health care provider will tell you what step you can take to keep from spreading tb germ to others this may include thing like covering your mouth with a tissue when you cough or staying home from work or school after taking your medicine for a few week you will feel better and you may no longer be infectious to othersnactive tb disease in the lung or throat can be infectious this mean the germ can spread to other people tb disease in other part of the body such a the kidney or spine is usually not infectiousnpeople with active tb disease are most likely to spread it to people they spend time with every day this includes family member friend and coworkers or schoolmatesnif you think you have beenexposedto someone with active tb disease you should contact your health care provider or local or state health department about getting atb blood test or tb skin test be sure to tell the health care provider when you spent time with the person who ha active tb diseasenyou may have been exposed to tb germ if you spent time near someone with active tb diseasenyou have a higher risk of being exposed to tb germ if younwere born in or frequently travel to country where tb is common including some country in asia africa and latin americanlive or used to live in large group setting where tb is more common such ashomeless sheltersprisons orjailsnrecently spent time with someone who hasactive tb diseasenwork in place where tb is more likely to spreadnyou have a higher risk of developing active tb disease once infected if younwere recently infected with tb germsnhave a weaker immune system because of certain medication or health condition such asdiabetes cancer orhivnsome people develop active tb disease soon within week after becoming infected before their immune system can fight the tb germ other people may get sick year later when their immune system becomes weak for another reasonncausesnhow it spreadsnprevention methodsnwhen transmission is possiblenrisk factorsnresources malaria about symptom malaria symptom range from very mild to severe disease and even deathntravelers with symptom of malaria should see a healthcare provider a soon a possible even if still travelingnsome people are at higher risk of having serious malariarelated problem if they get sicknmalaria is a curable disease if diagnosed and treated quickly and correctlynmost people begin to feel ill asearly a one week after infection or a late a a year or morenmalaria symptom can includenfever and flulike illnessnchillsnheadache muscle ache and tirednessnnausea vomiting and diarrheansee a healthcare provider if you have any these symptomsnmalaria symptom may become more severenanemia low red blood cell and jaundice yellow coloring of the skin and eyesnif not treated right away the infection can become serious it may cause kidney failure seizure mental confusion coma and deathnthe type of mosquito that carry the malaria parasite is ananophelesmosquito when an infectiveanophelesmosquito bite you and pass on the malaria parasite there is a period of time before the first symptom show this time between mosquito bite and first sign of symptom is called the incubation periodnthe incubation period in most case of malaria range from u day different specie of parasite that cause malaria in human can cause shorter or longer incubation periodsnin addition some malaria parasite specie can remain dormant inactive in the liver for month or year after the initial infection later after returning from an area with malaria these parasite can then leave the liver and infect red blood cell and cause another episode of illness proper diagnosis and treatment can prevent malaria illness caused by these dormant parasitesnkeep readingmalaria incubation period prevention you can take medication to prevent malariancheck to see if malaria spread in the region or country you will be visiting before you travelntake medication to prevent malaria a prescribed including the period before travel and after you return from travelnavoid mosquito bite even if you are taking medication to prevent malarianif you experience symptom of malaria especially fever while traveling or after returning seek immediate medical attentionnthis information is for traveler who live in the united state traveler from other country should consult healthcare provider in their country for information on prevention recommendation and availability of antimalarial drugsfor more health recommendation for international travel visit thecdc yellow booknevery year million of u resident travel to country where malaria is present about case of malaria are diagnosed in the u in a typical year mostly in returned traveler you can prevent malaria when travelling in area where malaria spread by taking medication called antimalarial and preventing mosquito bite there is no vaccine for malaria currently available in the usnmalaria doe not regularly occur in the in the u so there is usually no exposure to the disease here traveler especially to subsaharan africa region of south america and southeast asia have the greatest risk of getting malaria and potentially dying from their infection if not diagnosed promptly and appropriately treated all traveler to country wheremalaria is presentmay be at