WHO PACK AGE OF ESSEN T IAL NONCOMMUNICABLE (PEN) DISE ASE IN TERVEN T IONS FOR PRIMARY HEALTH CARE WHO package of essential noncommunicable (PEN) disease interventions for primary health care ISBN 978-92-4-000922-6 (electronic version) ISBN 978-92-4-000923-3 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specifi c organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, fi gures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specifi c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. WHO PACKAGE OF ESSENTIAL NONCOMMUNICABLE (PEN) DISEASE INTERVENTIONS FOR PRIMARY HEALTH CARE CONTENTS Foreword iii Acknowledgement v Abbreviations v 1 Introduction 1 2. Components of WHO PEN 5 2.1 Cardiovascular diseases 8 2.2 Diabetes 18 2.3 Chronic respiratory diseases 28 2.4 Cancer early diagnosis 40 2.5 Healthy lifestyle counselling 50 2.6 Self-care 54 2.7 Palliative care 58 3. Adapting WHO PEN 62 4. Annexes 69 Annex 4.1. Health facility assessment 69 Annex 4.2. Core list of medicines 70 Annex 4.3. Essential technologies and tools 71 Annex 4.4. Sample clinical record 72 Annex 4.5. Indicators 75 Annex 4.6. Additional reading 77 ii FOREWORD The adoption of the Global Strategy for the Prevention and Control of Noncommunicable Diseases (NCDs) at the World Health Assembly in 2000 was an act of solidarity with the many low- and middle-income countries facing the catastrophic consequences of NCDs. It was also an acknowledgement that the long-term needs of people living with NCDs were being neglected, and was a turning point that has inspired action over the past two decades. The risk of a 30-year-old person dying from any of the four major NCDs (cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes) before the age of 70 years declined by 15% globally between 2000 and 2012. This rapid improvement was largely due to policy, legislative and regulatory measures put in place to provide more people with access to screening; early diagnosis and treatment for hypertension (such as aspirin, beta blockers, diuretics and statins); and to protect people against tobacco use (such as through tobacco- control legislation). Despite the important progress made in the fi rst decade of the 21st century, momentum has since dwindled, with annual reductions in age-standardized premature mortality rates slowing for the main NCDs. Between 2000 and 2016 overall NCD risk declined only 18% globally – with the risk of diabetes showing a 5% increase. In the past two decades NCDs have killed 200 million women and men aged between 30 and 70 years, the majority living in low- and middle-income countries. Most of these premature deaths could have been avoided. Unless immediate action is taken, Sustainable Development Goal (SDG) target 3.4 (reduce premature mortality from NCDs by one third) by 2030 will not be met. It is therefore more important than ever for the global community to mobilize for accelerated action to progressively cover 1 billion additional people with essential health services and medicines for the prevention and control of NCDs. iii WHO has been providing guidance to advance this work. The Package of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings was fi rst introduced in 2010 as a prioritized set of cost-eff ective interventions able to deliver an acceptable quality of care, even in resource-limited settings. Information on the cost-eff ectiveness of the interventions helped to make limited resources go further. From 2010, many additional elements were added and in 2013 a comprehensive set of tools was developed. The total cardiovascular risk assessment charts and management of type 2 diabetes were further updated in 2019. The result today is this user-friendly WHO package of essential noncommunicable (PEN) disease interventions for primary health care resource, which brings together all these updates as protocols that are adaptable to local settings and able to empower primary care physicians, as well as allied health workers, to contribute to NCD management. WHO PEN is not meant to be exhaustive or prescriptive, but rather to be an important fi rst step for integration of NCD management into primary health care. WHO PEN is also suitable for emergency and humanitarian settings. When implemented, it will bring more people living with or aff ected by NCDs into contact with the health system and promote universal health coverage. Dr Bente Mikkelsen Director, Department of Noncommunicable diseases iv ABBREVIATIONSACKNOWLEDGEMENT CKD chronic kidney disease COPD chronic obstructive pulmonary disease CRD chronic respiratory diseases CVD cardiovascular diseases HDL-C high-density lipoprotein cholesterol HPV human papilloma virus NCD noncommunicable diseases PHC primary health care TC total cholesterol UHC universal health coverage WHO World Health Organization The World Health Organization would like to thank all the contributors external collaborators, reviewers and WHO staff whose dedication, support and expertise over many years have made possible this latest edition of the WHO PEN. v 1. INTRODUCTION INTRODUCTION Noncommunicable diseases (NCDs), also known as chronic diseases, tend to be of long duration and are the result of a combination of genetic, physiological, environmental and behavioural factors. The main types of NCDs are cardiovascular diseases (CVDs like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease – COPD and asthma) and diabetes. NCDs kill 41 million people each year, equivalent to 71% of all deaths globally. NCD prevention and control includes population- wide interventions to reduce risk factor exposure, individual approaches to modify risk factors for high- risk individuals, and treatment of NCDs. Investing in better management of NCDs is critical. Management of NCDs includes detecting, screening and treating these diseases, and providing access to palliative care for people in need. High-impact essential NCD interventions can be delivered through a primary health care approach to strengthen early detection and timely treatment. Evidence shows such interventions are excellent economic investments because, if provided early to patients, they can reduce the need for more expensive treatment. Countries with inadequate health insurance coverage are unlikely to provide universal access to essential NCD interventions. Yet NCD management interventions are essential for achieving the global target of a 25% relative reduction in the risk of premature mortality from NCDs by 2025, and the SDG target of a one-third reduction in premature deaths from NCDs by 2030. An integrated approach is particularly important for low- resource settings for effi cient use of limited resources. Several approaches are needed to contain the escalating costs of health care required for providing sophisticated medical services for NCDs and their complications. First, there should be more investment in prevention and primary care. Second, the cost of treating CVD, diabetes and COPD can be reduced to a minimum by carefully selecting essential evidence-based interventions. Third, the cost of treating complications of NCDs that require hospitalization (e.g. heart attacks, strokes, amputations, and blindness due to diabetic or hypertensive retinopathy, or end stage renal disease requiring dialysis) can be reduced. WHO Package of Essential NCD interventions will help to improve the coverage of appropriate services for people with NCDs services in primary care settings. WHO package of essential noncommunicable (PEN) disease interventions for primary health care The Package of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings, fi rst published in 2010, is a prioritized set of cost-eff ective interventions that can be delivered to an acceptable quality of care, even in resource-poor settings. The interventions were upated in 2017 as the “best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. Modules of the WHO HEARTS technical package were released in 2019–2020. This version, WHO package of essential noncommunicable (PEN) disease interventions for primary health care (WHO PEN), is developed by integrating these additional technical guidance to serve as an important fi rst step for integration of NCD into PHC and for reforms that need to cut across the building blocks of the national health system. It provides protocols and tools for NCDs to strengthen national capacity to integrate and scale up care of NCDs in primary health care. WHO PEN 1 WHO PEN TO SUPPORT PEOPLE WITH NCDS THROUGH UNIVERSAL HEALTH COVERAGE Universal health coverage (UHC) means that all individuals and communities receive the health services they need without suff ering fi nancial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care. UHC enables everyone to access the services that address the most signifi cant causes of disease and death, and ensures that the quality of those services is good enough to improve the health of the people who receive them. Effi cient use of limited health care resources, sustainable health fi nancing mechanisms, access to basic diagnostics and essential medicines and organized medical information and referral systems are imperative for provision of equitable care for people with and at risk of NCDs. People with NCDs require long-term care that is proactive, patient- centered, community-based and sustainable. Such care can be delivered equitably only through health systems based on primary health care. NCD services are part of the essential health services and are required in humanitarian and other crisis situations. The WHO PEN aligns with these objectives and provides a mechanism of organizing NCD service delivery with an aim of addressing UHC. The global move towards UHC off ers an opportunity to explicitly prioritize NCD interventions in benefi t packages for UHC. ENABLING ACTIONS Explore viable health-fi nancing mechanisms and innovative economic tools supported by evidence. Scale-up early detection and coverage, prioritizing cost-eff ective, high-impact interventions. Train the health workforce and strengthen the capacity of health systems, particularly at the primary care level, to address the prevention and control of noncommunicable diseases. Improve the availability of the aff ordable basic technologies and essential medicines, including generics, required to treat major noncommunicable diseases, in both public and private facilities. Strengthen and orient health systems to address noncommunicable diseases and risk factors through people-centred health care and universal health coverage. Develop and implement a palliative care policy, including access to opioid analgesics for pain relief, together with palliative care training for health workers. Expand the use of digital technologies to increase health service access and effi cacy for NCD prevention, and to reduce the costs in health care delivery. 2 INTRODUCTION WHO PEN ROADMAP OF WHO PACKAGE OF ESSENTIAL NONCOMMUNICABLE (PEN) DISEASE INTERVENTIONS FOR PRIMARY HEALTH CARE 2010200720052002 2013 3 202020182017 20192016 4 The WHO PEN defines a minimum set of interventions to address major NCDs in primary care. The interventions are for the detection, diagnosis, treatment and care of cardiovascular diseases, diabetes and chronic respiratory diseases. A section for cancer early diagnosis is also included. Components of healthy lifestyle, self care and palliative care also feature in the package. Sample templates and tools are also provided. These components are feasible even in low- resource settings, and can be delivered by primary care physicians and non-physician health workers. Contents of WHO PEN can be adapted to emergency and humanitarian settings. Countries can expand on the core interventions according to their needs and resources. COMPONENTS WHO PEN 2. COMPONENTS OF WHO PEN 5 CARDIOVASCULAR DISEASES CVD risk assessment and management Hypertension management 2.1 DIABETES Management of diabetes 2.2 CHRONIC RESPIRATORY DISEASES Management of asthma and exacerbation Management of COPD, and exacerbation 2.3 CANCER EARLY DIAGNOSIS Early diagnosis Cervical cancer Breast cancer 2.4 PALLIATIVE CARE Practice points for palliative care 2.7 SELF CARE Self-care among patients with cardiovascular disease, diabetes or respiratory disease 2.6 ADAPTING WHO PEN 3 HEALTHY LIFESTYLE COUNSELLING Health education Counseling on tobacco cessation 2.5 6 7 CARDIOVASCULAR DISEASES CVD RISK ASSESSMENT AND MANAGEMENT HYPERTENSION MANAGEMENT 2.1 8 – known hypertension – known diabetes mellitus (DM) – history of premature CVD in first degree relatives – history of DM or kidney disease in first-degree relatives – aged over 40 years – history of tobacco use – overweight WHEN TO USE THIS PROTOCOL http://www.who.int/cardiovascular_diseases/hearts/en/ HEARTS TECHNICAL PACKAGE CARDIOVASCULAR DISEASES OVERVIEW OF CONTENTSCardiovascular disease risk assessment and management CARDIOVASCULAR DISEASES WHO PEN 9 1. Ask about Diagnosed heart disease, stroke, Transient Ischaemic Attack (TIA), DM, kidney disease Angina, breathlessness on exertion and lying fl at, numbness or weakness of limbs, loss of weight, increased thirst, polyuria, puffi ness of face, swelling of feet, passing blood in urine etc Medicines that the patient is taking Current tobacco use (yes/no) (answer yes if tobacco use during the last 12 months Alcohol consumption (yes/no) (if “Yes”, frequency and amount) Occupation (sedentary or active) Engaged in more than 30 minutes of physical activity at least 5 days a week (yes/no) Family history of premature heart disease or stroke in fi rst-degree relatives 2. Assess (physical exam) Measure blood pressure Look for pitting oedema Palpate apex beat for heaving and displacement Auscultate heart (rhythm and murmurs) Auscultate lungs (bilateral basal crepitations) Examine abdomen (tender liver) In DM patients examine feet; sensations, pulses, and ulcers CVD RISK ASSESSMENT & MANAGEMENT 10 10 Calculate CVD risk using a lab-based chart https://apps.who.int/iris/bitstream/ handle/10665/333221/9789240001367-eng.pdf? sequence=1&isAllowed=y HEARTS TECHNICAL PACKAGE FOR CARDIOVASCULAR DISEASE MANAGEMENT IN PRIMARY HEALTH CARE: RISK BASED CVD MANAGEMENT DIAGNOSE 2.1 CARDIOVASCULAR DISEASES WHO PEN – age – sex – current smoking status Parameters required prior to using the charts: – presence or absence of diabetes* – systolic blood pressure – total cholesterol** 11 Eastern Sub-Saharan Africa Risk Level 0 <5% 5 5% to <10% 10 10% to <20% 20 20% to <30% 30 ш30% Age SBP (years) (mmHg) 22 24 27 29 32 28 30 33 36 39 16 17 17 18 19 22 23 24 25 26 180 18 20 22 24 26 23 25 28 30 33 14 14 15 15 16 19 20 20 21 22 160-179 70-74 15 17 18 20 22 19 21 23 25 28 12 12 13 13 14 16 17 17 18 19 140-159 12 14 15 16 18 16 17 19 21 23 10 10 11 11 12 14 14 15 15 16 120-139 10 11 12 14 15 13 14 16 17 19 8 9 9 9 10 12 12 12 13 14 <120 18 19 21 23 26 23 26 28 31 34 12 13 14 14 15 19 19 20 21 23 180 14 16 17 19 21 19 21 23 25 28 10 11 11 12 13 15 16 17 18 19 160-179 65-69 11 12 14 15 17 15 17 19 21 23 9 9 9 10 10 13 13 14 15 16 140-159 9 10 11 12 14 12 14 15 17 19 7 7 8 8 9 11 11 12 12 13 120-139 7 8 9 10 11 10 11 12 14 15 6 6 6 7 7 9 9 10 10 11 <120 14 15 17 19 21 19 21 24 27 30 10 10 11 11 12 15 16 17 18 20 180 11 12 13 15 17 15 17 19 21 24 8 8 9 9 10 13 13 14 15 16 160-179 60-64 8 9 10 12 13 12 13 15 17 19 6 7 7 8 8 10 11 12 12 13 140-159 7 7 8 9 10 9 11 12 14 15 5 5 6 6 7 8 9 9 10 11 120-139 5 6 6 7 8 7 8 9 11 12 4 4 5 5 5 7 7 8 8 9 <120 11 12 13 15 17 16 18 20 23 26 7 8 8 9 10 13 14 15 16 17 180 8 9 10 11 13 12 14 16 18 20 6 6 7 7 8 10 11 12 13 14 160-179 55-59 6 7 8 9 10 10 11 12 14 16 5 5 5 6 6 8 9 9 10 11 140-159 5 5 6 7 8 7 8 9 11 13 4 4 4 5 5 6 7 8 8 9 120-139 4 4 5 5 6 6 6 7 8 10 3 3 3 4 4 5 6 6 7 7 <120 8 9 10 12 13 13 15 17 19 22 6 6 7 7 8 11 12 12 14 15 180 6 7 8 9 10 10 11 13 15 17 4 5 5 6 6 8 9 10 11 12 160-179 50-54 5 5 6 7 8 8 9 3 4 4 5 6 6 6 7 9 10 3 3 3 3 4 5 5 6 7 7 120-139 3 3 3 4 5 4 5 6 7 8 2 2 2 3 3 4 4 5 5 6 <120 6 7 8 9 11 11 12 14 16 19 4 5 5 6 6 9 10 11 12 13 180 5 5 6 7 8 8 9 11 12 14 3 4 4 4 5 7 7 8 9 10 160-179 45-49 3 4 4 5 6 6 7 8 9 11 2 3 3 3 4 5 6 6 7 8 140-159 2 3 3 4 4 4 5 6 7 8 2 2 2 2 3 4 4 5 5 6 120-139 2 2 2 3 3 3 4 4 5 6 1 2 2 2 2 3 3 4 4 5 <120 5 6 6 7 9 9 10 12 14 16 3 4 4 4 5 7 8 9 10 11 180 3 4 4 5 6 6 7 9 10 12 2 3 3 3 4 5 6 7 8 8 160-179 40-44 2 3 3 4 5 5 5 6 7 9 2 2 2 2 3 4 5 5 6 6 140-159 2 2 2 3 3 3 4 5 5 7 1 1 2 2 2 3 3 4 4 5 120-139 1 1 2 2 2 2 3 3 4 5 1 1 1 1 2 2 3 3 3 4 <120 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 WomenMen People without Diabetes Total cholesterol (mmol/l) Non-smoker Smoker Non-smoker Smoker < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 2 1 4 3 5 4 - 4 . 