Republic of South Sudan

Standard Treatment Guidelines

(STGs)
4. Hospital
May 2019

Ministry of Health,
Republic of South Sudan
Contents
Preface...............................................................................................................................................................10
Acknowledgements...........................................................................................................................................11
List of abbreviations.................................................................................................................................... 11
Introduction............................................................................................................................................... 15
Danger signs.......................................................................................................................................................17
Standard precautions.........................................................................................................................................17
Prescribing paracetamol....................................................................................................................................18
1. Maternal & Reproductive Health........................................................................................................ 20
1.0 Basic Emergency Obstetric and Neonatal Care and Comprehensive Emergency Obstetric and Neonatal
Care....................................................................................................................................................................20
1.1 Birth Spacing................................................................................................................................................21
Short-acting Methods....................................................................................................................................22
Long acting Methods.....................................................................................................................................26
1.2 Antenatal Care.............................................................................................................................................28
1.3 Antenatal Care Complications.....................................................................................................................31
Malaria in Pregnancy.....................................................................................................................................31
High Blood Pressure in Pregnancy.................................................................................................................31
Diabetes in Pregnancy..................................................................................................................................33
Anemia in pregnancy.....................................................................................................................................33
Nausea and vomiting.....................................................................................................................................33
Thyroid disease in Pregnancy........................................................................................................................34
Brucellosis in pregnancy................................................................................................................................34
Pre-term labour.............................................................................................................................................34
Bleeding in Pregnancy...................................................................................................................................34
Antepartum haemorrhage (APH)..................................................................................................................35
1.4 Normal Labour.............................................................................................................................................35
Induction and augmentation of labour.........................................................................................................37
1.5 Labour Complications..................................................................................................................................38
Initial management of an obstetric emergency............................................................................................38
Unsatisfactory Progress of Labour................................................................................................................39
Malpresentations..........................................................................................................................................39
Fetal Distress in Labour.................................................................................................................................40
Prolapsed Cord..............................................................................................................................................41
Caesarean section.........................................................................................................................................41
1.6 Postnatal Care Normal.................................................................................................................................41
1.7 Postnatal Care Complications......................................................................................................................42

1
 Preventing Mother To Child Transmission (PMTCT) of HIV..........................................................................42
Post-Partum Infection..................................................................................................................................42
Post Partum Haemorrhage............................................................................................................................42
Other postnatal conditions..........................................................................................................................43
1.8 Newborn Care Normal.................................................................................................................................44
Detecting danger signs.................................................................................................................................45
1.9 Newborn Care Complications......................................................................................................................46
Immediate Management..............................................................................................................................46
Gasping or Not Breathing.............................................................................................................................46
Resuscitation.................................................................................................................................................46
Low Birth Weight or Preterm Babies...........................................................................................................48
Hypoglycaemia..............................................................................................................................................48
Newborn seizures.........................................................................................................................................49
Jaundice of newborns...................................................................................................................................49
Exchange transfusion for treating haemolytic disease of the newborn.....................................................49
1.10 Gynaecology...............................................................................................................................................50
Gynaecology in Adolescents.........................................................................................................................50
Menstrual Problems.....................................................................................................................................50
Pelvic Pain.....................................................................................................................................................51
Genital tract disorders..................................................................................................................................51
Menopause...................................................................................................................................................51
Delaying Periods............................................................................................................................................52
Sexual and gender-based violence (SGBV)....................................................................................................52
Intimate Partner Violence.............................................................................................................................52
FGM...............................................................................................................................................................52
2. Child Health............................................................................................................................................ 54
2.1 Immunisations.............................................................................................................................................54
2.2 Nutrition.......................................................................................................................................................55
Micronutrients...............................................................................................................................................56
Anemia...........................................................................................................................................................56
Blood transfusion for severe anemia...........................................................................................................57
Treatment steps for severe decompensated anemia.................................................................................57
Deworming medicine....................................................................................................................................58
Severe acute malnutrition (SAM) without complications.............................................................................58
Treatment of SAM with medical complications............................................................................................58
1. Stabilisation Phase:...................................................................................................................................58
2. Transition Phase:.......................................................................................................................................59
3. Stabilisation Phase.....................................................................................................................................60

2
 2.3 Paediatric Conditions...................................................................................................................................60
Childhood constipation.................................................................................................................................60
3. Communicable Diseases.......................................................................................................................... 61
3.1 Diarrhoea.....................................................................................................................................................61
Treatment steps............................................................................................................................................61
No dehydration (Plan A):...............................................................................................................................61
Some dehydration (Plan B):...........................................................................................................................62
Severe dehydration (Plan C).........................................................................................................................62
Anti-microbial treatment..............................................................................................................................63
Treatment of children with SAM (severe acute malnutrition) and dehydration.......................................64
Children with HIV...........................................................................................................................................64
3.2 Acute Respiratory Infections.......................................................................................................................65
Common cold................................................................................................................................................65
Croup.............................................................................................................................................................65
Tonsillitis........................................................................................................................................................66
Ear infection..................................................................................................................................................67
Sinusitis..........................................................................................................................................................68
Flu..................................................................................................................................................................68
Acute bronchitis............................................................................................................................................69
Pneumonia and difficult breathing................................................................................................................69
Severe Pneumonia........................................................................................................................................69
Pneumonia without signs of serious illness..................................................................................................70
Bronchiolitis...................................................................................................................................................71
3.3 Malaria.........................................................................................................................................................71
1st line treatment for malaria with Artesunate/Amodiaquine......................................................................72
Treatment of other Malaria species..............................................................................................................73
Treatment of severe malaria with artesunate............................................................................................73
Alternative treatment of severe malaria with quinine...............................................................................73
Follow-on treatment of severe malaria with ASAQ......................................................................................74
Cerebral malaria............................................................................................................................................74
Hypersplenism...............................................................................................................................................74
Prevention and Control of Malaria in Pregnancy..........................................................................................74
Effective treatment of clinical malaria cases.................................................................................................74
Intermittent preventive treatment (IPT).....................................................................................................75
Malaria in pregnant women who are HIV positive.......................................................................................75
Treatment of Severe Falciparum Malaria in pregnancy..............................................................................75
3.4 Other Febrile Diseases.................................................................................................................................76
Measles..........................................................................................................................................................76

3
 Treatment of mild and moderate measles...................................................................................................76
Treatment of severe measles........................................................................................................................76
Meningitis & septicaemia..............................................................................................................................77
Typhoid fever.................................................................................................................................................77
3.5 Sexually Transmitted Infections...................................................................................................................78
Prevention of STIs & HIV...............................................................................................................................78
Management of STIs......................................................................................................................................78
Treatment of STIs..........................................................................................................................................80
3.6 HIV (Human Immunodeficiency Virus)........................................................................................................82
Testing...........................................................................................................................................................82
Standard precautions for avoiding transmission of HIV and other pathogens in health facilities...............82
What to do after a positive HIV test..............................................................................................................82
Treating opportunistic infections before initiating ART................................................................................83
Co-trimoxazole Prophylaxis for PLHIV...........................................................................................................84
TB Preventive Therapy (TPT).........................................................................................................................84
Initiating ART.................................................................................................................................................85
Follow Up On ART..........................................................................................................................................87
Second Line ART............................................................................................................................................87
Prevention of mother to child transmission (PMTCT)...................................................................................88
Care of Children Living with HIV....................................................................................................................90
New 2018 ART guidelines..............................................................................................................................92
Malnutrition in Children with HIV.................................................................................................................92
Immune Reconstitution Inflammatory Syndrome (IRIS)...............................................................................92
Post-exposure prophylaxis (PEP)...................................................................................................................92
Pre-exposure Prophylaxis (PrEP)...................................................................................................................93
3.7 Opportunistic Infections with HIV...............................................................................................................93
3.8 Tuberculosis.................................................................................................................................................96
Diagnosis........................................................................................................................................................96
Standardised TB treatment regimes.............................................................................................................97
Treating TB in children..................................................................................................................................99
Treatment regimens in special situations...................................................................................................100
Managing side effects from TB drugs..........................................................................................................100
Interactions of TB drugs..............................................................................................................................101
Drug resistant TB (DR-TB)............................................................................................................................101
Treating DR-TB.............................................................................................................................................102
3.9 HIV-TB Coinfection.....................................................................................................................................103
3.10 Viral hepatitis...........................................................................................................................................106
Hepatitis A and E.........................................................................................................................................107

4
 Hepatitis B and C.........................................................................................................................................107
Hepatitis B (HBV).........................................................................................................................................107
Hepatitis C (HCV).........................................................................................................................................108
Hepatitis D (HDV).........................................................................................................................................109
3.11 Neglected Tropical Diseases....................................................................................................................109
Leishmaniasis...............................................................................................................................................109
Management of visceral leishamaniasis.....................................................................................................110
Cutaneous leishmaniasis.............................................................................................................................111
Human African Trypanosomiasis (HAT) - Sleeping Sickness.......................................................................111
Schistosomiasis............................................................................................................................................113
Helminthiasis...............................................................................................................................................114
1.Onchocerciasis (River Blindness)..............................................................................................................114
2.Loa-Loa (Loaisis).......................................................................................................................................115
3.Lymphatic Filariasis (LF)............................................................................................................................116
4.Soil Helminthiases....................................................................................................................................116
5. Guinea Worm (Dracunculus Medinensis)...............................................................................................116
6. Tapeworm...............................................................................................................................................117
Nodding Syndrome......................................................................................................................................117
Anthrax........................................................................................................................................................118
Brucellosis....................................................................................................................................................118
Buruli ulcer..................................................................................................................................................119
Mycetoma...................................................................................................................................................119
Leprosy........................................................................................................................................................119
Rabies..........................................................................................................................................................120
4. Non-communicable Diseases................................................................................................................. 122
4.1 Skin Disease...............................................................................................................................................122
Acne:............................................................................................................................................................122
Scabies:........................................................................................................................................................122
Head lice:.....................................................................................................................................................122
Eczema, dermatitis and allergic rash...........................................................................................................122
Fungal infection:..........................................................................................................................................123
Nappy rash:.................................................................................................................................................124
Impetigo:.....................................................................................................................................................124
Folliculitis:....................................................................................................................................................124
Abscess:.......................................................................................................................................................124
Ulcer:...........................................................................................................................................................124
4.2 Cardiovascular Disease..............................................................................................................................124
Hypertension...............................................................................................................................................124

5
 Management of hypertension....................................................................................................................126
Management of severe hypertension (BP > 180/110)..............................................................................127
Cardiovascular (CV) disease - management and secondary prevention....................................................128
Treatment of angina...................................................................................................................................128
Treatment of myocardial infarction (MI)...................................................................................................128
Treatment of peripheral arterial disease....................................................................................................129
Treatment of heart failure..........................................................................................................................129
Treatment of stroke (Cerebrovascular accident - CVA)............................................................................129
Atrial Fibrillation (AF).................................................................................................................................130
Rheumatic fever..........................................................................................................................................131
4.3 Diabetes.....................................................................................................................................................131
Type 1 diabetes...........................................................................................................................................132
Hypoglycaemia (Blood sugar ≤ 3.0mmol/l or 54mg/dl)............................................................................133
Hyperglycaemia..........................................................................................................................................133
Type 2 diabetes...........................................................................................................................................134
Medication for Type 2 diabetes:.................................................................................................................134
4.4 Respiratory Disease...................................................................................................................................135
Asthma.........................................................................................................................................................135
Management of asthma..............................................................................................................................136
Management of acute exacerbations of asthma......................................................................................137
Chronic obstructive airways disease, (COPD).............................................................................................138
Management of COPD.................................................................................................................................138
Management of acute exacerbations of COPD.........................................................................................139
4.5 Gastrointestinal.........................................................................................................................................139
Mouth ulcers:..............................................................................................................................................139
Oral candidiasis:..........................................................................................................................................140
Noma...........................................................................................................................................................140
Gastritis, gastric-oesophageal reflux disease (GORD).................................................................................140
Paediatric Gastro-oesophageal Reflux Disease...........................................................................................141
Chronic liver disease....................................................................................................................................141
Haemochromatosis.....................................................................................................................................141
Biliary colic..................................................................................................................................................141
Amoebic liver abscess.................................................................................................................................141
Primary Biliary Cirrhosis..............................................................................................................................141
Hepatocellular cancer:................................................................................................................................141
Liver flukes and Schistosomiasis.................................................................................................................141
Ascariasis and hookworm............................................................................................................................142
Toxocariasis.................................................................................................................................................142

6
 Diverticular disease.....................................................................................................................................142
Inflammatory bowel disease.......................................................................................................................142
Haemorrhoids..............................................................................................................................................142
4.6 Urinary Tract..............................................................................................................................................142
Urinary Tract Infection................................................................................................................................142
Acute pyelonephritis..................................................................................................................................143
Glomerulonephritis and acute nephritis:....................................................................................................143
Nephrotic syndrome:...................................................................................................................................143
Acute Kidney Injury (AKI)...........................................................................................................................143
Chronic Kidney Disease (CKD).....................................................................................................................144
4.7 Neurological Disease..................................................................................................................................144
Epilepsy........................................................................................................................................................144
Cerebral Palsy..............................................................................................................................................147
Migraine......................................................................................................................................................147
Parkinson’s Disease.....................................................................................................................................148
4.8 Thyroid Disease..........................................................................................................................................148
Thyrotoxicosis..............................................................................................................................................148
Thyrotoxic crisis (thyroid storm)................................................................................................................149
Hypothyroidism...........................................................................................................................................150
Endemic goitre............................................................................................................................................151
4.9 Blood Disorders..........................................................................................................................................151
Anemia.........................................................................................................................................................151
Thalassaemia...............................................................................................................................................153
Sickle cell disease........................................................................................................................................153
4.10 Eye Disease..............................................................................................................................................155
Stye..............................................................................................................................................................156
Blepharitis....................................................................................................................................................156
Conjunctivitis...............................................................................................................................................156
Allergic conjunctivitis...................................................................................................................................156
Neonatal Conjunctivitis...............................................................................................................................157
Herpes simplex keratoconjunctivits............................................................................................................157
Corneal ulcer...............................................................................................................................................157
Iritis/ Uveitis................................................................................................................................................157
Orbital cellulitis............................................................................................................................................158
Trachoma.....................................................................................................................................................158
Vitamin A deficiency/Xerophthalmia..........................................................................................................159
Glaucoma.....................................................................................................................................................159
Cataract.......................................................................................................................................................160

7
4.11 Ears, nose, throat and oral.......................................................................................................................160
Ear wax........................................................................................................................................................160
Chronic suppurative otitis media................................................................................................................160
Otitis externa...............................................................................................................................................161
Teeth and gums...........................................................................................................................................161
Preventive dental care................................................................................................................................162
Gingivitis......................................................................................................................................................162
Vitamin C deficiency....................................................................................................................................162
Dental caries................................................................................................................................................162
Dental abscess.............................................................................................................................................162
Stomatitis.....................................................................................................................................................163
Aphthous ulcers...........................................................................................................................................163
Oral and oropharyngeal candidiasis............................................................................................................163
Oral herpes..................................................................................................................................................164
Nose bleeds (epistaxis)................................................................................................................................164
Allergic rhinitis.............................................................................................................................................164
Nasal Polyps.................................................................................................................................................165
4.12 Musculoskeletal and pain control...........................................................................................................165
Pain control.................................................................................................................................................165
Medications for musculoskeletal pain........................................................................................................166
Musculoskeletal conditions.........................................................................................................................168
Gout.............................................................................................................................................................168
Rheumatoid Arthritis...................................................................................................................................169
Osteoarthritis..............................................................................................................................................170
Use of steroids for disease suppression......................................................................................................170
Acute osteomyelitis.....................................................................................................................................171
Chronic osteomyelitis..................................................................................................................................171
Septic arthritis.............................................................................................................................................171
4.13 Palliative care...........................................................................................................................................172
Symptom Control........................................................................................................................................173
End of Life Care............................................................................................................................................178
4.14 Mental Health..........................................................................................................................................178
Psychosocial Interventions..........................................................................................................................179
Depression...................................................................................................................................................179
Self-harm and suicide.................................................................................................................................181
Anxiety disorders.........................................................................................................................................181
Psychosis......................................................................................................................................................182
Bipolar disorder...........................................................................................................................................184

8
 Medically unexplained symptoms (MUS)...................................................................................................185
Substance Misuse - Alcohol Use Disorders.................................................................................................186
Management of alcohol withdrawal.........................................................................................................187
5. Emergencies.......................................................................................................................................... 188
5.1 Emergency Medical Care...........................................................................................................................188
Triage...........................................................................................................................................................188
Assess the ABCDE........................................................................................................................................188
Treatment of anaphylaxis..........................................................................................................................190
Treatment of shock:....................................................................................................................................191
Management of major haemorrhage........................................................................................................192
Fever management.....................................................................................................................................193
Treatment of life-threatening infection.....................................................................................................194
Meningitis...................................................................................................................................................195
Tetanus........................................................................................................................................................196
Febrile convulsions in children...................................................................................................................197
Treatment of convulsions...........................................................................................................................197
5.2 Viral Hemorrhagic Fevers (VHF).................................................................................................................198
Ebola............................................................................................................................................................198
Yellow fever................................................................................................................................................199
5.3 Emergency Treatment of Poisoning..........................................................................................................199
General treatment steps for poisoning.....................................................................................................200
Paracetamol poisoning...............................................................................................................................200
Organophosphate insecticide poisoning...................................................................................................201
5.4 Blood Transfusion......................................................................................................................................201
Treatment of a transfusion reaction..........................................................................................................202
Disseminated intravascular coagulation....................................................................................................203
5.5 Anaesthesia................................................................................................................................................204
General Anaesthesia (GA):..........................................................................................................................204
Regional/Local Anaesthesia (LA):................................................................................................................204
5.6 Emergency Surgical Care...........................................................................................................................205
5.7 Trauma.......................................................................................................................................................206
Minor wound management.......................................................................................................................206
Major wound management.......................................................................................................................206
Bites.............................................................................................................................................................206
Snake bites..................................................................................................................................................207
Fractures.....................................................................................................................................................208
Burns...........................................................................................................................................................208
Index of Drugs........................................................................................................................................... 210

9
Index of conditions................................................................................................................................... 211
Resuscitation and Basic Life Support......................................................................................................... 213

Preface

Acknowledgements

10
List of abbreviations

ACE Angiotensin converting enzyme

ACR Albumin to creatinine ratio
ALT Alanine transaminase
ANC Antenatal care
ARB Angiotensin receptor blocker
ARI Acute respiratory infection
ART Antiretroviral therapy
ARV Antiretroviral
ASAQ Artesunate/Amodiaquine
ASB Asymptomatic bactiuria
AZT Zidovudine
BCG Bacille Calmette Guerin
BHT Boma Health Team
BMI Body mass index
BPD Bipolar disorder
BPHNS Basic package of health and nutrition sevices
BEmONC Basic emergency obstetrical and neonatal care
BP Blood pressure
CEmONC Comprehensive emergency obstetrical and neonatal care
COC Combined oral contraceptive
COPD Chronic obstructive pulmonary disease
CPR Cardiopulmonary resuscitation
CRT Capillary refill time
CS Caesarean section
CSB Corn soya blend
CV Cardiovascular
CVD Cardiovascular disease
CVA Cerebrovascular accident (stroke)
D&C Dilatation & curettage
DM Diabetes mellitus
DOT Directly Observed Therapy
DR-TB Drug resistant tuberculosis
DTP Diphtheria, tetanus, pertussis
DVT Deep vein thrombosis
ECG Electrocardiogram
ECP Emergency contraceptive pills
EML Essential medicines list
EPHS Essential Package of Health Services
EPI Expanded programme of immunisation
EPTB Extra-pulmonary tuberculosis
F100 F100 therapeutic milk
F75 F75 therapeutic milk
FANC Focussed antenatal care
FBC Full blood count
FDC Fixed dose combination
FEV1 Forced expiratory volume in 1 second
FSH Follicle stimulating hormone
FVC Forced vital capacity

11
GAD Generalised anxiety disorder
GDM Gestational diabetes mellitus
G6PD Glucose-6 phosphate dehydrogenase
GFR Glomerular filtration rate
GI Gastrointestinal
HbS Sickle Haemoglobin
HBV Hepatitis B virus
HCV Hepatitis C virus
HEI HV exposed infants
HiBV Haemophilus influenzae vaccine
IOP Intraocular pressure
iPT Intermittent presumptive treatment
IMCI Integrated Management of Childhood Illnesses
INR International normalised ratio
IPV Intramuscular polio vaccine
IUD Intrauterine contraceptive device
IUS Intrauterine system
LARC Long acting reversible contraceptive
LBW Low birth weight
LDL Low density lipoprotein
LH Luteinising hormone
MAM Moderate acute malnutrition
MCV Mean cell volume
MDA Mass drug administration
MDT Multiple drug therapy
MI Myocardial ischaemia/ infarction
mHGap Mental Health Gap
MIYCN Maternal, infant and young child nutrition
MSM Men who have sex with men
MOH Ministry of health
MTCT Mother to child transmission
MUAC Mid-upper arm circumference
MUS Medically unexplained symptoms
NCD Non-communicable disease
NG Nasogastric
NSAID Non steroidal anti inflammatory drug
OPV Oral polio vaccine
ORS Oral rehydration solution
ORT Oral rehydration therapy
OTP Outpatient therapeutic programme
Penta Pentavalent vaccine
PE Pulmonary embolism
PEP Post exposure prophylaxis
PHCC Primary health care centre
PHCU Primary health care unit
PLHIV People living with HIV
PMTCT Prevention of mother-to-child transmission
PTSD Post traumatic stress disorder
POP Progestogen-only pill
PPH Post partum haemorrhage
PrEP Pre-exposure prophylaxis
PTB Pulmonary tuberculosis
PWID People who inject drugs
RBG Random blood glucose
ReSoMal Rehydration solution for the malnourished

12
RHD Rheumatic heart disease
RUTF Ready-to-use therapeutic food
RDT Rapid diagnostic test
RR Respiratory rate
SAM Severe acute malnutrition
SC Stabilisation centre
SFP Supplementary feeding programme
SLE Systemic lupus erythematosus
SMOH State Ministry of Health
SPO2 Oxygen saturation pressure
SSRI Selective serotonin reupdate inhibitor
STG Standard treatment guideline(s)
STI Sexually-transmitted infection
TB Tuberculosis
TIA Transient ischaemic attack
UPSI Unprotected sexual intercourse
UTI Urinary tract infection
VCT Voluntary testing and counselling
VL Viral load
VTE Venous thrombo-embolism
VOC Vaso-occlusive crisis
WHO World Health Organisation

Abbreviations used for treatments

DOTS Directly Observed Treatment Short course

dpm drops per minute
g gram
IM intramuscular
IU international units
IV intravenous
kg kilogram
mcg microgram
mg milligram
ml millilitre
per for each
PO Per os (by mouth)
SC subcutaneous
Tab tablet
u Unit
x times (eg four times for each day = 4 x per day)

13
Introduction
A health system without treatment guidelines is like a transport system without rules. If
drivers could drive as fast as they liked, put in any fuel, drive on any side of the road and
have as noisy and polluting cars as they liked, then the number of accidents and deaths
would spiral. It would become much more dangerous to pedestrians and other drivers than if
drivers followed the simplest of rules, and the net effect would be more harm than good. It is
the same with a health system. If clinicians prescribe whatever they like with no guidance
then they are likely to cause great harm to patients, resulting in more suffering and even
deaths than from the original disease for which they consulted.

Health systems need rules, and above all the use of medicines needs to be very carefully
controlled. All medicines are developed by pharmaceutical companies because of their
potential benefits and impact on saving millions of lives. But used in the incorrect way, these
agents of humankind can exacerbate suffering and even provoke premature death.

That is why health professionals need to be very well trained in the use of medicines,
treatment guidelines and diseases protocols. Ministries of health are responsible to ensure
that people prescribed treatments by health professionals receive the most effective
medicine for the indication with the fewest side effects. And with limited budgets and wanting
to limit the bills that patients pay, health ministries have to constantly look for the most cost-
efficient treatments as well as those that are the most effective.

The purpose of the South Sudan National Standardised Treatment Guidelines STG

These STG outline principles for prescribing, and list the best treatments that are currently
available at affordable prices. The application of these guidelines in South Sudan brings
huge benefits to the health status and well-being of the population, limits potential harm that
incorrect prescribing can cause and eases the task of the thousands of health professionals
navigating their way through dozens of manuals and protocols. Developed as pocket guides
for different levels of the South Sudanese health system in line with the Basic Package of
Health and Nutrition Services (BPHNS), the availability of STG greatly simplifies the task of
health professionals in prescribing and ensures that those using the health system know that
they are getting the best treatments with the least chance of side effects at low cost. With
STG, the use of medicines becomes rational.

STG bring everyone involved in medicines together with the same purpose. They are used
by policy makers in the health ministries to set standards and regulate practices. Supply
chain managers consult them to ensure affordable generic medicines are available in line
with the STG. Prescribers (health professionals) consult them to ensure all their prescribing
is appropriate, evidence-based, and affordable. Dispensers (pharmacists and those
authorised to dispense) check that health professionals are prescribing correctly and not
duplicating medicines unnecessarily or using inappropriate or expensive medicines.
Dispensers also check that prescribed medicines are in line with the formulary for that level
facility. Patients benefit from the application of the STG in knowing that they are receiving
the best evidence-based, effective and affordable medicines, greatly improving the quality of
treatment they receive and limiting any out of pocket expenses.

The scope of the STG

The STG are the authoritative medicine prescribing guide for policy makers, managers,
dispensers and health professionals in the Republic of South Sudan. They are updated and

14
extended from the previous guidelines written for hospitals and health centres in 2006. The
hospital STG aim to cover the majority of conditions that hospital prescribers and dispensers
are treating. The next edition will be more comprehensive and include guidelines for more
internal medical and surgical conditions, include anaesthetics and rarer conditions such as
cancers, metabolic conditions and dialysis for which few centres currently offer treatment.

The concept and format of the STG

These STG are written in a format designed to be concise, clear and easy to use by
dispensers in pharmacies and by health professionals during consultations, at the bedside,
in the operating theatre or on a home visit. Unlike national treatment guidelines in some
countries, the STG have been “stripped back” to include just treatments and a few points
related to the treatment indication, dosage and key important side effects and interactions.
The STG are not diagnostic guidelines or clinical protocols, and do not provide detailed
descriptions of disease, although do include some diagnostic pointers. This information can
be found in other documents including training manuals, reference text books, on-line
resources and disease-specific protocols. To have included this information would have
made the STG much longer and not as easy to reference during consultations. The STG are
primarily about medicines: when and how to best use them. In the future clinical protocols
may be produced to accompany the STG.

The Authority of the STG

The STG are developed, approved and adopted by the Ministry of Health of the Republic of
South Sudan. They are the standardised treatments that should be followed at each level of
the health system. Application of the STG brings huge benefits for patient well-being,
reduces the harm caused by inappropriate prescriptions and brings large cost savings for
health facilities and the population. Only health professionals licenced to practice (whether in
the public or private sector) by the Ministry of Health the health professional associations are
authorised to use these guidelines. The guidelines assume that the health professional at
each level has been trained to use the treatment described. Each set of guidelines outlines
which professionals are authorised to prescribe which treatments.

These guidelines must not be used by someone who has not been trained to give a
treatment or by someone who is not authorised by the health ministry to work in a health
facility.

The STG are based on the current evidence-based prescribing practices from South Sudan,
from WHO and from other international standards, with cost-effectiveness taken into
account. In medicine the evidence is constantly changing as new research is carried out. At
times the Ministry of Health may issue statements on small adjustments to be made to these
STG based on new evidence about a medicine, but with budgetary constraints the full STG
will only be updated every few years.

Principles of prescribing and dispensing

Principle Explanation of principle

Efficacy The best-known treatment is given for the appropriately diagnosed

medical condition.
Evidence-based Treatments are selected based on their efficacy and credibility as
proven by research from around the world.

15
Updated As the evidence changes, health ministries may issue small
adjustments to the STGs.
Cost-effective The most effective and affordable options are chosen. Generic names
are used instead of brand names.
Harm-limiting All medicines have negative as well as positive effects. Treatments
are selected that are likely to be as safe as possible, causing the
fewest side-effects to patients.
Professional Only registered health professionals are authorised by health
ministries to prescribe. Prescribers and dispensers behave with the
utmost professionalism in adhering to treatment guidelines and in
following ethical codes of conduct. They are not influenced by
medicines branding or by the advertising pressure of pharmaceutical
companies.
Quality-controlled All medicines dispensed are supplied from quality-controlled
procurement and supply chains.

Standard National Treatment Guidelines (STG) for Hospitals

Danger signs
Hospital and RHC staff must be very attentive to any child or adult presenting with danger
signs. Appropriate action must be taken and relevant life-saving medication given as
appropriate. These signs include the following:

Signs of severe infection

 high fever (over 40°)
 drowsiness, blue or very pale colour
 convulsions
 stiff neck

Signs of severe dehydration

 Lethargic or unconscious
 Sunken eyes
 Not able to drink, or drinking poorly
 Skin pinch goes back very slowly (children and young adults only)

Signs of severe pneumonia

 very rapid or noisy breathing
 chest indrawing

Signs of shock
 Fast, feeble pulse
 Low BP
 Cold, clammy skin
 Pallor or blue colour
 Drowsiness or unconscious

Standard precautions for avoiding transmission bloodborne and other pathogens in

health facilities.
Standard universal precautions of infection prevention and control must be taken routinely
with all clients at all times (consult guidelines):

16
 1. Hand hygiene. Hand washing with soap or hand rubbing with alcohol gel before and
after any direct patient contact.
2. Gloves. Wear gloves when touching blood, body fluids, secretions, excretions, mucus
membranes, non-intact skin. Remove after use and perform hand hygiene.
3. Facial protection (eyes, nose, mouth). Wear a procedure mask and eye protection
during activities that are likely to generate splashes or sprays of blood, body fluids,
secretions and excretions.
4. Gown. Wear during activities that are likely to generate splashes or sprays of blood,
body fluids, secretions and excretions. Remove soiled gown and perform hand
hygiene. If there is any possibility of a patient having a viral haemorrhagic disease
like Ebola then full personal protective equipment must be worn as per the Ebola
Virus Disease (EBV) guidelines.
5. Prevention of needle-stick injuries. Use care when handling needles, scalpels and
other sharp instruments, when cleaning instruments and when disposing of used
needles, which should put in a sharps box.
6. Respiratory hygiene and cough etiquette. Persons with respiratory symptoms should
cover their nose and mouth when coughing / sneezing with tissue or mask, disposed
of used tissue or mask and perform hand hygiene after contact with respiratory
secretions. Place acute febrile respiratory symptomatic patients at least 1 metre
away from others.
7. Environmental cleaning. Ensure the floors and surfaces of all clinical spaces are
clean at all times. Clean up any blood or bodily fluids immediately with 0.5% chlorine
solution.
8. Linen. Handle and transport used linen in a way that prevents skin and mucous
membrane exposure.
9. Waste disposal. Ensure waste is safely segregated at point of generation and in the
external waste zone, not accessible to patients and children, and collected regularly.
Sharps boxes should be available at all sites using needles/ scalpels and not more
than ¾ full. No unprotected sharps should be left on surfaces and needles should
never be re-used. Infectious waste must be treated and disposed of safely and no
bandages/ infectious waste lying exposed. Waste needs to be transported and stored
securely.
10. Patient care equipment. Equipment should be handled in a way that prevents any
exposure of skin or mucus membranes to blood, body fluids, secretions and
excretions. All equipment must be cleaned, disinfected and reprocessed resusable
before use with another patient.

Prescribing paracetamol
Paracetamol is the most common medicine used in the health system. It helps reduce fever,
pain and symptoms associated with the common cold such as cough and congestion. A
medicine used for pain control is called an analgesic and a medicine used for fever is called
an antipyretic. For fever it is given if the temperature is over 38.5°. It is given for many of the
conditions described in the STG. Paracetamol should not be given more than every 6 hours
(not more than 4 x per day). There are several preparations on the SSEML - 500mg tablets
and 125mg tablets, 100mg dispersible tablets, 125mg/5ml liquid and 125mg suppositories,
so it is very important that the right amount is given for each preparation.

Like all medicines, paracetamol is effective in the prescribed dosage but may be very
dangerous if this dose is exceeded. If a patient accidentally takes too much, or a parent has
accidentally given a child more than double the recommended dosage, then hospitalise
immediately. Depending on the history, and on serum paracetamol levels if available, a
specific antidote (acetylcysteine – see 5.4) may need to be given.
The following dosage table is used whenever “Give paracetamol” is mentioned in the STGs.
Medicine Age Dose Side effects

17
Paracetamol Infants < 2 months 30mg/ kg 3 x per day Common: no
Infants 2 – 6 months 60mg 4 x per day common
(2.5mls of 125mg/ 5mls syrup or ½ Rare: skin reaction.
125mg tablet)
Children 6 months to 3 120mg 4 x per day Very dangerous in
years (5mls of 125mg/5mls syrup or over-dosage, refer
125mg tablet) all cases.
Children 3 years to 7 250mg 4 x per day
years (10mls of 125mg/5ml syrup or 2 x
125mg tablet or ½ x 500mg tablet)
Children 8 to 11 years 500mg 4 x per day
(1 x 500mg tablet)
Children 12 to 15 750mg 4 x per day
years (1½ 500mg tablet)
Adults (16 years and 1000mg 4 x per day
over) (2 x 500mg tablets)

18
 1. Maternal & Reproductive Health
1.0 Basic Emergency Obstetric and Neonatal Care and Comprehensive
Emergency Obstetric and Neonatal Care

Basic emergency obstetric and neonatal care (BEmONC) is a set of lifesaving services
considered essential to reduce maternal and neonatal mortality around normal delivery. An
extension of this is comprehensive emergency obstetric and newborn care (CEmONC). This
includes all BEmONC services and adds surgical capacity, managing complications of
delivery and blood transfusion.

Where appropriate these terms will be referenced in later chapters.

Basic EmONC (BEmONC)

1. Parenteral treatment of infection (antibiotics)

2. Parenteral treatment of severe pre-eclampsia/eclampsia (e.g., MgSO4)
3. Treatment of PPH (e.g., uterotonics)
4. Manual vacuum aspiration of retained products of conception
5. Assisted vaginal delivery (e.g., vacuum-assisted delivery)
6. Manual removal of placenta
7. Newborn resuscitation

Comprehensive EmONC

All components 1 to 7 of BEmONC plus:

1. Surgical capability, including anaesthesia (e.g., Caesarean section)

2. Blood transfusion

Major obstetric complications cause the majority of preventable maternal deaths. Each of the
functions acts to combat this.

Major obstetric complication Signal function

Haemorrhage
Prolonged or obstructed
labour
Postpartum sepsis
Complications of abortion
Antepartum:
Perform blood transfusion
Perform surgery (e.g., caesarean section for placenta praevia)
Postpartum:
Administer uterotonic drugs
Perform blood transfusion.
Perform manual removal of placenta
Perform removal of retained products
Perform surgery (hysterectomy) for uterine rupture
Perform assisted vaginal delivery
Perform surgery (caesarean section)
Administer uterotonic drugs
Perform neonatal resuscitation
Administer parenteral antibiotics
Remove retained products
Perform surgery for pelvic abscess
For haemorrhage:
Perform blood transfusion and Remove retained products
For sepsis:

19

Pre-eclampsia or eclampsia
Ectopic pregnancy
Ruptured uterus
Newborn distress
(intrapartum)
Administer parenteral antibiotics and Remove retained products
For intra-abdominal injury:
Administer parenteral antibiotics, perform blood transfusion and
surgery
Administer parenteral anticonvulsants
Perform neonatal resuscitation
Perform surgery (caesarean section)
Perform surgery
Perform blood transfusion
Perform surgery
Perform blood transfusion
Administer parenteral antibiotics
Perform newborn resuscitation
Perform surgery (caesarean section)

1.1 Birth Spacing

Birth Spacing Saves Lives
Saves Women’s Lives
 At least one woman dies every minute from causes related to pregnancy and
childbirth: In developing countries, a woman’s lifetime risk of dying due to pregnancy
and childbirth is almost 100 times higher than the risk for a woman in more
developed countries—1 in 75, compared to 1 in 7,300.
 Family planning could prevent up to one-third of all maternal deaths by
allowing women to delay motherhood, space births, avoid unintended pregnancies
and unsafely performed abortions, and stop childbearing when they have reached
their desired family size.
 Family planning prevents abortions: An estimated 20 million unsafely
performed abortions take place each year— resulting in 67,000 deaths annually,
mostly in developing countries. Family planning can prevent many of these tragic
deaths by reducing the number of unintended pregnancies that lead to abortions.
Saves Children’s Lives
 Closely spaced births result in higher infant mortality: International survey data show
that babies born less than two years after their next oldest brother or sister are twice
as likely to die in the first year as those born after an interval of three years.
Saves Adolescent Lives
 Young women face higher risks of dying from pregnancy or childbirth: Women aged
15 to 19 are twice as likely to die from maternal causes as older women; many adolescents
are physically immature, which increases their risks of suffering from obstetric complications.
 Young women have high rates of unintended pregnancy: Each year 2.5 million
teenagers in developing countries end their pregnancy by undergoing abortions that are
performed either by persons lacking the necessary skills or in unsafe conditions, or both.
Cost effectiveness
 Voluntary family planning is one of the most cost-effective investments a country can
make in its future. Every dollar spent on family planning can save governments up to 6
dollars that can be spent on improving health, housing, water, sanitation, and other public
services. (according to Bill and Melinda Gates Foundation)
 Family planning is an effective approach to reducing costs associated with HIV/AIDS:
Researchers found a potential savings of almost US$25 for every dollar spent on family
planning at HIV/AIDS care and treatment facilities.

20
Methods
Birth spacing counselling and services are provided during the continuum of care from
antenatal through postnatal periods and include counselling on both natural and modern
contraceptive methods.
Natural Contraceptive methods are safe but not very reliable. Approximately 1 in 4 women
will fall pregnant each year using fertility awareness methods. This involves abstaining or
using condoms on fertile days. The newest methods (standard days method and 2-day
method) may be the easiest and consequently more effective. The lactational amenorrhea
method (LAM) is a highly effective temporary form of contraception.
Women living with HIV are advised to use dual method (condom and another contraceptive
method). The condom prevents re-infection with other HIV strains or STIs. Women with HIV
can use most methods of birth spacing apart from spermicides, the diaphragm or caps with
spermicide.

Modern contraceptive methods fall into 3 categories – short acting (requiring the user to
remember to use/take the contraceptive), long acting (usually administered by the medical
practitioner for the duration of use) and permanent. Anyone prescribing contraception should
be trained and follow approved protocols for use of each method. What follows is a brief
summary of appropriate treatment.

The phrase ‘reasonable sure she is not pregnant’ will be used on a number of occasions to
determine this. Ask the patient questions 1-6: As soon as the client answers yes stop and
follow the instruction below:

1. Did you last monthly bleeding start within the past 7 days?
2. Have you abstained from sexual intercourse since your last monthly bleeding,
delivery, abortion or miscarriage?
3. Have you been using a reliable contraceptive method consistently and correctly since
your last monthly bleeding, delivery, abortion or miscarriage?
4. Have you had a baby in the last 4 weeks?
5. Did you have a baby less than 6 months ago, are you fully or nearly-fully
breastfeeding, and have you had no monthly bleeding since then?
6. Have you had a miscarriage or abortion in the past 7 days? (or 12 days if planning on
starting the copper IUD)

If the patient answer Yes to any of the questions we can be ‘reasonably sure’ she is not
pregnant, if she answers No to ALL of the questions, pregnancy needs to be excluded by
other means

Short-acting Methods
Barrier methods
This includes the male and female condoms, diaphragms and caps; however, the male
condom is the most readily available. Counselling is given on condom use at appropriate
moments in consultations with men, women and adolescents in line with training and
national birth spacing guidelines. Condoms must be used correctly to prevent STIs and to
reduce pregnancies. The risk is greatest when condoms are not used with every act of sex.

21
 Combined Oral Contraceptive Pill (COC)
Medicine Dose Duration
Ethinylestradiol + 1 Continuous ; take
Levonorgestrel 30mcg tablet next pill packet
+ 150mcg tablet, per without a break.
28 pack with 7 inactive day
tabs
Side effects
Common: shorter, lighter periods, nausea, breast
changes, mood changes, acne (improve or worsen),
migraine
Rare: deep vein thrombosis (in calf of leg) can also cause
pulmonary embolus (but DVT risk less than in pregnancy)

Medicine Dose Duration Side effects

Ethinylestradiol + 1 See below As above
Levonorgestrel 30mcg tablet
+ 150mcg tablet, 21 per
pack day

The COC can be used for contraception and/or helping control menstrual bleeding with
some gynaecological disorders. There is no evidence that one COC pill is more effective
than another, though thrombotic risk is variable. If available, COCs different from those
described above, maybe preferred in certain circumstances to others e.g. presence of break
through bleeding. The COC protects against ovarian and endometrial cancer. The COC may
slightly increase the risk of breast cancer in those who have used the COC within the last
10yrs and slightly increase lifetime risk of cervical cancer in those who have taken the COC
for more than 5yrs. These are small risks.

Most combined hormonal contraception is licensed for 21 days of pill taking followed by 7
days off. The endometrial lining is shed during this 7 day hormone-free ‘period’. However,
there is no biological need to have a monthly endometrial shedding. The only reason to
have a withdrawal bleed is to prevent break-through bleeding which may be inconvenient or
irritating. Therefore, women may take the COC as an extended regime, during which pills
are taken every day, without a pill free week. There are many advantages to using an
extended regime including reduced risk of unintended pregnancy, reduced bleeding days
and suppression of hormonal symptoms.

In summary, the COC can be taken in one of three ways.

Traditional Taking 21pills followed by a 7 day break (or 7 inactive pills)
Scheduled extended cycles Taking 2 or 3 packs consecutively followed by 4-day break (or up to 7
(‘bicycling/tricycling’ packs) days).
Unscheduled extended cycles Pills are taken continuously for a minimum of 28 days. When/if break-
(‘tailored’ regimes) through bleeding occurs, take a 4-day hormone-free break (up to 7
days).
Key messages:
 Take one pill every day, at about the same time each day.
 Take any missed pill as soon as possible. Missing pills risks pregnancy and may
make some side effects worse. See ‘missed pills rules’ below
 Bleeding changes are common but not harmful.
Starting the COC:
 A woman can start using COC’s any time she wants if it is reasonably certain she is
not pregnant
 The COC should be prescribed with caution in smokers and for women with obesity,
and smoking-cessation advice or weight-reduction advice should be given.
 Ensure no personal history of heart, breast or liver disease, of sickle cell disease, or
history of a deep vein thrombosis, pulmonary embolus or stroke, or of migraine
headaches. (The COC should not be given if any of these are positive in the history).
 Check BP to ensure it is normal (though if this is not possible arrange to take at the
earliest opportunity)
 Give 3 packs for 3 months with a full explanation..

22
  Review in 3 months, ask about side effects, check BP. If all is well a further 6 months
treatment (6 packs) can be given.

Stopping the COC:

 The COC should be stopped if there is sudden severe chest pain, sudden
breathlessness, unexplained swelling in the calf, severe stomach pain, severe
headache or migraine or neurological effects, hepatitis or significantly raised BP.
 The woman admitted immediately, investigated and treated for possible DVT, PE or
other pathology.
 The COC should be stopped before surgery, but resumed once again when the
women is mobile after the surgery.
Missed pill rules: If women are established on an extended regime, the missed pill rules
become irrelevant unless more than 3 pills are missed around the time of the 4-7 day break.
However, it is useful to know the missed pill rules for the benefit of women established on
traditional regimes. If vomiting a pill within 2hrs, take a further pill and continue as normal, if
vomiting or severe diarrhoea for more than 2 days follow instruction below for two or more
missed pills.

One missed pill Take a pill now immediately even if this means taking two at the same time, continue
with the rest of the packet.

Two or more Take a pill immediately even if this means taking two at the same time, discard the
missed pills remaining missed pills, continue with the rest of the packet, use extra precautions, if
has had UPSI in the 7 days prior may need emergency contraception, seek advice.

A note on Breastfeeding and the COC:

Breast Feeding <6 weeks post Do not use <21d postnatal: concern about VTE
partum risk because residual pro-thrombotic
>6weeks to Use with caution state of pregnancy
<6months post COC after 6w postpartum reduces milk
partum volumes. After 6w there is no
>6months post Safe detrimental effect on infant growth
partum
Post Natal not <3w Do not use Do not use
Breast Feeding 3-6w Use with caution Don not use if other risk factors for
VTE present
>6w Safe Use with caution if other risk factors for
VTE present

Women with HIV can safely use the COC unless they are on the ARV ritonavir. Condoms
are also advised to help prevent HIV transmission.

Progesterone Only Pill (POP)

Medicine Dose Duration Side effects
Levonorgestrel Take 1 Continuous Common: irregular periods (may spot or bleed throughout
30mcg 28 pack per day treatment. cycle); nausea, headache
Rare: vomiting, breast discomfort, depression, skin disorders

POPs are a good alternative to COCs when oestrogens are contraindicated. The POP
needs to be taken within 3 hours of the same time each day otherwise the contraceptive
effect may be lost. It is not an ideal method for women who find it difficult to remember to
take pills. Women with HIV can safely use the POP unless they are on the ARV ritonavir.

Key Messages
 Take one pill every day, no breaks between packs

23
  Provides effective contraception when breastfeeding
 Frequent or irregular bleeding is common but not harmful
 Can be given to a woman at any time to start immediately or later

Starting the POP:

 A woman can start using the POP any time she wants if it is reasonably certain she is
not pregnant
 Do not give if continued vaginal bleeding, severe cirrhosis of the liver, current
DVT/PE, taking medication for TB/seizures (refer to guidelines), have ever had
breast cancer or current severe hypertension.
 Check BP
 Give 3 packs for 3 months and fully explain how to take it, at the same time each day
and without a break.
 Review in 3 months, ask about side effects, check BP. If all is well a further 6 months
treatment (6 packs) can be given.
 If starting less than 3 weeks postpartum, condoms are not needed; if more than 3
weeks postpartum then condoms should be used for sex or abstinence in the first 2
days after starting the POP.

The POP can be taken one way:

Continuous Take one pill every day without a break

If switching from COC, continue directly from one method to the other without a break. If the
COC pack has inactive pills discard these and proceed directly to POP without a break.

Missed pill rules: If vomiting within 2 hours, she should take another pill. If she continues
vomiting or has diarrhoea for more than 24 hours she should continue taking the pill but use
other precautions (condoms) for 2 days after recovery or abstain from sex for those 2 days.

One missed pill If the pill is missed by more than 3hours then the contraceptive effect may be lost. The
pill is taken but condoms should be used or abstinence for the next 2 days. If she has
had sex in the past 5 days she may need consider emergency contraception.

A note on breast feeding and the POP:

If fully breastfeeding <6months after birth
If fully breastfeeding >6months after birth
If partially breastfeeding <6months after birth
If partially breastfeeding >6months after birth
If monthly bleeding hasn’t started start POP any
time. If it has returned, then she can start at any
time if pregnancy has been excluded
As above but use a backup method for first 2 days
of use.
If monthly bleeding hasn’t started start POP any
time and use backup method for first 2 days of use,
having excluded pregnancy
Start as per women with normal menstrual cycles.

24
Long acting Methods
Progesterone Only Injection DMPA (Depot medroxyprogesterone acetate) and NET-EN
(norethisterone enanthate)
Medicine Dose Duration Side effects
Norethisterone 100mg/ml 8 weeks Common: absence of periods, or irregular
enanthate 100mg/ml periods; delayed return to fertility
Depo- 1 deep 12 weeks
medroxyprogesterone IM/SC Rare: prolonged bleeding
acetate DMPA -IM or injection
DMPA-SC every 3
months
Contain a progestin like natural hormone progesterone in a women’s body and are given
either intramuscularly (DMPA-IM, NET-EN) or subcutaneously (DMPA-SC). They are useful
for women who either forget or do not want to take a pill daily. They typically cause a
reduction in menstrual flow or amenorrhoea, which may be beneficially especially in those
with menorrhagia, sickle cell or iron deficiency anemia. There is usually a delay in return to
fertility of 3-4months but no evidence of permanent infertility. A woman must be warned that
from the time when the next injection is due, if she doesn’t have it, she may ovulate and
become pregnant before having a period. However, in practice, an injection may be as
much as 4 weeks late for DMPA or 2 weeks late for NET-EN without a significant loss of
contraceptive effect.

DMPA is now available for subcutaneous injection in a prefilled syringe with a short needle
designed for injection just under the skin. The Uniject system (marketed under the brand
name Sayana Press) may be particularly useful in community-based programs as women
can easily learn how to self-administer. It is as effective as effective as DMPA given IM, but
can be given discretely by the woman to herself. It has the same side effects.

Key Messages:
 Bleeding changes are common but not harmful
 Coming back every 3 months (12weeks) for DMPA or every 2 months for NET-EN is
important for greatest effectiveness
 Gradual weight gain is common, averaging 1-2kg a year.

Starting the Progesterone Injectable:

 A woman can start the injectable any time she wants if it is reasonably certain she is
not pregnant
 Use a backup method for 7 days if starting later than Day 5 of her cycle
 Do not give if severe liver disease, severe hypertension, diabetes with complications,
heart disease, breast cancer or unexplained vaginal bleeding
 Give either IM or SC, ensure patient knows when to return. If given SC demonstrate
use and on the second occasion watch the patient self-administer, the patient can
then be given 3 further SC injectables to self-administer before returning for an
annual review.

A note on HIV: Some research has found that women who use progestin-only injectables
and are exposed to HIV are more likely than other women to get HIV infection. Providers
should discuss this finding with women.
A note on breast feeding: Progestin injectables are a safe and reliable method to use whilst
breast feeding but must not be started until 6 weeks after birth.

25
 Contraceptive Implant
Medicine Dose Duration Side Effects
Etonogestrel 68mg 1 radiopaque rod 3years Common: change in bleeding pattern,
Implant Rare: acne, mood changes, weight gain
Levonorgestrel 75mg 2 silicone rods 5yrs

Key messages:
 Implants are small flexible rods placed just under the skin of the upper arm
 Depending on the type of implant the provide immediately reversible protection for 3-
5yrs
 Requires a specifically trained provider to insert and remove
 Bleeding changes are common but not harmful

Starting the implant:

 A woman can start the implant any time she wants if it is reasonably certain she is
not pregnant
 Do not start if severe liver disease, a current DVT/PE, a current or past history of
breast cancer or unexplained vaginal bleeding.
 Can be inserted within 7 days after the start of her monthly bleeding, or after if it
reasonably certain she is not pregnant. She will need a back up method for the first 7
days after insertion.

A note on HIV:
Women who are living with HIV or on ARV therapy can safely use implants, however
Efavirenz may reduce effectiveness so women are advised to use condoms in addition.

A note on breast feeding: Implants are safe to use whilst breast feeding. If fully breast
feeding and less than 6 months post partum, the implant can be inserted without back up. If
over 6 months, if fully or partly breastfed, and bleeding has not returned, pregnancy must be
excluded before insertion, that must then be followed by 7 days backup. If bleeding has
returned treat as if not breast feeding.

Intrauterine Contraceptive Device

An IUD is a flexible device fitted inside the uterus. The most effective IUD is the intra-uterine
system (IUS) that are plastic devices with slow release progestogen, but these are
expensive. The IUS is also useful in reducing menorrhagia (see 1.10). More widely available
is the copper IUD (Cu-IUD), (currently the TCu380A) made of plastic in a “T” shape, with
copper sleeves on the arms and copper wire wrapped around the stem. It provides
protection from pregnancy for as long as 12 years. Return of fertility is not delayed after
removal.
Medicine Dose Duration Side Effects
Tcu380A Intrauterine - 10yrs Often heavier and longer periods (Cu-IUD only)
Contraceptive Device (Cu- Pelvic inflammatory disease (PID) may occur if
IUD) the woman has chlamydia or gonorrhoea at the
Levonorgestrel releasing 52mg 5yrs (unless fitted after time of IUD insertion
intrauterine system. Mirena 45yrs old, then 7yrs) Risk of expulsion 1:10, Infection 1:100 and
perforation 1:1000 after fitting

Key Messages:
 Provides effective, long lasting, immediately reversible pregnancy protection
 Ideal for a woman who has delivered one baby, but wishes to space out her next
pregnancy and does not wish to consider hormonal contraceptive
 Requires fitting by a specially trained service provider

26
 Starting the Cu-IUD
 Do not fit if the patient gave birth more than 48hrs and less than 4 weeks ago, if she
had an infection following childbirth/abortion, if there is unexplained vaginal bleeding,
or genital/pelvic conditions, HIV with severe or advanced disease, high risk of STI’s
 Ensure a pelvic examination is carried out to exclude where possible STI’s, PID and
anatomical abnormality that would prevent fitting.
 As long as it is reasonably sure the patient is not pregnant the IUD can be fitted
without requirement for a backup method.

Starting the IUS (Mirena)

 As Cu-IUD + do not fit if current or past history of breast cancer, current DVT/PE,
severe liver disease
 As long as it is reasonably sure the patient is not pregnant the IUS can be fitted at
any time but if after day 7 requires 7days use of a backup method.

A note on breast feeding: Both the IUD and IUS are safe and effective to use whilst breast
feeding as long as fitted <48hrs or >4weeks after delivery.

A note on HIV: Women living with HIV can safely have an IUD inserted if they have mild or
no clinical disease, whether or not they are on antiretroviral therapy. Those with advanced or
severe clinical disease should not have an IUD inserted. If a woman becomes infected with
HIV while she has an IUD in place, it does not need to be removed. An IUD user living with
HIV who develops advanced or severe clinical disease can keep the IUD but should be
closely monitored for pelvic inflammatory disease. The IUD does not increase the risk of
becoming infected with HIV.

Permanent Methods
Female and Male Sterilisation

1.2 Antenatal Care

Antenatal care models, with eight contacts, are 2016 WHO ANC Model
recommended to reduce perinatal mortality and First Trimester
improve women’s experience of care Contact 1: Up to 12 weeks
Second Trimester
The aim is to provide pregnant women with
Contact 2: 20weeks
respectful, individualized, person-centred care at
Contact 3: 26 weeks
every contact, with implementation of effective Third Trimester
clinical practices (interventions and tests), and Contact 4: 30 weeks
provision of relevant and timely information, and Contact 5: 34 weeks
psychosocial and emotional support, by Contact 6: 36 weeks
practitioners with good clinical and interpersonal Contact 7: 38 weeks
skills within a well-functioning health system. Contact 8: 40 weeks
Return for delivery at 41 weeks if not
Nutritional Interventions given birth
In the undernourished, balanced energy and protein dietary supplementation is
recommended for pregnant women to reduce the risk of stillbirths and small-for-gestational-
age neonates. Staff screen women with MUAC bands at ANC.

Women enrolled where possible in a Supplementary feeding programme (SFP) are

Moderate Acute given take-home dry rations or supplementary Plumpy®. The quantities given are
Malnutrition (MAM) monitored as part of any SFP that are available, and clear instructions are given on
how to give supplementary Plumpy® or prepare CSB or UNIMIX at home.

27
Severe Acute Malnutrition As above, plus enrolled in either outpatient therapeutic care or the inpatient
(SAM) therapeutic centre if complications

Daily oral iron and folic acid supplementation with 30 mg to 60 mg of elemental iron and
400 mcg (0.4 mg) of folic acid is recommended for pregnant women to prevent maternal
anemia, puerperal sepsis, low birth weight, and preterm birth. If a woman is diagnosed with
anemia during pregnancy, her daily elemental iron should be increased to 120 mg until her
Hb concentration rises to normal (110 g/L or higher).

If there is low dietary calcium intake, daily calcium supplementation (1.5–2.0 g oral elemental
calcium) is recommended for pregnant women to reduce the risk of pre-eclampsia. Dividing
the dose may make it more tolerable.

Vitamin A supplementation is only recommended for pregnant women in areas where

vitamin A deficiency is a severe public health problem, to prevent night blindness. Up to
25,000IU weekly.

Multiple micronutrient, Vitamin B6 (pyridoxine) C, D, E supplementation are NOT

recommended for pregnant women to improve maternal and perinatal outcomes

Maternal Assessment
Provider-initiated testing and counselling (PITC) for HIV should be considered a routine
component of the package of care for pregnant women in all antenatal care settings.

Systematic screening for TB - ask if a pregnant woman if she has ONE of the following
currently:
 Cough for any duration
 Fever for any duration
 Night sweats
 Weight loss OR failure to gain weight in pregnancy
If Yes, she should have sputum investigation for TB. If positive she will need to be enrolled
for TB treatment (See 3.8)

Hyperglycaemia first detected at any time during pregnancy should be classified as either
gestational diabetes mellitus (GDM) or diabetes mellitus in pregnancy, according to WHO
criteria and treated accordingly (Section 4.2)

A 7-day antibiotic regimen is recommended for all pregnant women with asymptomatic
bacteriuria (ASB) to prevent persistent bacteriuria, preterm birth and low birth weight.
Amoxicillin 500mg 3x per day and Nitrofurantoin 200mg twice a day are safe to use
throughout pregnancy.

Preventative Measures
Preventive anthelminthic treatment is recommended for pregnant women after the first
trimester as part of worm infection reduction programmes. Albendazole 400mg is given as a
single dose once during pregnancy in the 2nd or 3rd trimester.

Tetanus toxoid vaccination is recommended for all pregnant women, depending on

previous tetanus vaccination exposure, to prevent neonatal mortality from tetanus.

Administration of tetanus toxoid by staff specifically trained to give immunisations:

Tetanus toxoid
Type of vaccine Toxoid
Number of doses At least two primary doses (life time total of 5)

28
Schedule See next table
Contraindications Anaphylactic reaction to previous dose
Adverse reactions Mild local or systemic reactions are common and increase in frequency with
increasing numbers of doses, and may constitute a contraindication to
further doses
Dosage 0.5ml
Injection site Outer upper arm
Injection type Intramuscular
Storage Store between 2°C–8°C. Never freeze

Between 0 and maximum 3 doses of tetanus toxoid immunisation (TT2+) are given during
pregnancy depending on previous immunisation history. The following table is consulted:
Dose Time of administration Duration of protection
TT1 At first contact No protection
TT2 4 weeks after TT1 Three years
TT3 At least 6 months after TT2 Five years
TT4 At least one year TT3 Ten years
TT5 At least one year after TT4 For thirty years (throughout a woman’s reproductive life)

Intermittent preventive treatment of malaria with sulfadoxine-pyrimethamine (IPTp-SP)

is recommended for all pregnant women living in areas of moderate to high malaria
tramsmission. Dosing should start in the second trimester, and doses should be given at
least one month apart, with the objective of ensuring that at least three doses are received.
(3 tablets per dose)

Haemolytic disease of the newborn (HDN) is caused by antibodies that are produced by
the mother which cross the placenta and destroy the baby’s red cells. HDN due to ABO
incompatibility between mother and infant does not affect the foetus in utero but is an
important cause of neonatal jaundice. HDN due to Rh D incompatibility is an important cause
of severe fetal anemia. The fetal red cells are haemolysed, causing severe anemia or death
in utero, brain damage after birth from high levels of bilirubin.

Screening and management in pregnancy and after delivery.

The ABO and Rh D group of all pregnant women should be determined when they first
attend for antenatal care if testing is available. If no antibodies are detected at the first
antenatal visit, the pregnant woman should have a further antibody check at 28–30 weeks
gestation.
 Anti-Rh D immunoglobulin prevents the sensitisation and production of antibodies in
a Rh D -ve mother to Rh D +ve red cells that may have entered the maternal
circulation.
 Postpartum prophylaxis is the most common approach to prevention of Rhesus
disease.
 Give anti-Rh D immunoglobulin in a dose of 500 mg/IM to a Rh D -ve mother within
72 hours of delivery if the fetus is Rh D +ve.

If any sensitizing event occurs during the antenatal period, give:

250 mg of anti-Rh D immunoglobulin IM up to 20 weeks gestation
500 mg of anti-Rh D immunoglobulin IM from 20 weeks to term.

Antenatal prophylaxis: If available, the following can be given to all pregnant women who are
Rh D -ve: 500 mg anti-Rh D immunoglobulin IM at 28 and 34 weeks OR a single larger dose:
1,200 mg IM early in the third trimester.

Human Immunodeficiency Virus (HIV)

29
All women are offered voluntary counselling and tests for HIV and other diseases as part of
routine bloods in the ANC. All women who test positive for HIV or syphilis are enrolled in the
appropriate treatment programme (for PMTCT see 3.6)

Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil fumarate (TDF) should
be offered as an additional prevention choice for pregnant women at substantial risk of HIV
infection as part of combination prevention approaches.

1.3 Antenatal Care Complications

Some women experience health problems during pregnancy. These complications can
involve the mother's health, the foetus’s health, or both. Even women who were healthy
before becoming pregnant can experience complications. These complications may make
the pregnancy a high-risk pregnancy. Receiving early and regular antenatal care can help
decrease the risk for problems by enabling health care providers to diagnose, treat, or
manage conditions before they become serious.

Malaria in Pregnancy
Insecticide-treated nets should be used to reduce the risk of malaria in pregnant women.
Women with malaria in pregnancy need to have the severity of the condition assessed in
order to guide management. Uncomplicated Malaria: see 3.3 Severe Malaria: see 3.3

Women in the 2nd and 3rd trimesters are more likely to have severe malaria than other
adults, and, in low-transmission settings, this is often complicated by pulmonary oedema and
hypoglycaemia. Maternal mortality is approximately 50%. Fetal death and premature
labour are common.

Parenteral antimalarial drugs should be given to pregnant women with severe malaria in full
doses without delay. Parenteral artesunate is the treatment of choice in all trimesters. See
3.3. Treatment must not be delayed. If artesunate is unavailable, intramuscular artemether
should be given, and if this is unavailable then parenteral quinine should be started
immediately until artesunate is obtained.

Obstetric advice should be sought at an early stage, where possible a paediatrician alerted
and blood glucose checked frequently. Hypoglycaemia should be expected, and it is often
recurrent if the patient is receiving quinine. Severe malaria may also present immediately
after delivery. Postpartum bacterial infection is a common complication and should be
managed appropriately.

High Blood Pressure in Pregnancy

Measure blood pressure at every clinic or antenatal visit. Pre-eclampsia is diagnosed with
raised blood pressure (more than 140/90) AND proteinuria. Take it seriously even in women
who appear well. It can get worse rapidly (over a few hours or few days). Get experienced
help and follow local protocols – maternal and fetal death may occur.
3 Categories:
 Chronic hypertension = women who have high blood pressure before conception
 Gestational hypertension = women who develop hypertension in pregnancy
 Pre-eclampsia = hypertension with proteinuria in pregnancy
If Proteinuria is ABSENT manage chronic and gestational diabetes in the same way. Offer
aspirin 75mg daily from 12 weeks to delivery to reduce risk of pre-eclampsia. Do NOT advise
bed rest: no evidence of benefit and increases risk of pulmonary emboli
If BP less than Monitor BP once weekly
150/100 Test urine for proteinuria at each visit (because at risk of developing pre-

30
 eclampsia)
All other antenatal care to continue as normal
If BP 150/100 or more Start drug treatment: methyldopa or hydralazine (or labetalol if available).
Doses: see below.
Check blood count, and renal and liver function when drugs started (if
possible) to check for signs of pre-eclampsia. Do not repeat unless
proteinuria develops.
Monitor BP at least 2x a week.
Test for proteinuria at each visit (risk of developing pre-eclampsia).
If BP 160/110 or more Admit to hospital: seek expert advice
Start or increase drug treatment: methyldopa or hydralazine (or labetalol
if available). Doses: see below.
Check blood count, renal and liver function when drugs started (if possible)
to check for signs of pre-eclampsia. Repeat weekly.
Monitor BP at least 4x a day.

If Proteinuria is PRESENT manage as below. Once pre-eclampsia is diagnosed no need to

test for proteinuria again
If BP less than Do NOT start drug treatment unless BP rises.
150/100 Check BP weekly (twice weekly if possible).
Blood count, renal and kidney function once weekly to monitor pre-eclampsia.
If BP 150/100 or more ADMIT TO HOSPITAL TODAY
Delivery may be advised: seek expert advice.
Start drug treatment: methyldopa or hydralazine (or labetalol if available).
Doses: see below.
Monitor BP at least 4x a day.
Blood count, renal and liver function 3 times a week to monitor.
Drug Doses:
Methyldopa Tablets: Start at 250mg 2-3x daily, maximum 3g/day.
Labetalol Tablets: Start at 100mg twice daily, maximum dose 2400mg/day.
(never in asthma) Intravenous infusion: 2 mg/minute until good response then stop; usual total dose 50–200 mg.
Hydralazine Tablets: Start at 25mg twice daily. Usual maximum dose 50mg twice daily
Slow IV injection: 5-10mg in 10ml sodium chloride 0.9%; may be repeated after 20–30 minutes.
(Mix 20mg of hydralazine from ampoule with 20ml normal saline (0.9% sodium chloride from a
perfusion bag) but only give 5 to 10ml of the mixed solution.)

Emergency treatment of pre-eclampsia and eclamptic fits

If unconscious:
 Check her airway
 Put her in the recovery position on her left side

If she is also convulsing

 Put her in the recovery position on her left side
 Protect her from injuries (fall) but do not restrain her
 A member of staff must stay with her at all times
 Give Magnesium Sulphate by slow IV injection and also by IM injection

Once the convulsions have been controlled, emergency delivery will be needed by whatever
method is most appropriate.

Treatment with Magnesium Sulphate

Preparation of Magnesium Sulphate injection: Mix 8ml of Magnesium Sulphate 500mg/ml
(50% solution) from ampoule with 12ml of water for injection or normal saline (0.9% sodium
chloride from a perfusion bag).

31
Loading dose: Give 4g of Magnesium Sulphate by slow IV injection over 10 to 15 minutes
timed on a clock. Then give 10g by deep IM injection, 5g into each buttock, adding 1ml of
2% lignocaine.

Maintenance dose: 5mg Magnesium Sulphate + 1ml of 2% lignocaine every 4 hrs into
alternate buttocks.

Withhold Magnesium Sulphate if any of the following:

 Respiratory rate < 16 per minute
 Urinary output < 30ml per hour
 Patellar reflex is absent

ONLY if Magnesium Sulfate is not available, give IV or rectal diazepam. Either give slow IV
Diazepam 10mg or give rectally.Follow this with IV infusion by mixing 40mg of diazepam
from 4 x 2ml ampoules into 500ml of 5% Dextrose given as a continuous infusion over 24
hours.

Diabetes in Pregnancy
All women with pre-existing diabetes should have optimum control of their diabetes before
becoming pregnant (See 4.3). Tight control is associated with markedly improved outcomes
for mother and baby. Ideally all pregnant women should be screened for gestational
diabetes:
 Oral Glucose Tolerance test at 24-28 weeks
If this is not possible, high risk women must be screened:
 family history
 history of large babies- 4kg or more
 previous gestational diabetes
 obesity
 hypertension
 history of pre-eclampsia or polyhydramnios

2 Hour Oral Glucose Tolerance Test

75g anhydrous glucose dissolved in 250-300ml water or equivalent (e.g. 394mls Lucozade
Energy Drink). Drink within 5 minutes. Test a venous blood sample (more accurate than
capillary) at 2hrs.

Diagnose gestational diabetes if EITHER:

 FASTING GLUCOSE > 5.6mmol/l (100.8 mg/dl)
 OR 2hr GLUCOSE > 7.8 mmol/l (140.4 mg/dl)
Oral medication is increasingly being used, Metformin is safe in pregnancy and can use
used alone or in combination with insulin. Sulphonylureas are safe from 11 weeks gestation.
Insulin is used either as basal bolus or twice daily premixed.