risk for infectionnusbased traveler going to an area where malaria spread even if they had some level of immunity to malaria in the past are still at risk for infection it important to note that acquired immunity to protection from malaria weakens the longer you are away from an area where malaria is widespread or endemic if you have been away from your country of origin even a short time you can lose your protective immunity very quickly and should use the same preventative measure a all traveler preventative medication mosquito bite prevention etcnbefore you travellearn about the health risk and precaution for malaria and other disease for your destination get a detailed itinerary of all the possible destination or place you may visit during the trip check to see if malaria is present and spread in these location cdc yellow book chapter on malaria prevention by country provides detailed information about the specific part of country where malaria spread it also provides additional information including the specie of malaria that occur there if there is resistance to any of the antimalarial drug and the specific medicine that cdc recommends for use for malaria prevention in each country or regionnto understand your level of risk for getting malaria and if you need to take malaria prevention medication consider the followingndestination country or regionnspecific itinerary including specific city type of accommodation hotel with ac or openair tent season and style of travelnpregnancy status other medical condition and current medication you takenantimalarial drug resistance at your destinationnyou should discus with a healthcare provider a detailed itinerary of where you are traveling your activity accommodation and your medical history to understand your risk of malaria and if you need to take medication to prevent malarianthere are various option of medication available to prevent malaria and based on the countrycountries the urgency of the trip and how often you prefer to take medication daily v weeklynif your provider recommends malaria prevention medication it is important to take them a prescribed including the period before travel and after you return from travelnin some area where only a few case of malaria occur cdc recommends preventing mosquito bite a the only way to prevent malarianbe aware ofcounterfeit fake or substandard not made according to u standard drugssold in some country this includes country where malaria spread these drug may not be effective get all your medication including antimalarial drug in the u before traveling overseasnhealthcare provider can reference the risk assessment page to ensure they provide appropriate recommendation for all traveler at risk for malaria including those returning to visit friend and relativenit is important to take step toavoid mosquito biteseven if you are taking medication a an added layer to prevent malariansteps to prevent mosquito bitesnuseenvironmental protection agency eparegistered insect repellentswith one of the active ingredientsdeet insect repellent that contain deet offer the best protection against mosquito bitespicaridin known a kbr and icaridin outside the usiroil of lemon eucalyptus oleparamenthanediol pmdundecanonndeet insect repell diagnosis only a healthcare provider can diagnose malariana lab test will confirm malaria parasite infection using a small sample of your bloodnmalaria is a serious disease which can become severe if not treated quickly quick and accurate diagnosis of malaria is important to ensure treatment begin a soon a possible with the correct medication prompt treatment also help to prevent further infection in the community by breaking the cycle of infection from infected person via local mosquito delay in diagnosis and treatment is a leading cause of death in malaria patient in the united statesnonly a lab test using a small sample of your blood can confirm a malaria diagnosisnif you have traveled to an area in the last year where malaria spread you should get tested a soon a you experience symptom of malarianthere are a few diagnostic test to confirm if you have malarianblood smear microscopy test is where a small sample of blood is taken from a patient and sent to a laboratory to be examined under a microscope it is the best way to confirm if a patient ha malaria and to determine which specie only a healthcare provider can order a microscopy testnmalaria rapid diagnostic test or rdts are useful test option when reliable microscopic diagnosis is not readily available malaria rdts detect very small piece from malaria parasitesnin the u only a healthcare provider can order an rdt test a small sample of blood from the patient is collected and applied to the test card sample pad rdts are less sensitive than other lab test a blood smear microscopy test must always confirm both positive and negative rdt result in a patient with suspected malaria despite theselimitations rdts can provide result in less than minutesnpcr test or polymerase chain reaction test are also available to detect malaria parasite these test are more sensitive than routine blood smear microscopy test or rdts but the result take longer making them less ideal for initial diagnosis and treatment an advantage