9 6 6 Using the WHO CVD risk (lab-based) charts Eastern Sub-Saharan Africa (Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Mozambique, Malawi, Rwanda, Somalia, United Republic of Tanzania, Uganda, Zambia) 1 2 3 4 5 6 7 8 Select the regional chart covering your country. Countries included in each region can be found in +($576502'8/( Select the section of the chart as relevant for people with or without diabetes Select men or women table as appropriate Select smoker or non-smoker box Select age group :LWKLQWKHVHOHFWHGER[ȴQGWKHFHOOZKHUHWKHLQGLYLGXDOȇVV\VWROLF blood pressure (SBP) and total blood cholestorol intersect The colour of the cell indicates the 10-year risk of a fatal or non-fatal cardiovascular event. The value within the cell is the risk percentage. Colour coding is based on the grouping as indicated in the box Counsel, treat and refer according to risk level Green < 5% Yellow 5% – < 10% Orange 10% – < 20% Red 20% – < 30% 'HHSUHG Ȳ * Fasting plasma glucose ≥ 7.0 mmol/L (126 mg/dl), or 2-h plasma glucose ≥ 11.1 mmol/L (200 mg/dl), or HbA1c ≥ 6.5% , or known diabetes ** Cholesterol values are to be entered in the chart as mmol/L . To convert cholesterol mg/dl to mmol/L, multiply by 0.02586 Example: TC : 200 mg/dl x 0.02586 = 5.172 mmol/L 12 TREAT mRISK LEVEL: m Counsel on diet (which includes lipid-lowering diet), physical activity, smoking cessation and avoiding harmful use of alcohol TREAT COUNSEL Consider drug treatment if SHUVLVWHQW%3ȲPP+J Consider if SHUVLVWHQW%3Ȳ PP+J Give a statin &RQVLGHULISHUVLVWHQW%3Ȳ PP+J (consistent with national policy) $QWLK\SHUWHQVLYH GUXJV &&%7KLD]LGH $&(ΖRU$5% /LSLGORZHULQJGUXJV 6WDWLQV 2.1 CARDIOVASCULAR DISEASES WHO PEN 13 Follow-up every 3 months If there is no reduction in cardiovascular risk after 6 months of follow up refer to next level FOLLOW-UP Follow up every 3 months until targets are met, then 6–9 months thereafter Follow up in 12 months if treatment not initiated Follow-up every 3–6 months )RUDGGLWLRQDODFWLRQVIRUSHRSOHZLWK'0 UHIHUWR6HFWLRQ'LDEHWHV Diagnosis and management of type 2 diabetes (HEARTS-D). https://www.who.int/publications-detail/who-ucn-ncd-20.1 Some individuals are at very high cardiovascular risk because they have already experienced a cardiovascular event or have very high levels of individual risk factors. Risk stratifi cation is not necessary for making treatment decisions for these individuals as they belong to the high risk category; all of them need intensive lifestyle interventions and appropriate drug therapy. Risk prediction charts may tend to underestimate cardiovascular risk in such individuals, who include the following: patients with established angina pectoris, coronary heart disease, myocardial infarction, transient ischaemic attacks, stroke, or peripheral vascular disease, or who have had coronary revascularization or carotid endarterectomy; those with left ventricular hypertrophy (shown on electrocardiograph) or hypertensive retinopathy (grade III or IV); individuals without established CVD who have a total cholesterol ≥ 8 mmol/L (320 mg/dl) or low-density lipoprotein (LDL) cholesterol ≥ 6 mmol/L (240 mg/ dl) or TC/HDL-C ratio > 8; individuals without established CVD who have persistent raised blood pressure (> 160–170/100–105 mmHg); For individuals with blood pressure above 140/90 mmHG, management may be provided as per nationally agreed protocols. patients with type 1 or 2 diabetes, with overt nephropathy or other signifi cant renal disease; patients with known renal failure or renal impairment. WHEN CAN TREATMENT DECISIONS BE MADE WITHOUT THE USE OF WHO CVD RISK-PREDICTION CHARTS? 14 Blood pressure measurement and control is particularly important in adults who: HYPERTENSION • have had a prior heart attack or stroke • have diabetes • have chronic kidney disease (CKD) • are obese • use tobacco • have a family history of heart attack or stroke Measuring blood pressure is the only way to diagnose hypertension, as most people with raised blood pressure have no symptoms. (HFWLYHWUHDWPHQWDOJRULWKPVIRUK\SHUWHQVLRQDUHGHSHQGHQWRQ accurate blood pressure measurement. The following advice should be followed for measuring blood pressure: Although at the initial evaluation it is preferable to measure blood pressure in both arms and use the arm with the higher reading thereafter, this may not be practical in a busy primary care environment. The patient should be sitting with back supported, legs uncrossed, empty bladder, relaxed for 5 minutes and not talking. For persons who are getting their blood pressure measured IRUWKHȴUVWWLPHLWLVSUHIHUDEOHWRWDNHDWOHDVWWZRUHDGLQJV and to use the second reading. 8VHWKHDSSURSULDWHFXVL]HQRWLQJWKHOLQHVRQWKHFXWR ensure that it is positioned correctly on the arm. (If the arm FLUFXPIHUHQFHLV!FPXVHODUJHFX Measuring blood pressure ASSESS 2.1 CARDIOVASCULAR DISEASE WHO PEN 15 V\VWROLFEORRGSUHVVXUHRQERWKGD\VLVȲPP+Jand/or GLDVWROLFEORRGSUHVVXUHRQERWKGD\VLVȲ PP+J In general, hypertension is diagnosed if, on two YLVLWVRQGLHUHQWGD\V DIAGNOSE NO TREAT TREATMENT GOAL NON-PHARMACOLOGICAL PHARMACOLOGICAL For most patients, blood pressure is considered controlled when SBP < 140 mmHg and DBP < 90 mmHg. However, for patients with diabetes or a high risk of CVD, certain guidelines recommend lower targets: SBP < 130 mmHg and DBP < 80 mmHg. Lifestyle counselling (on healthy diet, physical activity, the harms of tobacco use, and harmful use of alcohol) is a critical component of good hypertension management and is often recommended DVDȴUVWVWHSIRUSDWLHQWVZLWKEORRG pressure of SBP 130–139 mmHg and /or DBP 80–89 mmHg who do not have other CVD risk factors There are four main classes of antihypertensive medications: 1. angiotensin converting enzyme (ACE) inhibitors 2. angiotensin receptor blockers (ARB) 3. calcium channel blockers (CCB) 4. thiazide and thiazide-like diuretics Any of these four classes of antihypertensive medication PD\EHXVHGXQOHVVWKHUHDUHVSHFLȴFFRQWUDLQGLFDWLRQV Proper treatment of hypertension usually requires a combination of hypertension medications. Sample protocols for treatment of hypertension are available in (PRGXOHRIWKH+($576WHFKQLFDOSDFNDJH https://apps.who.int/iris/bitstream/handle/10665/260421/ WHO-NMH-NVI-18.2-eng.pdf?sequence=1 16 17 DIABETES TYPE 2 DIABETES MANAGEMENT 2.2 18 DIABETES A healthy diet to achieve or maintain normal body weight and regular physical activity are the mainstay of diabetes management. All patients should be advised on avoidance of tobacco use and harmful use of alcohol. Management of risk factors and referral as appropriate Oral hypoglycaemic agents for type 2 diabetes, if glycaemic WDUJHWVDUHQRWDFKLHYHGZLWKOLIHVW\OHPRGLȴFDWLRQ 0HWIRUPLQFDQEHXVHGDVWKHȴUVWOLQHPHGLFLQH Other classes of antihyperglycaemic agents, added to metformin if glycemic targets are not met Statins are recommended for all people with type 2 diabetes older than 40 years, but only if this does not negatively impact access to glucose-lowering and blood pressure lowering medication. Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys, and nerves. TREATMENT OPTIONS Regular (3–6 months) visual inspection and examination of patients’ feet by trained personnel for the detection of risk factors for ulceration (assessment of foot sensation, palpation of foot pulses, inspection for any foot deformity, inspection of footwear). PREVENTION OF COMPLICATIONS* FOOT COMPLICATIONS: Optimal glycaemic control Angiotensin-converting enzyme inhibitor for persistent albuminuria PREVENTION OF ONSET AND PROGRESSION OF CHRONIC KIDNEY DISEASE: Screening for diabetic retinopathy and referral for laser treatment if indicated Optimal glycaemic control and blood pressure control PREVENTION OF ONSET AND PROGRESSION OF DIABETIC RETINOPATHY: Optimal glycaemic control PREVENTION OF ONSET AND PROGRESSION OF NEUROPATHY: +($576Ȃ'PRGXOHRQGLDJQRVLVDQGPDQDJHPHQWRIW\SHGLDEHWHV https://www.who.int/publications-detail/who-ucn-ncd-20.1 MORE INFORMATION WHO PEN2.2 DIABETES 19 Test adults who are symptomatic, or aged >40 years and who are overweight (BMI > 25), or obese (BMI > 30), or follow national guidelines Polyuria (excessive passing of urine) Polydipsia (excessive thirst) Unexplained weight loss Polyphagia (excessive hunger) Vision changes Fatigue Symptoms Acute metabolic deterioration and/or acute presentation of chronic complications Severe dehydration Kussmaul’s respiration Altered level of consciousness Complications (acute coronary disease, stroke, kidney disease, vision loss, diabetic foot) Signs ASSESS Ȃ+LVWRU\RIJHVWDWLRQDOGLDEHWHVRU SUHHFODPSVLD Ȃ+LVWRU\RI&9'K\SHUWHQVLRQG\VOLSLGDHPLD Ȃ2YHUZHLJKWREHVLW\ Ȃ3K\VLFDOLQDFWLYLW\ Ȃ+DYLQJDȴUVWGHJUHHUHODWLYHZLWKGLDEHWHV RISK FACTORS 20 Fasting plasma glucose (FPG) is the most practical test for low-resource settings, given its low cost. HbA1c can also be used, but is more costly. Plasma glucose 2 hours after a 75 g oral glucose load (OGTT) can also be used to screen for and diagnose diabetes, but is less practical and more costly. If patient is not fasting and has symptoms, a random plasma glucose (RPG) test can also be performed. It is the least accurate of the diagnostic WHVWVΖWLVXVHIXOWRFRQȴUPWKHGLDJQRVLVLQSHUVRQ with symptoms; however, a negative test does not rule out the diagnosis of diabetes. DIAGNOSE TEST mmol/L mg/dl mmol/L % Fasting plasma glucose (FPG)a,b Ȳ Ȳ Random plasma glucose (RPG)b Ȳ Ȳ Haemoglobin A1c Ȳ Ȳ 3ODVPDJOXFRVHKRXUVDIWHUDJ oral glucose load-OGTTb Ȳ Ȳ a Fasting: no food and only water for 8–14 hours before the test b Point of care devices can be used in diagnosing diabetes if laboratory services are not available. WHO PEN2.2 DIABETES 21 TREAT TREATMENT GOAL PHARMACOLOGICAL NON-PHARMACOLOGICAL +E$F LVJHQHUDOO\FRQVLGHUHG to be adequate glycaemic control If HbA1c is not available, fasting SODVPDJOXFRVH )3* PPRO/ or < 126 mg/dl) MetforminLVUHFRPPHQGHGDVWKHȴUVWOLQHPHGLFLQH in the treatment of diabetes. Sulfonylurea (e.g. gliclazide) is recommended as the second-line treatment, and human insulin as the third-line treatment. Patients may require two or three medicines. Although there are other medicine classes usually used as second- and third-line treatment, including thiazolidinediones (TZDs), DPP-4 inhibitors, SGLT2 inhibitors, and GLP-1 receptor agonists, these medicines tend to be more costly than metformin, sulfonylurea and insulin, with currently limited evidence of superior HHFWLYHQHVV7KH\PD\KRZHYHUEHFRQVLGHUHGLQWKH rare cases when treatment with metformin, sulfonylurea, and insulin is not possible. Insulin treatment should be introduced and monitored according to national practices. NOTE: Hypertension treatment is indicated when SBP ȲDQGRU'%3Ȳ6WDWLQVDUHUHFRPPHQGHGIRUDOO people with type 2 diabetes older than 40 years, but only if this does not negatively impact access to glucose- lowering and blood pressure-lowering medication. Patients should receive counselling and support on lifestyle change including diet, physical activity and smoking cessation at the time of diagnosis, then annually and whenever changes in treatment occur. *URXSHGXFDWLRQLVHHFWLYHDQGOHVVFRVWO\WKDQ individual programmes See following pages for detailed management of type 2 diabetes 22 TREAT MANAGEMENT OF TYPE 2 DIABETES YES FPG/RPG > 18 mmol/L (325 mg/dl) '1(õNNPM-(126mg/dl) and < 18 mmol/L (325 mg/dl) 31(õNNPM- NHEM BOE NNPM- NHEM OR REASSESS IN 3 MONTHS Counsel on diet and physical activity Counsel on diet and physical activity and adherence (at all visits) If goal not achieved BEGIN METFORMIN 500 mg 1 x daily. REFER to higher- level of care If goal not achieved Increase dose to 1000 mg 1x daily REASSESS EVERY 3 MONTHS TEST urine ketones If ketonesȲ &RXQVHORQGLHWPRGLȴFDWLRQ physical activity and adherence to medicines BEGIN gliclazide 80 mg 2 x daily If ketones REASSESS IN 3-5 DAYS WHO PEN2.2 DIABETES 23 Counsel on hypoglycaemia at all subsequent visits If goal not achieved ADD gliclazide 80 mg 1 x daily If goal not achieved, despite adherence to medication healthy diet and physical activity REFER to higher-level health care facility for starting insulin t i r-l l lt r f ilit f r t rti i li * YES If goal not achieved Increase dose to 1000 mg 2 x daily If goal not achieved Increase dose to 80 mg 2 x daily REFER to higher level of care Continue gliclazide, diet and physical activity NO IMPROVEMENT If goal not achieved REFER to higher-level of care REASSESS IN 2-3 MONTHS IMPROVEMENT ΖIWKH\DUHPRUHDRUGDEOHWKDQLQVXOLQ'33LQKLELWRUV6*/7LQKLELWRUVRUSORJOLWD]RQHFDQEHXVHG before insulin in cases of treatment failure with metformin and gliclazide. Introduce and titrate insulin treatment according to local practices. PPRO/ PJGO PPRO/ PJGO PPRO/ PJGO Consider less stringent glycaemic control in patients with frequent severe hypoglycaemia, complications, serious comorbidities and/or limited life expectancy REASSESS EVERY 3 MONTHS 24 COMPLICATIONS WHO PEN2.2 DIABETES SEVERE HYPOGLYCAEMIA OR SIGNS (plasma glucose < 50 mg/dl or 2.8 mmol/L) If conscious, give a sugar-sweetened drink If unconscious, give 20–50 ml of 50% glucose (dextrose) IV over 1–3 minutes SEVERE HYPERGLYCAEMIA OR SIGNS AND SYMPTOMS (plasma glucose > 18 mmol/L (325 mg/dl) and urine ketone 2+) Set up intravenous drip 0.9% NaCl 1 litre in 2 hours; continue at 1 litre every 4 hours REFER to hospital Measure blood pressure at every scheduled visit, review medication as per hypertension protocol REFER for dilated-pupil retinal exam upon diagnosis and every 2 years thereafter, or as per ophthalmologist recommendation Examine feet for ulcers at every visit REFER to higher level of care if ulcer present Assess risk of lower limb amputation annually (foot pulses, sensory neuropathy by monofi lament, presence of healed or open ulcers, calluses) REFER to higher level of care if ulcer present or pulse absent Test for proteinuria annually – REFER to higher level of care if positive MANAGEMENT OF ACUTE COMPLICATIONS SCREENING FOR CHRONIC COMPLICATIONS 25 When diabetes is diagnosed, monitor glycaemic control every 3 months until diabetes is controlled, then every 6 months after that. HbA1c is the most accurate measurement of long-term glycaemic control and represents the average blood glucose over the previous two to WKUHHPRQWKV+E$F LVJHQHUDOO\FRQVLGHUHG to be adequate glycaemic control. In people with frequent severe hypoglycaemia, severe complications and low life-expectancy, the goal for HbA1c could be relaxed, e.g. to <8%. )DVWLQJSODVPDJOXFRVH )3* PPROORU PJGO can also be used to monitor control when HbA1c testing is not available. FOLLOW UP 5HIHUWRKLJKHUOHYHORIFDUHLIJRDOLVQRWDFKLHYHGLQPRQWKVLINHWRQHV DUHDQGLIWKHUHLVQRLPSURYHPHQWLQXULQHNHWRQHVDIWHUSKDUPDFRORJLFDO LQWHUYHQWLRQGLHWDQGH[HUFLVHPRGLȴFDWLRQ 26 27 2.3 CHRONIC RESPIRATORY DIEASES MANAGEMENT OF ASTHMA, MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) 28 CHRONIC RESPIRATORY DISEASES Chronic respiratory diseases (CRDs) are chronic diseases of the airways and other structures of the lung. WHO PEN focuses particularly on bronchial asthma and chronic obstructive pulmonary disease (COPD), which are PDMRUSXEOLFKHDOWKSUREOHPVDFFRXQWLQJIRUDVLJQLȴFDQW burden of morbidity and mortality in low- and middle- income countries. https://apps.who.int/iris/bitstream/handle/10665/133525/ 9789241506557_eng.pdf?sequence=1 IMPLEMENTATION TOOLS: PACKAGE OF ESSENTIAL NONCOMMUNICABLE (PEN) DISEASE INTERVENTIONS FOR PRIMARY HEALTH CARE IN LOW-RESOURCE SETTINGS WHO PEN2.3 CHRONIC RESPIRATORY DISEASES 29 30 Previous diagnosis of asthma Symptoms since childhood or early adulthood History of hayfever, eczema and/or allergies Intermittent symptoms with asymptomatic periods in between Symptoms worse at night or early morning Symptoms triggered by respiratory infection, exercise, weather changes or stress Symptoms respond to salbutamol Previous diagnosis of COPD History of heavy smoking, i.e. > 20 cigarettes per day for > 15 years History of heavy and prolonged exposure to burning fossil fuels in an enclosed space, or high exposure to dust in an occupational setting Symptoms started in middle age or later (after age 40) Symptoms worsened slowly over a long period of time Long history of daily or frequent cough and sputum production starting before shortness of breath Symptoms that are persistent with little day-to-day variation PATIENT PRESENTS WITH FRXJKGLɝFXOWEUHDWKLQJWLJKWFKHVWDQGRUZKHH]LQJ DIAGNOSIS OF ASTHMA LIKELY DIAGNOSIS OF COPD LIKELY ASSESS WHO PEN2.3 CHRONIC RESPIRATORY DISEASES 31 0HDVXUHSHDNH[SLUDWRU\ȵRZUDWH 3()5 *LYHWZRSXVRIVDOEXWDPRODQGPHDVXUHDJDLQDIWHUPLQXWHV COPD LIKELYASTHMA LIKELY 20% < 20% ΖIWKH3()5LPSURYHVE\ DIAGNOSE 32 MANAGEMENT OF ASTHMA ΖVWKHDVWKPDZHOOFRQWUROOHG" YES NO exhibits daytime asthma symptoms and uses a beta agonist one or two times a week; exhibits night time asthma symptoms one or two times per month puts no or only minimal limitations on daily activities; has had no severe exacerbation (i.e. requiring oral steroids or admission to hospital within a month); a PEFR, if available, above 80% predicted. TREAT Ask if the patient exhibits ALL of the following: Inhaled salbutamol prn 6WHSZLVHDSSURDFK 3KDUPDFRORJLFDODSSURDFK 1RQSKDUPDFRORJLFDODSSURDFK 1 This should be advised in all patients to help in better control of the disease. Exposure prevention – Smoking cessation and avoid exposure to passive smoke – Avoid asthma triggers if known – $YRLGGXVW\DQGVPRNHȴOOHGURRPV – Avoid drugs like NSAIDs and beta blockers NO ASSESS SYMPTOMS OF BRONCHIAL ASTHMA – Cough Ȃ'LɝFXOWEUHDWKLQJ These symptoms are episodic or seasonal, vary over time and intensity and are worse during night and early morning – Chest tightness – Wheezing YES WHO PEN2.3 CHRONIC RESPIRATORY DISEASES 33 At each step, check the patient’s adherence to treatment and observe their inhaler technique Referral for specialist when: asthma remains poorly controlled the diagnosis of asthma is uncertain regular oral prednisolone is required to maintain control Inhaled salbutamol prn plus low-dose inhaled EHFORPHWDVRQHVWDUWLQJZLWKƉJWZLFHGDLO\IRU DGXOWVDQGƉJRQFHRUWZLFHGDLO\IRUFKLOGUHQ Patient and family education Key educational messages include: The importance of physical activity and regular exercises Information on the reversible nature of the illness, and