Anemia in pregnancy All women are screened for anemia at all visits and given
supplements (see above). If blood transfusion is needed, see 5.4.

Nausea and vomiting. Nausea in the first trimester of pregnancy is generally mild and
does not require drug therapy. On rare occasions if vomiting is severe, treat with short-term
treatment with an antihistamine, promethazine, 25mg PO, one a day may be enough but
max 3 x per day. Hyperemesis gravidarum is severe vomiting in pregnancy, which requires
admission, regular antiemetic therapy, with metochlopramide 10mg PO (or 10mg IM if
unable to take by mouth), intravenous fluid with Ringers Lactate, or Normal saline. (with 5%
Dextrose given every 3rd bag of IV fluid if still unable to take by mouth).

32
Thyroid disease in Pregnancy. See 4.8

Brucellosis in pregnancy. Brucellosis can cause miscarriage and is also very dangerous
to the woman. For treatment, See 3.11

Pre-term labour Prelabour rupture of membranes (PROM) is rupture of the membranes

before labour has begun. PROM can occur either when the foetus is immature or preterm (<
37 weeks) when the foetus is mature (term). If there are palpable contractions and blood-
stained mucus discharge, suspect preterm or term labour. Confirm gestational age of the
pregnancy using all information (LMP, physical exam in early pregnancy, ultrasound
performed in the first trimester, symphysis fundal height).

Amnionitis: If there are signs of infection (fever, foul-smelling vaginal discharge), give the
woman antibiotics regardless of gestational age
 Ampicillin 2 g IV every 6 hours + Gentamicin 5 mg/kg body weight IV every 24 hours.
Antibiotic prophylaxis
If there are no signs of infection, and the pregnancy is less than 37 weeks, give antibiotics to
the mother to reduce maternal and neonatal infective morbidity
 Amoxicillin PO 500mg 3 x day and Erythromycin PO 250mg 3 x per day for 7 days
Lung Maturity
If gestational age is 24-34 weeks and preterm birth is considered imminent, give
corticosteroids to the mother to improve fetal lung maturity and chances of neonatal survival.
 Betamethasone 12 mg IM, two doses 24 hours apart OR dexamethasone 6 mg IM,
four doses 12 hours apart.
Neuroprotection
If gestational age is < 32 weeks and preterm birth is likely within the next 24 hours, consider
giving magnesium sulphate to the mother as an IV infusion or IM injections to prevent
cerebral palsy in the infant.
 IM Magnesium Sulphate 5g every 5hrs for 24hrs or until delivery OR IV Magnesium
Sulphate 4g over 30mins and then 2g per hour.
Induction of labour
If <37 weeks: Induce labour using oxytocin IV or misoprostol (25mcg every 2 hours orally or
25mcg every 6 hours vaginally, in a non-scarred uterus) at 37 weeks. If there are
contraindications for vaginal birth, prepare for caesarean birth at 37 weeks
If 37 weeks or more: If confirmed Group B streptococcus colonization, give prophylactic
antibiotics to help reduce Group B streptococcus infection in the neonate, even if the woman
received antibiotics previously: Ampicillin 2 g IV every 6 hours until birth.
Assess the cervix; if favourable (soft, thin, partly dilated), induce labour using oxytocin IV, if
unfavourable (firm, thick, closed) and there is no scar on the uterus, ripen the cervix using
misoprostol (orally or vaginally) or oxytocin IV. If there is a previous uterine scar do not give
oxytocin, and monitor the woman very closely during labour. If there are contraindications for
vaginal birth, prepare for caesarean section.

Bleeding in Pregnancy
Either in the first trimester (known at this point as threatened abortion or miscarriage) or
second/third trimester (known as antepartum haemorrhage).
If bleeding is severe the patient may be in Shock, a life-threatening condition that requires
immediate and intensive treatment. This can happen at any stage of pregnancy, with
infection or trauma (see 5.1)
Threatened abortion
If light bleeding stops continue to monitor in antenatal clinic. If heavier of persistent bleeding
monitor vital signs, do not delay treatment for shock, be aware of the possibility of ectopic

33
 pregnancy, send a blood sample for type and screen, start IV fluids. Consider rhesus
incompatibility (if the woman is Rhesus negative). Give simple pain relief if needed.
Inevitable and Incomplete abortion
Expectant (if haemodynamically stable), medical and surgical management are all
acceptable options.
Inevitable Surgical Medical
<12-14 weeks Manual Vacuum Misoprostol 800 mcg by vagina or sublingual every 3–
Aspiration 12 hours; maximum three doses
>12-14 weeks Dilation and Misoprostol 400 mcg by vagina or sublingual every
evacuation three hours, maximum five doses OR Oxytocin 40 units
in 1 L IV fluids at 40 drops per minute

Incomplete Surgical Medical

<12-14 weeks Manual Vacuum Misoprostol 400 mcg sublingual or 600 mcg by mouth for one
Aspiration dose
>12-14 weeks Dilation and Misoprostol 200 mcg by vagina every four hours until expulsion,
Evacuation maximum 800 mcg OR
Oxytocin 40 units in 1L IV fluids at 40 drops per minute

Complete Abortion
Evacuation of the uterus is usually not necessary. Observe for heavy bleeding. If heavy
bleeding ensues, proceed to manual vacuum aspiration to ensure that there are no
remaining products, and administer 800 mcg of misoprostol for management of post-abortal
haemorrhage. Ensure follow-up of the woman after treatment.

Antepartum haemorrhage (APH)

All women with bleeding in the 2nd and 3rd trimesters need urgent assessment with
ultrasound. If bleeding is severe, urgent obstetrical intervention is needed. See obstetrics
guide for further management and see 1.5.

1.4 Normal Labour

This refers to vaginal delivery without complications, and can be managed under BEmONC
services. Provide care to all women in a manner that maintains their dignity, privacy and
confidentiality, ensures freedom from harm and mistreatment, and enables informed choice
and continuous support during labour and childbirth. There should be effective
communication between maternity care providers and women in labour, using simple and
culturally acceptable methods. A companion of choice is recommended for all women
throughout labour and childbirth and continuity of care promoted. A partogram is used to
monitor progression of labour. PMTCT guidelines for HIV are followed and adhered during
labour as during antenatal care (see 3.6).

1st Stage of Labour The latent 1st stage is a period of time characterised by painful uterine contractions and
variable changes of the cervix, including some degree of effacement and slower progression of
dilatation up to 5 cm for first and subsequent labours.
The active 1st stage is a period of time characterized by regular painful uterine contractions, a
substantial degree of cervical effacement and more rapid cervical dilatation from 5 cm until full
dilatation for first and subsequent labours.
Duration of the first The standard duration of the latent 1st stage can vary widely from one woman to another.
stage of labour However, the duration of active first stage (from 5 cm until full cervical dilatation) usually does
not extend beyond 12 hours in first labours, and usually does not extend beyond 10 hours in
subsequent labours.
Progress of the first For women with spontaneous labour onset, cervical dilatation rate threshold of 1 cm/hour
stage of labour during active first stage (as depicted by the partograph alert line) is inaccurate to identify

34
 women at risk of adverse birth outcomes and is therefore not recommended for this purpose.
Labour may not naturally accelerate until a cervical dilatation threshold of 5 cm is reached. The
use of medical interventions to accelerate labour and birth (such as oxytocin augmentation or
caesarean section) before this threshold is not recommended, provided fetal and maternal
conditions are reassuring.
Routine assessment Auscultation using a Doppler ultrasound device or Pinard fetal stethoscope is recommended on
of fetal well-being on admission.
admission
Digital vaginal At intervals of 4 hours is recommended for routine assessment of active first stage of labour in
examination low-risk women
Intermittent fetal With either a Doppler ultrasound device or Pinard fetal stethoscope is recommended for
heart rate healthy pregnant women in labour.
auscultation during
labour
Analgesia for pain Parenteral opioids, such as pethidine, are recommended options for healthy pregnant women
relief requesting pain relief during labour. Relaxation and manual techniques (e.g. massage) are
other options.
Oral fluid and food For women at low risk, oral fluid and food intake during labour is recommended
Maternal mobility and Encouraging the adoption of mobility and an upright position during labour in women at low risk
position is recommended

2nd Stage of Labour The 2nd stage is the period of time between full cervical dilatation and birth of the baby, during
which the woman has an involuntary urge to bear down, as a result of expulsive uterine
contractions. Women should be informed that the duration of the 2nd stage varies. In first
labours, birth is usually completed within 3 hours whereas in subsequent labours, birth is
usually completed within 2 hours.
Birth position Encouraging the adoption of a birth position of the individual woman’s choice, including upright
positions, is recommended.
Method of pushing Women in the expulsive phase should be encouraged and supported to follow their own urge to
push.
Techniques for Techniques to reduce perineal trauma & facilitate birth (including perineal massage, warm
preventing perineal compresses & a “hands on” guarding of the perineum) are recommended based on a woman’s
trauma preferences & available options.

3rd Stage of Labour: delivery of the placenta

Prophylactic The use of uterotonics for the prevention of postpartum haemorrhage (PPH) during the 3rd
uterotonics stage of labour is recommended for all births.
Oxytocin (10 IU, IM/IV) is the recommended uterotonic drug for the prevention of postpartum
haemorrhage (PPH), see 1.7
Delayed umbilical cord Delayed umbilical cord clamping (not earlier than 1 minute after birth) is recommended for
clamping improved maternal and infant health and nutrition outcomes.
Controlled cord Controlled cord traction (CCT) is recommended for vaginal births if the care provider and the
traction (CCT) woman regard a small reduction in blood loss and a small reduction in the duration of the 3rd
stage important.
Uterine massage Sustained uterine massage is not recommended as an intervention to prevent postpartum
haemorrhage (PPH) in women who have received prophylactic oxytocin.
4th stage of Labour The hour or two after delivery when the tone of the uterus is reestablished as the uterus
contracts again, expelling any remaining contents. These contractions are hastened by
breastfeeding, which stimulates production of the hormone oxytocin. Monitor closely and take
action if any PPH (see 1.7)

The following are NOT recommended:

 Routine clinical pelvimetry or cardiotocography for the assessment of fetal well-being
on labour admission in healthy pregnant women presenting in spontaneous labour.
 Routine perineal/pubic shaving, vaginal cleansing or administration of enema.
 The use of IV fluids, antispasmodic agents, amniotomy alone or early amniotomy
with early oxytocin augmentation for prevention of delay/shortening the duration of labour.

35
  Routine or liberal use of episiotomy for women undergoing spontaneous vaginal
birth.
 Application of manual fundal pressure to facilitate childbirth during the second stage
of labour.

Pethidine for pain control during labour: If pain control is needed during labour, pethidine IM
may be used with care. Pethidine should only be used if available if naloxone is available in
case of respiratory depression in the newborn.
1. Give prochlorperazine 5mg to prevent nausea from pethidine.
2. Give IM injection of 50mg pethidine.
3. Assess after 30 minutes and if analgesia not adequate and no side effects may
repeat IM injection.
4. Further IM injection may given 3 – 4 hours later but not before.

Treatment note: Onset of action of IM pethidine within 10 -20 min and lasts for 2-4 hours.

Medicine Age Dose Duration Side effects

Pethidine Adults 1 x 50mg vial 1 x 50mg IM can be repeated Common: nausea & vomiting, lower
50mg/ml in 1ml given by deep after 30 minutes if pain BP, faster or slower heartbeat,
vials IM injection in control not adequate. drowsiness
buttock. Injection can be repeated Rare: depression of breathing
after 3 to 4 hours. (increases with dose), palpitation

Precaution: Do not exceed dose. May cause depression of breathing of fetus and mother.
Must not give more than 400mg pethidine in 24 hours. Do not give if woman has any
difficulty breathing or any fetal distress.

Induction and augmentation of labour

Augmentation of labour with oxytocin is only used in CEmONC centres by experienced staff
where on-site operative delivery is available, but not if the woman has had a previous C-
section. Assisted delivery with vacuum extractor (ventouse) may only be performed by staff
trained in the technique following CEmONC guidelines. Oxytocin may be used if the cervix is
favourable (Bishop score > 6) and the membranes are ruptured, and contractions have
slowed up with a delay in progression (assessed by an experienced obstetrician).
Induction of labour: Either Insertion of Foley (balloon) catheter in cervix for 12 hours,
followed by amniotomy and oxytocin.
Or Oral misoprostol 25 micrograms every 2hrs maximum 12 doses or vaginal misoprostol 25
micrograms every 6hrs maximum 4 doses.
Augmentation of labour: Use oxytocin 5IU in 500ml 0.9% sodium chloride. Commence at 15
drops per minute and increase by 15dpm every 30mins to a maximum of 60dpm. Aim to
produce 3 contractions in 10 minutes lasting 40-45secs. Reduce rate as sensitivity to
oxytocin usually increases as labour progresses.
If hyperstimulation occurs, stop the infusion. If necessary, give salbutamol 5mg in 500ml
normal saline perfusion at 10dpm if available. Do not give salbutamol my mouth as the
prolonged effect my stop contractions for a longer period of time.

1.5 Labour Complications

The survival of a woman experiencing an obstetric emergency is determined by the amount

of time it takes for care to be delivered and by the level and quality of care provided. When a
woman of childbearing age presents with a problem, rapidly assess her condition to
determine the extent of her illness.

36
 Initial management of an obstetric emergency.
 Stay calm. Think logically and focus on the needs of the woman. Take charge. Avoid
confusion by choosing one person to be in charge.
 CALL FOR HELP. Have one person go for help and have another person gather
emergency equipment and supplies (e.g. oxygen cylinder, emergency kit).
 If the woman is unconscious, assess the airway, breathing and circulation. Begin
resuscitation of the woman, as needed (e.g. assist breathing, start IV infusion).
 If shock is suspected, immediately begin treatment (see 5.1). Even if signs of shock
are not present, keep shock in mind as you evaluate the woman further, because
status may worsen rapidly. If shock develops, begin treatment immediately.
 Position the woman lying down on her left side with her feet elevated. Loosen tight
clothing. Talk to the woman and help her stay calm. Ask her or someone with her
what happened, what symptoms she is experiencing and when they started.
 Perform a rapid evaluation of the woman’s general condition, level of consciousness,
presence of anxiety and/or confusion, blood loss, colour, and temperature of skin.
 Check the fetal heart rate and ask about fetal movements: If there are fetal heart rate
abnormalities (< 100 or > 180 beats per minute), suspect fetal distress. If fetal heart
cannot be heard, ask others to listen or use a Doppler stethoscope, if available.
 Put in one or two large-bore IV cannulae/needles. Get blood samples before infusing
IV fluids. Adjust the flow rate based on the woman’s condition and potential risks of
fluid overload (e.g. pre-eclampsia).
 Perform a rapid targeted history and physical examination to make a differential
diagnosis of the problem.
 Consider catheterization if monitoring urinary output or a distended bladder.
 Document history, findings, actions and plan for continued management based on
the cause of the emergency.

Specific Management
Condition
Abruptio placentae (Detachment of a
normally located placenta from the
uterus before birth of the baby)
Ruptured Uterus
Placenta praevia (Implantation of the
placenta at or near the cervix)
Atonic Uterus (Failure of the uterus to
contract after childbirth)
Tears to the Cervix, Vagina or
Perineum
Pre-eclampsia or Eclampsia
Treatment
Assess clotting status, transfuse if necessary. If bleeding is heavy deliver as
soon as possible If light-moderate assess fetal heart rate and proceed
accordingly
Infuse IV fluids before surgery, when stable deliver via laparotomy, consider
whether surgical repair is a viable option
Diagnose by ultrasound. Do not perform a vaginal examination unless
preparations have been made for an immediate caesarean. Restore circulating
volume with IV fluids. If bleeding heavily, arrange for caesarean section
irrespective of fetal maturity, if bleeding is light and the foetus is alive consider
expectant management keeping the mother in hospital
Continue to massage the uterus, see 1.7 for management of PPH
Examine carefully and repair, if bleeding occurs then consider management of
PPH.
See 1.3

Unsatisfactory Progress of Labour

 The cervix is not dilated beyond 4 cm after eight hours of regular contractions.
 Cervical dilatation is to the right of the alert line on the partograph.
 The woman has been experiencing labour pains for 12 hours or more without giving
birth (prolonged labour).
 Inadequate uterine contractions (< 3 strong contractions per 10 minutes)
 The cervix fully dilated, and the woman has the urge to push, but there is no descent.

37
 A = augment labour with oxytocin, C=perform a caesarean, F = forceps, V=obstetric
vacuum,
Condition Treatment
False Labour Examine for UTI, other infection or ruptured membranes and treat accordingly. If none, discharge
the woman and encourage to return if signs of labour recur or danger signs.
Prolonged latent If in the latent phase for > 8 hours and little sign of progress, reassess the cervix: No change –
phase review whether she is in labour. If change in cervical effacement or dilatation, A. If she has not
entered the active phase > 8 hours of oxytocin, C.
Prolonged Assess uterine contractions: If contractions are inefficient (<3 contractions in 10 minutes, lasting <
active phase 40 seconds), suspect inadequate uterine activity. If contractions are efficient (3 or more
contractions in10 minutes, lasting > 40 seconds), suspect cephalopelvic disproportion (CPD),
obstruction, malposition or malpresentation. If no signs of CPD or obstruction and membranes
intact, A. Do not rupture membranes, especially when HIV prevalence high.
Cephalopelvic If the foetus is alive, C.
disproportion
Obstruction If the foetus is alive, the cervix is fully dilated and the fetal head is not > 1/5 above the symphysis
pubis, or the leading bony edge of the fetal head is at 0 station or below, assist with V. If the foetus
is alive and the head is between 1/5 and 3/5 above the symphysis pubis or the leading bony edge
of the fetal head is at −2 station, C. If the foetus is alive but the cervix is not fully dilated or if the
fetal head is too high for V (the head is more than 3/5 above the symphysis pubis or the leading
bony edge of the fetal head is above −2 station), C.
Prolonged If malpresentation and obvious obstruction have been excluded, A. If no descent after
Expulsive Phase augmentation: Assist using V or F if the fetal head is not > 1/5 above the symphysis pubis or the
leading bony edge of the fetal head is at 0 station.
Perform C if: the fetal head is between 1/5 and 3/5 above the symphysis pubis or the leading bony
edge of the fetal head is between 0 station and −2 station; or the fetal head is > 3/5 above the
symphysis pubis or the leading bony edge of the fetal head is above −2 station.

Malpresentations
Malpositions are abnormal positions of the vertex of the fetal head (with the occiput as the
reference point) relative to the maternal pelvis. Malpresentations are all presentations of the
foetus other than vertex.
Occiput Posterior Spontaneous rotation occurs in 90%. If there are signs of obstruction but fetal heart rate is normal
encourage walking around for spontaneous rotation, is signs of fetal distress C.
If the cervix is not fully dilated and there are no signs of obstruction A
If the cervix is fully dilated but there is no descent in the expulsive phase of the second stage of labour,
assess for signs of obstruction. If there are no signs of obstruction A
If the cervix is fully dilated and the fetal head is no more than 2/5 above the symphysis pubis, or the
leading bony edge of the fetal head is at 0 station, assist birth with V or F. Otherwise, C.
Brow Presentation In brow presentation, engagement is usually impossible and arrested labour is common, spontaneous
conversion is rare. Proceed to C.
Face Presentation Chin Anterior Position - If the cervix is fully dilated: Allow normal childbirth to proceed. If there is slow
progress and no sign of obstruction A.  If descent is unsatisfactory, assist the birth with V or F. If the
cervix is not fully dilated and there are no signs of obstruction A. Review progress as with vertex
presentation.
Chin Posterior Position - If the cervix is fully dilated C. If the cervix is not fully dilated, monitor descent,
rotation and progress. If there are signs of obstruction, C.
Breech Ideally, every breech birth should take place in a hospital with the ability to perform an emergency
Presentation caesarean.
Specialist only: Attempt external cephalic version (ECV) if: breech presentation is present at or after 37
weeks, vaginal birth is possible; facilities for emergency caesarean are available; membranes are intact
and amniotic fluid is adequate; there are no complications (e.g. fetal growth restriction, uterine
bleeding, previous caesarean birth, fetal abnormalities, twin pregnancy, hypertension, fetal death).
If ECV is successful, proceed with normal childbirth If ECV fails, proceed with vaginal breech birth
(below) or C.
A Vaginal Breech by a skilled health care provider is safe and feasible under the following conditions:
Complete or frank breech, foetus is not too large; no previous caesarean for cephalopelvic
disproportion; fetal head is flexed.

38
 Examine the woman regularly and record progress on a partograph. If the membranes rupture,
examine the woman immediately to exclude cord prolapse.
Note: Do not rupture the membranes.
If the cord prolapses and birth is not imminent, C. If there are fetal heart rate abnormalities (less than
100 or more than 180 beats per minute) or prolonged labour, C
Note: Meconium is common with breech labour and is not a sign of fetal distress if the fetal heart rate is
normal.
The woman should not push until the cervix is fully dilated. Full dilatation should be confirmed by
vaginal exam.
Caesarean Breech is safer than vaginal breech birth and recommended in cases of: Double footling
breech; a small or malformed pelvis; a very large foetus; a previous caesarean for cephalopelvic
disproportion; or a hyperextended or deflexed head.
Tranverse Lie of If a woman is in early labour and the membranes are intact, attempt ECV: If ECV is successful,
Shoulder Position proceed with normal childbirth. If ECV fails or is not advisable, perform a caesarean. Monitor for signs
of cord prolapse. If the cord prolapses and birth is not imminent, C

Fetal Distress in Labour

 Abnormal fetal heart rate (less than 100 or more than 180 beats per minute)
 Thick meconium-stained amniotic fluid

General Management
 Prop up the woman or place her on her left side.
 Stop oxytocin if it is being administered.
 Give oxygen 4–6 L by mask or nasal cannulae.

Abnormal Fetal Heart Rate

 A normal fetal heart rate may slow during a contraction but usually recovers to
normal as soon as the uterus relaxes.
 A very slow fetal heart rate in the absence of contractions or persisting after
contractions is suggestive of fetal distress.
 A rapid fetal heart rate may be a response to maternal fever, drugs causing rapid
maternal heart rate (e.g. terbutaline or ritodrine), hypertension or amnionitis. In the
absence of a rapid maternal heart rate, a rapid fetal heart rate should be considered
a sign of fetal distress.

 If a maternal cause is identified (e.g. maternal fever, bleeding, drugs), initiate

appropriate management.
 If a maternal cause is not identified and the fetal heart rate remains abnormal
throughout at least three contractions, perform a vaginal examination to check for
explanatory signs of distress:
 If the cord is below the presenting part or in the vagina, manage as prolapsed cord
 If fetal heart rate abnormalities persist or there are additional signs of distress (thick
meconium-stained fluid), plan for the woman to give birth.
 If the cervix is fully dilated and the fetal head is not more than 1/5 above the
symphysis pubis, or the leading bony edge of the fetal head is at 0 station, assist the
birth with V or F.
 If the cervix is not fully dilated, or the fetal head is more than 1/5 above the
symphysis pubis, or the leading bony edge of the fetal head is above 0 station, C.

Prolapsed Cord
If the cord is pulsating, the foetus is alive.
Put the woman in the knee chest position or in left lateral with a pillow underneath her left
Hip or in Trendelenburg or manual elevation of the fetal head:

39
If the woman is in the 1st stage of labour: Wearing sterile gloves, insert a hand into the
vagina. Push the presenting part up to decrease pressure on the cord and dislodge the
presenting part from the pelvis. Place the other hand on the abdomen in the suprapubic
region to keep the presenting part out of the pelvis. Once the presenting part is firmly held
above the pelvic brim, remove the other hand from the vagina. Keep the hand on the
abdomen until an emergency caesarean can be performed. If available, give tocolytics to
reduce contractions: Give a loading dose of 20 mg nifedipine immediate-release capsule
sublingually. If required, give an additional 10 mg every 15 minutes up to a maximum of 40
mg in the first hour.
If the woman is in the second stage of labour: Expedite birth with V or F. Prepare for
resuscitation of the newborn. If the cord is not pulsating, the foetus is dead. Proceed with
birth of the baby in the manner that is safest for the woman.

Caesarean section Follow CEmONC guidelines.

 Start IV infusion (ringers or normal saline), take blood for Haemoglobin, Group and
cross-match 2 units.
 General, regional or local anaesthesia according to MOH and hospital guidelines,
with ketamine or spinal preferred. (see 5.4)
 With ketamine by IV bolus or infusion, diazepam is not given until after delivery of the
baby.
 IV oxytocin 5iu is given slowly after deliver of the baby, and the placenta delivered by
controlled cord traction (less risk of endometritis than from manual removal).

1.6 Postnatal Care Normal

After an uncomplicated vaginal birth in a health facility, healthy mothers and newborns
should receive care in the facility for at least 24 hours after birth . If birth is in a health facility,
mothers and newborns should receive postnatal care for at least 24 hours after birth. If at
home, the first postnatal contact should be as early as possible within 24 hours of birth.
At least three additional postnatal contacts are recommended for all mothers and newborns,
on day 3 (48–72 hours), between days 7–14 after birth, and six weeks after birth.

First 24 hours after birth: All postpartum women should have regular assessment of vaginal
bleeding, uterine contraction, fundal height, temperature and heart rate (pulse) routinely
during the first 24 hours starting from the first hour after birth. BP should be measured
shortly after birth. If normal, the 2nd blood pressure measurement should be taken within 6
hours. Urine void should be documented within 6 hours.

Beyond 24 hours after birth: At each subsequent postnatal contact, enquiries should be
made about general well-being and assessments made regarding:
 micturition and urinary incontinence, bowel function, healing of any perineal wound,
headache, fatigue, back pain, perineal pain and perineal hygiene, breast pain, uterine
tenderness and lochia.
 Breastfeeding progress should be assessed at each postnatal contact.
 At each postnatal contact, women should be asked about emotional well- being and
encouraged to tell their health care professional about and changes in mood,
emotional state and behaviour outside of the woman’s normal pattern.

10–14 days after birth: all women should be asked about resolution of mild, transitory
postpartum depression (“maternal blues”). If symptoms have not resolved, the woman’s
psychological well-being should continue to be assessed for postnatal depression.
Women should be observed for any risks, signs and symptoms of domestic abuse and told
whom to contact for advice and management.

40
All women should be given information about the physiological process of recovery after
birth, and to report any health concerns to a health care professional, in particular: signs and
symptoms of PPH, pre-eclampsia/eclampsia, infection, thromboembolism.
Iron and folic acid supplementation should be provided for at least three months.
The use of antibiotics among women with a vaginal delivery and a 3rd or 4th degree perineal
tear is recommended for prevention of wound complications.

1.7 Postnatal Care Complications

After delivery, the woman is monitored in closely for any signs of further bleeding or anemia,
ensuring that the uterus remains well contracted. BP and signs of infection are monitored.
For raised BP and anemia refer to the guidelines previously in this section on maternal
health.

Preventing Mother To Child Transmission (PMTCT) of HIV see 3.6

Full PMTCT guidelines are followed and adhered to after delivery for mother and baby in
referral centres. Women not previously tested are given pre-test counselling, and have
voluntary testing for HIV, followed by post-test counselling. Any women with HIV and HIV
exposed infants who had not previously been referred before or during labour need initiation
of ARV and appropriate interventions. See 3.6

Post-Partum Infection
If Uterine (Fever and foul-smelling lochia) or other significant infection is suspected:
 Give antibiotics: Ampicillin 2g IV or Amoxicillin PO 2g every 8 hours AND
metronidazole IV or PO 400-500mg every 8 hours AND gentamicin 5mg/kg IM once
every 24 hours. (If the woman is allergic to penicillin or amoxicillin give erythromycin
instead of amoxicillin).
 Put up IV fluids, 500ml Ringers lactate.
 Give paracetamol for pain
A combination of antibiotics is given until the woman is fever-free for 48 hours. If fever is still
present 72 hours after starting the antibiotic regime outlined above, assess for a focus of
infection (such as a pelvic abscess).

Post Partum Haemorrhage

Primary postpartum haemorrhage (PPH) is defined as a blood loss of 500 ml or more within
24 hours after birth; secondardy PPH is after 24 hours.  PPH is the leading cause of
maternal mortality in low-income countries, and the primary cause of nearly one quarter of all
maternal deaths globally. Most deaths resulting from PPH occur during the first 24 hours
after birth; the majority of these could be avoided through the use of prophylactic uterotonics
during the third stage of labour and by timely and appropriate management.

Prevention: The use of an effective uterotonic for the prevention of PPH during the third
stage of labour is recommended for all births. To effectively prevent PPH, only one of the
following uterotonics should be used, in order of preference (1st choice is Oxytocin):
 Oxytocin (10 IU, IM/IV)
 Carbetocin (100 mcg, IM/IV)
 Misoprostol* (either 400 mcg or 600 mcg, PO)
 Ergometrine/methylergometrine 5 IU/500 mcg, IM) is recommended for the
prevention of PPH in contexts where hypertensive disorders can be safely excluded prior to
its use.
 Oxytocin and ergometrine fixed-dose combination
*In settings where skilled health personnel are not present to administer injectable
uterotonics, misoprostol may be given for PPH by community/lay health workers.

41
 Treatment
 Follow full CEmONC guidelines for PPH.
 Repair any tears (cervical, vaginal).
 Insert 2 large bore IV cannulas and test Hb, blood group, and X-match blood.
 Intravenous oxytocin alone is the recommended uterotonic drug for the treatment of
PPH. The use of isotonic crystalloids is recommended in preference to the use of
colloids for the initial intravenous fluid resuscitation of women with PPH.
 Give IV ringers or 0.9% sodium chloride (not dextrose). Add oxytocin 40iu to 500ml.
 If intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin,
the use of intravenous ergometrine, oxytocin-ergometrine fixed dose, or a
prostaglandin drug (including sublingual misoprostol, 800 mcg) is recommended.
 The use of tranexamic acid is recommended for the treatment of PPH if oxytocin and
other uterotonics fail to stop bleeding or if it is thought that the bleeding may be partly
due to trauma. Give tranexamic acid at a fixed dose of 1 g in 10 mL (100 mg/mL) IV
at 1 ml per minute (i.e., administered over 10 minutes), with a second dose of 1 g IV
if bleeding continues after 30 minutes.
 Uterine massage is recommended for the treatment of PPH.
 In uterine atony, for those who do not respond to uterotonics, alternatives include the
use of intrauterine balloon, uterine artery embolization is recommended as a
treatment for PPH due to uterine atony and use of bimanual uterine compression.
Surgical treatment is a further option.
 If the placenta is not expelled spontaneously, the use of IV/IM oxytocin (10 IU) in
combination with controlled cord traction is recommended. Give oxytocin 10IU in
500ml perfusion at 60dpm.
 A single dose of antibiotics (ampicillin or cefalexine) is recommended if manual
removal of the placenta is practised.

NB The use of ergometrine for the management of retained placenta is NOT recommended as this
may cause tetanic uterine contractions which may delay the expulsion of the placenta.

Other postnatal conditions

Lower Urinary Tract UTI
Malaria
Urinary Incontinence
Pus or pain in perineum
Abnormal vaginal discharge
Treat with oral antibiotics see 4.6
Treat as per section 3.3 (but consider other reasons for fever)
Check for perineal trauma, treat as per lower UTI
Remove sutures if necessary, clean wound, give analgesia, give antibiotics if
evidence of infection
Consider whether treatment may be needed for thrush or STI’s

Breast Problems
For all conditions listed encourage continued breast feeding, check correct positioning and
attachment and ensure adequate breast support.
Nipple Soreness or Fissure If persists, consider expressing from affected side, apply glycerine gel or vaseline
after feeding the newborn
Breast Engorgement If persists, consider expressing prior to feeds to relieve discomfort
Mastitis (fever, breast pain and Give antibiotic:
tenderness)  Cloxacillin 500mg 4x per day for 7 – 10 days OR
 Co-amoxiclav 500mg/125mg 3 x per day for 7 - 10 days. OR
 (If there is penicillin allergy)
 Erythromycin 500mg 4 x per day for 7 – 10 days.
Give paracetamol
Abscess (a collection of pus in If abscess, give first dose of antibiotic, pain control
the breast) Consider incision and drainage.

Mental Health - For the treatment of depression and psychosis see 4.14
Postnatal Within first 2 As below but for less than 2 weeks

42
 Blues weeks
Post Partum Usually after 2 Two or more of the following symptoms during the same 2 week period representing
Depression weeks a change from normal:
 Inappropriate guilt or negative persistent sad or anxious mood, irritability
Low interest or pleasure in carrying out activities that used to be pleasurable.
 Difficulties carrying out usual activities.
 Negative feelings about herself or the newborn.
 Multiple symptoms (aches, pains, palpitations, numbness) with no clear
physical cause.
Puerperal Usually after 2 Much rarer, presents with the woman feeling depressed one moment then very
psychosis weeks happy, or saying things that are obviously untrue (delusions), often related to the
baby or hearing voices.
If antipsychotic medications are used, be aware that medication can be passed
through breastmilk, so decisions about treatment must take into consideration and
address a woman’s breastfeeding status.

1.8 Newborn Care Normal

Newborn deaths account for 45% of deaths among children under 5 globally, resulting in 2.7
million lives lost each year. In addition, 2.6million babies die in the last 3 months of
pregnancy or during childbirth. We can prevent at least 2/3rds of these deaths.

Immediate Newborn Care

Within the first 30seconds
Dry and provide warmth Immediately dry the baby thoroughly using a clean dry cloth and do a quick check of baby’s
breathing while drying. Cover the baby and mother with a warm clean cloth and the baby’s head
with a bonnet. Do not routinely use suction.
From 30 seconds to 3 minutes
If breathing or crying Continue skin to skin contact with the head to one side
If gasping or not Call for help. Clamp and cut the cord with sterile scissors and with sterile gloves on. Transfer to
breathing warm, firm surface. Inform the mother in a kind and gentle tone that the baby has difficulty
breathing and that you will help the baby to breathe. Start ventilation
DO NOT wipe off vernix/bathe
Appropriately time cord Ensure gloves are sterile when touching or handling the cord. Clamp and cut the cord after cord
clamping and cutting pulsations have stopped (between 1–3 minutes)
Within 90 minutes
Breastfeeding Provide breastfeeding support to ensure good positioning and attachment. If attachment or
suckling is not good, try again, and reassess. If the breast is engorged, express a small amount of
breast milk before starting breastfeeding to soften the areola area so that it is easier for the baby
to attach. If the baby has signs of illness or does not show readiness to feed, i.e. feeding cues
within 90 minutes, EXAMINE the baby and MANAGE urgent conditions.
HIV If the mother is HIV-positive, take measures to prevent mother-to-child transmission. (See 3.6)
Eye Care After baby has located the breast, administer erythromycin or tetracycline ointment, or 2.5%
povidone-iodine drops, to both eyes according to national guidelines. Apply from the inner corner
of each eye, outwards.
Maternal Complications If the mother cannot keep the baby in skin-to-skin contact because of complications: wrap the
baby in a clean, dry, warm cloth; place in a cot; cover with a blanket; and encourage another
family member to keep the baby in skin-to-skin contact or use a radiant warmer if room is < 28 °C.
90minutes to 6 hours
Examine the baby Checking for abnormalities, including breathing difficulties and birth injury, and plot the newborn’s
birth weight, height and head circumference on a growth chart
For complications see 1.9
Give Vitamin K Inject a single dose of vitamin K (phytomenadione) 1 mg IM.
prophylaxis
Inject Hepatitis B and As per EPI programme. BCG at birth and Hep B as part of Penta timetable see 2.1. if mother Hep
BCG vaccinations B +ve give Hep B immunisation at birth see 3.10.
Dry Cord Care Instruct the mother to: keep cord stump loosely covered, wash stump with clean water and soap,
only if it is soiled and dry it thoroughly with a clean cloth; fold diaper below the stump; put nothing
on the stump; seek care if the umbilicus is red or draining pus

43
Care prior to discharge
Advise on staying in the After an uncomplicated vaginal birth, advise the mother that she and her healthy baby should
facility receive care in the birthing facility for at least 24 hours.
General advice Support unrestricted, on demand breastfeeding, day and night. Ensure warmth of the baby,
demonstrate good hygiene, look for danger signs including signs of jaundice
Check for infection Look for signs of local infection: – eyes, umbilicus, skin, baby’s mouth
Follow Up Promote birth registration and timely vaccinations, according to national guidelines. Counsel the
mother on prompt recognition of danger signs. Schedule postnatal contacts at Day 3, between the
1st and 2nd week and around the 6th week

All newborns should be given a dose of oral polio vaccination

BCG
Type of vaccine Live bacterial
Number of doses One
Schedule As soon as possible after birth
Booster None
Contraindications Symptomatic HIV infection
Adverse reactions Local abscess, regional lymphadenitis; rarely, distant spread to osteomyelitis,
disseminated disease
Special precautions Correct intradermal administration is essential. A special syringe and needle is
used for the administration of BCG vaccine
Dosage 0.05ml
Injection site Outer upper left arm or shoulder
Injection type Intradermal
Storage Store between 2°C–8°C (vaccine maybe frozen for long-term storage but not
the diluent). Discard if > 6 hours after reconstitution.

Detecting danger signs

The following signs are assessed when the newborn is in the maternity and when seen on
postnatal visits. The family should be encouraged to seek health care early if they identify
any of the following danger signs in-between postnatal care visits:
 Unable to suck or feed well
 Convulsions
 Fast breathing (breathing rate ≥60 per minute), severe chest in-drawing
 No spontaneous movement
 Fever (temperature >37.5 °C)
 Low body temperature (temperature <35.5 °C)
 Any jaundice in first 24 hours of life, or yellow palms and soles at any age
 Bulging fontanelle
 Bleeding or infection of umbilical stump
 Any signs of congenital abnormality
 Not passing urine or stools
 Diarrhoea or vomiting

1.9 Newborn Care Complications

Immediate Management
Many serious conditions in newborns—bacterial infections, malformations, severe asphyxia
and respiratory distress syndrome due to preterm birth— present in a similar way, with
difficulty in breathing, lethargy, and poor or no feeding. Even if a specific diagnosis cannot
be made; nevertheless, treatment must start immediately, even without a clear diagnosis of
a specific cause
Infection/ sepsis: Give the first dose of both ampicillin and gentamicin IM in the thigh before
referral for possible serious illness, severe umbilical infection or severe skin infection.

44
  Gentamicin 5 mg/kg body weight IM if at term, 4 mg/kg body weight IM if preterm,
every 24 hours; PLUS
 Ampicillin 50 mg/kg body weight IM every 12 hours.
Gasping or Not Breathing
If usual methods of drying fail (see section 1.8) attempt the following:
 Stimulate breathing by rubbing the baby’s back two or three times.
 Clear the airway: remove secretions from the baby’s mouth, then nose. Suctioning
should be done only if amniotic fluid was meconium stained or the mouth or nose is full of
secretions.
 In settings where mechanical equipment to generate negative pressure for suctioning
is not available and a newly born baby requires suctioning, a bulb syringe (single-use or
easy to clean) should be used.
If, after stimulation and clearing the airway, the baby is still not crying/breathing:
 Call for help.
 Clamp and cut the cord.
 Transfer the baby to a firm, warm surface, if possible, under a radiant heater

Resuscitation
Initial Assessment Action
Pink, breathing regularly, heart rate >100bpm Dry and wrap, give baby to mother
Blue, breathing inadequately, heart rate <60bpm Dry and wrap, open airway, given inflation breaths
Blue or white, note breathing, heart rate <60bpm Dry and wrap, open airway, inflation breaths, reassess, call help
 Start resuscitation within 1 minute of birth if the baby is not breathing or is gasping for
breath. Initially, an assessment of heart rate is made, by listening with a stethoscope
at the apex of the heart. This is done because heart rate is used to assess the
effectiveness or otherwise of the resuscitate spontaneously.
 Call for help. Start the clock. Dry the baby, wrap in a fresh towel and keep warm.
Assess initially by listening with a stethoscope at the apex.
 The Apgar score is then calculated at 1-5 minutes and is a tool for evaluating baby’s
condition at birth. It is not used as a guide to resuscitation.
The Apgar scoring system
System 0 1 2
Heart Rate Absent Nil Below 100/min Slow, 100/minute or higher
Respiratory Effort Limp Nil irregular Some Regular, with cry Active
Muscle Tone Reflex Pallor or Generalised tone in limbs Grimace flexion of limbs
Irritability Colour Cyanosis Only Body pink, Cry Pink
extremities blue all over
Airway:
 Position the head in the neutral position to open the airway. Overextension or flexion
will collapse the airway. A towel folded to 2-3cm thickness placed under the
shoulders will help to achieve the correct position.
 Most babies, even those born not breathing, will resuscitate themselves given a clear
airway. If the baby is floppy, use the jaw thrust to bring the tongue forward and open
the airway.
 Very gentle suction of the oropharynx, or nostril ONLY using soft suction catheter.
Deep suction is dangerous and should not be used – it can cause bradycardia and
spasm of the larynx.
 In the unconscious baby, airway obstruction is usually due to loss pharyngeal muscle
tone and to foreign material in the airway. Simply opening the airway will solve the
problem.
Breathing: If the baby does not respond to opening the airway as described above:
 Place the mask (attached to the bag) firmly over the newborn’s mouth, chin and
nose, to form a seal between the mask and the newborn’s face.
 Using the bag and mask, given 5 inflation breaths, each of 2-3 seconds.

45
  Check the rise of the chest. The chest may not move during the first one to three
inflation breaths, which are needed to displace fluid from the lungs.
 Check the seal and that the chest rises and falls with inflation breaths after that.
 Reassess the heart rate after the first 5 breaths: an increasing heart rate or a heart
rate maintained at more than 100 beats per minute is a sign of adequate ventilation.
If the heart rate has not responded check again for chest movement and check for
patent airway when attempting to deliver ventilations.
 Ventilations should be continued at 30-40breaths/minute.
Note: For newly born term or preterm (more than 32 weeks’ gestation) babies requiring
positive pressure ventilation, ventilation should be initiated with air. For preterm babies born
before or at 32 weeks of gestation, start ventilation with 30% (not 100%) oxygen. If this is not
possible, ventilation should be started with air.
Circulation: If there is no heartbeat or the heartbeat is less than 60bpm, even when the chest
is being ventilated, give chest compression. However, the most common reason for the heart
rate remaining low is that successful ventilation has not been achieved.
 Chest Compressions: The best way to give cardiac massage is the encircle the
baby’s chest with 2 hands so that the thumbs meet on the sternum below the line
between the nipple. Compress chest by one third of its depth – 3 times for each
inflation.
 Once the heart rate is above 60bpm, chest compressions can be discontinued.
Aftercare: If the baby’s breathing is normal (30-60 breaths/minute) and there is no indrawing
of the chest and no grunting:
 Put in skin to skin contact with mother, observe at frequent interval, measure temp
and keep above 36 degrees C, encourage breastfeeding, keep under observation for
at least 6 hours.
 If there is no breathing or gasping at all after 20minutes of ventilation, or gasping but
no breathing after 30mins of ventilation, stop ventilating.

Naloxone for respiratory depression in newborn: Naloxone is only stocked if pethidine is

authorised for use for pain control during labour. It is only used to reverse the effect of
pethidine.
 If Apgar score < 7 at birth or if breathing decreases after birth there may be
respiratory depression caused by pethidine.
 Continued breathing support is given with a mask and bag to the newborn
 If spontaneous respiration has still not established after continued bag use, naloxone
may be needed.
 If indicated, give Naloxone 0.1mg/kg IM single dose.
 Continue with bag and mask if needed

Treatment note: Measure the naloxone very carefully. It usually comes in vials of 0.4mg in
1ml. For 2kg baby give 0.2mg (0.5ml) naloxone. 3kg baby give 0.3mg (0.75ml). 4kg baby
give 0.4mg (1ml) naloxone.

Medicin Age Dose Duration Side effects

e
Naloxone Newborn 2kg 0.2mg (0.5ml) IM Single dose Common: fast heart
0.4mg in Newborn 3kg 0.3mg (0.75ml) IM rate
1ml Newborn 4kg 0.4mg (1ml) IM Rare: vomiting

Low Birth Weight or Preterm Babies: Newborns weighing <2000g at birth should
be provided kangaroo mother care as soon as clinically stable and close to continuously as
possible. The key features of kangaroo mother care for preterm infants are early, continuous
and prolonged skin-to-skin contact between the mother and the baby, and exclusive
breastfeeding (ideally) or feeding with breastmilk.

46
Very Low Birth Weight or Very Preterm Babies: If a baby is <1500g or <32 weeks, severe
health problems are likely and include difficulty in breathing, inability to feed, severe jaundice
and infection. Kangaroo care as above plus:
 Ensure that the baby’s head is covered to prevent heat loss. Encourage the mother
to begin breastfeeding or provide alternative breastmilk feeding to prevent
hypoglycaemia. If the baby’s axillary temperature drops below 36.5°C, rewarm the
baby (using radiant heater, blankets, skin to skin as available, only use an incubator
if power is guaranteed).
 Move to the special care baby unit, maintaining kangaroo care during transfer and
ensuring breast milk has been given (expressed, using a cup and spoon) or glucose.
 If maternal history indicates possible bacterial infection, give a first dose of
antibiotics: Gentamicin 3 mg/kg body weight IM; PLUS ampicillin 50 mg/kg body
weight IM.
 If the baby is cyanotic (bluish) or is having difficulty breathing (less than 30 or more
than 60 breaths per minute, indrawing of the chest, or grunting), give oxygen by
nasal catheter or prongs*
 *Nasal prongs are the preferred method for delivering oxygen, with a flow rate of 0.5–
1 L per minute, increased to 2 L per minute in severe respiratory distress to achieve
oxygen saturation greater than 90% but less than 95%.
Monitor the baby closely. Prior to feeds check levels of consciousness, tone, temperature,
respiration and colour. Any changes in these may indicate hypothermia, hypoglycaemia or
sepsis.
Hypothermia
Monitor the baby’s axillary temperature hourly until normal (or for at least three hours):
 If the baby’s temperature has increased at least 0.5°C per hour over the last three
hours, rewarming has been successful; continue measuring the baby’s temperature
every two hours.
 If the baby’s temperature does not rise or is rising more slowly than 0.5°C per hour,
look for signs of sepsis
 Once the baby’s temperature is normal, measure the temperature every three hours
for 12 hours.
Hypoglycaemia
Prevent hypoglycaemia by ensuring breast feeding within an hour of birth. For premature
babies, light for weight or newborns with infection or other complications, breastmilk may
need to be expressed and given with a cup and spoon.
Signs of hypoglycaemia: apnoea, cyanosis, jitter movements or convulsions. Give oral
glucose gel, or sugar and water, or (if experienced) give IV 10% dextrose.
Asymptomatic Newborns exposed to Infection
Newborns at risk of infection (premature rupture of membranes, maternal fever, offensive
amniotic fluid) or with signs of infection (fever, very fast heart > 140/minute, fast breathing >
60/ minute, floppy, blue colour or pallor, bulging fontanelle) are treated with antibiotics benzyl
penicillin and gentamicin. If a newborn has pustules on the skin antibiotics are given.
Diagnosing the site of infection is difficult and meningitis, pneumonia and septicaemia may
present with these similar signs.
 Keep the baby with the mother and encourage the mother to continue breastfeeding.
 Take blood cultures if possible.
 Treat the newborn with prophylactic antibiotics: ampicillin (IM or IV) and gentamicin
for at least two days. Treat all newborns with signs of infection with these two drugs.
Treatment with benzylpenicillin
Medicine Age Dose Duration Side effects
Benzylpenicillin Newborns < 25mg/kg IM 2 x day (every 12 2 days for Rare: allergy,
600mg 7 days hours) prevention,10 mild or severe
powder/inj vials Newborns 7 25mg/kg IM 3 x day (every 8 hours) days for reaction,
– 28 days treatment

47
 Prescribing tip: Dosage must be calculated very carefully.

Treatment with gentamicin

Medicine Age Dose Duration Side effects
Gentamicin Newborns < 7 days 2.5mg/kg IM every 12 hours (2 x day) 2 days for prevention Rare: vomiting,
80mg vials Newborns 7 – 28 2.5mg/kg IM every 12 hours (2 x day) 7 days for treatment deafness,
(40mg/ml) days kidney damage
Prescribing tip: Dosage must be calculated very carefully.

Newborn seizures
Seizures in newborns should only be treated if they last longer than 3 minutes or are
repeated. Glucose is given to all babies with seizures by staff who are trained to give it
(5ml/kg of 50% glucose given IV). If there are other signs of infection, antibiotics are given.

Jaundice of newborns
Newborns with jaundice appearing on the first day or deeply coloured enough to appear on
palms and soles usually needs treating. If there is very mild yellow colouration of the
conjunctiva that appears after the first day and there are no signs of infection or illness the
baby may be initially observed.

Treatment of newborns with jaundice (from indirect hyperbilirubinaemia)

Treatment with phototherapy can only be carried out by staff specifically trained to do this
following hospital standard operating procedures (SOPs)
 Treat underlying causes of hyperbilirubinaemia and factors that increase risk of
kernicterus (sepsis, hypoxia, etc.).
 Hydration.
 Initiate phototherapy. Filtered sunlight is as effect as artificial light but must be
administered according to strict hospital protocols, using a filter, and monitoring and
correcting any possible decrease or increase in temperature.
 Monitor bilirubin levels if available
 Give exchange transfusion when indirect serum bilirubin levels reach maximum
levels, or severe clinical jaundice

Exchange transfusion for treating haemolytic disease of the newborn

 This can only be carried out by staff specifically trained to do this following hospital
standard operating procedures, and consult page 149 – 151 of “WHO (2002) The
clinical use of blood”
 Use a group O blood unit that does not carry the antigen against which the maternal
antibody is directed: For HDN due to anti-D: use group O Rh D -D negative
An exchange transfusion of two times the neonate’s blood volume (about 170 ml/kg) is most
effective to reduce bilirubin and restore the haemoglobin level; this can usually be carried out
with one unit of whole blood but calculate according to the WHO guidelines or hospital
standard operating procedure.

1.10 Gynaecology
Gynaecology in Adolescents
Primary Amenorrhoea: Absence of periods should be investigated if there is a failure to
establish menstruation by the age of 14years in girls without secondary signs of sexual
development, or by the age of 16 in the presence of normal secondary sexual
characteristics. The most common causes are constitutional delay, Turners syndrome or an
absent vagina/uterus. Ultrasound and FSH/LH levels may be helpful in determining cause.

48
Primary Dysmenorrhea: Has a high prevalence in adolescents and can be associated with
school absenteeism and decreased socialisation. It is caused by increased levels of uterine
tone and muscular activity and significantly reduces after pregnancy.
Treatment options include use of NSAIDs (regular use at the correct dose is more effective
than use as required) and the combined oral contraceptive. If inadequate relief, consider
other causes e.g. endometriosis.

Dysfunctional Uterine Bleeding: is irregular bleeding arising from anovulation. If very heavy
and prolonged bleeding occurs check for anemia and consider coagulopathies. NSAID’s
may reduce loss by 30%, and the combined oral contraceptive is an alternative treatment.

Menstrual Problems
These can be absence of regular menstrual bleeding (amenorrhoea), heavy bleeding
(menorrhagia), increased frequency of bleeding (polymenorrhoea), intermenstrual bleeding,
painful periods (dysmenorrhoea) or pre-menstrual syndrome. When bleeding is not thought
to be related to the menstrual cycle (intermenstrual bleeding or persisting bleeding, bleeding
in post-menopausal women) it may need urgent investigation to exclude cancer of the cervix
or uterus.

Premenstrual Syndrome: Diagnosis requires a history of a single physical or mood symptom

occurring in a cyclical basis. Many different symptoms are possible but often include; mood
problems (e.g. irritability anxiety and appetite changes), cognitive or performance symptoms
(e.g. difficulty in concentrating) and fluid retention. Most women suffer from mild
premenstrual symptoms which do not require treatment but 3-5% suffer more extreme
cases.
Treatment : the SSRI antidepressants are effective in treating PMS, particularly where mood
is affected, this can either be issued continuously or just during the luteal phase. Fluoxetine
20-40mg is recommended. Alternative treatments include the use of the combined oral
contraceptive, the Mirena coil (both suppressing ovulation) and Vitamin B6 100mg daily.

Secondary amenorrhoea: Is defined as the absence of menstruation for 6 consecutive

months in a woman who has previously had regular periods. Investigation and treatment of
the underlying cause is important to prevent complications arising from oestrogen deficiency
and where appropriate counselling the women regarding future fertility.

Menorrhagia: For women presenting with heavy menstrual loss do a blood count and unless
a structural or histological abnormality is suspected then try pharmacological treatment.
If anaemic, consider a daily dose of 60-180mg of iron. In order of efficacy the following
treatment options can be considered; intra-uterine system (Mirena coil), Oral progesterone
2.5-10mg daily (days 5-25), Tranexamic Acid (1 g 3 times a day for up to 4 days), or
combined oral contraceptive.

Pelvic Pain
Chronic Pelvic Pain: is defined as a recurrent or constant pelvic pain of at least 6 months
duration, is difficult to manage because of the wide range of possible causes and overlap of
symptoms. Major causes include endometriosis, adenomyosis, pelvic inflammatory disease,
irritable bowel syndrome and urethral syndrome. Treatment is directed at cause but an
SSRI antidepressant may be considered in intractable pain. Try to avoid escalating
analgesia in the form of opioids as this can lead to dependency.

Endometriosis
Endometriosis is the presence of endometrial tissue outside the lining of the uterine cavity
inducing a chronic inflammatory reaction. Endometrial tissue is responsive to hormones and

49
 so causes cyclical bleeding. The medical treatment of endometriosis usually involves
suppression of the ovarian cycle.
Drug Mechanism Length of treatment Adverse Notes
recommended Effects
Medroxyprogesterone Ovarian suppression Long Term Weight gain, PO/IM/SC
acetate/progestogens bloating, acne,
irregular
bleeding
COC Ovarian suppression Long Term Nausea/ Use as per
Headaches ‘extended regime’
IUS Endometrial suppression Long term, (change Irregular Reduces
Ovarian suppression in every 5-7 years bleeding menstrual loss
some women dependent on age)

Genital tract disorders

Vulvovaginal condition
Thrush (vulvovaginal candidiasis) classically causes itch, is odourless and gives a white
discharge. When severe it can cause erythema and fissuring. Treatment is with either
Fluconazole 150mg stat dose oral (use in preference in pregnancy) or Clotrimazole pessary
500mg + Clotrimazole 1% cream. Consideration also needs to be given to causative factors
i.e. recent use of antibiotics, increased incidence in those with diabetes mellitus, and
transmission during sexual activity (partners only require treatment if they are symptomatic).

Bacterial Vaginosis is a common condition giving a thin watery discharge with a ‘fishy’ odour.
It is important particularly because it puts women at greater risk of contracting HIV, it can
also lead to infective complications after surgery and premature birth. First line of bacterial
vaginosis is oral metronidazole, 400mg 3 x a day for 7 days.

For Sexually transmitted infections, see 3.5

For Pelvic Inflammatory Disease, see 3.5

Menopause
Women as said to be post-menopausal after 1 year of amenorrhoea. Many changes are
associated with the menopause including vasomotor symptoms, sleep disturbance,
urogenital symptoms and mood changes. Treatment for the menopause will be included in
the next edition of the STGs.

Delaying Periods
If a woman wants to delay a period for a few days, give norethisterone PO 3 x per day for up
to 10 days. It should be started 3 days before the period is due.

Sexual and gender-based violence (SGBV) refers to any act that is perpetrated
against a person’s will and is based on gender norms and unequal power relationships. It
encompasses threats of violence and coercion. It can be physical, emotional, psychological,
or sexual in nature, and can take the form of a denial of resources or access to services. It
inflicts harm on women, girls, men and boys.

Clinical management of rape: There are a number of steps involved in providing good
medical care to survivors of rape: Prepare the survivor for examination and treatment, take
the history, perform the examination, collect forensic evidence, prescribe treatment, counsel
the survivor and follow-up care of the survivor. Core treatment goals:

Treat life threatening Assess vital signs e.g. BP, pulse, temperature

50
complications first
Prevent HIV transmission Provide PEP < 72 hours of rape, but: 1st dose the sooner the better (see 3.6)
Provide full 28-day supply of medications at initial visit
Provide enhanced adherence counselling
For recurrent exposures requiring repeat PEP consider crisis intervention and offer
protection
Prevent pregnancy <5 days provide but the sooner the better (see 1.1)
Presumptively treat STI’s Treat for syphilis, chlamydia, gonorrhoea (see 3.5)
Treat for other sexually transmitted infections if common (trichomonas, chancroid)
Shortest available course, easy to take (e.g. 1 g azithromycin and 400 mg cefixime)
Use local treatment protocols if available
Vaccinate for Hepatitis B if available
Injury Care Clean and treat wounds
Suture if needed/possible
Provide tetanus prophylaxis and vaccination
Mental Health Care Remember psychological first aid (LIVES – Listen, Inquire about needs and concerns,
Validate, Enhance safety, Support)
Consider: 5 – 10 mg diazepam at night for 2 or 3 days (Caution: benzodiazepine
dependence)
If severe psychological distress: EARLY referral
If incident > 3 months ago + severe disabling symptoms + no relief from counselling +
referral not possible: consider trial of antidepressant medication
NB: The same applies for male survivors excepting pregnancy prevention

Intimate Partner Violence

Refers to behaviour by an intimate partner or ex-partner that causes physical, sexual or
psychological harm, including physical aggression, sexual coercion, psychological abuse
and controlling behaviours.

FGM
Female Genital Mutilation, also known as ‘female circumcision’ or cutting, is the partial or
total removal of the external female genitalia or other injury to the female genital organs for
non-medical reasons. There are immediate complications:
 Infection (see below)
 Severe pain (see 4.12)
 Urinary retention
 Shock from severe pain or/and haemorrhage (see 5.1 and 5.3)

Treatment of Infection post-FGM

 Give antibiotics: Ampicillin 2g IV or Amoxicillin PO 2g every 8 hours AND
metronidazole IV or PO 400-500mg every 8 hours AND gentamicin 5mg/kg IM once
every 24 hours. (If the woman is allergic to penicillin or amoxicillin give erythromycin
instead of amoxicillin).

And long-term complications:

 Obstetric – complications during delivery including difficulties assessing, tearing to
perineum, development of obstetric fistula, obstructed labour, birth injury to the baby
 Gynaecological: fistula, incontinence, chronic pelvis infection, sexual dysfunction
 Psychological
 Physical complications: keloid formation, clitoral neuroma, epithelial inclusion cysts, vulval
abscesses, UTI’s, menstrual disorders

51
 2. Child Health
2.1 Immunisations
The health centre and health post are the key sites where children under five and pregnant
women are immunised against preventable diseases but staff in all health facilities including
hospitals should ensure all children are fully immunised and give doses if these have been
missed. Routine doses are also given to pregnant women and newborn children. Staff
promote immunisation, encouraging parents to ensure children follow the full immunisation
schedule. Tetanus toxoid is given up to 5 times to all women of reproductive age, with up to
3 doses administered in the ANC. At birth, the oral polio vaccine is given and BCG (see 1.8).
See table below.

Only staff trained to give vaccines are authorised to do so. They must carefully follow the
detailed instructions for each vaccine in the EPI guide, which includes how to store vaccines
at the right temperature, how to reconstitute vaccines with diluent, the multi-dose vial policy,
how to administer vaccines, contraindications to vaccines and adverse events after
immunisation. (see Simplified Field Guide for Vaccinators, MoH SS 2018)

Transport of vaccines must safeguard the cold chain – using freezing compartments in
fridges to prepare ice packs and Styrofoam boxes with ice packs when transporting vaccines
to rural settings is important.

South Sudan Immunisation Schedule

Visit BCG OPV IPV Pentavalent Measles
(DTP, Hep B,Hib)
Birth 1 X X OPV0
6 weeks 2 X OPV1 X Penta 1
10 weeks 3 X OPV2 X Penta 2
14 weeks 4 X OPV3 X X Penta 3
9 months (from 6 months in 5 X Measles 1
campaign)
Further measles dose. NB this may campaign X Measles 2
be given during campaigns.

BCG
Protection Against tuberculosis (TB)
Number of doses One
Schedule At or as soon as possible after birth. Do not
give BCG after 1 year of age
Diluent Use the same diluent from the same
manufacturer of BCG
Dosage and administration 0.05ml, intradermal, left forearm
Storage temperature Store between +2°C to +8°C

Measles
Type of vaccine Live attenuated viral
Number of doses One dose.
Schedule At 9–11 months of age, but need a second dose at 13 months (often given during
campaigns). In campaigns may is also given from 6 months upwards.
Booster A second opportunity for measles immunization is recommended (routine or campaign)
Contraindications Severe reaction to previous dose; pregnancy; congenital or acquired immune disorders
(not HIV infection)
Adverse reactions Malaise, fever, rash 5–12 days later; idiopathic thrombocytopenic purpura; rarely,
encephalitis, anaphylaxis
Special precautions None

52
Dosage 0.5ml
Injection site Rt upper arm
Injection type Subcutaneous
Storage 2°C–8°C (vaccine maybe frozen for long-term storage but not the diluent)

Pentavalent Vaccine. (Diphtheria, Tetanus, Pertussis, Hepatitis B & haemophilus influenza (Hib))
Type of vaccine Pentavalent vaccine
Number of doses Three
Schedule 6, 10, 14 weeks of age, (each dose 4 weeks apart).
Booster None
Contraindications Do not use as a birth dose
Adverse reactions Mild local and systemic reactions are common
Special precautions Do not use as a birth dose, usually not given over 6 years of age
Dosage 0.5ml
Injection site Outer left mid-thigh
Injection type Intramuscular
Storage 2°C–8°C. Never freeze

OPV
Type of vaccine Live oral polio vaccine (OPV)
Number of doses Four in endemic countries (including birth dose)
Schedule At birth, 6, 10, 14 weeks (each dose 4 weeks apart)
Booster Supplementary doses given during polio eradication activities
Contraindications None
Adverse reactions VAPP (paralysis) occurs very rarely (approximately 2 to 4 cases per
million children vaccinated)
Special precautions Children known to have rare congenital immune deficiency syndromes
should receive IPV rather than OPV.
Dosage 2 drops by mouth
Storage Store between 2°C–8°C (maybe frozen for long-term storage)

IPV
Protection Against poliomyelitis (polio)
Number of doses One
Schedule 14 weeks
Dosage and administration 0.5ml, intramuscular, outer right mid-thigh
Storage temperature Store between +2°C to +8°C; do not freeze.
Staff may also be involved in immunisation campaigns during epidemics. Immunisation as
part of outbreak response is subject to availability of vaccines, but vaccines will be available
for measles and polio, and may sometimes be available for meningitis.

2.2 Nutrition
Malnutrition can be under or over nutrition. Undernutrition often results from a combination of
insufficient nutritional intake, poor absorption and diseases. The 4 forms of undernutrition
are acute malnutrition (or wasting), stunting, underweight and micronutrient deficiencies
(including anemia).

SAM, or severe acute malnutrition, is defined by the presence of bilateral pitting oedema or
severe wasting, and other clinical signs such as poor appetite. A child with SAM is highly
vulnerable, and has a high risk of death.
MAM, or moderate acute malnutrition, is defined by moderate wasting.

53
All health and nutrition staff provide a vital role in preventing, detecting and treating
malnutrition.
All staff are involved in the following key nutrition activities:
1. Promoting good nutrition: teach parents and caregivers about infant and young child
feeding (IYCF) and exclusive breastfeeding, and how to give micronutrient
supplements. Staff and volunteers are also trained with a check list for home visits of
children who may be malnourished and to give key nutritional messages on
prevention and treatment.
2. Detecting malnutrition: Active case finding is done in the community by trained
volunteers by house to house visits, doing MUAC and oedema assessments and
referring identified cases to health facilities. Passive case finding is done in health
facilities by health workers for self-referred cases, and staff actively assess all
children with MUAC and looking for oedema. MUAC should be measured of any
child or pregnant woman thought to have malnutrition in health facilities and height
and weight in addition.
3. Treating malnutrition and anemia: All staff may be involved in providing care for
malnourished children. Children with SAM and complications are treated in the
Stabilisation Centre in hospitals. Children with SAM without complications are
managed in the outpatient therapeutic programmes (OTP) in health centres
(sometimes also in health units). Supplementary feeding programmes (SFP) for
children and pregnant and lactating women with Moderate Acute Malnutrition (MAM)
are run from health centres, health units or in the community by BHTs.

Micronutrients
Young children are given vitamin A and, if indicated, iron and folic acid to help prevent
chronic and acute malnutrition and anemia and to help reduce the impact and likelihood of
getting infections. But do not give vitamin A, iron or folic acid if child is receiving therapeutic
feeding which already contains these.

Vitamin A
 Infants 6 – 11 months 100,000 IU. Give a single dose every 4 – 6 months. Give 3
drops from red capsule or 1 blue capsule.
 Children 12 to 59 months (1 to 5 years) 200,000 IU. Give a single dose every 4 - 6
months. 1 red capsule or 2 blue capsules.

Anemia
Anemia is a reduction in the amount of red blood cells that is sign of many underlying
conditions. It is caused by one of the following categories:
 poor nutrition (insufficient iron or folate or Vitamin B12 in the diet)
 loss of blood (including bleeding or dysentery)
 rapid breakdown of red cells as happens with malaria or sickle cell disease
 reduced production of red cells by the bone marrow (as in a leukaemia).
Symptoms and signs include irritability, tiredness and pallor of the conjunctivae, lips, tongue,
nail beds and palms. Jaundice if rapid breakdown of red cells.
Diagnosis: measurement of haemoglobin. Moderate anemia is between 7 and 10.9g/dl and
severe anemia is < 7g/dl.

Normal Haemoglobin levels by age

Age Lower limit of normal range Hb (g/dL)
2 months 9.0
2 – 6 months 95
6 – 24 months 10.5
2 – 11 years 11.5

54
 >12 years female – 12.0 male – 13.0

Treatment for most moderate and mild cases is with iron and folate tablets.
Severe anemia can present with breathlessness and tachycardia and may need urgent
blood transfusion.

Many of the STG treatments help prevent anemia. These include micronutrient
supplementation and the prevention and treatment of malaria. Children with thalassemia and
sickle cell disease need regular follow up. Deworming medication is given regularly to young
children to prevent and treat all worms including the hookworms which cause anemia.
Deworming medication is usually given once to pregnant women during an ANC visit from
the 2nd trimester.

Treatment steps
1. Test the haemoglobin for all suspected cases of anemia. Cases of breathlessness
from anemia may need urgent blood transfusion.
2. Give iron and folate for 3 months if anemia diagnosed in the health centre.
3. Do not give iron if the person has sickle cell anemia (or thalassemia) (see 4.9).
4. Micronutrient and malaria control programmes help prevent and treat anemia.
5. All young children receive deworming medicine if they have not already received it.
6. Pregnant women are given deworming medicine at ANC in the 2nd trimester.
Precaution: Albendazole must not be given in the first trimester of pregnancy. It is not
given to women who are breastfeeding in case they are in early pregnancy.
7. Reinforce all prevention measures, including handwashing, exclusive breastfeeding,
infant & young child feeding (IYCF) and the best food for children and pregnant
women.

Iron folate for treating anemia:

Medicine Age Dose Duration Side effects
Iron & folate Children < 2 years ½ tablet per day (30mg iron + 200 3 months Common:
tablets (60mg micrograms) Abdominal
iron + 400 Children 2 – 12 years 1 tablet per day (60mg iron + 400 3 months discomfort;
microgrammes micrograms folate) constipation
folate) Adults including pregnant women 2 tablets per day (120mg + 400 folate) 3 months
Advice slot: Follow up can be in the HC if they can check Hb.