is that pcr test can confirm the exact specie of malaria parasite if microscopy testing is not able to do so this help guide which medicine to use to treat a patient with malariansee a healthcare provider immediately they can conduct the most appropriate diagnostic test a soon a possible if they suspect malarianif you test positive for malaria your healthcare provider will start you on medication to treat the disease immediately the medication prescribed will be based on the type of malaria you havenif you test negative for malaria work with your healthcare provider to determine the cause of your symptomsnwhy get testednwhen to get testedntypes of testsnhow to get testedntesting result treatment malaria is a medical emergency and can become lifethreatening if not quickly diagnosed and appropriately treatednonly a healthcare provider can diagnose and treat a patient for malarianprescription drug available in the u can cure malariansee a healthcare provider if you are sick and have recently been in an area where malaria is widespreadnstarting treatment immediately is the best way to treat malaria and prevent serious and lifethreatening issue the type of drug prescribed and length of treatment depend onnthe type of malarianthe geographic location where the infection likely happened and likelihood of drug resistancenyour agenif you are pregnant or breastfeedingnhow sick you are at the start of treatmentnpatients in the u are typically hospitalized for malaria treatmentnhealthcare provider can refer to the cdcsclinical guidance malaria diagnosis treatment in the usfor specific information cause most people get malaria from the bite of an infective mosquito also called a vectornmost case of malaria diagnosed in the u are in people who have traveled to or from other country where malaria is widespread we call this imported malarianlocally acquired mosquitotransmitted malaria is a rare event in the usnmalaria is a disease caused by a parasitenmost people get malaria when bitten by an infective mosquito carrying the malaria parasite only femaleanophelesmosquitoes can spread malaria from one person to another for theanophelesmosquito to become infective they must bite or take a blood meal from a person already infected with the malaria parasite about one week later that same mosquito will bite the next person and subsequently inject the parasite via her saliva and the cycle of infection continuesnin rare occasion malaria can spread throughnblood transfusionsnorgan transplantnsharing needle or syrinx contaminated with malariainfected blood orncongenitally meaning from a mother to her unborn infant before or during deliverynmalaria is not contagious people cant spread malaria to other people like a cold or the flu you cant get malaria through casual contact sitting next to a person with malaria close physical contact or even sexual contactnanyone can get malaria most case occur in people who live incountries with widespread malaria these country are also called malariaendemic region people from or living in country with no malaria can become infected when they travel to country with malarianplasmodium falciparumis the parasite specie causing malaria that can be severe and lifethreatening it is very common in many country in africa south of the sahara desertnindividuals with the most risk of getting very sick and dying from malaria includenpeople who have little or no recent exposure to malaria parasite this can include young child and pregnant woman or traveler coming from area with no malarianpeople heavily exposed to the bite of mosquito infected withp falciparumnpeople living in rural area who lack access to health carendue to these risk factor an estimated of death caused by malaria occur in africa south of the sahara desert and most of these death occur in child under year of agencausesnhow it spreadsnrisk factorsnpopulations most at risk hiv about hiv is a virus that attack the body immune systemnthe only way to know if you have hiv is to get testednthere are many way to prevent hiv like using prep pep condom and never sharing needlesnhiv treatment help people live long healthy life and prevents hiv transmissionnhiv human immunodeficiency virus is a virus that attack the body immune system without treatment it can lead to aid acquired immunodeficiency syndromenthere is currently no effective cure once people get hiv they have it for life but proper medical care can control the virusnpeople with hiv who get on and stay on effective hiv treatment can live long healthy life and protect their partnersnmost people haveflulike symptomswithin to week after infection symptom may last for a few day or several weeksnhaving these symptom alone doesnt mean you have hiv other illness can cause similar symptomsnsome people haveno symptomsat all theonly way to knowif you have hivis to get testednmost people who get hiv get it through anal or vaginal sex or sharing needle syrinx or other drug injection equipmentnonly certain body fluid can transmit hiv these fluid includenbloodnsemen cumnpreseminal fluid precumnrectal fluidsnvaginal fluid andnthese fluid must come in contact with a mucous membrane or damaged tissue or be directly injected into the bloodstream from a needle or syringe for