that asthma can be controlled but may need continuous therapy and regular follow up 5DWLRQDOHIRULQKDOHGGUXJVGLHUHQWLQKDOHU devices and inhalation techniques Information that inhalers are not habit-forming, and are safe and better than tablets or syrup Patients should to carry their device at each follow up visit The need for adherence to prescribed drugs to control the condition Advice regarding dealing with triggers/precipitants 2 Same as step 2, but give higher doses of inhaled EHFORPHWDVRQHƉJRUƉJWZLFHGDLO\ 3 Add low-dose oral theophylline to Step 3 treatment (assuming long-acting beta agonists and leukotriene antagonists are not available) 4 Add oral prednisolone, but in the lowest dose possible to control symptoms (nearly always less than 10 mg daily) 5 FOLLOW UP 5HYLHZDVWKPDFRQWUROHYHU\ȂPRQWKVDQGPRUH IUHTXHQWO\ZKHQWUHDWPHQWKDVEHHQFKDQJHGRUDVWKPD LVQRWZHOOFRQWUROOHG – Symptoms are present only during the day (daytime asthma) – Use of salbutamol is limited to no more than twice a week – Night symptoms occur fewer than twice a month – No or minimal limitation of daily activities – No severe exacerbations within a month – PEFR > 80% of predicted $VWKPDLVFRQWUROOHGZKHQ 34 MANAGEMENT OF EXACERBATION OF ASTHMA ? YES NO Very severe Altered conscious level, exhaustion, arrhythmia, hypotension, cyanosis, silent FKHVWSRRUUHVSLUDWRU\HRUW SpO2 < 92% TREATFirst-line treatment ASSESS SEVERITY 3UHGQLVRORQHȂPJIRUȴYHGD\VIRUDGXOWVDQG mg per kg for three days for children, or longer, if necessary, until they have recovered 1 Severe PEFR 33–50% best or predicted Respiratory rate more than 25 breaths/minute (adult) +HDUWUDWHȲEHDWVPLQXWH DGXOW Inability to complete sentences in one breath FACTORS THAT MAY TRIGGER OR WORSEN ASTHMA – indoor allergens (for example house dust PLWHVLQEHGGLQJFDUSHWVDQGVWXHG furniture, pollution and pet dander) – outdoor allergens (such as pollens and moulds) – tobacco smoke – chemical irritants in the workplace – cold air – extreme emotional arousal such as anger or fear – physical exercise – certain medications, such as aspirin and RWKHUQRQVWHURLGDQWLLQȵDPPDWRU\GUXJV and beta-blockers WHO PEN2.3 CHRONIC RESPIRATORY DISEASES 35 Second-line treatment Reassess at intervals depending on severity Regarding treatment, ensure that the patient or parent: Knows what to do if the asthma gets worse 8QGHUVWDQGVWKHEHQHȴWRIXVLQJLQKDOHUVUDWKHU than tablets, and why adding a spacer is helpful Is aware that inhaled steroids take several days or HYHQZHHNVWREHIXOO\HHFWLYH Regarding prevention Avoid cigarette smoke and trigger factors for asthma, if known $YRLGGXVW\DQGVPRNHȴOOHGURRPV Avoid occupations that involve agents capable of causing occupational asthma Reduce dust as far as possible by using damp cloths to FOHDQIXUQLWXUHVSULQNOLQJWKHȵRRUZLWKZDWHUEHIRUH sweeping, cleaning blades of fans regularly and minimizing soft toys in the sleeping area It may help to eliminate cockroaches from the house (when the patient is away) and shake and expose mattresses, pillows, blankets, etc. to sunlight Increase frequency of dosing via an metered dose inhaler and spacer or by nebulizer, or give salbutamol by continu- ous nebulization at 5–10 mg per hour, if appropriate nebulizer available For children, nebulized ipratropium, if available, can be added to nebulized salbutamol Salbutamol in high doses by metered dose LQKDOHUDQGVSDFHU HJIRXUSXVHYHU\ 20 minutes for 1 hour) or by nebulizer Oxygen, if available, and if oxygen saturation levels are low (below 90%) 2 3 COUNSEL IF NOT RESPONDING 36 MANAGEMENT OF COPD ? MODERATE EXACERBATION OF COPD SEVERE YES If breathless at rest TREAT ASSESS SEVERITY Antibiotics should be given for all exacerbations with evidence of infection ΖQKDOHGVDOEXWDPROWZRSXVDVUHTXLUHG up to four times daily1 If breathless with normal activity Measure PEFR and oxygen saturation, if possible SYMPTOMS SUGGESTIVE OF COPD – Breathlessness (or a "need for air") – Chronic cough – Sputum (mucous) production * Depending on the local risk of infection with Tuberculosis, pulmonary TB should always be suspected if cough lasts more than 2 weeks. WHO PEN2.3 CHRONIC RESPIRATORY DISEASES 37 Advice to patients and families cook with wood or carbon outside the house, if possible, or build an oven in the kitchen with a chimney that vents the smoke outside stop working in areas with occupational dust or high air pollution – using a mask may help, but it needs to have an appropriate design and provide adequate respiratory protection ensure they understand that smoking and indoor air pollution are the major risk factors for COPD – therefore, patients with COPD must stop smoking and avoid dust and tobacco smoke keep the area where meals are cooked well ventilated by opening windows and doors For severe exacerbations, give oral predniso- lone 30–40 mg for around seven days Give high doses of inhaled salbutamol by nebulizer or metered dose inhaler with spacer HJIRXUSXVHYHU\PLQXWHVIRUKRXU or by nebulizer Oxygen, if available, should be given through a mask that limits the concentration to 24% or 28% If symptoms are still troublesome, consider low-dose oral theophylline If ipratropium inhalers are available, they can be used instead of or added to salbutamol, but they are more expensive 2 3 COUNSEL 38 39 CANCER EARLY DIAGNOSIS EARLY DIAGNOSIS CERVICAL CANCER BREAST CANCER 2.4 40 CANCER Identify presenting features of cancer and refer WRQH[WOHYHOIRUFRQȴUPDWLRQRIGLDJQRVLV EARLY DIAGNOSIS Guide to cancer early diagnosis https://www.who.int/cancer/publications/ cancer_early_diagnosis/en/ Comprehensive cervical cancer control: A guide to essential practice CERVICAL CANCER http://www.who.int/reproductivehealth/publications/ cancers/cervical-cancer-guide/en/ Cervical cancer is the fourth most frequent cancer among women. Primary prevention through vaccination against +39HHFWLYHVFUHHQLQJDQGHDUO\GLDJQRVLVDQGWLPHO\ quality treatment of invasive cancers can reduce incidence and mortality rates. Mammography position paper BREAST CANCER https://www.who.int/cancer/publications/mammography_screening/en/ Breast cancer is the most frequent cancer among women. There are two early detection strategies for breast cancer: early diagnosis and screening. 41 ASSESS FOR EARLY DIAGNOSIS common cancer signs and symptoms &DQFHUV\PSWRPVFDQEHQRQVSHFLȴF\HWLWLVLPSRUWDQWWKDWDQ\ȊUHGȵDJȋV\PSWRPV are recognized by providers and investigated further. SITE OF CANCER COMMON SYMPTOMS* Breast Cervix Colon, rectum Oral cavity Naso-pharynx Larynx Lump in the breast, asymmetry, skin retraction, recent nipple retraction, blood stained nipple discharge, eczematous changes in areola Post-coital bleeding, excessive vaginal discharge Change in bowel habits, unexplained weight loss, anaemia, blood in the stool (rectal cancer) White lesions (leukoplakia) or red lesions (erythroplakia), growth or ulceration in mouth Nosebleed, permanent bocked nose, deafness, nodes in upper part of the neck Persistent hoarseness of voice Stomach Skin melanoma Other skin cancers Urinary bladder Prostate Retinoblastoma Testis Upper abdominal pain, recent onset of indigestion, weight loss Brown lesion that is growing with irregular borders or areas of patchy colouration that may itch or bleed Lesion or sore on skin that does not heal Pain, frequent and uneasy urination, blood in urine Difficulty (long time) in urination, frequent nocturnal urination White spot in the pupil, convergent strabismus (in a child) Swelling of one testicle (asymmetry) SITE OF CANCER COMMON SYMPTOMS* Common symptoms and signs that may be due to cancer. These common symptoms may be due to cancer or due to a different medical condition. People with these symptoms should seek medical attention without delay. * 42 WHO PEN2.4 CANCER EARLY DIAGNOSIS TREAT Primary care providers should explain to patients that symptoms may be related to cancer and that timely UHIHUUDOLVQHFHVVDU\:KHQGLVFXVVLQJFDQFHUPDQDJHPHQWSODQVHRUWVVKRXOGEHPDGHWRLQFOXGHWKH patient’s social support system and a second consultation may be required. Clear steps to the next level of care VKRXOGEHSURYLGHGWRPLQLPL]HORVVWRIROORZXS7RIXUWKHUUHGXFHWKLVULVNVWDFRXOGFRQWDFWSDWLHQWVZLWK cancer at predesignated intervals or consider a patient navigation programme. Finally, primary care providers VKRXOGDOVRFRXQVHOSDWLHQWVRQULVNUHGXFWLRQVXFKDVEHKDYLRXUDOPRGLȴFDWLRQ HJVPRNLQJFHVVDWLRQ COUNSEL 7UHDWPHQWIRUFDQFHULVSURYLGHGDWWHUWLDU\DQGVRPHWLPHVVHFRQGDU\KHDOWKFDUHIDFLOLWLHVZKHUH DSSURSULDWHLQIUDVWUXFWXUHLVDYDLODEOH$WWKHSULPDU\FDUHOHYHOWUHDWPHQWLVOLPLWHGWRWUHDWPHQWIRU SUHFDQFHURXVOHVLRQVRIWKHFHUYL[7KLVFDQLQFOXGHFU\RWKHUDS\WKHUPDOFRDJXODWLRQDQGRUORRS HOHFWURVXUJLFDOH[FLVLRQSURFHGXUH /((3 DFFRUGLQJWRWKHORFDOFRQWH[WDQGQDWLRQDOSURWRFROV 43 Follow-up services at the primary care level must be coordinated with providers who diagnose and treat cancer. Information transfer between providers (e.g. pathology unit and primary care provider) is necessary to inform decision-making in cancer management. A direct link between primary care facilities and higher levels of care improves timely access and patient adherence to care. FOLLOW UP 44 Assess signs and symptoms (i.e. history, intensity, duration, progression) Identify relevant risk factors: age (aged 30 years or above) Speculum examination 'LHUHQWLDOGLDJQRVLV DERUWLRQLQSUHPHQRSDXVDO women, infections (e.g. chlamydia, gonorrhoea), JHQLWDOXOFHUVFHUYLFDOLQȵDPPDWLRQXWHULQHSRO\SV dysfunctional uterus hemorrhage, endometrial or vaginal cancer ASSESS LIKELIHOOD Where women present with any of the following: $EQRUPDOYDJLQDOEOHHGLQJ LHDIWHUFRLWXVEHWZHHQ PHQVWUXDOSHULRGVSRVWPHQRSDXVH )RXOVPHOOLQJGLVFKDUJH 3DLQGXULQJYDJLQDOLQWHUFRXUVH CERVICAL CANCER WHO PEN2.4 CANCER EARLY DIAGNOSIS 45 NO $UHWKHDERYHV\PSWRP V DVVRFLDWHGZLWKSDOSDEOHSHOYLFPDVV ZLWKSHUVLVWHQWORZEDFNRUDEGRPLQDOSDLQ" REFER IMMEDIATELY TO NEXT LEVEL NO &OLQLFDOO\GHWHFWHGFHUYLFDO JURZWKRUXOFHUDWLRQ" YES YES Follow obstetric and gynaecological guidelines as appropriate NOTE: Detailed information regarding cervical cancer assessment, diagnosis, treatment and follow-up is provided in the WHO Comprehensive cervical cancer control: A guide to essential practice (C4GEP). Referral of women with the above symptoms may lead to a diagnosis of “early invasive cervical cancer”, particularly in women aged 30 years or above. If condition is not manageable at PHC, or persists or worsens http://www.who.int/reproductivehealth/publications/cancers/ cervical-cancer-guide/en/ 46 Assess signs and symptoms (i.e. history, intensity, duration, progression) Identify relevant breast cancer risk factors (such as age, family history, previous history of breast cancer, chest irradiation) Clinical examination of both breasts, axillae and neck 'LHUHQWLDOGLDJQRVLV EHQLJQEUHDVWGLVHDVHV HJDGHQRPD adenosis, mastitis, abscess, etc.) ASSESS LIKELIHOOD Where women present with any of the following: A%UHDVWOXPSRUDQ\FKDQJHLQWKHVKDSHRUFRQVLVWHQF\RIWKHEUHDVW B%UHDVWOXPSWKDWHQODUJHVDQGRULVȴ[HGDQGKDUG C2WKHUEUHDVWSUREOHPV LHHF]HPDWRXVVNLQFKDQJHVQLSSOHUHWUDFWLRQ SHDXGȇRUDQJHXOFHUDWLRQXQLODWHUDOQLSSOHGLVFKDUJHȂSDUWLFXODUO\ EORRG\GLVFKDUJHOXPSLQWKHD[LOOD ZLWKRUZLWKRXWSDOSDEOHOXPS BREAST CANCER WHO PEN2.4 CANCER EARLY DIAGNOSIS 47 REFER IMMEDIATELY TO NEXT LEVEL 3UHVHQWLQJZLWKV\PSWRPA Referral of women with small breast lumps may lead to diagnosis of “early breast cancer” If symptoms B or C at follow-up NO YES $OVRSUHVHQWLQJZLWKUHOHYDQWULVN IDFWRUVRUV\PSWRPVB or C " ΖQYLWHIRUIROORZXSYLVLWDIWHU PHQVWUXDOSHULRG Age of woman< 30 > 30 https://www.who.int/cancer/publications/ cancer_early_diagnosis/en/ FOR MORE INFORMATION: GUIDE TO CANCER EARLY DIAGNOSIS 48 49 HEALTHY LIFESTYLE COUNSELLING HEALTH EDUCATION COUNSELLING ON CESSATION OF TOBACCO USE 2.5 50 HEALTHY LIFESTYLE COUNSELLING Counselling for healthy lifestyles involves guiding and supporting patients in making changes in certain behaviours to reduce the risk of NCDs https://apps.who.int/iris/bit- stream/handle/10665/260422/WHO-NMH-NVI-18.1-eng.pdf?se quence=1&isAllowed=y TECHNICAL PACKAGE FOR CARDIOVASCULAR DISEASE MANAGEMENT IN PRIMARY HEALTH CARE: HEALTHY-LIFESTYLE COUNSELLING. https://apps.who.int/iris/bitstream/handle/10665/112833/ 9789241506939_eng.pdf?sequence=1 A GUIDE FOR TOBACCO USERS TO QUIT WHO PEN2.5 HEALTHY LIFESTYLE COUNSELLING 51 STOP TOBACCO AND AVOID HARMFUL USE OF ALCOHOL Encourage all non-smokers not to start smoking Strongly advise all smokers to stop smoking and support them in their eff orts Individuals who use other forms of tobacco should be advised to quit Alcohol abstinence should be reinforced. People should not be advised to start taking alcohol for health reasons Advise patients not to use alcohol when additional risks are present, such as: – driving or operating machinery – pregnant or breast feeding – taking medications that interact with alcohol – medical conditions made worse by alcohol – diffi culties in controlling drinking ADHERE TO TREATMENT If the patient is prescribed medication: – teach the patient how to take it at home – explain the diff erence between medicines for long- term control (e.g. blood pressure) and medicines for quick relief (e.g. for wheezing) – tell the patient the reason for prescribing the medication Show the patient the appropriate dose Explain how many times a day to take the medication Label and package the tablets Check the patient’s understanding before the patient leaves the health centre Explain the importance of: – keeping an adequate supply of the medication – the need to take the medication regularly as advised even if there are no symptoms BE PHYSICALLY ACTIVE Progressively increase physical activity to moderate levels (such as brisk walking) at least 30 minutes per day on 5 days of the week Control body weight and avoid overweight by reducing high-calorie food and taking adequate physical activity EAT A HEART HEALTHY DIET Salt (sodium chloride) – Restrict to less than 5 grams (1 teaspoon) per day – Reduce salt when cooking, limit processed and fast foods Fruits and vegetables – 5 servings (400–500 g) of fruits and vegetable per day – 1 serving is equivalent to 1 orange, apple, mango, banana or 3 tablespoons of cooked vegetables Fatty food – Limit fatty meat, dairy fat and cooking oil (less than two tablespoons per day) – Replace palm and coconut oil with olive, soya, corn, rapeseed or saffl ower oil – Replace other meat with chicken (without skin) Fish – Eat fi sh at least 3 times per week, preferably oily fi sh such as tuna, mackerel, salmon EDUCATE YOUR PATIENT TO: Be physically active Eat a “heart healthy” diet Stop tobacco and avoid harmful use of alcohol Adhere to treatment 52 COUNSELLING ON CESSATION OF TOBACCO USE (5 As) 1. ASK 3 . ASSESS 4 . ASSIST 5 . ARRANGE 2 . ADVISE NO'R\RXXVHWREDFFR" $UH\RXZLOOLQJWRPDNHDTXLWDWWHPSWQRZ" Advise not to start tobacco use and to avoid secondhand exposure Promote motivation to quit Provide information on health hazards of WREDFFRDQGJLYHOHDȵHWWRWKHSDWLHQW Assist in preparing a quitting plan – Set quit date – Inform family and friends – Ask for their support At follow-up visit – Congratulate success and reinforce – If patient has relapsed, consider more intensive follow-up and support from family – Remove cigarettes/tobacco – Remove objects/articles that prompt you to smoke – Arrange follow up visit* YES Advise to quit in a clear, strong and personalized manner “Tobacco use increases the risk of developing a heart attack, stroke, lung cancer and respiratory diseases. Quitting tobacco use is the one most important thing you can do to protect your heart and health, you have to quit now.” NOYES Ideally a second follow-up visit is recommended within the same month and every month thereafter for 4 months and evaluation after 1 year. If not feasible, reinforce counseling whenever the patient is seen. * WHO PEN2.5 HEALTHY LIFESTYLE COUNSELLING 53 SELF-CARE SELF-CARE AMONG PATIENTS WITH CARDIOVASCULAR DISEASE, DIABETES OR RESPIRATORY DISEASES 2.6 54 IMPLEMENTATION TOOLS: PACKAGE OF ESSENTIAL NONCOMMUNICABLE (PEN) DISEASE INTERVENTIONS FOR PRIMARY HEALTH CARE IN LOW-RESOURCE SETTINGS SELF-CARE https://apps.who.int/iris/bitstream/handle/10665/133525/ 9789241506557_eng.pdf?sequence=1 All patients with NCDs can perform some level of self-care. WHO PEN2.6 SELF-CARE 55 SELF-CARE AMONG PATIENTS WITH CARDIOVASCULAR DISEASE, DIABETES OR RESPIRATORY DISEASE FIRST VISIT All patients with NCDs perform some level of self-care. Health workers can work to strengthen self-care strategies among these patients by following this protocol Conselling patients on self-care can be integrated into existing care structures All interactions with patients can be seen as opportunities to understand and improve patients' self-care strategies Strategies to improve adherence should form part of self-care for NCDs. Promoting self-care among patients with NCDs should take into account patients' beliefs and concerns DERXWPHGLFLQHVDQGWKHLUHHFWVRQDGKHUHQFH No single strategy to improve overall adherence is recommended over another. Health workers should use their skills, resources, and patient preferences to devise plans to improve adherence *URXSHGXFDWLRQSURJUDPPHVUDWKHUWKDQLQGLYLGXDOHGXFDWLRQPD\RHUDFRVWHHFWLYHVWUDWHJ\ to deliver education in low- and middle-income countries Identify opportunities to improve self-care Provide written or visual educational materials and training in self-care For self-care recommendations that require an action plan, agree on and provide a written or visual action plan FOLLOWING VISITS Check the patient’s progress If necessary and the patient wishes it, repeat the steps from WKHȴUVWYLVLW 56 CONDITION-SPECIFIC RECOMMENDATIONS ON SELF-CARE CARDIOVASCULAR DISEASES Raised blood pressure – Self-measurement to monitor blood pressure is recommended for the management of hypertension in appropriate patients where the aff ordability of the technology has been established. Heart failure – Appropriate patients could benefi t from being educated on the benefi ts of cardiac rehabilitation, and can be encouraged to undertake rehabilitation exercise in the home setting. Need for anticoagulation – Self-monitoring of blood coagulation and self- adjustment of dosage in patients receiving oral anticoagulation agents is recommended if aff ordable and according to an agreed action plan with a health professional. DIABETES Diabetes Type 1 and 2 – People with type 1 and type 2 diabetes on insulin should be off ered self-monitoring of blood glucose based on individual clinical need. Diabetes Type 1 – Self-monitoring and self-adjustment of dosage is recommended in type 1 diabetes according to an agreed action plan with a health professional. RESPIRATORY DISEASES Asthma and chronic obstructive pulmonary disease – Self-monitoring in asthma and COPD and self-adjustment of dosage is recommended according to an agreed action plan with a health professional. Chronic obstructive pulmonary disease – Appropriate patients may benefi t from being educated on the benefi ts of chronic obstructive pulmonary disease rehabilitation, and encouraged to undertake rehabilitation exercise. WHO PEN2.6 SELF-CARE 57 PALLIATIVE CARE PRACTICE POINTS FOR PALLIATIVE CARE 2.7 58 PALLIATIVE CARE https://apps.who.int/iris/bitstream/handle /10665/250584/ 9789241565417-eng.pdf?sequence=1 WHAT IS PALLIATIVE CARE ESTABLISHING PALLIATIVE CARE Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening LOOQHVVWKURXJKWKHSUHYHQWLRQDQGUHOLHIRIVXHULQJE\PHDQVRIHDUO\ LGHQWLȴFDWLRQDQGLPSHFFDEOHDVVHVVPHQWDQGWUHDWPHQWRISDLQDQG other problems, physical, psychosocial and spiritual. :+2'HȴQLWLRQRI3DOOLDWLYH&DUH KWWSV ZZZZKRLQWFDQFHUSDOOLDWLYHGHȴQLWLRQHQ Palliative care services can be established or expanded in a number of ways, depending on the local situation. For instance, a country may decide to begin by: – Setting up a palliative home-care service or integrating palliative home care into existing homecare services – Setting up a community-based palliative care service – Setting up a hospital-based palliative care service PLANNING AND IMPLEMENTING PALLIATIVE CARE SERVICES: A GUIDE FOR PROGRAMME MANAGERS. 