Blood transfusion for severe anemia

A child with severe anemia may have adapted to having a very low haemoglobin. However,
the pulse and respiratory rate may well be raised. When the person can no longer cope (the
anemia becomes decompensated), other signs develop such as rapid breathing and signs of
respiratory distress, difficulty eating, poor capillary refill, enlarged liver and spleen and signs
of left and right heart failure. There is no exact level of haemoglobin to transfuse at as it
depends on the clinical condition and presence of other illnesses.

Treatment steps for severe decompensated anemia

 Sit the child up, not lying down
 Give oxygen from a concentrator if available
 Urgently test and crossmatch blood
 Give paracetamol if fever
 Treat signs of heart failure with furosemide 2mg/kg by mouth or 1mg/kg IM.
 Treat any infection
 Transfuse (see 5.4).

Thalassemia and sickle cell disease (see 4.9)

55
 Deworming medicine
Medicine Age Dose Duration Side effects
Infants < 12 months Do not give any deworming medicines. Common:
Albendazol Children 12 – 23 ½ tablet (200mg) of albendazole 400mg Single dose Abdominal
e tablet months discomfort
Children 24 months 1 tablet (400mg) of albendazole 400mg Single dose Rare: Diarrhoea,
and older dizziness
Prescribing tip: Children: Children over 1 year old should have deworming medicine once a year.
Advice slot: Mebendazole can be given as an alternative to albendazole.

Severe acute malnutrition (SAM) without complications - outpatient therapeutic

programme
OTPs are usually held in health centres. Once a child has recovered from SAM with
complications in the Stabilisation Centre they can be referred back to the OTP.

Treatment of SAM with medical complications in the inpatient Stabilisation Centre

(SC)
Medical treatment and nutrition rehabilitation is done in 3 phases: 1. stabilisation, 2.
transition and 3. rehabilitation. Consult: Guidelines for Inpatient Management of SAM.

1. Stabilisation Phase covers nutrition and medical stabilization, treatment of medical

complications and oedema, and commences nutritional rehabilitation.
2. Transition Phase covers a gradual increase in diet leading to some weight gain while
preventing complications of over-feeding. Transfer to transition only if medical
complications treated, oedema is decreasing, and an NG tube is no longer needed.
3. Rehabilitation Phase is a rapid weight-gain phase (catch-up growth). It is most often
implemented at the OTP but can be done at the in-patient facility under some
circumstances.

The 10 steps of care in the SC are (see Guidelines for inpatient management of SAM):
1. Treat/ prevent hypothermia
2. Treat/ prevent hypoglycaemia
3. Treat/ prevent dehydration
4. Correct electrolyte inbalances
5. Treat/ prevent infections
6. Correct micronutrient deficiencies
7. Start cautious feeding
8. Achieve catch up growth
9. Provide sensory stimulation and emotional support
10. Prepare for follow up after recovery

1. Stabilisation Phase: Weigh the child or estimate weight to calculate fluid

requirements. Assess pulse and respiratory rate, and blood glucose. If no facility to test,
assume hypoglycaemia is present otherwise test and treat if blood glucose < 3mmol/L (or
54mg/dl).
Treat hypoglycaemia and ensure nutrition.
 If child can drink give 50ml of 10% sucrose orally.
 If alert but not drinking, give 50mls by NG tube.
 If lethargic or unconscious give 5mls/kg of 10% dextrose IV followed by 50mls 10%
sucrose by NG tube (but do not give by NG tube child in shock and IV continued).
 Give F-75 half an hour after the glucose and every half-hour during the 1st 2 hours

56
If shock (as defined by WHO: cold hands, + CRT> 3 secs + weak, fast pulse)
 IV fluids 15mls/kg over 1 hour. Ringer’s lactate may be used if either Ringer’s lactate
with 5% glucose or half strength Darrow’s solution with 5% glucose are not available.
 Monitor pulse and respiratory rate every 5-10 minutes. Stop the infusion if
 Respiratory rate increases 5/min
 Pulse rate increases 15/min
 Increased oedema or facial swelling
 Improvement: Repeat 15ml/kg as IV bolus over 1 hour if pulse and respiratory rate
improve. Switch to oral or NG feed if not comatose - give hourly feeds 10mls/kg/h
alternating ReSoMal with F75 if available. Assess hydration status every 2-3 hours
and continue hourly feeds for maximum 10 hours, avoiding fluid overload. Continue
with F 75 feeds
 No improvement: Give maintenance IV fluids (4mls/kg/hr) then give 10mls/kg fresh
whole blood over 3hours or packed cells 5 – 7 ml/kg over 3 hours, and may need
furosemide 1mg/kg IV with transfusion. Do not feed during transfusion. After
transfusing start frequent low volume feeds with F75 or low lactose/low osmolality
equivalent. Give IV antibiotics (see below).
Correct electrolyte imbalance. F-75 and feeds contain all electrolytes needed. But if feeds do
not contain minerals and vitamins then give:
 potassium 4mmol/kg and magnesium 0.6mmol/kg, using CMV or electrolyte/ mineral
solution or 10% postassium chloride added to feeds.
Antibiotics for SAM. Give broad spectrum antibiotics on admission.
 No complications: Amoxicillin oral 25mg/kg every 12 hours for 5 days
 Complications: Gentamicin 5mg/kg IV or IM once daily and ampiciliin 50mg/kg IV or
IM 4 x day for 2 days followed by amoxicillin 25mg/kg PO 2 x day for 5 days.
Correct micronutrient deficiencies.
 Ensure therapeutic foods are providing 5000 IU daily of vitamin A, if not give
100,000IUs vitamin A to 6-12 months and 200,000IU vitamin A to 12 – 59 months on
admission.
 If therapeutic foods do not contain folic acid, give all infants and children over 6
months folic acid 5mg on admission and 1mg daily.
 If combined mineral vitamin mix (CMV) is not used to prepare feeds, give
multivitamin drops (that do not contain iron) daily.
Cautious feeding in stabilisation and transition phase
 On the 1st admission day give a small amount of F-75 every 2 hours (12 feeds in 24
hours). Give ¼ of the 2-hourly amount every half-hour in the first 2 hours if the child
is hypoglycemic.
 On the 2nd day onwards, give F-75 feeds every 3 or 4 hours. Use correct volume as
to whether has oedema or not. If no oedema or oedema + or ++ give 130ml/kg/day. If
oedema +++ give 100ml/kg/day (see F-75 Look-up table & F-75 with oedema++)
 Use NGT tube if child very weak, has mouth ulcers or does not take 80% of oral
feeds. But at each feed give some F-75 orally first. Remove NGT once child taking
80% feeds orally.

2. Transition Phase: Patients normally remain in Transition Phase for two to three days.
F75 is replaced with F100 or a locally made-up milk of the equivalent nutritional value. The
patient’s diet is increased from 100kcal/kg/day to 130kcal/kg/day for children. The quantity of
milk remains the same, but the calorie content changes by changing milk formulas from
75kcal to 100kcal per 100ml of milk. The child is gradually transferred onto RUTF after doing
the acceptance test (eats a third of one sachet). If RUTF is not available or the child does
not accept it, give F100. NB. Infants < 6 months should not receive full strength F-100 but
the F-100 should be further diluted by adding 30% safe water.

57
3. Stabilisation Phase: Patients move from Transition Phase into Phase 2 when they
have a good appetite, are tolerating the diet given, have no major medical complications and
oedema is resolved. The patient receives F100 at 200kcal/kg/day or the equivalent in the
form of RUTF. Recovered patients are transferred to the OTP at the health centre.

2.3 Paediatric Conditions

Medical conditions affecting children are included in all sections of these STG. More detailed
guidelines on treating children and conditions more common in childhood will be included in
the next edition of the STG.

Childhood constipation
Acute simple constipation may occur after illness and respond to increase in fluids. Treat any
underlying cause. There is no evidence for increasing fluids above the recommended daily
level in managing chronic constipation. Ensure adequate fibre and consider natural laxatives
(fruits & whole grains). Encourage regular toileting after meals, rewards for passing stool,
encourage praise and positive feedback from parents

Medication needs to be used long term and not suddenly stopped- treat for at least 3 months
before reviewing and always aim for gradual reduction in medicine use. A third of young
children may need treatment until aged 2 years old, a third until aged 5 years old and a third
need longer term treatment.

Treatment
Lactulose to soften stool (note: can take 48 hours before it begins to work)
 For Child 1–11 months:  2.5 mL twice daily, adjusted according to response.
 For Child 1–4 years:  2.5–10 mL twice daily, adjusted according to response.
 For Child 5–17 years: 5–20 mL twice daily, adjusted according to response.

Docusate (older children)

 For Child 12–17 years: Up to 500 mg daily in divided doses, adjusted according to
response.

Senna to stimulate bowel (tablets, not under 2y)

 For Child 2–3 years: 3.75–15 mg once daily, adjusted according to response.
 For Child 4–5 years: 3.75–30 mg once daily, adjusted according to response.
 For Child 6–17 years: 7.5–30 mg once daily, adjusted according to response.
Can take 8-12 hours to act. Side effects include abdominal pain, diarrhoea. Adjust doses to
response (e.g at weekly review).

Treat any fissure – even with barrier cream to reduce pain and reduce withholding. Admit if
needed (for suppositories/enema /manual evacuation). Urgent referral for red flags e.g
Hirschsprung’s , bowel obstruction, neurological signs. Consider referral if faltering growth,
developmental delay, concern about child’s wellbeing.

58
3. Communicable Diseases
3.1 Diarrhoea

Diarrhoea is the presence of loose stools three times or more a day and has many causes
Commonly it is caused by viruses, sometimes by bacteria or other organisms and
sometimes by other illness in the body. Stools can be very watery (acute watery diarrhoea or
cholera) or may have blood in them (dysentery). Most diarrhoea does not need antibiotic
treatment. Diarrhoea causes dehydration, that may lead to kidney failure and death, so the
priority of treatment is urgently giving fluids (rehydration).

Treatment steps
 Assess for dehydration
 Give extra fluids.
 Give zinc sulphate supplements
 Give vitamin A for children if vitamin A given in past 6m.
 Continue feeding infants.
 Give antimicrobials for diarrhoea with blood (dysentery).
 Malnourished children and people with HIV may need special treatment for diarrhea.

Dehydration from diarrhoea is graded for treatment by IMNCI:

 Plan A (green) – no dehydration, person can be treated at home according to 4 rules
of home treatment
 Plan B (yellow) – some dehydration, treat with ORS and observe in HF
 Plan C (red) – severe dehydration, give IV fluids and refer if no improvement within 4
hours
Precaution: Do not give ibuprofen to dehydrated children because it can damage their
kidneys.

No dehydration (Plan A):

Give as much fluid as the person will take. If a child, tell the parent to:
 Breast feed frequently and for longer at each feed
 Give ORS or clean water. For infant, continue breast-fed infants as well.
 If not exclusively breast fed, give one or more of the following: ORS, food based
fluids e.g soup, rice water and yoghurt drinks

Home-made ORS
 ½ teaspoon or a good pinch of salt
 6 teaspoons of sugar (or 2 x 4-finger handfuls)
 1 litre of boiled, cooled water
Wash your hands with soap and water, mix salt, sugar and water together in a clean
container, stir until dissolved.

ORS from a packet - Give the person or parent 2 sachets to make up at home.
Check size of packet carefully, as comes in 2 sizes. One has to be diluted in 1 litre of water.
The other has to be diluted in ½ litre.
 Pour all the powder into a clean container
 Pour 1 litre of boiled and cooled water into the container….

How to give ORS

 Give in frequent small sips from a cup with a spoon (child under 2 years: 1 teaspoon
every 1 -2 minutes

59
  Throw away the solution after one day and make up more in a clean container
 If a person vomits, try again 10 minutes later but give more slowly
 Give extra fluids and breastfeed infants until the diarrhoea stops.
 Show the carer/parent how much fluid to give in addition to the usual drinks:
Up to 2 years: 50 to 100 ml after each loose stool
2 years or more: 100 to 200 ml after each loose stool

Some dehydration (Plan B):

Two or more of the following signs
 Restlessness, irritability
 Sunken eyes
 Drinks eagerly, thirsty.

Treatment with ORS in first 4-hour period for children under 5 years
Weight < 6 kg 6 - 10 kg 10 - 12 kg 12 - 19 kg

Age Up to 4 months 4 months to 12 months 12 months to 2 years 2 years to 5 years

Amount in mls to give 200 - 400 400 - 700 700 - 960 960 - 1400
over a 4-hour period
Use the child's age only when you do not know the weight. The approximate amount of ORS
required (in ml) can also be calculated by multiplying the child's weight (in kg) times 75.

If a person wants more ORS than shown, give more. For infants under 6 months who are not
breastfed, also give 100 - 200 ml clean water during this period. Reassess after 2 to 4 hours,
classify for dehydration and select plan A, B or C:
 If improving, begin feeding a child/ allow the person to eat.
 Change to Plan A when dehydration is corrected (a child usually passes urine )
 If signs indicate some dehydration repeat Plan B but start to offer food as in Plan A
 If signs indicate severe dehydration move on to Plan C

Severe dehydration (Plan C)

At least two of the following signs.
 Lethargy/ unconsciousness
 Sunken eyes
 Unable to drink or drink poorly
 Skin pinch goes back very slowly > 2 seconds
Give ORS, give fluids by IV.

IV fluids for severe diarrhoea:

Give 30ml per kg of Ringer’s Lactate or Normal saline or ½ strength Darrow’s solution in
2.5% dextrose in 1 hour IV. If IV fluid not possible, give 20ml per kg per hour by NG tube
(but only if trained to use NG tube).
After one hour, if good response:
 give IV fluids 10ml per kg per hour.
 give ORT (about 5ml per kg per hour) as soon as the person can drink.
 Give zinc
After one hour, if not good response:
 Repeat IV fluid 30ml/kg in next hour
 Then continue IV fluid at 10ml per hour for next 4 hours.
 Give zinc.

For older children and adults, give an initial 20ml/kg IV followed by maintenance therapy of
10ml/kg per hour.

60
 Reassess every 1-2 hours. If hydration status is not improving, give the IV drip more rapidly.
Also give ORS (about 5 ml/kg/hour) as soon as the person can drink, usually after 2-4 hours
(infants) and 1-2 hours in older patients. Reassess after 3 hours. Reclassify dehydration.

Give zinc supplements to all children over 6 months and adults with diarrhea.
Medicine Age Dose Duration Side effects
Zinc Infants < 6 months 10mg (½ 20mg tablet) 14 days Rare: Nausea, sore
per day mouth/ throat,
Children > 6 months One 20mg tablet per day 14 days indigestion
Adults One 20mg tablet per day 14 days
Prescribing tip: Infants: Tablets can be dissolved in ORS or breast milk. Older children can chew whole; or tablets
can be crushed and dissolved in a spoon of water
Give zinc for 14 days even when the child is better

 Give Vitamin A if prolonged diarrhoea in children. Give vitamin A 50,000 IU for infants
2 – 6 months; 100,000 units for infants 6 – 11 months and 200,000 units for children
> 1 year.
 Continue nutrition – breast feeding and eating. For infants over 6 months and
children parents may need to crush food or make porridge or soups and give with a
cup and spoon. Adults should start eating once they are not vomiting.

Anti-microbial treatment
Most acute diarrhoeas are caused by viruses and do not respond to antimicrobials.
 If there is blood in the diarrhoea (dysentery) with no fever or abdominal pain, treat
dehydration and do stools microscopy test.
 If amoebae are found, treat with metronidazole.
 If there is blood in the diarrhoea with fever and abdominal pain (acute dysentery
caused by bacteria) treat dehydration and treat with ciprofloxacin.
 Antibiotics lessen the risk of serious complications and death, shorten the duration of
symptoms and reduce the elimination of shigella in the stools, limiting the spread of
infection.
 The SMoH must be immediately informed of any case of bloody diarrhoea with fever.

Treatment steps
1. Rehydrate with ORS.
2. If no fever or abdominal pain, do microscopy. If amoeba found, treat with
metronidazole. If diarrhoea cases with giardia found on stool microscopy, treat with
metronidazole.
3. If fever and abdominal pain, treat with ciprofloxacin for acute dysentery

Treatment of amoebic dysentery with metronidazole (amoebae seen in stools)

Medicine Age Dose Duration Side effects
Metronidazole Infants 6 - 12 months Give half a 250mg tablet crushed 3 x 5 days Common: nausea
250mg tablet day Rare: vomitng
Children aged 1 – 4 125mg (1/2 tablet) 3 x per day 5 days
years
Children aged 5 – 12 250mg (1 tablet) 3 x per day 5 days
years
Children over 12 years 500mg (2 tablets) 3 x per day 5 days
Adults 750mg (3 tablets) 3 x per day 5 days

If giardia is found in the stools and the person has symptoms (diarrhoea, abdominal
discomfort, nausea), then a single dose of 2g tinidazole PO can be given to adults if
available. Or treat with metronidazole:

61
 Treatment of giardia with metronidazole (giardia seen in stools)
Medicine Age Dose Duration Side effects
Infants < 12 months Give half a 250mg tablet crushed 2 x 3 days Common: nausea
Metronidazole day Rare: vomiting
250mg tablet Children aged 1 – 5 125mg (1/2 tablet) 2 x per day 3 days
years
Children aged 5 – 12 250mg (1 tablet) 2 x per day 3 days
years
Children over 12 500mg (2 tablets) 2 x per day 5 days
years
Adults 500mg (2 tablets) 3 x per day 5 days

Ciprofloxacin for diarrhoea with blood and fever (acute dysentery)

Ciprofloxacin Infants < 12 months 63.5mg 2 x day 5 days Common: nausea
250mg tablet Children aged 1 – 5 125mg (1/2 tablet) 2 x day 5 days Rare: vomiting
years
Children aged 5 – 12 250mg (1 tablet) 2 x day 5 days
years
Children over 12 500mg (2 tablets) 2 x day 5 days
years
Adults 500mg (2 tablets) 2 x day 5 days
Do NOT give to
pregnant women
Prescribing tip: will need a 5 days course.

Treatment of children with SAM (severe acute malnutrition) and

dehydration
Children with SAM and diarrhoea and moderate dehydration should not be given normal
ORS but given ReSoMal instead. Give fluid slowly to prevent overload or heart failure.
 Give ReSoMal orally or by NG tube
 Give: 5ml/kg every 30 minutes for first 2 hours
 Give 5-10mls hourly until weight gain has been achieved
 Breastfeeding is continued

Children with SAM and severe dehydration need IV fluids. Weigh child first.
1. Use ringer lactate with 5% dextrose, half strength 0.9% sodium chloride with 5%
dextrose (ie an equal quantity of 5% dextrose with either ringer lactate or 0.9%
sodium chloride).
2. Give 15ml/kg IV over the first hour, then reassess.
3. If there is no weight gain then repeat the 15ml/kg iV over the next hour, continue until
there is weight gain.
4. If there is weight gain but no clinical improvement the child may have septicaemia or
other complications which must be treated.
5. Stop the IV fluids when pulse rate returns to normal and treat with ReSoMal
10mg/kg/hour.

Children with HIV

Prevention of Diarrhoea
 Vitamin A supplementation is recommended for all HIV -infected children and
exposed children aged 6 months to 5 years.
 Give 100,000 IU every 6 months for children aged 6-12 months.
 Give 200,000 IU every 6 months for children age over 12 months.
 Ciprofloxacin for 3 days at an oral dose of 15mg/kg is recommended for treating
bloody diarrhoea in all HIV infected and exposed children.

62
Daily multiple micronutrients for 2 weeks are recommended for all HIV infected or exposed
infants and children with persistent diarrhoea.

3.2 Acute Respiratory Infections

Upper airway: common cold, croup, tonsillitis, ear infection, sinusitis, epiglottis, influenza
Lower airway: pneumonia, bronchitis, bronchiolitis (in infants)

Common cold
May be caused by more than 200 different viruses, including rhinoviruses. Treatment aims to
relieve symptoms of runny or blocked nose, sneezing, sore throat, cough, mild fever,
headache. Most colds resolve in 7 – 10 days but cough may persist for14 days.
Treatment steps
 Give paracetamol for symptom relief (see Prescribing paracetamol).
 Advise to drink more fluids.
 Breastfeed infants frequently and clear a blocked nose with 0.9% sodium chloride
drops: place child on back, turn head to side, instil 0.9% sodium chloride into nostril.
 If fast, difficult or noisy breathing, consider pneumonia or croup.

Croup
Presents with a characteristic hoarse voice and “barking” cough. Severe episodes are more
likely to present in children < 2 years and may present with stridor and decreased
oxygenation (blueness of the lips). Antibiotics do not help as the cause is viral.
Treatment of Croup
In absence of inspiratory stridor or retraction treat symptomatically, ensuring adequate
hydration.

If stridor is present with agitation, hospitalise for observation.

Give dexamethasone PO according to table. (open an IV ampoule and mix with with sugar
water, 10% or 50% glucose or juice and give orally).
Dexamethasone 4mg/ml ampoules
Age 3-11 months 1-2 years 3-4 years
weight 6-9kg 10-13kg 14-17kg
Dose in mg 4mg 8mg 10mg
Dose in ml 1ml 2ml 2.5ml

if child is vomiting; 0.6mg /kg IM single dose.

If no dexamethasone available give oral prednisolone.mCrush steroid tablets (prednisolone)

in water and give by mouth.
 Child 1 mg/kg oral prednisolone x 1. Repeat after 12 hours if necessary
Precaution: Do not give steroids in croup caused by measles.

If danger signs are present (stridor at rest, respiratory distress admit in intensive care).
 Give oxygen continuously at least 5 litres per minute to maintain SpO2 94-98%
 Insert an IV line and provide IV hydration.
 Give epinephrine (adrenaline) via nebuliser (1mg/ml: 1ml ampoule) 0.5mg/kg
(maximum dose 5mg) to be repeated every 20 minutes if danger signs persist.
 Monitor heart rate during nebulisation. (Stop nebulisation if heart rate > 200bpm)

Epinephrine (adrenaline)
Age 3 months 4-6 months 7-9 months 10-11 months 1-4 years
Weight 6kg 7kg 8kg 9kg 10-17 kg
Dose in mg 3mg 3.5mg 4mg 4.5mg 5mg
Dose in ml 3ml 3.5ml 4ml 4.5ml 5ml

63
 NaCl 0.9% 1ml 1ml

Suspect bacterial tracheitis in a critically ill child (weak grunting or crying, drowsiness,
difficult to arouse, does not smile, unconjugated or anxious gaze, pallor or cyanosis, general
hypotonia. that does not improve with above treatment). If wheezing is present, give
salbutamol inhaler via a nebuliser 2-3 puffs every 20-30 minutes as needed.
In very severe case emergency measures may need to be taken to open the airway
(intubation or emergency tracheostomy). Steroids are given orally where possible (for severe
cases only) as parenteral administration (IM or IV) may increase distress and may provoke
closure of the airway.

Tonsillitis
Most throat infections of tonsils or pharynx are caused by viruses. Mild infections:
(pharyngitis or moderately swollen tonsils with no pus) are treated with analgesia alone. In
severe infections (tonsils very enlarged, with pus, fever and swollen lymph nodes), give
antibiotic. Treatment aims to relieve symptoms, duration of the disease and complications of
Group A streptococcus which mainly affects children age 3 to 14 years.
Treatment steps
 Pain and fever control. Mild tonsillitis is treated with analgesia alone. For children,
give paracetamol as first choice, ibuprofen as second choice; for adults, give
ibuprofen or paracetamol for pain and fever. Ibuprofen is more effective than
paracetamol for pain control in tonsillitis in adults.
 Penicillin for severe tonsillitis. If allergic to penicillin, give erythromycin.
Review if there is no improvement after two days or any new symptoms. Encourage a child
to continue to eat and drink plenty. It may help to crush food and give soups. When
prescribing suspensions, a plastic measuring spoon usually comes with the medicine. If this
is not available, it is important to show the parent how to measure a similar quantity using a
tea spoon.

Pain and fever control: Give paracetamol (see Introduction) or give ibuprofen
 Do NOT give children aspirin.
 Do not give ibuprofen to dehydrated children because it can damage their kidneys
Medicine Age Dose Side effects
Ibuprofen Infants < 2 months Give paracetamol instead. Common:
Infants 2months - 1 year 50mg (1.25mls of 200mg/5ml syrup) 3 x per day nausea and
Children 1 – 4 years 100mg (2.5mls of 200mg/5ml syrup) 3 x per day abdominal pain,
Children 5 – 8 years 200mg (5mls of 200mg/5ml syrup) or 1 x 200mg tablet 3 bronchospasm
x per day Rare: allergic
Children 9 – 15 years 300mg (7.5mls of 200mg/5ml syrup) or 1½ x 200mg reaction; ulcer in
tablet 3 x per day stomach; damage
Adults 400mg tablet 3 x per day to kidneys & liver

Antibiotics for severe tonsillitis

Medicine Age Dose Duration Side effects
Penicillin V Infants 6 – 11 months 62.5mg (1/4 tablet) 4 x 10 days Common: none
(Phenoxymethylpenicillin) per day Rare: allergic
250mg tablet Children 1 – 5 years 125mg (½ tablet) 4 x per 10 days rash, allergic
day reaction
Children 6 to 11 years 250mg (1 tablet) 4 x per 10 days (anaphylaxis)
day
Children over 12 and 500mg (2 tablets) 4 x per 10 days
Adults day
Prescribing tip: Older children: tablets can be crushed.

64
Advice: Give for the full 10 days. Use IM benzathine if a 10-day course of oral penicillin cannot be taken.
Adults: Benzathine penicillin G 1.2 million U IM once
Children: Benzathine penicillin G 25,000 U/kg IM once (maximum 1.2 million U)

Erythromycin: tonsillitis, ear infection, pneumonia in case of allergy, resistance to penicillin.

Medicine Age Dose Duration Side effects
Erythromycin 250mg Infants 6 – 11 months 62.5mg (1/4 tablet) 4 x 10 days Common:
tablet per day nausea, vomiting,
Children 1 – 5 years 125mg (½ tablet) 4 x per 10 days indigestion
day Rare: rash,
Children 6 to 11 years 250mg (1 tablet) 4 x per 10 days jaundice
day
Children over 12 and 500mg (2 tablets) 4 x per 10 days
Adults day
Prescribing tip: Older children: tablets can be crushed.
Advice: Give for the full 10 days

Ear infection
Mild ear infections are often caused by viruses and can be treated with analgesia alone. And
do not need antibiotics. Antibiotics are only used if there is a high temperature and severe
earache, or if the person has HIV.
Treatment steps
1. Pain and fever control. For children, give paracetamol as first choice, ibuprofen as
second choice; for adults, give ibuprofen or paracetamol for pain and fever. Ibuprofen
is more effective than paracetamol for pain control in ear infection in adults.
2. Amoxicillin for severe earache and high temperature. Also consider in children whose
assessment suggests severe infection (vomiting, fever, >39 C severe pain) or
children at risk of unfavourable outcome eg malnutrition, HIV ear malformation.) Give
erythromycin if allergy to penicillin/ amoxicillin.
3. Admit If there is fast or difficult breathing, or if a child is drowsy, has a rash or is very
unwell.
Treatment note: Most people with ear infection get better without antibiotics.
Advice: Review if there is no improvement or any new symptoms. Make sure the child
continues to eat and drink plenty.

1. Pain and fever control

Give paracetamol or ibuprofen.
Medicine Age Dose Duration Side effects
Ibuprofen, Infants < 2 months give paracetmol instead Common: nausea
syrup Infants 2 months – 1 year 50mg (2.5mls (1/2 spoon) of 2 – 5 days and abdominal pain
100mg/5ml; 100mg/5ml syrup) 3 x per day Rare: allergic
200mg and Children 1 – 4 years 100mg (5mls (1 spoon) of 2 - 5 days reaction; ulcer in
400mg 100mg/5ml syrup) 3 x per day stomach; damage
tablets Children 5 – 8 years 200mg (10mls (2 spoons) of 2 - 5 days to kidneys & liver
100mg/5ml syrup) 3 x per day
Children 9 – 15 years 3000mg (15mls (3 spoons) of 2 - 5 days
100mg/5ml syrup) 3 x per day
Adults 400mg – 800mg (1 – 2 tablets) 2 - 5 days
3 x per day
Prescribing tip: If children or adults have indigestion after taking ibuprofen then paracetamol should be given
instead.
Advice: Give after food.

Precaution: Do not give ibuprofen to dehydrated children because it can damage their
kidneys. Do not give ibuprofen to children with asthma as it can cause an exacerbation.

65
 2. Amoxicillin for severe earache/ otitis media
Amoxicillin for severe earache if not allergic to amoxicillin or penicillin
Medicine Age Dose Duration Side effects
Amoxicillin 125mg/5ml Infants 2 months to 1 125mg (5ml or ½ tablet) 2 5 days Common:
suspension or year x day diarrhoea
Amoxicillin 250mg Children 1 – 5 years 250mg (10ml or 1 tablet) 2 5 days Rare: allergic
tablet/ capsule. (May x per day rash, allergic
also come in 250mg/5ml Children 6 to 11 years 500mg (20ml or 2 tablets) 5 days reaction
suspension and in 500mg 2 x per day (anaphylaxis)
capsules) Children over 12 and 750mg (3 tablets) 2 x per 5 days
Adults day
Prescribing tip: Older children: tablets can be crushed.
Precaution: Ask the parent if the child is allergic to amoxicillin or penicillin. In case of allergy,
give erythromycin.

Sinusitis
Sinusitis is an infection of the sinus spaces of the front part of skull, most commonly in the
maxillary or ethmoid sinuses. It is usually caused by viruses but may be caused by bacteria.
As well as symptoms of a viral cold, the person may have pain and tenderness over these
sinuses, with a yellow pus discharged. Normally it can be managed with pain control
medicine (ibuprofen or paracetamol) alone. In more severe cases nasal steroids may help
(beclomethasone nasal spray. Give 2 puffs both nostrils 2 x per day). An alternative is 0.9%
sodium chloride solution. When the sinus is very tender or there is a large amount of pus
discharge, antibiotics may be needed. Very rarely sinusitis can cause complications such as
meningitis or an abscess in the brain.

Antibiotics for severe sinusitis

First Line
 Children. Amoxicillin 30mg/kg 3 times a day orally for 7-10 days.
 Adults 1gm 3 times a day for 7-10 days.
If penicillin allergic:
 Give doxycycline to adults (not to pregnant women), 100mg 1 x day for 7 days or
erythromycin 500mg 4 x day for 7 days.

Flu
Flu starts as an upper airway infection by the influenza A & B viruses.
Presentation:
 like the common cold with runny nose and sore throat but:
 accompanied by high fever, muscle pains, headache and exhaustion.
 most symptoms last less than a week, but:
 the cough can continue for two weeks.
 In children there may also be nausea and vomiting.
Complications of flu include:
 a viral pneumonia or secondary bacterial pneumonia,
 sinusitis and exacerbations of asthma.
 It is more dangers for young children, older people, those with chronic disease and
pregnant women.
Treatment is supportive, giving paracetamol and encouraging the person to take more oral
fluids. Treat signs of pneumonia see below.

Outbreaks of the Influenza A strain of flu may come in large epidemics, which can be very
dangerous depending on the particular sub-strain of virus. Bird flu and pig or swine flu are
variants of the influenza A virus that predominantly infect these animals but can also infect
humans. Immunisation may become available in the country if there are new epidemics and

66
epidemic control measures put in place. Antiviral medication is expensive, does not help the
majority of cases and is not routinely available in the country. The flu vaccine may become
available in serious epidemics, and should in particular be offered to elderly people and
those with chronic lung diseases and those on ARVs.

Acute bronchitis
Acute bronchitis is an infection in the smaller air passages of the lungs without consolidation
of the lung parenchyma as seen in pneumonia. Consider acute bronchitis if a patient
presents with a cough and green or yellow sputum, with or without fever, but without fast
breathing. Most mild cases of acute bronchitis will resolve with paracetamol for fever;
antibiotics are rarely needed. If the person is coughing up a lot of yellow or green sputum
treat with antibiotics:

Amoxicillin 500mg 3 x per day for 5-7 days OR

Erythromycin (if penicillin allergic) 500mg 4 x per day for 5 – 7 days.
If there is fast breathing, high fever or any danger signs or if symptoms are not improving
then treatment will be needed for pneumonia (see below).

Pneumonia and difficult breathing

Pneumonia is an infection in the lung, in the lower airway caused mainly by bacteria. The
signs of pneumonia are fast and difficult breathing, chest indrawing, cough, fever, sputum. It
is a very dangerous disease. Antibiotics are needed for pneumonia. The IMCI guide can be
followed.
Children
Latest guidelines suggest classifying pneumonia into two categories.

Severe Pneumonia
Any danger sign. Danger signs include:
 Very fast breathing. A child has fast breathing if:
 infants under 1 month > 60 breaths per minute
 Infants 1 month to 11 months > 50 breaths per minute
 Children aged 1 year to 5 years > 40 breaths per minute
 Children > 5 years and adults > 30 breaths per minute
 Noisy breathing (not coming from the nose).
 Chest indrawing in children.
 Signs of consolidation.
 Blue colour to the lips and tongue. Or SpO2 <90%
 Drowsiness.
 Convulsion. Inability to eat or drink.
This may be severe pneumonia.

Treatment
Admit to hospital.
Children under 2 months
First line treatment is combination of ampicillin slow IV (3 minutes) for 10 days and
gentamicin slow IV (3 minutes) or Im for 5 days.
Children 0-7 days <2kg Ampicillin 50mg/kg every 12 hours + gentamicin 3mg/kg once daily
Children 0-7 days >2kg Ampicillin 50mg/kg every 8 hours + gentamicin 5mg/kg once daily
Children 8 days <1 month Ampicillin 50mg/kg every 8 hours + gentamicin 5mg/kg once daily
Children 1 month -< 2 months Ampicillin 50mg/kg every 6 hours+ gentamicin 6mg/kg once daily

If ampicillin is not available, alternatives may be cefotaxime slow IV (3 minutes) or infusion

(20 minutes) or IM for 10 days.

67
 Children 0-7 days <2kg Cefotaxime IV 50mg/kg every 12 hours
Children 0-7 days >2kg Cefotaxime IV 50mg/kg every 8 hours
Children 8 days <1 month Cefotaxime IV 50mg/kg every 8 hours
Children 1 month -< 2 months Cefotaxime IV 50mg/kg every 6 hours

If child’s condition does not improve after 48 hours, add cloxacillin IV for 10 to 14 days.
Children 0-7 days < 2kg Cloxacillin 50mg/kg every 12 hours

Children 0-7 days> 2kg Cloxacillin 50mg/kg every 8 hours

Children <7 days <2kg Cloxacillin 50mg/kg every 8 hours

Children <7 days>2kg Cloxacillin 50mg/kg every 6 hours

Children from 2 months to 5 years

 First line treatment is Ceftriaxone IM or slow IV (3 minutes) 50mg/kg once daily OR
 Ampicillin slow IV (3 minutes) or IM 50mg/kg every 6 hours
 + gentamicin slow IV (3 minutes) or IM 6mg/kg once daily.
Ampicillin is preferably administered in 4 divided doses. If context does not permit this, the
daily dose must be divided in at least 3 doses.

Treatment should be administered by parenteral route for at least 3 days then if clinical
condition has improved and oral treatment can be tolerated switch to amoxicillin orally
30mg/kg 3 times daily to complete 10 days of treatment.
If cloxacillin has been used, when clinically well enough and 3 days without fever, change to
amoxicillin/clavulanic acid (co-amoxiclav) orally to complete 10 to 14 days. The dose is
expressed in amoxicillin 50mg/kg 2 times daily. If condition does not improve after 48 hours
of treatment with ceftriaxone + cloxacillin consider TB. If TB is unlikely continue with
ceftriaxone + cloxacillin and add azithromycin.

Supportive therapy
1. If the child or adult is wheezing then treat for asthma (give antibiotics as well if there
is a productive cough and/or signs of consolidation).
2. Give paracetamol for fever > 38.5°
3. If available check pulse oximetry and give oxygen by nasal prongs or nasal catheter
to maintain SpO2 > 90%.
4. Clear airway (nasal irrigation with 0.9% saline if needed.
5. Nurse on an incline (head elevated or in a semi-sitting position.)
6. Maintain adequate hydration and nutrition In children with respiratory difficulty place
an IV line and give IV fluids
7. Resume normal feeding as soon as possible (no respiratory difficulty, ability to eat
normally) Use nasogastric tube only if an IV line cannot be established:
 children under 12 months: 5 ml /kg/hour
 over 12 months 3 to 4 ml/kg/hour, alternate milk and water.
Resume normal feeding as soon as possible. In absence of severe respiratory
difficulty: breast feed on demand milk/food by spoon on demand
8. Give Vitamin A 50,000 IU for infants 2 – 5 months; 100,000 units for infants 6 – 11
months and 200,000 units for children > 1 year.

Pneumonia without signs of serious illness

Fast breathing and chest withdrawing but no other signs of severe illness. Treated with oral
amoxicillin. Age <2 months admit and treat as for severe pneumonia above.

68
Category of Age and weight of child Dose of amoxicillin
pneumonia
Fast breathing 2-12 months (4-10kg) Amoxicillin 250mg1 tablet twice a day for 5 days
(10 tablets)
Fast breathing 12 months -5 years (10-19 kg) Amoxicillin 250mg 2 tablets twice a day for 5 days
(20 tablets)
Fast breathing with 2-12 months(4-10kg) Amoxicillin 250mg 1 tablet twice a day for 5 days
chest withdrawing (10 tablets)
Fast breathing with 12 months to 3 years (10-14kg) Amoxicillin 250mg 2 tablets twice a day for 5 days
chest withdrawing (20 tablets)
Fast breathing with 3 -5 years (14-19kg) Amoxicillin 250mg 3 tablets twice a day for 5 days
chest withdrawing (30 tablets)
Side effects Common: diarrhoea
Rare: allergic rash, anaphylaxis
Advice: If a child is being treated as an outpatient advise the parents or carer to come back
day or night if the child is not improving and the breathing is getting faster.

Precaution: Ask the parent if the child is allergic to amoxicillin or penicillin. If an adult or child
has allergy to penicillin/ amoxicillin then give erythromycin.
 For children age 6-11 years give Amoxicillin 750mg twice a day
 Children over 12 and adults give Amoxicillin 1gm twice a day

Bronchiolitis
Bronchiolitis is a common infection caused by the respiratory syncytial virus (RSV) in infants,
presenting with fast breathing, wheeze and loose cough. On listening to the chest there are
often widespread fine crackles but not focal consolidation.

Treatment of bronchiolitis
 Give more oral fluids/ breastfeeding.
 Paracetamol if fever or distressed
 Antibiotics are not needed if the clinician is confident it is not pneumonia.
 Give amoxicillin if any chest indrawing, course crackles, consolidation or other sign of
pneumonia.
If severe bronchiolitis, hospitalise. If available check pulse oximetry and give oxygen by
nasal prongs or nasal catheter if oxygen concentration < 95%. Gentle nasal suction may be
required.

3.3 Malaria
 Transmission: Malaria is caused by a parasite that is injected into the body through
the bite of infected Anopheles mosquitos which spread the disease. Malaria is more
common in some parts of the country and may come in seasons especially after the
rain. The majority of malaria in South Sudan is due to P. falciparum.
 Symptoms: The parasite destroys the red blood cells and causes fever and
symptoms of malaria such as headache, chills, sweating, body pains. In children it
commonly presents with vomiting and diarrhoea.
 Complications: Malaria is a very dangerous disease that causes complications
including anemia, miscarriage, enlarged spleen, convulsions and death. It is a major
cause of death in South Sudan particularly in children under 5 years.
 Diagnosis: is confirmed with the Rapid Diagnostic Test, RDT and/or thick film.
Hospital staff should do everything to support prevention programmes in the
community. Do not repeat RDT within 3 weeks of antimalarial treatment because the

69
 test may stay positive even though the malaria parasites have all been destroyed in
the blood. Instead use microscopy to confirm malaria infection.

1st line treatment for malaria with Artesunate/Amodiaquine

1. If RDT +ve, treat with Artesunate/Amodiaquine (ASAQ ) first dose under DOT and
follow-up doses at home. This combination can be given to pregnant women in their
first trimester. If RDT –ve do not give antimalarials.
2. Give paracetamol if fever above 38.5°. Other causes of acute febrile illness should
also be looked for.
3. Give fluids. Patients with fever need more fluids. Encourage mothers to provide extra
breastfeeding. If there is diarrhoea, assess and treat as per the diarrhoea guidelines.
4. Ask the patient to come back immediately in case of danger signs or after 2 days if
persisting fever.
5. Treat for severe malaria if any danger signs (unable to drink, repeated vomiting,
anemia, drowsiness, jaundice, convulsions, unconscious, passing no urine, weak or
rapid pulse, severe dehydration, bleeding, difficulty breathing, neck stiffness).
6. If not improving on the treatment given but no danger signs, change treatment to 2nd
line treatment and look for other causes of fever.

Treatment note: The patient should be stay in the health facility for about 30 minutes after
the first dose under DOT (directly observed treatment) in case he or she vomits up the
medication. If so, another dose should be given but counted as the first dose and observed.
Hospitalise if further vomiting.

Advice: Children and adults with fever need to drink more and need food. This is hard when
they don’t want to eat. Parents should give children small amounts of fluid by cup and spoon
more often and make food that are easy to eat (like soups and porridge). Adults are
encouraged to drink more.

Dosage schedule for Artesunate (AS) and Amodiaquine (AQ) using fixed dose
combination tablets (ASAQ)
Age group and Day 1 Day 2 Day 3
weight
Age 2-11 months 1 Tablet 1 Tablet 1 Tablet
Weight 4.5kg-8kg 25mg/67.5mg 25mg/67.5mg 25mg/67.5mg

Age 1-5 years 1 tablet 1 tablet 1 tablet

Weight 9-17kg 50mg/135mg 50mg/135mg 50mg/135mg
Age 6-13 years 1 tablet 100mg/270mg 1 tablet 1 tablet
18kg-35kg 100mg/270mg 100mg/270mg
Age >14 year 2 tablet 100mg/270mg 2 tablet 100mg/270mg 2 tablet 100mg/270mg
Weight >36kg
ASAQ can be given throughout pregnancy and in children weighing less than 5kg. In such
children use the same dosage schedule as for children weighing 5kg.

2nd line treatment with artemether + lumefantrine

If ASAQ cannot be given because of allergy or it is not available, then the second line
treatment, artemether + lumefantrine may be given. It is also used for treatment failures.
Each tablet contains a combination of artemether 20mg and lumefantrine 120mg. A six-dose
regimen of artemether–lumefantrine is administered twice a day for 3 days:

Body Number of tablets of artemether 20mg –lumefantrine 120mg

weight (kg) Day 0 Day 1 Day 2
1st dose 2nd dose 3rd dose 4th dose 5th dose 6th dose
5–14 1 1 1 1 1 1

70
 15–24 2 2 2 2 2 2
24–34 3 3 3 3 3 3
≥35 4 4 4 4 4 4

Artemether-lumefantrine can be given throughout pregnancy and in children weighing less

than 5kg. In such children use the same dosage schedule as for children weighing 5kg.

Treatment of other Malaria species

 P. vivax, P. malariae, and P. ovale cause milder forms of malaria compared to P.
falciparum. They are all sensitive to ACTs (Artemisin-based combination therapies)
 P. vivax and P.ovale can form hypnozoites, parasite stages in the liver that can
cause multiple relapses.
 Treat with ACTs in combination with primaquine. Primaquine should be given for 14
days. (adult dose 0.25mg/kg body weight a day.
 Recommended treatment for P. vivax and P.ovale is Artesunate +Amodiaquine FDC
tablet for 3 days plus primaquine 15mg base for 14 days. Primaquine should always
be taken with food never on an empty stomach.
 Note that primaquine should not be given to anyone previously diagnosed with G6PD
deficiency.
 Anti-pyretic treatment with paracetamol should be given. Anemia should be treated

If there is failure of treatment,

 Ensure the patient has taken the full course of treatment
 They may have vomited the treatment
 Consider whether there might be another cause for the fever
 Consider whether the quality of the drug is poor, ie there has been incorrect storage
and the drug may have passed its expiry date.

Treatment of severe malaria with artesunate

If any danger signs are present, then treat with artesunate.
 Give artesunate 2.4 mg/kg body weight IV or IM given on diagnosis, repeated 12
hours later, then once the next day
 then change to oral ASAQ unless the patient is still in a critical state and unable to
take oral medication.
Mix the vial of artesunate powder with 1 ml of 5% sodium bicarbonate solution (provided)
and shake for 2–3 minutes. The solution should be prepared freshly for each administration
and should not be stored.

IV administration: add 5 ml of 5% glucose or normal saline to make the concentration of

artesunate as 10 mg/ml and administer by slow infusion, giving 2.4mg/kg IV.
Example: if a patient weighs 30 kg, the required dose can be calculated as:
2.4 mg/kg × 30 kg body weight = 72 mg This patient will then need 7.2 ml given IV.

IM administration: add 2 ml of 5% glucose or normal saline to make the concentration of

artesunate 20 mg/ml.
Example: if a patient weighs 20 kg, the required dose can be calculated as:
2.4 mg/kg × 20 kg body weight = 48 mg. This patient will then need 2.4 ml given IM.

Alternative treatment of severe malaria with quinine

If artesunate is not available or a person is allergic to artesunate, then the alternative
treatment with quinine is given instead.

71
  Loading dose: 20 mg quinine/kg. Omit the loading dose if the patient has had an
adequate dose of quinine (>40 mg/kg) in the previous 2 days. The loading dose
should be given as an IV infusion over 4 hours.
 Maintenance dose: 10 mg quinine/kg. The maintenance dose must be given every 8
hours. The maintenance dose should be given as slow infusion over 4 hours
 If IV therapy is still required after 48 hours, the maintenance dose should be reduced
to 7 mg/kg to avoid the risk of accumulation.
 A minimum of three doses of IV quinine should be given before changing to follow-on
oral treatment with ASAQ.
 Quinine can be diluted in 5% dextrose, 10% dextrose or normal (0.9%) saline
 Dilute quinine to a total volume of 10 ml/kg (the same volume is used for both loading
and maintenance doses) and infuse over 4 hours
 Quinine can cause hypoglycaemia, therefore blood glucose should be monitored
every 4 hours

Follow-on treatment of severe malaria with ASAQ

Once the patient can tolerate oral medication, or after at least 24 hours of parenteral
treatment, stop artesunate and complete treatment with a full course of ASAQ

Cerebral malaria is a form of severe malaria that may present with coma and convulsions.
The treatment is as for severe malaria. If there are convulsions, then treat these with
diazepam (see 5.1). Do not give steroids or any other medication. Follow hospital standard
operating procedures for managing a patient in coma.

Hypersplenism. Repeated infections with malaria can leave a person with a very large
spleen. Treatment is with a course of ASAQ, followed by malaria prophylaxis for 3 to 6
months (weekly mefloquine, weekly sulphadoxine/pyrimethamine or daily doxycycline).

Prevention and Control of Malaria in Pregnancy

Malaria in pregnancy can adversely affect the pregnant woman, the developing foetus and
the newborn infant. In areas of intense and moderate transmission of P.falciparum most
adult women are semi-immune to malaria but immunity may reduce during pregnancy, and
malaria may contribute to severe anemia in the mother, which leads to low birth weight
babies and higher infant mortality. In lower levels of P.falciparum transmission, women have
a low level of immunity and are more prone to developing a severe illness and are at risk of
death, spontaneous abortion, premature labour or stillbirth. For prevention and control of
malaria in pregnancy the following recommendations are made:
 Effective treatment of confirmed malaria cases
 Intermittent Preventive treatment (IPT)
 sleeping under long lasting insecticide treated mosquito nets.

Effective treatment of clinical malaria cases

 Consider diagnosis in all pregnant women with a fever
 Do a blood smear for microscopy to confirm malaria
 If not available do a RDT (rapid diagnostic test.)

Recommended medicines for treatment and prevention of malaria during pregnancy

Stage of pregnancy First line treatment for Intermittent preventive
malaria treatment indication
Before 20 weeks ASAQ No
2nd and 3rd Trimester (From ASAQ Yes SP
20-40 weeks) (Sulphadoxine/Pyrimethamine)

72
 Post delivery ASAQ No
 Oral quinine is safe and is an alternative treatment for uncomplicated malaria in
first trimester Dose is 600mg of quinine 3 times a day for 7 days
 ASAQ can be given in 1st trimester (Dosage as above)

Intermittent preventive treatment (IPT)

This is recommended for all pregnant women at each scheduled ante-natal visit (WHO
recommends 4 ante-natal visits). IPT reduces parasites in the placenta and therefore
adverse consequences in the pregnancy
 Treatment is with Sulphadoxine/Pyrimethamine(SP)
 First dose given at 16-20 weeks
 Each SP dose given at least 1 month apart during the pregnancy
 Last dose can be administered up to time of delivery
 Ideally should be administered as directly observed therapy.
 SP can be given on an empty stomach
 Folic acid at a dose of 5mg or above should not be given with SP as it decreases its
efficacy as an anti-malarial.

Malaria in pregnant women who are HIV positive

 HIV positive pregnant women are at greater risk of developing malaria and get
higher levels of parasitaemia compared to other pregnant women
 They should be given at least 4 doses of SP for IPT
 If taking co-trimoxazole prophylaxis for their HIV infection they should not be given
SP for IPT

Treatment of Severe Falciparum Malaria in pregnancy

 Start immediate resuscitation measures especially the airways
 Insert an intravenous line
 Correct hypoglycaemia if present by giving IV dextrose over 3-5 minutes (1ml/kg
50% dextrose diluted with equal amount of saline) OR 5ml/kg 10% dextrose by slow
IV infusion
 Recheck blood glucose 2-4 hourly during course of treatment
 Give recommended anti-malarial drug (see below)
 Reduce body temperature with paracetamol, tepid sponging
 Correct convulsions with IV(0.3mg/kg of body weight maximum dose 10mg in adults)
or rectal diazepam (01.0mg/kg body weight) Paraldehyde (0.1ml/kg is an
alternative)
 Consider need for a blood transfusion

For pregnant women, adults and children Recommended anti-malarial drugs for
severe malaria.
 Artesunate 2.4mg/kg body weight IV or IM then at 12 and 24 hours change to oral
once able to swallow OR
 Artemether 3.2mg/kg body weight IM on admission then 1.6mg/kg once daily until
patient can swallow OR
 Quinine 20mg dihydrochloride salt/kg body weight (loading dose) followed by a
maintenance dose 10mg/kg over 4 hours. Maintenance dose should be repeated
every 4 hours. The 600mg vial of quinine dihydrochloride should be diluted to 10ml
with 5% dextrose or saline fluid. It should not be given as a bolus dose because
of risk of hypotension. NB a loading dose of quinine should not be given if the

73
 patient has received quinine, quinidine or mefloquine within the previous 12 hours.
Start with quinine 10mg salt/kg.
Quinine can be given IM into anterior thigh (not buttock) in two different sites. If
possible it should be diluted for IM use to a concentration of 60-100mgsalt/ml OR
 Artemisinin suppositories 40mg/kg loading dose then 20mg/kg 24, 48 and 72 hours
later followed by oral antimalarial drug OR
 Artesunate suppositories 200mg intra-rectally at 0, 12, 24, 36 , 48 and 60 hours (trial
still under way).

3.4 Other Febrile Diseases

This section contains measles and typhoid. For meningitis and septicaemia, see 5.1.

Measles Measles is highly contagoius with high mortality in children who have not been
immunised. It presents with:
 typical viral rash
 conjunctivitis
 sore throat
 cough
 mouth ulcers
 ear infection
 Koplik spots

with serious complications such as diarrhoea, pneumonia (50% with secondary bacterial
infection), malnutrition, meningitis and blindness. Measles is a notifiable disease and is
highly contagious. It is rarely seen in infants under 3 months as they have some protection
from maternal antibodies.

Treatment of mild and moderate measles

1. If measles is suspected, hospitalise all cases with major complications with the child
kept isolated from other children and notify the State MoH.
Major complications include:
 Inability to eat or drink.
 Altered consciousness
 Dehydration
 Severe pneumonia, ie with respiratory distress or cyanosis.
 Croup
 Corneal lesions (pain photophobia, erosions or opacities)
 Severe oral lesions that prevent eating
 Acute malnutrition.
2. Give supportive measures for the symptoms. These are: ORS, other fluids, zinc,
paracetamol for fever and distress, gentian violet in the mouth for ulcers and
tetracycline ointment for conjunctivitis. (For dosage see the relevant sections).
3. Give vitamin A 50,000 IU for infants 2 – 6 months; 100,000 units for infants 6 – 11
months and 200,000 units for children > 1 year.
4. If the child already has signs of pneumonia treat with antibiotics (see 3.2).
5. Begin all measures for control of an epidemic, guided by the State MoH.

Treatment note: All children with measles should be followed up.

Advice: Parents must take the child to the Health Centre or Hospital immediately and bring
any other children that may have a similar illness. All unimmunised contacts should be
immunised.
Precaution: Measles is dangerous and contagious. It is important the care and rapid referral
of the child is a top priority.

74
Treatment of severe measles
Follow the guidelines given in other sections of this manual for the management
of the following complications of measles:
 Pneumonia: Give antibiotics for pneumonia to all children with measles and
signs of pneumonia (see 3.2)
 Otitis media (see 3.2)
 Diarrhoea: Treat dehydration, bloody diarrhoea or persistent diarrhoea.
 Measles croup. Give supportive care. If moderately severe, give dexamethasone PO
150mcg/kg as a single dose. If severe, give nebulised epinephrine (adrenaline)
1mg/ml ampoule. Dose is 0.5ml/kg (maximum 5ml) Give oxygen if cyanosis or SpO2
is <90%
 Eye problems. Conjunctivitis and corneal and retinal damage may occur due
to infection, vitamin A deficiency or harmful local remedies. In addition to giving vitamin
A, treat any infection present. Clean the eyes with a clean cloth dipped in clean water.
Apply tetracycline eye ointment three times a day for 7 days. DO NOT USE TOPICAL
STEROIDS
 Mouth ulcers. If the child can drink and eat, clean the mouth with clean, salted water
(a pinch of salt in a cup of water) at least four times a day.
– Apply 0.25% gentian violet to sores in the mouth after cleaning.
– If the mouth ulcers are severe and/or smelly, give IM or IV benzylpenicillin (50
000 U/kg every 6 h) and oral metronidazole (7.5 mg/kg three times a day) for
5 days.
– If the mouth sores result in decreased intake of food or fluids, the child may
require feeding via a nasogastric tube.
 Neurological complications. Convulsions, excessive sleepiness, drowsiness or coma
may be symptoms of encephalitis or severe dehydration. Assess the child for
dehydration and treat convulsions accordingly. Intensive nursing care.
 Severe acute malnutrition: see 2.2

Meningitis & septicaemia,

For treatment of life-threatening infections, see 5.1.

Typhoid fever
While being a very dangerous disease, typhoid is also the most over-diagnosed disease in
Africa. This is because of misinterpretation of antibody tests. Typhoid is a systemic disease
caused by ingestion of food or water contaminated with Salmonella typhi or paratyphi, or
contracted from persons who are acutely ill with or healthy carriers (1 – 3% of those who
recover) of the disease. It presents with fever and headache, diarrhoea or constipation,
anorexia and nausea. 50% of patients have enlargement of the liver and spleen. The rose
spots are difficult to see. Complications include intestinal bleeding and perforation,
pneumonia, myocarditis, convulsions and meningitis.

Diagnosis should be made primarily clinically. Antibody tests should be used to confirm a
clinical presentation and not the other way round as in clinical trials antibody tests correlate
poorly with blood culture results. Many healthy people have antibodies from previous
infection with one of the 200 related salmonella organisms that cause mild diarrhoeal
disease.

Treatment of typhoid fever is difficult because the organism has become resistant in many
areas to antibiotics that have been used (chloramphenicol, co-trimoxazole and ciprofloxacin).
When a new case presents one of these may still be used in the 1st line but stool samples
should be sent off under the surveillance programme so that antibiotic sensitivity can be

75
identified. If the disease is known locally to be sensitive from previous experience to
chloramphenicol, then this can be used. If resistance patterns are not known, then
ciprofloxacin can be given as first line treatment.

Chloramphenicol PO 500mg (or 12.5mg/kg per dose) 4 x per day for 14 to 21 days OR
Ciprofloxacin PO 500mg (or 7.5 – 15 mg/kg per dose) 2 x per day for 14 to 21 days

These are not normally given to pregnant women who should be treated initially with
amoxicillin if the organism may be sensitive Amoxillin PO 1gm 3 x per day or a
cephalosporin. If typhoid is resistant to both these then azithromycin or cefotaxime may be
needed if available.

Azithromycin PO Adults: 1gm once daily Children: 10-20mg/kg once daily (maximum 1g
daily) OR

Cefixime PO Adults 200mg twice daily. Children 10mg/kg 2 x per day (maximum 400mg
daily)

In severe cases:
Ceftriaxone IV Adults 2g 1-2 x per day. Children 50-100mg once daily (max 4g daily)

3.5 Sexually Transmitted Infections

Prevention of STIs & HIV
Dual protection is proposed against STIs (including HIV, hepatitis B and C) and unplanned
pregnancy. It can be achieved by the consistent use of condoms, or the use of one method
to protect against unplanned pregnancy (a hormonal method or IUD, see 1.1) and a second
method to protect against STIs and HIV (a male or female condom). The involvement of men
is crucial to the success of dual protection. Hormonal methods do not protect women against
STIs including hepatitis B, C and HIV.

Condoms
Male condoms significantly reduce the risk of becoming infected with HIV or another STI
when used correctly with every act of sex. All men and women can safely use male condoms
except those with a severe allergic reaction to latex. Correct condom use must be explained
when dispensing condoms.

Consistent messaging to prevent HIV and STIs

 Stigma reduction by raising awareness
 HIV prevention through Behavioural Change Communication (BCC)
 Display and dissemination of educational materials;
 Provision of condoms
 Post-test clubs
 Community mobilization
 Promotion of abstinence; faithfulness and condom use
 Promotion of partner engagement.

Management of STIs
Vaginal discharge
1. Establish clinical diagnosis based on sexual history and risk assessment.
2. If facilities exist, take a swab for culture
3. If patient has lower abdominal pain as well as discharge, treat for pelvic inflammatory
disease (but first see Lower Abdominal Pain, below)

76
 4. If possible, visualise the cervix with a speculum. If cervicitis is present, treat for
chlamydia and gonorrhoea (treat partner also)
5. If assessed to be sexually high risk, treat for chlamydia and gonorrhoea (treat partner
also).
6. If sexually active, but low risk and discharge is frothy and green, treat for
trichomonas (treat partner also)
7. If low risk and discharge is grey with a fish-like smell, treat for bacterial vaginosis
8. If low risk and discharge is white and creamy, with itch, treat for candida
9. Advise on risk reduction, HIV counselling and testing and condom use if appropriate
10. Remember that there may be more than one cause present, that discharge may be
physiological or due to a foreign body in the vagina
11. Ask to return in 3 days if not better

Genital ulcer disease, women and men

1. Establish clinical diagnosis based on sexual history, risk assessment and clinical
examination.
2. If has a number of painful vesicles or small ulcers, treat for genital herpes simplex
3. If has single ulcer and no enlarged or tender inguinal nodes, treat for syphilis and
chancroid
4. If has a single ulcer and tender inguinal lymph nodes, treat for syphilis and
chancroid, and also for lymphogranuloma venereum
5. Add treatment for chlamydia and gonorrhoea if has positive sexual risk factors or if
urethral or vaginal discharge is present.
6. Advise on risk reduction, HIV counselling and testing and condom use
7. Treat partner as appropriate
8. Ask to return for in 3-7 days if not improving
9. If ulcer still present and not healing a course of treatment might be needed for an
alternative diagnosis.

Lower abdominal pain, women

1. If missed or overdue period, recent delivery or abortion, abdominal mass, rebound
tenderness or guarding or abnormal vaginal bleeding, investigate as potential ectopic
pregnancy: do urine pregnancy test, ultrasound if available. Monitor closely. Surgical
team on stand-by. If ruptured ectopic pregnancy is possible, then treat as
emergency, with IV fluids, do blood group and cross match blood, and surgical
intervention as appropriate.
2. If ectopic pregnancy excluded, and vaginal discharge is present, treat for pelvic
inflammatory disease (below)
3. Further clinical examination and investigation and appropriate treatment if pain still
present

Urethral discharge in men and women

1. Unless sure that it is NOT due to a sexually transmitted disease, treat for chlamydia
and gonorrhoea
2. Advise on risk reduction, HIV counselling and testing and condom use
3. Notify and manage partner
4. Ask to return for retest in 3 to 7 days
5. If re-infection or poor compliance, treat again
6. If re-infection unlikely and compliance good, treat for trichomonas.

Precaution: The following antibiotics should not be prescribed during pregnancy, child birth
and breastfeeding:
 Ciprofloxacin
 Doxycycline

77
  Fluconazole
 Tetracycline
 Metronidazole (in high doses)

Treatment of STIs
Vaginal pessary for candida (either clotrimazole or miconazole)
Medicine Age Dose
Clotrimazole 200mg or Adults Woman to insert in vagina at home:
500mg vaginal pessary 200mg Clotrimazole pessary for 3 consecutive nights OR
1 x 500mg Clotrimazole pessary. Single dose
Miconazole 200mg vaginal Woman to insert in vagina at home:
pessary 1 x 200mg Miconazole pessary each night for 3 nights

Oral fluconazole for candida

Medicine Age Dose Duration
Fluconazole 150mg capsule Adults 1 x 150mg capsule Single dose
by mouth
NB Do not give Fluconazole in pregnancy.

Treatment of bacterial vaginosis and trichomonas

Metronidazole for bacterial vaginosis and trichomonas
Medicine Age Dose Duration Side effects
Metronidazole 200mg Adults 2000mg (2gr) (8 x 250mg caps or 10 x Single dose Common: nausea
tablets or 250mg capsules 200mg tabs) oral single dose or 400mg or for 7 Rare: vomiting,
– 500mg tablet 2 x per day for 7 days. days
Tinidazole appears to be superior to
metronidazole but may not be available
Prescribing tip: In case of suspected trichomonas, treat partner also

Treatment of chlamydia
 Azithromycin 1g (4x 250mg capsule) single dose OR
 Doxycycline 100mg orally 2 x per day for 7 days
 In pregnancy: Azithromycin 1g (4x 250mg capsule) single dose

In children/adolescents. <45kg urogenital/rectal

 Erythromycin 50mg/kg/day orally in 4 divided doses daily for 14 days
Neonates: ophthalmia neonatorum, pneumonia
 Erythromycin 50mg/kg/day orally in 4 divided doses daily for 14 days

Treatment of gonorrhea
Adults and children >45kg, uncomplicated gonococcal infection in any site:
 Ceftriaxone 125mg IM single dose PLUS
 Azithromycin 1gm orally as a single dose

Children <45kg urogenital, rectal, pharyngeal

 Ceftriaxone 25-50mg/kg IV or IM (not to exceed 125mg IM in a single dose)

Treatment of chlamydia and gonorrhea

Consider concurrent treatment for gonococcal infection if at risk of gonorrhoea or lives in a
community where the prevalence of gonorrhoea is high. Presumptive treatment with anti-
bacterials for C. trachomatis and N. gonorrhoea should be provided for women at increased
risk eg those aged <25 years, with a new sexual partner , a sex partner who has other
partners or has a STI, especially if follow up cannot be ensured, or if testing is not possible.

78
 Treatment note: The choice of antibacterial regime depends on local availability and
changing sensitivity and resistance of organisms.

Azithromycin 1gm (4x 250mg cap) single dose + ciprofloxacin 500mg cap single dose OR
Ceftriaxone 125mg IM single dose

Treatment of genital herpes:

Acyclovir for genital herpes
Medicine Age Dose Side effects
Acyclovir 400mg capsules Adults First episode:1 capsule (400mg) 3 x per day for 7-10 days Common:
Episodic therapy: 400mg 3 x per day for 5 days Abdominal
OR pain,
800mg 2x day for 5 days diarrhoea,
Suppressive therapy give: vomiting
1 capsule (400mg) 2 x per day
For patients with HIV: for episodic infections Acyclovir 400mg 3 x per day for 5-10 days
For daily suppressive therapy: Acyclovir 400-800mg daily 2-3 times a day

Treatment of syphilis and chancroid:

Primary, secondary or early latent< 1 year
If not allergic to penicillin:
 Benzathine penicillin 2.4 million units IM, divided into 2 and injected in each side,
single dose

If penicillin allergy give :

 Doxycycline PO 100 mg 2 x per day for 14 days OR
 Ciprofloxacin 500 mg PO 2 x per day for 3 days OR
 Erythromycin PO 500 mg 4 x per day for 7 days

Latent syphilis> 1 year : Benzathine penicillin 2.4 million units IM in 3 doses each at 1 week
intervals (7.2 million units total)

Treatment of lymphogranuloma venereum

 Doxycycline PO 100mg 2 x per day for 21 days OR
 Erythromycin 500mg 4 x per day for 21 days OR
 Azithromycin 1g PO every week for 3 weeks

Treatment of pelvic inflammatory disease, PID (women)

If not pregnant: Parenteral regimes:
 Ceftriaxone 250-500mg deep IM single dose AND
 Doxycycline 100mg 2 x per day for 14 days AND
 Metronidazole 500 mg 2 x per day for 14 days

If pregnant, give ceftriaxone and metronidazole but do not give doxycycline, but replace with
azithromycin 1g PO as a single dose OR Erythromycin 500 mg 4 times for 14 days.

Epididymitis:
For acute epididymitis most likely caused by sexually transmitted chlamydia and gonorrhoea
 Ceftriaxone 250mg IM in a single dose PLUS
 Doxycycline 100mg orally 2 x day for 10 days.

Genital warts
 Self application: Imiquimod 3.75% or 5% cream OR
 Podophyllin 0.5% solution or gel. Apply weekly in small amounts OR

79
  Cryotherapy OR
 Trichloroacetic acid or 80-90%

3.6 HIV (Human Immunodeficiency Virus)

South Sudan has a generalized HIV epidemic with a prevalence of 2.6%. The highest HIV
concentration is in the country’s southern region. Most new infections occur in sex-workers,
their clients, and through peri-natal transmission, and new infections are more common in
women than men. Testing should focus on these groups and other high-risk groups such as:
truck drivers; migrant workers; people in prisons and other closed settings; members of the
uniformed forces; men who have sex with men (MSM); refugees; internally displaced
populations and survivors of sexual assault. Testing should also be carried out on all those
with tuberculosis (TB) and opportunistically, when treating for other illnesses such as
pneumonia, diarrhoea, sexually transmitted infections, malnutrition and in pregnancy.

Treating people living with HIV (PLHIV)

Clinicians should follow South Sudan 2017 National Consolidated Guidelines on Use of Anti-
retroviral drugs (ARVs) for HIV Treatment and Prevention. These include guidelines on
assessing HIV status and on voluntary counselling and testing, clinical review of patients,
reviewing TB status, managing chronic problems, dispensing medication, positive prevention
for People Living with HIV (PLHIV) and special considerations in chronic HIV care/ ante-
retroviral therapy (ART) for children. These guidelines are summarised here.

Testing
HIV testing is either patient initiated or provider initiated. Provider initiated testing should be
offered to everyone. Regardless of the approach or model, testing is voluntary.

Testing must adhere to the five C’s

 Consent
 Confidentiality
 Counselling
 Correct test results and
 linkage to Care.

Key populations noted above should be retested at least annually. This is also
recommended for HIV negative partners in serodiscordant couples. Prior to ART initiation it
is recommended that all positive tests are repeated to confirm the result. This is to minimise
false positive results as these obviously have great implications for people.