transmission to occurnfactors like a person viral load other sexually transmitted infection and alcohol or drug use can increase the chance of getting or transmitting hivnbut there are powerful tool that can help prevent hiv transmissionntodaymoretools than ever are available to prevent hivnprevention strategy includenusing condom the right way every time you have sexnnever sharing needle syrinx or other drug injection equipmentnusing prep preexposure prophylaxis and pep postexposure prophylaxisnif you have hiv there are many way to prevent transmitting hiv to others including taking hiv treatment to get and keep an undetectable viral loadnthe only way to know your hiv status is to get tested knowing your status give you powerful information to keep you and your partner healthynthere are many option for quick free and painless hiv testing if yourtest result is positive you can take medicine to treat hiv to help you live a long healthy life and protect others if yourtest result is negative you can take action to prevent hivneveryonebetween the age of and should get tested for hivat least oncepeople with certain risk factor should get tested more oftennhiv treatment antiretroviral therapy or art involves taking medicine a prescribed by a health care provider you should start hiv treatmentas soon a possibleafter diagnosisnhiv treatment reduces the amount of hiv in the blood viral load hiv treatment can make the viral load so low that a test cant detect it undetectable viral load if you have an undetectable viral load you will not transmit hiv to others through sex having an undetectable viral load also reduces the risk of hiv transmission through sharing drug injection equipment and during pregnancy labor and deliverynwhen people with hiv dont get treatment they typically progress through three stage but hiv treatment can slow or prevent progression of the disease with advance in hiv treatment progression to stage aid is less common todaynpeople have a large amount of hiv in their blood and are very contagiousnmany people have flulike symptomsnif you have flulike symptom and think you may have been exposed to hiv get testednthis stage is also called asymptomatic hiv infection or clinical latencynhiv is still active and continues to reproduce in the bodynpeople may not have any symptom or get sick during this phase but can transmit hivnpeople who take hiv treatment a prescribed may never move into stage aidsnwithout hiv treatment this stage may last a decade or longer or may progress fasternat the end of this stage the amount of hiv in the blood viral load go up and the person may move into stage aidsnthe most severe stage of hiv infectionnpeople receive an aid diagnosis when their cd cell count drop below cell per milliliter of blood or they develop certain illness sometimes called opportunistic infectionsnpeople with aid can have a high viral load and may easily transmit hiv to othersnpeople with aid have damaged immune systemsnthey can get an increasing number of other serious illnessesnwithout hiv treatment people with aid typically survive about three yearsnoverviewnsymptomsnhow it spreadsnpreventionntestingntreatmentnhow it progress cause most people get hiv through anal or vaginal sex or sharing needle syrinx or other drug injection equipmentnonly certain body fluid can transmit hivnthere are powerful tool to help prevent hiv transmissionnthese fluid must come into contact with a mucous membrane or damaged tissue or be directly injected into the bloodstream from a needle or syringe for transmission to occur there are mucous membrane inside the rectum vagina penis and mouthnyou can get hiv if you have anal or vaginal sex with someone who ha hiv without using protection likecondomsormedicine to prevent hiv you can also get hiv from sharing needle syrinx or other drug injection equipment for example cooker with someone who ha hiv you can pas hiv to your baby during pregnancy childbirth and nursing breastfeedingneither partner can get hiv during anal sexnbeing the bottom or having your partner penis inside your rectum butthole make you more likely to get hiv than being the top or putting your penis inside your partner rectumnhiv can enter the body through the lining of the rectum butthole the opening at the tip of the penis urethra the foreskin or cut or sore on the penisneither partner can get hiv during vaginal sexnhiv can enter a person body through the tissue that line the vagina and cervixnvaginal fluid and blood can pas through the opening at the tip of the penis urethra the foreskin or cut or soresnused needle syrinx and other injection equipment may have someone elses blood in themnpeople who inject drug may be more likely to engage in sexual behavior that increase their chance of getting hivnhiv can pas to a baby during pregnancy childbirth and nursing breastfeeding this is calledperinatal transmissionnthis is the most common way that child get hivnhiv treatment reduces the chance of transmission to others through sex or syringe sharing and during pregnancy childbirth and nursing breastfeedingnyou cant get or transmit hiv from activity that dont involve contact with body fluid eg touching hiv doe not survive long outside the human body for example on surface