59 PRACTICE POINTS FOR PALLIATIVE CARE Integrating palliative care and symptom relief into primary health care: a WHO guide for planners, implementers and managers https://apps.who.int/iris/bitstream/handle/10665/274559/9789241514477-eng.pdf?sequence=1&isAllowed=y TREAT AND REFER WHEN NECESSARY FOR: CONSIDER AND MANAGE PHYSICAL CARE NEEDS CARE PLANNING AND COORDINATION Pain (all types) Respiratory problems (dyspnoea, cough) Gastrointestinal problems (constipation, nausea, vomiting, dry mouth, mucositis, diarrhoea) Delirium Wounds, ulcers, skin rash and skin lesions Insomnia Identify support and resources available; develop and implement care plan based on patient's needs Provide care in the last weeks/days of life Facilitate the availability and access to medications (especially opioids) Identify the psychosocial/spiritual needs of professionals providing care (including self-care) COMMUNICATION ISSUES Communicate with patient, family and caregivers about diagnosis, prognosis, treatment, symptoms and their management, and issues relating to care in the last days/weeks of life Identify and set priorities with patient and family/caregivers Provide information and guidance to patients and caregivers according to available resources Psychological distress Anxiety 6XHULQJRIIDPLO\RUFDUHJLYHUV Spiritual needs and existential distress Depression Bereavement support for family/caregivers Fatique Anorexia Anaemia Drowsiness or sedation Sweating PSYCHOLOGICAL, EMOTIONAL, AND SPIRITUAL CARE NEEDS 60 61 ADAPTING WHO PEN 3 62 ADAPTING WHO PEN 3. ADAPTING WHO PEN A stepwise approach to implementation of WHO PEN is presented below. The key advantage of a stepwise approach, whether to pre- vention, surveillance or management, is that it off ers a framework to help countries get started and to focus on what is practical, taking into account the available human, fi nancial and other resources. ENGAGE STAKEHOLDERS DEVELOP A SERVICE DELIVERY MODEL FOR PHC Hold introductory meetings with stakeholders Obtain ministry of health endorsement Establish technical working group Identify demonstration site Develop a package of service delivery for NCDs based on WHO PEN 1 3 ASSESS CURRENT STATUS OF NCDs Desktop review of existing plans, policies (including public policies) and guidelines that contribute to NCD control in the country Assess the capabilities of the primary care health infrastructure Review and summarize exisiting NCD services at all levels of the health system Conduct a strengths, weaknesses, opportunities, threats (SWOT) analysis 2 63 REVIEW AND PLAN FOR SCALE UP Review and evaluate WHO PEN implementation at demonstration sites Cost WHO PEN package implementation Finalise service delivery model Develop a plan for phased scale up 6 MONITORING AND EVALUATION Define indicators and existing tools for measurement Establish a monitoring process 5 CAPACITY BUILDING Conduct training for healthworkers on agreed upon model and protocols Host ongoing inservice trainings Appoint mentors Develop supervision checklists and ensure supportive supervision is done at regular intervals 4 64 ENGAGE STAKEHOLDERS Identify key stakeholders invested in the current NCD health service delivery system to invite to the consultation. This is to build consensus and garner broad-based support. National-level: Ministry of Health, Ministry of Finance, Ministry of Social Welfare, political leaders at state or division-levels Local/Community-level: Local political leaders, community leaders, public sector health providers, private sector health providers Other sectors: NCD specialists, media, research groups or academic institutions, civic groups or health-oriented nongovernmental organizations (NGOs) Obtain an agreement to adapt WHO PEN and strengthen NCD management in primary care Establish technical working group Composition: Public health and clinical staff members (including medical, nursing and pharmaceutical) Role: To provide overall direction, leadership and supervision to the local adaptation of the WHO PEN and to national rollout; advise on the number of additional personnel needed, the required competencies, skills and their roles and responsibilities; and provide specifi c technical advice or support for the adaptation or development of the protocols Identify demonstration site The recommended criteria for selection of site: – Geographic access and communication – Health centres with a referral care facility – Agreement from local government – Support from professional associations and civil society groups List all primary health care centres Select a sample of facilities – usually 10% of the total number of facilities in the selected site Establish an agreement with demonstration site (e.g provincial agreement or district agreement) and include operational structure Conduct facility assessment First create a map of the sample of health facilities at demonstration site and the referral linkages Conduct a facility assessment (Annex 4.1) Analyse the information collected and identify gaps in training, equipment, drugs, record keeping, and management practices Determine minimum requirements of skilled staff , equipment, devices and medicines needed for implementing the package 1 65 ASSESS CURRENT STATUS OF NCD Desktop review of all related strategies, policies (including public policy measures on tobacco, alcohol, diet and physical activity) and guidelines relating to NCDs in primary health care Using the template to the right determine the current PHC infrastructure Map the current patient pathway for NCD service delivery Conduct a SWOT analysis of the country’s NCD service delivery system using the template below 2 GOVERNANCE AND LEADERSHIP • Is NCD risk management in primary health care included in the: national/district health strategy; national NCD strategy; national operational plans; basic package of services? • Is management of CVD /Hypertension /diabetes /CRD/ cancer included in national clinical guidelines for primary health care? • Do national clinical guidelines for primary health care include evidence-based protocols for risk- based CVD management? • Are there standardized systems/tools for mentoring and supervision of primary health-care staff ? • What is the frequency of district management meetings? Who attends? HEALTH FINANCING • Is there a specifi c NCD budget within health fi nancing? If yes, what is it? • In those systems with health insurance, are NCD services and medicines included in benefi t packages? ACCESS TO ESSENTIAL MEDICINES AND TECHNOLOGIES • Are the minimum essential medicines (Annex 4.2) for NCDs included in the national essential medicines list and the minimum primary health care medicines list? • Are the essential NCD technologies and tools (Annex 4.3) included in minimum standards for primary health care facilities? • Describe the national medicines supply management system (selection, quantifi cation, procurement, storage, distribution). HEALTH WORKFORCE • Are there dedicated management staff for NCD management at national and district levels? • Which staff cadres have authority to prescribe and/or authorize medication refi lls? • Have task-sharing approaches in primary health care been adopted or considered? • Do in-service training packages exist for management of CVD, hypertension or diabetes in primary health care? • Has any in-service training on NCD risk management occurred in last 2 years? If yes, who delivered it? HEALTH INFORMATION SYSTEMS • Are there mechanisms for data feedback from national, to subnational, to facility level? • Are there dedicated staff to collect data at district level? • Describe the district-level database for routine health management information system and other facility data. • Are NCD management indicators included in a national minimum indicator set? • Describe the type of individual patient record format used in public primary health-care facilities. • An sample clinical record is given (Annex 4.4) ORGANIZATION OF SERVICE DELIVERY • Describe the facility levels within the public health system. • Describe NCD management services available at each level of care including a healthy lifestyle counselling component. • Are catchment populations defi ned for primary health care? • What is the current service delivery model(s) in public primary health-care facilities? For example, general outpatient services where patients see any available provider; disease specifi c clinics. Are there established national and/or district-level quality improvement systems for primary health care? STRENGTHS 1. 2. 3. THREATS 1. 2. 3. WEAKNESSES 1. 2. 3. OPPORTUNITIES 1. 2. 3. SWOT 66 DEVELOP A SERVICE DELIVERY PACKAGE FOR PHC Develop a service delivery package relevant to the local context by adapting WHO PEN. Elements to consider when developing a service delivery package: – Health facility should be equipped to provide basic promotive, preventive and some curative services along with referrals and follow up – A matrix can be developed to map the various units of service and details under each unit as services, infrastructure, equipment and personnel – Once each unit matrix is ready then the fi nal matrix can be developed by matching the matrices for common items Consider urban vs rural service delivery models Decide on appropriate WHO PEN protocols for implementation Decide which protocol to implement based on community and health systems capacity assessments, and consideration of health priorities and the availability of human and technical resources. Adapt management protocols as required to refl ect country context, availability of drugs etc CAPACITY BUILDING As per service model, conduct appropriate training to primary care workers to deliver integrated NCD care – to assess, diagnose, manage and refer patients appropriately. Primary care workers should be able to: Apply relevant WHO PEN protocols and tools and interpret the results Understand referral thresholds Be familiar with the system and information to record and track to monitor WHO PEN implementation Deliver preventive health interventions and empower patients Plan for improving patient adherence to follow-up visits Consider incorporating the WHO PEN training into medical, nursing and allied health course curriculum, and providing continuing education courses for primary care health workers MONITORING AND EVALUATION Health facilities should have a system for collection of data. Sample clinical record is provided in Annexe 4.4. Data collation and analysis may be done at appropriate levels. Indicators for hypertension and diabetes are provided in Annex 4.5. They can serve as tracers for assessing the services. Establish monitoring process: Second-level facility (e.g. national, provincial or district health offi ce) to conduct visits to fi rst-level health facilities at least once every three months Conduct periodic audits of facilities providing the services 3 4 5 67 REVIEW AND PLAN FOR SCALE UP Review and evaluate demonstration phase Conduct an external assessment and audit of clinical practice. Analyse the fi ndings to assess the model and make necessary refi nements. Finalize service delivery model and requirements Agree on the service delivery model based on the feasibility and sustainability. Finalize the national protocols, referral criteria, and the equipment, drugs and consumables required. Agree on the human resources needed, their roles and responsibilities, and the training curriculum. Finalize the requirements of the health information system and clinical recording system. Agree on the monitoring and evaluation system, and the tools for auditing. Develop a multi-year plan to expand services nationwide Estimate the cost for the national expansion plan. Utilize cost information from the demonstration phase and from the costing study. Have a plan to ensure most cost-eff ective procurement and distribution of drugs and consumables. E.g. include core NCD drugs and technologies in the essential drug list; ensure transparency in the tender process; purchase cheaper quality generics and consider removing taxes and duties on essential drugs and technologies. Strengthen demand forecasting and supply chain mechanisms; strengthen health information system and analyse ordering cycle at the health centre. Obtain administrative order to expand services nationwide. Detail service model, roles and responsibilities, national protocols, and plan of action. Secure allocation in national health budget. Mobilize development partners, private sector, academia and the community to contribute to strengthening NCD management in primary health care. Conduct periodic monitoring and regular evaluation. Repeat annually for short-term indicators (e.g. impact indicators) and every 3–5 years for medium-term progress indicators (e.g. outcome indicators). 6 68 D om ain O bservation points Com m ents H ow are N CD s m anaged now ? W hat N CD s are covered? Flow of patients in the facility, w here is BP taken, how are N CD s m anaged? Patient care services Is there a separate N CD clinic? N CD treatm ent guidelines available? Staff D edicated staff for N CD s? Staff trained in N CD diagnosis and treatm ent? Equipm ent BP apparatus G lucom eter W eighing m achine H eight m easuring tape Laboratory services U rine for album in, sugar, ketones Blood sugar, cholesterol M edicines Are essential N CD drugs available? (m etform in, am lodipine, etc.) Records and reports D o patients have a unique ID num ber? W ho prepares the reports? Is there a separate N CD register? Com puterized records? Referral system N earest referral centre (approxim ately in km s) - Secondary - Tertiary W hat w orks (w hat are the strengths)? W hat doesn’t w ork (w hat are the challenges)? W hat should be done next (H ow can N CD services be im proved)? A N N EX 4.1: H EA LTH FA CILITY A SSESSM EN T Adaptation of the W H O PEN package can start w ith a quick assessm ent of the facility. A sam ple form at is given here. Please use this observation checklist as a guide and don’t restrict your observations to the points be- low . Feel free to add m ore depending on your observations. SU M M A RY O F H EA LTH FA CILITY A SSESSM EN T 69 • Am oxicillin • Angiotensin inhibitor (enalapril) • Aspirin • Beclom ethasone • Beta-blocker (atenolol) • Calcium channel blocker (am lodepine) • Codeine • D extrose infusion • D iazepam • Epinephrine • Erythrom ycin • Furosem ide • G libenclam ide • G lucose injectable solution • G lyceryl trinitrate • H eparin • H ydrocortisone • Ibuprofen • Insulin • Isosorbide dinitrate • M agnesium sulphate • M etform in • M orphine • O xygen • Paracetam ol • Prednisolone • Prom ethazine • Salbutam ol • Senna • Sodium chloride infusion • Spironolactone • Statin (sim vastatin) • Thiazide diuretic A N N EX 4.2: CO RE LIST O F M ED ICIN ES [For prim ary care facilities w ith physicians] (for PC facilities w ith only non-physician health w orkers m ost of the m edicines below are required for refi ll of prescriptions issued by physicians at a higher level of care) 70 A N N EX 4.3: ESSEN TIA L TECH N O LO G IES A N D TO O LS TEC H N O LO G IES • Therm om eter • Stethoscope • Blood pressure m easurem ent device* • M easurem ent tape • W eighing m achine • Peak fl ow m eter** • Spacers for inhalers • G lucom eter • Blood glucose test strips • Sem m es-W einstein 10 g m onofi lam ent • U rine protein test strips • U rine ketones test strips A dd w hen resources perm it: • N ebulizer • Pulse oxim eter • Blood cholesterol assay • Lipid profi le • Serum creatininine assay • Troponin test strips • U rine m icroalbum inuria test strips • Tuning fork • Electrocardiograph (if training to read and interpret electrocardiogram s is available) • D efi brillator TO O LS • W H O CVD risk prediction charts • Evidence-based clinical protocols • Flow charts w ith referral criteria • Patient clinical record • M edical inform ation register • Audit tools * For facilities w ith nonphysician health w orkers a validated blood pressure m easurem ent device w ith digital reading is preferable for accurate m easurem ent of blood pressure ** D isposable m outh pieces requried. Peak fl ow m eters w ith one-w ay fl ow preferable. 