Standard precautions for avoiding transmission of HIV and other pathogens in

health facilities.
Standard precautions of infection prevention and control must be taken routinely with all
patients at all times. Standard precautions include:
 Use safe injection techniques, with 1 injection given by one person, and dispose of
syringe and needle.
 Handle and clean instruments safely
 Handle and dispose sharps safely in safety box.
 Use personal protective materials
 Handle and dispose of waste safely
 Manage needle-stick and other workplace exposure to HIV with post-exposure
prophylaxis (PEP)

80
 What to do after a positive HIV test
After a positive HIV test a patient should ideally have a counselling session to explain the
diagnosis and then have an assessment by a health care worker. The following tests should
be measured at diagnosis BUT lack of laboratory tests should not be a barrier to treatment in
settings where resources are limited.
Lab Test
Confirm HIV serostatus Retest to confirm HIV status

CD4 testing Baseline level useful but do not need to wait for this to start ART

Pregnancy test Refer for ante-natal care (ANC) if positive

Consider TB testing If any of cough/fever/weight loss/night sweats - send sputum sample
for gene expert if possible - VERY important to identify co-infection
Serum creatinine To detect renal insufficiency at baseline – important if starting on a
Tenofovir (TDF) containing regimen but NOT essential

Blood pressure Baseline measurement

Random blood sugar For early diagnosis of diabetes mellitus

Hepatitis B and C testing To identify co-infection

Full blood count (FBC) or Haemoglobin (Hb) If requires zidovudine (AZT) or ANC
Alanine aminotransferase level (ALT) To exclude liver disease, if elevated check screen for Hepatitis B
and C if possible – ONLY needed if initiating Nevirapine (NVP)
based regimen
Serum Cryptococcus antigen if CD4 count < To detect asymptomatic infection with Cryptococcus neoformans
100 infection, if positive should be given fluconazole prophylaxis.
 WHO staging should be carried out at time of diagnosis and at follow-up
appointments. Patients should be weighed and assessed for malnutrition and local
guidelines followed if concerns. (See section 2.2).
 CD4 count <100 at diagnosis needs special attention and more intensive screening
for opportunistic infections including checking serum cryptococcus antigen
 If known to be using any hazardous substances patients should be advised to
gradually reduce.
 If patient is pregnant follow prevention of mother to child transmission (PMTCT)
guidelines (see below).

Treating opportunistic infections before initiating ART

Any pre-existing infections should be treated as a priority. Many patients will present with
opportunistic infections at time of diagnosis.

 If TB is diagnosed TB treatment should be initiated FIRST. ART should be started

after 2-8 weeks on TB treatment. Wait at least 4 weeks if TB meningitis. (See
Section 3.9 on HIV/TB).
 If a patient is found to be cryptococcus positive at screening but asymptomatic they
should be treated with pre-emptive fluconazole therapy. Dose is 800mg/day for 2
weeks, then 400mg/day for 8 weeks, then maintenance of 200mg/day. ART can be
initiated 2 weeks after starting pre-emptive treatment. If Cryptococcal meningitis is
diagnosed ART initiation should be delayed by at least 4 weeks. Patients who have
had cryptococcal meningitis, are given secondary prevention by giving fluconazole
200mg once a day for at least a year. This should only be stopped if 2 successive
CD4 counts 6 months apart are > 100 and viral load is suppressed.
 ART initiation should also be delayed by 2 weeks if patient is known to have
cytomegalovirus retinopathy.

81
 Co-trimoxazole Prophylaxis for PLHIV
Co-trimoxazole prophylaxis should be started immediately in all those diagnosed with HIV:
adults; children > 6 weeks old; and HIV exposed infants > 6 weeks old. It is contra-indicated
in infants < 6 weeks as it can cause hepatotoxicity.

Co-trimoxazole is a fixed-dose combination of two antimicrobial drugs (sulfamethoxazole

and trimethoprim) that covers a variety of bacterial, fungal and protozoan infections.
Cotrimoxazole prevents against pneumocystis carinii pneumonia but also other organisms
causing pneumonia, toxoplasmosis, diarrhoea and malaria. Co-trimoxazole preventive
therapy is a feasible, well-tolerated and inexpensive intervention for people living with HIV to
reduce HIV-related morbidity and mortality.
 Treatment: The adult dose is Co-trimoxazole 960mg od for adults.
 Treatment note: In South Sudan, co-trimoxazole prophylaxis should be continued for
adults (including pregnant women) with HIV infection even when clinically stable on
ART. They are also taken for those with TB co-infection.
 Advice: If nausea from co-trimoxazole then take after food.
 Precaution: Do not give if previous reaction to a sulfa medicine. If grade 1 allergic
skin reaction, try desensitization with continued administration of cotrimoxazole and
antihistamine. Those with a serious skin reaction are switched to Dapsone 100mg 1 x
per day by mouth.
Medicine Age (weight) Dose Duration Side effects
Co-trimoxazole syrup Infants 6 weeks – 100mg/20mg (2.5ml or 1 tablet) PO 1 x day Daily, Common:
200mg/40mg in 5ml 6 months (3 – lifelong nausea
or 100mg/20mg tablet 5.9kg) Rare: allergic
Co-trimoxazole syrup Children 6months 200mg/40mg (5ml or 2 tablets) PO 1 x day skin reaction;
200mg/40mg in 5ml – 6 years (6 – jaundice;
or 100mg/20mg tablet 13.9kg) anemia
Co-trimoxazole syrup Children 6 -11 400mg/80mg (10ml or 1 tablet) PO 1 x day
200mg/40mg in 5ml years (14 –
or 400mg/80mg tablet 24.9kg)
Co-trimoxazole Adults & children 800mg/ 160mg (2 x 400mg/80mg tablet or 1
400mg/80mg tablet > 11 years (25kg x 800mg/160mg tablet) PO 1 x day
800mg/ 160mg tablet and above)

TB Preventive Therapy (TPT)

All adults and children diagnosed with HIV should be considered for IPT. TB is 20 times
more common in people living with HIV. Studies have shown that IPT reduces TB incidence
by about 60% in HIV infected individuals. In order to prevent TB disease in PLHIV the “three
I’s” strategy is implemented: Intensified Case Finding (ICF), Isoniazid Preventive Therapy
(IPT) and Infection control whenever PLHIV present to health facilities.

Intensified case finding involves asking if a PLHIV has any ONE of the following currently:
 Cough for any duration
 Fever for any duration
 Night sweats
 Weight loss OR failure to gain weight in pregnancy

If so they should be referred for sputum testing for TB. Ideally sputum should be tested with
gene Xpert to look for rifampicin resistance. Isoniazid preventive therapy is recommended
for all PLHIV who to take for 6 months. It should only be given if the patient has NO evidence
of current TB infection or contraindications to Isoniazid. Women who do not have symptoms
of TB are all encouraged to take it for 6 months during pregnancy. It is given with the B
vitamin Pyridoxine to prevent the side effect of peripheral neuropathy.

82
 Treatment note: If peripheral neuropathy develops, double pyridoxine to 100mg 1 x per day
in adults.
Advice: Needs to be taken for 6 months. Do not drink alcohol while on isoniazid.
Precaution: Do not give if regular alcohol intake, if hepatitis or if peripheral neuropathy.
Medicine Age Dose Duration Side effects
Isoniazid 100mg Children 10mg/ kg PO 1 x per day 6 months Common: anorexia,
tablet nausea, indigestion
Isoniazid 100mg Adults 300mg 1 x per day (5mg/kg 1 x Rare: rash, hepatitis,
tablet per day for those < 60kg) neuropathy,
Pyridoxine 50mg Children 25mg (½ tablet) x 1 per day confusion
tablet
Pyridoxine 50mg Adults 50mg (1 tablet) x 1 per day
tablet (including
pregnant
women)
Prescribing tip: if anorexia, nausea or indigestion give at bedtime. If major side effects stop Isoniazid

In children IPT should be given as for adults if aged > 1 yrs. If < 1 yr only those who have
definite contact with a case of TB should be given IPT – and only after being actively
assessed for TB. IPT is also recommended for children of breastfeeding mothers with active
TB and for any HIV infected children exposed to TB through household contacts. Must
always exclude active TB before starting.

Initiating ART
ALL HIV positive adults, adolescents, and children are eligible to start ART irrespective of
CD4 count or WHO stage.
(This section will deal with treatment for adults and adolescents. See later sections for detail
of treatment in infants and children/PMTCT.)

If prioritisation is required, start treatment first in all those with CD4 count < 350 or WHO
clinical disease stage 3 or 4. Prior to starting ART patients should receive psychosocial
assessment and adherence counselling. To achieve viral suppression very high levels of
adherence are needed – taking at least 95% of prescribed doses. Aim to start ART within 7
days of diagnosis of HIV. Treatment may need to be delayed if treating an opportunistic
infection.

Currently the preferred first line regimen in South Sudan for adults (including adolescents,
and pregnant and breast-feeding women) is:

Tenofovir /TDF (300mg), lamivudine/3TC (300mg) and efavirenz/EFZ (600mg).

This should be given as a Fixed Dose Combination. This regimen is simple, effective and
well tolerated. It enhances adherence and simplifies procurement and supply chain
management. It is effective against Hep B infection and can be used with anti-TB drugs. It is
safe in pregnancy and breast-feeding.

WHO guidance has recently changed to recommend a first line regimen of tenofovir,
lamivudine and dolutegravir. South Sudan may change its guidance in the near future.
Details of new recommendations given at end of section.

Things to consider when choosing first line ART regimen

Tenofovir (TDF) is associated with increased risk of renal dysfunction. Ideally Creatinine
clearance (Cr clearance) should be calculated prior to starting and AVOID if Cr clearance <
50. Also AVOID if on nephrotoxic drugs, long-term diabetes, uncontrolled hypertension,
known renal failure.

83
 Cr Clearance in men = (140-age in yrs) x weight in kg x1.22 x 0.85 in women
Serum Cr in micromoles/L
 Efavirenz (EFZ) can cause psychiatric side effects in 2%, worse if previous
psychiatric history.2 AVOID if psychiatric history.
 Zidovudine (AZT) can cause bone marrow toxicity. AVOID if Hb < 7g/dL.
 Nevirapine (NVP) can cause hepatitis, more likely at high CD4 counts. AVOID if
known liver disease or raised ALT. Higher risk at CD4 > 250 in women and > 400 in
men.
 Stavudine (D4T) is an old drug which causes many side effects including
lipodystrophy. WHO has recommended to switch patients away from it.

What to Start – FIRST LINE

For ALL adults and adolescents TDF +3TC +EFV
Contraindication to EFV – psychiatric co-morbidity or intolerance TDF +3TC +NVP
Contraindication to TDF – renal disease/on other nephrotoxic AZT + 3TC + EFV
drugs
Contraindication to TDF and AZT – renal disease and anemia ABC + 3TC + EFV
Currently on d4T-based regimen – try and switch even if well TDF + 3TC + EFV
tolerated
Adolescents <35kg ABC + 3TC + EFV

Dosages of ART for adults

Nucleotide reverse-transcriptase inhibitors (NtRTIs):
 Tenofovir (TDF) 300 mg once daily

Nucleoside reverse-transcriptase inhibitors (NRTIs):

 Abacavir (ABC) 300 mg twice daily or 600 mg once daily
 Emtricitabine (FTC) 200 mg once daily
 Lamivudine (3TC) 150 mg twice daily or 300 mg once daily
 Zidovudine (AZT) 300 mg twice daily

Non-nucleoside reverse-transcriptase inhibitors (NNRTIs):

 Efavirenz (EFV) 600 mg once daily or 400mg once daily
 Nevirapine (NVP) 200 mg once daily for 14 days, followed by 200 mg twice daily

Proteases inhibitors (PIs):

 Lopinavir / Ritonavir (LPV/r) 400 mg/100 mg twice daily
 Atazanavir / Ritonavir (ATV/r) 300 mg/100mg once daily
 Darunavir / Ritonavir (DRV/r) 800 mg /100mg once daily or 600 mg /100mg bd if
previous use of a PI

Integrase inhibitors:
 Dolutegravir (DTG) 50mg od
 Raltegravir (RAL) 400mg bd

EFV 400mg can be used instead of 600mg as fewer side effects. NO evidence to support
use of 400mg in pregnant women, lactating women and TB patients. Lower dose EFV may
be introduced – seek local guidance.

Follow Up On ART
See at 2 weeks: Ask about side effects and adherence. Nevirapine dose is increased after 2
weeks.

84
 See at 4 weeks: Watch for signs of Immune Reconstitution Inflammatory Syndrome (IRIS).
(See below).
See monthly until 6 months.
Then see 6 monthly if clinically stable and adherent to ART.

At follow-up appointments monitor weight. Refer for nutritional support if available and
appropriate. Treat any inter-current infections. Record WHO staging.If ongoing infections
and illness after 6 months on ART, consider treatment failure.

Lab Tests & Screening During Follow-up

Test Test outcome Action to be taken
CD4 every 6 months To monitor immune response to ART Continue if low every 6m
(should increase by 100-150 in first 6-12 Can be stopped if VL tested and
months of treatment) shows VL suppressed
Viral load at 6m, 12m and every 12m To confirm response to treatment. Level Continue testing every 12m
> 1000 indicates likely treatment failure.
TB symptom screening If positive, do further clinical and lab If TB detected then treat for TB
tests for TB
Only if needed and available
ALT if on NVP To identify NVP toxicity If toxicity stop NVP and go onto
2nd line
FBC at month 1,3 and 6 if on AZT To indentify AZT toxicity If toxicity stop AZT and go onto
2nd line
Creatinine if signs or symptoms of renal To identify TDF toxicity If toxicity stop TDF and go onto
failure (at months 1,4,12 and annually) 2nd line
Viral Load monitoring is recommended as the preferred approach to diagnose and confirm
treatment failure. However viral load testing currently has limited availability in South Sudan.
In this situation CD4 count monitoring and clinical assessment should be used as a first line
assessment for treatment failure. Viral load should only be requested if treatment failure is
suspected. Viral Load < 1000 copies/mL is consistent with viral suppression and treatment
should be continued.

If Viral Load > 1000 copies/mL patients should have 3 sessions of enhanced adherence
counselling 1 month apart, and then have a repeat viral load after 3 months. If the result is
still > 1000 patient should be substitute to second line ART immediately. These patients
need continued intensive adherence support and evaluation. Delay in changing to second
line ART can cause worsening resistance. If after 3 months viral load has gone down to <
1000 patients can continue on their current regime with continued support and
encouragement.

Second Line ART

Second line ART is decided based on previous ART exposure.
Second Line ART
Failing on TDF based 1st line AZT +3TC +LPV/r or ATV/r
Failing on AZT based 1st line TDF + 3TC + LPV/r or ATV/r
HIV and TB co-infection NRTI backbone + double dose LPV/r
HIV and Hep B failing on TDF based 1st line AZT + TDF + 3TC + LPV/r or ATV/r

Third Line ART

Any adult or adolescent failing any second line regimen should be changed to Dolutegravir
50mg + Darunavir (600mg) /ritonavir (100mg) twice daily. These patients should be referred
to specialist clinics at tertiary referral centres if possible.

If Dolutegravir is not available Raltegravir 400mg 2 x a day can be used.

Common Serious side effects of ART

85
 Tenofovir Renal toxicity May need to switch
Zidovudine Myopathy Need to switch
Lipoatrophy
Bone marrow suppression
Abacavir Hypersensitivity reaction Rare but if occurs, stop ABC
immediately and never give
again
Nevirapine Rash – can develop Stevens- Johnson Stop if severe rash and if
syndrome ALT > 120 with symptoms of
Hepatitis hepatitis
Efavirenz Psychiatric side effects Switch if symptoms
Encephalopathy
Can also cause rash and hepatitis Avoid NVP if rash/hepatitis
Protease Diarrhoea/vomiting Switch to ATV/r if lipids very
Inhibitors Hepatitis high or diarrhoea intolerable
Lipid abnormalities and Impaired
glucose tolerance
Integrase Hepatitis If occurs need to switch to
Inhibitors Hypersensitivity reaction drug from another class
Many of the ARVs cause minor side effects which include nausea and vomiting, diarrhoea,
tiredness, headache, fatigue, abdominal/flank pain, and depression. If side effects are mild
try to continue on the same regimen. A major complication of ART is Immune reconstitution
inflammatory syndrome (IRIS) (See below).

Prevention of mother to child transmission (PMTCT)

Globally 90% of children get HIV from mothers during pregnancy, childbirth and
breastfeeding. Without intervention the rate of transmission ranges from 15-35%.

The 4 main strategies for PMTCT are:

1. Primary prevention of HIV infection
2. Prevention of unintended pregnancies in women living with HIV
3. Prevention of HIV transmission from women living with HIV to their infants
4. Provision of care and support to women infected with HIV, their children and
families

PMTCT is offered at ANC, during delivery and postnatally as an integrated service.

Antenatal care
Women are offered pre-test counselling, and have voluntary testing for HIV, followed by
post-test counselling. Women should be tested in first trimester/or at first ANC visit; in 3rd
trimester during labour/or delivery; and at 6 weeks post-natally.

HIV +ve women are seen in the ART centre and by the team who will supervise their
delivery care. If newly diagnosed with HIV, women should be started on ART as soon as
possible. Pregnant and breast-feeding women should receive the same care and treatment
services as other PLHIV. Viral load monitoring if available should be a priority in this group.

Couple testing should be offered as well with support for disclosure if needed. If a women is
negative but her partner positive, consider PrEP.

At least monthly ANC visits are recommended. Offer:

1. Co-trimoxazole prophylaxis
2. TB screening, counselling and prophylaxis
3. Nutrition education, counselling and nutrition assessment.
4. Education about preventive WASH activities at home.

86
 5. Apply principles of good chronic care.
6. Birth spacing counselling for after delivery

During delivery
Testing should be carried out in labour if a women has not been previously tested or tested
negative more than 3 months ago.To reduce obstetric risk of HIV transmission it is
suggested that medical staff:

- Use a partogram to avoid prolonged labour

- Avoid routine artificial rupture of membranes
- Avoid routine episiotomy
- Avoid frequent vaginal examinations
- Do not milk umbilical cord before cutting
- Actively manage the third stage of labour
- HIV infection is NOT an absolute indication for Caesarean section

Postnatal care
ARV prophylaxis for HIV exposed infants is administered based on the level of risk of HIV for
the infant. A high risk infant is defined as follows:
1. High maternal viral load > 1000 copies/mL during the last 4 weeks before delivery
OR
2. An infant born to an HIV infected women who has received less than 4 weeks of
ART at the time of delivery OR
3. An infant born to a newly diagnosed HIV infected women during labour, delivery
and postpartum (incident HIV infection)

All other infants are classified as low risk infants. ARV prophylaxis is decided on the basis of
this level of risk – see table below.
High Risk Low Risk
Breast-fed Daily AZT + Daily NVP for 6 weeks
NVP for 12 weeks
Formula -fed Daily AZT + Daily NVP for 6 weeks
NVP for 6 weeks

Doses are shown in table below.

NVP AZT
Birth – 6 weeks
Birth weight 2000-2499g 10mg od 10mg twice daily
(1ml syrup od) (1ml syrup twice daily)
Birth weight >2500g 15mg od 15mg twice daily
(1.5ml syrup od) (1.5ml syrup twice daily)
> 6 weeks -12 weeks
20mg od Use treatment dose 60mg twice daily
(2ml syrup od or half a 50mg tablet once (6ml syrup twice daily OR
daily) 60mg tablet twice daily)

Specially trained staff gives the first ART dose before the newborn leaves the delivery room.
 Mothers known to be infected with HIV (and whose infants are HIV uninfected or of
unknown HIV status) should exclusively breastfeed their infants for the first 6 months
of life. The ideal is then to stop breastfeeding and give appropriate complementary
foods thereafter.
 If there is inadequate alternative feeding, breastfeeding may need to be continued for
the first 12 months of life. Breastfeeding should then only stop once a nutritionally
adequate and safe diet without breast-milk can be provided.

87
  Breastfeeding women should be aware that the key to avoiding HIV transmission is
adherence to ART in the mother.
 If a mother cannot breastfeed, then the child’s feeding is entirely switched to bottle
with full correct instructions on cleaning bottles and teats and no further
breastfeeding encouraged.
 HIV exposed infants (HEI) can have very fast disease progression. Without
treatment, one out of every two children infected at birth die by two years of age.

Joint follow-up visit at 6 weeks should involve for the mother:

- post-partum check
- provision of vitamin A
- family planning counselling services
- review of ART regimen and adherence support
- re-enforcement of safe—feeding practices
- cervical cancer screening where available

For the child:

- ongoing ARV prophylaxis if appropriate
- Infant HIV testing – DNA PCR at 6 weeks
- Routine immunization, growth and development monitoring
- Co-trimoxazole prophylaxis from 6 weeks
- Vitamin A every 6 months
- Isoniazid prophylaxis to prevent TB if appropriate
- Mother and family care

Infants who are diagnosed as being HIV infected will receive full ART with 3 medicines but
no longer the prophylactic NVP/AZT dose. All HIV exposed and infected individuals should
be immunized as per the South Sudan nations Expanded Programme for Immunization
schedule. BCG should not be given to infants and children with symptomatic HIV infection.

Regular follow-up should continue for mother and HEI until child is 18 months or until mother
stops breastfeeding. HIV infection below 18 months is confirmed using DNA PCR. Infection
among children 18 months and older can be confirmed using rapid HIV antibody tests.

Care of Children Living with HIV

ALL infants and children with HIV should be started on ART regardless of WHO stage or
CD4 count. This includes those less than 18 months who have a presumptive diagnosis of
HIV.

Prior to starting treatment children and parents/guardians should receive adherence

counselling. They should be educated that treatment will be life-long. The counselling covers
topics similar to adult counselling but in addition touches on timing of disclosure of status,
the challenge of sustaining confidentiality and minimizing stigma. Prior to starting treatment
as assessment is made by a doctor or nurse similar to in adult care. Children are examined
and screened for opportunistic infections as appropriate. In children weight, height and head
circumference should be measured. CD4 count should be measured if possible but should
NOT delay starting treatment. No other baseline bloods are needed unless ABC cannot be
tolerated.

Suggested treatment regimens are shown in the table below.

First Line Regimens for Children
Category Regimen Comment
Infants and children 2 weeks ABC + 3TC +LPV/r Do not use AZT if child is

88
 – 3 years
Children 3-10yrs and
adolescents < 35kg
Infants and Children under 3
yrs who develop TB whilst
on ART
If LPV/r is not available to use as first line. NVP can be used for children < 3 years.
> 3 yrs NVP is preferred.
anaemic (Hb< 7.5g/dL)
Alternatives Do not use EFV if < 3 yrs or
AZT+3TC+LPV/r 15kg
ABC+3TC+NVP Do not use ATV/r if < 3 months
AZT+3TC+NVP
ABC +3TC +EFV When VL monitoring available,
EFV can be substituted for
Alternatives LPV/r at 3 years if VL
ABC +3TC+NVP suppressed
AZT+3TC+EFV When > 3yrs EFV is preferred to
AZT+3TC+NVP NVP
TDF+3TC+EFV or NVP Do not use AZT is child anaemic
( Hb< 7.5g/dL)
TDF can affect bone growth in
children so monitor carefully
ABC + 3TC - AZT Switch NVP or LPV/r to AZT
because of interactions between
rifampicin and NVP or LPV/r

Doses of children’s ART are all calculated depending on weight. Weight dosing charts are
available to help with prescribing and regular weighing is essential to ensure correct dosing.
These can be found in the South Sudan guidelines.

Follow-up visits should be at the same time as mother’s visits. Infants should be seen at
weeks 2,4 and 8 and then every 4 weeks for the first year. Children can be seen at weeks
2,4,8,12 and then every 2-3 months if stable. At visits understanding and adherence should
be checked. Height, weight and head circumference should be monitored. Key signs of
response to ART include improvement in growth and reduced frequency of infections. TB
screening questions should be asked at every visit.

CD4 should be checked at 6 months and then every 6 months. VL should be checked after 6
months of treatment, then at 12 months and annually. If not readily available it should be
checked when suspicion of treatment failure. FBC should be checked at months 1,2, and 3
and annually if on AZT. ALT should be checked if jaundice or a rash on NVP.

Treatment failure is defined in the same way as adults. If VL > 1000copies/ml on 2 separate
occasions 3 months apart, despite adherence support. A child must have been on ARVs for
6 months before being classed as treatment failure. Clinical failure is indicated by new or
recurrent clinical events in keeping with severe immunodeficiency after 6 months of effective
treatment. Or if CD4 levels remain < 200 in age < 5 yrs or < 100 in age > 5 yrs.

Second Line ART in children/adolescents

 If failure of first line with boosted PI, try RAL + two NRTIS for second line.
 If failure of first line with NNRTI-based regimen, try boosted PI with two NRTIs for
second line.
 If failed with ABC+3TC, try AZT+3TC for second line.
 If failed with AZT+3TC, try ABC or TDF + 3TC.

Third line ART in children

Seek specialist advice about third line ART for children.

89
 New 2018 ART guidelines
WHO guidance has recently changed to recommend a first line regimen of tenofovir,
lamivudine and dolutegravir – see below. South Sudan is changing in line with this.
New First Line New Second Line New 3rd Line
Adults TDF +3TC + DTG AZT+3TC + LPV/r or DRV/r + DTG + 2
(300mg/300mg/50mg in FDC) ATV/r NRTIs
(genotype if possible)
TDF +3TC +EFV AZT +3TC+ DTG

Children > 6 years ABC +3TC +DTG AZT+3TC + LPV/r

ABC+3TC+ LPV/r AZT +3TC + DTG
ABC +3TC + EFV or NTRTI AZT + 3TC + DTG
Children 4 weeks – 6 years ABC + 3TC/FTC + LPV/r
Newborn – 4 weeks AZT + 3TC/FTC + RAL
There are some concerns about the safety of DTG in early pregnancy so WHO advise:
-During pre-conception and in the first 8 weeks of pregnancy: TDF + 3TC/FTC + EFV
-During second and third trimester and breastfeeding: TDF + 3TC/FTC + DTG

DTG has not been validated for use in children < 6 yrs of age. RAL can be used in children
from birth. All children’s ARV doses are dependent on weight.

Malnutrition in Children with HIV

Severe acute malnutrition (SAM) is a common presentation of HIV, especially in children.
Any child with malnutrition should be tested for HIV. Children with SAM who are HIV-infected
should be treated in the same way as those who are not HIV-infected. F-75 is initially used
for feeding as per local treatment guidelines. If not receiving F-75, F-100 or therapeutic food,
HIV infected children with SAM should receive high dose vitamin A and zinc if they have
diarrhoea. (See 2.2).

Overall, amongst infants (SAM and non-SAM), early ART initiation is associated with a 4-fold
reduction in mortality. Children with SAM who are HIV infected should be started on ART as
soon as possible after stabilisation of metabolic complications and sepsis. This would be
indicated by return of appetite and resolution of oedema. There have been no clinical trials
looking at timing but the consensus is to aim for initiation 7-10 days after moving into the
resolution phase of SAM. HIV-infected children with SAM should be monitored closely once
on ART to identify opportunistic infections and metabolic complications. If TB is identified at
presentation of SAM, TB treatment should be given before ART, and ART initiation delayed
by at least 2 weeks. Other minor opportunistic infections should be treated at presentation
but this should not delay ART initiation.

Immune Reconstitution Inflammatory Syndrome (IRIS)

IRIS is more common in patients with advanced HIV disease, CD4 < 50. It usually occurs in
the first few weeks of starting ART. It is due to the unmasking of a previously occult
opportunistic infection by the improving immune system. Previously diagnosed disease can
also get worse (known as paradoxical IRIS). IRIS most commonly occurs with TB – this can
present with new or worsening disease or enlarged lymph nodes. It can also occur with
cryptococcal meningitis, Kaposi’s sarcoma, skin infections and any other opportunistic
infection. Mild IRIS can be managed symptomatically but more severe IRIS can be treated
with corticosteroids. Seek specialist advice if suspect IRIS.

Post-exposure prophylaxis (PEP)

PEP is short term use of ART to reduce the likelihood of acquiring HIV infection after
potential exposure either occupationally or through sexual intercourse.

90
In the occupational setting this initially involves giving immediate care after a sharps injury or
exposure. PEP can only be given in the 72 hours after exposure and when there has been a
definite risk of HIV infection.
 wash the wound or exposed area thoroughly.
 counsel about HIV risk and benefits of PEP

PEP can be given after sexual assault again up to 72 hours after exposure. There must be a
definite risk of infection.
 counsel about HIV risk and benefits of PEP
 strongly recommend VCT. If tests HIV+ve then refer for HIV care
 prophylaxis considered for other STIs.
 Before starting PEP, assess for any co-morbidities or possible drug interactions.

ART is given for a full 28 day course.

 For adults TDF+3TC+LPV/r or ATV/r is recommended.
 For children < 10yrs AZT + 3TC + LPV/r is recommended. (or ABC or TDF instead of
AZT)
 The earlier PEP is started, the more effective it is.
 PEP should not be delayed while waiting for HIV test results.
 Adherence to PEP treatment is very important for the full 28 days.
 PEP can be taken while breastfeeding.
 While taking PEP, it is especially important to use condoms and not to donate blood.
 After the initial HIV test at exposure, repeat testing is done at 3 and 6 months.

Pre-exposure Prophylaxis (PrEP)

PrEP is defined as the use of ART by people who are not infected with HIV before HIV
exposure in order to prevent HIV infection. This is offered in some high-risk areas in South
Sudan to certain high risk groups. It is offered as part of a “Combination Prevention”
package that includes HIV testing services, ART for positive patients, condom provision,
voluntary male circumcision and STI prevention management.

Eligibilty: individuals must be at high risk of contracting HIV and be HIV –ve and willing to
adhere to PrEP.

Giving PrEP
 combination of Tenofovir (300mg) and Emtricitabine (200mg) given as a fixed dose
daily.
 After initiating PrEP, reviewed after 1 month and then 3 monthly.
 They have HIV tests at each visit.
 PrEP may be used intermittently during periods of perceived high risk of infection.
 PrEP medication should be continued for 28 days after the last date of potential
exposure to HIV.
 It takes 7 days for PrEP to become effective.
 Pregnancy is not a contraindication for PrEP.
 Impaired renal function is a contraindication for this type of PrEP.

3.7 Opportunistic Infections with HIV

Most of the problems in this section indicate active HIV disease, either because ART has not
yet, or only recently been started. They can also indicate a problem with adherence or
resistance. All opportunistic infections should be treated prior to initiating ART. Some may

91
delay initiation of treatment. If symptoms are not improving after initial treatment seek
specialist advice.

Persistent diarrhoea (for more than 2 weeks)

 Treat chronic diarrhoea empirically:
 Treat with co-trimoxazole for 7 days (Adult; 960mg 8hrly for 7 days, Child: 80mg/kg 8
hourly for 7 days). If no response after one week treat with metronidazole (Adult:
800mg 8 hourly for 7 days, Child: 15mg/kg 8 hourly for 7 days), and also
albendazole. (Adult 400mg 12 hourly for 2 weeks). ART should also be started and
may aid recovery.
 Give fluids as per guidelines.
 Ensure a supportive diet, give zinc supplements for 10 days

Vaginal candidiasis: Give fluconazole 200mg on the first day, then 100mg 1 x per day for 10
days. Do not give during pregnancy.

Oral candidiasis:
1. Use nystatin oral suspension for 7-14 days (Adults: 4ml 6 hourly, Child:1ml 6
hourly).
2. If no response give fluconazole (Adult; 100mg od for 14 days, Child: 6mg/kg day
1, then 3mg/kg for 14 days). Alternatively try ketoconazole or miconazole gum
patch.
3. May need intermittent treatment regime if continues after the 14 days.

Oesophageal Candidiasis: Treat with fluconazole (Adult: 200mg od for 14 days,

Child:12mg/kg day 1 then 6mg/kg for 14 days)

Herpes Zoster: Treat with acyclovir (Adult: 800mg 5 times/day for 7 days, Child: 20mg/kg 8
hourly for 7 days). Start treatment before blisters burst. If face affected refer to eye
specialist.

Tinea Corporis/Cruris/Pedis: Treat with clotrimazole cream or gentian violet paint. Use
griseofulvin tablets if not settling (Adults: 500mg 12 hourly for 4-6 weeks, Child: 200mg/kg
per day for 4-6 weeks).

Persistent fever
1. Test and treat for malaria if RDT +ve.
2. If RDT -ve manage as acute fever. See section 3.4
3. If fever persists after acute treatment, consider chronic causes of fever including
TB.
4. Make detailed clinical history, examination and laboratory investigations.
5. Empirical treatment of chronic infections such as TB may be needed under
specialist care.

Prolonged Acute Respiratory Infection (ARI)

PLHIV and particularly children commonly present with prolonged ARIs. Antibiotic treatment
should be given for longer and the doses of amoxicillin or erythromycin may be increased.
Children can get frequent and severe otitis media.

Pneumonia
 If mild infection use amoxicillin (Adults: 500mg 8 hourly for 7 days,
 Child: 30mg/kg 8 hourly) or doxycycline in adults.

92
  Seek specialist advice if severe admit to hospital and use IV chloramphenicol (Adult
and Child: 12.5-25mg/kg every 6 hours and Benzyl Penicillin (Adults 1.2-2.4 g every
4 hours Child:50mg/kg every 4-6 hours).

Pneumocystis Carinii pneumonia (PCP)

Suspect if CD4< 200/ stage 4 disease on WHO criteria and not been on co-trimoxazole
prophylaxis. Presents with progressive shortness of breath, dry cough, progresses rapidly.
Causes low oxygen levels especially on exertion. CXR has a classical appearance with
ground glass/hazy shadowing most obvious in the lower zones. It is important to try and
differentiate this from normal pneumonia, as treatment is different. Steroids are given in PCP
treatment but NOT in normal pneumonia treatment.
Seek specialist advice. Admit to hospital and treat with oxygen, co-trimoxazole (Adults:
4x480mg 8 hourly for 21 days, Child: 80mg/kg 8 hourly for 21 days) and prednisolone, for
moderate to severe disease (Adults: 40mg 12 hourly for5 days, 40mg 24 hourly for 5 days,
20mg 24 hourly for 11 days, Child: 2mg/kg 24hrly for 7 days, 1mg/kg 24hourly for 7 days,
0.5mg/kg 24 hourly for 7 days).

Cryptococcal Meningitis
Seek specialist advice. Admit to hospital, diagnosed via lumbar puncture if possible.
Removal of up to 20ml of CSF can be beneficial if persistent headache or other signs of
raised intracranial pressure. Treatment depends on what is available.
 If possible, treat with Amphotericin B (Adult and child: 1mg/kg IV over 6 hours 24
hourly for 14 days) and then Fluconazole (Adult: 400mg 24 hourly for 42 days then
200mg 24 hourly for life, Child: 6mg/kg 24 hourly for life).
 If Amphotericin B not available substitute with high dose fluconazole for first 14 days
of treatment (Adult: 1200mg 24 hourly for 14 days, Child: 12mg/kg 24 hourly for 14
days) then reduce dose as for Amphotericin B treatment.
 Patients should be prehydrated with 1L of normal saline with 20mmol potassium
chloride prior to treatment with Amphotericin B to reduce Amphotericin B renal
toxicity. Monitor renal function during treatment.

Toxoplasmosis
Seek specialist advice. Usually diagnosed with CT scan. Adult: treat with pyrimethamine
75mg once daily, sulfadiazine 1.5g 6 hourly and leucovorin 10-25mg od for 6 weeks.
Alternatively treatment can be given with cotrimoxazole 60mg/kg/day in divided doses. Then
give cotrimoxazole maintenance therapy.

Kaposi’s sarcoma
Seek specialist advice. Treat with analgesia, symptomatic treatment and ART. Consider
chemotherapy with vincristine.

Tuberculosis (see HIV-TB Co-infection 3.9)

93
3.8 Tuberculosis
Tuberculosis (TB) is a major public health problem in South Sudan. In 2014, WHO estimated
a prevalence of 319 cases / 100,000 population. TB is responsible for more than 25% of all
deaths amongst PLHIV and the prevalence of HIV infection in TB patients is thought to be
about 15%. Other high-risk groups for TB infection are household contacts of TB cases,
internally displaced populations, prisoners, refugees, migrant workers and members of the
uniformed forces.

TB is a chronic mycobacterium infection that most commonly affects the lungs but can also
affect every other part of the body. In healthy people, infection with Mycobacterium
tuberculosis (MTB) often causes no symptoms, since the person's immune system acts to
“wall off” the bacteria. About one in ten latent infections eventually progresses to active
disease which, if left untreated, has more than 50% mortality. The symptoms of active TB of
the lung are coughing, sometimes with sputum or blood, chest pains, weakness, weight loss,
fever and night sweats. Tuberculosis is treatable with a six-month course of antibiotics.

TB can be transmitted to health care workers so patients should be assessed outdoors, or in

a well ventilated area if possible. Face masks should be used by patients and staff if
available to prevent nosocomial transmission.

Diagnosis
The diagnosis of TB refers to the recognition of an active case, i.e. a patient with
symptomatic disease due to M. tuberculosis. Diagnosis may be based on a positive sputum
result, symptoms, or clinical and x-ray findings. Diagnosis can be defined as:

Presumptive diagnosis of TB - based on symptoms & exclusion of other causes;

Clinical diagnosis of TB - clinical and x-ray signs, but bacilli not identified;
Bacteriologically-confirmed TB - sputum + for acid-fast bacilli or approved rapid test.

TB is either pulmonary (PTB) (infection situated in the lung tissue) or extra-pulmonary

(EPTB) (in other sites of the body, including TB-infected mediastinal lymph nodes and
pleural effusion if no lung involvement). Extra-pulmonary infection can be found in any tissue
in the body, but is more commonly found in: pleura, lymph nodes, abdomen, genitourinary
tract, skin, joints and bones and meninges. EPTB is diagnosed from clinical findings,
bacteriological confirmation and/or histological findings. TB is further defined as either drug-
sensitive or drug-resistant TB. Drug resistant TB has an increasing prevalence worldwide.

Traditionally TB has been diagnosed on initial smear microscopy looking for acid-fast bacilli
and then culture of mycobacterium tuberculosis which takes about 8 weeks. Drug sensitivity
can be checked on the culture of TB only. TB treatment has been revolutionised over the
past few years by the development of a new test for TB called GeneXpert. This test is a
molecular (genotypic) test that can identify the DNA of MTB in sputum and in some extra-
pulmonary samples. It is also able to detect the presence of resistance to rifampicin. It has a
high sensitivity and specificity in sputum when compared to culture, as well as in smear
negative samples.

It has a number of advantages compared to smear microscopy:

 The test itself is able to give results in about 2 hours but access to the result may be
longer, depending on access to the GeneXpert machine and the administration of
results.
 This 2-hour process also includes the detection of rifampicin resistance, a much faster
process than culture and drug sensitivity testing (DST)
 GeneXpert is fully automated and does not require a high-level laboratory.

94
GeneXpert MTB/RIF assays
Xpert MTB/RIF assays can be performed in most of the state TB laboratories of South
Sudan. Xpert MTB/RIF tests MUST be carried out in adults and children in South Sudan who
are:
- Retreatment TB cases
- TB patients who are still positive at the end of the intensive phase of
treatment
- Contacts of Multi Drug Resistent-TB cases (or suspected MDR-TB cases)
- PLHIV who need to be evaluated for TB
- Persons with unknown HIV status who present strong clinical evidence
of HIV infection or belong to a high risk group for HIV and who have
signs or/and symptoms compatible with TB
- Patients suspected of having TB meningitis in whom Xpert MTB/RIF
testing needs to be performed on cerebrospinal fluid specimens

Whenever and wherever possible, Xpert MTB/RIF testing needs to be undertaken to

establish the diagnosis of:
 TB in children (eg. using gastric fluid)
 EPTB - using non-respiratory specimens (eg. lymph node discharge fluid
or tissue biopsy specimens).

When and where possible, Xpert MTB/RIF testing can be used in patients with
presumptive TB in whom sputum smear microscopy did not identify any TB bacilli.
As GeneXpert becomes more widely available it should be used for diagnosis of all new
cases of pulmonary TB and EPTB if possible.

Standardised TB treatment regimes

The aims of treatment of TB are the following:
 to cure the patient of TB;
 to prevent death from active TB or its late effects;
 to prevent relapse of TB;
 to decrease transmission of TB to others;
 to prevent the development and transmission of acquired drug resistance
tuberculosis.
 to treat any co-infection with HIV

There are three main properties of TB drugs: bactericidal activity, sterilizing activity and the
ability to prevent resistance. The TB drugs possess these properties to different extents.
Isoniazid and rifampicin are the most powerful bactericidal drugs. Rifampicin is the most
potent sterilizing drug available. Pyrazinamide is also bactericidal against certain populations
of TB bacilli. Ethambutol is used in association with more powerful drugs to prevent the
emergence of resistant bacilli. Fixed dose regimes with combined medicines are used where
possible when quality control is assured, to facilitate acceptability and adherence.

Treatment for Drug Sensitive TB

Treating new cases:
Treatment regimens have an intensive directly-observed therapy (DOT) phase lasting 2
months and a continuation phase usually lasting 4 months. During the initial phase intensive
treatment is with isoniazid, rifampicin, pyrazinamide and ethambutol, and there is rapid killing
of tubercle bacilli. Infectious patients become rapidly non-infectious (within approximately 2
weeks). Symptoms decrease. The vast majority of patients with sputum smear-positive TB
cases become smear-negative on sputum testing within 2 months, in which case they can
proceed to the continuation phase. In the continuation phase fewer drugs are necessary but

95
for a longer time. The sterilizing effect of the drugs eliminates remaining bacilli and prevents
subsequent relapse.

Standard regimen for new TB patients:

Intensive phase Continuation phase Dosing frequency
2 months of RHZE 4 months of RH Daily

(R-Rifampicin, H-Isoniazid, Z-Pyrazinamide, E-Ethambutol)

The initial phase is 2 RHZE. The duration of the phase is 2 months. Drug treatment is daily,
with isoniazid (H), rifampicin (R), pyrazinamide (Z) and ethambutol (E) in fixed dose
combination. The continuation phase is 4 (RH). The duration is 4 months, drug treatment is
daily with isoniazid and rifampicin, in fixed dose combination.

Treatment regimen of EPTB is similar to pulmonary tuberculosis. TB meningitis should be

treated for 9–12 months given the serious risk of disability and mortality and TB of the bones
for 9 months because of the difficulties of assessing treatment response. In case of
meningitis and pericarditis, adjuvant corticosteroid treatment is recommended. Seek
specialist advice for management plan for these patients.

Treatment of Mycobacterium bovis.

M. bovis may account for 2.8% TB cases in Africa, and could be higher in South Sudan. It is
commoner in people who drink raw milk. Prevention is by boiling or pasteurizing milk. It
presents in similar ways to other TB but can present with very large lymph nodes in the
neck.
Treatment is as above, but without Pyrazinamide (M bovis is resistant to it), and given for 9
months as only 3 drugs are used:
Intensive phase Continuation phase Dosing frequency
2 months HRE 7 months of HR Daily

Dosages of fixed-dose preparations of tuberculosis drugs in adults

Weight in kg
30 – 39 40 - 54 55 – 70 >70
Initial phase (daily)
RHZE (75mg+150mg+400mg+275mg) 2 tabs 3 tabs 4 tabs 5 tabs

Continuation phase (daily)

Either RH (75mg+150mg) 2 tabs 3 tabs 4 tabs 5 tabs
(R-Rifampicin, H-Isoniazid, Z-Pyrazinamide, E-Ethambutol)

Retreatment cases:
Retreatment cases include all TB patients who were treated as new cases for more than one
month and are now smear or culture positive (failure, relapse, return after default). They
have a higher likelihood to have drug resistance which may have been acquired through
inadequate prior chemotherapy.

Previously these retreatment cases were managed differently from new cases with 8 months
of treatment called category 2. Streptomycin was given in addition to the normal four drugs.
Since the development of GeneXpert this management has been stopped. This is because
evidence has shown that this was actually harmful and could make drug resistance worse.
All retreatment cases should be assessed by GeneXpert. Now all cases of drug sensitive TB
– new and retreatment - are treated for 6 months with a combination of RHZE treatment.

96
Treating TB in children
Children (0-14 years) account for up to one-third of all TB cases. Most cases are PTB cases.
Extra pulmonary TB (EPTB) is also common and presentation varies with age. TB disease
can be more severe and of rapid onset in infants and young children. Children with TB
disease usually have poor weight gain, may lose weight or be malnourished. The
presentation and approach to diagnosis of pulmonary TB in older children (>10 years) and
adolescents is similar to that for adults. Have a low threshold for diagnosis of TB in a child if
a close family member has PTB, especially if the child is HIV infected.

Suggested Algorithm for TB diagnosis in children (non-HIV infected)

TB suspected on basis of typical and persistent symptoms

Sputum smear Negative or not Sputum smear positive

done

Clinical  Positive contact history

Diagnosis  Physical signs suggestive of
PTB TREAT FOR TB
 CXR suggestive of PTB

If only one or none of the features Make a diagnosis of TB if two or more of

are present these features are present

If child sick, admit to hospital for If child well, review after 2-4 weeks
further investigation

Dosage of fixed-dose preparation tuberculosis drugs in children

Weight in kg
Up to 7 8-9 10-14 15-19 20-24 25-29
Initial phase- daily
HRZ 1 1½ 2 3 4 5
(30mg+60mg+150mg)
E 400mg - - - - 1 1

Continuation phase- daily

HR (60mg + 30mg) 1 1½ 2 3 4 5

Child contact screening and management

Isoniazid preventive therapy (IPT) greatly reduces the risk of an infant or young child
exposed to TB infection developing disease:

97
  All children who are close contacts with cases with smear-positive TB should be
screened for TB
 If the TB source case is the child’s parent and is HIV-infected, test all the children for
HIV
 Symptoms alone are used to screen child contacts for possible TB disease.
 All children aged less than 5 years and all HIV-infected children (less and more than
5 years of age) who were exposed to an index TB case and in whom TB assessment
did not identify any active TB should receive isoniazid preventive therapy.1

Treatment regimens in special situations
Treatment for Co-infection with HIV/TB:See section 3.9. ARV doses/regimens may need to
be altered.

Treatment for pregnant and breastfeeding women:

It is important to ask a woman before starting TB treatment if she is pregnant. Most TB drugs
are safe for use in pregnant and breastfeeding women and so the standardised regime can
be used. Pyridoxine supplementation is recommended for all pregnant or breastfeeding
women taking isoniazid. When active TB in the baby is ruled out, the baby should be given 6
months of isoniazid preventive therapy, followed by BCG vaccination.

Women on oral contraceptives:

Rifampicin interacts with contraceptive medications with a risk of decreased protective
efficacy against pregnancy. A woman who is receiving contraception may choose between
the following two options while receiving treatment with rifampicin: either take an oral
contraceptive pill containing a higher dose of oestrogen (50mcg) or use another form of
contraception.

Treatment for patients with liver disorders:

Although anti-tuberculosis drugs are hepatotoxic, patients with: known hepatitis B or C; a
past history of acute hepatitis; or current excessive alcohol consumption can still receive the
usual TB regimens, provided that there is no clinical evidence of chronic liver disease.
Careful monitoring of these patients is crucial. See section 3.9.

Treatment of patients with renal failure:

Isoniazid and rifampicin are eliminated by biliary excretion, so no change in dosing is
necessary. There is significant renal excretion of ethambutol and metabolites of
pyrazinamide, and doses should therefore be adjusted. TB patients with renal failure should
be treated with 2HRZE/4RH with adjusted doses. 3 x per week administration of these two
drugs at the following doses is recommended: pyrazinamide (25 mg/kg), and ethambutol (15
mg/kg). Patients with severe renal insufficiency receiving isoniazid are given pyridoxine to
prevent peripheral neuropathy.

Managing side effects from TB drugs

Side effects are infrequent, but should be properly managed.

Symptom-based approach to side effects of TB drugs

Side effects Drug Management
Minor Continue TB drugs, check dose
Anorexia, nausea, abdominal pain Pyrazinamide, Give drugs with small meals or last
rifampicin thing at night
Joint pains Pyrazinamide Aspirin

98
 Burning sensation in the feet Isoniazid Pyridoxine 100 mg daily

Orange/red urine Rifampicin Reassurance to patients, this is

normal

Major Stop responsible drug

Itching, skin rash (R,H,Z) Stop TB drugs
Jaundice (other causes excluded), Isoniazid, Stop TB drugs, see below
hepatitis pyrazinamide,
rifampicin)
Confusion (suspect drug-induced Most TB drugs Stop TB drugs. Urgent liver
acute liver failure if jaundice function tests and prothrombin time
present) test
Visual impairment (other causes Ethambutol Stop ethambutol
excluded)
Shock, purpura, acute renal failure Rifampicin Stop rifampicin
National TB guidelines must be consulted for more detailed management of drug side
effects.

Interactions of TB drugs
The commonest anti-tuberculosis drug that interacts with other drugs is Rifampicin.
Rifampicin induces liver enzymes to metabolize other drugs, thereby reducing their
concentration and effect. To maintain a therapeutic effect, dosages of the other drugs may
need to be increased. When rifampicin is discontinued, its metabolism-inducing effect
resolves within about 2 weeks, and dosages of the other drug(s) will need to be reduced.
The drugs whose concentrations and effects are substantially reduced by rifampicin include:
 Anti-microbials (mefloquine, azole antifungal agents, clarithromycin, erythromycin,
doxycycline, atovaquone, chloramphenicol)
 Hormone therapy, including ethinylestradiol, norethindrone, tamoxifen, levothyroxine;
 Cardiovascular agents including digoxin, verapamil, nifedipine, diltiazem, propranolol,
enalapril, losartan;
 Methadone; Warfarin; Cyclosporin; Corticosteroids; Anticonvulsants (including
phenytoin); Theophylline; Sulfonylurea hypoglycaemics;
 Anti-retrovirals (See 3.9)

Drug resistant TB (DR-TB)

WHO estimate the prevalence of DR-TB among new TB cases and retreatment TB cases at
2.2% and 11% respectively. WHO also estimated that the number of DR-TB cases among
new and retreatment TB cases was 225 in 2014. DR-TB develops because of poor
adherence to treatment but, the vast majority of DR-TB is transmitted between patients. This
means someone can have DR-TB even if it is his or her first episode of TB infection.
Infection control and early diagnosis are vital aspects in the management of DR-
TB.GeneXpert detects rifampicin resistance and if found patients should be treated with 2nd
line TB treatment (DR-TB treatment).

It is possible to test for drug resistance to the other TB drugs using culture and sensitivity but
this can take months. There is another genotypic test called a Hain’s test which takes two
hours to detect resistance to other TB drugs. This may not currently be available in South
Sudan.

DR-TB can be defined in the following way:

- Multidrug resistance (MDR): Resistance to both isoniazid and rifampicin.
- Pre-XDR: Resistance to both rifampicin and INH, as well as either a

99
 fluoroquinolone or an aminoglycoside (a sort of half-way mark between MDR and
XDR). Pre-XDR TB, though an important definition clinically, is not an official definition.
- Extensive drug resistance (XDR): Resistance to any fluoroquinolone (ofloxacin/
levofloxacin/moxifloxacin/gatifloxacin) and at least one of three second line injectable
drugs (capreomycin, kanamycin and amikacin) in addition to MDR as defined above.

Other resistance pattern definitions are:

- Mono-resistance: A term that refers to resistance to one first line anti-TB drug only
(rifampicin, INH, pyrazinamide or ethambutol). Rifampicin mono- resistance is
important because it requires a second line TB drug regimen.
- Poly-resistance: resistance to more than one first-line drug, other than both isoniazid
and rifampicin

Treating DR-TB
Treatment of DR-TB is longer and more complicated than for drug sensitive TB.
Patients must be counselled about their condition, the length of treatment and possible side
effects of treatment. Additional baseline assessments may be required for DR-TB patients
before starting treatment. These are due to some of the potential side effects of drugs and
include: creatinine level, potassium level, thyroid stimulating hormone, ALT, amylase,
audiometry, visual tests, ECG, FBC. Tests needed depend on what medications are being
used.

Patients with DR-TB should be treated using mainly ambulatory care but for some cases
hospitalization may be needed. Often it is only for the first few months of the initial phase of
treatment, but doses after discharge must also be observed (DOT). It is recommended that
anyone diagnosed with DR-TB in an IDP camp be admitted to the nearest DR-TB treatment
centre to ensure effective and uninterrupted treatment and aid infection control.Seek
specialist advice for management of DR-TB.

The general principles involved in selection of 2nd line treatment are:

1. Regimens should be based on the history of drugs taken by the patient
2. Drugs commonly used in the country and prevalence of resistance to them
should be taken into account
3. Regimens should consist of at least 4 drugs with either certain or almost certain
effectiveness. Often more than 4 drugs may be started if the susceptibility is
unknown.

South Sudan 2016 guidelines suggest that treatment should include:

- any first line drug available – pyrazinamide or ethambutol
- a fluoroquinolone
- an injectable agent – Kanamycin or Amikacin
- One or more of Cyloserine/Ethionamide/PAS/Linezolid
- One or more of: Bedaquiline/Delamanid/Clofazimine/Imipenem/Meropenem/Co-
amoxiclav/Clarithromycin/high doses INH
The aim is to choose 4-6 effective drugs.

Since the publication of the 2016 South Sudan DR-TB guidelines there have been advances
in management of DR-TB and WHO treatment recommendations have changed quite
significantly

New Guidelines are shown below:

Group A Moxifloxacin or Levofloxacin
Use all 3 medicines (unless they cannot be Bedaquiline
used) Linezolid

100
 Group B Clofazamine
Add both medicines (unless they cannot be Cycloserine or Terizidone
used)
Group C Ethambutol
Add to compliment the regimen and when Delamind
medicines from Groups A and B cannot be Pyrazinamide
used Imipenem-cilastatin OR Meropenem
Amikacin OR Streptomycin
Ethionamide OR Prothionamide
Para-amino-salicylic acid
Standard treatment length is 18-20 months.Shortened regimes have also been introduced
lasting 9-12 months. These can be used if patients fit specific criteria.

Treatment is monitored with sputum smear and culture. Cure is achieved when a patient has
had a least 3 or more consecutive negative cultures from samples collected 30 days apart in
the final 12 months of treatment.There are many toxicities and interactions of the drugs used
for treatment of DR-TB, in particular with ART treatment. Specialist care is needed for the
successful management of this condition.

3.9 HIV-TB Coinfection

Tuberculosis is one of the most common opportunistic infections in People living with HIV
(PLHIV). HIV increases the risk of acquiring and developing active TB disease following
exposure to M. tuberculosis. Globally people living with HIV are 20 x more likely to fall ill
with TB than those without HIV in 2017. TB is responsible for 25% of deaths among PLHIV.

HIV fuels the TB epidemic through progression of recent and latent M. tuberculosis infection
to active TB disease. HIV also increases the rate of recurrent TB. The immune system is
less able to prevent the growth and local spread of M. tuberculosis. Active TB can present
differently in the presence of a weakened immune system. There are less lung cavities and
so less bacilli in the sputum; this makes it more difficult to diagnose TB using smear
microscopy. Disseminated and extra-pulmonary disease is more common in PLHIV.

It is important to screen PLHIV for TB as a diagnosis of TB can affect the timing of when
ART is initiated and sometimes influence the choice of ART due to drug interactions.

HIV-positive and suspected of having TB:

Suspicion of TB is defined by the presence of any one of the following symptoms:
 Adults or adolescents living with HIV: current cough, fever, night sweats, weight loss
 Children living with HIV: poor weight gain, fever, current cough or history of contact
with a TB case. In children living with HIV there should be a higher suspicion for TB
and lower threshold for treatment.

A sputum sample should be sent for Xpert MTB/RIF testing if above symptoms are present.
Symptoms should be screened for at each clinic visit. For people suspected of having
extrapulmonary TB, extrapulmonary specimens should be obtained for Xpert MTB/RIF
(cerebrospinal fluid, lymph nodes and other tissues: Xpert MTB/RIF has low sensitivity for
pleural fluid and data are limited for stool, urine or blood).

 If Xpert MTB/RIF testing is positive start treatment for TB.

 If Xpert MTB/RIF shows rifampicin resistance, treatment for drug-resistant TB (DR-
TB) should be initiated. If low risk for rifampicin resistance, a 2nd Xpert MTB/RIF test
should be performed on a fresh specimen. Collect and refer a sample for TB culture
and additional drug sensitivity testing where feasible.

101
  If Xpert MTB/RIF testing is not available or negative for TB then further testing for TB
should be arranged.

Further investigations for TB include chest X-ray, clinical assessment and a repeat Xpert
MTB/RIF using a fresh specimen. Refer a sample for TB culture where feasible. If Xpert
MTB/RIF is not available, conduct acid-fast bacillus (AFB) microscopy. AFB-positive is
defined as at least one positive smear, and AFB-negative as two or more negative smears. If
extrapulmonary TB is suspected, extrapulmonary specimens should be obtained and sent
for culture and abdominal ultrasound may be performed.

Where possible, lateral flow urine lipoarabinomannan assay (LF-LAM) may be used to assist
in the diagnosis of active TB in adult PLHIV, with signs and symptoms of TB (pulmonary
and/or extrapulmonary), who have a CD4 cell count less than or equal to 100 cells/mm3 and
are unable to produce sputum or PLHIV who are seriously ill regardless of CD4 count or with
unknown CD4 count.

Co-trimoxazole should be initiated for all PLHIV (adults and children) who have been
diagnosed with TB, regardless of CD4 count.

Diagnosis of TB in PLHIV who have not already initiated ART:

TB treatment should be initiated FIRST followed by ART as soon as possible within the first
8 weeks of treatment. (See 3.8).

6-month rifampicin based regimen 2RHZE/4HR remains the recommended regimen.

(H-Isoniazid, R-Rifampicin, Z-Pyrazinamide, E-Ethambutol)

All patients must be started on vitamin B6 (pyridoxine) to reduce the chance of developing
peripheral neuropathy caused by isoniazid.

Timing of ART initiation after starting TB treatment:

Clinical situation
All TB cases with CD4 count <50
All TB cases with CD4 count >50
Young children (especially < 1 year)
All DR TB cases
Timing of ART initiation
Within 2 weeks
Within the first 2–8 weeks
Within 2 weeks if possible
Within 2 weeks if DR TB treatment tolerated

If neurological TB (meningitis, brain, spinal cord) is diagnosed, regardless of CD4 count,

ART is delayed by 4 weeks.

Which ART regimen should be initiated?

Adults: Currently the preferred first line regimen in South Sudan for adults (including
adolescents, and pregnant and breast-feeding women) is

Tenofovir, lamivudine and efavirenz (TDF, 3TC and EFV). This should be given as a Fixed
Dose Combination.

The MoH have recently changed to recommend a first line regimen of tenofovir, lamivudine
and dolutegravir. If the patient is started on dolutegravir the dose of dolutegravir needs to be
doubled to 50mg 2 x per day.

Children and Adolescents

Please refer to South Sudan ART guidelines 2017 for recommended ART regimens for
children and adolescents initiating ART whilst on TB treatment.

102
TB-associated immune reconstitution inflammatory syndrome (IRIS) is common in
patients with TB started on ART but is usually self-limiting. Patients who develop IRIS
should continue their antituberculosis and ART treatments.

Diagnosis of Drug sensitive TB in PLHIV who are already on an ART regime:

If an adult or child already on ARTs is diagnosed with TB, the ART regimen may need to be
modified due to drug interactions. Rifampicin induces liver enzymes thus reducing the serum
levels of most ARV drugs including all PIs, and the NNRTIs especially NVP. Efavirenz
remains effective in the presence of rifampicin. In circumstances where a PI has to be used
e.g. for people diagnosed with TB while on second line ART, LPV/r can be used with
rifampicin-containing regimens, but the dose needs to be doubled. If a patient is on double
dose LPV/r they will require monthly ALT monitoring. The dose of LPV/r can be reduced to
standard dose 2 weeks after TB treatment is completed. (Refer to SS ART guidelines 2018
for recommended regimen for children and adolescents are initiated on TB medication while
taking ART).

PLHIV with suspected Drug Resistant TB

Xpert MTB/RIF testing should be used where possible as this will rapidly detect rifampicin
resistance. Refer PLHIV to specialised treatment centres for specific DR-TB medication.
PLHIV and DRTB should be initiated on ART regimen as early as possible (within 8 weeks)
following initiation of TB medication.

Drug-induced liver injury:

There are many toxicities and interactions of the drugs used for treatment of TB (in particular
medication for DR-TB) with ART treatment. Most liver injury will occur within 10-30 days of
starting a drug but it can take up to 3 months to occur.

Diagnosis of drug-induced liver injury:

 ALT > 120 IU/I and symptomatic (nausea, vomiting, abdominal pain, jaundice) OR
 ALT > 200 IU/I and asymptomatic OR
 Bilirubin > 40 mmol/L

If diagnosed seek specialist advice. All causative drugs must be stopped immediately; ARVs,
TB drugs, co-trimoxazole and any other drug the patient may be on which is hepatotoxic.

Review the basis for TB diagnosis.Consider if the patient needs alternative TB medication
based on how sick the patient is with TB (disseminated TB or TB meningitis). This can
consist of an aminoglycoside (kanamycin), quinolone (levofloxacin) and ethambutol. If an
aminoglycoside cannot be used ethionamide can be used instead. Once the patient has
stabilised a re-challenge regimen can be started. This can be considered when ALT < 100
IU/L and bilirubin < 30mmol/L.

Suggested protocol:
 Day 1: Rifampicin (stop aminoglycoside if this has been started)
 Day 3: Check ALT
 Day 4: If ALT unchanged add isoniazid (stop quinolone now if this has been started)
 Day 7: Check ALT
 Day 8: If ALT unchanged consider pyrazinimide rechallenge

If the ALT rises the most recently introduced drug is the likely cause and needs to be
stopped.

103
  If rifampicin is stopped, use18 month regimen with isoniazid, moxifloxacin,
ethambutol and kanamycin for 2 months, then isoniazid, moxifloxacin and ethambutol
for 16 months. Seek specialist advice.
 If isoniazid is stopped use a 12 month regimen of rifampicin, moxifloxacin and
ethambutol.
 If pyrazinamide is stopped a 9 month regimen of rifampicin, isoniazid and
ethambutol.

Once the patient is back on a TB regimen, the ART is reintroduced. If drug-induced liver
injury happened within 3 months of starting ART then NNRTI or PI is the possible cause.
ALT needs to be checked at 3-4 days. Do no re-challenge nevirapine. Efavirenz re-challenge
can be considered unless liver damage was severe. If liver damage occurred on double
dose LPV/r with rifampicin, replace the rifampicin with rifabutin and standard dose LPV/r if
possible; otherwise give half-dose LPV/r with gradual dose escalation to full dose over a few
weeks. Check ALT weekly for 1 month after a successful re-challenge.

3.10 Viral hepatitis

Viral hepatitis is an inflammation of the liver caused by five viruses: A, B, C, D and E.

Hepatitis A and E are transmitted by the faecal-oral route.
 B, C and D are transmitted by infected blood; poor sterilisation techniques; by sexual
spread (hepatitis B and possibly C and D); and vertical spread from mother to child.
 Hepatitis A, and E cause acute infections whilst B, D and C can cause chronic
infections. This chronic active hepatitis can progress to cirrhosis and liver cancer
(hepatoma).
 More than 90% of healthy adults who are infected with hepatitis B virus will recover
naturally from the virus within the first year. This number is much less in those co-
infected with HIV and Hep B infection.

It is estimated that at least one in ten adults test positive for either Viral Hepatitis B or C in
South Sudan. However, screening, diagnostic and treatment services coverage is quite low
with only one in fifty people who are living with hepatitis aware they are infected and
accessing treatment.
 Hepatitis E is also a common cause of outbreaks resulting in deaths due to acute
hepatitis among displaced populations in internally displaced camps and refugee
settings.
 Individuals are often co-infected with both Hepatitis B and C, or with one of them and
HIV or Tuberculosis (TB). Co–infection rates for Hepatitis B Virus (HBV) and
Hepatitis C Virus (HCV) with TB are at 12.8% and 8.0% respectively.

Clinical presentation
All of the viruses may present as an acute phase infection with high fever, jaundice,
anorexia, vomiting, fatigue, dark urine, enlarged tender liver and significantly raised ALT.
Occasionally this can result in fulminant hepatitis but can also be asymptomatic, particularly
with hepatitis B in children. To diagnose the type of viral of hepatitis, serology must be
checked for the different viruses – but these tests are rarely all available. Fulminant hepatitis
has a very high mortality. Treatment of acute phase infection should be supportive. There is
no role for steroids.

104
Hepatitis A and E
Hepatitis A and E can take up to 6 weeks to settle, with some improvement usually seen
after 3 weeks. Alcohol, paracetamol and any unnecessary medicines should be avoided
during this acute illness. Most people do recover fully after the infection. Pregnant women
have a higher mortality rate (up to 20%) with fulminant hepatitis E infection. It can be
associated with post-partum haemorrhage.

Hepatitis A, and E can be prevented by ensuring clean water and sanitation is available and
used. In camps with displaced people one of the most urgent priorities is to install clean
water and sanitation and promote hygiene to prevent the spread of water-borne disease like
hepatitis A and E. There is an effective vaccination for Hepatitis A which can provide
protection if available to use in an outbreak.

Hepatitis B and C
Hepatitis B and C are caused by different viruses, but result in a very similar disease
process. Both start with an acute infection, which can vary from being asymptomatic to
causing fulminant hepatic failure. This infection may then resolve entirely and the patient will
become immune or it may progress to a chronic infection. This chronic infection can
eventually result in cirrhosis or hepatocellular cancer if untreated.

Both infections have become a public health concern in Sub-Saharan Africa with both
thought to have a prevalence > 5%. In Sub-Saharan Africa there are an estimated 4 million
people co-infected with HBV and HIV and similar numbers co-infected with HCV and HIV.
Co-infection with HIV accelerates both viruses and causes much higher than normal rates of
cirrhosis and death.

Hepatitis B (HBV)
Most HBV is transmitted via mother to child transmission (MTCT) and in early childhood
whilst playing, It is also transmitted via sex and saliva, and via people who inject drugs.
There is a risk of occupational exposure for health care workers.

HBV can be PREVENTED by vaccination. All children should be vaccinated via the EPI
programme with doses given three times at 6, 10 and 14 weeks. The complete course gives
protection for at least 20 years and is probably lifelong. Healthcare workers who are HBV
negative should also be vaccinated. PLHIV who are HBV negative should be vaccinated.

Diagnosis of HBV can be complicated but is usually limited to a few tests in South Sudan. If
available, hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (HBsAb) can
be checked. Presence of HBsAg indicates ongoing infection. If this infection is cleared and
the patient becomes immune they develop HBsAb and HBsAg disappears. Screening for
HBV should be carried out in the following groups: all PLHIV; household and sexual contact
of HBV positive people; people who inject drugs (PWID); men who have sex with men
(MSM); commercial sex-workers; prisoners and pregnant women. People found to be HBV
positive should be counselled about reducing spread by using condoms and not sharing
needles, toothbrushes, razors etc. Negative contacts should be vaccinated.

If babies are born to mothers with known HBV, they should be vaccinated immediately at
birth with HBV vaccine. They can also receive passive immunization against hepatitis B with
HepB Immunoglobulin (HBIG):
 Temporary immunity is conferred by administering HBIG for post-exposure
prophylaxis. HBIG prophylaxis, in conjunction with HBV vaccination, may be of
additional benefit for the following: newborn infants whose mothers are HBsAg-
positive, particularly if they are also HBeAg-positive. In fullterm neonates born to

105
 mothers who are HBsAg-positive but HBeAg-negative, protection against perinatally
acquired infection achieved by immediate vaccination against HBV (given within 24
hours) may not be significantly improved by the addition of HBIG.