and can not reproduce outside a human hostnviral load is the amount of hiv in the blood of someone who ha hiv the higher someone viral load the more likely that person is to transmit hiv viral load is highest during the earliest stage acute phase to week of having hiv and can remain high without hiv treatmentnlearn more about how takinghiv treatmentand having an undetectable viral load prevents hiv transmission through sex or sharing needle syrinx or other injection equipment and during pregnancy childbirth and nursing breastfeedingnif you haveanother sexually transmitted infection sti you may be more likely to get or transmit hiv getting tested and treated for stis can lower your chance of getting or transmitting hiv and other stis if youre sexually active you and your partner should get tested for stis even if you dont have symptomsnwhen you use drug you may be more likely to engage in behavior that increase your chance of getting or transmitting hiv such asnhaving anal or vaginal sex without protection like a condom or medicine to prevent hivnsharing needle syrinx or other drug injection equipmentufor example cookersnhaving sex with multiple partnersntrading sex for money or drugsnusing drug ordrinking alcoholcan alter your judgment lower your inhibition and impair your decision about sex or drug usenif youre going somewhere you know youll be drinking or using drug bring a condom to reduce your chance of getting or transmitting hiv through sexnthere is little to no risk of getting hiv from the activity below for transmission to occur something very unusual would have to happennoral sex involves putting the mouth on the penis fellatio vagina or vulva cunnilingus or anus rimming ejaculation in the mouth with oral ulcer bleeding gum or genital sore or the presence of other stis can increase the chance of hiv transmission you can get other stis from oral sexnthe most likely cause is injury with a contaminated needle or another sharp object careful practice of standard precaution protects patient and health care personnel from possibleoccupational hiv transmissionnthe u blood supply and donated organ and tissue are thoroughly tested it is very unlikely that you would get hiv from blood donation or transfusion blood product or organ and tissue transplant you can not get hiv from donating blood blood collection procedure are highly regulated and safenthe only known case of hiv transmission through food have been when blood from a caregiverus mouth mixed with prechewed food and an infant ha eaten it you can not get hiv from consuming food handled by someone with hivnthis rare transmission ha only occurred through contact between broken skin wound or mucous membr prevention many tool are available to help prevent hivnyou can choose not having sex activity with lower chance of hiv transmission never sharing needle and using condomsnyou can also use hiv prevention medicine such a prep or pepnif you have hiv you can prevent transmitting hiv to othersnmost people who get hiv get it through anal or vaginal sex or sharing needle syrinx or other drug injection equipment for example cooker however there are powerful tool that can help prevent getting or transmitting hivnthere is little to no chance of getting hiv through oral sexnyou cant get hiv from sexual activity that dont involve contact with semen vaginal fluid or bloodnmost condom are highly effective in preventing hiv and other stis like gonorrhea and chlamydiancondoms are less effective at preventing stis that can be transmitted through sore or cut like genital herpes and syphilisnyou can buy condom online instore or get them for free at your local clinicnprep preexposure prophylaxis is medicine people take to prevent getting hivnprep is highly effective for preventing hiv from sex and injection drug use when taken a prescribednnot having sex being abstinent is a effective way to make sure you wont get hiv through sexnyou can be abstinent at different time in your life for different reasonsnnot having sex also prevents other stis and pregnancynif you have another sti you are more likely to get hivnmany people with an sti may not know they have one because they dont have symptomsnuse new clean syrinx and injection equipment every time you injectnyou can get new needle and syrinx and safely dispose of used at syringe service program sspsfind an sspnear younsome pharmacy sell needle without a prescriptionnif you do share syrinx use bleach to clean them a disinfected syringe is not a good a a new sterile syringe but it can greatly reduce your chance for hiv and viral hepatitisnnot injecting drug is a effective way to make sure you wonut get hiv through injection drug usentalk with a counselor doctor or other health care provider about treatment for substance use disorder including medicationassisted treatmentnfind a treatment center near you atfindtreatmentgovorsamhsagovnpep postexposure prophylaxis is medicine people take to prevent hiv after a possible exposurenif you think you may have been exposed to hiv in the last hour talk to your health care provider an emergency room doctor or an urgent care provider right away about pepnthis is the most important thing people with hiv can do to stay healthynpeople with hiv who take