71 N C D clinic registry A tool for N C D treatm ent and follow up N C D ID : D ate: M ale / Fem ale / O ther Yes / No No / Yes (on treatm ent)/ Yes (not on treatm ent) No / Yes (on treatm ent)/ Yes (not on treatm ent) Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Present / Absent Yes / No No/O ccasional/Daily/Harm ful use Yes / No PA TIE N T IN FO R M A TIO N P atient N am e G ender D ate of B irth A ge at the tim e of R egistration A ddress Line1 A ddress Line 2 C ontact no. E m ail N ationality H IS TO R Y O F N C D H /o H ypertension H /o D iabetes H /o A sthm a H /o C O P D H /o C ancer H /o C oronary artery diseases H /o S troke H /o C honic K idney D isease A S S E S S M E N T Tobacco use - sm oking Tobacco use - sm okeless A lcohol use S ystolic B lood P ressure at R egistration D iastolic B lood P ressure at R egistration H eight (in m eters) W eight (in kg) B M I IN V E S TIG A TIO N S Fasting blood glucose (m g/dl) R andom blood glucose (m g/dl) H bA 1C (% ) S erum potassium (m E q/L) S erum creatinine (m g/dL) S erum urea (m g/dL) Total cholesterol (m g/dL) U rine protein Foot exam ination Fundus exam ination C ervical cancer screening D IA G N O S IS H ypertension D iabetes H yperlipidaem ia C O P D A sthm a O ther C V D risk - lab based C V D risk - non lab based A N N EX 4.4: SA M PLE CLIN ICA L RECO RD 72 D ate for follow up M edicines dispensed R eferred - R eason for referral - S ignature of D octor TR E A TM E N T M edicines for H ypertension N am e of M edicine 1 D ose A dvice N am e of M edicine 2 D ose A dvice N am e of M edicine 3 D ose A dvice N am e of M edicine 1 D ose A dvice N am e of M edicine 2 D ose A dvice N am e of M edicine1 D ose A dvice N am e of M edicine 2 D ose A dvice N am e of M edicine D ose A dvice N am e of M edicine D ose A dvice N am e of M edicine D ose A dvice M edicine for D iabetes M edicines for H yperlipidaem ia M edicines for C O P D M edicines for A sthm a O thers Yes / No 73 Systolic BP Diastolic BP W eight BM I HTN M edicine 1 Low er lim b am putation Fasting blood glucose DM M edicine 2 Hospitalization for Asthm a Serum Creatinine Fundus exam ination HTN M edicine 2 Renal failure Random blood glucose Statins Signature Serum urea Foot exam ination HTN M edicine 3 Coronary Artery Disease HbA1c O thers Total cholesterol Cervical cancer screening DM M edicine 1 Stroke Serum potassium Urine protein P atient N am e N C D ID A S S E S S M E N T D ate D ate D ate D ate D ate TR E A TM E N T N E W C O M P LIC A TIO N S O N FO LLO W U P V IS ITS IN V E S TIG A TIO N S Follow -up V isits N C D clinic registry A tool for N C D treatm ent and follow up Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al 74 A N N EX 4.5: IN D ICA TO RS H ealth-facility level N o. Indicator Source of data Reporting frequency H ealth system considerations 1 Six-m onthly control of blood pressure am ong people treated for hypertension H ealth facility record O nce in six m onths Feasible in all settings in prim ary health care and a core indicator for quality of services Subnational (district/province/state) level (aggregated from health facilities off ering the services w ithin the program m e) N o. Indicator Source of data Reporting frequency Considerations in the interpretation 2 Control of blood pressure am ong people w ith hypertension w ithin the program m e Aggregated reports from all the health facilities reporting the hypertension indicator in a defi ned subnational area; estim ation of hypertension prevalence O nce in 12 m onths This w ill give estim ated com m unity control rates w ith the num erator com ing from facilities reporting as part of the program m e (in som e instances patients m ay be receiving BP m eds from private sector or other levels of care w ithin the public system ) 3 Availability of core cardiovascular disease/ diabetes drugs Aggregated reports from all the health facilities reporting drug availability indicators in a defi ned subnational area O nce in 3 m onths This is for the program m e quality control and w ill assist w ith forecasting of m edicines and im provem ents in supply chain m anagem ent Population level (control of hypertension, diabetes and CVD risk) N o. Indicator Source of data Reporting frequency Considerations in the interpretation 4 H ypertension control in the population Population-based sam ple survey (STEPS or sim ilar survey) O nce in 3–5 years Population-level survey as part of national survey or a special survey for the program m e 5 Proportion of eligible persons receiving drug therapy and counselling (including glycaem ic control) to prevent heart attacks and stroke (1) Population-based sam ple survey (STEPS or sim ilar survey) O nce in 5 years Population-based (preferably nationally representative) survey, including behavioural param eters w ith physical and biochem ical m easurem ents TA B LE 1: IN D ICA TO RS FO R H YPERTEN SIO N A N D CVD H EARTS Technical package for cardiovascular disease m anagem ent in prim ary health care: system s for m onitoring. https://apps.w ho.int/iris/bitstream /handle/10665/260423/W H O -N M H -N VI-18.5-eng.pdf;jsessionid=519A7089AD 2410B8245D 0BA1EBC0C946?sequence=1 75 Indicator D escription N um ber of patients being treated for diabetes N um ber of patients and num ber of new patients w ith diabetes Frequency of reporting: m onthly Control rate am ong people treated for diabetes N um erator: num ber of patients w ith diabetes w ith good glycaem ic control at the last clinical visit in the last 6 m onths (H bA1c <7.0% (53 m m ol/m ol), or FPG <7.0 m m ol/L (126m g/dL) and (if available) a postprandial PG value <9.0 m m ol/L (160 m g/dL) D enom inator: num ber of patients w ith diabetes in the facility during the last 6 m onths Frequency of reporting: every 6 m onths Com plications due to diabetes: • diabetic foot • nephropathy • retinopathy • neuropathy • cardiovascular diseases N um erator: num ber of new diabetes com plications in the past year D enom inator: num ber of patients w ith diabetes in the past year Frequency of reporting: annually TA B LE 2: IN D ICA TO RS FO R D IA B ETES M ELLITU S D iagnosis and m anagem ent of type 2 diabetes (H EARTS-D ) https://w w w .w ho.int/publications/i/item /w ho-ucn-ncd-20.1 76 A N N EX 4.6: A D D ITIO N A L REA D IN G 1. Com prehensive cervical cancer control: A guide to essential practice. G eneva: W orld H ealth O rganization; 2014 (http://w w w .w ho.int/reproductivehealth/publications/cancers/cervical-cancer-guide/en/, accessed 16 July 2020). 2. G uide to cancer early diagnosis. G eneva: W orld H ealth O rganization; 2017 (https://w w w .w ho.int/cancer/publica- tions/cancer_early_diagnosis/en/, accessed 16 July 2020). 3. H EARTS-D . D iagnosis and m anagem ent of type 2 diabetes. G eneva: W orld H ealth O rganization; 2020 (https:// w w w .w ho.int/publications/i/item /w ho-ucn-ncd-20.1, accessed 16 July 2020). 4. H EARTS Technical package for cardiovascular disease m anagem ent in prim ary health care. G eneva: W orld H ealth O rganization; 2018 (https://w w w .w ho.int/cardiovascular_diseases/hearts/en/, accessed 16 July 2020). 5. Im plem entation tools. Package of Essential N oncom m unicable (PEN ) disease interventions for prim ary health care in low -resource settings. G eneva: W orld H ealth O rganization; 2013 (http://apps.w ho.int/iris/bitstream /han- dle/10665/133525/9789241506557_eng.pdf, accessed 16 July 2020). 6. Planning and im plem enting palliative care services: a guide for program m e m anagers. G eneva: W orld H ealth O rganization; 2016 (https://apps.w ho.int/iris/bitstream /handle/10665/250584/9789241565417-eng.pdf, accessed 16 July 2020). 7. Tackling N CD s. “Best buys” and other recom m ended interventions for the prevention and control of non- com m unicable diseases. G eneva: W orld H ealth O rganization; 2017 (http://apps.w ho.int/iris/bitstream /han- dle/10665/259232/W H O -N M H -N VI-17.9-eng.pdf, accessed 16 July 2020). 8. W orld H ealth O rganization cardiovascular disease risk charts: revised m odels to estim ate risk in 21 global re- gions. The W H O C VD Risk Chart W orking G roup. Lancet G lob H ealth. 2019;7:e1332–45 Published O nline Septem - ber 2, 2019 http://dx.doi.org/10.1016/ S2214-109X(19)30318–3. 9. A guide to im plem entation research in the prevention and control of noncom m unicable diseases; 2019 (https:// apps.w ho.int/iris/bitstream /handle/10665/252626/9789241511803-eng.pdf, accessed 16 July 2020). 10. Classifi cation of diabetes m ellitus. G eneva: W orld H ealth O rganization; 2019. (https://apps.w ho.int/iris/bitstream / handle/10665/66040/W H O _N CD _N CS_99.2.pdf?sequence=1\, accessed 16 July 2020). 11. Integrating palliative care and sym ptom relief into prim ary health care: a W H O guide for planners, im plem enters and m anagers.; 2018 (https://apps.w ho.int/iris/bitstream /handle/10665/274559/9789241514477-eng.pdf?se- quence=1& isAllow ed=y, accessed 16 July 2020). 12. G uide to cancer early diagnosis; 2017 (https://w w w .w ho.int/cancer/publications/cancer_early_diagnosis/en/, accessed 16 July 2020). 13. N CD in em ergencies; 2016 (https://apps.w ho.int/iris/bitstream /handle/10665/204627/W H O _N M H _N VI_16.2_eng.pdf?sequence=1& isAl- low ed=y, accessed 16 July 2020) 77 For more information, please contact: World Health Organization Department of NCD 20, avenue Appia 1211 Geneva 27 Switzerland E-mail: NextGenNCD@who.int https://www.who.int/teams/ncds/
WHO PACK AGE OF ESSEN T IAL NONCOMMUNICABLE (PEN) DISE ASE IN TERVEN T IONS FOR PRIMARY HEALTH CARE WHO package of essential noncommunicable (PEN) disease interventions for primary health care ISBN 978-92-4-000922-6 (electronic version) ISBN 978-92-4-000923-3 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specifi c organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, fi gures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specifi c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. WHO PACKAGE OF ESSENTIAL NONCOMMUNICABLE (PEN) DISEASE INTERVENTIONS FOR PRIMARY HEALTH CARE CONTENTS Foreword iii Acknowledgement v Abbreviations v 1 Introduction 1 2. Components of WHO PEN 5 2.1 Cardiovascular diseases 8 2.2 Diabetes 18 2.3 Chronic respiratory diseases 28 2.4 Cancer early diagnosis 40 2.5 Healthy lifestyle counselling 50 2.6 Self-care 54 2.7 Palliative care 58 3. Adapting WHO PEN 62 4. Annexes 69 Annex 4.1. Health facility assessment 69 Annex 4.2. Core list of medicines 70 Annex 4.3. Essential technologies and tools 71 Annex 4.4. Sample clinical record 72 Annex 4.5. Indicators 75 Annex 4.6. Additional reading 77 ii FOREWORD The adoption of the Global Strategy for the Prevention and Control of Noncommunicable Diseases (NCDs) at the World Health Assembly in 2000 was an act of solidarity with the many low- and middle-income countries facing the catastrophic consequences of NCDs. It was also an acknowledgement that the long-term needs of people living with NCDs were being neglected, and was a turning point that has inspired action over the past two decades. The risk of a 30-year-old person dying from any of the four major NCDs (cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes) before the age of 70 years declined by 15% globally between 2000 and 2012. This rapid improvement was largely due to policy, legislative and regulatory measures put in place to provide more people with access to screening; early diagnosis and treatment for hypertension (such as aspirin, beta blockers, diuretics and statins); and to protect people against tobacco use (such as through tobacco- control legislation). Despite the important progress made in the fi rst decade of the 21st century, momentum has since dwindled, with annual reductions in age-standardized premature mortality rates slowing for the main NCDs. Between 2000 and 2016 overall NCD risk declined only 18% globally – with the risk of diabetes showing a 5% increase. In the past two decades NCDs have killed 200 million women and men aged between 30 and 70 years, the majority living in low- and middle-income countries. Most of these premature deaths could have been avoided. Unless immediate action is taken, Sustainable Development Goal (SDG) target 3.4 (reduce premature mortality from NCDs by one third) by 2030 will not be met. It is therefore more important than ever for the global community to mobilize for accelerated action to progressively cover 1 billion additional people with essential health services and medicines for the prevention and control of NCDs. iii WHO has been providing guidance to advance this work. The Package of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings was fi rst introduced in 2010 as a prioritized set of cost-eff ective interventions able to deliver an acceptable quality of care, even in resource-limited settings. Information on the cost-eff ectiveness of the interventions helped to make limited resources go further. From 2010, many additional elements were added and in 2013 a comprehensive set of tools was developed. The total cardiovascular risk assessment charts and management of type 2 diabetes were further updated in 2019. The result today is this user-friendly WHO package of essential noncommunicable (PEN) disease interventions for primary health care resource, which brings together all these updates as protocols that are adaptable to local settings and able to empower primary care physicians, as well as allied health workers, to contribute to NCD management. WHO PEN is not meant to be exhaustive or prescriptive, but rather to be an important fi rst step for integration of NCD management into primary health care. WHO PEN is also suitable for emergency and humanitarian settings. When implemented, it will bring more people living with or aff ected by NCDs into contact with the health system and promote universal health coverage. Dr Bente Mikkelsen Director, Department of Noncommunicable diseases iv ABBREVIATIONSACKNOWLEDGEMENT CKD chronic kidney disease COPD chronic obstructive pulmonary disease CRD chronic respiratory diseases CVD cardiovascular diseases HDL-C high-density lipoprotein cholesterol HPV human papilloma virus NCD noncommunicable diseases PHC primary health care TC total cholesterol UHC universal health coverage WHO World Health Organization The World Health Organization would like to thank all the contributors external collaborators, reviewers and WHO staff whose dedication, support and expertise over many years have made possible this latest edition of the WHO PEN. v 1. INTRODUCTION INTRODUCTION Noncommunicable diseases (NCDs), also known as chronic diseases, tend to be of long duration and are the result of a combination of genetic, physiological, environmental and behavioural factors. The main types of NCDs are cardiovascular diseases (CVDs like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease – COPD and asthma) and diabetes. NCDs kill 41 million people each year, equivalent to 71% of all deaths globally. NCD prevention and control includes population- wide interventions to reduce risk factor exposure, individual approaches to modify risk factors for high- risk individuals, and treatment of NCDs. Investing in better management of NCDs is critical. Management of NCDs includes detecting, screening and treating these diseases, and providing access to palliative care for people in need. High-impact essential NCD interventions can be delivered through a primary health care approach to strengthen early detection and timely treatment. Evidence shows such interventions are excellent economic investments because, if provided early to patients, they can reduce the need for more expensive treatment. Countries with inadequate health insurance coverage are unlikely to provide universal access to essential NCD interventions. Yet NCD management interventions are essential for achieving the global target of a 25% relative reduction in the risk of premature mortality from NCDs by 2025, and the SDG target of a one-third reduction in premature deaths from NCDs by 2030. An integrated approach is particularly important for low- resource settings for effi cient use of limited