There is no cure for HBV but it can be controlled using anti-viral medication. This treatment
can prevent the development of cirrhosis, reduce incidence of liver cancer and improve long-
term survival. The medications used are Tenofovir (TDF) and Lamivudine (3TC) which are
also used in the treatment of HIV, and need to be lifelong. Entacavir can also be used. All
PLHIV are now started on ART and should be screened for HBV at baseline if possible. Most
people will be started on TDF and 3TC anyway, as they are part of recommended first line
treatment for HIV (see 3.6). These drugs should definitely be used if a PLHIV is known to be
HBV positive.

Problems arise when a PLHIV with known HBV needs to be changed from these ARVs to a
different regimen for some reason. Even if their HIV virus is thought to be resistant to TDF
they should continue on TDF in addition to their new ART to maintain control of Hep B
infection. It is important to avoid 3TC monotherapy as 90% of HBV will become resistant to
3TC within 5 years. In mild renal failure TDF dose can be reduced and continued but in
severe renal impairment TDF may have to be stopped. Entacavir at 0.5mg od can be used
instead in some cases but this does not work against HIV.

In HIV-ve / HBV+ve patients, Tenofovir 300mg 1 x per day or Entacavir 0.5mg 1 x per day
lifelong, but local guidelines should be consulted to see if there is any funding for this
treatment. International experience shows that stopping treatment even with viral
suppression can lead to reactivation of the disease.

Hepatitis C (HCV)
Most HCV is transmitted by body piercing, blood products and People Who Inject Drugs
(PWID). Unsafe injections and reuse of needles in medical facilities is also a significant risk.
There is a risk of occupational exposure for health workers. Risk of sexual transmission is
much less than with HBV but is higher in PLHIV especially in MSM. Mother-to-child
transmission (MTCT) is also higher in PLHIV.

Diagnosis is made by checking for HCV antibodies. If these are present another test for HCV
RNA is needed. There are many known genotypes for HCV infection which can affect the
type of treatment recommended. Screening should be done in high risk groups, in areas of
high prevalence. These groups include PLHIV, PWID, pregnant women, MSM, prisoners,
people with tattoos and piercings.

People who test positive for HCV should be counselled about trying to reduce risk of onward
transmission by using condoms, not sharing needles or razors etc. They should also be
given advice about reducing alcohol intake as this can accelerate decline in liver function.

HCV is actually now CURABLE using medication called directly acting anti-virals.
Unfortunately this treatment is expensive, but is gradually becoming more widely accessible.
Even if treatment is not yet available in an area, it is important to screen for this condition so
accurate data about incidence and prevalence can be gathered.
WHO recommends that all people > 12 years old infected with HCV virus should be offered
treatment. It is recommended that anyone found to be infected < 12 years old should have
treatment deferred until they are > 12 years old.

Adults > 18 yrs should be treated with directly acting anti-virals. Different regimens are
recommended depending on the presence or absence of cirrhosis of the liver. In low cost

106
setting it is suggested that cirrhosis could be looked for by calculating the aspartate/platelet
ratio index (APRI) or Fibrosis 4 score (FIB 4 score).

APRI = AST (IU/L) / AST (IU/L) upper limit of normal x 100 / platelet count x 10 9/L

AST = Aspartate aminotransferase

APRI < 0.5 indicates no fibrosis

APRI > 1.5 indicates likely cirrhosis

FIB 4 = age (yrs) x AST (IU/L) / platelet count 109/L x ALT (IU/L) x ½

ALT = Alanine aminotransferase

FIB 4 < 1.45 indicates no fibrosis

FIB 4 > 3.25 indicates likely cirrhosis
The regimens recommended are very similar with or without cirrhosis. For adults without
cirrhosis, the following regimens can be used:
- Sofosbuvir 400mg /velpatasvir 100mg for 12weeks (FDC)
- Sofosbuvir 400mg /daclatasvir 60mg for 12weeks

For adults with compensated cirrhosis, the following regimens can be used:
- Sofosbuvir 400mg /velpatasvir 100mg for 12weeks (FDC)
- Sofosbuvir 400mg /daclatasvir 60mg for 24weeks
- Sofosbuvir/ 400mg /daclatasvir 60mg for 12weeks

For adolescents aged 12-17 years treatment guidelines are based on genotype and this
testing is unlikely to be available in South Sudan.

Treatment of HCV should be initiated by a specialist. There are few contra-indications to the
directly acting anti-virals and they are generally well tolerated. Drug interactions do exist
between these anti-virals, ARVs and TB medication, and need to be considered before
starting treatment. Treatment of HCV can cause a flare-up of HBV if the patient has both
infections. A repeat HCV RNA test is performed 12 weeks after completion of therapy to
confirm a sustained virological response (cure).

Patients with known cirrhosis due to HBV and/or HCV should be followed up every 6 months
with an ultrasound and alpha-feta protein (AFP) blood test to assess for hepatocellular
cancer.

Hepatitis D (HDV)
HDV is a form of chronic hepatitis which occurs only in people who already have established
chronic Hep B infection. It is transmitted in the same way as HBV and causes similar
disease. In some countries it can be treated with interferon, but responses are poor. This
infection would not yet be diagnosed or treated in South Sudan.

3.11 Neglected Tropical Diseases

Leishmaniasis
 Leishmania species are a group of protozoans transmitted to humans by bites of
infected female sandflies
 About 10% of infected persons will have symptoms. Leishmaniasis results from
symptoms arising from Leishmania infection.

107
  There are 3 main types: cutaneous, visceral and mucocutaneous, of which visceral is
seen in South Sudan in concentrated epidemics areas, and sporadic cases of
cutaneous leishmaniasis may be seen in the northern rim and far south-eastern
corner of the country.

Management of visceral leishamaniasis (VL/ Kala-Azar).

See: Guidelines for diagnosis, treatment and prevention of VL/KA in South Sudan

Symptoms and signs:

2- 6 months of incubation then fever, anorexia, headaches, abdominal pain, nosebleeds and
symptoms of anemia. Disease progression leads to splenomegaly, hepatomegaly, weight
loss and eventually death in 95% of cases if untreated.

Diagnosis:
Suspect VL/KA if history of prolonged fever > 2 weeks AND splenomegaly or sudden weight
loss

Investigations:
 Commonest differential diagnosis is Malaria: Do a malaria RDT.
 RDT tests for VL/KA (rK39 dipsticks) or DAT (direct agglutination test): If RDT
positive, admit for treatment. If negative, admit patient, perform DAT and give folic
acid and iron whilst results are awaited (normally 2-3 days).
 Parasitological tests for VL/KA: Lymph node, spleen or bone marrow aspirates are
100% specific but need to be done in hospital with appropriate laboratory support.
 A TOC (test of cure) is done after 2 weeks and at the end of treatment.

The objectives of VL/KA treatment are:

 to reduce parasites to “below the level of detection”
 support the patient’s nutrition and hydration
 to treat complications
 to prevent resistance development
 to reduce or interrupt transmission of infection in the community

Treatment for new cases (in specialist centres only):

 Register all patients with VL/KA in a designated treatment book
 First line: Sodium stibogluconate (SSG) and paromomycin combination therapy:
sodium stibogluconate (20mg/kg body weight /day) & paromomycin injection,
(15mg/kg body weight /day) IM for 17 days OR
 Sodium stibogluconate (monotherapy) 20 mg/ kg/day IM for 30 days
 For severe vomiting: stop SSG for 2 to 5 days. When vomiting stops restart
treatment
 If severe ascites; subtract 5kg from weight > 40kg; subtract 2kg from weight
24-40kg; subtract 1kg from weight <24kg and calculate SSG dose OR
 Liposomal amphotericin B: 3–5 mg/kg per day IV by infusion over 6–10 days up to a
total dose of 30 mg/kg. Reserved for relapses, severe cases, pregnancy and HIV co-
infection
 A TOC (test of cure) is done after 2 weeks and at the end of treatment.
In addition:
 Daily monitoring of symptoms and signs
 Record baseline information such as spleen size and haemoglobin and monitor
weekly if possible
 Weight should be taken weekly and medicine dosage adjusted accordingly.

108
  70 – 75% of patients are moderately-severely malnourished. Treat according to
national guidelines for integration of acute malnutrition.
 Arrange 6 month follow up after discharge from treatment. Absence of signs and
symptoms defines final cure.

Post kala–azar dermal leishmaniasis (PKDL) commonly occurs 6 months after VL/KA and is
a macula, papular or nodular rash that starts in the face and spreads to the rest of the body.
It can come and go, get progressively worse or resolve spontaneously. Severe cases of
PKDL will require standard VL/KA treatment.

Relapses
Relapses within 6 months occur in 5% of cases and can rise to 50% if HIV co-infection.
1st line:
 SSG 20 mg/kg/day IM 17 – 30 days plus paromomycin 15 mg/kg/day IM for 17 days.
TOC are done weekly from day 17 to monitor response. If no response by day 30 of
treatment move to second line. OR
 SSG 20 mg/kg/day IM for 40 to 60 days. TOC are done weekly from day 30. If no
response after 40 days, move to second line
2nd line:
 Liposomal amphotericin B: 3–5 mg/kg per day IV by infusion over 6–10 days up to a
total dose of 30 mg/kg
 Amphotericin B deoxycholate: 0.75–1.0 mg/kg/d IV for 30 alternate days (15 mg/kg
total dose) infused with 1 litre of 5% dextrose over 2–12 hrs. An initial test dose of 1
mg of the first dose to be infused over 20 to 30 minutes with 1 hour’s observation. If
tolerated, continue treatment. TOC at end of treatment
 Second relapses require maximal amphotericin B treatment.

Cutaneous leishmaniasis
A raised red lesion develops weeks or months after bite by the sandfly. This can ulcerate,
have a crust or develop into a nodule, and causes scarring. Other lesions may appear and
lymphadenopathy.

Treatment of cutaneous leishmaniasis

 Small lesions < 4cm. Apply antiseptic and dressing and review at 2wks, 1m, 2m &
6m. May heal spontaneously.
 Persisting lesions < 4cm. Specialists only. Apply topical paramomycin BD for 3
weeks. AND apply antiseptic and inject local anaesthetic around the lesion and inject
1 – 4mls of Sodium Stibogluconate around the lesion. Twice a week for 4 weeks.
 Large lesions > 4cm and/ or > 4 lesions and/ or immunocompromised or has
diabetes. Treat as for KA/VL with Sodium stibogluconate (monotherapy) 20 mg/
kg/day IM for 20 days. OR liposomal amphotericin B as above.

Human African Trypanosomiasis (HAT) - Sleeping Sickness

HAT (sleeping sickness) is potentially fatal if left untreated. South Sudan continues to remain
endemic for HAT and has experienced several outbreaks in the last few decades. HAT is
caused by the protozoan Trypanosoma brucei gambiense in South Sudan and is transmitted
to humans and animals through the bite of the tsetse fly. It can also be vertically transmitted
to the fetus during pregnancy, through blood transfusion and needle stick injury. Incubation
is from weeks to many years. The protozoa on entry into the blood stream multiplies rapidly
in the blood and lymph of the person – the haemo-lymphatic stage. The parasite eventually
crosses the blood-brain barrier into the central nervous system with the start of the meningo-
encephalitic stage.

Symptoms and signs:

109
  Haemo-lymphatic stage: Can be asymptomatic or there may be non-specific
symptoms: headaches, fever, arthralgia, joint stiffness and lymphadenopathy.
 Meningo-encephalitic stage (3 weeks to 2 months after the first stage):
 abnormal tone and mobility, ataxia
 deep sensory dysfunction – parasthesiae, numbness, pain
 disruption of the sleeping cycle (hence the term sleeping sickness –
with daytime somnolence and insomnia at night)
 psychiatric symptoms (confusion, irritability, depression, mania)
 seizures, coma and eventually death.

Diagnosis:
The non-specific symptoms of the first stage make it difficult to make a diagnosis of HAT.
Because of its endemicity in South Sudan, consider HAT in patients who have persistent
non-specific symptoms for >2 weeks.
1. Serological test – the Card agglutination test techique (CATT) identifies possible
infection. Better, if available, is the HAT Rapid Diagnostic Test (RDT). If positive,
confirmation will be needed:
2. Parasitological tests:
 Lymph node aspirates: Select from rubbery, non-tender and mobile lymph nodes
in the posterior cervical chain. Giemsa stain of a thin blood smear.
 If no lymphadenopathy/no trypanosomes seen on aspirate then perform the woo
test by centrifugation of 6 capillary tubes of blood which concentrates the parasite
in the buffy coat with direct examination under the microscope. {Better results can
be obtained with the Mini-anion exchange centrifugation technique (m-AECT)}.
3.Disease staging occurs by CSF examination:
Positive parasitological tests confirm infection. Treatment depends on disease stage.
CSF obtained by lumbar puncture is centrifuged and assessed for presence of
trypanosomes and white blood cells.
HAT first-stage is defined by both:
 A CSF white blood cell count of ≤5 cells/μl, AND
 No trypanosomes observed in the CSF.
HAT second-stage is defined by at least:
 A CSF white blood cell count ≥6 cells/μl, OR
 Trypanosomes observed in the CSF

Treatment
Side effects of treatment can be quite severe. Patients will need close monitoring. First stage
treatment as an outpatient. Second stage treatment must be done as an inpatient.

1st stage:
Pentamidine Isetionate 4mg/kg by deep IM. 7-10days.
Administration guidance: Sweet food or drink one hour prior to injection. After injection
patient to lie down for 1 hour post injection and be monitored for hypoglycaemia and/or
hypotension.

Other side effects: injection site pain and transient swelling, change in the taste (metallic
taste), abdominal pain and diarrhoea, nausea and vomiting, hypoglycaemia, sterile
abscesses and tissue necrosis in the injection site, hyperglycaemia and diabetes mellitus,
vertigo, anaphylaxis, cardiac arrhythmia and shock.

2nd stage (for 1st stage relapse)

1. NECT = Eflornithine (DFMO, Ornydil®) + nifurtimox (Lampit®) combination therapy
 Nifurtimox oral: 15mg/kg/day in 3 divided doses for 10 days

110
  Eflornithine iv infusion over 2 hours: 200mg/kg every 12 hours for 7 days.
Insertion of the infusion catheter under aseptic technique, site must be
covered if not in use and catheter should be changed every 48hours. Monitor
for phlebitis.
 Side effects include: fever, dizziness, seizures, confusion, abdominal pain,
nausea and/or vomiting, diarrhoea and tissue infection

2nd stage relapse

If there is a relapse after NECT, then NECT-long is to be given. NECT-long is the same as
NECT but the eflornithine infusions are continued for 7 additional days, for a total of 14 days.
Nifurtimox is given for 10 days exactly as in the NECT schedule. If the patient relapses after
NECT-long then melarsoprol has to be considered under specialist use.

Pregnancy
Although HAT treatment is potentially toxic for pregnancy with risk of pregnancy loss and
fetal malformations, it is important that HAT infections are treated in pregnancy. Treatment
should begin in the 2nd trimester where possible. Pentamidine is preferred even when the
disease has progressed to the 2nd stage to reduce vertical transmission to fetus. 2nd stage
treatment can be started after delivery but If severely unwell, can begin during pregnancy.

HAT caused by T.b. rhodesiense (rare in South Sudan) has a shorter incubation period (<
3weeks), is rapidly progressive and patients often die within 3-6 months from myocarditis.

Prevention and control:

 HAT surveillance in South Sudan involves screening with sero-parasitological
surveys in populations and at special centres in counties with high prevalence rates.
 HAT is a notifiable disease
 Vector control through use of insecticides
 Individuals can prevent bites by avoiding vector sites (near rivers), wearing long
sleeves and covering the legs, and use of repellents

Schistosomiasis
Schistosomiasis is a waterborne parasitic infection caused by several species of trematode
worms of which two forms occur in South Sudan.
 Schistosoma mansoni which affects the gastroenterological system
 Schistosoma haematobium which affects the genitourinary system.
Infection begins when humans enter schistosoma-infested water. Larvae penetrate the skin
and migrate to different tissues of the body. Initial entry often passes unnoticed and
symptoms are related to parasite activities in different body systems.

Schistosoma mansoni infection presents with:

 Non-specific abdominal symptoms – abdominal pain, diarrhoea, blood in stool, liver
and spleen enlargement.
 Complications include portal hypertension, ascites, oesophageal varices, anemia.
 Diagnosis is by visualisation of S. mansoni eggs in stools on microscopy

Schistosoma haematobium infection presents with:

 Urinary symptoms: polyuria, dysuria, haematuria
 Genital symptoms: pelvic pain, discharge, dyspareunia, vulval and cervical lesions in
women; haematospermia in men
 If left untreated: scarring and calcification of the genito-urinary system and recurrent
infections, infertility, bladder cancer.

111
  Diagnosis: by visualisation of S. haematobium eggs in urine on microscopy

Treatment
Praziquantel Tablet: 600 mg. Give 40-60mg/kg by mouth as a single dose. (dose below)
The drug should not be taken on an empty stomach.
Side effects: may include abdominal discomfort, nausea, vomiting, headache and (rarely)
hypersensitivity reactions.

Schistosomiasis control focuses on reducing disease through periodic, large-scale Mass

Drug Administration (MDA) with praziquantel. A more comprehensive control approach is
also needed in increasing availability of drinking water, adequate sanitation and snail control.

Praziquantal drug dose for treatment and MDA

Body weight (kg) Height (cm) Number of tablets
10 – 14.9 94 – 109 1
15 – 22.4 110 – 124 1½
22.5 – 29.9 125– 137 2
30 – 37.4 138 – 149 2½
37.5 – 44.9 150 – 159 3
45 – 59.9 160 – 177 4
≥ 60 ≥ 178 5

Helminthiasis
1.Onchocerciasis (River Blindness)
Caused by a tissue-dwelling nematode; the micro-filaria onchocerca volvulus transmitted
from human to human by bites of the black fly. Black flies breed near fast-flowing water.

Symptoms and Signs

Skin:
 onchocercomas – single, multiple or clustered subcutaneous nodules on bony
prominences
 acute papular onchodermatitis: intensely itchy, papular rash on lower limbs and
buttocks.
 Hyperpigmented/Hypopigmented patches
Eye infestation occurs with skin symptoms:
 Invasion of the eye by microfilariae can cause pruritis, reduced visual acuity and
visual field defects, corneal lesions, iritis, chorioretinal lesions and eventually
blindness

Investigations: treat if symptoms suggestive. Detection of micro-filariae in snip biopsy of skin

nodules. Check for loa-loa co-infection. If taenia solium is detected then treat for potential
cystircercosis before treating for onchocerciasis.

Treatment (not for children <5yrs or <15kg, or pregnant women)

112
Ivermectin kills the microfilariae (larvae) but not the adult worms. Given as a single dose. If
symptoms persist repeat after 3 months. Give yearly thereafter for up to 15 years when the
adult worms would have died.

Treatment with doxycycline (recommended by the US CDC but not yet WHO). Doxycycline
kills the bacterium that the adult worms depend upon to survive and to produce microfilariae.
It thereby kills many of the adult worms and sterilising others. Doxycycline may be used by a
specialist used to treating the disease. Ivermectin would be given first, then one week later a
6 week course of Doxycycline 100mg 2 x a day given. A further dose of ivermectin would
normally be given 6 months later. But specialists should consult latest guidelines before
prescribing.

Prevention and control

South Sudan has a MDA programme for prevention of onchocerciasis and loa-loa. All >5yrs
in communities at risk receive one dose of ivermectin as per the above table.

Reduce or avoid contact with black flies by

 Cultivating, fishing or washing during times when the black fly doesn’t bite
 Staying in open places
 Covering arms and legs when in high risk areas
 Sleeping under a net

2.Loa-Loa (Loaisis)
Caused by a tissue dwelling nematode: Loa loa microfiliaria transmitted from human to
human by day-biting tabanid flies (chrysops). Microfilariae mature into adult worms in the
subcutaneous tissues. Microfilariae produced by the worms also circulate in the blood.

Symptoms/Signs:
Recurrent swellings predominantly at extremities which last 1-3 days – ‘calabar swellings’,
due to a hypersensitivity to allergens from migrating worms. Subconjunctival migration of the
adult worm can often be seen and is indicative of infection

Investigation:
Detection and quantification of microfilariae in Giemsa stained blood film collected between
10am and 5pm. Check for onchocerciasis also.

Treatment:
Diethylcarbamazine (DEC) can be given when microfiliariae (mf) count is <2000/ml:
Start at 3-6mg/day in 2 divided doses; doubling the dose daily to a maximum of 3mg/kg/day
in children and 6mg/kg/day in adult. This is a 28 day course and can be repeated after 4
weeks if still symptomatic or microfilariae present. It is contraindicated if:
 Mf count >2000/ml : risk of severe encephalopathy
 Onchocerciasis co-infection: risk of severe eye lesions
 Pregnancy, infants and very unwell patients
Start with ivermectin till mf count<2000/ml then follow with DEC. High risk of encephalopathy
whilst on ivermectin at counts >30,000/ml. Consider not treating or treating initially with
albendazole 400mg/day in 2 divided doses for 3 weeks till mf count <30,000/ml followed by
ivermectin and DEC when mf count appropriate.
Loa loa eradication is also included with onchocerciasis with MDA using ivermectin.

113
3.Lymphatic Filariasis (LF)
Caused by the tissue-dwelling nematode – Wucheria bancrofti locally. Infection is passed
from human to human through the bites of female mosquitoes. The adult worms mature in
the lymph vessels.

Symptoms and signs

Acute (after up to 1 year incubation): Adenolymphangitis: recurrent episodes of lymph node
and duct inflammation associated with fever, general malaise, nausea and vomiting. Resolve
spontaneously.
Chronic (5 -20years after acute infection): Lymphoedema: due to obstruction of the lymph
vessels by microfilariae with eventual chronic oedema, skin hypertrophy and permanent
swelling of the affecting limb(s); elephantiasis. Chyluria – lymph in urine. Breast and
testicular enlargement.

Investigations: detection of microfilariae in the thick blood film of blood taken between 9pm
and 3am; ultrasound. Check for co-infection with onchocerciasis and loaisis.

Treatment for chronic cases:

 Diethylcarbamazine( if no other co-infection; not pregnant): 6mg/kg/day(adults) or
3mg/kg/day(children< 10yrs) for 12 days
 Treat with ivermectin and/or albendazole first if co-infection
 Mass Drug Administration in endemic areas: 6mg/kg/day annually
 Supportive treatment: Wash affected limb daily, keep nails clean and short. Treat
infections quickly with antibiotics/antifungals as appropriate. Wear comfortable
footwear. Elevate limb where possible; massage regularly to encourage lymph flow.

4.Soil Helminthiases
Soil-transmitted helminths are intestinal worms infecting humans acquired from
contaminated soil. Helminths in the intestinal tract release eggs into the faeces of infected
humans passed into soil. There is often co-infection with different worms
 Ascariasis and Trichuriasis eggs in soil contaminate food and are ingested
 Ankylostoma and Strongyloides penetrate skin when humans walk barefoot on
contaminated soil
 Enterobious vermicularis from soil contaminated food or auto-infection
Usually asymptomatic, symptoms present when there is heavy infestation, causing
abdominal pain, distension, diarrhoea sometimes bloody, obstruction, rectal prolapse and
hypersensitivity reactions.

Investigations: Detection of parasite eggs in stools

Treatment:
 Albendazole 400mg once or Mebendazole 200mg daily in 2 divided doses for 3 days
for all >6months or >10kg. Repeat after 1 month.
 Strongyloidosis can also be treated with ivermectin 200mcg/kg stat dose if >15kg.
 Children with ankylostoma infection can have anemia from blood loss with diarrhoea
and may need iron supplementation
 Mass Drug Administration: Mebendazole 500mg/Albendazole 400mg once every 6
months to children between 1 and 15 years.

5. Guinea Worm (Dracunculus Medinensis)

Is caused by the large filarial worm dracunculus medinensis. Humans drink water
contaminated by guinea worm larvae. The larvae enter the bloodstream through the
digestive system, mature into worms which migrate through the subcutaneous tissues to the
lower limbs primarily the feet. At the exit point a blister forms as the worm tries to emerge

114
which is painful and prompts the infected person to soothe the foot in water. The worm
releases thousands of the larvae into the water. This process takes 10 -14 months.

Treatment is supportive:
 Seek help at health facility within 24 hours of worm emerging for dressing and advice
on how to remove worm
 Removal of the worm which can be up to a metre long by slowly winding round a
small stick.
 Give tetanus toxoid.
 Keeping the skin clean and dry and advise not to wade in open bodies of water
 Treat complications including cellulitis, abscesses. Give Cloxacillin 500mg qds for 7
days. Drain abscesses.

Prevention
 Sieve drinking water with guinea worm cloth filter or pipe filter
 Avoid wading in open bodies of water if there is guinea worm infestation
 Providing safe and reliable source of drinking water

6. Tapeworm
Taenia Saginata and Taenia solium are adult tapeworm infestations acquired by ingesting
raw or undercooked beef or pork respectively. Mostly asymptomatic but can also cause
abdominal pain, distension, nausea, diarrhoea.

Diagnosis: is by detection of eggs or tapeworm segments in stools

Treatment: Niclosamide:
 Adults and children >6yrs: 1g 1 hour before breakfast and 1g 1 hour after breakfast.
 Children 2 -6 yrs: 500mg before breakfast and 500mg after breakfast
 Children <2 yrs: 250mg before breakfast and 250mg after breakfast OR
Adults and children >4yrs: Praziquantel 5 -10mg/kg as a single dose OR
Albendazole 400mg once daily for 3 days

Prevention:
Thorough cooking of meat and monitoring of abattoirs

Nodding Syndrome
is a neurological disorder characterised by progressive cognitive dysfunction, neurological
deterioration, stunted growth and a characteristic nodding of the head. The head nodding is
thought to be a generalised form of epilepsy (an atonic seizure) and is involuntary, the
episodes occurring 5 to 10 times in a minute in response to food or drink. It affects children
between 5 and 15years. The atiology is yet unknown but appears to occur in areas
hyperendemic for onchocerciasis.

Control of onchocerciasis for potential reduction of Nodding Syndrome

This may reduce prevalence of Nodding Syndrome (recent experience in Uganda). Special
focus of Mass Drugs Administration of ivermectin (see dosage table above) to all population
over 5 years in areas with cases of Nodding Syndrome, and larviciding and spraying black
fly breeding sites.

Treatment is supportive (see: Proposed guidelines for the management of nodding

syndrome):

115
  seizure control (see below and 4.7).
 management of mental health (see 4.14)
 management of malnutrition and anemia (see 2.2)
 treatment of parasitic infections including microfilaria and helminths (see above)
 nursing care
 rehabilitation for functional difficulties
 sexual and reproductive health services (and protection of teenagers from sexual
abuse)
 documentation, referral, surveillance, community education
 parent – parent peer counselling to improve coping strategies

Seizure control: 1st Line: Sodium Valproate; 10mg/kg/day divided in 2 doses, increased by
5mg/kg/ day increments up to maximum dose of 40mg/kg/day and LFTs monitored, but
should not be used in girls of reproductive age.
2nd Line: phenytoin or phenobarbitone. Carbamazepine is not recommended.

Anthrax
Anthrax, caused by Bacillus anthracis can infect the skin (cutaneous – 95% of cases),
gastrointestinal tract, or lungs (inhalation). Humans who come into contact with infected
cattle, sheep or goats can get infected. Cutaneous anthrax, quite commonly seen in South
Sudan, occurs when anthrax spores touch a cut or scrape on the skin, in those is contact
with infected animals. The anthrax spores need to germinate during 1 to 6 days, then
causing bleeding, swelling and tissue necrosis.
 Cutaneous anthrax: itchy sore that may blister and form a black ulcer.
 Gastrointestinal anthrax: abdo pain, bloody diarrhea, fever
 Inhalation anthrax: fever, cough, chest pain (symptoms after 60 days)
Diagnosis: microscopy and culture (if available).
Treatment
 Cutaneous: Ciprofloxacin 500mg bd for 10 days (OR
 Doxycyline 100mg bd and amoxicillin 500mg bd for 10 days
o Children 6m – 4years. Ciprofloxacin 125mg bd for 10 days; 5 – 9 years
250mg bd for 10 days.
 Inhalation & gastrointestinal: specialist to confirm diagnosis. Rx as above for 60 days.
Post-exposure prophylaxis:
Adults & children > 10yrs: Doxycycline 100mg OD, 10 days
Children 6m – 4 years: amoxicillin 125mg bd 10 days; Aged 5 – 9yrs: 250mg bd 10 days

Brucellosis
People contract the Brucella bacteria from infected animals (particularly from drinking raw
milk) and develop symptoms after incubation of 5 to 60 days. Symptoms are general (fever,
weakness, joint pain, lymphadenopathy) and specific (including hepatosplenomegaly and
meningitis). Key prevention is to boil or pasteurise milk. Diagnosis is clinical and by serum
antibody testing or culture.
Treatment
 Adults & children > 10 years: Doxycycline 100mg bd AND Rifampicin 15 – 20mg/ kg
per day in 1 or 2 doses for 6 weeks.
 Pregnant women. Co-trimoxazole 480mg bd AND rifampicin as above. 6 weeks.
 Children 6months – 4 years Co-trimoxazole 240mg BD for 6 weeks
 Children 5 – 9 years: 480mg Co-trimoxazole BD for 6 weeks.

116
Buruli ulcer
Is caused by the bacterium mycobacterium ulcerans. It produces mycolactone, an enzymatic
toxin, which breaks down skin and soft tissue to cause large ulcers on arms and legs, if
untreated, affected persons are left with significant reduction in limb function. Infection may
begin as a painless nodule or plaque or localised oedema with progression to an ulcer within
4 weeks. The disease is staged according to severity. The mode of transmission is uknown

Treatment:
 Rifampicin (10 mg/kg once daily) and streptomycin (15 mg/kg once daily) for 8 weeks
pregnant women: rifampicin (10 mg/kg once daily) and moxifloxacin (400 mg once
daily) may be used (not yet licensed)
 Wound management and surgery (debridement and skin grafting)

Mycetoma
Is a chronic infective and inflammatory process involving skin and soft tissues due to entry of
bacteria or fungi through minor breaks in the skin. The triad of painless subcutaneous mass,
multiple sinuses and discharge containing grains are typical with resulting destruction of
tissue and significant loss of function in affected limbs. Sepsis may also result. The
causative organism is detected from biopsy of the affected skin or culture of fluid from the
draining sinuses.
Treatment is directed at the causative organism(s) and is usually a combination of antibiotic
and/or antifungal agents. Wound support and surgery may also be needed. Prevent infection
with footwear and avoid walking barefoot.

Leprosy
Caused by mycobacterium leprae. Leprosy is uncommon but staff should be vigilant when
examining new rashes. Possible signs:
 hypo-pigmented (light coloured) skin lesions with loss of sensation
 nodules
 generalised infiltration of the skin
All patients with signs suggestive of leprosy must be examined for loss of sensation – light
touch, pin-prick and temperature where possible. Palpate peripheral nerves for tenderness,
thickening and nodules.

Classification of leprosy lesions(WHO):

 Paucibacillary leprosy: ≤5 lesions (PB)
 Multibacillary leprosy: >5 lesions (MB)

Diagnosis:
Ziehl-Nielsen stain of fluid from a skin lesion, skin lesion snip or nasal smear

Treatment:
Multi-drug therapy (MDT) for leprosy is provided in blister packs according to whether it is
PB or MB:

Adult treatment regimen for MB leprosy. Duration: 12 months (12 blister packs)
Rifampicin: 600 mg 1 x per month
Clofazimine: 300 mg 1 x per month, and 50 mg 1 x per day
Dapsone: 100 mg 1 x per day

Adult treatment regimen for PB leprosy. Duration: 6 months (6 blister packs)

Rifampicin: 600 mg 1 x per month
Dapsone: 100 mg 1 x per day

117
 Child (age 10-14) treatment regimen for MB leprosy. Duration: 12 months (12 blister packs)
Rifampicin: 450 mg 1 x per month
Clofazimine: 150 mg 1 x per month, and 50 mg 1 x every other day
Dapsone: 50 mg x per day

Child (age 10-14) treatment regimen for PB leprosy. Duration: 6 months (6 blister packs)
Rifampicin: 450 mg 1 x per month
Dapsone: 50 mg 1 x per day

For children under 10 years of age, follow same regime with following dosages:
Rifampicin: 10 mg/kg; Clofazimine: 1 mg/kg; Dapsone: 2 mg/kg

MDT can be given to HIV-positive patients, those on antiretroviral treatment and to patients
on treatment for TB. If a leprosy patient is treated for TB, the MDT regimen should omit
rifampicin as long as the TB regimen already contains rifampicin. PB patients need two
drugs for six months while MB patients need three drugs for 12 months. Every effort must be
made to ensure regularity of drug intake so that PB cases complete their treatment in six
months and MB cases in 12 months. Relapse and default cases are treated as new cases

Common drug side-effects: reddening of the urine and darkening skin are inevitable.
Dapsone can cause anemia so iron folate is given. Allergy can occur to both dapsone and
rifampicin in which case they should be stopped. If rifampicin causes jaundice it should also
be stopped.
Leprosy reactions can occur and can be treated. They include the skin rash becoming red
and swollen again, pain or numbness in the limbs, weakness of hand or feet, loss of vision,
pain or redness of the eyes. Mild reactions can be treated with acetylsalicylic acid or
chloroquine. Severe reactions can be treated with a reducing dose of prednisolone.

Prevention of deformities in leprosy: Permanent damage to nerves will require long-term

care to prevent ulceration and eventual loss of limb/function. Keep skin clean and
moisturised, check regularly for injuries and wear appropriate protective footwear.

Rabies
Rabies is a zoonotic viral disease spread by the bites of dogs and other animals. Once a
person has contracted the disease it is always fatal. Incubation time could be up to 12
weeks. A prodromal phase of parasthesiae and pain around the bite is followed by the acute
phase of hyperexcitability, irritability, painful laryngeal spasms and hydrophobia as the virus
spreads throughout the central nervous system eventually progressing to paralysis, coma and
death. Post-exposure prophylaxis and wound management as soon as possible is key:

Post-exposure prophylaxis (PEP)

 Immediately wash the wound for a minimum of 15 minutes with soap and water,
detergent, 10% povidone iodine or other substances that kill the rabies virus. Do not
suture the wound except to stop bleeding. Dress with a dry gauze.
 Give ampicillin/amoxicillin
 Give tetanus toxoid and immunoglobulin (if not immune)
 Give rabies vaccination and immunoglobulin as per table guidance below
 Inform medical and veterinary authorities

Categories of contact with suspect rabid animal Post-exposure prophylaxis measures

Category I – touching or feeding animals, licks on intact None

skin

118
Category II – nibbling of uncovered skin, minor scratches
or abrasions without bleeding
Category III – single or multiple transdermal bites or
scratches, licks on broken skin; contamination of mucous
membrane with saliva from licks, contacts with bats
Immediate vaccination and local treatment of the wound
Immediate vaccination and administration of rabies
immunoglobulin; local treatment of the wound

Human rabies immunoglobulin is given at a dose of 10 IU/kg. Infiltrate as much of this by

injection in the depth and around the edges of the wound site and give the rest by IM
injection. If rabies immunoglobulin is not immediately available, give vaccine and give
immunoglobulin up to 7 days after exposure.

119
4. Non-communicable Diseases
4.1 Skin Disease
Acne: Acne is caused by blocked sebaceous glands (comedones) which lead to inflamed
lesions (papules, pustules and/or nodules). It affects mainly the face and upper body, can
range from mild to severe, and cause scarring and pigmentation.
Treatment: Avoid excess use of oil- based creams and ointments, as well as cosmetics
Comedones: apply benzoyl peroxide cream 2.5% at night to clean skin. Alternatively, use
sulphur and salicylic acid cream or ointment (2%+2%)
Pustules or other inflamed lesions: add doxycycline 100mg 2x per day until significantly
better (may take several weeks), then reduce to 100mg once daily until cleared (may take
months).

Scabies: Scabies is an allergic reaction to infestation of the skin by a small insect resulting
in a raised very itchy rash. It is often found in web spaces between the fingers and toes and
on the penis. The rash may be badly scratched and there may be secondary bacterial
infection.
Treatment steps
1. Wash the body with soap, drying, then apply benzyl benzoate 25% lotion on the
whole body but not on the face or genitals. For young children dilute the lotion with
the same quantity of water to make a 12.5% lotion.
2. Apply an antiseptic, gentian violet, to any infected areas. If badly infected, give
amoxicillin, (or cloxacillin if available) or, if allergic to pencillin, erythromycin.
3. The next day benzyl benzoate is applied again without washing.
4. A further dose may be applied on the third day
5. Bathe 24 hours after the last application
6. Give chorphenamine (see under allergic rash for dose) if the patient is very itchy
7. Treat all children and adults in the family and advise them to expose clothes and
bedding to the sun as this helps to kill the insect.
Side effect: Benzyl benzoate may cause skin irritation and burning.

Permethrin is a very effective treatment for scabies but is more expensive than benzyl
benzoate. It is applied as 5% cream to the body and left on for 24 hours before washing off,
then the treatment is repeated one week later.

Itching that continues for several days after treatment does not mean treatment has failed
and can be treated with chlorphenamine. Severe scabies is seen in immunocompromised
patients, e.g. HIV.

Head lice: Use a fine comb to reduce infestation. Treat with permethrin 1% rinse and wash
off after 12 hours.
Body lice: launder clothes, towels and bedding in a hot wash. Lice can be removed from
clothing, but eggs should be left to be killed by washing.

Eczema, dermatitis and allergic rash

Eczema (atopic) and dermatitis are inflammatory conditions of the skin presenting with a
raised itchy rash. In children this commonly occurs behind the elbows and knees and can be
on the face. Infants may have a scaly rash on their scalps. Treatment aims to break the
cycle of dry skin causing itch and scratching which causes inflammation and the risk of
secondary bacterial infection.

Treatment steps for eczema

 Avoid soap and known irritant or allergic triggers.

120
  Apply an emollient at least twice daily to dry skin, and always after bathing. Shea
butter, coconut or palm oil may be used as emollients
 Use lotions or cream for weeping areas; use ointments for chronic, lichenified areas
 Remove thick scales with salicylic acid ointment before applying steroid creams
 Apply a small amount of steroid cream or ointment to more inflamed areas for up to 7
days. Avoid strong steroids in children. Hydrocortisone 1%, a weak steroid, can be
used on the face and flexures. Treat the body in adults with severe eczema with
betamethasone 0.1%. Apply an emollient first and then the steroid on top.
 Coal tar solution 5% may be considered combined with emollient for chronic severe
eczema
 Use sulphur and salicylic acid (2%+2%) with a base cream or steroid in seborrhoeic
eczema
 For severe itching give chlorphenamine by mouth.
 (Consider a short course of oral prednisolone for severe, non-responsive cases only,
for 5 to 7 days. Do not use for more than 2 weeks as this causes
immunosuppression).
 Apply gentian violet to infected areas.
 Give penicillin V (or cloxacillin if available) by mouth if rash is badly infected, or
erythromycin in case of allergy to penicillin.
 Encourage breastfeeding where there is a family history of eczema as this may help
reduce risk of eczema in infants.

Chlorphenamine for severe itch or allergic rash.

Medicine Age Dose Duration Side effects
Infants < 12 months Do not give Common:
Chlorphenamin Children 1 – 2 years 2.5mls (1mg) or ¼ tablet (1mg) 2 x 2 – 3 days drowsiness
e syrup per day Rare: headache,
(2mg/5ml) and Children 2 – 6 years 2.5mls (1mg) or ¼ tablet (1mg) 2 - 4 x 2 – 3 days dry mouth,
Chlorphenamin per day (every 6 hours) abdominal
e tablet (4mg) Chilldren 6 – 12 5mls (2mg) or ½ tablet (2mg) 2 – 4 x 2 – 3 days discomfort
years per day (every 6 hours)
Adults and children 1 tablet (4mg) 2 – 4 x per day (every 2 – 3 days
over 12 years 6 hours)

Seborrhoeic eczema affects the scalp, eyebrows, nasolabial folds, axillae, groins and upper
chest. It appears as a greasy rash with yellow scales and may be severe in HIV infection.
Allergic contact dermatitis is a local reaction to contact with some plants, metal, rubber,
cosmetics or medicinal lotions and creams.
Allergic rashes may occur in response to food or drink, or in response to medicines.
Eczema herpeticum is eczema that has become infected with herpes simplex virus. Treat
with oral acyclovir for one week if sure of the diagnosis.

Fungal infection:
Tinea pedis: macerated itchy areas between the toes. Treat with clotrimazole cream 1% or
miconazole cream 2% twice daily for at least 7 days or until the infection has resolved
Tinea corporis (ringworm): raised, itchy circular rash on the body. Treat with terbinafine
cream or ointment 1%. Benzoic acid 6% and salicylic acid 3%, clotrimazole 1% or
miconazole 2% may also be used. Treat twice daily for 2 – 4 weeks.
Tinea capitis: raised itchy circular white lesions on scalp. For small lesions apply
miconazoéle 2%. For larger lesions need oral treatment: Adults and children over 11 years,
give griseofulvin 500mg; children give 10mg/kg PO 1 x day for 2 to 4 weeks, OR (if it comes
onto EML) terbinafine 250mg 1 x day for 2 weeks to 4 weeks. But check LFTS 10 day after
starting treatment and do not give to people with liver disease.

121
Onychomycosis (Tinea unguium): chronic infection of part of whole of nail. This needs oral
treatment: Adults and children over 11 years, give griseofulvin 500mg; children give 10mg/kg
PO 1 x day for 6 weeks to 3 months, or (if it comes onto EML) terbinafine 250mg 1 x day for
6 weeks to 3 months. But check LFTS 10 day after starting treatment and do not give to
people with liver disease.

Nappy rash: Caused by irritation from urine or stools and sometimes by thrush (candida).
Treatment steps
 Wash the area with soap and dry.
 Apply an emollient cream or zinc oxide 10% cream
 If there is a red rash, with satellite lesions, it is thrush (candida). Apply clotrimazole
1% or miconazole 2% twice a day for 5 days.
 Any ulcerated areas need the application of gentian violet and the infant admitted or
seen daily.
 Advise parents to change the baby cloth/ diaper as frequently as possible. Exposure
to the air without a nappy also helps the rash to clear.

Impetigo: Impetigo is a bacterial infection of the skin presenting with oozing golden-yellow
crusts.
Treatment: Wash the area with soap and water. Apply gentian violet. Give penicillin V or
cloxacilin if there are many spots or if the patient is unwell, or erythromycin in case of allergy
to penicillin.

Folliculitis: Bacterial or fungal infection causing inflammation and infection of the hair
follicles. Treat with antibiotics as above or use an antifungal cream daily for 1- 3 weeks) as
needed. Chronic deep folliculitis seen in men may require treatment with doxycycline 100mg
daily for up to several months, combined with betamethasone 0.1% cream for skin lesions.

Abscess: Very small pus swellings may discharge themselves, and can be treated with
antiseptic and a gauze dressing and observed (ask the patient to come back). Larger or
deep abscesses will need incision and drainage and treatment with penicillin V (or cloxacillin
if available) or erythromycin if allergy to penicillin.

Ulcer: An ulcer is a chronic break in the skin that is red and may ooze pus.
 Apply antiseptic (diluted chlorhexidine)
 Apply paraffin gauze dressing
 Change daily if infected. Once the ulcer is bright red without infection, the paraffin
gauze dressing can be applied and left for 10 days.
 Give penicillin V (or cloxacillin if available) or erythromycin if allergy to penicillin for
medium or large ulcers if infected.
 Large ulcers may need admission, surgical debridement, daily dressing until clean
and red with no infection, and then vaseline dressing applied and left for 2 weeks.
 Patients who have ulcers on the feet may have undiagnosed diabetes. Screen for
this with a fasting blood sugar.

4.2 Cardiovascular Disease

Hypertension
Hypertension is not a disease, it is a risk factor for cardiovascular disease (CVD). As well as
being the leading cause of death worldwide, CVD also leads to significant disabilities for

122
 those affected. Identifying and treating hypertension is an important risk reduction strategy
for CVD.
Hypertension is mostly asymptomatic. Symptoms are present when there are associated
complications. 90% of hypertension – essential hypertension has no aetiology. There is an
increased risk of developing hypertension if the following factors are present:

Non-modifiable:
 Older age
 Ethnicity (more common in black people)
 Family history of hypertension
 Being male
Modifiable:
 Excess salt in the diet
 Poor diet and obesity
 Harmful use of alcohol
 Physical inactivity

For 10% of hypertension cases there is an identifiable cause (secondary hypertension).

Consider secondary hypertension in patients <30yrs and hypertension that is proving difficult
to control.

Note: this section does NOT apply to pregnant women: in pregnancy BP 140/90 or more can
be a sign of pre-eclampsia which can be fatal: see 1.3 for treating hypertension in
pregnancy.

Diagnosis of hypertension
BP measurements need to be taken with the patient seated, relaxed and not talking.
 If ≥140 and /or 90mmHg then repeat immediately.
 If still high repeat after 30 minutes.
 If still high, and where possible repeat after one week
(If BP ≥180/100 do not wait to treat – see management of severe hypertension below)

Hypertension is persistent blood pressure ≥140 and /or 90.

As hypertension is asymptomatic, consider screening for hypertension in:

 Age ≥ 30years
 BMI ≥ 30 or abdominal circumference ≥80cm in women and ≥94cm in men
 Family history of hypertension
 Medical history of hyperlipidaemia, diabetes mellitus, heart disease, kidney disease,
 hypertension in pregnancy and/or stroke
 Social history of smoking and alcohol intake of more than 2 standard units daily

Diagnosis of Hypertension Table 1

BP Investigations at diagnosis
1. BP < 140/90BMI, waist circumference
2. BP 140-159 BMI, waist circumference, normal fasting glucose and
and / or 90-99HbA1C, normal kidney function, normal lipids.
3. BP 140-159 BMI, waist circumference
and / or 90-99Diabetes: Raised fasting glucose or HbA1C OR
Kidney disease: proteinuria on urine dipstick or
abnormal creatinine/GFR OR
Hyperlipidaemia: Raised serum total and LDL cholesterol
4. BP 160-179 As above
and / or 100-
109
Management
Give lifestyle advice. Recheck BP in 2 years.
Give lifestyle advice, review in 6m. If no
change to BP, consider drug therapy.
If diabetes, kidney disease or raised lipids
diagnosed as well then give lifestyle advice
and start on appropriate drug therapy for
hypertension and other diseases.
Give lifestyle advice and start on appropriate
drug therapy

123
5. BP > See management of severe hypertension
180/110

Management of hypertension
Lifestyle advice for all:
 If BMI > 30 or waist circumference >102cm(men); >88cm(women), advise weight
loss
 Diet: A healthy diet with little fat, moderate portion of protein and starch with plenty of
fruits and vegetables. Salt should be no more than a teaspoon a day. Do not add salt
to already cooked food. Aim to drink about 2 litres of water a day and avoid fizzy,
carbonated and sweetened drinks. Alcohol intake should be no more than one large
glass or bottle of beer/lager, a shot of spirits or a small glass of wine a day.
 Exercise: 150 minutes of exercise a week which is the same as 30 minutes a day for
5 days of the week. Exercise should be intense enough to cause some
breathlessness, make the heart race faster and allow talking but not singing
 Advise smoking cessation. Smoking increases CV risk
 Assess CV risk. Use WHO chart: http://tinyurl.com/WHO-CVD-risk. Use chart AFR-E.

Drug therapy for hypertension, Table 2

Class Example Starting Maximum Common side Comments
dose dose effects
Calcium channel Amlodipine 5mg 1x 10mg 1 x Headache
blocker (CCB) per day per day Oedema
Thiazide diuretic Hydrochlorthiazide 12.5mg 1 25mg 1 x Hypokalemia Not on the EML
x per day per day Hyponatremia
Hyperglycemia
Hyperuricemia
ACE inhibitor Enalapril 5mg 1 x 40mg 1 x Cough First choice in patients
(angiotensin-converting per day per day Hyperkalemia with diabetes
enzyme inhibitor) Raised
creatinine
ARB Losartan 50mg 1 x 100mg 1 x Vertigo Used when ACE
(Angiotensin-receptor per day per day Headache inhibitor causes cough
blocker)
Beta blocker Atenolol 25mg 1 x 100mg 1 x Bradycardia Contra-indicated in
per day per day asthma
NB. Amlodipine is more convenient than Nifedipine as it can be given once a day. Bisoprolol (2.5mg
OD) is a good alternative to atenolol. Lisinopril (10mg OD) is a good alternative to enalapril. Do not
use other diuretics instead of a thiazide diuretic, but alternative thiazide diuretics are chlorthalidone
(25mg OD) or the thiazide-like indapamide (2.5mg OD).

Treatment steps:
o Start treatment according to table 1. (i.e. only treat if in row 3 or above).
o Start with either calcium channel blocker or thiazide diuretic (except in
diabetes/kidney disease where ACE inhibitor preferred). See table 2.
o Educate about the importance of taking medication as prescribed
o Review every 2-4 weeks and if needed increase up to maximum tolerated
dose before adding next agent from another class. Repeat this process till on
maximum tolerated doses of 4 classes (see table 2):
Either ACE inhibitor or ARB but not both together. Ideally renal function
should be checked after every dose increase.
o Aim for treatment target <140/90
Prevention

124
 o If history of cardiovascular disease (CVD): start on atorvastatin 20mg and
aspirin 75mg (secondary prevention)
o Use CVD chart to assess CVD risk and if >20%: start on atorvastatin 20mg
( primary prevention)
o Once stable, review patient every 3 months. Check adherence to lifestyle
advice and medication. Check CVD risk and screen for diabetes and kidney
disease yearly.

Management of severe hypertension (BP > 180/110)

Note: this section does NOT apply to pregnant women: in pregnancy BP 140/90 or more can be a
sign of pre-eclampsia which can be fatal: see 1.3 for treating hypertension in pregnancy.

This is a medical emergency. These patients are at significant risk of end-organ damage to
the brain, eyes, heart and kidneys and will need immediate assessment, treatment and close
monitoring.
 First reading ≥180/100. Repeat after resting for 30 minutes
 If second reading ≥180/100mmHg then check for end-organ damage.

Step 1: Is the patient having a stroke/cerebrovascular accident (CVA)? Do the FAST-

Test:
 Face: ask the person to smile. Does one side of the mouth or face
drop?
 Arms: ask the person to raise both arms. Can they do this? Does
one drift down?
 Speech: Ask the person to repeat a sentence. Can they repeat it
correctly? Do they slur their words?
 If any of the above are present, arrange for admission and
management of stroke (see below) within a short Time

Step 2:
If FAST-Test negative. Check for other end-organ damage:
 Acute coronary syndrome (chest pain, chest tightness, palpitations)
 Pulmonary oedema (shortness of breath at rest, basal crepitations, ankle
swelling)
 Renal failure (proteinuria, raised creatinine, reduced eGFR)
 Hypertensive encephalopathy (headaches, lethargy, convulsions, coma)
 Papilloedema/retinal haemorrhages (identifiable on fundoscopy)

If any of the above are present then this is a Hypertensive Crisis

 Admit
 Hydralazine by slow intravenous injection: 5–10mg diluted with 10ml
sodium chloride 0.9%. Repeat after 30 minutes
 Lower BP by 20% over 2 hours
 Treat heart failure if present (furosemide)
 Once stable, manage according to hypertension treatment guidelines

If there are no signs of end-organ damage then this is Hypertensive Urgency

 Admission is ideal
 Treat with amlodipine orally 5mg initially, maximum 10mg (not other CCBs)
 Aim to reduce BP over 24 – 48 hours
 Once stable, manage according to hypertension treatment guidelines

125
Note that sublingual nifedipine is no longer used to treat severe hypertension as it can
worsen heart failure. Do not give loop diuretics (furosemide) to manage severe hypertension
as it can cause too much fluid loss (unless heart failure is present).

Cardiovascular (CV) disease - management and secondary prevention

It is very important to prevent further CV complications in those who have already had a CV
event such as angina, myocardial infarction (MI), heart failure, atrial fibrillation, transient
ischaemic attack (TIA), a stroke (cerebrovascular accident – CVA) or peripheral arterial
disease.

Disease monitoring in CV disease

 Review every 3 - 6 months:
 Ensure following:
 Recommended lifestyle advice
 Aspirin 75 – 100mg daily
 Atorvastatin 20mg daily
 Monitor for CVD related symptoms of angina, heart failure and peripheral
arterial disease
 Check BP and ensure controlled. If low consider adjusting antihypertensives
 Check pulse and ensure not too fast or too slow. If fast >100bpm, check for
causes and manage appropriately. If slow <50bpm may be secondary to beta-
blocker overtreatment. If not, check for causes and manage appropriately.
 Ensure taking all medication as prescribed
 Check for raised cholesterol, abnormal kidney function and raised blood sugar
every year
 Check for end-organ damage: eyes – fundoscopy, heart failure:
breathlessness at rest and/or on exertion, basal crepitation in the lungs and
swelling of ankles.
 Check for anemia and thyroid disease every 2 years as they make CVD
worse

In addition to the above that is common to all CV disease, there are specific treatments for
each disease:

Treatment of angina
 Suspect angina if chest pain brought on by activity, which is like a tight band and may
radiate to jaw of left arm. Pain goes away on resting.
 Investigate with ECG to see ischaemia. If unavailable do treatment trial.
 Symptomatic relief: give glyceryl trinitrate, 0.5mg sublingual with pain or before
activity
 Add beta-blocker: Start with bisoprolol 2.5mg once day and increase to maximum of
10mg once daily OR atenolol 25 – 50mg once daily and increase to maximum of
100mg once daily. Avoid in asthma.
 Add calcium channel blocker if still getting pain: amlodipine 10mg once day. (not
verapamil or diltiazem which can cause heart failure).
 Add long acting nitrate if still getting pain: isosorbide dinitrate 5mg twice daily,
increasing to a maximum of 40mg three times a day.
 Add ACE inhibitor if diabetic to protect the heart: enalapril 5mg and increase to
maximum 20mg once daily.
(Ideally renal function should be checked after every dose increase)
 Lifestyle advice, aspirin, cholesterol lowering and BP control

126
Treatment of myocardial infarction (MI)
Consider in 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 BP and tachycardia
 Admit patient
 Give 300mg Aspirin stat dose
 Perform an ECG if available. If not available or ECG negative for ischaemia, have a
high index of suspicion in patients with risk factors for CVD: hypertension, DM.
smoker, hyperlipidaemia, kidney disease.
 Glyceryl trinitrate 500 micrograms sublingually. Repeat after 5 min if no response
 Oxygen therapy if oxygen saturation < 94%
 Morphine 2.5-5 mg IV if persisting pain; with anti-emetic, metoclopramide, 10mg IM
 Simvastatin 40 mg or atorvastatin 80 mg
 Enoxaparin 1 mg/kg SC every 12 hours
 Treat complications pulmonary oedema, arrhythmias
 Check for risk factors: diabetes, hypertension
Once stable:
 ACE inhibitor: enalapril 5mg and increase to maximum 20mg once daily.
 Add beta blocker: use for the first 12 months unless heart failure or angina. Give
Bisoprolol, start with 2.5mg once daily and increase every month to maximum of
10mg once daily or Atenolol 25 -50mg to a maximum of 100mg once daily (or if
Carvedilol 6.25mg 2 x day) (Avoid in asthma)
 Aspirin 75 -100mg once daily
 Atorvastatin 40-80mg (Simvastatin 40mg) once daily
 Ensure good diabetic and BP control
 Lifestyle advice

Treatment of peripheral arterial disease

Symptoms include claudication pain on walking, worse going up a hill and relieved on rest.
Peripheral foot pulses are absent.
 Advise to walk to the point of pain and a little beyond to encourage new blood supply.
Vasodilators make little difference.
 Lifestyle, aspirin, cholesterol lowering and BP control

Treatment of heart failure

The main symptom is breathlessness when lying flat and ankle swelling. Bilateral
crepitations in lower chest. ECG may indicate left ventricular hypertrophy. Note that digoxin
is not as effective as ACE inhibitor or beta-blocker and should be used only in severe
disease.
 Start with oral furosemide 40mg once daily. Increase if needed and monitor kidney
function especially potassium levels. In severe disease, add oral spironolactone
starting at 25mg once daily and increase if necessary to 50mg once daily.
 Add ACE inhibitor, enalapril (see treatment of myocardial infarction)
 Add beta blocker (see treatment of myocardial infarction)
 Lifestyle, aspirin, cholesterol lowering and BP control

Treatment of stroke (Cerebrovascular accident - CVA)

Most strokes are thrombotic. A haemorrhagic stroke is more likely if the patient is already on
warfarin or aspirin or has a clotting disorder. A Brain CT scan will differentiate between them
but may not be available.

127
  Management is aimed at reducing risk of progression of the stroke and restoring
function as much as possible. BP: Must be lowered slowly as reducing BP quickly
could worsen the stroke
 Lifestyle advice, cholesterol lowering, checking for and treating diabetes and
controlling BP are important
 Aspirin 75-100mg OR Clopidogrel 75mg AND statins are indicated after a thrombotic
stroke (caused by a clot), but not if it definitely was a hemorrhagic stroke (caused by
a bleed).
Restoration of function:
 Intensive physiotherapy to prevent contractures and pressure sores
 Assess safe swallowing for oral intake
 Screen and treat for anxiety and depression
 May need help to do basic daily tasks (washing, dressing, toileting, feeding).
 Nutritional support especially if difficulty swallowing. May need an NG tube to protect
the airway.
 Specific aids/ adaptations are needed at home to help rehabilitation.

Atrial Fibrillation (AF)

Due to disordered atrial contraction which also affects ventricular contraction and cardiac
function. Patients will have an irregular pulse and the heart rate may be fast. AF also
increases the risk of heart failure and a thromboembolic event.

Principles of management:
 Control heart rate
 Restore normal rhythm if possible (specialist only)
 Prevent or treat complications
 Treat underlying conditions
Management
Perform ECG if possible
Investigate for causes: hyperthyroidism, ischaemic heart disease and heart failure and
manage appropriately
Rate control: start with beta blocker (atenolol, bisoprolol). In patients with asthma, where
beta blockers are contra-indicated, use digoxin. (Loading dose of digoxin 0.5 to 1mg in 3 -4
divided doses on the first day. Maintain on 0.25mg daily)
Digoxin can be toxic so halve the loading dose and maintenance doses or give on alternate
days in the elderly, malnourished and those with kidney disease.
Prevention of thromboembolic events:
 Aspirin 75mg – 100mg daily AND Clopidogrel 75mg daily (if available)
 If oral anticoagulants (warfarin) are available, and coagulation can be measured with
an INR, then perform CHA2DS2VASc and HAS-BLED assessments, and give
anticoagulation if patient at high risk instead of aspirin and clopidogrel.

HA2DS2-VASc Score HAS-BLED Score

Hypertension (systolic blood pressure >160
Congestive heart failure 1 1
mm Hg)
Abnormal renal and liver function* (1 point
Hypertension 1 1 or 2
each)
Age ≥75 y 2 Stroke 1
Diabetes mellitus 1 Bleeding tendency/predisposition* 1
Stroke/TIA/TE 2 Labile INRs (if on warfarin)* 1
Vascular disease (prior MI, PAD, or 1 Elderly (eg, age >65 y) 1
aortic plaque) Drugs or alcohol (1 point each)* 1 or 2

128
HA2DS2-VASc Score HAS-BLED Score
Aged 65 to 74 y 1
Sex category (ie, female sex) 1
Maximum score 9 Maximum score 9

Rheumatic fever
Rheumatic fever is a non-contagious inflammatory disease that involves the heart, joints,
skin, and brain. The disease typically develops two to four weeks after a streptococcal
tonsillitis.
Signs and symptoms include fever, multiple painful joints and a characteristic but uncommon
rash. The heart is involved in about half of cases (rheumatic heart disease (RHD)), affecting
all layers of the heart and permanently damaging the valves, with stenosis, and regurgitation
causing heart failure, and atrial fibrillation in 10%.

Treating people who have streptococcal throat with antibiotics, such as penicillin, decreases
their risk of getting rheumatic fever. Children who have been affected can present with RHD
and heart failure.

Treatment of acute rheumatic fever

This needs supervision by a cardiologist or paediatrician
1. Antibiotics for streptococcus – give benzathine penicillin (or erythromycin if allergic to
penicillin).
Adult and child > 30kg give 900mg (1.2 million IU) IM single dose monthly
Child < 30kg give 450 – 675mg (0.6 – 0.9 IU) IM single dose monthly
Continue these for 5 years if no carditis, for 10 years if carditis and until aged 40 or
lifelong if chronic rheumatic valvular disease.
2. Anti-inflammatories – aspirin is used at high doses under expert supervision. There is
a very small risk of Reyes’s syndrome (liver failure).
3. Oral steroids (prednisolone) may be given instead of aspirin
4. Heart failure is treated with furosemide and spironolactone and digoxin if needed.

Treatment o rheumatic heart disease (RHD)

1. Give monthly benzathine penicillin IM (or erythromycin if allergic to penicillin) to
prevent further deterioration of the heart valves. This is secondary prophylaxis.
Adult and child > 30kg give 900mg (1.2 million IU) IM single does 1 x every 4 weeks
Child < 30kg give 450 – 675mg (0.6 – 0.9 IU) IM single dose 1 x every 4 weeks
2. Diuretics and digoxin may be needed for heart failure.
3. Active surveillance with echocardiography if available

4.3 Diabetes
Diabetes mellitus (DM) is characterised by high blood sugar levels (hyperglycaemia). It is
due to either the pancreas not producing enough insulin (Type 1 diabetes) or the cells of the
body not responding properly to the insulin produced (Type 2 diabetes). Type 1 disease has
no clear aetiology, but an association with autoimmune disease. Type 2 diabetes is more
likely to occur if the following risk factors are present:
 Modifiable: Hypertension, obesity, hyperlipidaemia, physical inactivity, unhealthy diet
 Non-modifiable: > 40years, ethnicity, family history, history of gestational diabetes.

Symptoms of diabetes:
 Polydipsia: excessive thirst – the 3 ‘P’s
 Polyuria: frequency of urination
 Polyphagia: excessive hunger

129
  Weight loss
 Increasing tiredness and lethargy
 Change in vision
 Slow healing of wounds, recurrent frequent infections
If untreated, diabetes can lead to disability; loss of limbs and vision and life-threatening
complications like stroke, CVD, coma and death

Diagnosis of Diabetes:
If symptoms (polydipsia, polyuria), diabetes is diagnosed if:
Fasting blood glucose (after 10 hour fast) ≥ 7mmol/l or 126mg/dl OR
Random blood glucose ≥11.1mmol/l or 200mg/dl OR
Hba1c (glycosylated haemoglobin) ≥48mmol/mmol or 6.5%. Hba1c not reliable for type 1.

If asymptomatic, diabetes is diagnosed if:

2 fasting blood glucose readings on 2 separate days ≥7mmol/l or 126mg/dl OR
2 random blood glucose readings on 2 separate days ≥11.1mmol/l or 200mg/dl (but fasting
blood glucose tests are more reliable) OR
2 Hba1c (glycosylated haemoglobin) ≥48mmol/mmol or 6.5% tested two weeks apart.

Type 1 diabetes
Tends to present in children and younger adults. Management requires a careful diet, blood
sugar monitoring and subcutaneous insulin injections. In addition to diabetic symptoms
above, patients may also present with diabetic ketoacidosis (see management of diabetic
ketoacidosis below) .

Treatment goals:
 Hyperglycaemic control
 Prevention and treatment of associated risk factors
 Prevention and treatment of acute and chronic complications
 Control of high blood pressure

Non-drug treatment:
Diabetic Diet
Liberal water intake – 2litres/water a day
Weight control
Regular exercise
Smoking cessation advice and keep alcohol intake at a minimum

Medication:
Insulin only. Aim for 0.6-1.5 u/kg/day SC. To be started by personnel who are trained in
insulin therapy.
 Insulin short acting, regular soluble (e.g. Actrapid) Can be given 3 times daily, 30
minutes before meals. It has a rapid onset within 30 minutes, peaks at 2-5 hours,
duration of effect is 5-8 hours
 Insulin intermediate acting NPH (e.g. Insulatard). Can be given once or twice daily
(evening +/- morning). Onset within 1-3 hours; peaks at 6-12 hours, duration of effect
is 16 – 24 hours
 Insulin biphasic, mixture of regular and NPH (e.g. Mixtard 30/70). Can be given once
or twice daily. Onset within 30 minutes, peaks at 2-12 hours, duration of effect is 16 -
24 hours.
Options:
1. A combination of short acting and intermediate acting agents. Give short acting before
meals and intermediate acting (should be 40-50% of total daily insulin requirement) in
the evenings, eg a 50kg 16-year-old type 1 diabetic will require total insulin about

130
 1u/kg/day – 50u SC. 25u (50%) can be given as intermediate insulin in the evenings and
the short acting can be given pre-meals: 8u at breakfast, 9u at lunch and 8u at dinner.
2. Insulin biphasic mixture given twice daily. 2/3rds of daily dose 30 minutes before
breakfast and 1/3rd 30 minutes before dinner in the evening: eg a 50kg 16 year old type
1 diabetic with a 50u daily requirement, can have 33u in the morning and 17u in the
evening
All patients will need close monitoring of their blood sugars to ensure they are not
overtreated or undertreated. They should check their own blood sugars where possible or
be seen frequently at the clinic till their blood sugar levels are stable.
Aim for:
 Fasting blood sugar <7 mmol/l (126mg/dl)
 Postprandial sugar (2 hours after a meal) <10 mmol/l (180mg/dl)
Keep insulin and syringes out of reach of children in a cool, dry place.

Hypoglycaemia (Blood sugar ≤ 3.0mmol/l or 54mg/dl)

Teach patients how to recognise and respond to symptoms of hypoglycaemia: tremors,
feeling lightheaded, sweaty, pale and confused; may progress quickly to coma. They should
immediately have 200mls of a sweet drink or 4 teaspoons of sugar dissolved in water.
Repeat after 15 minutes and go to the health facility.
Unconscious patients must be taken immediately to hospital:
 Adults: glucose 50% 20-50 ml IV slowly (3 ml/minute) or diluted with normal saline,
followed by 10 % dextrose infusion at 5-10 mg/kg/min till patient regains
consciousness.
 Children: Dextrose 10% IV 2.5ml/kg bolus then 5-10mg/kg/min infusion
Observe with regular blood sugar monitoring for at least 12 hours.
Assess for cause: overtreatment, dehydration, intercurrent illness, fasting, excessive alcohol
intake.
Adjust insulin regime as appropriate. Advise to keep well hydrated and to seek medical help
early when unwell.

Hyperglycaemia (Diabetic Ketoacidosis) RBG ≥18mmol/l (325mg/dl) with ketonuria

 Acute onset
 May have recent history of polydipsia, polyuria, weight loss and increasing tiredness
 Abdominal pain, vomiting
 Alterated consciousness, coma
 Deep breathing (acidotic)
 Sweet, acetone smell on the breath (from ketosis)
 Hypotension

Hyperosmolar Hyperglycaemic State (HHS) is of slower onset, more severe dehydration and
fluid deficit with no ketonuria and associated with type 2 diabetes
Management:
 Rehydrate: rapidly rehydrate with 0.9% Normal saline IV 500-1L per hour until the
patient stabilises, and then reduce the volume while monitoring the patient, the blood
sugar and the potassium level (if available). Children: 10-20ml/kg in first hour and 5-
15ml/kg/hour thereafter.
 Reduce hyperglycaemia: Short-acting insulin 4-6u IM hourly until ketosis resolves.
Adult and Child>5yrs: 0.1u/kg/hr; child<5yrs: 0.05iu/kg/hr. This same dose can be
given in IV infusion but with the utmost care to ensure at this rate.
 Potassium supplementation:
If serum potassium unavailable: Add 20mls of potassium per litre of fluids once passing urine
If serum potassium monitoring available:
K <3.5 mmol/L: add 40 mmol (2 ampoules) per litre of fluid

131
K 3.5-5.5 mmol/L: add 20 mmol (1 ampoule) per litre of fluid
K >5.5 mmol/L: do not add any potassium
 Monitor BP, urine output, presence of ketones and blood sugar hourly
 Insert Urinary catheter if unconscious
 Treat infections if present
 Prevent thromboembolism with Enoxaparin 4000 IU SC until patient is able to move
If blood glucose reaches <14mmol/l and patient clinically unwell or unable to eat/drink,
change fluids to 5% dextrose and continue monitoring as above.
Once clinical condition normalises (normal BP, consciousness, urine output, and able to
eat), can start on SC insulin at least 1-2hours before stopping IM insulin

Type 2 diabetes: screening, diagnosis and monitoring.