hiv medicine and get and keep an undetectable viral load will not transmit hiv to their sex partnersnif your test result is negative and you or your partner engage in behavior that increase your chance of getting or transmitting hiv get tested again in your third trimesternif your test result is positive you can reduce the chance of transmitting hiv to your baby by taking hiv medicine a prescribed throughout pregnancy labor and delivery getting and keeping a suppressed viral load and giving hiv preventive medicine to your baby after giving birthnif you have a partner with hiv and are considering getting pregnant talk to your health care provider aboutprepnmale circumcision may decrease the chance of hiv transmission in some situation but less than some other prevention option talk to your health care provider about the benefit and drawback of male circumcisionnoverviewnprevention step and strategy diagnosis everyone between the age of and should get tested for hiv at least oncenpeople with certain risk factor should get tested more oftennmost hiv test are available for free or at a reduced costnvisit gettestedcdcgov to find hiv testing in your areanthe only way to know your hiv status is to get tested knowing your hiv status give you powerful information to keep you and your partner healthy if yourtest result is positive you can take medicine totreat hivto help you live a long healthy life and protect others if yourtest result is negative you can take action toprevent hivneveryone between the age of and should get tested for hiv at least oncenpeople with certain risk factor should get tested more often you should get testedat least once a yearifnyoure a man who ha had sex with another mannyouve had anal or vaginal sex with someone who ha hivnyouve had more than one sex partner since your last hiv testnyouve shared needle syrinx or other drug injection equipment for example cookersnyouve exchanged sex for drug or moneynyouve been diagnosed with or treated for another sexually transmitted infection hepatitis or tuberculosis tbnyouve had sex with someone who ha done anything listed above or you dont know their sexual historynbefore having sex with a new partner talk about your sexual and druguse history disclose your hiv status and consider getting tested together even if you and your partner are having sex only with each other you should both find out your hiv statusnsexually active gay or bisexual men may benefit from more frequent testing every to month talk to your health care provider about your risk factor and what testing option are available to younpregnant people should get tested for hiv during each pregnancy testing pregnant people and treating those who have hiv is a highly effective way to prevent baby being born with hivnthere are three type of hiv testsantibody testsantigenantibody test andnucleic acid test nat antibody are produced by your immune system when youre exposed to virus like hiv antigen are foreign substance that cause your immune system to activate if you have hiv an antigen called p is produced even before antibody developnhiv test are typically performed on blood or oral fluid they may also be performed on urinenanantibody testlooks for antibody to hiv in your blood or oral fluid most rapid test and the only hiv selftest approved by the u food and drug administration fda are antibody test antibody test that use blood from a vein can detect hiv sooner than test done with blood from a finger stick or with oral fluidnanantigenantibody testlooks for both hiv antibody and antigen antigenantibody test are recommended for testing done in lab and are common in the united state this lab test involves drawing blood from a vein there is also a rapid antigenantibody test available that is done with blood from a finger sticknanatlooks for the actual virus in the blood with a nat the health care provider will draw blood from your vein and send the sample to a lab for testing this test can tell if a person ha hiv or how much virus is present in the blood hiv viral load test a nat can detect hiv sooner than other type of test this test should be considered for people who have had a recent exposure or a possible exposure and have early symptom of hiv and who have tested negative with an antibody or antigenantibody testntalk to your health care provider about what type of hiv test is right for younvisitgettestedcdcgovto see if any organization in your area are offering free or reduced cost selftests you can also buy an hiv selftest at a pharmacy or onlinena selftest can be used at home or in a private location with an hiv selftest you can get your test result within minute you should always interpret hiv selftest result according to themanufacturers instruction if the hiv selftest is invalid then the test did not work you will need to use another hiv selftest or find testing at a health care provider or testing centernyou can ask your health care provider for an hiv test many medical clinic substance abuse program community health center and hospital offer them too use the locator below to find hiv testing service in your areanif you get an hiv test in a health care setting or lab the health care provider will take a sample of blood or oral fluid with a rapid