resources. Several approaches are needed to contain the escalating costs of health care required for providing sophisticated medical services for NCDs and their complications. First, there should be more investment in prevention and primary care. Second, the cost of treating CVD, diabetes and COPD can be reduced to a minimum by carefully selecting essential evidence-based interventions. Third, the cost of treating complications of NCDs that require hospitalization (e.g. heart attacks, strokes, amputations, and blindness due to diabetic or hypertensive retinopathy, or end stage renal disease requiring dialysis) can be reduced. WHO Package of Essential NCD interventions will help to improve the coverage of appropriate services for people with NCDs services in primary care settings. WHO package of essential noncommunicable (PEN) disease interventions for primary health care The Package of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings, fi rst published in 2010, is a prioritized set of cost-eff ective interventions that can be delivered to an acceptable quality of care, even in resource-poor settings. The interventions were upated in 2017 as the “best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. Modules of the WHO HEARTS technical package were released in 2019–2020. This version, WHO package of essential noncommunicable (PEN) disease interventions for primary health care (WHO PEN), is developed by integrating these additional technical guidance to serve as an important fi rst step for integration of NCD into PHC and for reforms that need to cut across the building blocks of the national health system. It provides protocols and tools for NCDs to strengthen national capacity to integrate and scale up care of NCDs in primary health care. WHO PEN 1 WHO PEN TO SUPPORT PEOPLE WITH NCDS THROUGH UNIVERSAL HEALTH COVERAGE Universal health coverage (UHC) means that all individuals and communities receive the health services they need without suff ering fi nancial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care. UHC enables everyone to access the services that address the most signifi cant causes of disease and death, and ensures that the quality of those services is good enough to improve the health of the people who receive them. Effi cient use of limited health care resources, sustainable health fi nancing mechanisms, access to basic diagnostics and essential medicines and organized medical information and referral systems are imperative for provision of equitable care for people with and at risk of NCDs. People with NCDs require long-term care that is proactive, patient- centered, community-based and sustainable. Such care can be delivered equitably only through health systems based on primary health care. NCD services are part of the essential health services and are required in humanitarian and other crisis situations. The WHO PEN aligns with these objectives and provides a mechanism of organizing NCD service delivery with an aim of addressing UHC. The global move towards UHC off ers an opportunity to explicitly prioritize NCD interventions in benefi t packages for UHC. ENABLING ACTIONS Explore viable health-fi nancing mechanisms and innovative economic tools supported by evidence. Scale-up early detection and coverage, prioritizing cost-eff ective, high-impact interventions. Train the health workforce and strengthen the capacity of health systems, particularly at the primary care level, to address the prevention and control of noncommunicable diseases. Improve the availability of the aff ordable basic technologies and essential medicines, including generics, required to treat major noncommunicable diseases, in both public and private facilities. Strengthen and orient health systems to address noncommunicable diseases and risk factors through people-centred health care and universal health coverage. Develop and implement a palliative care policy, including access to opioid analgesics for pain relief, together with palliative care training for health workers. Expand the use of digital technologies to increase health service access and effi cacy for NCD prevention, and to reduce the costs in health care delivery. 2 INTRODUCTION WHO PEN ROADMAP OF WHO PACKAGE OF ESSENTIAL NONCOMMUNICABLE (PEN) DISEASE INTERVENTIONS FOR PRIMARY HEALTH CARE 2010200720052002 2013 3 202020182017 20192016 4 The WHO PEN defines a minimum set of interventions to address major NCDs in primary care. The interventions are for the detection, diagnosis, treatment and care of cardiovascular diseases, diabetes and chronic respiratory diseases. A section for cancer early diagnosis is also included. Components of healthy lifestyle, self care and palliative care also feature in the package. Sample templates and tools are also provided. These components are feasible even in low- resource settings, and can be delivered by primary care physicians and non-physician health workers. Contents of WHO PEN can be adapted to emergency and humanitarian settings. Countries can expand on the core interventions according to their needs and resources. COMPONENTS WHO PEN 2. COMPONENTS OF WHO PEN 5 CARDIOVASCULAR DISEASES CVD risk assessment and management Hypertension management 2.1 DIABETES Management of diabetes 2.2 CHRONIC RESPIRATORY DISEASES Management of asthma and exacerbation Management of COPD, and exacerbation 2.3 CANCER EARLY DIAGNOSIS Early diagnosis Cervical cancer Breast cancer 2.4 PALLIATIVE CARE Practice points for palliative care 2.7 SELF CARE Self-care among patients with cardiovascular disease, diabetes or respiratory disease 2.6 ADAPTING WHO PEN 3 HEALTHY LIFESTYLE COUNSELLING Health education Counseling on tobacco cessation 2.5 6 7 CARDIOVASCULAR DISEASES CVD RISK ASSESSMENT AND MANAGEMENT HYPERTENSION MANAGEMENT 2.1 8 – known hypertension – known diabetes mellitus (DM) – history of premature CVD in first degree relatives – history of DM or kidney disease in first-degree relatives – aged over 40 years – history of tobacco use – overweight WHEN TO USE THIS PROTOCOL http://www.who.int/cardiovascular_diseases/hearts/en/ HEARTS TECHNICAL PACKAGE CARDIOVASCULAR DISEASES OVERVIEW OF CONTENTSCardiovascular disease risk assessment and management CARDIOVASCULAR DISEASES WHO PEN 9 1. Ask about Diagnosed heart disease, stroke, Transient Ischaemic Attack (TIA), DM, kidney disease Angina, breathlessness on exertion and lying fl at, numbness or weakness of limbs, loss of weight, increased thirst, polyuria, puffi ness of face, swelling of feet, passing blood in urine etc Medicines that the patient is taking Current tobacco use (yes/no) (answer yes if tobacco use during the last 12 months Alcohol consumption (yes/no) (if “Yes”, frequency and amount) Occupation (sedentary or active) Engaged in more than 30 minutes of physical activity at least 5 days a week (yes/no) Family history of premature heart disease or stroke in fi rst-degree relatives 2. Assess (physical exam) Measure blood pressure Look for pitting oedema Palpate apex beat for heaving and displacement Auscultate heart (rhythm and murmurs) Auscultate lungs (bilateral basal crepitations) Examine abdomen (tender liver) In DM patients examine feet; sensations, pulses, and ulcers CVD RISK ASSESSMENT & MANAGEMENT 10 10 Calculate CVD risk using a lab-based chart https://apps.who.int/iris/bitstream/ handle/10665/333221/9789240001367-eng.pdf? sequence=1&isAllowed=y HEARTS TECHNICAL PACKAGE FOR CARDIOVASCULAR DISEASE MANAGEMENT IN PRIMARY HEALTH CARE: RISK BASED CVD MANAGEMENT DIAGNOSE 2.1 CARDIOVASCULAR DISEASES WHO PEN – age – sex – current smoking status Parameters required prior to using the charts: – presence or absence of diabetes* – systolic blood pressure – total cholesterol** 11 Eastern Sub-Saharan Africa Risk Level 0 <5% 5 5% to <10% 10 10% to <20% 20 20% to <30% 30 ш30% Age SBP (years) (mmHg) 22 24 27 29 32 28 30 33 36 39 16 17 17 18 19 22 23 24 25 26 180 18 20 22 24 26 23 25 28 30 33 14 14 15 15 16 19 20 20 21 22 160-179 70-74 15 17 18 20 22 19 21 23 25 28 12 12 13 13 14 16 17 17 18 19 140-159 12 14 15 16 18 16 17 19 21 23 10 10 11 11 12 14 14 15 15 16 120-139 10 11 12 14 15 13 14 16 17 19 8 9 9 9 10 12 12 12 13 14 <120 18 19 21 23 26 23 26 28 31 34 12 13 14 14 15 19 19 20 21 23 180 14 16 17 19 21 19 21 23 25 28 10 11 11 12 13 15 16 17 18 19 160-179 65-69 11 12 14 15 17 15 17 19 21 23 9 9 9 10 10 13 13 14 15 16 140-159 9 10 11 12 14 12 14 15 17 19 7 7 8 8 9 11 11 12 12 13 120-139 7 8 9 10 11 10 11 12 14 15 6 6 6 7 7 9 9 10 10 11 <120 14 15 17 19 21 19 21 24 27 30 10 10 11 11 12 15 16 17 18 20 180 11 12 13 15 17 15 17 19 21 24 8 8 9 9 10 13 13 14 15 16 160-179 60-64 8 9 10 12 13 12 13 15 17 19 6 7 7 8 8 10 11 12 12 13 140-159 7 7 8 9 10 9 11 12 14 15 5 5 6 6 7 8 9 9 10 11 120-139 5 6 6 7 8 7 8 9 11 12 4 4 5 5 5 7 7 8 8 9 <120 11 12 13 15 17 16 18 20 23 26 7 8 8 9 10 13 14 15 16 17 180 8 9 10 11 13 12 14 16 18 20 6 6 7 7 8 10 11 12 13 14 160-179 55-59 6 7 8 9 10 10 11 12 14 16 5 5 5 6 6 8 9 9 10 11 140-159 5 5 6 7 8 7 8 9 11 13 4 4 4 5 5 6 7 8 8 9 120-139 4 4 5 5 6 6 6 7 8 10 3 3 3 4 4 5 6 6 7 7 <120 8 9 10 12 13 13 15 17 19 22 6 6 7 7 8 11 12 12 14 15 180 6 7 8 9 10 10 11 13 15 17 4 5 5 6 6 8 9 10 11 12 160-179 50-54 5 5 6 7 8 8 9 3 4 4 5 6 6 6 7 9 10 3 3 3 3 4 5 5 6 7 7 120-139 3 3 3 4 5 4 5 6 7 8 2 2 2 3 3 4 4 5 5 6 <120 6 7 8 9 11 11 12 14 16 19 4 5 5 6 6 9 10 11 12 13 180 5 5 6 7 8 8 9 11 12 14 3 4 4 4 5 7 7 8 9 10 160-179 45-49 3 4 4 5 6 6 7 8 9 11 2 3 3 3 4 5 6 6 7 8 140-159 2 3 3 4 4 4 5 6 7 8 2 2 2 2 3 4 4 5 5 6 120-139 2 2 2 3 3 3 4 4 5 6 1 2 2 2 2 3 3 4 4 5 <120 5 6 6 7 9 9 10 12 14 16 3 4 4 4 5 7 8 9 10 11 180 3 4 4 5 6 6 7 9 10 12 2 3 3 3 4 5 6 7 8 8 160-179 40-44 2 3 3 4 5 5 5 6 7 9 2 2 2 2 3 4 5 5 6 6 140-159 2 2 2 3 3 3 4 5 5 7 1 1 2 2 2 3 3 4 4 5 120-139 1 1 2 2 2 2 3 3 4 5 1 1 1 1 2 2 3 3 3 4 <120 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 WomenMen People without Diabetes Total cholesterol (mmol/l) Non-smoker Smoker Non-smoker Smoker < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 < 4 4 - 4 . 9 5 - 5 . 9 6 - 6 . 9 7 2 1 4 3 5 4 - 4 . 9 6 6 Using the WHO CVD risk (lab-based) charts Eastern Sub-Saharan Africa (Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Mozambique, Malawi, Rwanda, Somalia, United Republic of Tanzania, Uganda, Zambia) 1 2 3 4 5 6 7 8 Select the regional chart covering your country. Countries included in each region can be found in +($576502'8/( Select the section of the chart as relevant for people with or without diabetes Select men or women table as appropriate Select smoker or non-smoker box Select age group :LWKLQWKHVHOHFWHGER[ȴQGWKHFHOOZKHUHWKHLQGLYLGXDOȇVV\VWROLF blood pressure (SBP) and total blood cholestorol intersect The colour of the cell indicates the 10-year risk of a fatal or non-fatal cardiovascular event. The value within the cell is the risk percentage. Colour coding is based on the grouping as indicated in the box Counsel, treat and refer according to risk level Green < 5% Yellow 5% – < 10% Orange 10% – < 20% Red 20% – < 30% 'HHSUHG Ȳ * Fasting plasma glucose ≥ 7.0 mmol/L (126 mg/dl), or 2-h plasma glucose ≥ 11.1 mmol/L (200 mg/dl), or HbA1c ≥ 6.5% , or known diabetes ** Cholesterol values are to be entered in the chart as mmol/L . To convert cholesterol mg/dl to mmol/L, multiply by 0.02586 Example: TC : 200 mg/dl x 0.02586 = 5.172 mmol/L 12 TREAT mRISK LEVEL: m Counsel on diet (which includes lipid-lowering diet), physical activity, smoking cessation and avoiding harmful use of alcohol TREAT COUNSEL Consider drug treatment if SHUVLVWHQW%3ȲPP+J Consider if SHUVLVWHQW%3Ȳ PP+J Give a statin &RQVLGHULISHUVLVWHQW%3Ȳ PP+J (consistent with national policy) $QWLK\SHUWHQVLYH GUXJV &&%7KLD]LGH $&(ΖRU$5% /LSLGORZHULQJGUXJV 6WDWLQV 2.1 CARDIOVASCULAR DISEASES WHO PEN 13 Follow-up every 3 months If there is no reduction in cardiovascular risk after 6 months of follow up refer to next level FOLLOW-UP Follow up every 3 months until targets are met, then 6–9 months thereafter Follow up in 12 months if treatment not initiated Follow-up every 3–6 months )RUDGGLWLRQDODFWLRQVIRUSHRSOHZLWK'0 UHIHUWR6HFWLRQ'LDEHWHV Diagnosis and management of type 2 diabetes (HEARTS-D). https://www.who.int/publications-detail/who-ucn-ncd-20.1 Some individuals are at very high cardiovascular risk because they have already experienced a cardiovascular event or have very high levels of individual risk factors. Risk stratifi cation is not necessary for making treatment decisions for these individuals as they belong to the high risk category; all of them need intensive lifestyle interventions and appropriate drug therapy. Risk prediction charts may tend to underestimate cardiovascular risk in such individuals, who include the following: patients with established angina pectoris, coronary heart disease, myocardial infarction, transient ischaemic attacks, stroke, or peripheral vascular disease, or who have had coronary revascularization or carotid endarterectomy; those with left ventricular hypertrophy (shown on electrocardiograph) or hypertensive retinopathy (grade III or IV); individuals without established CVD who have a total cholesterol ≥ 8 mmol/L (320 mg/dl) or low-density lipoprotein (LDL) cholesterol ≥ 6 mmol/L (240 mg/ dl) or TC/HDL-C ratio > 8; individuals without established CVD who have persistent raised blood pressure (> 160–170/100–105 mmHg); For individuals with blood pressure above 140/90 mmHG, management may be provided as per nationally agreed protocols. patients with type 1 or 2 diabetes, with overt nephropathy or other signifi cant renal disease; patients with known renal failure or renal impairment. WHEN CAN TREATMENT DECISIONS BE MADE WITHOUT THE USE OF WHO CVD RISK-PREDICTION CHARTS? 14 Blood pressure measurement and control is particularly important in adults who: HYPERTENSION • have had a prior heart attack or stroke • have diabetes • have chronic kidney disease (CKD) • are obese • use tobacco • have a family history of heart attack or stroke Measuring blood pressure is the only way to diagnose hypertension, as most people with raised blood pressure have no symptoms. (HFWLYHWUHDWPHQWDOJRULWKPVIRUK\SHUWHQVLRQDUHGHSHQGHQWRQ accurate blood pressure measurement. The following advice should be followed for measuring blood pressure: Although at the initial evaluation it is preferable to measure blood pressure in both arms and use the arm with the higher reading thereafter, this may not be practical in a busy primary care environment. The patient should be sitting with back supported, legs uncrossed, empty bladder, relaxed for 5 minutes and not talking. For persons who are getting their blood pressure measured IRUWKHȴUVWWLPHLWLVSUHIHUDEOHWRWDNHDWOHDVWWZRUHDGLQJV and to use the second reading. 8VHWKHDSSURSULDWHFXVL]HQRWLQJWKHOLQHVRQWKHFXWR ensure that it is positioned correctly on the arm. (If the arm FLUFXPIHUHQFHLV!FPXVHODUJHFX Measuring blood pressure ASSESS 2.1 CARDIOVASCULAR DISEASE WHO PEN 15 V\VWROLFEORRGSUHVVXUHRQERWKGD\VLVȲPP+Jand/or GLDVWROLFEORRGSUHVVXUHRQERWKGD\VLVȲ PP+J In general, hypertension is diagnosed if, on two YLVLWVRQGLHUHQWGD\V DIAGNOSE NO TREAT TREATMENT GOAL NON-PHARMACOLOGICAL PHARMACOLOGICAL For most patients, blood pressure is considered controlled when SBP < 140 mmHg and DBP < 90 mmHg. However, for patients with diabetes or a high risk of CVD, certain guidelines recommend lower targets: SBP < 130 mmHg and DBP < 80 mmHg. Lifestyle counselling (on healthy diet, physical activity, the harms of tobacco use, and harmful use of alcohol) is a critical component of good hypertension management and is often recommended DVDȴUVWVWHSIRUSDWLHQWVZLWKEORRG pressure of SBP 130–139 mmHg and /or DBP 80–89 mmHg who do not have other CVD risk factors There are four main classes of antihypertensive medications: 1. angiotensin converting enzyme (ACE) inhibitors 2. angiotensin receptor blockers (ARB) 3. calcium channel blockers (CCB) 4. thiazide and thiazide-like diuretics Any of these four classes of antihypertensive medication PD\EHXVHGXQOHVVWKHUHDUHVSHFLȴFFRQWUDLQGLFDWLRQV Proper treatment of hypertension usually requires a combination of hypertension medications. Sample protocols for treatment of hypertension are available in (PRGXOHRIWKH+($576WHFKQLFDOSDFNDJH https://apps.who.int/iris/bitstream/handle/10665/260421/ WHO-NMH-NVI-18.2-eng.pdf?sequence=1 16 17 DIABETES TYPE 2 DIABETES MANAGEMENT 2.2 18 DIABETES A healthy diet to achieve or maintain normal body weight and regular physical activity are the mainstay of diabetes management. All patients should be advised on avoidance of tobacco use and harmful use of alcohol. Management of risk factors and referral as appropriate Oral hypoglycaemic agents for type 2 diabetes, if glycaemic WDUJHWVDUHQRWDFKLHYHGZLWKOLIHVW\OHPRGLȴFDWLRQ 0HWIRUPLQFDQEHXVHGDVWKHȴUVWOLQHPHGLFLQH Other classes of antihyperglycaemic agents, added to metformin if glycemic targets are not met Statins are recommended for all people with type 2 diabetes older than 40 years, but only if this does not negatively impact access to glucose-lowering and blood pressure lowering medication. Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys, and nerves. TREATMENT OPTIONS Regular (3–6 months) visual inspection and examination of patients’ feet by trained personnel for the detection of risk factors for ulceration (assessment of foot sensation, palpation of foot pulses, inspection for any foot deformity, inspection of footwear). PREVENTION OF COMPLICATIONS* FOOT COMPLICATIONS: Optimal glycaemic control Angiotensin-converting enzyme inhibitor for persistent albuminuria PREVENTION OF ONSET AND PROGRESSION OF CHRONIC KIDNEY DISEASE: Screening for diabetic retinopathy and referral for laser treatment if indicated Optimal glycaemic control and blood pressure control PREVENTION OF ONSET AND PROGRESSION OF DIABETIC RETINOPATHY: Optimal glycaemic control PREVENTION OF ONSET AND PROGRESSION OF NEUROPATHY: +($576Ȃ'PRGXOHRQGLDJQRVLVDQGPDQDJHPHQWRIW\SHGLDEHWHV https://www.who.int/publications-detail/who-ucn-ncd-20.1 MORE INFORMATION WHO PEN2.2 DIABETES 19 Test adults who are symptomatic, or aged >40 years and who are overweight (BMI > 25), or obese (BMI > 30), or follow national guidelines Polyuria (excessive passing of urine) Polydipsia (excessive thirst) Unexplained weight loss Polyphagia (excessive hunger) Vision changes Fatigue Symptoms Acute metabolic deterioration and/or acute presentation of chronic complications Severe dehydration Kussmaul’s respiration Altered level of consciousness Complications (acute coronary disease, stroke, kidney disease, vision loss, diabetic foot) Signs ASSESS Ȃ+LVWRU\RIJHVWDWLRQDOGLDEHWHVRU SUHHFODPSVLD Ȃ+LVWRU\RI&9'K\SHUWHQVLRQG\VOLSLGDHPLD Ȃ2YHUZHLJKWREHVLW\ Ȃ3K\VLFDOLQDFWLYLW\ Ȃ+DYLQJDȴUVWGHJUHHUHODWLYHZLWKGLDEHWHV RISK FACTORS 20 Fasting plasma glucose (FPG) is the most practical test for low-resource settings, given its low cost. HbA1c can also be used, but is more costly. Plasma glucose 2 hours after a 75 g oral glucose load (OGTT) can also be used to screen for and diagnose diabetes, but is less practical and more costly. If patient is not fasting and has symptoms, a random plasma glucose (RPG) test can also be performed. It is the least accurate of the diagnostic WHVWVΖWLVXVHIXOWRFRQȴUPWKHGLDJQRVLVLQSHUVRQ with symptoms; however, a negative test does not rule out the diagnosis of diabetes. DIAGNOSE TEST mmol/L mg/dl mmol/L % Fasting plasma glucose (FPG)a,b Ȳ Ȳ Random plasma glucose (RPG)b Ȳ Ȳ Haemoglobin A1c Ȳ Ȳ 3ODVPDJOXFRVHKRXUVDIWHUDJ oral glucose load-OGTTb Ȳ Ȳ a Fasting: no food and only water for 8–14 hours before the test b Point of care devices can be used in diagnosing diabetes if laboratory services are not available. WHO PEN2.2 DIABETES 21 TREAT TREATMENT GOAL PHARMACOLOGICAL NON-PHARMACOLOGICAL +E$F LVJHQHUDOO\FRQVLGHUHG to be adequate glycaemic control If HbA1c is not available, fasting SODVPDJOXFRVH )3* PPRO/ or < 126 mg/dl) MetforminLVUHFRPPHQGHGDVWKHȴUVWOLQHPHGLFLQH in the treatment of diabetes. Sulfonylurea (e.g. gliclazide) is recommended as the second-line treatment, and human insulin as the third-line treatment. Patients may require two or three medicines. Although there are other medicine classes usually used as second- and third-line treatment, including thiazolidinediones (TZDs), DPP-4 inhibitors, SGLT2 inhibitors, and GLP-1 receptor agonists, these medicines tend to be more costly than metformin, sulfonylurea and insulin, with currently limited evidence of superior HHFWLYHQHVV7KH\PD\KRZHYHUEHFRQVLGHUHGLQWKH rare cases when treatment with metformin, sulfonylurea, and insulin is not possible. Insulin treatment should be introduced and monitored according to national practices. NOTE: Hypertension treatment is indicated when SBP ȲDQGRU'%3Ȳ6WDWLQVDUHUHFRPPHQGHGIRUDOO people with type 2 diabetes older than 40 years, but only if this does not negatively impact access to glucose- lowering and blood pressure-lowering medication. Patients should receive counselling and support on lifestyle change including diet, physical activity and smoking cessation at the time of diagnosis, then annually and whenever changes in treatment occur. *URXSHGXFDWLRQLVHHFWLYHDQGOHVVFRVWO\WKDQ individual programmes See following pages for detailed management of type 2 diabetes 22 TREAT MANAGEMENT OF TYPE 2 DIABETES YES FPG/RPG > 18 mmol/L (325 mg/dl) '1(õNNPM-(126mg/dl) and < 18 mmol/L (325 mg/dl) 31(õNNPM- NHEM BOE NNPM- NHEM OR REASSESS IN 3 MONTHS Counsel on diet and physical activity Counsel on diet and physical activity and adherence (at all visits) If goal not achieved BEGIN METFORMIN 500 mg 1 x daily. REFER to higher- level of care If goal not achieved Increase dose to 1000 mg 1x daily REASSESS EVERY 3 MONTHS TEST urine ketones If ketonesȲ &RXQVHORQGLHWPRGLȴFDWLRQ physical activity and adherence to medicines BEGIN gliclazide 80 mg 2 x daily If ketones REASSESS IN 3-5 DAYS WHO PEN2.2 DIABETES 23 Counsel on hypoglycaemia at all subsequent visits If goal not achieved ADD gliclazide 80 mg 1 x daily If goal not achieved, despite adherence to medication healthy diet and physical activity REFER to higher-level health care facility for starting insulin t i r-l l lt r f ilit f r t rti i li * YES If goal not achieved Increase dose to 1000 mg 2 x daily If goal not achieved Increase dose to 80 mg 2 x daily REFER to higher level of care Continue gliclazide, diet and physical activity NO IMPROVEMENT If goal not achieved REFER to higher-level of care REASSESS IN 2-3 MONTHS IMPROVEMENT ΖIWKH\DUHPRUHDRUGDEOHWKDQLQVXOLQ'33LQKLELWRUV6*/7LQKLELWRUVRUSORJOLWD]RQHFDQEHXVHG before insulin in cases of treatment failure with metformin and gliclazide. Introduce and titrate insulin treatment according to local practices. PPRO/ PJGO PPRO/ PJGO PPRO/ PJGO Consider less stringent glycaemic control in patients with frequent severe hypoglycaemia, complications, serious comorbidities and/or limited life expectancy REASSESS EVERY 3 MONTHS 24 COMPLICATIONS WHO PEN2.2 DIABETES SEVERE HYPOGLYCAEMIA OR SIGNS (plasma glucose < 50 mg/dl or 2.8 mmol/L) If conscious, give a sugar-sweetened drink If unconscious, give 20–50 ml of 50% glucose (dextrose) IV over 1–3 minutes SEVERE HYPERGLYCAEMIA OR SIGNS AND SYMPTOMS (plasma glucose > 18 mmol/L (325 mg/dl) and urine ketone 2+) Set up intravenous drip 0.9% NaCl 1 litre in 2 hours; continue at 1 litre every 4 hours REFER to hospital Measure blood pressure at every scheduled visit, review medication as per hypertension protocol REFER for dilated-pupil retinal exam upon diagnosis and every 2 years thereafter, or as per ophthalmologist recommendation Examine feet for ulcers at every visit REFER to higher level of care if ulcer present Assess risk of lower limb amputation annually (foot pulses, sensory neuropathy by monofi lament, presence of healed or open ulcers, calluses) REFER to higher level of care if ulcer present or pulse absent Test for proteinuria annually – REFER to higher level of care if positive MANAGEMENT OF ACUTE COMPLICATIONS SCREENING FOR CHRONIC COMPLICATIONS 25 When diabetes is diagnosed, monitor glycaemic control every 3 months until diabetes is controlled, then every 6 months after that. HbA1c is the most accurate measurement of long-term glycaemic control and represents the average blood glucose over the previous two to WKUHHPRQWKV+E$F LVJHQHUDOO\FRQVLGHUHG to be adequate glycaemic control. In people with frequent severe hypoglycaemia, severe complications and low life-expectancy, the goal for HbA1c could be relaxed, e.g. to <8%. )DVWLQJSODVPDJOXFRVH )3* PPROORU PJGO can also be used to monitor control when HbA1c testing is not available. FOLLOW UP 5HIHUWRKLJKHUOHYHORIFDUHLIJRDOLVQRWDFKLHYHGLQPRQWKVLINHWRQHV DUHDQGLIWKHUHLVQRLPSURYHPHQWLQXULQHNHWRQHVDIWHUSKDUPDFRORJLFDO LQWHUYHQWLRQGLHWDQGH[HUFLVHPRGLȴFDWLRQ 26 27 2.3 CHRONIC RESPIRATORY DIEASES MANAGEMENT OF ASTHMA, MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) 28 CHRONIC RESPIRATORY DISEASES Chronic respiratory diseases (CRDs) are chronic diseases of the airways and other structures of the lung. WHO PEN focuses particularly on bronchial asthma and chronic obstructive pulmonary disease (COPD), which are PDMRUSXEOLFKHDOWKSUREOHPVDFFRXQWLQJIRUDVLJQLȴFDQW burden of morbidity and mortality in low- and middle- income countries. https://apps.who.int/iris/bitstream/handle/10665/133525/ 9789241506557_eng.pdf?sequence=1 IMPLEMENTATION TOOLS: PACKAGE OF ESSENTIAL NONCOMMUNICABLE (PEN) DISEASE INTERVENTIONS FOR PRIMARY HEALTH CARE IN LOW-RESOURCE SETTINGS WHO PEN2.3 CHRONIC RESPIRATORY DISEASES 29 30 Previous diagnosis of asthma Symptoms since childhood or early adulthood History of hayfever, eczema and/or allergies Intermittent symptoms with asymptomatic periods in between Symptoms worse at night or early morning Symptoms triggered by respiratory infection, exercise, weather changes or stress Symptoms respond to salbutamol Previous diagnosis of COPD History of heavy smoking, i.e. > 20 cigarettes per day for > 15 years History of heavy and prolonged exposure to burning fossil fuels in an enclosed space, or high exposure to dust in an occupational setting Symptoms started in middle age or later (after age 40) Symptoms worsened slowly over a long period of time Long history of daily or frequent cough and sputum production starting before shortness of breath Symptoms that are persistent with little day-to-day variation PATIENT PRESENTS WITH FRXJKGLɝFXOWEUHDWKLQJWLJKWFKHVWDQGRUZKHH]LQJ DIAGNOSIS OF ASTHMA LIKELY DIAGNOSIS OF COPD LIKELY ASSESS WHO PEN2.3 CHRONIC RESPIRATORY DISEASES 31 0HDVXUHSHDNH[SLUDWRU\ȵRZUDWH 3()5 *LYHWZRSXVRIVDOEXWDPRODQGPHDVXUHDJDLQDIWHUPLQXWHV COPD LIKELYASTHMA LIKELY 20% < 20% ΖIWKH3()5LPSURYHVE\ DIAGNOSE 32 MANAGEMENT OF ASTHMA ΖVWKHDVWKPDZHOOFRQWUROOHG" YES NO exhibits daytime asthma symptoms and uses a beta agonist one or two times a week; exhibits night time asthma symptoms one or two times per month puts no or only minimal limitations on daily activities; has had no severe exacerbation (i.e. requiring oral steroids or admission to hospital within a month); a PEFR, if available, above 80% predicted. TREAT Ask if the patient exhibits ALL of the following: Inhaled salbutamol prn 6WHSZLVHDSSURDFK 3KDUPDFRORJLFDODSSURDFK 1RQSKDUPDFRORJLFDODSSURDFK 1 This should be advised in all patients to help in better control of the disease. Exposure prevention – Smoking cessation and avoid exposure to passive smoke – Avoid asthma triggers if known – $YRLGGXVW\DQGVPRNHȴOOHGURRPV – Avoid drugs like NSAIDs and beta blockers NO ASSESS SYMPTOMS OF BRONCHIAL ASTHMA – Cough Ȃ'LɝFXOWEUHDWKLQJ These symptoms are episodic or seasonal, vary over time and intensity and are worse during night and early morning – Chest tightness – Wheezing YES WHO PEN2.3 CHRONIC RESPIRATORY DISEASES 33 At each step, check the patient’s adherence to treatment and observe their inhaler technique Referral for specialist when: asthma remains poorly controlled the diagnosis of asthma is uncertain regular oral prednisolone is required to maintain control Inhaled salbutamol prn plus low-dose inhaled EHFORPHWDVRQHVWDUWLQJZLWKƉJWZLFHGDLO\IRU DGXOWVDQGƉJRQFHRUWZLFHGDLO\IRUFKLOGUHQ Patient and family education Key educational messages include: The importance of physical activity and regular exercises Information on the reversible nature of the illness, and that asthma can be controlled but may need continuous therapy and regular follow up 5DWLRQDOHIRULQKDOHGGUXJVGLHUHQWLQKDOHU devices and inhalation techniques Information that inhalers are not habit-forming, and are safe and better than tablets or syrup Patients should to carry their device at each follow up visit The need for adherence to prescribed drugs to control the condition Advice regarding dealing with triggers/precipitants 2 Same as step 2, but give higher doses of inhaled EHFORPHWDVRQHƉJRUƉJWZLFHGDLO\ 3 Add low-dose oral theophylline to Step 3 treatment (assuming long-acting beta agonists and leukotriene antagonists are not available) 4 Add oral prednisolone, but in the lowest dose possible to control symptoms (nearly always less than 10 mg daily) 5 FOLLOW UP 5HYLHZDVWKPDFRQWUROHYHU\ȂPRQWKVDQGPRUH IUHTXHQWO\ZKHQWUHDWPHQWKDVEHHQFKDQJHGRUDVWKPD LVQRWZHOOFRQWUROOHG – Symptoms are present only during the day (daytime asthma) – Use of salbutamol is limited to no more than twice a week – Night symptoms occur fewer than twice a month – No or minimal limitation of daily activities – No severe exacerbations within a month – PEFR > 80% of predicted $VWKPDLVFRQWUROOHGZKHQ 34 MANAGEMENT OF EXACERBATION OF ASTHMA ? YES NO Very severe Altered conscious level, exhaustion, arrhythmia, hypotension, cyanosis, silent FKHVWSRRUUHVSLUDWRU\HRUW SpO2 < 92% TREATFirst-line treatment ASSESS SEVERITY 3UHGQLVRORQHȂPJIRUȴYHGD\VIRUDGXOWVDQG mg per kg for three days for children, or longer, if necessary, until they have recovered 1 Severe PEFR 33–50% best or predicted Respiratory rate more than 25 breaths/minute (adult) +HDUWUDWHȲEHDWVPLQXWH DGXOW Inability to complete sentences in one breath FACTORS THAT MAY TRIGGER OR WORSEN ASTHMA – indoor allergens (for example house dust PLWHVLQEHGGLQJFDUSHWVDQGVWXHG furniture, pollution and pet dander) – outdoor allergens (such as pollens and moulds) – tobacco smoke – chemical irritants in the workplace – cold air – extreme emotional arousal such as anger or fear – physical exercise – certain medications, such as aspirin and RWKHUQRQVWHURLGDQWLLQȵDPPDWRU\GUXJV and beta-blockers WHO PEN2.3 CHRONIC RESPIRATORY DISEASES 35 Second-line treatment Reassess at intervals depending on severity Regarding treatment, ensure that the patient or parent: Knows what to do if the asthma gets worse 8QGHUVWDQGVWKHEHQHȴWRIXVLQJLQKDOHUVUDWKHU than tablets, and why adding a spacer is helpful Is aware that inhaled steroids take several days or HYHQZHHNVWREHIXOO\HHFWLYH Regarding prevention Avoid cigarette smoke and trigger factors for asthma, if known $YRLGGXVW\DQGVPRNHȴOOHGURRPV Avoid occupations that involve agents capable of causing occupational asthma Reduce dust as far as possible by using damp cloths to FOHDQIXUQLWXUHVSULQNOLQJWKHȵRRUZLWKZDWHUEHIRUH sweeping, cleaning blades of fans regularly and minimizing soft toys in the sleeping area It may help to eliminate cockroaches from the house (when the patient is away) and shake and expose mattresses, pillows, blankets, etc. to sunlight Increase frequency of dosing via an metered dose inhaler and spacer or by nebulizer, or give salbutamol by continu- ous nebulization at 5–10 mg per hour, if appropriate nebulizer available For children, nebulized ipratropium, if available, can be added to nebulized salbutamol Salbutamol in high doses by metered dose LQKDOHUDQGVSDFHU HJIRXUSXVHYHU\ 20 minutes for 1 hour) or by nebulizer Oxygen, if available, and if oxygen saturation levels are low (below 90%) 2 3 COUNSEL IF NOT RESPONDING 36 MANAGEMENT OF COPD ? MODERATE EXACERBATION OF COPD SEVERE YES If breathless at rest TREAT ASSESS SEVERITY Antibiotics should be given for all exacerbations with evidence of infection ΖQKDOHGVDOEXWDPROWZRSXVDVUHTXLUHG up to four times daily1 If breathless with normal activity Measure PEFR and oxygen saturation, if possible SYMPTOMS SUGGESTIVE OF COPD – Breathlessness (or a "need for air") – Chronic cough – Sputum (mucous) production * Depending on the local risk of infection with Tuberculosis, pulmonary TB should always be suspected if cough lasts more than 2 weeks. WHO PEN2.3 CHRONIC RESPIRATORY DISEASES 37 Advice to patients and families cook with wood or carbon outside the house, if possible, or build an oven in the kitchen with a chimney that vents the smoke outside stop working in areas with occupational dust or high air pollution – using a mask may help, but it needs to have an appropriate design and provide adequate respiratory protection ensure they understand that smoking and indoor air pollution are the major risk factors for COPD – therefore, patients with COPD must stop smoking and avoid dust and tobacco smoke keep the area where meals are cooked well ventilated by opening windows and doors For severe exacerbations, give oral predniso- lone 30–40 mg for around seven days Give high doses of inhaled salbutamol by nebulizer or metered dose inhaler with spacer HJIRXUSXVHYHU\PLQXWHVIRUKRXU or by nebulizer Oxygen, if available, should be given through a mask that limits the concentration to 24% or 28% If symptoms are still troublesome, consider low-dose oral theophylline If ipratropium inhalers are available, they can be used instead of or added to salbutamol, but they are more expensive 2 3 COUNSEL 38 39 CANCER EARLY DIAGNOSIS EARLY DIAGNOSIS CERVICAL CANCER BREAST CANCER 2.4 40 CANCER Identify presenting features of cancer and refer WRQH[WOHYHOIRUFRQȴUPDWLRQRIGLDJQRVLV EARLY DIAGNOSIS Guide to cancer early diagnosis https://www.who.int/cancer/publications/ cancer_early_diagnosis/en/ Comprehensive cervical cancer control: A guide to essential practice CERVICAL CANCER http://www.who.int/reproductivehealth/publications/ cancers/cervical-cancer-guide/en/ Cervical cancer is the fourth most frequent cancer among women. Primary prevention through vaccination against +39HHFWLYHVFUHHQLQJDQGHDUO\GLDJQRVLVDQGWLPHO\ quality treatment of invasive cancers can reduce incidence and mortality rates. Mammography position paper BREAST CANCER https://www.who.int/cancer/publications/mammography_screening/en/ Breast cancer is the most frequent cancer among women. There are two early detection strategies for breast cancer: early diagnosis and screening. 