Screening:
 Obesity: BMI>30 or waist circumference >94cm in men and >80cm in women
 Hypertension or cardiovascular disease
 Frequent infections, particularly skin infections (HIV screen also)
 On drugs that cause high blood glucose: oral steroids, antiretrovirals, antipsychotics
(courses over 1 month).
 History of gestational diabetes (screen every 2 years, sooner if develop symptoms)
 Family history of diabetes (parent, brother sister) (screen every 2 years, sooner if
develop symptoms).
 TB infection
Diagnosis: same criteria as listed above for type 1 diabetes

Management and monitoring

Treatment goals:
 Hyperglycaemic control
 Prevention and treatment of associated risk factors
 Prevention and treatment of acute and chronic complications
Investigations at diagnosis and at review:
 Blood pressure, BMI and waist circumference (every review)
 Kidney function: urine dipstick for microalbuminuria,
 HbA1C and creatinine or eGFR where available (annually)
 Hyperlipidaemia: serum cholesterol if available (annually)
 Eyes: fundoscopy to assess for diabetic retinal changes and check for cataracts
(annually)
 Feet: annual foot examination for nerve damage, ask about burning pain. Look for
ulcers, deformities. Check foot pulses
 Autonomic neuropathy assessment: GI symptoms; erectile dysfunction; no warning of
hypoglycaemia (annually)

Non-drug treatment:
Diabetic Diet
Liberal water intake – 2litres/water a day
Weight control: Aim for BMI <30 or waist circumference <94cm in men and <80cm in women
Regular exercise at least 150 minutes a week
Smoking cessation advice and keep alcohol intake at a minimum

Medication for Type 2 diabetes:

CVD prevention: Atorvastatin 20mg daily. If hypertensive, start on an ACE inhibitor and aim
for BP<135/85mmHg (< 140/90mmHg also acceptable).
If signs of diabetic complications; kidney damage, eye damage, nerve damage in the feet or
severe hyperglycaemia then start treatment immediately,

132
 If none of the above; then encourage lifestyle changes for 3 months and review.
Oral diabetic treatment: Start with metformin 500mg once daily for 1 week and titrate up
weekly to a maximum of 1g twice daily till blood sugar at goal: <7mmol/l (126mg/dl). Avoid
metformin in severe kidney impairment
Add in a sulphonylurea:
 Glbenclamide start at 5mg once daily (2.5 mg in the elderly) to a maximum 10mg
daily in divided doses OR
 Glimepiride start at 1mg, titrate up to a maximum of 4mg once daily OR Gliclazide
start at 30mg titrate up to a maximum dose of 120mg daily in divided doses.
Advise patients of risk of hypoglycaemia (see section on hypoglycaemia above).
Review patients every 1- 3months according to blood sugar control
If blood sugar not controlled on oral medication and lifestyle changes then will need to start
insulin (see section on treatment with insulin above). Stop sulphonylurea if changing to
insulin and maintain on metformin if possible as has CVD prevention effect.

Blood sugar control: Aim for blood sugar less than:

Venous glucose Capillary glucose Glycosylated
haemoglobin (HbA1c)
mg/dl mmol/l mg/dl mmol/l
Fasting 75 – 130 4–7 115 6.5 64mmol/mol or 8%
After meal 180 10 160 9

Management of complications:
 Improve blood sugar control
 CVD secondary prevention: Atorvastatin 80 mg and Aspirin 75-100mg daily
 Kidney impairment: ACE inhibitor or ARB (see hypertension 4.1 for drugs and doses)
 Eyes: diabetic changes and cataracts to be reviewed by ophthalmologists
 Feet: Manage ulcers and prevent secondary infection

Advice for diabetics regarding feet:

 Never walk barefoot. use emollients for dry and cracked feet for prevention of ulcers.
 Wear shoes that enclose the feet
 Ensure that feet fit comfortably into the shoes, without any compression of the feet,
especially the toes
 Check feet every night looking for injuries, colour change, infection, coldness or
ulcers. Report to health centre if present.
Check inside shoes before putting them on, to ensure there are no stones inside

4.4 Respiratory Disease

For ARI see 3.2

Asthma
Asthma is a chronic disease of airways. Inflammation of the airways leading to thickening of
the walls and a build-up of mucus results in narrowing of the passages and reduces air flow
in and out of the lungs. Symptoms: Wheezing, shortness of breath, chest tightness or cough.
Symptoms are often worse at night.
Asthma triggers:
 Changes in the air due to dust, perfumes, pollution, cigarette smoke, smoke from
open fires during cooking
 Mouldy environment; when the air is damp and there is little or no ventilation
especially in the rainy season/cold and wet months
 Weather changing from hot to cold or damp to dry and vice versa

133
  Medications like aspirin, beta-blockers (atenolol, bisoprolol, carvedilol)
 Exercise
 Allergies to certain foods
 Pollen from flowering plants, grasses and trees
 Contact with animal fur
 Strong emotions like stress or anger

Examination findings depend on severity of the asthma. Chest examination may be normal
or there may be faster breathing than normal and there may be some wheezing on
auscultation of the chest.

Symptoms and signs of an acute exacerbation of asthma:

The patient is
 sitting and leaning forward with hands on knees. May be agitated becoming quiet
when severe
 Not talking in full sentences which can progress to not talking at all when severe
 Using accessory muscles for breathing: nasal flaring, indrawing of the chest wall,
paradoxical breathing
 Audible wheezing which may disappear when the attack becomes severe
SpO2 92 – 95% on air
 MAXIMUM <6y 6-10y >10y to adult
Pulse >130 >120 >110
Respiratory rate >50 >30 >25

In severe and life-threatening exacerbations, there will be:

 Feeble respiratory effort
 Exhaustion/confusion/coma
 Cyanosis
 Bradycardia or hypotension
 Silent chest
 SpO2 <92% on air (See management of acute severe asthma below)

Diagnosis
1.Trial of oral steroids if peak flow [PF] meter not available:
 For adults and children over 6 years and older: 30mg prednisolone daily for 2 weeks
and review.
 For children 2-5 years: 20mg prednisolone daily for 2 weeks and review.
At review ask if there have been any changes to asthma symptoms: cough, chest tightness,
breathing and/or wheeze. If there has been improvement, then diagnose asthma.

2. Using a peak flow (PF) meter: Measure PF and record. Then ask patient to inhale 2 puffs
of 200 mcg of salbutamol. Wait 10 minutes and measure PF again and record.

Percentage PF change = PF after salbutamol – PF before salbutamol

--------------------------------------------------------- x 100
PF before salbutamol
If >20% change in PF, then diagnose asthma

Check for signs of alternative diagnosis:

 Heart failure: history of hypertension, ankle swelling
 COPD: chronic productive cough, history of smoking
 TB: chronic cough, night sweats, weight loss, haemoptysis

134
  Hyperventilation: light-headedness, tingling in fingers and toes, normal examination

Management of asthma
 Advise person to stop smoking
 Start with step 1 (below) and only increase to next step if symptoms persist
 Always use a spacer with an inhaler.
 Ask about and check inhaler use
 Encourage exercise. Treat obesity/ malnutrition
 Increase medication if often breathless
 Look for anxiety/ depression as breathlessness is frightening.
 Once condition is stable, review every 6 months

5 step management of chronic stable asthma

Medicine
Step 1 Start reliever: Short acting bronchodilator
via spacer (salbutamol or if not better after
1 month try ipratropium)
Step 2 Add preventer: Inhaled steroids at
normal dose – beclomethasone. Continue
reliever therapy.
Step 3 Add second preventer: (If available)
Over 5 years old: long acting beta agonist
(LABA). Aged 2 -5 leukotriene receptor
agonist (montelukast)
Step 4 Check inhaler use & technique. Review
diagnosis. Increase to ‘high dose’ inhaled
steroids. Continue other medicines.
Step 5 In adults only: consider oral steroids
(prednisolone) OR oral theophylline or
oral salbutamol or leukotriene inhibitor.
Note that oral steroids are usually
sufficient, aminophylline should NOT be
used routinely in Step 5.
Dosage
Salbutamol 200mcg as needed.
(Ipratropium 40mcg as needed.
Adults: 200 - 400mcg 2 x per day.
Children: 100 – 200mcg 2 x per day
Salmeterol 50-100mcg 2 x per day
Montelukast Child 2-5y 4mg;
Adults: Beclomethasone 1000mcg 2
x per day
Child > 5 400mcg 2 x per day.
Adult doses
Prednisolone: start at 25mg 1 x per
day. Aim to reduce to 5-10mg 1 x per
day.
Theophylline: 200-500mg of slow
release 2 x per day
(NB aminophylline 200m tabs can be
used as short term alternative if slow
release theophylline not available but
do not use for longer than 200mg 2 x
day for 5 days in adults and children
over 40kg)
Salbutamol: 4mg PO 3-4 x per day
Montelukast : 10mg 1 x per day
Treatment advice
Only give oral salbutamol if no
inhaler available. Only use
ipratropium if salbutamol not
working as risk to heart and
not as effective
All inhaled steroids are equally
effective – use the cheapest
available.
Never use LABA without
inhaled steroids as there is a
risk of death. Do not give to
children < 6 years.
In children inhaled steroids can
affect growth: seek specialist
help.
Severe chronic side effects of
steroids: thin bones, weight
gain, diabetes, gastric ulcer.
Only use theophylline if dose
can be monitored due to
toxicity.

Management of acute exacerbations of asthma

 Give high flow oxygen via a face mask
 Assess the severity (pulse, BP, respiratory rate, temperature, colour, how much they
can talk, oxygen saturation < 92% is abnormal at any age)
 Give bronchodilator (salbutamol via spacer, 10 puffs, over 10-15 minutes, shaking
inhaler before each puff). Or nebulised salbutamol (< 10 years 2.5 - 5mg; over 10
years 10mg). Repeat inhaled salbutamol : 4 – 6 puffs via spacer or via nebuliser 2 –
4 hourly for up to 24 hours.
 Give steroids. Oral prednisolone 2 – 5 years: 20mg; 6 – 15 years 30 – 40mg, adult 40
– 50mg PO for 3 days then stop. There is no need to tail off the dose. In addition, can

135
 give IV hydrocortisone for the first dose (2 – 5 years: 25mg IV: 6 – 10 years 50mg IV;
10 – 15 years & adults 100mg IV).
 In life threatening asthma when all the above has already been given, and no
improvement with nebuliser, give Magnesium sulphate 1.2-2g IV slowly over 20
minutes. Only give aminophylline IV (5mg/kg IV over slow IV injection over 20
minutes) if magnesium sulphate not available. Then by infusion if still needed but limit
to 4 hours due to toxicity of aminophylline. Adults & children 12 years and over:
500micrograms/kg/hr; children 1 – 11 years: 1mg(kg/hour; elderly 300
micrograms/kg/hr. Aminophylline can cause arrhythmias, delirium, hyperthermia,
mania, abdominal pain.
 Start inhaled steroids.
 Antibiotics are not indicated unless there is clear evidence of infection (fever,
productive cough, crepitations in the chest). If pneumonia, treat (see 3.2).
 Ensure person and parents know how to use inhaler and spacer, how to take oral
prednisolone and know signs of exacerbation and when to return. Review 3 – 7 days.

Oral salbutamol for acute wheeze (only if salbutamol inhaler not available)
Medicine Age Dose Frequency Side effects
Salbutamol Infants < 12 months Do not give, but refer immediately Common: tremor,
syrup Children 1 – 5 years 1mg (2.5ml or ¼ tablet) 3 times daily headache
(2mg/5ml), Children 5 – 12 years 2mg (5ml or ½ tablet) 3 rimes daily Rare: fast heart,
4mg tablet Adults and children 4mg single dose 3 times daily irregular heart
over 11 years

Chronic obstructive airways disease, (COPD)

COPD is a respiratory disease that affects the airways. Damage to the airways over time
leads to recurrent build-up of mucus and a permanent narrowing of the air passages
therefore reducing airflow in and out of the lungs.

Risk factors for COPD:

 Adults > 35 years who are cigarette smokers or used to smoke
 Adults who have been exposed to smoky environments like open fires when cooking
for 10 year or more
Symptoms:
 Difficulty breathing, feeling breathless and/or wheezing especially after exercise
 Chronic cough (without symptoms suggestive of TB)
 Producing a lot of sputum especially in the rainy season/ colder and wetter months
 Recurrent chest infections requiring treatment

Diagnosis of COPD: The diagnosis is essentially a clinical diagnosis

 chronic cough, productive cough, history of smoking
 Spirometry (if available): FEV1/FVC < 0.7 and clinical history
 Chest Xray can help rule out other potential diagnoses

Management of COPD
Check for signs of alternative diagnosis
 Heart failure: history of hypertension, ankle swelling
 TB: chronic cough, night sweats, weight loss, haemoptysis
 Hyperventilation: light-headedness, tingling in fingers and toes with a normal
examination
 Advise person to stop smoking
 Start with step 1 (below) and only increase to next step if symptoms persist
 Always use a spacer with an inhaler.

136
  Encourage exercise. Treat obesity/ malnutrition
 Increase medication if often breathless
 Ask about and check inhaler use
 Look for anxiety/ depression as breathlessness is frightening.
 Once condition is stable, review every 6 months

4 step management of COPD

Medicine
Step 1 Short acting bronchodilator
via spacer (salbutamol or if
not better after 1 month try
ipratropium)
Step 2 Add long acting drug (if
available) : tiotropium or
salmeterol.
Step 3 Add inhaled corticosteroids
(beclomethasone)
Step 4 Add oral daily steroids OR
theophylline
Note that oral steroids are
usually sufficient,
aminophylline should NOT
be used routinely in Step 4.
Dosage
Salbutamol 200mcg as needed.
(Ipratropium 40mcg as needed)
Tiotropium 18mcg one puff 1 x per day
NOT MORE than once per day)
Salmeterol 50-100mcg inhaled 2 x per
day.
200 – 400mcg inhaled 2 x per day.
Oral prednisolone 1 – 5mg 1 x per day.
OR Theophylline 250 – 500mcg 2 x
per day. OR aminophylline 200mg 2 x
per day, avoid long term use if
possible.
Treatment advice
Only give oral salbutamol if no
inhaler available. Only use
ipratropium if salbutamol not
working as risk to heart.
Give these if available and not
too expensive, otherwise go to
step 3.
Inhaled steroids reduce
exacerbations but increase risk
of pneumonia. Only use if
severe disease.
Severe side effects of steroids:
thin bones, weight gain,
diabetes, gastric ulcer. Tail off
gradually if used for > 3 weeks
Only use theophylline if dose
can be monitored due to toxicity.

Management of acute exacerbations of COPD

Patients may present with:
 Worsening breathlessness
 Fever
 Wheezing
 Productive cough with plenty of discoloured sputum
 Tachypnoea ≥ 25 cycles/min
 Tachycardia ≥100 beats/min
 SpO2 ≤90% on air

 Give bronchodilator (salbutamol via spacer, 10 puffs, over 10-15 minutes, shaking
inhaler before each puff, then 4 – 6 puffs every 2 – 4 hours) OR nebulised salbutamol
(5mg) every 30 minutes till better
 Give steroids. Oral prednisolone 30 – 40mg 1 x per day for 7 – 10 days. There is no
need to tail off the dose. Do not give IM or IV.
 Give antibiotics (oral amoxicillin 500mg 3 x per day for 5 – 7 days). If allergic to
penicillin give erythromycin 500mg 4 x per day for 7 days (but not if on theophylline)
OR doxycycline 200mg on day 1 then 100mg 1 x per day for 6 days.
 Oxygen if cyanosis, decreased saturation and if available, to a maximum
concentration of 28% (2l/min with nasal canula)
 Once stable, review and adjust medication as needed

4.5 Gastrointestinal

Upper gastrointestinal tract

137
Mouth ulcers: Treat small ones with gentian violet. Treat chronic ones with an oral
prednisolone tablet crushed and applied. May need biopsy if single persistent painless ulcer
to rule out malignancy.

Glossitis and Angular Stomatitis: Check for iron or vitamin deficiency and treat.

Oral candidiasis: Treat with nystatin (100,000iu/ml) 1ml four x per day in infants and
adults, and holding in mouth for as long as possible before swallowing. Treatment continues
48 hours after clinical cure. Severe cases involving oesophagus: treat oral fluconazole 50-
100mg daily for 2 weeks and check HIV status via VCT.

Noma: Gangrenous stomatitis- malnourished children at risk. Treat with wound

debridement, IV penicillin and metronidazole, nutrition and surgery.

Gastritis, gastric-oesophageal reflux disease (GORD) and gastric and duodenal

ulcers
For mild indigestion symptoms in adults (burning or indigestion after food) give magnesium
trisilicate compound, 1 -2 tabs as needed (maximum 8 a day). OR
Another simple magnesium or aluminium antacid in tablet or liquid form
Advice: Chew the tablets. Magnesium tablets may cause belching or mild diarrhoea.
Precaution: Do not take ibuprofen, indomethacin, naproxen or diclofenac if symptoms of
indigestion.

If symptoms last more than 2 days, if moderate to severe symptoms, then treat with a H2-
receptor antagonist (cimetidine or ranitidine) or a proton pump inhibitor (PPI) (omeprazole or
lansoprazole). Only one of the following:

 Cimetidine PO 400mg 1 or 2 x per day OR

 Ranitidine, PO 150mg 1 or 2 x per day OR
 Omeprazole PO 20mg 1 or 2 x per day OR
 Lansoprazole PO 15 – 30mg 1 x per day

Side effects of the H2-receptor antagonists: diarrhoea, headache, dizziness. Rarely rash and
allergy.
Side effects of the PPIs: GI disturbance, headache,.dry mouth, dizziness. Long term use
may increase risk of ischaemic heart disease.

Consider stool microscopy to check for GI parasites- treat if present. If symptoms persist, the
person may need to take a course of treatment for Helicobacter pylori. The H pylori breath
test or stool test is not currently available but should be used if available and not too
expensive.

Eradication therapy for Helicobacter pylori

Omeprazole PO 20mg 2 x per day or lansoprazole PO 30mg 2 x per day AND
Clarithromycin PO 250mg 2 x per day AND
Amoxicillin PO 1g 2 x per day OR
Metronidazole PO 400mg 2 x per day All for 7 days

If clarithromycin is not available, give PPI, amoxicillin and metronidazole instead. Alternative
to metronidazole, give tinidazole 500mg 2 x per day for 7 days.

For severe symptoms, any history of haematemesis or melaena or severe epigastric pain,
treat as above but if possible investigate with gastroscopy. Endoscopy may reveal stricture

138
or malignancy- surgical treatment and follow up required. Normally medical treatment will
heal most ulcers, but a bleeding or perforated ulcer may need emergency laparotomy.

Laparotomy also required to deal with other surgical causes of acute abdomen presentation
(especially if no resolution with immediate management, fluid resuscitation measures and
blood transfusion with antibiotic cover given as needed).

Paediatric Gastro-oesophageal Reflux Disease

Reflux is physiological and settles usually by a year. Disease is noted by distress, e.g. with
feed aversion, back arching, increased distress and crying. In mild cases ensure frequent
lower volume responsive feeds with correct positioning post feeds. Ensure sterile water
measures if using formula, may need thickener, antacid, ranitidine or omeprazole at
paediatric doses. Some (2-3%) may require cow’s milk free formula, but most non-allergy
cases improve over time. Ranitidine dose 1mg/kg 3 x per day

Viral hepatitis- see 3.10

Chronic liver disease

 Treat underlying cause, e.g. parasitic disease
 Avoid alcohol, drugs including paracetamol
 Ensure nutrition and hydration is adequate
 Treat any infections, and ascites (low dose spironolactone 25mg- 200mg daily; large
volume ascites may require repeated drainage and diuretics to prevent re-
accumulation)
 Itch can be treated with Colestyramine 4-8g daily

Haemochromatosis (hereditary) and haemosiderosis

Initially weekly venesection (remove one unit) then after achieving mild iron deficiency,
maintenance venesection every 2-3 months to maintain ferritin < 50ng/ml and transferrin
saturation < 50%. Avoid Vitamin C and screen for disease in relatives in hereditary cases
(haemochromatosis). Treat co-morbidity (cardiomyopathy and diabetes)

Biliary colic: give strong analgesia and antispasmodics (hyoscine 20mg IM or IV , repeat
after 30 minutes). Cholecystitis- may also be caused by parasites- treat as appropriate
Treat with combination eg ceftriaxone (1g once daily) and metronidazole (500mg IV 3 x per
day) and surgery as required

Amoebic liver abscess

For amoebic dysentery and giardiasis see 3.1. Treat with metronidazole 800mg PO 3 x per
day x 5 days orally then paromomycin PO 500mg 3 x per day. Consider surgical drainage if:
 left lobe abscess
 very ill patients where abscess may be about to rupture
 diagnostic uncertainty
 lack of response after 4-5 days treatment

Primary Biliary Cirrhosis: Colestyramine for itch, low fat diet and vitamins. Monitor – if
develops portal hypertension, manage and prevent oesophageal variceal bleeding, and
other complications (including bacterial peritonitis – needs IV ceftriaxone promptly and may
need prophylaxis with ciprofloxacin 500mg daily to prevent recurrence). Hepato renal
syndrome may also occur – supportive treatment should be given as prognosis is poor

139
Hepatocellular cancer: Treatment usually palliative (see 4.13)- analgesia, anti-pruritus
medicines, drain ascites, transfuse for anemia. Surgical resection leading to cure is only
possible in 2% and can only be done by specialist liver surgeons.

Liver flukes and Schistosomiasis- can cause gallstones or intrahepatic stones as a

complication. Treat schistosomiasis- see 3.11.
Treat liver flukes with praziquantel 25mg/kg 3 x day for 2 days
Ascariasis and hookworm- see 3.11.Treat parasites with albendazole. Intestinal or
biliary obstruction is managed conservatively by passing an NG tube, and treating with IV
fluids, and analgesia and antispasmodics, then albendazole after the acute phase has
passed. Surgery via emergency laparotomy may be required.

Toxocariasis may cause liver and spleen enlargement, and more widespread disease.
Arises from contact with contamination by pet faeces. Treat with Albendazole 400mg oral 2 x
per day or 5 days

Lower Gastro-intestinal Tract

Causes of diarrhoea and rectal bleeding include infective causes not covered here see 3.1

Diverticular disease: Maintaining high fibre with fluids to prevent infection is key.
Diverticulitis may present with fever, abdominal pain with rectal bleeding. Treat with bed rest,
high fibre diet and antibiotics. Laparotomy and surgical management may be required if
perforation occurs.
Amoxicillin with Clavulanic acid 500mg +125mg 3 x per day for 7 days (or ciprofloxacin with
metronidazole if patient is allergic to penicillin)

Inflammatory bowel disease: Rare in resource poor areas. Can present with
complications requiring surgery. Diagnosed following sigmoidoscopy or colonoscopy. Acute
symptoms treated with prednisolone but ensure exclude infective cause first (eg giardiasis,
amoebiasis, shigella).

Haemorrhoids: Mild cases treated with any topical product that might soothe the pain
(such as 1% hydrocortisone or bismuth) or suppositories. Larger ones that have not reduced
may need reduction if required, then surgery (band ligation or sclerotherapy). Thrombosed
piles – treat with analgesia and bed rest. Zinc oxide cream might bring some relief.

4.6 Urinary Tract

Urinary Tract Infection: Mild lower UTI (urinary tract infection) in women may be treated
without investigation unless very frequent (recurrent). Pregnant women with asymptomatic
bacteriuria or UTI should be treated. In men and children UTI may be a sign of underlying
disease so all cases should be treated and investigated with ultrasound if available.
Treatment steps
 Test urine with urine dipstick. If nitrites and/or leucocytes +ve on dipstick, give
nitrofurantoin as first line treatment (except in children under 3 months of age)
 If symptoms persist for more than 2 days or if symptoms worsen, test urine again and
if still +ve on dipstick, consider other antibiotic: ciprofloxacin PO 250mg 2 x per day
for 3 days; for severe infection give 500m 2 x per day for 5 – 7 days).
 Admit a person with moderate to severe symptoms (including high fever, abdominal
pain, blood)
 Children under 3 months should be treated in hospital with IV ampicillin and
gentamicin until the infection responds
Treatment note: Bacteria causing UTIs are often resistant to many antibiotics.

140
 Advice: Drink plenty of fluids.
Medicine Age Dose Duration Side effects
Nitrofurantoin Child 3 months – 11 years 750mcg/kg 4 days Common : Anorexia, nausea
50mg tablets x per day 5 days if more severe symptoms Rare : vomiting and
diarrhoea; allergic reaction
Child 12 years and adults 50mg 4 x day 3 days.
5 days if more severe symptoms
Prescribing tip: Do not give if previous allergic reaction to nitrofurantoin. Avoid in pregnant women near term – consider
amoxicillin 500 mg three times daily for 5 days
 In patients with frequent recurrent infections or renal tract anomalies, low dose long-
term therapy may be required. Use nitrofurantoin: child 3 months – 11 years 1mg/kg
PO at night; child 12 years and adults 50 – 100mg PO at night.
Acute pyelonephritis: can lead to septicaemia and if the patient is severely ill should
be treated by injection with a broad spectrum antibiotic:
 ciprofloxacin 400mg every 8 – 12 hours to be given over 60 minutes until patient
has improved, then 250 – 750 mg 2x per day PO.
 Gentamicin can also be used: 3-5mg/kg daily in divided doses each dose to be
given at 8 hour intervals. Duration of treatment should be 10 – 14 days.

Glomerulonephritis and acute nephritis: Usually occurs after streptococcal infection;

diagnosed by noting red blood cell casts and proteinuria after presenting with haematuria. If
low urine output (< 0.5mls/kg/h), ensure fluids restricted to previous output over 24 hours
plus 500mls. Also restrict salt and potassium, give furosemide and treat hypertension. Treat
infection with phenoxymethylpenicillin 500mg 4x per day for 10 days; if penicillin allergy:
erythromycin 250-500mg 4x per day for 10 days.

Nephrotic syndrome: This is proteinuria (>3g/24h, or albumin/creatinine ratio >300),

reduced serum albumin, and oedema. Most are of unknown cause (idiopathic), but this also
arises from infection (HIV, hepatitis B or C), diabetes, leprosy, TB, sickle cell disease, cancer
or autoimmune conditions such as lupus.
Treatment steps:
Reduce salt and treat oedema cautiously with diuretics, monitoring fluid balance in case of
fluid depletion (reduced urine output and hypotension).
Weigh regularly and check serum electrolytes.
Treat proteinuria (with lisinopril 5mg daily or enalapril 5mg daily, (children enalapril PO: 0.1
to 0.3 mg/kg 2 times daily ) and treat the underlying cause.
Steroids may be used with caution in idiopathic cases (primary nephrotic syndrome ) with
oral prednisolone 2 – 5 years: 10mg; 6 – 15 years 20mg, adult 30mg PO for 6 weeks then
may need lower dose for further 6 weeks: oral prednisolone 2 – 5 years: 4mg; 6 – 15 years
10mg, adult 15mg PO for 6 weeks

. Complications include
 renal vein thrombosis: treat with heparin or enoxaparin
 Peritonitis: treat with appropriate IV antibiotics for sepsis, and consider ongoing
prophylaxis with phenoxymethylpenicillin 500mg 2x per day while oedema persists.
 Hyperlipidaemia. Give simvastatin 40mg or atorvastin 20mg 1 x per day for 6 weeks
(Adults only. This reverses during treatment, unless prior hyperlipidaemia)

Acute Kidney Injury (AKI) (acute renal failure)

 Pre-renal causes: fluid or blood loss, dehydration, sepsis, renal disease (includes
infections such as malaria and leptospirosis), snake bites, drugs and toxins, post
streptococcal glomerulonephritis

141
  Post renal causes (investigate with ultrasound): obstructive – stones, blocked
catheter, pelvic mass, large prostate
Treatment steps
 Look for cause, treat if possible
 Stop any nephrotoxic and potassium sparing medication (diuretics, anti-
hypertensives (especially ACE / ARB), NSAIDs. Stop drugs that build up in acute
kidney injury e.g. metformin
 Manage with careful fluid replacement if fluid depleted, catheterise to monitor output
 Consider peritoneal or haemodialysis (if potassium >6.5, acidosis, uraemia or
pulmonary oedema)
 Treat sepsis
 Monitor fluid balance, weights and electrolytes – when fluid replaced, restrict to
previous day loss +500ml. Start low potassium diet but avoid dehydration and
hypokalaemia.
 Hyperkalaemia should be treated if potassium >6.5 or ECG changes (peaked or
tented T waves, then flattening of p waves, then changes in QRS complexes).Treat
with insulin 5-10 units with 50mls 50% glucose over 15 minutes by IV infusion and
also give calcium gluconate 10% 10ml during SLOW IV injection. Doctor to stay with
 patient during calcium administration. If patient on digoxin, give calcium gluconate
more slowly, in 100mL glucose 5% over 20 minutes.

Chronic Kidney Disease (CKD)

A progressive decline in kidney function is initially symptomless, later resulting in fatigue,
anemia, osteomalacia, and effects of fluid overload and raised urea (causing anorexia,
vomiting, neuropathy, confusion). Causes of CKD include nephrotoxic drugs, chronic
obstruction (stones, prostate enlargement), glomerulonephritis, hypertension, diabetes, HIV
and some tropical disease e.g. schistosomiasis. Diagnosis is based on a steadily rising or
persistently raised Glomerular Filtration Rate (GFR) which can be calculated from the serum
creatinine level (www.mdcalc.com/mdrd-gfr-equation)
Treatment aims to prevent AKI and gradual progression to end stage renal failure.
 Treat urine infections, stop all nephrotoxic medication, relieve any obstructive causes
 Keep salt intake to <5g per day (< one small teaspoon)
 Prevent AKI by preventing dehydration (high fluid intake, advice during Ramadan),
prompt treatment with fluids when unwell, avoid drugs that can trigger AKI
 Aim for BP < 140/90 in all patients and < 130/80 if proteinuria.
 Use ACEI or ARB first but do not use if GFR < 15. Check creatinine 1 – 2 weeks after
starting and after every dose increase. If creatinine rises 15-30% continue and re-
check after another 1-2 weeks. If creatinine rises > 30% stop (or reduce dose to
previous level). Recheck after 7 days. Use another medication
Other medication to control hypertension
Beta blockers Calcium channel blockers Diuretics
Safe to use in renal impairment. Safe to use in renal impairment Thiazides: ineffective if eGFR<30.
If eGFR <20 maximum dose of bisoprolol is Hydralazine: reduce dose if eGFR<30
10mg.
Contraindicated in asthma.
 Patients with CKD are at increased risk of cardiovascular disease. Give atorvastatin
20mg daily. Encourage smoking cessation, weight loss if overweight, exercise
 Investigate anemia and replace iron deficiency with ferrous sulphate 200mg 2x per
day PO for 3 months
 Intensify control of diabetes if present
 Severe CKD affects bone health. Seek specialist advise if available.

142
4.7 Neurological Disease
Epilepsy
Epilepsy is a chronic neurological condition, characterized by recurrent unprovoked seizures.
It has several causes:
 genetic
 past history of birth trauma, brain infections or head injury.
 in some cases, no specific cause can be identified.
Seizures are caused by abnormal discharges in the brain and can be of different forms;
people with epilepsy can have more than one type of seizure. The two major forms of
seizures are convulsive and non-convulsive. 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, so may be confused with them. Convulsive
epilepsy has features of generalised convulsions such as sudden muscle contraction,
causing the person to fall and lie rigidly and unconscious, followed by the muscles
alternating between relaxation and rigidity, with or without loss of bowel or bladder control.
This type is associated with greater stigma and higher morbidity and mortality. Treatments
are only given here for generalised convulsions. The next edition of the STGs will include the
treatment of non-convulsive epilepsy.

For management of a person with convulsions as an emergency, see 5.1.

Generalised convulsions (Tonic-Clonic seizures)

These may be the result of epilepsy or secondary to such problems as fever, meningitis,
head injury, substance withdrawal or metabolic abnormality (hypoglycaemia,
hyponatraemia)):
 May start with a warning sensation or aura such as flashing lights, sounds,
smells, or abdominal pain
 Abrupt loss of consciousness with initial stiffness/rigidity (tonic phase)
 Followed by rapid jerking movements lasting longer than 1–2 minutes (clonic
phase)
 There may be tongue biting, frothing, incontinence of urine or faeces
 Followed by a period of drowsiness, confusion, abnormal behaviour and
headache or muscles aches (post-ictal phase)

Differential diagnosis includes

 vasovagal syncope (simple faint)
 rigors
 postural hypotension
 cardiac syncope
 dissociative seizures.
If the event was definitely a seizure: rule out provoking factors, such as drug/alcohol
use/withdrawal, meningitis or electrolyte disturbance and treat these. Do not give epilepsy
medication if the seizure was provoked.

Confirm diagnosis: ask if there have been at least 2 convulsions in the past year on 2
different days with no underlying cause. If so, then consider epilepsy and initiate treatment.
The person should be encouraged to keep a seizure diary.

Start with one treatment and lowest dose and build up slowly. The aim of treatment is to
achieve the lowest maintenance dose that provides complete seizure control. Adherence to
medication is very important. If a single drug at maximum tolerated dose is not controlling
seizures, then add in a second drug, increase up to therapeutic levels THEN slowly reduce
and stop the first drug. If the patient is not controlled on one medication, use two together.

143
 Initial follow up is monthly to monitor for side effects, but once the person is seizure-free and
with very few side effects then they can be reviewed every 3 months.

Treatment may be reduced slowly (and eventually stopped) if there has been absence of
seizures for 2 years but dose increased again if there are further seizures after reducing the
dose. A person should not drive or use heavy machinery with a history of epilepsy unless
they have been stabilised on medication and after being at least 1-year seizure free.

Treatment with antiepileptic medicines

Most medications are given twice a day but phenobarbital can be given once a day. Seizures
may still occur during the first 2 to 3 weeks of starting phenobarbital as blood levels increase
slowly.

Child Adult and adolescent

Starting dose Maintenance dose Starting dose Maintenance dose
Carbamazepine 2.5 mg/kg twice daily 5mg / kg 2-4 x daily 100 – 200 mg twice 400 – 600mg twice
daily daily
Phenobarbital 1-1.5 mg / kg twice 2 – 4 mg / kg in 1-2 30 – 60 mg at night 1-3mg/kg at night
daily doses
Phenytoin 1.5 -2mg / kg / twice 2.5 – 4 mg / kg tin 1-2 150 – 300 mg daily 200 – 500 mg daily
daily doses (max 4mg/kg
twice daily)
Sodium valproate 7.5 – 10 mg / kg 15 – 30 mg / kg in 2-3 400 mg daily 400 – 2000 mg in 2
twice daily doses doses
Lamotrigine 25 mg daily 100-200mg in 1-2
doses

Side effects of carbamazepine: double/blurred vision, impaired coordination, rashes/urticaria,

gastrointestinal upset, increased liver enzymes. Rarely blood disorders (anemia, leucopenia,
increased bleeding) and Stevens-Johnson syndrome.

Side effects of phenobarbital: drowsiness, lethargy, hyperactivity in children, skin rash.

Rarely bone marrow depression, liver failure.

Side effects of phenytoin: drowsiness, unsteadiness, tremor, confusion, coarsening of

features of face and gums, acne, hirsutism, gastrointestinal upset, headache, anemia,
hepatitis. Rarely hepatitis, blood disorders and Stevens-Johnson syndrome.

Side effects of valproate: 10% risk of teratogenicity. Hair loss, behaviour changes, tremor,
gastrointestinal upset, weight gain, menstrual disturbance. Rarely pancreatitis, bone marrow
failure. Use with caution in liver disease.

Side effects of lamotrigine: rash, blurred or double vision

If on antiretrovirals for HIV use valproate in preference to other epilepsy drugs (as it is not an
enzyme inducer).

In women of child bearing age: talk about contraception, preconception advice and
pregnancy.
All epilepsy drugs increase the risk of congenital anomalies and valproate has the highest
risk (10%). Carbamazepine and lamotrigine have the lowest risk. (The copper coil is a good
choice for contraception as it is not affected by any epilepsy drugs). All women of child
bearing age should take folic acid 5mg daily to reduce the risk of neural tube disorders if
they do get pregnant.

144
When discussing contraception with women taking anti-epilepsy drugs, consult specialist
guidance, as most anti-epilepsy drugs induce enzymes that can reduce the effectiveness of
oral contraceptives

Prescribing in pregnancy
Where possible pregnant women should only be given one antiepileptic medicine (not
valproate). All five medicines can be used during breastfeeding though valproate can cause
bleeding problems in infants. At birth, the newborn is given vitamin K 1mg IM if the mother
has been on epilepsy medication.

Absence seizures
Absence seizures are mainly a disorder of children and are characterised by a brief lack of
awareness (staring vacantly into space) for several seconds. These can occur multiple times
a day. In most children absence seizures resolve but they may persist into adulthood.
Absence seizures are treated with sodium valproate (see doses above) or ethosuximide.

Ethosuximide
Children 1 month – 6 years, initially 5mg/kg twice daily, usual: 20-40 mg/kg a day in 2 doses
Children > 6 years, initially 250 mg twice daily, usual dose 500-750mg twice daily
Side effects: gastrointestinal upset, gum hyperplasia, drowsiness, blood disorders

Cerebral Palsy
Cerebral Palsy is a neurological syndrome caused by damage to the immature brain. It
usually occurs prenatally but can also occur perinatally and up to the age of 3 years. Causes
include toxins, teratogens, genetic problems, intrauterine infections, metabolic problems
(such as damage to the cornea), perinatal hypoxic-ischaemic injury, meningitis, cerebral
malaria and other infections, seizures and head injury. It results in permanent disability with
posture and movement disorders (poor coordination, weakness, spasticity, ataxia and
involuntary movements) and intellectual disabilities (communication, behavioural and
emotional difficulties). It also can cause problems with vision, hearing and swallowing.

Diazepam or baclofen can be used to treat spasticity. Baclofen is preferable for chronic
severe spasticity. (NB not currently on Essential Medicines list).

Baclofen
Child 1 month – 17 years initially 300 mcg/kg in 4 divided doses increasing gradually until
satisfactory response (< 7 years max 40mg, 7 -17 years max 60mg).
Adult 10mg three times a day (increase up to 100mg daily).
Side effects: drowsiness, weakness, dizziness, seizures, nausea, vomiting, headache

Migraine
Migraine is a periodic severe headache which usually occurs unilaterally and is often
described as throbbing and worse with physical activity. It typically lasts between 4-72 hours,
with associated nausea and or/vomiting, and sensitivity to light and/or sound. Some patients
have migraine with aura. This typically lasts for 5-60 minutes before the headache starts and
may be visual (flashing lights/jagged lines), or sensory (numbness/tingling).

Treatment of the acute episode is with ibuprofen or acetylsalicylic acid.

 Ibuprofen 400mg every 6-8 hours
 Acetylsalicylic acid 300 – 900 mg every 4-6 hours (maximum 4g daily)
 If unable to take ibuprofen or aspirin use paracetamol 1g every 6 hours
 Add promethazine 25mg or metoclopramide 10mg for nausea

145
  If not responding/severe give Diclofenac 75 mg IM plus metoclopramide 10mg IM/IV
for nausea and vomiting
 Or ergotamine 2mg sublingual, then 1-2 mg hourly to a maximum of 6 mg/24 hours

Migraine Prophylaxis
 For those patients with migraines occurring at least twice a month or for those whose
migraines are severe, prolonged or disabling give prophylactic medication.
 Amitriptyline 10-75 mg at night
 or Propranolol 40-80 mg twice daily
 Sodium valproate can be used as second-line for prophylaxis 400-1500mg/day
(usual dose 600mg twice daily)

Parkinson’s Disease
Parkinson’s Disease is a degenerative condition of the brain caused by loss of dopamine
releasing neurones in the brain. It presents as a progressive movement disorder that causes
tremor, stiffness, and movement problems. It is a disease of the elderly. Certain drugs such
as chlorpromazine and promethazine can cause drug-induced parkinsonism.

The diagnosis is clinical:

 tremor at rest (unilaterally initially but progressing to bilateral, often worse on one
side)
 rigidity (stiffness noted with passive movement)
 bradykinesia (slowness of voluntary movements and reduced movements such as
arm swing, spidery writing)
 balance and gait disorder (difficulty in rising from a sitting position and starting to
walk, small shuffling steps, difficulty turning and stopping, falls)

Other features include loss of facial expression, impaired communication and understanding,
mood and behaviour changes, sleep problems, orthostatic hypotension and postural
instability, bowel/bladder problems, unexplained pain, hypersalivation, dementia, and altered
sensation of smell. Some of these can occur before the presentation of motor symptoms.

Parkinson’s disease dementia is similar to Alzheimer’s but may include visual hallucinations
and fluctuations in lucidity. Depression is common.

Drugs provide symptomatic relief, not cure. Initial treatment is with levodopa which is
converted to dopamine in the brain. It is given with carbidopa, which prevents peripheral
conversion to dopamine. Levodopa has a high risk of causing abnormal movements.

Levodopa-carbidopa 25/100 mg
Initially 25/100mg 3 times a day increased in steps of 12.5/50mg – 25/100mg once a day or
every other day up to 200/2000mg daily, depending on response.
It is important to tell patients to avoid abrupt withdrawal (risk of neuroleptic malignant
syndrome and rhabdomyolysis).
Side effects: nausea, vomiting, dyskinesias, orthostatic hypotension, impulse control
disorders, excessive sleep and sudden onset of sleep, hallucinations and delusions

Biperidine (benzhexol)
Benhexol is used to help dyskinetic movements and spastic contractions in patients with
Parkinsons disease. It works by reducing the effects of relative central cholinergic excess
that occurs as a result of dopamine deficiency. It can aggravate dementia.
Start 1mg/day, and increase up to 15mg daily 1-3 times a day, usual dose 6-10mg/day in 3-4
divided doses

146
Side effects: drowsiness, dry mouth, palpitations, urinary retention, constipation, agitation.

4.8 Thyroid Disease

Thyrotoxicosis
This should be suspected in people with goitre, tremor, heat intolerance, sweating, anxiety,
weight loss and palpitations. The pulse may be faster. There may also be exophthalmos.
Most cases are caused by Grave’s disease which is an autoimmune disease. If Thyroid
Stimulating Hormone (TSH) measurement is available it should be measured (in
thyrotoxicosis before treatment it is <0.01mIU/L, with a raised T3/4).

Treatment steps
If the diagnosis of Grave’s disease is most likely then:
 Give beta-blocker (atenolol or propranolol, but not to asthmatics) to improve
symptoms until the person is euthyroid. Use pulse rate to monitor dose.
(Propranolol 20mg to 40mg or atenolol 50mg 2 to 3 x a day).
 Carbimazole is prescribed to treat the hyperthyroidism. Can harm the unborn
child so should only be given to pregnant women by a specialist, or alternative
medical treatment considered if available.
 Surgery may be considered only by a surgeon specialised in thyroidectomy, but
there are very dangerous potential complications and the person is left with
permanent hypothyroidism.
 Atrial fibrillation is a complication of hyperthyroidism and should be treated by
reducing the cardiac rate (with a beta blocker like atenolol or propranolol).

Carbimazole is initially given between 15mg to 40mg daily (max 60mg). This is continued
until the patient becomes euthyroid (usually between 4 and 8 weeks) when the dose is
gradually reduced to a maintenance dose of between 5 to 15mg daily for 12 to 18 months.
Many people relapse after treatment and will need re-treatment. Only a specialist should
treat thyrotoxicosis in children.

Side effects: rash and itching, if not severe, can be treated with an antihistamine and
treatment with carbimazole continued. A rare and dangerous side effect of carbimazole is
agranulocytosis (very low white blood cells) - an urgent blood count is done if there is a sore
throat or fever. Treatment must be stopped.

Other causes of thyrotoxicosis:

Subacute thyroiditis (de Quervains) is transient viral infection which presents with painful
goitre and fever.

 Give supportive treatment with beta-blockers (atenolol or propranolol, but not to

asthmatics) and analgesia until symptoms improve. The thyroid function normalises
at 4 to 6 weeks.

Toxic nodular goitre is more common in elderly and iodine deficient areas. Nodules secrete
thyroid hormone. Remember that isolated thyroid nodules may be malignant.

 Carbimazole is given and a beta-blocker (but not to asthmatics) to control symptoms

until a more definitive treatment can be given by a specialist.

147
Thyrotoxic crisis (thyroid storm)
This is a rare but life-threatening complication of thyrotoxicosis caused by excessive release
of thyroid hormone. If left untreated it can be fatal. Patients may have a pre-existing
diagnosis of hyperthyroidism or this may be the initial presentation.

The diagnosis is clinical and usually most of the following signs/symptoms are present:

 Fever>38.5°C and frequently hyperpyrexia (>41°C), profuse sweating

 Tachycardia
 Poor feeding in children and weight loss
 Hypertension – which may lead to congestive heart failure and subsequently
cardiac arrhythmias, hypotension and shock
 GI symptoms – vomiting, diarrhoea, jaundice and abdominal pain
 Neurological symptoms - anxiety, altered behaviour, seizures/coma

Patients will require urgent supportive care as an inpatient:

 Fluid resuscitation
 Give paracetamol 1g PO/IV
 Steroids – IV hydrocortisone (100mg every 6 hours) if available or prednisolone 60-
80mg/day PO for adults
 Beta-blocker – propranolol (can be given IV if available) . 40mg 4 x a day.
 Carbimazole – 15 – 40mg/day
 Potassium iodide (stops release of preformed thyroid hormone). Use 5–10 drops (1ml) of
Lugol's solution (Iodine and potassium iodide 5%+10% ,130mg total iodine/ml) orally
every 6– 8 hours (For use by specialist only)
 Once clinically improved taper steroids and continue hyperthyroid management.

Hypothyroidism
Hypothyroidism refers to an underactive thyroid gland. It affects 1-2% of the population
worldwide and is most commonly caused by low iodine in the diet. Almost one third of the
world’s population live in areas of iodine deficiency. It is also caused by autoimmune
disease, post-thyroiditis and is always present after a total thyroidectomy. It is more common
in women. It is particularly important to diagnose hypothyroidism in pregnancy as it is
associated with congenital hypothyroidism in the newborn. This can affect brain
development of the fetus and cause delayed development and disability.

Symptoms and signs: non-specific, including weight gain, poor concentration, tiredness,
depression, muscle weakness, facial puffiness, dry skin, hair loss and fertility problems. It is
associated with impaired cardiac function and in children, it can lead to delays in growth and
intellectual development. In extreme cases it can be fatal.

The diagnosis of hypothyroidism is based on a raised TSH. T4, if measured, is usually low. It
is easily treated by giving the thyroid hormone levothyroxine in replacement doses. (In sub-
clinical hypothyroidism the TSH is high but the T4 is normal).

Levothyroxine
Start with 50 – 100 micrograms (less if heart disease) or 1.6 mcg/kg daily. The dose can be
increased in steps of 25 micrograms every 3 -4 weeks according to response. The
maintenance dose is likely to be between 100 and 200 micrograms for an adult. The goal of
treatment is to improve symptoms and for most patients that will be achieved at (if the test is

148
available) a TSH between 0.4 and 2.5 mU/l. Repeat TSH 6-8 weeks after initiation of
treatment or a change in dose. Once stable check annually. Treatment is life-long.
Educate patients on use of iodised salt.

Side effects: mainly if the dose is too much, in which case: diarrhoea, palpitations,
arrhythmias, tremor, weight loss and other signs of hyperthyroidism.

Pregnancy can trigger the progression of subclinical hypothyroidism to overt hypothyroidism

and can increase levothyroxine requirements. If a woman with hypothyroidism becomes
pregnant increase the usual levothyroxine dose by 30% as soon as it is known she is
pregnant. If available, monitor TSH at least once each trimester. Women with subclinical
hypothyroidism who are trying to conceive should be given levothyroxine.

If hypothyroidism is diagnosed during pregnancy, specialist assessment is advised to aim to

correct TSH as quickly as possible. This includes for infants born with hypothyroidism which
needs urgent treatment, and the dose monitored according to growth, clinical response and
biochemistry.

Endemic goitre
Endemic goitre is an enlargement of the thyroid gland and occurs in iodine deficient areas of
the world. It can also be caused or aggravated by goitrogens such as manioc, cabbage,
turnips and millet. Vitamin A deficiency and protein energy malnutrition can be contributing
factors. Thyroid function usually remains normal but in pregnancy it can cause fetal and
perinatal mortality, and physical and mental retardation.

The use iodised salt has made it a rare disease in many areas and supplying iodised
salt/sugar/oil capsules through national programmes is the recommended method of
prevention. In South Sudan most programmes do not exist and iodised salt is not alwys
available. If iodised salt is not available use iodised oil as a single yearly dose (190mg
capsule).
 Children under 1 year – 1 capsule
 Children 1 - < 6 years – 2 capsules
 Children 6-15 years – 3 capsules
 Women child bearing age 2 capsules

Curative doses are the same and are especially important in pregnant women, women of
child bearing age and children. The goitre can disappear with treatment in children but may
not in adults. Surgery is sometimes indicated if causing mechanical complications.

4.9 Blood Disorders

Anemia
Anemia needs investigation of its cause in order to treat it and prevent its recurrence.

Causes:

Decreased production of red blood cells

 Nutritional iron, and/or folic acid/vitamin B12 deficiency (poor diet or poor absorption)
 Depressed bone marrow function (leukaemia, aplastic crisis)
 Infections (TB, malaria, visceral leishmaniasis)
 Anemia of chronic disease (eg kidney failure, liver disease)
Increased destruction of red blood cells (haemolysis)
 Malaria

149
  Drug side effects (dapsone, cotrimoxazole, zidovudine)
 Haemoglobinopathies (eg sickle cell anemia, thalassaemia)
Loss of red blood cells
 Acute and chronic blood loss (trauma, hookworm infestation, pregnancy,
menorrhagia, schistosomiasis, GI bleeding)

The mean cell volume (MCV) and reticulocyte count can help determine the cause:

Low MCV (microcytic anemia)

 Iron deficiency anemia (often nutritional and/or chronic blood loss)
 Thalassaemia
Normal MCV (normocytic anemia)
 Acute blood loss
 Anemia of chronic disease
 Bone marrow failure (aplastic crisis, no reticulocytosis)
 Haemolysis or splenic sequestration (may have increased MCV, reticulocyte count
high)
High MCV (macrocytic anemia)
 B12 or folate deficiency
 Alcohol excess or liver disease
 Thyroid disease
 Antifolate drugs

If the haemoglobin is below 6 g/dl (or the patient has rapid breathing), admit for further
treatment including transfusion.

Iron deficiency anemia

Common; often due to poor nutritional intake and chronic blood loss.
Treat with a combination of ferrous sulphate and folic acid.

Ferrous sulphate 200mg/Folic acid 0.4mg for 2-3 months. Doses:

 0-12 months ¼ tablet PO daily
 1-4 years ½-1 tablet PO daily
 5-10 years 1-2 tablets PO twice daily
 Children over 10 years and adults 1-2 tablets PO twice daily

Other formulations:
 Ferrous sulphate tablet (60mg iron)
 Ferrous sulphate paediatric 25 mg iron/ml

Also give presumptive treatment for worms:

 Albendazole PO
Children > 2 years and adults 400mg single dose (not during first trimester of
pregnancy) (If child 1 to < 2 years give 200mg single dose)
 Or Mebendazole PO
Children > 2 years and adults 500mg/day single dose (not during first trimester of
pregnancy) (If child 1 to < 2 years give 200mg single)

For children also give Vitamin A (if last dose > 4 weeks ago)

Vitamin B12 deficiency anemia

Vitamin B12: hydroxycobalamin injection 1mg/ml

150
1mg IM daily for 5 days then 1mg once weekly for 3 weeks then 1mg every 2-3 months (for
pernicious anemia)

Folate acid deficiency rarely occurs in isolation.

Nutrition: Patients should be encouraged to increase intake of foods high in iron, folic acid
and Vitamin B12 such as lemons, mangoes, tomatoes and other fruit, dark green
vegetables, wholemeal bread, beans, meat and liver.

Thalassaemia
Thalassaemia is an inherited disease with faulty haemoglobin production. It is not common
in South Sudan. Thalassaemia minor (a person has the thalassaemia gene from only one
parent) presents with mild anemia > 10g/dl and is asymptomatic. Thalassaemia major (when
a person has inherited thalassaemia genes from both parents) is a permanent condition of
severe anemia, jaundice and splenomegaly with complications of recurrent infection and
bone deformities. Treatment involves repeated blood transfusions. These result in iron
overload which causes endocrine failure (pituitary, thyroid and diabetes mellitus), cardiac
toxicity and liver disease (haemochromatosis). Long-term chelation therapy is needed to
avoid too much iron deposition from repeated transfusions.

Treatment of thalassaemia major

 Life-long blood transfusions are needed
 Long-term chelation therapy helps prevent iron overload
 Folic acid
Children < 1 year: 2.5 mg once daily
Children ≥ 1 year and adults: 5 mg once daily
 Immunisation as per national guidelines, especially against pneumococcus, hepatitis
B and haemophilus influenzae type B
 Splenectomy is sometimes performed to reduce the need for repeat transfusions in
adults and children > 6 years (not before as high rate of infections in those without a
spleen)
 In post-splenectomy patients. long-term prophylactic penicillin is recommended (see
under sickle cell anemia)
Iron chelation in thalassaemia
 Desferrioxamine subcutaneous infusion/IV 25–50 mg/kg/day over 8–12 hours, 5–7
days per week.
Young children should be started on a dose of 25–35 mg/kg/day, increasing to a
maximum of 40 mg/kg/day after 5 years of age and increasing further up to 50
mg/kg/day after growth has ceased
 Give ascorbic acid (vitamin C) up to 200 mg/day orally one hour after initiating
chelation to promote iron excretion

Sickle cell disease

Sickle cell disease is common amongst South Sudan populations. It is an inherited disease
with faulty haemoglobin production leading to red cells that form a crescent shape. In sickle
cell trait the person inherits the gene from only one parent and the only effect is mild anemia.
In sickle cell disease a person inherits the genes from both parents. There is increased
destruction of red blood cells (haemolysis), an increase in blood viscosity and obstruction of
capillaries (vaso-occlusion), causing severe chronic anemia, jaundice, splenomegaly,
skeletal abnormalities and delayed puberty. Acute complications include painful vaso-
occlusive, haemolytic or aplastic crises. Life threatening complications include stroke,
overwhelming infections and acute chest syndrome.

151
Chronic anemia
Hb 6-9 g/dl

Painful vaso-occlusive crisis (VOC)

Common, due to microvascular occlusion precipitated by cold, infection, dehydration or hypoxia.
Children under 2 years of age present with pain and swelling in the hands and feet (dactylitis), or non-
specific signs such as irritability, refusal to walk and lack of appetite. Older children and adults
present with acute pain in the back, chest, abdomen and extremities. Vaso-occlusion can cause stroke,
acute chest syndrome, acute abdomen (mesenteric ischaemia), priapism, renal infarction and bone
infarction
 Treatment is with analgesics, warm compresses and rehydration.
 It is important to manage pain effectively, morphine is often needed.
 Pain medications:
o Paracetamol 1g every 6-8 hours, child 10-15 mg/kg every 6-8 hours
o Ibuprofen 400-600mg every 6-8 hours, child 5-10 mg/kg hourly
o Diclofenac 50mg 8 hourly, child > 9 years and >35 kg 2mg/kg in 3 divided doses
o Codeine 30-60 mg every 6 hours (>12 years)
o Tramadol 50-100mg every 6-8 hours (>12 years)
o Oral morphine 0.2-0.6 mg/kg every 4 hours
o IV morphine child 0.1-0.2 mg/kg per dose, adult 5-10mg per dose and re-assess
 Rehydrate with oral fluids and if necessary IV normal saline.
 Correct hypoxia: give supplemental oxygen if needed, and available.
 Treat malaria if needed.
 Treat bacterial infections. Look for pneumonia, cellulitis, meningitis, osteomyelitis and sepsis
(especially due to pneumococcus, meningococcus and haemophilus influenzae). Consider
osteomyelitis in a painful limb not responding to analgesia
 Hydroxyurea can reduce painful episodes by 50%. Give hydroxyurea 10–15 mg/kg/day given
as a single daily dose. Because is suppresses the bone marrow, white cells will decrease and
can increase liver enzymes. Also can cause nausea and vomiting. Stop using if white cells fall
too low or LFTs rise too high.
 Stroke
Usually ischaemic, may resemble meningitis or cerebral malaria. In addition to treatment for
vasculo-occlusive crisis give oxygen to maintain O2 saturation 94-98% and transfuse if
needed. Transfer to a specialised facility if possible, (an exchange transfusion can lower the
concentration of HbS). Hydroxyurea may help. See above.
 Acute chest syndrome
This presents with chest pain, tachypnoea, respiratory distress, hypoxia, fever, and infiltrate
on chest X-ray. It can lead to multiorgan failure. In addition to treatment for vasculo-
occlusive crisis give oxygen to maintain O2 saturation 94-98%, transfusion if needed, empiric
antibiotics (ceftriaxone and azithromycin), salbutamol if wheezing, and encourage deep
breathing (incentive spirometry hourly)
 Acute abdomen
In addition to treatment for vasculo-occlusive crisis give nil by mouth, naso-gastric tube on
free drainage and antibiotics - ceftriaxone and metronidazole and surgical review
 Priapism
Can occur in boys and men and lead to necrosis and irreversible erectile dysfunction. Treat
with hydration, warm compresses and analgesia, consider transfusion and refer to surgery
urgently if not improving

Severe anemia
Acute on chronic severe anemia may be precipitated by splenic sequestration, haemolysis or an
aplastic crisis.
Look for:

152
  Malaria - fever, dark urine/haemoglobubinuria, yellow conjunctivae
 Splenic sequestration - more common age 1-4 years - sudden enlargement of the spleen, left
upper quadrant pain, thrombocytopenia, signs of shock
 Aplastic crisis - no reticulocytosis, impalpable spleen
Treat the underlying infection if present, IV fluids for shock and with transfusion if Hb < 5g/dl.

Prevention
 Treat all infections promptly
 Avoid precipitating factors like dehydration, hypoxia, infection and cold
 If severe anemia give transfusion
 Give phenoxypenicillin to prevent pneumococcal infections till age 15 years (at a
minimum to 5 years old), starting at 1-2 months of age:
Children < 1 year: 125 mg/day in 2 divided doses
Children 1 to < 5 years: 250 mg/day in 2 divided doses
Children 5 to 15 years: 500 mg/day in 2 divided doses
Or give benzathine penicillin 2.4 million IU IM once a month
 Immunisations as per national guidelines: Hepatitis B, polio, DTP, measles,
Haemophilus influenzae type B, pneumococcal conjugate vaccine PCV13 (or if
unavailable PCV 7) and pneumococcal 23-valent vaccine (at age 2) and
meningococcal vaccine in endemic areas.
 Folic acid. Children < 1 year: 2.5 mg once daily. Children ≥ 1 year and adults: 5 mg
once daily
Malaria chemoprophylaxis is very important for people with sickle cell disease to reduce
anemia and prevent painful crises, but there is no consensus on which drug to use. Use one
of the following:
o sulphadoxine- pyrimethamine child 2-5 ½ tab monthly, 5-10 years 1 tab
monthly, 10-15 years 2 tabs monthly, > 15 years 3 tabs monthly. OR
o Mefloquine PO: Children 6 months to 5 years and > 5 kg: 5 mg base/kg once
weekly. Do not use to treat malaria OR
o chloroquine adult 300mg base weekly, child 5mg/kg base weekly AND
o Paludrine (proguanil) 100mg for adults/1.5mg/kg in children is given daily or
sometimes as intermittent preventive in the rainy season.

Congenital bleeding and clotting disorders

Treatments are not currently available. This will be covered in future edition of STGs.

Disseminated intravascular coagulation (DIC)

For transfusion for DIC see Section 5.3

Leukaemia
A group of cancers that usually begin in the bone marrow and result in high numbers of
abnormal white blood cells (leukaemia cells). Presents with infections, fever, tiredness,
bleeding, bruising and anemia. Treatment is not currently available in South Sudan for the
four types of acute and chronic lymphocytic and myeloid leukaemias. Treatment will be
covered in future edition of STGs.

Burkitt’s lymphoma is a cancer of the lymphatic system. Usually aggressive and fast
growing it is a non-Hodgkin’s lymphoma associated with Epstein-Barr virus. Risk factors
include HIV/AIDS and chronic malaria. More common in children. Presents with swelling of
affected jaw/bones and rapidly enlarging non-tender lymph nodes in the neck/jaw. The
disease characteristically involves the jaw or other facial bone, distal ileum, caecum, ovaries,
kidney or the breast. Refer to cancer treatment specialist centres for management. Survival
rate is high with localised disease and treatment.

153
4.10 Eye Disease
Diagnostic eye drops
 Fluorscein and Rose Bengal eye drops are used to stain the eye to identify corneal
and conjunctival damage – use sufficient amount to stain area.
 Atropine, cyclopentolate and phenylephrine eye drops cause mydriasis and are used
to dilate the pupil to examine the fundus.
 Tetracaine eye drops are used for topical anaesthesia.

Stye
This is a localised infection of a hair follicle of the eyelid which presents with a small swollen
area and pain. A stye usually clears up by itself. A warm compress may help.
 Apply tetracycline1% eye ointment 2-4 times daily
 Admit if the whole eye lid is swollen and give oral erythromycin 500mg 4 x a day for 5
to 7 days

Blepharitis
Blepharitis is a mild but chronic inflammation of the eye lids with small flakes/ scales.
Use warm water compresses to soften crust and scale and clean the eyelids gently with
baby shampoo or bicarbonate of soda. If persistent, treat with tetracycline 1% eye ointment
to the lid margins at night. This may be needed for several weeks.

Conjunctivitis
Conjunctivitis is an inflammation of the conjunctiva of the eye. Symptoms and signs include
eye discomfort and itch, and discharge and redness of conjunctiva (the white of the eye). It is
commonly bilateral and is often caused by infection (viral or bacterial). The discharge maybe
be watery or purulent (latter more likely with bacterial infection).
It can also be caused by trauma (chemical, foreign body), allergy or irritant (smoke). The
cornea is usually clear and visual acuity is normal. (Suspect keratitis, corneal ulcer or foreign
body if there is intense pain and photophobia. If present, use fluorescein (1 drop) to check
for corneal ulcerations).

Treatment
 For infective conjunctivitis apply chloramphenicol 0.5% eye drops or tetracycline 1%
eye ointment 4 times daily for 5 days.
 Clean eyes 4-6 times daily with boiled water.
 Admit if eye is painful, or if there is redness around the cornea, if the eye lids are
puffy or if there is photophobia, and treat for potential iritis.
 Admit if the conjunctivitis does not improve in 2 days.

Advice: Review if not rapidly improving. Do not put any other product in the eye or any herbs
or local medicines.

Other antibiotic eye drops include:

Ciprofloxacin eye drops 4 times daily, or more frequent for severe infection/corneal ulcer
Side effects: corneal deposits which disappear after treatment, ocular discomfort
Gentamicin eye drops every two hours then reduce to 3-4 x daily as infection is controlled for
48 hours after healing

Allergic conjunctivitis
This is a relatively benign condition that causes itch and watering of the eyes. It may present
with enlarged papillae of the upper eye lid, seen when this is inverted. It must be
distinguished from infectious conjunctivitis and other eye conditions such as uveitis.

154
Treatment
 Sodium cromoglycate eye drops ( if available), 2 drops applied to both eyes 4 x a day
 Oral antihistamines such as chlorphenamine 4mg and loratadine 10mg.

Neonatal Conjunctivitis
This is caused by Neisseria gonorrhoeae or Chlamydia trachomatis and occurs in babies
born to infected mothers. If there is purulent conjunctivitis within the first 28 days of life:
 Admit immediately. Give IM or IV ceftriaxone 25-50mg/kg once a day for 5 days.
 Clean eyes with 0.9% sodium chloride and apply tetracycline eye ointment hourly.
 If systemic treatment is not immediately available apply tetracycline eye ointment in
both eyes every hour until hospitalised.
 Continue hourly topical treatment and cleaning till pus stops then reduce to 4 x daily.
 Treat mother and partner.

Prevention: immediately at birth:

 Clean eyelids with sterile 0.9% sodium chloride.
 Apply tetracycline eye ointment 1% once in both eyes.
 (If the mother has herpes simplex virus infection apply acyclovir eye ointment and 12
hours later apply tetracycline).

Herpes simplex keratoconjunctivits

This is a dangerous infection of the eye that can cause ulcers, uveitis and blindness.
Treatment:
 Acyclovir eye ointment applied 5 x per day and for at least 3 days after complete
healing
 Tetracycline eye ointment or chloramphenicol eye drops applied 4 x per day for 7
days (to treat secondary bacterial infection).
 Atropine eye drops to dilate the pupil and prevent adhesions between the inflamed
iris and the lens
 An eye pad to cover and protect

Corneal ulcer
Corneal ulcers are very painful, and present with watering of the eye, photophobia and
redness around the cornea. Visual acuity is usually reduced. If not properly treated they can
cause blindness. Use anaesthetic drops (tetracaine) if pain is severe. Examination with
fluorescein drops shows up an abrasion or ulcer as an area of fluorescence – a dendriform
(branch like) lesion suggests herpetic disease. Look for foreign body and remove if possible.

Treatment:
 Antibiotic eye drops or eye ointment + acyclovir eye ointment if herpes suspected
 Atropine eye drops to relieve pain, dilate the pupil and prevent adhesions between
the inflamed iris and the lens
 An eye pad to cover and protect.

The eye is examined at least twice a day until the ulcer starts to heal. For fungal infections
use econazole eye drops and refer. Give vitamin A capsules for children (see under
xeropthalmia).

Iritis/ Uveitis
Anterior uveitis presents with photophobia, ciliary injection (red around cornea), poor vision,
a small and irregular pupil, and precipitates in the anterior chamber. Posterior uveitis
presents with poor vision and precipitates in the vitreous.

155
The diagnosis of uveitis requires an eye expert. It is usually an inflammatory autoimmune
condition and if not properly treated it can cause blindness. Treatment is with steroid drops
and atropine drops to dilate the pupil. These should only be given by a health professional
who is sure of the diagnosis (has been trained) and who can follow up the person, usually
with admission for the first 2 days until the adhesions that form between the iris and lens
have separated. Surgery may be needed to separate these in chronic uveitis.

 Atropine eye drops –Twice daily for 2-3 days (up to 3 times daily for 10 days)
Cyclopentolate eye drops are an alternative mydriatic.
 Steroid eye drops - prednisolone 4 times daily for 3 days, then 3 times daily for 3
days, then 2 times daily for 3 days, then once daily for 7 days
 Tetracycline eye ointment twice daily for 7 days
 Acetazolamide if raised IOP

Caution: Steroid drops should only be given by someone trained in eye care and when
there is no infection present, and only used for short period because they may cause a rise
in intraocular pressure and cause may cause chronic glaucoma and blindness. They must
never be given for an acute red eye caused by a bacterial infection or herpes simplex virus.