test oral fluid or finger stick you may be able to wait for the result with a lab test it may take several day for your result to be availablenif you are tested outside of a health care setting or a lab you will likely receive a rapid test oral fluid or finger stick the counselor providing the test should be able to answer question and provide referral for followup testing if needednhiv test are covered by health insurance without a treatment there is no cure for hiv but hiv treatment can reduce the amount of hiv in your bodynthere are two type of hiv treatment pill and shotsnmost people can get hiv under control within six monthsnhiv treatment prevents transmission to others and help you stay healthynhiv treatment antiretroviral therapy or art involves taking medicine prescribed by a health care provider when taken a prescribed hiv medicine can make the amount of virus in your body viral load so low that a test cant detect it undetectable viral loadnall people with hiv should take hiv treatment no matter how long theyve had hiv or how healthy they are if you delay treatment hiv will continue to harm your immune system and increase your chance of transmitting hiv to others getting sick and developing aidsnthere are two type of hiv treatment pill and shotsnpills are recommended for people just starting hiv treatment there are many fdaapproved single pill and combination medicine availablenhiv treatment shot are longacting injection given once a month or once every other month depending on your treatment plannshots may be right for you if you are an adult with hiv whonhas had an undetectable viral load or ha achieved viral suppression for at least three monthsnhas no history of treatment failure andnhas no known allergy to the medicine in the shotnyoull need to visit your provider regularly to receive your shot tell your health care provider a soon a possible if youve missed or plan to miss an appointment for your shotna health care team that is knowledgeable about hiv care will help you manage your care and treatment your primary hiv care provider should lead your health care team they willndetermine which hiv medicine is best for younprescribe hiv medicinenmonitor your progress and help you manage your healthnrefer you to otherhiv providerswho can address your needsnyour care team may include other provider who are expert in hiv care like nurse mental health provider pharmacist nutritionist and dentist social service provider like social worker case manager substance use specialist and patient navigator may help you find support servicesnyou can also use the locator below to find a local health center or a ryan white hivaids provider who can help you access medical caremedications and essential support servicesnthis will help keep your viral load low and your cd count highntake your hiv medicine exactly how your health care provider tell you touat specific time of the day with or without certain kind of foodntalk to your health care provider or pharmacist if you have question about when or how to take your medicine or if you are experiencing any side effectsnuse a calendar to mark your appointmentsnset reminder on your phonenkeep your appointment card in a place where you will see itnask a family member or friend to help you remember your appointmentsnduring your appointment your health care provider may ask question and conduct routine medical exam to see how hiv is affecting your body they mayntake a blood sample to check your viral loadnask about your health historynlook for other kind of infection or health problem or give you immunizationsndiscuss prescribe and monitor your hiv medicinendiscuss way to help you follow your hiv treatment plannhelp identify other support you may neednask about your sexual or injection partner and discus way to prevent them from getting hivnyour health care provider will use blood test to monitor your hiv these test help your health care provider make decision about change to your treatmentnyour cd count is the number of cd cell you have in your bloodncd cell help your body fight infectionsnhiv attack and lower the number of cd cell in your bloodnthis make it difficult for your body to fight infectionsnyour health care provider will check your cd count every to monthsnthis test look at the amount of hiv in your bloodnwhen your viral load is high you have more hiv in your body this may mean your immune system is having difficulty fighting the virus or that your hiv medicine isnt working wellnyou should have a viral load testevery to monthsbefore you take a new hiv medicine andaround to week after starting or changing medicinenevery to monthsnbefore you take a new hiv medicine andnaround to week after starting or changing medicinenif your viral load go down after starting hiv treatment that mean treatment is working continue taking your hiv treatment a prescribednif you miss your hiv treatment even now and then hiv can multiply rapidly in your bodynthis could weaken your immune system and you could become sicknif you have an undetectable viral load you will not transmit hiv through sex this is also known asundetectable untransmittablenhaving an undetectable viral load likely reduces the risk of hiv transmission through sharing needl