Orbital cellulitis
Orbital cellulitis is an infection of the tissues in the orbit which presents with painful swelling
of the eye, worse with eye movements, possible diplopia, decreased vision, fever and
headache. It usually arises as spread from sinusitis. It is treated in hospital with ceftriaxone
and, cloxacillin or clindamycin. If hospitalisation is not possible treat with cefalexin or co-
amoxiclav and follow up until improvement begins.

Trachoma
Trachoma is the leading cause of preventable blindness in the country. It is caused by
chlamydia trachomatis which is highly contagious and endemic in certain areas. Repeat
untreated infections and chronic inflammation cause scarring of the eyelid which turns
inwards (entropion) and causes the eyelashes to scratch the cornea (trichiasis). This in turn
causes chronic inflammation of the cornea, scarring, opacity and irreversible blindness.

The infection is identified by examining the upper tarsal conjunctiva which when infected
appears as follicular with whitish, grey or yellow elevations, paler then the surrounding
conjunctiva. With chronic inflammation the tarsal conjunctiva becomes red, rough and
thickened and then scars with white lines, bands and patches.

 Treat trachoma conjunctivitis with tetracycline ointment 1% 3 x daily for 7 – 14 days.

 For chronic eye problems treat with azithromycin by mouth 1g as a single oral dose
(child 20mg/kg), or erythromycin 500mg every 6 hours for 14 days (child 10-15 mg/kg
per dose).
 Failing this use tetracycline ointment 2 times daily for 6 weeks.
 Infants < 6 months are not given oral treatment but instead are given tetracycline eye
ointment.
 Surgery is needed to correct entropion/trichiasis before there is scarring of the
cornea.

Prevention of trachoma

SAFE is the WHO’s strategy for trachoma control:

156
  S = surgery for trichiasis including surgical campaign
 A = antibiotics for early treatment of conjunctivitis and mass treatment. The South Sudan
prevention guidelines advocate azithromycin distribution 1-2 times a year to everyone over
the age of 1 year in villages with high prevalence.
 F = facial cleanliness. Health promotion for use of soap; regular washing of hands and face.
 E= environmental improvement. This includes improved sanitation and separating people and
animals to reduce flies, use of latrines and better access to water.

Vitamin A deficiency/Xerophthalmia
Vitamin A deficiency can cause night blindness. This can progress to dry eyes, eye pain,
corneal ulcerations, keratomalacia and total blindness. High dose vitamin A supplementation
can prevent xeropthalmia and also reduce the severity and morbidity of certain childhood
infections, particularly measles and diarrhoea.

Treat suspected Vitamin A deficiency on days 1,2 and at 2-4 weeks

 Child < 6 months 50,000 IU
 Child 6-12 months 100,000 IU
 Adult and child > 1 year 200,000 IU

If eye show corneal clouding or ulceration, give chloramphenicol drops or tetracycline

ointment 4 times daily. If there is ulceration admit immediately. Parenteral antibiotics are
likely to be needed to treat or prevent secondary bacterial infection, and the child is likely to
also have severe acute malnutrition (SAM) so will need to be admitted for inpatient
therapeutic nutritional care.

Prevention: Prevention guidelines advocate Vitamin A to be given twice a year to children

under five during immunisation days.

 Children under 6 months 50,000 IU as a single dose

 Children 6-12 months 100,000 IU every 6 months
 Children 1-5 years 200,000 IU every 6 months
 Children with measles on day 1 and day 2
 Mothers after giving birth 200,000 IU as a single dose after delivery or within 8 weeks
of delivery

All doses of vitamin A should be recorded. Avoid excessive Vitamin D as this may cause
raised intracranial pressure, impaired consciousness and convulsions.

Glaucoma
Glaucoma is a dangerous disease of the eye caused by an increase in pressure that
damages the retina, causing initial loss of the peripheral vision (”tunnel vision”) but
progressing if untreated to blindness. It can be congenital, or acute angle-closure glaucoma
that needs treating with surgery, or chronic open-angle glaucoma that can be treated with
drops that reduce the pressure. Surgery may also be needed. It is very important that
glaucoma is diagnosed early, by routinely measuring the pressure of the eyes of people over
50 and in appropriate preventative treatment for people with trauma to eye or uveitis.

Acute angle-closure glaucoma occurs when the trabecular meshwork at the irido-corneal
angle is physically obstructed. It presents with sudden onset of severe eye pain and redness
associated with nausea, vomiting and headache, loss of vision in the affected eye and a
hazy looking cornea with a fixed semi-dilated pupil and elevated IOP (eye feels hard in
comparison to the other eye). This is a medical emergency.

157
  Give acetazolamide PO 250mg 2 – 3 x per day for short term use to urgently reduce
intraocular pressure.
 Ophthalmologist needs to operate urgently.
 Timolol 0.5% eye drops (beta-blocker – do not use if asthmatic or bradycardia), apply
1-2 drops twice daily
 Or Pilocarpine 2%, 4% eye drops, use 4 times daily
Side effects: pupil miosis causing blurred vision, ciliary spasm with headache and
brow-ache

Chronic open-angle glaucoma is more common, its prevalence increases with age. It is
usually asymptomatic with a history of gradual loss of vision or visual field. It is diagnosed by
finding cupping of the optic disc on routine fundoscopy or finding elevated intra-ocular
pressure on screening. (Glaucoma can be present with a normal IOP).
Treatment
 Timolol 0.5% eye drops (beta-blocker – do not use if asthmatic or bradycardia) one
drop twice daily, life-long
Can cause effects similar to oral beta-blockers – not recommended for those with
asthma, bradycardia
Side effects: anaphylaxis, keratoconjunctivitis, burning, dry eyes, itching
 or prostaglandin analogue eye drops such as latanoprost daily ( if available), in
evening Side effects: darkening of the iris and thickening of eyelashes
 Acetazolamide tablets 0.25-1g daily in divided doses
Side effects: ataxia, depression, diarrhoea, dizziness, excitement, fatigue, flushing,
headache, irritability, loss of appetite, nausea, paresthesiae, polyuria, reduced libido,
taste disturbance
 Ophthalmologist may do a trabeculectomy operation

Cataract
Cataract is an opacity of the lens that causes a progressive loss of visual acuity. Cataract is
common in the elderly. Children can be born with congenital cataracts. The presence of
cataract in both eyes leads to blindness. Surgery is the only treatment.

Retinal and choroidal disorders

Will appear in the next edition of STGs
4.11 Ears, nose, throat and oral
Ear wax
Wax occurs naturally in the ear canals and has a protective function. Do not remove wax
unless specifically trained to do so. If the canal is blocked, use vegetable oil or sodium
bicarbonate drops. These are applied at home for one week. Ear wax can be syringed out of
the canal by someone specially trained to do so.

Advice: Advise people never to put cotton buds or any instrument inside the ear canal.

For acute ear infections see Section 3.2

Chronic suppurative otitis media

Perforation of the tympanic membrane with a purulent discharge to the external canal from
the middle ear is a relatively frequent presentation of acute otitis media in children. These
perforations usually close within a few weeks. Antibiotics are often not needed in acute otitis
media but if the earache is severe or discharge continues for more than two weeks treat with
antibiotics:
 Amoxicillin PO for 7 days

158
 o Children 1 - 11 months 125 mg 3 x per day
o Children 1 - 4 years 250 mg 3 x per day
o Children > 5 years and adults 500 mg 3 x per day
 In case of allergy give erythromycin
 If the suppuration continues with no change, then a broad-spectrum antibiotic may be
needed. The causative organisms include S. aureus and pseudomonas
 Ciprofloxacin PO for 5 days
o Children 1 - 5 years 125 mg 2 x per day
o Children 6 - 12 years 250 mg 2 x per day
o Children > 12 years and adults 500 mg 2 x per day
 An alternative treatment is with topical ciprofloxacin ear drops 2 drops twice daily
 If symptoms persist, a specialist should exclude a cholesteatoma as a cause of a
chronic discharging middle ear
 Consider mastoiditis in case of new onset high fever, severe ear pain and/or tender
swelling behind the ear, in a patient who appears unwell. Hospitalise and treat with
ampicillin and gentamicin IM/IV
 Consider brain abscess or meningitis in case of impaired consciousness, neck
stiffness and focal neurological signs such as facial nerve paralysis

Otitis externa
Otitis externa is an inflammation of the external ear canal, which causes pain and discharge
and swelling and closing of the canal. Movement of the pinna can be tender. It is associated
with flaking of the skin in the canal.

 Mild infectious cases often respond to acetic acid drops which are anti-fungal and
anti-bactericidal (or aluminium acetate 3% ear drops)
 Some people have recurrent eczematous otitis externa and may benefit from steroid
drops alone (betamethasone or prednisolone ear drops)
 Betamethasone ear drops
2-3 drops every 2-3 hours, reduce frequency as improving, avoid prolonged use
Side effects: may cause local sensitivity reactions
 Persisting cases that don’t respond may need to be treated with antibiotic drops with
or without steroid drops (either separate or combined preparations, depending on
what is available)
o Gentamicin drops (for eye/ear) 2-3 drops 4-5 times daily, not for longer than two
weeks
o Ciprofloxacin ear drops 0.3%
o Dexamethasone + tobramycin ophthalmic solution 0.1% and 0.3% for use in ears
o Hydrocortisone + oxytetracycline + polymyxin B ophthalmic solution 1.5%, 0.5%,
10,000IU/ml can be used for ears
o Antifungal drops may be needed - especially if the discharge looks white or black
- Clotrimazole solution 1% 2-3 x per day and continue for at least 14 days after
disappearance of infection
 In severe infections, oral antibiotics may be needed (amoxicillin first line,
erythromycin or ciprofloxacin second line)
 Give paracetamol and/or ibuprofen for pain
 Treatment is usually for 5-7 days

If discharge, dry the ear by wicking – roll some cotton wool on a wick and put it in the ear for
about half a minute, remove it and repeat until the ear is dry. Chronic suppurative ear
infections may indicate immunosuppression, so may need to recommend VCT for HIV test.

159
Teeth and gums

Preventive dental care

Plaque formation leads to peridontal disease, gingivitis, dental caries, dental abscesses and
tooth loss. Oral hygiene helps prevent plaque formation. It includes:
 teeth brushing with fluoride toothpaste and flossing at least twice a day
 reduction of smoking
 minimising the eating of sweets and foods containing sugar
 regular dental check-ups

Gingivitis
This is an inflammation of the gums and is often a result of plaque accumulation. The gums
are swollen and red and bleed easily, especially with brushing.
Use a mouthwash three times daily:
 Warm salt solution
 Chlorhexidine gluconate solution 0.20% rinse or gargle 10 ml
 Hydrogen peroxide solution 6% rinse or gargle 15 ml diluted in warm water
 If systemic signs and symptoms present give amoxicillin or metronidazole (see under
dental abscess)
For severe cases consider immunodeficiency, vitamin C deficiency, leukaemia and drug
causes (phenytoin, nifedipine, cyclosporin).

Vitamin C deficiency
(Scurvy) is due to poor diet. It cause gingivitis with bleeding gums and lower limb pain in
infants (caused by subperiosteal haemorrhage).
Give Ascorbic acid:
 Child 150-200 mg/day in 3-4 divided doses
 Adult 500-700 mg/day in 3-4 divided doses
 Give treatment until symptoms improve (1-2 weeks), then a preventative dose as
long as dietary deficiency continues
 Preventative 25-50 mg daily for both children and adults

Dental caries
These are holes in the teeth caused by decay. This happens mainly as a result of poor oral
hygiene (e.g. teeth not brushed or flossed) where bacteria attack and corrode the teeth. In
adults, smoking or excess alcohol intake can be contributory causes. Signs and symptoms
include pain after hot and cold foods or drinks, or constant sharp pain, and a small hole may
be visible on examination. It is treated initially with pain control (ibuprofen or paracetamol)
but needs dental care. Where available the hole is filled by a dentist or dental assistant with
amalgam. Tooth extraction should be avoided unless there is no alternative to relieve severe
pain.

Dental abscess
A dental abscess is a collection of pus around an affected tooth, often secondary to dental
caries, which may spread into the surrounding tissue. A dental abscess may develop from
gum disease or dental decay. Signs and symptoms include throbbing pain, fever, painful
tooth when touched, tender swelling of the surrounding gum and discharge. The infection
may spread as life-threatening cellulitis through adjacent tissues causing facial or neck
swelling (Ludwig’s angina) or difficulty opening the mouth. Incision of a dental abscess must
be done by a specialist using anaesthesia
Treatment:

160
  Give paracetamol, ibuprofen or diclofenac for pain control
 Warm saline gargles or chlorhexidine mouth wash
 Amoxicillin 500mg three times daily, child 25 mg/kg (maximum 250mg) 3 x per day
 In severe abscess also give Metronidazole 400mg 3 x per day, child 12.5-25 mg/kg
(maximum 200 mg) 3 x per day
 Incision
 With facial and neck swelling, parenteral antibiotics are needed and emergency
measures may be needed to protect the airway

Mouth and Throat

Stomatitis
This is an inflammation of the mucous membranes of the mouth caused by fungal, viral or
bacterial infection, vitamin deficiency, an injury etc. Prolonged or painful stomatitis may
contribute to dehydration or may cause loss of appetite. It is important to maintain adequate
hydration and feeding.

Angular stomatitis (cheilitis) - fissures and inflammation at the corners of the mouth can be
caused by candidiasis, dentures and iron or riboflavin (vitamin B2) deficiency.

Glossitis - smooth, red, sore tongue, can be caused by iron, folate or vitamin B12 deficiency.

Aphthous ulcers - these are small, shallow, painful ulcers on the tongue or oral mucosa.
Most are short lived. They can be treated by applying gentian violet.

Advice: make a mild saline solution at home with salt and water for the child to rinse and spit
out. Or use chlorhexidine mouth wash.

Oral and oropharyngeal candidiasis - this is common in infants, immunocompromised

and diabetic patients. Other risk factors include treatment with oral antibiotics or high-dose
inhaled corticosteroids. On examination there are white patches on the tongue, inside the
cheeks and possible spread to the pharynx. If frequent recurrences or extensive with spread
to oesophagus (pain and difficulty with swallowing) consider HIV infection. Treatment is
usually with nystatin.

161
 Nystatin
Medicine Age Dose Duration Side effects
Nystatin Infants < 1 month Do not give Common: Oral
100,000 Infants and older 100,000 IU (1ml) 4 x per day (apply to 5 to 7days irritation
IU/ml oral children tongue and inside each cheek) Rare: Nausea
suspension Adults 100,000 IU 4 x per dy (keep in mouth for 5 to 7 days
2-3 minutes and then swallow)
Prescribing tip: 1ml is measured with the pipette, and given by parents.
Advice slot: Give after feeding. Continue giving treatment for 2 days after rash has gone

For oropharyngeal candidiasis:

 Fluconazole 400mg as loading dose then 150-200mg daily for 14-21 days
 Children 6mg/kg as loading dose then 3mg/kg daily

Oral herpes
Primary oral herpes infection typically occurs in children aged 6 months – 5 years and
presents with acute gingivostomatitis - multiple painful vesicles/ulcerations on oral mucosa
and lips. This can be severe with general malaise, fever and lymphadenopathy. There may
be significant pain and decreased feeding.
 Paracetamol and/or ibuprofen for pain
 Aciclovir for 5-7 days (if less than 48 hours since onset of symptoms
o Child 1 month – 1 year 100 mg 5 x per day
o Child > 2 years and adult 200 mg 5 x per day
 May need admission if poor fluid intake and dehydration
 Amoxicillin if secondary bacterial infection
 Side effects: abdominal pain, diarrhoea, headache, nausea, pruritis, photosensitivity,
rash, urticaria, vomiting

In some individuals periodic recurrences present with herpes labialis (cold sore). In patients
with frequent recurrences or extensive forms consider HIV infection. If immunocompromised
double the dose. Recurrent attacks and ulcers can be treated with an antiseptic such as
chlorhexidine cream and paracetamol for pain.

Tonsillitis see Section 3.2

Nose

Nose bleeds (epistaxis)

Nose bleeds are common in children and in some adults, and can occur spontaneously or
after mild trauma. Usually the bleeding comes from the lower, soft part of the nose.
Treatment
Advise the person to sit forward and hold the soft part of the nose for 10 minutes. A parent
may hold the soft part of a young child’s nose. Advise them not to blow or pick their nose
afterwards for the rest of the day. If bleeding continues, the nose may need to be packed.

Allergic rhinitis
This presents with a history of nasal itching, chronic clear nasal discharge, sneezing and
nasal congestion, worse when exposed to certain allergens (such as certain plant/ tree
pollens). There may be associated allergic conjunctivitis.
Treatment
Antihistamines:
 Chlorpheniramine 4 mg
o 12-23 months 1mg 2 x per day

162
 o 2 – 5 years 1 mg every 4-6 hours (maximum 6 mg)
o 6-11 years 2 mg every 4-6 hours (maximum 12 mg)
o >12 years 4 mg every 4-6 hours (maximum 24 mg)
 Loratadine 10 mg
o Child 2-11 years 5mg once daily (If > 30 kg give 10mg once daily)
o >12 years 10 mg once daily

Side effects: blurred vision, dry mouth, GI upset, headache, drowsiness, urinary retention

Nasal steroids:
 Beclometasone nasal spray, 1 – 2 sprays in both nostrils, 1 – 2 times daily

Xylometazoline paediatric nasal drops - this is a sympathomimetic for nasal congestion and
can only be used for short term relief
 6-11 years 1-2 drops 1-2 x daily for up to 5 days
 >12 years 2-3 drops 2-3 x daily for up to 7 days
 Caution: rebound congestion especially with prolonged use
 Side effects: cardiovascular, hallucinations, restlessness in small children, headache,
local irritation and nausea

Nasal Polyps
Nasal steroids may also reduce the development of nasal polyps. If nasal obstruction from a
nasal polyp is not improved with a nasal steroid spray, then surgical excision by a specialist
may be needed.

In severe cases of allergic rhinitis or nasal polyps, oral steroids may be given for short term
relief.
Prednisolone
 Initially 10-20 mg daily, to be reduced in a few days

4.12 Musculoskeletal and pain control

Pain control
Analgesics (pain medicines) can be divided into three groups:

1. Non-opioids: These include paracetamol (acetaminophen) and the non-steroidal anti-

inflammatory drugs (NSAIDs), e.g. aspirin, ibuprofen and diclofenac. NSAIDs are
useful in managing pain from bones and joints.
2. Opioids: These are the morphine-like drugs and include codeine, tramadol and
morphine. Morphine is usually reserved for severe pain conditions and in palliative
care.
3. Neuropathic pain medications: These are used for pain due to a nerve lesion. Usual
analgesics are often ineffective in neuropathic pain.

The first two groups are used for pain due to tissue inflammation and damage. WHO
classifies analgesics used for pain on a three-step ladder:

Step 1 non-opioid analgesics such as paracetamol and nonsteroidal anti-

inflammatory drugs (NSAIDs)
Step 2 weak opioid analgesics such as codeine and tramadol
Step 3 strong opioid analgesics such as morphine

Analgesics should be given:

163
  By mouth – Giving analgesics by mouth is the simplest and most reliable method for
most patients. If the patient cannot take tablets by mouth, then the subcutaneous,
rectal, and buccal routes are alternatives
 By the clock – Constant pain needs regular analgesics to keep it away. Pain that is
allowed to build up is more difficult to control. Do not wait for the pain to return but
give analgesics at regular intervals according to their duration of action, e.g. codeine
30mg every four hours
 By the ladder – The WHO analgesic ladder gives a logical way of increasing the
strength of analgesia in steps as pain increases (see below)

Explain to the patient:

 The medicine is to keep the pain away. Take it regularly and do not wait for the pain
to return before taking the next dose
 The medicine needs to be continued as long as the cause of the pain is still there. If
the cause of the pain was an infection that has now been treated, they may be able
to reduce or stop the medicine
 If the cause of the pain is something for which there is no available treatment, then
they will need to continue taking the medication

Medications for musculoskeletal pain

Paracetamol
 Tablet, liquid, dispersible tablet, suppository
 Child 10 mg/kg every 6 hours or 15 mg/kg every 4 hours
 Adult 500 mg 1 - 2 tablets every 4 - 6 hours (maximum 4 g daily)
 Side effects: rare, prolonged use of high doses may cause liver toxicity
Medicine Age Dose Side effects
Paracetamol Infants < 2 months Do not give Common: no
Infants 2 – 6 months 60mg 4 x per day common
(2.5mls of 125mg/ 5mls syrup or ½ 125mg tablet) Rare: skin
Children 6 months to 3 120mg 4 x per day reaction.
years (5mls of 125mg/5mls syrup or 125mg tablet)
Chilren 3 years to 7 250mg 4 x per day Very dangerous
years (10mls of 125mg/5ml syrup or 2 x 125mg tablet or ½ x in over-dosage,
500mg tablet) refer all cases.
Children 8 to 11 years 500mg 4 x per day
(1 x 500mg tablet)
Children 12 to 15 750mg 4 x per day
years (1½ 500mg tablet)
Adults (16 years and 1000mg 4 x per day
over) (2 x 500mg tablets)

164
 Like all medicines, paracetamol is effective in the prescribed dosage but may be very
dangerous if this dose is exceeded. See 5.4

Non-steroidal anti-inflammatory drugs (NSAIDs)

Aspirin
 300 mg – 1 g every 4 - 6 hours (maximum 4 g daily)
 Avoid in children < 16 years
Ibuprofen
 Tablet, liquid
 200 – 600 mg every 6 – 8 hours (maximum 2.4 g daily)
 Child > 3 months 5 -10 mg/kg/day every 6 – 8 hours (maximum 30 mg/kg daily)
 Adult 200 mg – 600 mg every 6 – 8 hours (maximum 2.4 g daily)

 Do NOT give children aspirin.

 Do not give ibuprofen to dehydrated children because it can damage their kidneys
Medicine Age Dose Side effects
Ibuprofen Infants < 2 months Do not give Common: nausea
Infants 2 – 1 year 50mg (1.25mls of 200mg/5ml syrup) 3 x per day and abdominal
Children 1 – 4 years 100mg (2.5mls of 200mg/5ml syrup) 3 x per day pain,
Children 5 – 8 years 200mg (5mls of 200mg/5ml syrup) or 200mg tablet 3 x per bronchospasm
day Rare: allergic
Children 9 – 15 years 300mg (7.5mls of 200mg/5ml syrup) or 1½ x 200mg tablet 3 reaction; ulcer in
x per day stomach; damage
Adults 400mg tablet 3 x per day to kidneys & liver

Diclofenac: Adult 25 - 50 mg three times daily

Side effects of NSAIDs:

 Gastritis, take with food and consider adding omeprazole 20 mg daily for
gastroprotection
 Risk of gastrointestinal ulceration and bleeding, especially in elderly
 Renal toxicity, avoid in renal impairment and if dehydrated
 Bronchospasm in asthmatics
 Increased risk of thromboembolic events

Opioids
Codeine: Child > 12 years and adult 30 – 60 mg every 4 hours (maximum 240 mg daily)

Tramadol
 Capsule
o Child > 12 years and adults 50 – 100 mg every 4 hours (maximum 400 mg daily)
o In elderly or with severe renal or hepatic impairment 25 – 50 mg every 12 hours
 Injection - IM, slow IV injection, infusion
o Child > 12 years and adults 50 - 100 mg every 4 - 6 hours (maximum 600 mg
daily)
Morphine: Analgesic effect is dose-dependent. It may be necessary to give increasing doses
in palliative care. Reduce dose and give less frequently in elderly and in those with severe
renal or hepatic impairment.

 Oral solution
o Child 1- 2 months initially 0.05 – 0.1mg/kg every 4 hours
o Child 3 -5 months initially 0.1 – 0.15 mg/kg every 4 hours
o Child 6 -11 months initially 0.2 mg/kg every 4 hours
o Child 1- 11 years initially 0.2 – 0.3 mg/kg every 4 hours

165
 o Child > 12 years and adult initially 2.5 – 5 mg every four hours
o Increase gradually as needed by 30 - 50% at a time

 Injection SC
o Child 1 – 5 months initially 0.1 – 0.2 mg/kg every 6 hours
o Child 6 months – 1 year initially 0.1 – 0.2 mg/kg every 4 hours
o Child 2 – 11 years initially 0.2 mg/kg every 4 hours
o Child 12 – 17 years initially 2.5 – 10 mg every 4 hours
o Adult SC or IM 5 - 10mg initially every 4 hours
 Injection slow IV
o Child 1 – 5 months initially 0.1 mg/kg every 6 hours
o Child 6 months – 11 years initially 0.1 mg/kg every 4 hours
o Child > 12 years and adult initially 5 mg every 4 hours

Side-effects of opioid drugs:

 Constipation – opioids commonly cause constipation, if needed give a laxative (such
as bisacodyl, lactulose)
 Nausea and vomiting – some patients develop nausea when they start morphine and
will need an antiemetic for the first few days (haloperidol or metoclopramide,
ondansetron in children)
 Drowsiness – this is common when first starting on morphine or when the dose is
increased. This usually improves after three to four days. If it does not improve, then
it may be a sign that the morphine dose is too high
 Sweating and itching –less common side-effect
 Respiratory depression especially with morphine (naloxone can be used as an
antagonist if severe respiratory depression)

Neuropathic Pain Medication

Amitriptyline: Adult 12.5 - 25 mg at night increasing up to 150 mg maximum as needed
(reduce dose in elderly)
 Side effects: Abdominal pain, fatigue, hypertension, mydriasis, oedema, palpitations,
restlessness, stomatitis
 Do not use with arrhythmias, heart block
Carbamazepine:
 Adult 100 mg twice daily for two weeks, then 200 mg2 x per daily for two weeks,
usual dose 200 mg 3 – 4 times daily (maximum 1.6 g daily)
 Side effects: rash, aplastic anemia, leucopoenia, blood disorders, ataxia, dizziness,
drowsiness, dry mouth, nausea, hyponatraemia, blurred vision, headache
 Patients should be told to stop immediately if signs of liver dysfunction, acute liver
disease, fever, bruising, bleeding

Musculoskeletal conditions
These include rheumatoid arthritis, osteoarthritis, gout, polymyalgia rheumatica, psoriatic
arthritis, SLE and many others. Specific management of some of these conditions will be
included in the next edition of the STGs. See below for use of steroids for disease
suppression for some of these conditions.

Gout
Gout is characterised by sudden onset intense pain, redness, warmth and swelling in the
affected joint.
It occurs most commonly in:
 the first metatarsal-phalangeal joint of the foot

166
  the mid foot
 ankle
 knee
 finger joints
 wrist
 elbow
It is more common in males and is usually associated with raised uric acid in the blood.
Urate crystals form on the joint cartilage are shed into the joint space, causing pain and
inflammation. An attack usually lasts about 2 weeks, less if treated. Recurrent attacks cause
joint damage and deposition of tophi in soft tissues.

Treatment of Acute attack

 NSAIDs, start as soon as possible OR
 Colchicine
o 0.5 – 1 mg initially and then 0.5 mg every 2-3 hours (maximum 6 mg a day)
o Do not repeat the course within next 3 days
o Side effects: vomiting and diarrhoea
 If NSAIDs and colchicine not available or not tolerated give prednisolone 40 mg
daily for 5 days

Prevention
 Weight loss
 Reduction of purine-rich foods (including meat and alcohol).
 Stop hyperuricemic drugs such as thiazides, loop diuretics
 Other risk factors should be assessed such as cardiovascular and diabetes risk, and
the body mass index (BMI) and BP measured
 If more than 2 attacks a year, renal stones or tophi give Allopurinol
o initially 100 mg daily after food. Increase monthly to usual maintenance dose
o in mild conditions 100–200 mg daily
o in moderately severe conditions 300mg - 600mg in divided doses
o in severe conditions 700 – 900 mg in divided doses
o Allopurinol should only be started more than 2 weeks after an attack which has
been treated with NSAIDs (with NSAIDs continued until the person is pain free)
o Continue allopurinol if attack develops and already on allopurinol
o Use lower dose with renal impairment (start with 50 mg and be cautious above
100 mg daily)
o Side effects: rash, gastrointestinal upset

Rheumatoid Arthritis
This is the most common inflammatory arthritis and is more common in women. It presents
with bilateral symmetrical joint involvement particularly affecting the fingers and
small/medium joints. There is pain and stiffness in the joints, usually worse in the morning,
and often with associated malaise. On examination joints are swollen, warm and tender. The
disease is variable with acute flares and remissions. Disease progression can lead to joint
deformity, rheumatoid nodules, tendon rupture and significant disability.
Treatment:
 NSAIDs and paracetamol for pain and inflammation in acute flare
 For severe inflammation a short course of steroids may be needed (see below)
 Weight loss and physiotherapy
 In severe cases refer to a specialist for disease modifying anti-rheumatic drugs
(DMARDs)
o Chloroquine

167
 o Methotrexate
o Penicillamine
These drugs need regular review and blood monitoring due to significant side-effects

Osteoarthritis
This is a degenerative condition and is the commonest form of joint disease. It may involve
any joint and is most common in knees, hips and spine. It causes pain, restriction of
movement and advanced disease results in joint deformity and disability.
Treatment
 Weight reduction
 Regular exercise to maintain mobility and increase muscle strength
 Using a walking stick of appropriate height
 Paracetamol – regular use
 Limited use of NSAIDs for acute exacerbations
 Consider intra-articular steroid injection
 Codeine and paracetamol for worsening pain

Use of steroids for disease suppression

Steroids are powerful drugs that can be lifesaving when used for treating conditions like
asthma and COPD (see Section 4.4) and can effectively suppress the inflammation of
diseases like rheumatoid arthritis and polymyalgia rheumatica. They are also very useful in
palliative care in reducing swelling and therefore pain from tumours. But steroids also have
serious side effects, so should be used with the utmost care, monitored carefully and
reduced or stopped as soon as they are not needed. Long term use is always associated
with side effects, so the benefits of taking steroids needs to be carefully considered against
their negative effects. If steroids are given short term for 2 weeks, they can be stopped
without reducing the dose first. If they have been given for more than 2 weeks, then they
should be gradually tailed off to help reduce the rebound side effects such as low BP caused
by adrenocortical suppression.

Side effects of steroids with prolonged use include: thinning bones (osteoporosis, causing
more fractures), weight gain, swelling of the face and ankles, thinning of the skin, muscle
weakness, diabetes, gastric ulcer, cataracts, and suppression of the immune system.

Steroids should be used with caution in any acute or chronic infective condition and usually
avoided in HIV and TB.

The dose of steroids depends on the condition, but the lowest dose should be given for as
short a time as possible.

Prednisolone
 Inflammatory arthritis: Initially 10 -20 mg daily, can often be reduced within a few
days but may need to be continued for weeks or months. Maintenance at lowest
dose possible. Cushingoid side effects are increasingly likely with doses above 7.5
mg daily.
 Polymyalgia rheumatica: start with 15 – 20 mg prednisolone daily. Maintain for 2 - 4
weeks. Then reduce by 2.5 mg every 4 weeks until 10 mg daily. After 1 month of 10
mg reduce thereafter by 1 mg each month. Treatment may need to maintained for 18
to 24 months. About half of people will relapse during treatment requiring
prednisolone to be increased again for a brief period before reducing more slowly. If
possible, monitor the disease with measurement of the Erythrocyte Sedimentation
Rate (ESR)

168
  Temporal arteritis, polyarteritis nodosa and systemic lupus erythematosus are treated
similarly to polymyalgia rheumatica but with a higher dose initial dose (up to 60 mg
daily), especially if there is severe disease (such as visual symptoms, pleurisy,
pericarditis or other systemic disease manifestations).

Acute side effects of steroids: abdominal distension, acute agitation, acute pancreatitis,
candidiasis, congestive heart failure, bruising, dyspepsia, facial flushing, headache,
increased appetite, insomnia, leucocytosis, malaise, sodium retention, weight gain.

Bone and joint infections

Acute osteomyelitis
This is an infection of bones, presenting particularly in the long bones of children or in adults
with diabetes or immunosuppression. Causative organisms include Staph. aureus, Strep.
pyogenes, Strep. pneumoniae and gram-negative organisms. In children with sickle cell
disease, salmonella species may cause osteomyelitis. The most common cause is blood
borne spread from an infection nearby, or from trauma or surgery. It presents with fever, pain
and reduced use of the affected limb, and tenderness and warmth at site of infection with
swelling.

Early treatment stops future deformity and allows normal growth of the long bone infected.
Treatment
 In the early stages, osteomyelitis can be treated with IV, then oral, antibiotics for 4 to
6 weeks.
 The choice of antibiotic is difficult unless bacteriological culture and antibiotic
sensitivity is available
 If not, a good first choice antibiotic would be either
o IV benzylpenicillin (followed by oral penicillin V)
o IV ampicillin (followed by oral amoxicillin)
o or IV cloxacillin
 These are given every 6 hours
 If treatment response if poor, then a broad-spectrum antibiotic such as ciprofloxacin
(twice daily) or ceftriaxone (once daily) may be needed
 For someone with sickle cell disease, the cause may be salmonella for which an
appropriate treatment would be with ciprofloxacin (see 3.7)
 Surgery may be needed for drainage of abscesses, debridement of tissue and
excision of sequestra (devitalised bone).

Chronic osteomyelitis
Chronic osteomyelitis usually presents with a suppurating wound. Suspect underlying
osteomyelitis in a deep or extensive ulcer that fails to heal (especially in diabetes or non-
healing fractures).The treatment is primarily surgical, because the pus originates from a
cavity where a small piece of dead bone is located (called a sequestrum). Surgical
management includes debridement and exposure of this bony cavity and sequestrectomy
(removal of the piece of dead bone). The wound is not closed or packed but covered in dry
gauze. If all the sequestrum is removed, the wound will granulise and start healing. For large
wounds, tissue flaps and/or skin grafts may be needed by a specialist.

Septic arthritis
This is an acute infection in joints. This is usually due to haematogenous spread from
another infection. Causative bacteria include Staphylococcus aureus, Haemophilus influenza
and group B Streptococcus. It presents with severe pain, a warm and swollen joint and
systemic symptoms.

169
Treatment
 The treatment is urgent drainage and wash-out by a specialist, intravenous
antibiotics and short-term immobilisation to reduce pain
 A first line antibiotic is cloxacillin (as for osteomyelitis but normally given for 2 to 4
weeks)
 If gonococcal arthritis is suspected, then daily ceftriaxone is needed for 2 weeks

4.13 Palliative care

What is Palliative Care?

Palliative care ensures maximum quality of life and relieves suffering in adults and children
with illnesses that cannot be cured, supporting them and their families through difficult times.
We can help people suffering from: HIV; cancer; progressive neurological illnesses including
dementia; kidney, liver or heart failure; end-stage lung disease; other life-limiting illness.
What makes palliative care different?: Holistic approach to care:

Palliative care =
Pain + symptom control + Psychological, Social and Spiritual Support

Common problems include:

 Physical – pain, cough, tiredness, fever
 Psychological – worries, fears, sadness, anger
 Social – needs of the family, issues of food, work, housing and relationships
 Spiritual – questions of meaning of life and death, the need to be at peace.
Good communication is essential. Important listening skills:
 Find a quiet place if possible
 Sit at the patient’s level
 Pay attention, keep eye contact
 Active listening
 Allow silence, do not interrupt
 Clarify and summarise
When talking to patients:
 Always be respectful and polite.
 Avoid medical terms that may not be understood
 Give information rather than advice
 Only give accurate information. It is okay to say that you do not know.
 Avoid false reassurance
 Check that the patient has understood
Tell the truth:
 Lying destroys trust and false reassurance is damaging.
 People cope with truth better than with uncertainty
 To allow people to make informed decisions about their treatment and care.
 To prevent unrealistic hope. Sometimes people spend much time and money looking
for treatment because no one has been brave enough to tell them that there is no
cure for their illness.
 To give opportunity for mending difficult relationships or exploring spiritual issues.
 To allow patients and families to prepare for the future – this might involve writing a
will, preparing financially, travelling to the family home, planning a funeral etc.

Assessing a Patient
Full history and examination.

170
 Diagnosis Medication Holistic Assessment
What is their main What medication are How are they coping?
illness? they taking?
How long have they What have they tried in What support do they
been ill? the past? have?
What do they Has any medicine How is their family
understand about their helped? coping?
illness?
What does their family Have they had any side Do they have food and
understand? effects? housing?
What treatment have Do they need all their Do they have any
they had? medication? spiritual concerns?
Do they have any other Can they access their What are their priorities
illnesses? medication? and goals?
What are their main Are they able to take Are they prepared for
problems/symptoms at oral medications? death?
the moment?

Make a problem list to help focus on the problems that are most affecting quality of life. Try
to establish the cause of each problem then make a plan with the patient and family to
address each one.

Treat the treatable

Palliative care seeks to relieve distressing symptoms of illness but the obvious place to start
is with the illness itself. If you can treat the illness you will reduce the symptoms. ARVs
should be used to treat HIV to improve patient’s condition and reduce symptoms. If
chemotherapy or radiotherapy is available to treat cancer, this may be the best way of
improving symptoms even if cure is not possible. Treat pneumonia with antibiotics to
improve cough and breathlessness; treat constipation to improve abdominal pain.
Weigh up benefits of treatment against burden. Consider: is the patient fit enough to cope
with the treatment and journey to hospital if needed? Could the side effects of the treatment
be worse than the patient’s current symptoms? Can the patient and family afford the
treatment and transport for the length of the treatment required?

Symptom Control
Ask questions to try and work out the cause of the pain and how to treat it.
 How many different pains are there? Useful to record them on a body map.
 Where is the pain, what does it feel like, how long has it been there?
 How does the pain affect your life/work/sleep?
 What makes it better or worse?
 Has any medication or other treatment helped?
 Does the pain get worse with movement? Are the bones or joints tender?
 Any changes in feeling of the skin at the site of pain? (may indicate neuropathic pain)
 Are the muscles tense or tender? (may indicate pain from muscle spasm)
 How severe is the pain on a scale of 1 to 10? (can also be used to monitor response
when treatment begins)
Start with simple analgesia and work up the WHO analgesia ladder. See section 4.12 for
information about simple analgesia and analgesia for neuropathic pain.

Morphine Preparations
Immediate release morphine solution (IR) (10mg/5ml)

171
 Begins to work after about 20 minutes, analgesia lasts 4 hours. Start with 2.5–5mg every 4
hours. Prescribe in mg not ml. Use smaller doses in the very frail or elderly. Double dose at
bedtime to avoid need for dose in middle of night. Take extra breakthrough doses (same
amount) up to hourly for pain that is not controlled by the regular doses. Patient/family to
record how many breakthrough doses required in a 24 hour period.
If patient still in pain after 24 hours, increase total daily morphine dose by adding together all
regular doses plus additional breakthrough doses used in last 24 hours. Divide the total daily
dose by 6 to give a new 4 hourly dose. This should also be the new breakthrough dose.
Continue to use breakthrough doses hourly if needed. If not at all effective, review patient to
reassess cause and type of pain as it may not be sensitive to morphine.
Modified Release morphine (MR)
These tablets are not currently available in South Sudan. They last 12 hours and should be
taken twice a day exactly 12 hours apart, e.g. 8am and 8pm. If available you can change to
MR morphine once pain controlled by IR morphine. Calculate total IR dose in 24 hours and
divide by 2 to give the 12 hourly MR morphine dose. Patient can still take IR morphine for
breakthrough pain – dose should be one sixth of total daily morphine dose.
See section 4.12 for side effects of opiates.
There is no maximum dose of morphine. The correct dose for each patient is the dose that
takes away the pain without giving unacceptable side effects or toxicity.
Signs of morphine toxicity and overdose (more likely if dehydrated or in renal failure):
 Drowsiness that does not improve or is severe
 Confusion
 Hallucinations
 Myoclonus (sudden jerking of the limbs)
 Respiratory depression – rare if morphine started at low dose and increased slowly to
match level of pain
Manage toxicity by reducing morphine dose by 50%. If patient has respiratory depression,
stop morphine. Haloperidol 1.5-5mg at night may help with hallucinations and confusion
caused by morphine.

Adjuvant analgesics
These are drugs which were not designed as analgesics but may help in certain kinds of
pain alongside standard analgesics. Can be started at any step of the analgesic ladder.
Pains that can be helped by adjuvants are:

Pain from severe swelling or inflammation - commonly seen in:

 Brain – headache from raised intracranial pressure
 Spinal cord – spinal cord compression
 Liver – abdominal pain from metastases stretching the liver capsule
 Neck, axilla and groin from pressure on nerves.
This type of pain can be treated with high dose corticosteroids. NB High dose corticosteroids
should only be used by a specialist certain of the diagnosis and able to monitor treatment
very closely.
If known raised intracranial pressure from Dexamethasone 16mg/day
brain tumour and spinal cord compression
All other severe swelling or inflammation Dexamethasone 6 -12mg/day
If improvement, reduce the dose by 2mg/week until you get to the lowest effective dose and
stay at this dose. If no improvement after one week reduce the dose by 50% every three to
four days and then stop.
Side effects of steroids include:
 Immune suppression (discuss use of steroids in HIV with specialist team)
 Swelling of face and ankles
 Thinning of skin and bruising

172
  Weakness of muscles at top of arms and legs
 Raised blood sugar (in diabetics monitor blood sugar as treatment may need to be
increased)
 Risk of adrenocortical suppression if stopped suddenly if high dose for more than
1week

Nerve damage pain (neuropathic pain)

 Nerve compression by cancer
 Viral damage to nerves: Herpes Zoster (shingles) or HIV
 Nerve damage from drugs (some ARVs or TB drugs)
 Severe diabetes causing neuropathy of hands and feet.
Neuropathic pain is less responsive to morphine and NSAIDS but can be helped by
adjuvants:
 Tricyclic antidepressants - amitriptyline 12.5 - 25mg at night, increase every 3 days to
maximum 50 - 75mg if tolerated).
 Anticonvulsants – start with low dose, gradually increase until pain improves eg
valproate 200mg 2x per day (increase to 600mg 2x per day if necessary) or
carbamazepine 100mg 2x per day (increase to 400mg 2x per day if necessary,
interacts with some ARVs, check with ARV team before use).
 High dose corticosteroids – may help if severe swelling or inflammation around
nerves. Specialist use only.
Muscle spasm
Can occur in neurological disease and in bed-ridden patients. Helped by benzodiazepines
e.g. diazepam 5-10mg at night or baclofen 5-20mg 3x per day.
Abdominal cramp and colic
Helped by anticholinergic drugs e.g. hyoscine butylbromide (buscopan) 20mg 4x per day.

Nausea and Vomiting

Treat possible reversible causes: oral or oesophageal candidiasis, constipation, infections
(malaria, gastroenteritis, urinary tract infection etc), raised intracranial pressure (treat with
dexamethasone), indigestion/heartburn.
 Review likely causes of nausea and vomiting including new medication
 Encourage fluids – small frequent sips are better absorbed. Cold drinks often
preferable
 If dehydrated, give fluid as ORS if available or fresh coconut water or rice water
 Consider trial of anti-emetic medication; choose according to suspected cause; only
use injectable medication if unable to tolerate oral.
o Gastroparesis: metoclopramide 10mg 3x per day PO or IM.
o Bowel obstruction or neurological/metabolic: promethazine 25mg 3x per day PO or
IM.
o Severe, persistent vomiting not settling with other measures: ondansetron 8mg 2x
per day PO or IM. Specialist use only.
Breathlessness
Treat any reversible causes. Possibilities include chest infection (TB, bacterial pneumonia or
PCP), anemia, asthma, heart failure, pleural effusion, anxiety.
 Find the most comfortable position for the patient (usually sitting up).
 Open windows to allow air to circulate. Use a fan if available.
 Arrange pillows so that patient can rest forwards on table or firm surface
 Teach the patient to move slowly and carefully to avoid increasing the
breathlessness.
 Demonstrate how to slow their breathing by breathing out through pursed lips (as if
about to whistle).
 Try to manage anxiety.

173
When breathlessness cannot be improved, symptoms may be helped by IR Morphine 2.5-
5mg every 4 hours. If a patient is dying and is distressed with breathlessness, may need to
use larger doses of morphine. If breathlessness is due to a swelling obstructing the
respiratory tract try dexamethasone 6-12mg once daily.

Constipation
Abdominal and rectal examination to assess why they are constipated. If the rectum is
empty, the problem is higher in the gut. Terminal patients will pass very little stool due to
poor oral intake – this does not need treatment.
Prevent constipation from opioids by always co-prescribing laxatives. Review the need for
other drugs which can cause constipation (e.g. amitriptyline, hyoscine).
 Encourage plenty of drinks and fruit and vegetables in diet.
 Give a tablespoon of vegetable oil before breakfast.
 Encourage patient to be as mobile as possible.
 Encourage the patient to take laxatives with opioids as prescribed.
 If available, dried papaya seeds can be chewed (five to 30 seeds at night).
 Hard stool which is painful to pass can be helped by petroleum jelly or a small pellet
of soap inside the anus
 “Soap enema” if the rectum is full of hard stool (using urinary catheter and soapy
water)
Medication: bisacodyl 5mg PO at night, increasing to 15mg if needed or senna 1 - 2 tablets
PO at night, increasing if necessary. Bisacodyl suppositories can be helpful. Use bisacodyl
or senna tablets in combination with stool softeners if hard stool (eg lactulose 10-20mls 2x
per day, docusate sodium 100-200mg 2x per day.)

Fever and Sweating

Commonly caused by viral infections, malaria and many opportunistic infections associated
with HIV. Look for and treat infections. HIV and some cancers, particularly lymphomas, may
also cause fever.
Paracetamol 1g 4x per day, or ibuprofen 200-400mg 3x per day, or aspirin 300-600mg 4x
per day (avoid in children). Amitriptyline 10-25mg at night can also reduce sweating.

Anxiety and sleeplessness

Serious illness frequently causes anxiety because of distressing symptoms and fears about
the future. Sleeplessness may result from physical problems such as pain or from anxiety or
depression.
 Encourage patient to talk about worries or concerns
 Avoid coffee and tea in the evening.
 Ensure room where they sleep is quiet with reduced light
 Assist patient to find a comfortable sleeping position
 Try relaxing music.
If necessary use short term treatment with Diazepam 2.5-10mg at night.

Depression
Diagnosis of depressive illness is difficult in palliative care as symptoms of depression such
as anorexia, weight loss, loss of energy, loss of sex drive and sleeplessness may be caused
by the illness itself. Ask about:
 Low mood more than 50% of each day
 Loss of any enjoyment or interest
 Excessive or inappropriate guilt
 Thoughts of suicide.

174
Treat pain which can be a major cause of depression. If antidepressant medication is
needed use amitriptyline 25mg at night, increasing gradually to 75-150mg or fluoxetine
20mg once a day. (See depression, 4.14).

Sore mouth and swallowing difficulty

 Treat candida (see 3.6) for opportunistic infections.
 Bacterial infection: penicillin V (500mg 4x per day for 5-7 days) plus metronidazole
(400mg 3x per day for 5-7 days).
 Oral Herpes simplex: aciclovir 200mg 5x per day.
For infections advise mouthwash after eating and at night (one pinch of salt or sodium
bicarbonate in cup of cooled boiled water, or one teaspoon of vinegar or lemon juice in one
litre of cooled boiled water). For dry mouth, moisten mouth with regular sips of cold water (or
ice if available), suck pieces of fruit, e.g. pineapple, passion fruit, lemon, etc; use petroleum
jelly on the lips.
Other medication to manage oral symptoms:
 Soluble aspirin 600mg 4x per day for painful mouth. Rinse, gargle and swallow.
 Metronidazole mouthwash for smelly mouth from oral cancer: mix crushed tablet with
fruit juice
 Prednisolone half tablet can be placed against aphthous ulcers (mouth ulcers) to give
relief
 Dexamethasone 8-12mg once daily for 7 days for severe oral or oesophageal
inflammation that prevents swallowing where other measures have not helped.
Always use an antifungal in addition. Specialist use only

Spinal cord compression (SCC)

Occurs when a cancer mass presses on the spinal cord. First sign may be back pain at the
level of tumour felt as band around body and can spread down legs. Both legs can become
weak with loss of sensation below the level of the tumour. There may be urinary retention
and incontinence of bowels. Treat with high dose steroids (dexamethasone 16mg once daily)
as soon as symptoms start and, if available, arrange radiotherapy. Specialist use only

Hiccups
Usually caused by distension of the stomach, diaphragm irritation or renal failure. Try
metoclopramide10mg PO 3x per day or Haloperidol 1.5-3mg PO at night or chlorpromazine
25-50mg PO at night.

Cough
Persistent dry cough not due to any reversible cause can be treated by codeine 30mg 4x per
day or IR morphine 2.5-5mg every 4 hours.

Diarrhoea
Chronic diarrhoea in a palliative patient that has not responded to empirical treatment (see
3.6 Opportunistic Infections) or ARVS can be treated with loperamide 2mg after each loose
stool up to 16mg/day or codeine 10mg 3x per day.

Vaginal discharge
Offensive vaginal discharge is a common, distressing and embarrassing symptom of cancer
of the cervix. Assess patient, examine and treat empirically for STIs and fungal infection.
(see section 3.5) If symptoms do not settle a 200mg metronidazole tablet can be inserted
daily into the vagina as a pessary or crushed and the powder applied.

Alternatives to oral medication when patient is unable to swallow

175
  Subcutaneous (SC) – preferred route. ‘Butterfly’ needle placed under the skin and
taped in place for repeat injections. Less painful than IM and much easier than IV.
Avoid if skin oedematous or inflamed
 Rectal – Some drugs are produced as suppositories to be given rectally but some
tablets can be used this way if no other route available
 Buccal – Some medications can be placed inside mouth, between cheek and teeth,
to be absorbed by the lining of the mouth (without swallowing it)
 Intramuscular (IM) – more painful than SC and needle cannot be left in place
 Intravenous (IV) – usually reserved for emergency medication in clinic or hospital
 Nasogastric (NG) /Percutaneous gastrostomy (PEG) – if fitted with NG or PEG tube
can be used to give medication
Morphine Conversion (oral to injectable)
If a patient is taking morphine for pain but can no longer swallow, injectable morphine (if
available) should be given SC four hourly. When changing from the oral to injectable route,
the dose must be divided by two, eg. A patient taking 10mg oral IR morphine every four
hours will need 10/2 = 5mg of SC morphine every 4 hours.
If injectable morphine is not available:
 IR Morphine solution can be given ‘buccally’ every 4 hours
Other Medication
 Paracetamol suppositories or tablets can be given rectally every 6 hours for pain or
fever
 Diazepam 5-10mg tds can be given rectally for seizures, agitation or restlessness
 Metoclopramide and haloperidol in injectable forms which can be given SC.

End of Life Care

As death approaches, talking about this with the patient and family can allow them to make
plans for the funeral, address spiritual issues, have important conversations and say
“goodbye.” Signs that death is approaching (the terminal phase):
 Patient’s condition is getting worse day by day or hour by hour
 Sleeping much of the time, may be confused or comatose
 Minimal oral intake – little hunger or thirst
 Reduced bowel and urine function, may be incontinent
 Breathing becomes irregular, sometimes noisy (‘death rattle’)
 Change in colour – skin becomes grey or purple, hands and feet cold.
At this stage rationalise medication:
 Only give medication that is going to help keep the patient comfortable.
 Medication for infections, heart or blood pressure problems can usually be stopped.
 Diabetic tablets can be stopped once the patient stops eating.
 Continue anticonvulsants for as long as able to swallow, then replace by rectal
diazepam
 Pain relief should be continued if possible even after patient is unconscious
When the patient can no longer swallow oral medication, the following can be used for end
of life symptoms:
 Morphine SC 4 hourly for pain.
 Haloperidol SC 1-5 mg once daily for nausea
 Haloperidol SC 2.5-10mg once daily for agitation
 Hyoscine SC 20mg 4x per day for secretions in chest/upper airway (noisy breathing)

Cancers
There are very few cancer treatments available in South Sudan. If cancer is suspected or
diagnosed seek specialist advice. Treatment of cancer will be included in the next edition of
the STGs.

176
4.14 Mental Health
Follow the WHO mental health guidelines, known as the mhGAP Intervention Guide. The following
treatments are mainly taken and adapted from the mhGap IG which should be consulted.

Mental health disorders often carry stigma and patients may be vulnerable to human rights
abuses. Psychoeducation should be provided to all patients and their families. This should
include:
 Patients should enjoy the same human rights as all people, including the right to
confidentiality and the right to be involved in decisions concerning their treatment
 Suffering and problems can be reduced by treatment
 Adherence to any prescribed medication is important
 It is important to continue regular social, educational and occupational activities
 It is important to try to stay healthy, by keeping physically active, eating a healthy
diet, avoiding tobacco, alcohol and other psychoactive substances and maintaining
personal hygiene.

Psychosocial Interventions can be as effective as medication in common mental

disorders and should be considered an important part of treatment. Refer to trained
psychologists if possible. Additional training to deliver most psychotherapeutic interventions
is required, but some simple interventions can be easily adopted by all health professionals
in primary and secondary care:
 Supportive counselling: empathetic listening; discussion of stressors and how they
may be addressed; exploring and strengthening support systems - family,
community, religious.
 Explaining Mind / Body relations: use simple examples from daily life to explain how
stressful emotions can generate physical symptoms
 Coping skills: teach simple strategies that help cope better with stress: regular
exercise, nutrition, leisure time, spiritual observance and work/life balance
 Sleep hygiene techniques: regularizing timings of going to bed and getting up;
avoiding caffeinated drinks and alcohol; improving the environment for sleep (quiet,
dark, temperature; avoiding stimulating activities at night)
 Focus on functional improvement: regularize daily routine; involve in home chores;
use distraction to change focus from symptoms to other activities; encourage return
to full normal functioning as soon as possible
 Involving and engaging family in care: educate families, support them and empower
them as co-therapists in the patient’s care

Depression
Diagnosing moderate to severe depression
Symptoms must be persistent for at least two weeks, cause difficulty in day-to-day
functioning, and include the following:
 Depressed mood (most of the day, almost every day)
 Loss of interest or pleasure in activities that are normally pleasurable

Several of the following additional symptoms should be present:

 Reduced concentration and attention
 Indecisiveness
 Reduced self-esteem and self-confidence
 Feelings of guilt and worthlessness
 Sense of hopelessness about the future
 Sleeping too much or too little

177
  Significant change in appetite or weight (may increase or decrease)
 Restlessness and agitation or talking or moving more slowly than usual
 Ideas or acts of self-harm or suicide

Multiple, persistent physical symptoms (headache, abdominal pain, musculoskeletal pain)

with no clear cause are a common presentation of depression. In patients with multiple
unexplained symptoms, ask about the symptoms of depression listed above.
(If the person also has symptoms of bipolar illness or psychosis see the next sections .)

Treatment for moderate to severe depression

Include one or a combination of:
 Psychoeducation of person and family/ caregivers.
 Address major stressors if possible
 Refer to other community resources as needed and available
 Strengthen coping skills: regular sleep
 Encourage a return to full activity as soon as possible
 Consider antidepressant medication

Use of Medication
 In mild depression (fewer symptoms and less impact) use psychosocial interventions
only; consider antidepressants if symptoms worsen
 Do not prescribe antidepressants in patients when symptoms are normal reactions to
a bereavement or major loss.
 Do not prescribe antidepressants in children younger than 12 years old
 In adolescents 12 – 18 years of age use psychosocial interventions first; consider
fluoxetine only if there is no improvement
 Avoid antidepressants in pregnancy (increased risk of congenital heart defects,
pulmonary hypertension and neonatal withdrawal symptoms) and breast feeding
unless symptoms are severe and are not responding to psychosocial interventions
 Avoid amitriptyline in the elderly and in patients with cardiovascular disease
 In patients at risk of self-harm or suicide, use fluoxetine as 1st line medication;
dispense small quantities (1 week) and review patient before issuing more capsules.
 Stop antidepressants immediately if the patient develops a manic episode.

Treatment with SSRI antidepressant:

Fluoxetine: starting dose 20mg (one capsule) once daily. If there is no response after 3 – 6
weeks, the dose may need to be increased to 40mg. Maximum dose is 60mg daily. Continue
treatment for at least 9 – 12 months after symptoms have improved.

Side effects of SSRIs: restlessness, insomnia, anorexia and GI disturbances, headache,

sexual dysfunction. In people aged under 30 there is a small increased risk of suicide.
Rarely: bleeding abnormalities (non-steroidal anti-inflammatories may exacerbate this so
should be avoided).

Treatment with tricyclic antidepressants:

Amitriptyline: starting dose 25mg at night, increase by 25mg every 1 -2 weeks. Usual
effective dose: 75 – 100mg. Maximum dose: 200mg.

Side effects: low BP on standing, dry mouth, constipation, difficulty urinating, dizziness,
blurred vision, sedation. Impaired ability to perform skilled tasks like driving (precautions
needed until used to medicine). Rarely: heart arrhythmias

Stopping antidepressant medication:

178
Continue treatment for at least 9 – 12 months after symptoms have improved and the patient
has returned to their usual activities. Reduce the dose gradually over a period of 4 weeks. If
the patient suffers severe withdrawal symptoms, or relapses, the antidepressant may need
to be reintroduced.

Self-harm and suicide

Suicide is the act of deliberately killing oneself. Self-harm is a broader term referring to
intentional self-inflicted poisoning or injury, which may or may not have a fatal intent or
outcome. Although suicidal thoughts are a common feature of moderate to severe
depression, not all suicidal patients are depressed. Adults and adolescents with any mental
health problems, chronic pain or acute emotional distress are at risk and should be asked
about thoughts or plans of suicide in the last month. Asking people about suicidal thoughts
does not increase the risk they may act on them; on the contrary it may lead to reduced
anxiety and helps the person to feel understood.

If someone is at risk of self-harm/suicide, the following should be done:

 Remove access to all possible means of self-harm
 Create a secure and supportive environment
 Do not leave the person alone. Admit if established suicide risk.
 Supervise and assign a named staff or family member to ensure safety
 Treat any depression, psychosis or BPD, or drug or alcohol use disorder.
 If medicines are indicated, use medicines that are the least dangerous in overdose
and give the prescription for a short duration (e.g. 1 week at a time).

Anxiety disorders
Generalised Anxiety Disorder (GAD)
GAD is diagnosed when the person has symptoms of worrying all or most of the time about
different things, that cause distress or difficulty with daily functioning. There may also be a
feeling of dread as if something bad is about to happen. Also consider GAD in patients with
multiple physical symptoms (gastrointestinal, palpitations, headache, back pain) for which no
medical cause can be found but who may not admit to worry or distress.

Panic Disorder
Sudden, unpredictable attacks with symptoms like sweating, shortness of breath, shakiness,
palpitations, nausea, fear of dying, often provoked by something the patient finds difficult and
often in a confined space or where it is difficult to leave

GAD and Panic disorder may co-exist. Both are more common in patients under current
physical or emotional stress or who have a past history of emotional or physical trauma.
Depression and anxiety disorders also commonly co-exist.

Differential Diagnosis:
 Side effects of medication: theophyllines, salbutamol, steroids, SSRIs
 Substance misuse: alcohol withdrawal, caffeine, cannabis
 Physical conditions: hyperthyroidism, phaeochromocytoma

Suicide Risk
Assess for suicide risk in moderate to severe GAD.Risk is increased if there is anxiety
severe enough to cause very poor day to day functioning or if there is severe co-existing
depression or other mental health disorder.

Treatment of GAD and Panic Disorder

 Try to help the patient find practical solutions to help with contributing stressors

179
  Co-existing depression is common; if more severe than anxiety, treat this first
 Co-existing substance misuse. Patients often ‘self-medicate’ with alcohol or other
substances as a way of coping with symptoms; treat first if harmful and dependent
 Co-existing medical conditions: ensure best possible management
 Explanation, reassurance and support
 Encourage exercise and measures to improve sleep
 Breathing exercises to train the person in slow, regular diaphragmatic breathing
 Progressive muscle relaxation to train the person to systematically tense and relax
muscle groups, working from the feet upwards

Use of Medication
Do not use benzodiazepines except in crisis because there is a very high risk of
dependency. There is little evidence that medication is better than psychological
interventions. SSRIs can be tried. SSRIs or tricyclics can also be used to treat co-existing
moderate to severe depression. See above treatment section under Depression

Psychosis
Psychosis is a severe mental health disorder in which there is extreme impairment of ability
to think clearly, respond with appropriate emotion, communicate effectively, behave
appropriately and understand reality. People with psychosis have lost insight and are
frequently unaware that they have a mental health condition. An acute psychotic episode
can be triggered temporarily by drug use (cannabis for example). If symptoms persist for
more than 3 months, chronic psychosis (schizophrenia) is likely. 80% of patients with chronic
psychosis start to have symptoms between the ages of 16 and 30.

Assess for disturbances in three main areas:

Perception: hallucinations - hearing or seeing things that are not there; suspicion
Thinking: delusions (fixed, false beliefs that most people from the same culture would agree
are wrong); incoherent speech; disorganised, illogical thoughts; believing others are inserting
thoughts in one’s mind, broadcasting one’s thoughts to others
Behaviour and Emotions: social withdrawal, apathy, personal neglect, bizarre behaviour,
aimless wandering, mumbling to oneself, giggling inappropriately, inactivity or hyperactivity;
loss of functioning – academic, social, occupational

Look for possible physical causes of psychotic symptoms:

Rule out delirium: acute onset, fluctuating symptoms of disturbed consciousness (agitation,
hyperalert or drowsiness, hypoactive) and disorientation in time, place and person usually
due to an underlying infection, metabolic disturbance or head injury
Other organic disease: frontal or temporal lobe tumours; HIV; syphilis; hyperthyroidism
Medication side effects: steroids, mefloquine
Drug or alcohol intoxication or withdrawal
Severe depression with psychotic features (especially in older people)

Look for symptoms of mania: Reduced need for sleep, euphoria, rapid mood swings,
hyperactivity, grandiose thinking, impulsive behaviour. If present, treat as Bipolar disorder.

Treatment of psychosis
 Provide education to the person and carers about psychosis and its treatment.
Families need to understand that a person with psychosis may not agree that they
are ill and may be hostile. They need to know that the person may hear voices or
believe things that are untrue and that confrontation and criticism should be avoided
 Start antipsychotics.
 Psychological and social interventions such as family therapy or social skills therapy

180
  Facilitate rehabilitation
 Regular follow-up.

Treatment with antipsychotics

IM treatment is used only if oral medication is not feasible, even in acute psychosis. Depot
injections should not be used in acute psychosis.

For severe agitation or aggression:

Haloperidol (oral medication is preferred): 1.5mg / dose, increase up to 2.5 – 5mg three
times a day. Maximum dose 20mg/day
Consider adding a dose of oral diazepam 5mg if the person remains agitated despite anti-
psychotic medication

For acute and chronic psychosis:

Prescribe one antipsychotic at a time, and “start low and go slow”. Try the medication at an
optimum dose for at least 4 – 6 weeks before considering the response is inadequate. If the
response is inadequate: ensure treatment adherence (consider using a depot injection if
necessary); consider increasing current medication or switching to another medication;
consider changing to a newer, second generation anti-psychotic (risperidone) if available.

Women with psychosis who are planning a pregnancy, are pregnant or breastfeeding should
use medication only if benefits outweigh the risks. If necessary, they should be treated with
low-dose oral haloperidol, chlorpromazine or risperidone.

Medication Risperidone Haloperidol Chlorpromazine Fluphenazine

depot/ long-
acting
Starting dose 2mg/day 1.5 – 3mg 75mg 12.5mg
Effective dose (mg) 4 – 6mg/day 3 – 20mg/day 75-300mg/day 12.5 – 100mg
every 2-5 weeks
Route Oral Oral (IM for acute Oral Deep IM injection
psychosis) in gluteal region
Significant side-
effects:
Sedation (+) + +++ +
Urinary hesitancy (+) + ++ +
Low BP on standing + + +++ +
Extrapyramidal (+) +++ + +++
effects
Tardive dyskinesia (+) + + +

These antipsychotics can all very rarely cause neuroleptic malignant syndrome. They are
contraindicated if there is bone marrow depression or impaired consciousness.

If extrapyramidal side-effects (such as parkinsonism or dystonia) occur:

 Reduce the dose of antipsychotic medication, and
 Consider switching to risperidone, or another antipsychotic (e.g. switching from
haloperidol to chlorpromazine).
 Consider anticholinergic medications for short-term use if these strategies fail or
extrapyramidal side-effects are acute, severe or disabling.

Anticholinergic medication for treating extrapyramidal side-effects

Trihexyphenidyl (Benzhexol): start at 1mg daily, increase in steps of 2mg every 3-5 days.
Usual maintenance dose is 5 – 15mg daily in 3 divided doses.

181
Side-effects include constipation, urinary retention, sedation, confusion and memory
disturbance, especially in the elderly. Rarely: angle-closure glaucoma

Follow up
All patients on anti-psychotic medication should be followed up regularly to assess
symptoms and signs of relapse. Medication should be continued for a minimum of two years
as the risk of relapse is high if stopped before this time. Ensure families know how to
recognise signs of relapse, and how to seek help. Anti-psychotic medication causes weight
gain and metabolic changes that increase the risk of cardiovascular disease. An annual
physical health assessment should be carried out to measure weight and BMI, waist
circumference, fasting blood glucose, blood pressure, and to encourage smoking cessation,
exercise and weight loss if indicated.

Bipolar disorder
Bipolar disorder (BPD) is characterized by episodes in which the person’s mood and activity
levels are significantly disturbed. This disturbance consists on some occasions of an
elevation of mood and increased energy and activity (mania), and on others of a lowering of
mood and decreased energy and activity (depression). Characteristically, recovery is
complete between episodes. People who experience only manic episodes are also classified
as having bipolar disorder. People who are not currently manic or depressed but who have a
history of 2 or more episodes of mania (or a single manic episode with adverse
consequences), or one episode of mania and one episode of depression, may need a mood
stabiliser and full support as below.

Signs of acute mania episode

Several days of:
 Markedly elevated or irritable mood
 Increased energy, activity, restlessness and excitement
 Reduced need for sleep
 Excessive talking
 Loss of normal social inhibitions and recklessness
 Elevated sexual energy or sexual indiscretion
Past history of:
 Depressed mood
 Decreased energy and activity

Signs of depression
See above: diagnosing moderate to severe depression

Prior episode of mania

Treatment of acute mania

 Begin treatment of acute mania with valproate, carbamazepine or with antipsychotics
(see below).
 Consider a short-term benzodiazepine (such as diazepam) for behavioural
disturbance or agitation
 Discontinue any antidepressants
 Advise the person to modify lifestyle; provide information about bipolar disorder and
its treatment.
 Provide regular follow-up.

Treatment of depression in BPD

 Begin treatment with a mood-stabilizer. This is often sufficient.

182
  Consider antidepressant combined with mood stabilizer for moderate / severe
depression. Before starting antidepressant, inform person of the risk of switching to
mania on this medication.
 Advise the person to modify lifestyle; provide information about bipolar disorder.
 Reactivate social networks.
 If available, consider psychological interventions.
 Pursue rehabilitation, including appropriate economic and educational activities,
using formal and informal systems
 Provide regular follow-up. Patients with BPD are at high risk of suicide.

Medication for BPD

Mood stabilisers: try to keep the patient on the same brand of medication as different
preparations may differ in their effects. Monitor closely all patients on these drugs for side
effects

Valproate: Starting dose 500mg daily in divided doses (tablets may be halved but not
crushed or chewed). Increase gradually to 1000 – 2000mg daily in two divided doses.
Side effects: sedation, weight gain, transient hair loss, liver dysfunction. Advise patients to
stop treatment and seek medical help if persistent vomiting, abdominal pain, jaundice or
bleeding develop
Cautions: Do not use in pre-existing liver or kidney disease. Do not use in pregnancy.
Ensure effective contraception if used in women of child-bearing age.

Carbamazepine: Starting dose 200mg at bedtime. Increase gradually to 400 – 600mg daily
in two divided doses.
Side effects: sedation, tremor, unsteadiness, diplopia, hyponatraemia, blood disorders,
weight gain, liver enzyme abnormalities. Rarely, Stevens-Johnson syndrome. Advise
patients to stop treatment and seek medical help if they develop fever, skin rash, mouth
ulcers or bleeding
Cautions: Avoid if there is a history of cardiac, kidney or liver disease. Avoid in pregnancy
and breast feeding. Give careful advice about contraception if used in women of child-
bearing age as induction of liver enzymes reduces efficacy of hormonal methods.

Medication for acute manic episode: oral risperidone 2mg daily, increased to 4 – 6mg daily.
Alternatively, oral or intramuscular haloperidol may be used. These medications can also be
used, if necessary, in pregnant and breast-feeding women.

Medication for depression in BPD: fluoxetine 20 – 40mg daily with a mood stabiliser as co-
prescribing is less likely to induce mania

Monitoring and follow up

Continue treatment with mood stabilisers for at least two years after the last episode of
mania or depression.Monitor frequently during a manic or depressive episode. Once stable,
monitor regularly as relapse rates are high and adherence to treatment is often poor as
people in a manic state lack insight into the need for treatment.

Medically unexplained symptoms (MUS)

"Medically unexplained" means "no underlying physical condition can be identified". It also
means that the patient is not thought to be suffering from moderate to severe depression.

It is unusual to make a diagnosis of MUS at first presentation. Look for:

 a history of multiple aches and pains that often move from one part of the body to
another

183
  patients presenting with a history of repeated collapse without seizures, or with
seizures that are not typical of epilepsy seizures.

To make the diagnosis, patients should have:

 symptoms that have been present for some time and are not explained by another
diagnosis;
 a reduced ability to do day to day activities

Before diagnosing MUS, assess for, and exclude:

 recent exposure to traumatic events, acute stress, loss or grief
 moderate to severe depression (with risk of suicide or self-harm) or anxiety
 harmful substance misuse
 abuse, domestic violence
 underlying physical illness

Take a thorough history (ensuring privacy) without interrupting, encouraging the person to
tell you in their own words about their symptoms and the impact these have on their daily
life. Ask about problems, stressors and significant life events. Do a full physical examination
and request relevant blood tests to ensure there is no underlying physical illness. The
person’s concerns should not be dismissed as being ‘imaginary’ and the person should not
feel judged. Take time to explain to the person that although their symptoms are real and
distressing, there is no serious underlying medical cause.

In ALL cases:

DO NOT:
 prescribe antidepressants or benzodiazepines (unless the diagnosis has been made
previously and the patient now has depression as well as MUS)
 manage complaints with placebos, injections or other ineffective treatments (eg
vitamins).
DO:
 Listen carefully and with empathy. Summarise what the patient has said about
symptoms and their impact and their relationship to life events
 Address current psychosocial stressors
 Avoid unnecessary investigations and referrals
 Try to make the link between bodily sensations and experiencing emotions (eg fear
inducing rapid heart rate, sweating and trembling)
 In adolescents and adults:
 Address inappropriate self-medication, and alcohol / substance misuse
 Reactivate social networks
 consider one of the following treatments: Behavioural activation, relaxation
training or problem-solving treatment.
 Continue to review the person. New symptoms will need to assessed with
history and examination, and on-going symptoms carefully reviewed to exclude
underlying physical illness or moderate to severe depression.

Substance Misuse - Alcohol Use Disorders

Misuse of alcohol may lead to:
 Harmful drinking - a person continues to drink despite knowing he has a physical or
social complication from alcohol eg liver damage; financial problems; violence
towards others

184
  Dependent drinking – a person has had at least three of the following over a one-
year period: craving (strong psychological desire for alcohol); tolerance (requires
more to have the same effect); preoccupying thoughts about drinking; loss of control
of drinking; withdrawal effects
 Signs and symptoms of acute intoxication
 Signs and symptoms of alcohol withdrawal

Manage harmful drinking using brief motivational techniques:

Ask: about the amount of alcohol used, the pattern of drinking and the person’s
understanding of the problem
Assess: harm to self and others: medical problems, injuries, accidents, financial, legal or
occupational problems, ability to care for dependents, relationship problems, violence;
nutritional status; motivation to stop drinking
Advise: provide information about the harmful effects and ways to reduce or stop drinking
Assist: with management of medical problems, helping the patient to formulate their own
plan to reduce or stop drinking, psychosocial support and follow up

Management of alcohol withdrawal

Typically occurs between 6 hours and 6 days after the last drink. Look for: tremor, sweating,
vomiting, agitation, tachycardia and increased blood pressure. Seizures and confusion
(delirium) are signs of severe withdrawal. Patient must be supervised and monitored closely.
 Treat signs of withdrawal with diazepam 10mg four times daily for 3-7 days. Reduce
dose to 5mg; increase time between doses if elderly or has impaired liver function.
 Give thiamine 100mg/day orally twice daily for 14 days.
In alcohol-withdrawal delirium:
 Give thiamine 100mg IV or IM three times daily for 5 days.
 In addition to the diazepam, use haloperidol 2.5 – 5mg orally if the patient has psychotic
symptoms:
Treat alcohol withdrawal seizures with rectal or intravenous diazepam

Manage dependency with a rehabilitation programme starting with planned withdrawal

 Plan withdrawal as an inpatient: if patient has been drinking more than 15 units a day; if
there is inadequate home support; a history of previous withdrawal delirium; seizures;
liver disease or coexisting psychosis or suicidal ideation. Use diazepam (dose as above)
but adjust dose and duration of treatment according to the severity of the withdrawal and
co-morbidities. Higher doses, given more frequently, may be needed.
 Manage withdrawal as an outpatient if none of the above criteria are present and patient
can be monitored continuously by their family. Treat withdrawal symptoms with a fixed
dose reducing regime of diazepam. Start with 10mg orally, then 5mg every 6 hrs for 3
days, then 5mg every 12 hrs for 2 days then 5mg daily for 2 days then stop
 Give all patients oral thiamine 100mg twice daily for 14 days
 Provide close follow up after alcohol withdrawal and psychosocial interventions if
available

185
5. Emergencies
5.1 Emergency Medical Care

Triage
Triage is the process of rapidly screening a sick person soon after their arrival at the HC, in
order to identify:

1. Those with emergency signs, who require immediate emergency treatment;

2. Those with priority signs, who should be given priority in the queue so that they can
be assessed and treated without delay; and
3. Non-urgent cases, who have neither emergency nor priority signs.

Emergency signs include:

 obstructed or absent breathing
 severe respiratory distress
 central cyanosis (blue colour of lips and tongue)
 signs of shock (cold hands, capillary refill time longer than 3 seconds, high heart rate
with weak pulse, and low or unmeasurable blood pressure) coma (or seriously
reduced level of consciousness)
 convulsions
 signs of severe dehydration in a person with diarrhoea (lethargy, sunken eyes and in
children: very slow return after pinching the skin or any two of these).

People with these signs require immediate emergency treatment to avert death.

Assess the ABCDE – Airway, Breathing, Circulation, Disability, Exposure

Ask for help

A Airway
 Assess patient
 Establish a patent airway
 Stabilize cervical spine with rigid collar if injured

B Breathing
 Assess patient
 Administer oxygen from concentrator if available
 Assist ventilation, if indicated
 Alleviate tension pneumothorax or massive haemothorax with chest drain
 Seal open chest wound (pneumothorax)

C Circulation and control of haemorrhage

Cardiopulmonary resuscitation (CPR) if required
 Direct pressure to bleeding site
 Assess patient
 Intravenous access and blood samples
 Fluid resuscitation
 Transfusion, if indicated
D Disability
 assess and protect brain and spine functions

186
E Exposure
 Identify all injuries and any environmental threats

If a problem is identified in any of these steps it must be addressed immediately before

moving on. The ABCDE approach should be performed in the first 5 minutes and
repeated whenever a patient’s condition changes or deteriorates

A - Assess the airway

Can the person talk normally? If so, the airway is open. If not :
Does the person’s breathing appear to be obstructed? Look at the chest wall movement and
listen to breath sounds to determine whether there is poor air movement during breathing.

Other emergency measures to secure airway if necessary by staff experienced in these

techniques:
 Forward jaw thrust
 Insert oro- or nas-pharyngeal airway
 Endotracheal intubation
 Cricothyroid puncture
 Tracheostomy
Stridor indicates obstruction. Stridor plus swelling and /or hives suggest a severe allergic
reaction(anaphylaxis).

Look and listen for fluid eg vomit or blood in the airway.

Remove with suction if available and, if no trauma, turn on side in recovery position.

Is a foreign body suspected?

If visible remove it, being careful not to dislodge it. If patient is choking, use age-appropriate
treatment to remove the foreign body eg chest or abdominal thrusts.

B - Assess breathing

Is there central cyanosis? Determine whether there is bluish or purplish discoloration

of the tongue and the inside of the mouth.
Is the person breathing? Look and listen to determine whether the person is breathing.

If there is obstructed or absent breathing, central cyanosis or severe respiratory distress:

Give ventilation with Ambu bag and mask if absent respiration.
Give oxygen if available

Is there severe respiratory distress?

The breathing is very laboured, fast or gasping, with chest indrawing, nasal flaring, grunting
or the use of auxiliary muscles for breathing (head nodding). The person is unable to eat
because of respiratory distress and tires easily. Listen to the chest:
 If wheezing: treat with salbutamol
 Check if breath sounds are equal on both sides.
 Dull to percussion and absent breath sounds, consider pleural effusion or
haemothorax. Give oxygen. May need chest drain (see surgical manual).
 If tension pneumothorax (no breath sounds one side, hypotension, shifted trachea)
perform needle decompression immediately, give IV fluids and oxygen

C - Assess circulation (for shock)

People in shock are lethargic and have cold skin, prolonged capillary refill, fast weak pulse
and hypotension.

187
  Check the pulse (very fast) and the BP (very low). If the radial pulse is strong and not
obviously fast, the person is not in shock. If you cannot feel the radial pulse, feel the
carotid pulse.

Check whether the person’s hand is cold. If so, determine whether the person is in shock.
 Check whether the capillary refill time is longer than 3 seconds. Apply pressure to
whiten the nail of the thumb or the big toe for 5 seconds. Determine the time from the
moment of release until total recovery of the pink colour. If capillary refill is longer
than 3 seconds, check the pulse. Is it weak and fast?
 Look for both internal and external bleeding (into chest, abdomen, from stomach,
intestine, pelvic or femur fracture), from wounds.
 If hypotension, distended neck veins and muffled heart sounds consider pericardial
tamponade.
 If cause unknown, consider possibility of trauma.

D - Disability
 Assess level of consciousness with AVPU scale (Alert, Voice, Pain, Unresponsive) or
in trauma cases Glasgow Coma Scale
 If altered mental status and no evidence of trauma, place in recovery position.
 Check blood glucose level in confused or unconscious patient.
 If glucose low< 3.5mmol/l give glucose. If glucose test not available and patient has
altered mental status give glucose.
 Check for pupil size, whether equal and reactive to light. If pupils small and patient is
breathing slowly, consider opiate overdose and give naloxone. Initially 400
micrograms, then 800 micrograms for up to 2 doses at 1 minute intervals. Then
increase to 2mg for one dose. If no response, review the diagnosis.
 If pupils are unequal, consider increased pressure on the brain and refer for
neurosurgical opinion if available
 Check movement and sensation in all four limbs
 Look for abnormal repetitive movements on one or both sides of the body (seizure)
 If pregnant and having seizures give magnesium sulphate initially 4g IV over 5-15
minutes followed by IV infusion 1gram/hour for 24 hours. If seizure recurs increase
infusion rate to 1.5-2.0g/hour or hive additional 2g by IV injection.

E - Exposure
 Examine whole body for hidden injuries, rashes, bites or other lesions.
 Rashes can indicate a serious infection.
 If snake bite suspected, immobilise the limb. (where snake bite took place: Take a
picture of the snake from a distance). Do not risk additional bites to catch/kill snake
 Remove all constricting clothing and jewellery
 Cover the patient to prevent possible hypothermia
 Acutely ill people have difficulty regulating body temperature
 Remove any wet clothes and dry patient.
 Respect the patient and protect modesty.
 Remember the possibility of trauma. If suspected spinal injury, only turn patient using
a log roll.

Treatment of anaphylaxis
A person may develop shock as an acute allergic reaction to a medicine, blood transfusion,
a bee sting or snake bite, or after eating a food that they are allergic to. They present with
fast rapid pulse, low BP, may be pale, cold and clammy and may have an urticarial allergic
rash or severe wheezing. They need immediate ABC life-saving measures and treatment
with adrenaline and IV fluids (Ringers lactate or 0.9% sodium chloride).

188
 Treatment steps for anaphylaxis
1. Restoration of blood pressure (lay the patient down, raise the legs or put in recovery
position)
2. Give IM adrenaline (epinephrine) injection.
3. Give IV fluids, ringers lactate or 0.9% sodium chloride. (500mls for adults; 20mls/kg
for children); may need to be given in 10 – 20 minutes depending on response in BP
and pulse.
4. Monitor pulse and BP and repeat adrenaline dose if necessary
5. Give IV or IM chlorphenamine
6. Give IV or IM hydrocortisone
7. If severe asthma, give inhaled salbutamol 8 puffs via a spacer
8. If the heart stops beating, cardiopulmonary resuscitation is needed by specially
trained staff.
Treatment note: Adrenaline is given IM on the anterolateral aspect, middle third of the thigh.

Adrenaline for anaphlyaxis

Medicine Age Dose Duration Side effects
Adrenaline Children < 6 years 150 micrograms, 0.15ml IM Single dose Common: nausea,
(epinephrine) Children 6 – 12 300 micrograms, 0.3ml IM may need vomiting, headache
1mg/1ml (1 years to be Rare: irregular
in a 1000) Adults & chldren > 500 micrograms, 0.5ml IM repeated heart beat,
12 years Every5 hypertension,
minutes urinary retention
Prescribing tip: Nurses should be trained to give adrenaline in emergencies, and must follow the indications and
the dose very carefully.

Chlorphenamine for anaphylaxis

Medicine Age Dose Duration Side effects
Chlorphenamine Infants 1-5 months 250mcg/kg Can be Dry mouth, blurred
Children 6 months – 2.5mg IM repeated vision
5 years up to 4
Children 6 – 11 5mg IM time in 24
years hours
Adults & children > 10mg IM or IV
12 years

Hydrocortisone for anaphylaxis

Medicine Age Dose Duration Side effects
Hydrocortisone Infants < 6 months 25mg IM Single dose Few side effects
100mg/1ml Children 6 months – 50mg IM with one off dose
5 years
Children 6 – 11 100mg IM
years
Adults & children > 200mg IM
12 years

Treatment of shock:
 Stop any bleeding
 Put them in Trendelenburg position (with head lower than body)
 Give IV fluids (Ringers lactate or 0.9 sodium chloride). But if a child has severe acute
malnutrition, give IV 5% glucose instead)
 Send blood for cross matching.
 Keep person warm
 For external bleeding apply direct pressure

189
IV fluids for treating shock
Replacement fluids are used in hypovolemic shock to replace abnormal losses of blood or
extracellular fluids by increasing the volume circulating in the blood vessels. Initial treatment
with these fluids may be life-saving and provide some time to control bleeding and obtain
blood for transfusion, if it becomes necessary.
 Crystalloid solutions with a similar concentration of sodium to plasma (normal saline
or balanced salt solutions) are effective as colloid replacement fluids. Crystalloid
replacement fluids should be infused in a volume three times the volume lost in
order to correct hypovolaemia. They are contraindicated in renal failure. Examples
include normal saline (0.9%), compound sodium lactate solution (Ringers lactate)
and Hartmann’s solution.
 Dextrose (glucose) solutions do not contain sodium and are poor replacement fluids
so should not be used.
 Colloid solutions (albumin, dextrans, gelatins) are replacement fluids but are not
better than crystalloids in resuscitation in adults. If used at all, colloid solutions
should be infused in a volume equal to the blood volume deficit.
 NB Dextrans interferes with the cross-match procedure. Therefore, if a transfusion is
likely take a sample for cross matching before giving the dextrans.

Age (weight) Volume of Ringer’s lactate or 0.9% sodium chloride (20 ml/kg)
2 months (< 4 kg) 50 ml
2–< 4 months (4–< 6 kg) 100ml
4–< 12 months (6–< 10 kg) 150ml
1–< 3 years (10–< 14 kg) 250ml
3–< 5 years (14–19 kg) 350ml

Severely malnourished children with shock should be managed in the stabilisation centre
(SC). IV fluids are diluted and given more slowly: either the same volume of 0.9% sodium
chloride or ringer’s lactate perfusion is mixed with 5% dextrose perfusion. This is given at
15ml/ kg over 1 hour.

For the clinical use of blood, see 5.4. For treatment of Convulsions see below

Management of major haemorrhage – surgical, traumatic, obstetrical

Major bleeding from whatever cause needs urgent management with initial measures to
ensure survival including fluid replacement and blood transfusion. Consult surgical and
obstetrical protocols.

Treatment steps for major bleeding.

1. Head down tilt/raise legs (Trendelenburg position).
2. Give oxygen if available from concentrator.
3. Establish intravenous access with 2 large-bore cannulae (14 g or 16 g).
4. Infuse crystalloid replacement fluids (0.9% sodium chloride or Ringers lactate) as
rapidly as possible. Restoration of normal circulating volume is a priority. Aim is to
give 20-30ml/Kg of resuscitation fluids over 30 minutes to any patient who has
lost>15% total blood volume. If possible warm the fluid to prevent further cooling of
the patient.
5. Identify the cause of the bleeding and do appropriate first measures to reduce blood
loss if possible while preparing for appropriate surgical intervention.
6. Send sample to blood bank for matching of further blood, but do not wait for cross-
matched blood if there is serious haemorrhage. Do a haemoglobin / full blood count.

190
 7. Give group O negative antibody-screened blood (and/or uncross-matched group
specific blood from the blood fridge) until fully cross-matched blood has been
prepared. See 5.4
8. Continuously monitor pulse rate, blood pressure, respiratory rate, conscious level.
9. Insert urinary catheter and measure hourly output.
10. Signs of normal blood volume restoration include:
 Decreasing heart rate
 Normalising capillary refill time
 Return of peripheral pulses
 Increasing urine output
 Return of normal BP
 Rising central venous pressure (check jugular venous pressure)

Replacement fluids in children

Hypovolaemia may be more difficult to recognise in children as there may be very little
change in vital signs. Tachycardia is often the first sign of hypovolaemia but this may also be
caused by fear or pain. It is easy to give too much IV fluid to children (fluid overload) which
can cause heart failure and death, so very close monitoring of the replacement fluids is vital.
 Give 20ml/kg of crystalloid fluid over 60 minutes.
 Depending on response, repeat up to 3 times ie up to a maximum of 60ml/kg.
 If no response give further crystalloid and blood transfusion.
 If transfusing, initially transfuse 20ml/kg of whole blood or 10ml/kg of packed cells
(see 5.4)
 Monitor vital signs very closely.

The only compatible fluids to give concurrently with blood are:

 Normal saline
 4% albumin
DO NOT GIVE 5% dextrose in water or hypotonic sodium solutions as it may cause red cell
lysis. DO NOT ADD drugs to the blood bag or transfusion set. If drugs are to be
administered through the same vein, flush first with normal saline and then again after the
drug has been given.

Blood salvage
Blood salvage is the collection of shed blood from a wound, body cavity or joint space and its
subsequent reinfusion into the same patient. It should only be carried out by someone
experienced in the technique. It can be used in emergency or trauma surgery using blood
taken from a previously closed cavity (e.g. from a ruptured ectopic pregnancy or ruptured
spleen) if the blood is clean. It must not be used if the blood is contaminated with bowel
contents, bacteria, fat, amniotic fluid, urine or malignant cells. Blood that has been shed for
more than 6 hours should not be used (the blood will be haemolysed and there is risk of
hyperkalaemia and infection).

Method of blood salvage by gauze filtration

This method is inexpensive and suitable for the salvage of blood from body cavities.
 At operation and using an aseptic technique, collect blood from the cavity using a
sterile ladle or small bowl.
 Mix the blood with anticoagulant.
 Filter the blood through gauze and reinfuse into the patient.

Fever management
Fever is a temperature of over 37.5° and is a response by the body to underlying infection
and disease. Fever is a positive reaction by the body in its fight against infection.

191
Treatment steps
1. Take the temperature of all patients complaining of being unwell or with history of
fever.
2. Admit all patients with high fever (> 40°) and danger signs – including drowsiness,
pallor, convulsions, signs of shock, severe dehydration, signs of meningitis. Give first
dose treatment with antibiotic in outpatients if severe infection suspected.
3. Do a RDT for malaria (and/or thick film) on all patients with fever over 37.5° If
positive, treat for malaria.
4. Ask other questions to establish cause of fever and treat underlying cause. Other
causes of fever include ARI, viral illness, UTI. Admit cases of hepatitis, measles,
meningitis and typhoid fever and isolate.
5. Give paracetamol. In the absence of other signs or symptoms and if the patient is
otherwise well, no other treatment is needed, but they should be told to return if not
improving.
6. Repeat the RDT after 3 days if fever persists. If RDT positive, treat as Section 3.3. If
RDT negative, admit and investigate.

Treatment note: Do not give antibiotics if there is mild fever but no obvious cause.
Advice: Do not overdress or underdress a child with fever. Sponging a child with water may
initially reduce the temperature but should not be done if it is likely to upset the child.

Treatment of life-threatening infection

Children and adults with life-threatening infections like meningitis, severe pneumonia and
septicaemia, may present with
 very high fever (> 40°),
 with very rapid breathing, (SpO2 <90%)
 stiff neck, photophobia (signs of meningitis)
 dark purple rash,
 vomiting,
 dehydration
 bulging fontanelle in infants,
 drowsiness or unconscious, and/or having fits.

Infants under 1 year with meningitis may not have the classic signs, but may be irritable, not
feeding, have apnoea episodes.

1. Put in recovery position if unconscious

2. Give rectal diazepam if prolonged convulsion
3. Give first dose antibiotic
4. Give IV fluids

Antibiotic for life-threatening infection (septic shock)

The first line treatment is
 IV ampicillin (Adults 1g 3 x day; children 50mg/kg 4 x day for 7 days)
 gentamycin IM: 5 mg/kg in 3 divided doses for 7 days.

When there is no improvement after 24 hours of this treatment, switch to:

When origin of infection is unknown:
 Continue Ampicillin and Gentamicin AND add:
 cloxacillin IV Adults: 1g 3 x day; Children: 30mg/kg 3 x day

When gastro-intestinal, or gynaecological origin:

 gentamycin IM: 5 mg/kg in 3 divided doses for 7 days AND

192
  ceftriaxone slow IV Adults 2g 1 x day then 1g 1 x day; Children: 100mg/kg 1 x day
then 50mg/kg 1 x day the following days AND
 metronidazole IV Adults 500mg 3 x day; Children: 7 - 10mg/kg 3 x day

When of cutaneous origin:

 cloxacillin IV Adults 1g 3 x day; Children: 30mg/kg 3 x day AND
 gentamycin IM: 5 mg/kg 1 x day for 7 days

When of pulmonary, urinary and other origin:

 ceftriaxone slow IV Adults 2g 1 x day then 1g 1 x day; Children: 100mg/kg in 1 x day
the 1st day, then 50mg/kg 1 x day AND
 ciprofloxacin PO Adults 500mg 2 x day; Children 10mg 2 x day for 7 days

Also add oral anti-fungal drugs if possibility of fungal infection (including for cryptococcal
meningitis – see 3.6).
 fluconazole PO. Adult 200mg 1 x day; Children 6mg/kg 1 x day for 14 days.

Meningitis
Meningitis is an acute bacterial infection of the meninges covering the brain and is an
emergency condition requiring early IV administration of antibiotics that penetrate into the
cerebrospinal fluid. Choice of antibiotics depends on age and context based on the likely
causative organism:

In epidemics: N. meningitdis A or C or W135

Infants 0 to 7 days: Gram-ve bacilli, Group B streptococcus, (Staph aureus

if likely skin infection including umbilical cord infection).
Infants > 7 days to 2 months: S. pneumoniae for 50% cases
Children 3 months to 4 years: S. pneumoniae, H. influenza B, N. meningitidis
Children 5 years and adults: S. pneumoniae, N. meningitidis

Immunosuppressed patients (HIV, SAM): Gram-ve bacilli (esp Salmonella) and TB

Sickle cell patients: Frequently Salmonella spp & Staph aureus
After skin infection or skull fracture: May be Staph aureus

Treatment of meningitis in an epidemic

Infants 0 to 2 months: ceftriaxone IV or IM 100mg/kg once daily for 7 days
Children > 3 months - < 5 years: ceftriaxone IV or IM 100mg/kg once daily for 5 days
Children 5 years & over & adults: ceftriaxone IV or IM 2 g once daily for 5 days
Check MoH guidelines during epidemic

Treatment of meningitis not in an epidemic, assuming bacteria not identified:

Children < 20 kg and adults: ceftriaxone IV or IM 100mg/kg once daily, 7 -10 days
Children > 20 kg & adults: ceftriaxone IV or IM 2 g once daily for 7- 10 days
If associated skin infection, then add:
Children < 40 kg and adults: cloxacillin IV 50mg/kg 4 x per day for 7-10 days
Children > 40 kg & adults: cloxacillin IV 2,500 mg 4 x per day for 7-10 days

Infants 0-7 days < 2kg
Infants 0-7 days > 2kg
Infants 8 days – 30 days
ampicillin IV 100mg/kg 2 x per day AND
gentamicin IV 3mg/kg once daily
ampicillin IV 100mg/kg 3 x per day AND
gentamicin IV 5mg/kg once daily
ampicillin IV 100mg/kg 3 x per day AND
gentamicin IV 5mg/kg once daily

193
Infants 1 – 3 months ampicillin IV 100mg/kg 4 x day AND
gentamicin IV 2.5mg/kg 3 x per day

If associated skin infection need cloxacillin in case of Staph aureus:

 give children < 40kg cloxacillin IV 50mg/kg 4 x per day with ceftriaxone
 give children > 40kg and adults cloxacillin IV 2,500mg 4 x per day with ceftriaxone
give infants cloxacillin instead of ampicillin with gentamicin:
Infants 0-7 days < 2kg cloxacillin IV 50mg/kg 2 x per day
Infants 0-7 days > 2kg cloxacillin IV 50mg/kg 3 x per day
Infants 8 days – 30 days cloxacillin IV 50mg/kg 4 x per day
Infants 1 – 3 months cloxacillin IV 50mg/kg 2 x per day

Tetanus
Tetanus presents as muscular rigidity beginning in the jaw, spreading to face and whole
body, and severe, painful muscle spasms, which are spontaneous or triggered by noise, light
and touch. In newborn tetanus, signs appear within 3 to 14 days of birth, and present with
irritability, difficulty sucking with the rigidity and spasms.

Treat the spasms, the pain, maintain hydration and inhibit toxin production:
Treatment for spasms
 Newborns: give diazepam 0.1 to 0.3mg/kg by slow IV injection (over 3 – 5 minutes)
every 1 to 4 hours depending on response as long as the RR is > 30.
 Children > 1 month: give diazepam. Give IV diazepam infusion made by diluting
10mg vial of IV diazepam in 50ml of 5% glucose (concentration of 0.2mg diazepam
per ml). Give 0.1mg/kg/hour of this solution.
 Children > 5 years: give give diazepam. Give IV diazepam infusion made by diluting
5 x 10mg vials (50mg) of IV diazepam in 250ml of 5% glucose or 0.9% sodium
chloride, (concentration of 0.2mg diazepam per ml). Give 0.1mg/kg/hour of this
solution.
When the frequency and severity of spams start decreasing, gradually decrease the rateof
the infusion. And then convert to oral diazepam (calculating the total dose given in 24 hours)
and give 4 x per day, initially by NG tube then my mouth 3 x per day.
Hydrate by NG tube taking great care to calculate the quantity of fluid required in 24 hours.
Avoid fluid overload. In infants use expressed breast milk.
Treat pain with oral morphine via NG tube if necessary (see 4.12). or paracetamol.
Inhibit toxin production with human tetanus immunoglobulin 500 IU divided in half and given
IM in 2 different sites as a single dose AND give:
metronidazole by IV Infusion:
 Infants 0 to 7 days & infants < 2kg: metronidazole IV infusion 15mg/kg 1 x per day on
day 1 and then then 7.5mg/kg 2 x per day
 Infants 8 days to < 1 month: metronidazole IV infusion 15mg/kg 2 x per day
 Children 1 month and over: metronidazole IV infusion 10mg/kg 3 x per day Adults:
metronidazole IV infusion of 500mg 3 x per day
 If metronidazole infusion not available, crush tablet and give same dosages via NG
tube)
Intensive nursing in dark, quiet room. Blindfold infants with cloth. Handle the patient as little
as possible. Gentle suction and oropharynx.
Tetanus vaccination is administered after recovery.

194
 Febrile convulsions in children
Children with high fever may have a febrile convulsion caused by the fever associated with
an infection. Most febrile convulsions do not need diazepam unless they continue for more
than 3 to 5 minutes.

Treatment steps
1. Put the child on their left side in the recovery position.
2. When recovered give fluids by mouth.
3. Treat as per Fever Management (above) and treat any cause of fever.
4. If prolonged convulsion give rectal diazepam.

How to give diazepam rectally

 Draw up the dose from an ampoule of diazepam into a tuberculin (1-ml) plastic
syringe. Base the dose on the weight of the child, when possible. Then remove the
needle.
 Insert the syringe gently 3–4 cm into the rectum and inject the diazepam solution.
 Hold the buttocks together for a few minutes.
 If convulsions continue after 10 min, give a second dose of diazepam
 Do not give more than two doses of diazepam

Precaution: If an infant or young child stops breathing after administering diazepam give
artificial ventilation with bag and mask.
Medicine Age (weight) Dose - Diazepam given rectally Duration Side effects
10 mg/2 ml solution. Dose 0.1 ml/kg
(0.5mg/kg)
Diazepam 2 weeks - < 2 months (<4kg) 0.3ml Single Common:
5mg/ml 2 – < 4 months (4 - < 6kg) 0.5ml dose. drowsiness,
2ml 4 - < 12 months (4–< 6 kg) 1.0ml confusion
ampules 1 - < 3 years (6–< 10 kg) 1.25ml Rare: stop
3 - < 5 years (14 – 19kg) 1.5ml breathing
5 – 12 years 2.0ml
Adult and child > 12 years 3.0ml
Prescribing tip: Must use a plastic syringe. Insert gently 3 – 4 cm into rectum via anus.

Treatment of convulsions
Treatment of convulsions causes like cerebral malaria and epileptic convulsions in children
and adults (for eclamptic fit see 1.3)

Treatment steps
1. Protect the person from injury and do not try to force anything into their mouth. A
brief convulsion does not require any treatment.
2. If prolonged convulsion give IV diazepam 0.3mg/kg (up to a maximum of 10mg) as a
slow IV injection over 2 minutes or give rectal diazepam as above.
3. If the patient continues to convulse, give further doses of diazepam every 10 minutes
(up to a maximum of three doses).
4. Treat patients who have multiple (three or more) or prolonged (lasting 30 minutes or
more) convulsions or in status epilepticus with a loading dose of IM phenobarbital,
10–15 mg/kg (or IV at a rate of 100mg/minute)
5. If convulsions continue give another drug if available (phenytoin 10mg/kg IV over
thirty minutes) and monitor for respiratory depression. Emergency intubation and
assisted ventilation may be needed.
6. When the convulsion stops, put the person on their left side in the recovery position.
7. When recovered give fluids by mouth.
8. If fever treat as per Fever Management (see above).

195
5.2 Viral Hemorrhagic Fevers (VHF)
(Consult national guidelines and WHO guidelines for full protocols)

Viral haemorrhagic fever (VHF) is a general term for a severe illness occurring in epidemics,
sometimes associated with bleeding, that may be caused by a number of viruses. In South
Sudan these may include Ebola, Marburg, Crimean-Congo haemorrhagic fever (CCHF),
yellow fever, dengue, and Rift Valley fever. All are zoonotic disease, with a reservoir in
animals and initially spread to humans by contact with infected bush meat or by insect bites.
During epidemics:
 Ebola, Marburg and CCHF are also transmitted person-to-person
 yellow fever and dengue are only transmitted to humans through mosquito bites
 Rift Valley Fever from contact with infected meat.

Clinical manifestation: The initial clinical manifestations of Ebola, Marburg, and CCHF
infections are non-specific and mimic many common infections, making them difficult to
diagnose early, and bleeding may not occur in > 50% of cases. Staff need a high suspicion
in fevers that are RDT-ve for malaria, are not responding to treatment for other infectious
diseases, and especially if there is unexplained bleeding or rapid deterioration.

Bleeding can be from puncture sites, in rashes, from the gums, conjunctiva, nose, vagina in
women, or in vomit, stools, sputum. Pregnant women may miscarry.

Clinical features of Crimrean-Congo hemorrhagic fever

Present 3 -7 days after a tick bite.
Onset is sudden with fever, anorexia, abdo pain and vomiting.
Bleeding as above. 30% have large spleen and liver.

Case definition, Ebola or Marburg suspected case:

 Sudden onset high fever after contact with Ebola case or dead animal OR
 High fever and 3 of: headache, vomiting, diarrhoea, anorexia, abdo pain, lethargy,
aching muscles or joints, difficulties swallowing or breathing, hiccups OR
 Unexplained bleeding OR
 Sudden unexplained death OR
 Clinical suspicion of Ebola or Marburg
Probable Case if they had a link to a confirmed EVD or MVD case
Confirmed case if tested positive for EVD or MVD

Ebola, Marburg and Crimean-Congo Hemorrhagic fever

Screening during epidemic: no physical exam but only temp is checked. Health workers
must wear light personal protective equipment (PPE: face shield, gown, clean gloves) during
interview.
Transfer & isolation. For suspect patients transfer by staff to Ebola Treatment Unit and while
providing clinical care wear full PPE. If transfer not available, isolate in hospital isolation unit
(may need to specially set aside an area of the hospital to do this with controlled entry/exit &
separate WASH facilities).
Immediate notification of any suspect case to SMoH.
Clinical support: (see MoH and WHO guidelines)
1. At least one clinical staff member per 4 patients in isolation (and wearing full PPE)
2. Ensure communication with family and friends is maintained while maintain a safe
distance with the patient.
3. Monitor vital signs and fluid volume intake and output
4. Monitor serum biochemistry and adjust fluid and electrolyte input accordingly

196
 5. Maintain nutrition if patient eating by mouth. If child has SAM see 2.2.
6. If patient has a chronic communicable or non-communicable disease, maintain
therapy if able to take by mouth.
7. If a woman is of child bearing age as if pregnant and do pregnancy test if needed.
8. Do an RDT and treat if RDT+ve (see 3.3)
9. Give paracetamol if fever > 38.5
10. Give pain relief, including the use of opioids for severe pain (see 4.12)
11. Oral rehydration with ORS and give zinc (see 3.2)
12. Give IV fluids for those unable to drink or if fluid loss more than oral intake. (see 3.1).
Treat shock with IV fluids (see 5.1). if life-threatening blood loss, transfuse. (see 5.4).
13. Give a broad spectrum antibiotic (such as ceftriaxone or ciprofloxacin). This is to treat
either an alternative diagnosis (a life-threatening sepsis) or an associated bacterial
infection with EVD.

Prevent transmission and prevent deaths of patients and staff from viral hemorrhagic fever:
1. Wear light PPE for all suspect cases and any suspect deaths
2. Wear full PPE for all probable & confirmed cases and deaths
3. Full intensive medical support (as above) for suspect, probabale and confirmed
cases has been proven to saves lives in people with VHF.
For control measures, including community awareness raising and ring vaccination of all
patient contacts, and all other measures implemented during epidemics of VHF, consult
MoH guidelines.

Yellow fever
Mild: Many people do not experience symptoms, but when these do occur, the most
common are fever, muscle pain with prominent backache, headache, loss of appetite, and
nausea or vomiting. In most cases, symptoms disappear after 3 to 4 days.
Severe: A small percentage of patients experience the 1st mild phase, start recovering but
within 24 hours enter a 2nd toxic phase. High fever returns and several body systems are
affected, usually the liver and the kidneys. In this phase people are likely to develop jaundice
(yellowing of the skin and eyes, hence the name ‘yellow fever’), dark urine and abdominal
pain with vomiting. Bleeding can occur from the mouth, nose, eyes or stomach, which is
associated.
Differential diagnosis: severe cases can be confused with severe malaria, leptospirosis, viral
hepatitis (especially fulminant forms), other haemorrhagic fevers, infection with other
flaviviruses (such as dengue haemorrhagic fever), and poisoning.

Management of Yellow fever

Mild symptoms are treated with analgesia, ORS, an anti-emetic and other supportive
measures.
Severe symptoms: give the same clinical support as with Ebola (see above), but careful
monitoring and management of potential hepatitis and kidney failure is needed.
For control measures, consult MoH guidelines. Mass vaccination is the standard for stopping
transmission during epidemics and in the future routine vaccination against yellow fever is
likely in line with the international Eliminate Yellow fever Epidemics (EYE) Strategy launched
in 2017.

5.3 Emergency Treatment of Poisoning

Some poisons have delayed action, leaving the person looking well soon after they first take
the poison or medicine in overdose. These include paracetamol, aspirin, iron, tricyclic
antidepressants and organophosphate pesticides. Close monitoring is needed. Some
poisons can be absorbed, removed or eliminated, but the mainstay of treatment is to follow
the general treatment steps for poisoning.

197
Removal or elimination of poisons
Absorption: Poisons toxic in small amounts like antidepressants can be absorbed using
activated charcoal. It needs to be given as soon as possible to be effective, but should be
within an hour of ingestion.

Repeat doses of activated charcoal may help with elimination of certain medicines like
quinine, carbamazepine or phenobarbital. 50mg of activated charcoal (or less if not
tolerated) PO is given in these cases to adults and children over 12 years initially and then
every 4 hours, and an antiemetic given.

Gastric lavage is potentially very dangerous and should never be used for caustic
substances like bleach or acids, kerosene or petrol/diesel. It should only be performed if the
airway can be protected. Ipecacuanha should never be given for induction of emesis
because of the increased risk of inhalation. It is only used when large amounts of
substances like iron or lithium have been ingested.

General treatment steps for poisoning

1. If unconscious put up IV 5% glucose and put in recovery position
2. If in shock, put up IV Ringers lactate.
3. Where possible establish the identity and dose of the poison.
4. Manage symptoms as they arise.
5. Poisons that depress consciousness also depress respiration. Both airway protection
and assisted ventilation may be needed. The airway may be opened with jaw thrust
or chin lift, or the use of an oropharyngeal airway. If this is not sufficient, then
intubation and ventilation with a bag may be needed. Oxygen can also be used when
giving assisted ventilation but the priority is ensuring adequate ventilation even with
room oxygen.
6. Oxygen should be given via a mask (or via assisted ventilation) if there is poisoning
by carbon monoxide or irritant gases.
7. If there is hypotension (with systolic BP < 70 mmHg), the person should be put in left
lateral position with the legs raised, and normal saline infused. They must NOT be
lying on their back as this may increase the risk of aspiration.
8. Heart arrhythmias may respond to treatment of underlying hypoxia and acidosis by
ensuring adequate oxygenation and/ or ventilation.
9. Hypothermia is managed by preventing further heat loss (covering person).
Hyperthermia is managed by removing unnecessary clothing and fanning.
10. Prolonged convulsions (> 5 minutes) should be treated with 10mg diazepam by slow
IV injection into a large vein in adults, or a weight appropriate dose in children.
11. For all cases of intentional poisoning (suicidal intent), full mental health assessment
is needed and follow up for moderate to severe depression (see 4.14).

Paracetamol poisoning
Toxic doses of paracetamol may cause liver and renal damage
In addition to the general measures of treating poisoning, a specific antidote, acetylcysteine,
may be needed if more than 12 x 500mg tablets have been taken in an adult (or if plasma-
paracetamol concentrations can be measured and are above the paracetamol treatment
graph). Acetylcysteine is given in 3 consecutive IV infusions over 21 hours. Consult
acetylcysteine dosage charts.
Children who have ingested more than 75mg/kg in one hour may suffer from liver damage.
Consider administration of activated charcoal if paracetamol in excess of 150mg/kg has
been ingested in the last hour.

198
Organophosphate insecticide poisoning
Further absorption of organophosphorus insecticide should be prevented by moving the child
or person to fresh air, removing soiled clothing and washing contaminated skin.
It is vital to maintain an airway, frequently remove bronchial solutions and maintain airway
and adequate ventilation.
Consider gastric lavage if airway is protected
In addition to the general measures of treating poisoning, atropine may be needed, but
should only be given by a doctor experienced in treating organophosphate poisoning (and
ideally an anaesthetist). Signs of poisoning include excessive salivation, bradycardia and
hypotension.
Adults: A dose of 3 x 600 micrograms/1ml of atropine is given as a single injection into the
midlateral thigh. Five minutes after giving the atropine, recheck pulse, BP, sweating, and
pupil size (which should dilate with atropine). If there is no change then the dose of atropine
should be repeated, and again in a further 10 minutes. The aim is to get the pulse rate
above 80/ minute and the systolic pressure about 80mmHg, usually with dilated pupils (if
very dilated this indicates atropine toxicity). A smaller dose of atropine may need to be
repeated over the next hours. Skin will become flushed and dry.
Children: 20micrograms/kg atropine should be given every 10 minutes.

5.4 Blood Transfusion

The following measures can reduce the need for blood transfusion:
 The prevention or early diagnosis and treatment of anemia and the conditions that
cause anemia. The patient’s haemoglobin level can often be raised by giving iron and
vitamin supplements without the need for transfusion.
 The correction of anemia and replacement of depleted iron stores before planned
surgery. This also includes ensuring pregnant women have anemia corrected so that
they have normal haemoglobin when they go into labour.
 The use of intravenous fluid replacement with crystalloids (or colloids) in cases of
acute blood loss.
 Good anaesthetic and surgical management, including using the best anaesthetic
and surgical techniques to minimize blood loss during surgery and stopping
anticoagulants and anti-platelet drugs before planned surgery.

Blood loss is initially managed by fluid replacement with crystalloid fluids (See Section 5.1).
If blood is still needed, then whole blood or packed cells are given depending on what is
available either from a blood bank or directly from a donor.

Blood should be:

 obtained from appropriately selected donors who have volunteered to donate and are
not paid
 screened for HIV, Hepatitis B and C and syphilis
 tested to ensure correct match for recipient
 procured according to national guidelines for procurement and use of blood and
blood products (see: National guidelines for the appropriate use of blood and blood
products in South Sudan)

Type of blood products available:

Whole blood: from blood donors stored at 2–6oC for 21 days or 35 days if Adenine is added.
Each unit of blood should have the collection and expiry dates are clearly marked and
should be cross-checked at all levels in the transfusion process. It can also be taken directly
from a donor in an emergency so that platelets and coagulation factors may still be active. A
450 ml whole blood donation (“one unit of blood”) contains 450 ml donor blood and 63 ml

199
anticoagulant-preservative solution. Autologous blood transfusion where blood is taken from
the individual before a planned operative procedure can also be done.

Packed red cells (PRC): Red cell concentrates obtained from centrifugation of whole blood
and stored at 2-6 oC for up to 42 days. Packed red cells are preferred because the
transfused volume is less at 200mls and the haematocrit is 60 -70%.

Storage
An approved blood bank refrigerator, fitted with a temperature chart and alarm. If stored,
changes occur in blood from red cell metabolism, and platelets and coagulation factors
become inactive. Transfusion should be started within 30 minutes of removal from
refrigerator and completed within 4 hours.

Indications for blood transfusion

 Red cell replacement in acute blood loss with hypovolaemia and shock
 Severe anemia
 Exchange transfusion in newborns with jaundice
 In disseminated intravascular coagulation (DIC) or other bleeding disorders when
plasma and clotting factors are not available
 In septic shock when crystalloids are not sufficient to maintain circulation

Side effects of transfusion

 Transfusion reaction (including anaphylaxis and haemolysis)
 Risk of volume overload in patients with chronic anemia and cardiac failure.
 Hypothermia in infants given blood that is not at body temperature

Ordering Blood:
Follow national and institutional guidelines for requesting blood, ensuring ABO and RhD
compatibility, collection of blood from blood bank, preparation for transfusion and
administering transfusion.

Performing the blood transfusion:

 Should be done by staff who have been trained to administer a blood transfusion
 Ensure that identification of patient and blood product correctly match the order
information and compatibility before transfusion
 Check for signs of deterioration of the blood product:
 Haemolysis at the interface between red cells and plasma (pink plasma)
 Evidence of unusual discolouration and turbidity
 Presence of large clots
 Perform the transfusion under aseptic technique and 1 unit should run over 3 -4
hours unless there is hypovolaemic shock where it can be transfused over 30
minutes
 No drugs should be given in the same line as the transfusion. 5% dextrose and
hypotonic solutions can cause red cell lysis. The only compatible fluids to give
concurrently with blood are normal saline and 4% albumin
 All patients receiving transfusions should be monitored closely. Record BP, pulse,
oxygen saturations and respiratory rate before the transfusion, 15 minutes after the
start of the transfusion, 30 minutes after the start of the transfusion and every 30
minutes thereafter till the transfusion is complete.
 Also monitor for other symptoms suggestive of transfusion reaction. See below:

Treatment of a transfusion reaction

All transfusion reactions must be recorded and doctor informed

200
 1. Mild reaction (itchy rash)
 Slow the transfusion
 Give chlorphenamine 0.1mg/kg IM
 Continue transfusion after 30 minutes at normal rate if not progression of symptoms.
2. Moderate reaction (urticarial, flushing, fever, rigor, faster pulse)
 Stop the transfusion
 Give 200mg hydrocortisone IV
 Give bronchodilator if wheezing (See 4.4)
 Give an antipyretic like paracetamol if needed
 If improvement, restart transfusion slowly with new blood
3. Life-threatening reaction (confusion, collapse and anaphylactic shock, rigor, fever,
black or dark urine, fast pulse and breathing, unexplained bleeding (DIC))
 Stop transfusion. Give 0.9% sodium chloride or ringers lactate infusion 20-30ml/ kg
 Give adrenaline (for dose see 5.1)
 Treat shock (see 5.1)
 Give a bronchodilator if wheezing (salbutamol by spacer or nebuliser or
aminophylline 5mg/kg: see 4.4)
 Give furosemide 1mg/kg IV.
 Give antibiotics as for septicaemia.

Transfusion for severe anemia

 Only give as much blood as necessary and not more to restore the clinical condition
and not to correct all the anemia.
 Patients with severe anemia may be pushed into heart failure by transfusion, so the
transfusion is given slowly over 3 - 4 hours and furosemide is given, 40mg IM for an
adult or 1mg/kg IM for children. If packed cells are available give this in preference to
whole blood as it gives less total fluid volume.
 Reassess and only give more blood if severe anemia persists.

Transfusion for sickle cell disease

 Given when Hb<5g/dl (<6g/dl in pregnant women) and no associated complications.
 Packed red cells is preferred if available
 Use whole blood if acute blood loss.
 Exchange transfusion may be indicated in cases of stroke, persistent priapism and
vaso-occlusive crisis

Disseminated intravascular coagulation

In disseminated intravascular coagulation (DIC), the clotting and fibrinolytic systems are both
activated, leading to deficiencies of the clotting factors, fibrinogen and platelets. Causes
include obstetrical (eclampsia, placental abruption and retained products of conception or
retained dead fetus), infection, cancer and trauma.

DIC presents with excessive, uncontrolled bleeding. The lack of platelets and coagulation
factors causes bleeding from multiple sites, and thrombi (clots) causing organ problems
including respiratory distress, coma, renal failure and jaundice. In the absence of lab tests
for coagulation factors and platelets, the diagnosis is based on the clinical presentation and
a test that can be done on the ward:

Clotting test for DIC

 Take 2–3 ml of venous blood into a clean plain glass test tube (10 x 75 mm).
 Hold the tube in your closed fist to keep it warm (i.e. body temperature).
 After 4 minutes, tip the tube slowly to see if a clot is forming. Then tip it again every
minute until the blood clots and the tube can be turned upside down.

201
  The clot will normally form between 4 and 11 minutes but, in DIC, the blood will
remain fluid well beyond 15 to 20 minutes.

Blood transfusion for DIC

Rapid treatment or removal of the underlying condition is imperative. If DIC is suspected, do
not delay treatment while waiting for the results of the clotting test. Treat the cause and give
blood transfusion to help control bleeding. Transfusion is given to help control bleeding until
the underlying cause has been dealt with and to maintain an adequate platelet count and
coagulation factor levels. Give fresh frozen plasma and platelet concentrates instead of
whole blood if available.

5.5 Anaesthesia
Objectives:
 Relieve pain
 Maintenance of optimal physiological function during the procedure

Provision of anaesthesia relies on the availability of the correct equipment, correct

medication and adequately trained staff.

Types of anaesthesia:

General Anaesthesia (GA): Allows a temporary loss of consciousness, promotes

muscular relaxation and diminishes reflexes. This makes GA appropriate for intermediate
and major operative procedures. Draw-over anaesthesia is not yet widely available in South
Sudan and there are very few qualified anaesthetists. Guidelines on draw-over anaesthesia will be
included in the next edition of the SDGs.

Ketamine is the drug of choice for GA especially for short procedures. It induces a state of
dissociative anaesthesia where the airway reflexes are maintained – the patient maintains
own airway It produces excessive salivation but premedication with atropine can prevent
this. Suction may be needed to prevent aspiration. Patients may also experience
hallucinations that can be treated with benzodiazepines.
During anaesthesia monitor: BP, pulse, respiratory rate and oxygen saturations. If used for
caesarean sections, it can cross the placenta and affect respiration of the baby. Have
resuscitation equipment at delivery.
Ketamine should be avoided in hyperthyroidism, thyroxine supplementation and
schizophrenia and should be used with care in hypertension and ischaemic heart disease.

Diazepam 2-5 mg IV is given, followed 2 minutes later by ketamine 80-100 mg IV (1-2

mg/kg) as a slow IV bolus over at least 20 seconds.
Intermittent boluses of ketamine IV, one-quarter of the induction dose, every 15 minutes.
Doses of benzodiazepines or opioids added as necessary in response to increasing
vocalization or purposeful movements with surgical stimuli.

Anaesthesia for Ceasarian: give ketamine first, and only give diazepam once the baby has
been delivered. Give oxytocin 5iu by slow IV injection after deliver of the baby, and the
placenta is delivered by controlled cord traction (see 1.5).

Regional/Local Anaesthesia (LA): Stops the detection of painful stimuli during the
operative procedure. There is no loss of consciousness. The location of the anaesthesia
depends on the anatomical location of the procedure:
 Surface anaesthesia
 Infiltration anaesthesia

202
  Intravenous regional anaesthesia
 Nerve block/plexus block
 Epidural anaesthesia
 Spinal anaesthesia

Lignocaine is used for LA. Nerve blocks and spinals should only be performed by specially
trained anesthetic assistants or anaesthetists.
 Infiltration: 2.5-5 mg/ml with or without adrenaline concentration 1:2,000,000
 Nerve block: 10-20 mg/ml with or without adrenaline concentration 1:2,000,000
 Spinal: 50 mg/ml hyperbaric solution
Dose should not be exceeded
 Plain lignocaine: 3 mg/kg body weight
 Lignocaine with adrenaline 6-7 mg/kg body weight. Lignocaine with adrenaline
should not be used to anaesthetise the following:
D – Digits (Fingers and toes), P – Penis, E – Ear, N – Nose tip

Using LA safely:
 Choose appropriate type of LA for the procedure
 Do a pre-operative assessment and prepare patient for the procedure
 Local infection is a contraindication
 Identify injection site and decide the appropriate route of injection
 Select the appropriate concentration and volume of lignocaine according to the
procedure
 Use a small-bore needle under aseptic technique and introduce a small amount of
the lignocaine
 Aspirate to ensure no accidental entry into a vessel
 Introduce the rest of the anaesthetic slowly
 Allow 5 – 10 minutes for anaesthetic effect
 Monitor the patient during the procedure

Local anaesthetic systemic toxicity (LAST)

Can occur when too much local anaesthetic is given, or rapid absorption has happened such
as after accidental intravenous injection.
Symptoms:
 Sudden alteration in mental status, severe agitation or loss of consciousness, with or
without tonic-clonic convulsions
 Cardiovascular collapse

Immediate Management:
 Stop injecting the LA
 Get help
 Maintain the airway, administer 100% oxygen and intubate if necessary
 Administer benzodiazepine in titrated doses to control seizures.
 Monitor BP, pulse, oxygen saturations and manage deteriorations appropriately

5.6 Emergency Surgical Care

Medicines used in surgical care, such as for surgical antibiotic prophylaxis will be included in
the next edition of the STGs.

Surgery in anticoagulated patients

Any patients on regular anticoagulants need to have their anticoagulant stopped before
surgery.

203
  Stop warfarin three days preoperatively
 Give heparin subcutaneously, if required.
 Stop heparin 6 hours preoperatively.
 Restart warfarin as soon as possible postoperatively.
 Give heparin as well for the first 3 days
 If emergency surgery and patient was still on warfarin, give vitamin K, 0.5–2.0 mg by
slow IV infusion.

Prophylaxis of deep-vein thrombosis (DVT) in high risk patients prolonged surgery

(including trauma patients) and during orthopaedic surgery)

For patients not on anticoagulants who need protection against DVTs, give:
 Enoxaparin: 40 mg SC for 1 dose, dose to be given 12 hours before surgery, then 40
mg SC every 24 hours. OR
 Heparin: 5,000 units SC for 1 dose, to be taken 2 hours before surgery, then 5,000
units every 8–12 hours. Do not give for more than a week.

5.7 Trauma
Minor wound management
Only staff trained to suture are authorised to do so. Do not suture dirty wounds or wounds
that are more than 6 hours old. These should be cleaned and covered. If they are closed
then very dangerous infections such as gangrene (from Clostridium welchii) may develop.
Later infections from poorly managed wounds include osteomyelitis

1. Clean wound with antiseptic (diluted chlorhexidine)

2. Cover with sterile bandage
3. Give tetanus toxoid IM
4. Suture small wounds if clean and a recent injury (within 6 hours) with a sharp clean
object like a knife. For any dirty injury or bite do not suture.
5. Review every 2 – 3 days and remove sutures after 7 days.
6. Surgical haemostasis of bleeding vessels.
7. Delayed primary closure of the wound. This is should only be done at least 3 days
after the injury, when the wound is clean and pink.

Major wound management

1. Stop bleeding with pressure with sterile gauze.
2. Treat with IV fluid if significant blood loss or signs of shock.
3. Emergency debridement and trauma surgery
4. Surgical hemostasis of bleeding vessels.
5. Only wounds that are caused by a clean object and less than 6 hours old are closed.
6. Delayed primary closure of the wound, see above
7. For major trauma, surgical prophylaxis with heparin or enoxaparin may be needed
(see 5.5)

Bites
1. Clean wound with antiseptic (diluted chlorhexidine)
2. Do not carry out any customary practices associated with snake or other animal
bites.
3. Cover with sterile bandage
4. Do not suture the wound.
5. Give tetanus toxoid IM

204
 6. Admit all snake bites, dog bites or those of wild animals. Refer to national guidelines
on use of antisnake venom. For the treatment of rabies, see 3.11.

Snake bites
Action to be taken
 Reassurance
 Assess the area of the bite to see if there is evidence of marks caused by fangs -
often the victim has not actually been bitten
 Immobilise bitten limb with sling/splint
 Avoid contact with wound (no vigorous cleaning, cutting, massage or application of
creams or herbs. Tourniquets are not recommended. Do not try to suck out the bite
 Admit avoiding movement, e.g. on stretcher
 Obtain description of snake, and try to identify the type of snake

Treatment steps in hospital

 Depending on the species, the following complications may occur:
o Neurotoxic- paralysis, nerve palsies and coma
o Vasculotoxic- extravasation of fluid, oedema and hypotension
o Haemorrhagic- bleeding from multiple sites
 Resuscitate if hypotensive, or in hypovolaemic or haemorrhagic shock (see 5.1)
 Note risk of sudden deterioration from release of previous wrongly applied tourniquet.
 Assess for nerve paralysis, oedema and bleeding
 Assess urine output - if urine dark, may indicate haemolysis or destruction of muscle
 Treat acute kidney injury with acute renal failure may develop (see 4.6)
 Tests, if available : 20 minute whole blood clotting test (to demonstrate
coagulopathy), full blood count , kidney and liver function tests
 Pregnant women require fetal monitoring (bradycardia may indicate distress), and
monitor for vaginal bleeding and threatened abortion. Monitor uterine contractions
and fetal heart rate. Lactating women should continue to breast feed

Give antivenom where available, where benefits outweigh risk

 Can be given as soon as indication arises - even 2-3 weeks later
 Anti-venom is the only effective antidote, but may be expensive or in short supply
 Use only where benefits of treatment outweigh risks e.g. signs of systemic and/or
severe local envenomation
 Always have adrenaline ready in case of early anaphylactic antivenom reaction
 Storage – lyophilized kept below 25 degrees C; liquid at 2-8 degrees C, not frozen.
Do not use liquid if becomes opaque
 IV slow injection at 2ml/min by skilled staff, or IV infusion over 1 h (diluted in 5-10mls
isotonic fluid/kg, e.g.250-500mls 0.9% saline for an adult)
 IM only if no IV route possible or in remote setting
 Dose may need repeating if persistent bleeding after 1-2 hours, persistent or
recurrent coagulopathy after 6 hours, deteriorating neurotoxic or cardiovascular signs
after 1-2 hours
 If early anaphylaxis reaction , stop anti-venom, give adrenaline 0.5mg IM lateral thigh
( adult), 0.01mg/kg (child). Repeat every 5-10 minutes if deteriorating
 If anaphylactic reaction persists, can add Chlorphenamine 10mg (adult) slow IV;
0.2mg/kg (child) slow IV and Hydrocortisone 100mg(adult) IV; 2mg/kg (child)IV

Other drugs may be needed to counteract complications:

 Neostigmine 0.25-0.5mg every 1-3 h max 10mg/day adult or 0.01-0.04mg/kg every 2-
4 hours for children (IM/SC/IV). Orally, Neostigmine 15mg 4 x per day

205
  Atropine: Adult 0.5-2mg IV Children 20mcg/kg
 Dopamine : 2-5mcg/kg/min as slow IV infusion

Fractures
1. Splint the fracture if trained to do so.
2. If substantial bleeding or signs of shock, give IV Ringers lactate.
3. Emergency trauma management and fracture management.
4. For major trauma, surgical prophylaxis with heparin or enoxaparin may be needed
(see 5.5)

Burns
Initial steps for burns
 Extracting person who is burnt: Check area is safe and wear protective equipment if
available if needed (eg. if managing chemical burn).
 Assess Airway, Breathing and Circulation
 Deal with other trauma which may be life threatening

Thermal burns
 Smother with blanket (to stop further burning by depriving the area of oxygen)
 Remove clothes which are not stuck and jewellery which may cause restriction
 Do not remove tar stuck to the skin
 If treating within 20 minutes of burn: irrigate with cool/tepid running water for 20-30
minutes or use wet towels
 Avoid hypothermia: use coats/blankets
 After cooling, cover with either layers of ‘cling film’ (not wrapped), clean plastic bag
for hand burns, or a clean cotton sheet
 Elevate area to reduce risk of oedema
 Give analgesia

Electrical burns
Low voltage only- assess and either switch off power or using wooden stick or chair, remove
person from source- admit to hospital
DO NOT approach high voltage source (1000 volts or more)

Chemical burns
Try and identify cause
Remove affected clothing – brush off skin if dry chemical, irrigate burn with water for 1 hour
Admit to hospital if:
 complex burns
 full thickness burns
 deep dermal burns (and circumferential)
 chemical and electrical burns
 burns associated with inhalation injury or sepsis, or trauma
 burns affecting face hands feet genitalia or perineum, flexural areas,
 where non accidental injury is suspected in children
 young children and older adults especially with co-morbidity.

Management of burns
Superficial mild burns
 Maintain hydration
 Symptom relief – cool baths or showers or compress, simple analgesia and topical
emollient (massage daily until skin no longer dry or itchy)

206
  Admit if signs of heat stroke (fatigue, dizziness, nausea, headache, irritability,
confusion, hallucinations, fever or tachycardia)
 Review if blisters develop (dermal burn)

Severe burns
 Analgesia
 Tetanus immunisation if needed
 Assess extent of burns with this chart:

 Fluid replacement. Requirement in first 24 hours:

o Weight of patient x percentage burn (using above chart) x 2 plus 2500mls
o Give half in first 8 hours, half in next 16 hours
 Cleanse gently with clean lukewarm water or if sterile technique required, use warm
0.9% saline
 Use gentle irrigation (no scrubbing or antiseptic)
 Specialist surgical debridement may be required
 Leave blisters intact to reduce infection risk (very large blisters that may rupture or
lying over a joint may need deroofed with aseptic technique)
 Dressings
o Do not use antibiotic or antimicrobial dressings or creams routinely
o Ideally use non-fibrous, non-adherent dressing
o Secure with light bandage
o Analgesia before changes.
 Assess wound for infection and redress at 48 hours, then every 3-5 days until healed
 If wound becomes infected, give cloxacillin 500mg 4 x per day for 7 days
( erythromycin if allergic to penicillin
 When healed, use emollient and cover with clothing to avoid sun exposure

Exudate in first 24-72 hours is common in superficial burns, and does not always mean
infection. If not healed by 2-3 weeks, consider surgical review as probably deeper

Preventing compression of circulation: Any full-thickness circumferential burns may stop the
circulation. The burns wounds may need to be incised (escharotomy) by a surgeon specially
trained to do this, to ensure the area distal to the injury still receives blood flow.

Preventing complications and contractures: Physiotherapy is vital to prevent pneumonia,

disability and contracture formation. It must be started at an early stage.

Nutrition for patients with severe burns: Severe burns increase the body’s metabolic rate, protein
breakdown resulting in weight loss and poor wound healing result. Morbidity and mortality can be
reduced by a high-protein, high calorie diet. Vitamin supplements (multivitamins) and iron folate
may be needed to prevent anemia. Daily needs in adult:

207
  Calories Use a formula such as the Curreri formula to make this calculation
 Proteins 1.5 to 2g/kg
 High energy foods are necessary if the burn surface area is greater than 20%.
 Provide 5 x the recommended daily vitamins and trace elements
 Start with small quantities on day 1 and gradually increase amount to recommended amounts
by day 3.
 Weigh patient twice weekly

Index of Drugs

208
Drug name Page Drug name Page Drug name Page
Drug name Drug name Drug name
Drug name Drug name Drug name

209
Index of conditions
Condition name Page Condition name Page Condition name Page
Condition name Condition name Condition name
Condition name Condition name Condition name

210
 Resuscitation and Basic Life Support
Table adapted from UK Resuscitation Council
MAKE SURE YOU, THE COLLAPSED PERSON AND THOSE AROUND ARE SAFE

CALL FOR HELP

Check for a response 

Gently shake shoulders and ask loudly: “Are you all right?"
If s/he responds leave them in the position in which you find them, provided there is no
further danger; try to find out what is wrong with them and get help if needed; reassess
them regularly.   

Open the airway 

Turn person on to back (if safe, no injury suspected)
Place your hand on their forehead and gently tilt their head back; with your fingertips
under the point of the victim's chin, lift the chin to open the airway
If cervical spine injury suspected, use jaw thrust or airway rather than tilting neck,
maintain in-line immobilisation of the cervical spine and avoid placing the patient in the
recovery position

Look, listen and feel for normal breathing for no more than 10 seconds 

The person may be barely breathing, or taking infrequent, slow and noisy gasps. Do not
confuse this with normal breathing. If you have any doubt whether breathing is normal, act
as if it they are not breathing normally and prepare to start CPR  

Send someone to get an defibrillator (Automated External Defibrillator, AED) if

available 
If you are on your own, do not leave the person, start CPR  

Start chest compressions 

Kneel by the side of the person
Place the heel of one hand in the centre of the chest; (which is the lower half of the
sternum)
Place the heel of your other hand on top of the first hand
Interlock the fingers of your hands and ensure that pressure is not applied over the ribs
Keep your arms straight
Do not apply any pressure over the upper abdomen or the bottom end of the bony
sternum
Position your shoulders vertically above the chest and press down on the sternum to a
depth of 5–6 cm
After each compression, release all the pressure on the chest without losing contact
between your hands and the sternum;

211
 Repeat at a rate of 100–120 /min

After 30 compressions open the airway again using head tilt and chin lift and give 2
rescue breaths 
Pinch the soft part of the nose closed, using the index finger and thumb of your hand on
the forehead
Allow the mouth to open, but maintain chin lift
Take a normal breath and place your lips around his mouth, making sure that you have
a good seal
Ventilate with ambubag. If unavailable, blow steadily into the mouth while watching for
the chest to rise, taking about 1 second as in normal breathing; this is an effective
rescue breath.
Maintaining head tilt and chin lift, take your mouth away from the victim and watch for
the chest to fall as air comes out
Inflate again with ambu bag (or take another normal breath and give breaths) Give a
total of two inflations or rescue breaths). Do not interrupt compressions by more than
10 seconds to deliver two breaths. Then return your hands without delay to the correct
position on the sternum and give a further 30 chest compressions
Continue with chest compressions and rescue breaths in a ratio of 30:2  

If you are untrained or unable to do rescue breaths, give chest compression only CPR (i.e.
continuous compressions at a rate of at least 100–120 x per minute)  

If more staff are present, can give compressions and ventilate with ambu bag
simultaneously.

Switch on the AED 

Attach the electrode pads on the victim’s bare chest
If more than one rescuer is present, CPR should be continued while electrode pads are
being attached to the chest
Follow the spoken/visual directions
Ensure that nobody is touching the victim while the AED is analysing the rhythm
If a shock is indicated, deliver shock 
Ensure that nobody is touching the victim
Push shock button as directed (fully automatic AEDs will deliver the shock
automatically)
Immediately restart CPR at a ratio of 30:2
Continue as directed by the voice/visual prompts
If no shock is indicated, continue CPR 
Immediately resume CPR
Continue as directed by the voice/visual prompts

212
 Do not interrupt resuscitation until: 
A senior team member tells you to stop
You become exhausted
The person is definitely waking up, moving, opening eyes and breathing normally
It is rare for CPR alone to restart the heart. Unless you are certain the person has
recovered continue CPR  

If you are certain the person is breathing normally but is still unresponsive, place
in the recovery position 
Remove their glasses, if worn
Kneel beside the victim and make sure that both his or her legs are straight
Place the arm nearest to you out at right angles to his body, elbow bent with the hand
palm-up
Bring the far arm across the chest, and hold the back of the hand against the cheek
nearest to you
With your other hand, grasp the far leg just above the knee and pull it up, keeping the
foot on the ground
Keeping his hand pressed against his cheek, pull on the far leg to roll the victim towards
you on to his side
Adjust the upper leg so that both the hip and knee are bent at right angles
Tilt the head back to make sure that the airway remains open
If necessary, adjust the hand under the cheek to keep the head tilted and facing
downwards to allow liquid material to drain from the mouth
Check breathing regularly
Be prepared to restart CPR immediately if there is any deterioration
   
Use high flow 100% oxygen and obtain IV or IO access

Algorithm for Advanced Life Support

Unresponsive patient with no signs

of life

CPR 30:2

Attach defib/monitor

Shockable ASSESS RHYTHM Non-Shockable

(Ventricular fibrillation) (Asystole)

ADRENALINE 1mg ( every 1-5 minutes)

Defibrillate x1

213
 During CPR
Resume Resume
Correct reversible causes
CPR 30:2 CPR 30:2
Check electrodes

Ensure iv/io access , airway and oxygen

214