41 ASSESS FOR EARLY DIAGNOSIS common cancer signs and symptoms &DQFHUV\PSWRPVFDQEHQRQVSHFLȴF\HWLWLVLPSRUWDQWWKDWDQ\ȊUHGȵDJȋV\PSWRPV are recognized by providers and investigated further. SITE OF CANCER COMMON SYMPTOMS* Breast Cervix Colon, rectum Oral cavity Naso-pharynx Larynx Lump in the breast, asymmetry, skin retraction, recent nipple retraction, blood stained nipple discharge, eczematous changes in areola Post-coital bleeding, excessive vaginal discharge Change in bowel habits, unexplained weight loss, anaemia, blood in the stool (rectal cancer) White lesions (leukoplakia) or red lesions (erythroplakia), growth or ulceration in mouth Nosebleed, permanent bocked nose, deafness, nodes in upper part of the neck Persistent hoarseness of voice Stomach Skin melanoma Other skin cancers Urinary bladder Prostate Retinoblastoma Testis Upper abdominal pain, recent onset of indigestion, weight loss Brown lesion that is growing with irregular borders or areas of patchy colouration that may itch or bleed Lesion or sore on skin that does not heal Pain, frequent and uneasy urination, blood in urine Difficulty (long time) in urination, frequent nocturnal urination White spot in the pupil, convergent strabismus (in a child) Swelling of one testicle (asymmetry) SITE OF CANCER COMMON SYMPTOMS* Common symptoms and signs that may be due to cancer. These common symptoms may be due to cancer or due to a different medical condition. People with these symptoms should seek medical attention without delay. * 42 WHO PEN2.4 CANCER EARLY DIAGNOSIS TREAT Primary care providers should explain to patients that symptoms may be related to cancer and that timely UHIHUUDOLVQHFHVVDU\:KHQGLVFXVVLQJFDQFHUPDQDJHPHQWSODQVHRUWVVKRXOGEHPDGHWRLQFOXGHWKH patient’s social support system and a second consultation may be required. Clear steps to the next level of care VKRXOGEHSURYLGHGWRPLQLPL]HORVVWRIROORZXS7RIXUWKHUUHGXFHWKLVULVNVWDFRXOGFRQWDFWSDWLHQWVZLWK cancer at predesignated intervals or consider a patient navigation programme. Finally, primary care providers VKRXOGDOVRFRXQVHOSDWLHQWVRQULVNUHGXFWLRQVXFKDVEHKDYLRXUDOPRGLȴFDWLRQ HJVPRNLQJFHVVDWLRQ COUNSEL 7UHDWPHQWIRUFDQFHULVSURYLGHGDWWHUWLDU\DQGVRPHWLPHVVHFRQGDU\KHDOWKFDUHIDFLOLWLHVZKHUH DSSURSULDWHLQIUDVWUXFWXUHLVDYDLODEOH$WWKHSULPDU\FDUHOHYHOWUHDWPHQWLVOLPLWHGWRWUHDWPHQWIRU SUHFDQFHURXVOHVLRQVRIWKHFHUYL[7KLVFDQLQFOXGHFU\RWKHUDS\WKHUPDOFRDJXODWLRQDQGRUORRS HOHFWURVXUJLFDOH[FLVLRQSURFHGXUH /((3 DFFRUGLQJWRWKHORFDOFRQWH[WDQGQDWLRQDOSURWRFROV 43 Follow-up services at the primary care level must be coordinated with providers who diagnose and treat cancer. Information transfer between providers (e.g. pathology unit and primary care provider) is necessary to inform decision-making in cancer management. A direct link between primary care facilities and higher levels of care improves timely access and patient adherence to care. FOLLOW UP 44 Assess signs and symptoms (i.e. history, intensity, duration, progression) Identify relevant risk factors: age (aged 30 years or above) Speculum examination 'LHUHQWLDOGLDJQRVLV DERUWLRQLQSUHPHQRSDXVDO women, infections (e.g. chlamydia, gonorrhoea), JHQLWDOXOFHUVFHUYLFDOLQȵDPPDWLRQXWHULQHSRO\SV dysfunctional uterus hemorrhage, endometrial or vaginal cancer ASSESS LIKELIHOOD Where women present with any of the following: $EQRUPDOYDJLQDOEOHHGLQJ LHDIWHUFRLWXVEHWZHHQ PHQVWUXDOSHULRGVSRVWPHQRSDXVH )RXOVPHOOLQJGLVFKDUJH 3DLQGXULQJYDJLQDOLQWHUFRXUVH CERVICAL CANCER WHO PEN2.4 CANCER EARLY DIAGNOSIS 45 NO $UHWKHDERYHV\PSWRP V DVVRFLDWHGZLWKSDOSDEOHSHOYLFPDVV ZLWKSHUVLVWHQWORZEDFNRUDEGRPLQDOSDLQ" REFER IMMEDIATELY TO NEXT LEVEL NO &OLQLFDOO\GHWHFWHGFHUYLFDO JURZWKRUXOFHUDWLRQ" YES YES Follow obstetric and gynaecological guidelines as appropriate NOTE: Detailed information regarding cervical cancer assessment, diagnosis, treatment and follow-up is provided in the WHO Comprehensive cervical cancer control: A guide to essential practice (C4GEP). Referral of women with the above symptoms may lead to a diagnosis of “early invasive cervical cancer”, particularly in women aged 30 years or above. If condition is not manageable at PHC, or persists or worsens http://www.who.int/reproductivehealth/publications/cancers/ cervical-cancer-guide/en/ 46 Assess signs and symptoms (i.e. history, intensity, duration, progression) Identify relevant breast cancer risk factors (such as age, family history, previous history of breast cancer, chest irradiation) Clinical examination of both breasts, axillae and neck 'LHUHQWLDOGLDJQRVLV EHQLJQEUHDVWGLVHDVHV HJDGHQRPD adenosis, mastitis, abscess, etc.) ASSESS LIKELIHOOD Where women present with any of the following: A%UHDVWOXPSRUDQ\FKDQJHLQWKHVKDSHRUFRQVLVWHQF\RIWKHEUHDVW B%UHDVWOXPSWKDWHQODUJHVDQGRULVȴ[HGDQGKDUG C2WKHUEUHDVWSUREOHPV LHHF]HPDWRXVVNLQFKDQJHVQLSSOHUHWUDFWLRQ SHDXGȇRUDQJHXOFHUDWLRQXQLODWHUDOQLSSOHGLVFKDUJHȂSDUWLFXODUO\ EORRG\GLVFKDUJHOXPSLQWKHD[LOOD ZLWKRUZLWKRXWSDOSDEOHOXPS BREAST CANCER WHO PEN2.4 CANCER EARLY DIAGNOSIS 47 REFER IMMEDIATELY TO NEXT LEVEL 3UHVHQWLQJZLWKV\PSWRPA Referral of women with small breast lumps may lead to diagnosis of “early breast cancer” If symptoms B or C at follow-up NO YES $OVRSUHVHQWLQJZLWKUHOHYDQWULVN IDFWRUVRUV\PSWRPVB or C " ΖQYLWHIRUIROORZXSYLVLWDIWHU PHQVWUXDOSHULRG Age of woman< 30 > 30 https://www.who.int/cancer/publications/ cancer_early_diagnosis/en/ FOR MORE INFORMATION: GUIDE TO CANCER EARLY DIAGNOSIS 48 49 HEALTHY LIFESTYLE COUNSELLING HEALTH EDUCATION COUNSELLING ON CESSATION OF TOBACCO USE 2.5 50 HEALTHY LIFESTYLE COUNSELLING Counselling for healthy lifestyles involves guiding and supporting patients in making changes in certain behaviours to reduce the risk of NCDs https://apps.who.int/iris/bit- stream/handle/10665/260422/WHO-NMH-NVI-18.1-eng.pdf?se quence=1&isAllowed=y TECHNICAL PACKAGE FOR CARDIOVASCULAR DISEASE MANAGEMENT IN PRIMARY HEALTH CARE: HEALTHY-LIFESTYLE COUNSELLING. https://apps.who.int/iris/bitstream/handle/10665/112833/ 9789241506939_eng.pdf?sequence=1 A GUIDE FOR TOBACCO USERS TO QUIT WHO PEN2.5 HEALTHY LIFESTYLE COUNSELLING 51 STOP TOBACCO AND AVOID HARMFUL USE OF ALCOHOL Encourage all non-smokers not to start smoking Strongly advise all smokers to stop smoking and support them in their eff orts Individuals who use other forms of tobacco should be advised to quit Alcohol abstinence should be reinforced. People should not be advised to start taking alcohol for health reasons Advise patients not to use alcohol when additional risks are present, such as: – driving or operating machinery – pregnant or breast feeding – taking medications that interact with alcohol – medical conditions made worse by alcohol – diffi culties in controlling drinking ADHERE TO TREATMENT If the patient is prescribed medication: – teach the patient how to take it at home – explain the diff erence between medicines for long- term control (e.g. blood pressure) and medicines for quick relief (e.g. for wheezing) – tell the patient the reason for prescribing the medication Show the patient the appropriate dose Explain how many times a day to take the medication Label and package the tablets Check the patient’s understanding before the patient leaves the health centre Explain the importance of: – keeping an adequate supply of the medication – the need to take the medication regularly as advised even if there are no symptoms BE PHYSICALLY ACTIVE Progressively increase physical activity to moderate levels (such as brisk walking) at least 30 minutes per day on 5 days of the week Control body weight and avoid overweight by reducing high-calorie food and taking adequate physical activity EAT A HEART HEALTHY DIET Salt (sodium chloride) – Restrict to less than 5 grams (1 teaspoon) per day – Reduce salt when cooking, limit processed and fast foods Fruits and vegetables – 5 servings (400–500 g) of fruits and vegetable per day – 1 serving is equivalent to 1 orange, apple, mango, banana or 3 tablespoons of cooked vegetables Fatty food – Limit fatty meat, dairy fat and cooking oil (less than two tablespoons per day) – Replace palm and coconut oil with olive, soya, corn, rapeseed or saffl ower oil – Replace other meat with chicken (without skin) Fish – Eat fi sh at least 3 times per week, preferably oily fi sh such as tuna, mackerel, salmon EDUCATE YOUR PATIENT TO: Be physically active Eat a “heart healthy” diet Stop tobacco and avoid harmful use of alcohol Adhere to treatment 52 COUNSELLING ON CESSATION OF TOBACCO USE (5 As) 1. ASK 3 . ASSESS 4 . ASSIST 5 . ARRANGE 2 . ADVISE NO'R\RXXVHWREDFFR" $UH\RXZLOOLQJWRPDNHDTXLWDWWHPSWQRZ" Advise not to start tobacco use and to avoid secondhand exposure Promote motivation to quit Provide information on health hazards of WREDFFRDQGJLYHOHDȵHWWRWKHSDWLHQW Assist in preparing a quitting plan – Set quit date – Inform family and friends – Ask for their support At follow-up visit – Congratulate success and reinforce – If patient has relapsed, consider more intensive follow-up and support from family – Remove cigarettes/tobacco – Remove objects/articles that prompt you to smoke – Arrange follow up visit* YES Advise to quit in a clear, strong and personalized manner “Tobacco use increases the risk of developing a heart attack, stroke, lung cancer and respiratory diseases. Quitting tobacco use is the one most important thing you can do to protect your heart and health, you have to quit now.” NOYES Ideally a second follow-up visit is recommended within the same month and every month thereafter for 4 months and evaluation after 1 year. If not feasible, reinforce counseling whenever the patient is seen. * WHO PEN2.5 HEALTHY LIFESTYLE COUNSELLING 53 SELF-CARE SELF-CARE AMONG PATIENTS WITH CARDIOVASCULAR DISEASE, DIABETES OR RESPIRATORY DISEASES 2.6 54 IMPLEMENTATION TOOLS: PACKAGE OF ESSENTIAL NONCOMMUNICABLE (PEN) DISEASE INTERVENTIONS FOR PRIMARY HEALTH CARE IN LOW-RESOURCE SETTINGS SELF-CARE https://apps.who.int/iris/bitstream/handle/10665/133525/ 9789241506557_eng.pdf?sequence=1 All patients with NCDs can perform some level of self-care. WHO PEN2.6 SELF-CARE 55 SELF-CARE AMONG PATIENTS WITH CARDIOVASCULAR DISEASE, DIABETES OR RESPIRATORY DISEASE FIRST VISIT All patients with NCDs perform some level of self-care. Health workers can work to strengthen self-care strategies among these patients by following this protocol Conselling patients on self-care can be integrated into existing care structures All interactions with patients can be seen as opportunities to understand and improve patients' self-care strategies Strategies to improve adherence should form part of self-care for NCDs. Promoting self-care among patients with NCDs should take into account patients' beliefs and concerns DERXWPHGLFLQHVDQGWKHLUHHFWVRQDGKHUHQFH No single strategy to improve overall adherence is recommended over another. Health workers should use their skills, resources, and patient preferences to devise plans to improve adherence *URXSHGXFDWLRQSURJUDPPHVUDWKHUWKDQLQGLYLGXDOHGXFDWLRQPD\RHUDFRVWHHFWLYHVWUDWHJ\ to deliver education in low- and middle-income countries Identify opportunities to improve self-care Provide written or visual educational materials and training in self-care For self-care recommendations that require an action plan, agree on and provide a written or visual action plan FOLLOWING VISITS Check the patient’s progress If necessary and the patient wishes it, repeat the steps from WKHȴUVWYLVLW 56 CONDITION-SPECIFIC RECOMMENDATIONS ON SELF-CARE CARDIOVASCULAR DISEASES Raised blood pressure – Self-measurement to monitor blood pressure is recommended for the management of hypertension in appropriate patients where the aff ordability of the technology has been established. Heart failure – Appropriate patients could benefi t from being educated on the benefi ts of cardiac rehabilitation, and can be encouraged to undertake rehabilitation exercise in the home setting. Need for anticoagulation – Self-monitoring of blood coagulation and self- adjustment of dosage in patients receiving oral anticoagulation agents is recommended if aff ordable and according to an agreed action plan with a health professional. DIABETES Diabetes Type 1 and 2 – People with type 1 and type 2 diabetes on insulin should be off ered self-monitoring of blood glucose based on individual clinical need. Diabetes Type 1 – Self-monitoring and self-adjustment of dosage is recommended in type 1 diabetes according to an agreed action plan with a health professional. RESPIRATORY DISEASES Asthma and chronic obstructive pulmonary disease – Self-monitoring in asthma and COPD and self-adjustment of dosage is recommended according to an agreed action plan with a health professional. Chronic obstructive pulmonary disease – Appropriate patients may benefi t from being educated on the benefi ts of chronic obstructive pulmonary disease rehabilitation, and encouraged to undertake rehabilitation exercise. WHO PEN2.6 SELF-CARE 57 PALLIATIVE CARE PRACTICE POINTS FOR PALLIATIVE CARE 2.7 58 PALLIATIVE CARE https://apps.who.int/iris/bitstream/handle /10665/250584/ 9789241565417-eng.pdf?sequence=1 WHAT IS PALLIATIVE CARE ESTABLISHING PALLIATIVE CARE Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening LOOQHVVWKURXJKWKHSUHYHQWLRQDQGUHOLHIRIVXHULQJE\PHDQVRIHDUO\ LGHQWLȴFDWLRQDQGLPSHFFDEOHDVVHVVPHQWDQGWUHDWPHQWRISDLQDQG other problems, physical, psychosocial and spiritual. :+2'HȴQLWLRQRI3DOOLDWLYH&DUH KWWSV ZZZZKRLQWFDQFHUSDOOLDWLYHGHȴQLWLRQHQ Palliative care services can be established or expanded in a number of ways, depending on the local situation. For instance, a country may decide to begin by: – Setting up a palliative home-care service or integrating palliative home care into existing homecare services – Setting up a community-based palliative care service – Setting up a hospital-based palliative care service PLANNING AND IMPLEMENTING PALLIATIVE CARE SERVICES: A GUIDE FOR PROGRAMME MANAGERS. 59 PRACTICE POINTS FOR PALLIATIVE CARE Integrating palliative care and symptom relief into primary health care: a WHO guide for planners, implementers and managers https://apps.who.int/iris/bitstream/handle/10665/274559/9789241514477-eng.pdf?sequence=1&isAllowed=y TREAT AND REFER WHEN NECESSARY FOR: CONSIDER AND MANAGE PHYSICAL CARE NEEDS CARE PLANNING AND COORDINATION Pain (all types) Respiratory problems (dyspnoea, cough) Gastrointestinal problems (constipation, nausea, vomiting, dry mouth, mucositis, diarrhoea) Delirium Wounds, ulcers, skin rash and skin lesions Insomnia Identify support and resources available; develop and implement care plan based on patient's needs Provide care in the last weeks/days of life Facilitate the availability and access to medications (especially opioids) Identify the psychosocial/spiritual needs of professionals providing care (including self-care) COMMUNICATION ISSUES Communicate with patient, family and caregivers about diagnosis, prognosis, treatment, symptoms and their management, and issues relating to care in the last days/weeks of life Identify and set priorities with patient and family/caregivers Provide information and guidance to patients and caregivers according to available resources Psychological distress Anxiety 6XHULQJRIIDPLO\RUFDUHJLYHUV Spiritual needs and existential distress Depression Bereavement support for family/caregivers Fatique Anorexia Anaemia Drowsiness or sedation Sweating PSYCHOLOGICAL, EMOTIONAL, AND SPIRITUAL CARE NEEDS 60 61 ADAPTING WHO PEN 3 62 ADAPTING WHO PEN 3. ADAPTING WHO PEN A stepwise approach to implementation of WHO PEN is presented below. The key advantage of a stepwise approach, whether to pre- vention, surveillance or management, is that it off ers a framework to help countries get started and to focus on what is practical, taking into account the available human, fi nancial and other resources. ENGAGE STAKEHOLDERS DEVELOP A SERVICE DELIVERY MODEL FOR PHC Hold introductory meetings with stakeholders Obtain ministry of health endorsement Establish technical working group Identify demonstration site Develop a package of service delivery for NCDs based on WHO PEN 1 3 ASSESS CURRENT STATUS OF NCDs Desktop review of existing plans, policies (including public policies) and guidelines that contribute to NCD control in the country Assess the capabilities of the primary care health infrastructure Review and summarize exisiting NCD services at all levels of the health system Conduct a strengths, weaknesses, opportunities, threats (SWOT) analysis 2 63 REVIEW AND PLAN FOR SCALE UP Review and evaluate WHO PEN implementation at demonstration sites Cost WHO PEN package implementation Finalise service delivery model Develop a plan for phased scale up 6 MONITORING AND EVALUATION Define indicators and existing tools for measurement Establish a monitoring process 5 CAPACITY BUILDING Conduct training for healthworkers on agreed upon model and protocols Host ongoing inservice trainings Appoint mentors Develop supervision checklists and ensure supportive supervision is done at regular intervals 4 64 ENGAGE STAKEHOLDERS Identify key stakeholders invested in the current NCD health service delivery system to invite to the consultation. This is to build consensus and garner broad-based support. National-level: Ministry of Health, Ministry of Finance, Ministry of Social Welfare, political leaders at state or division-levels Local/Community-level: Local political leaders, community leaders, public sector health providers, private sector health providers Other sectors: NCD specialists, media, research groups or academic institutions, civic groups or health-oriented nongovernmental organizations (NGOs) Obtain an agreement to adapt WHO PEN and strengthen NCD management in primary care Establish technical working group Composition: Public health and clinical staff members (including medical, nursing and pharmaceutical) Role: To provide overall direction, leadership and supervision to the local adaptation of the WHO PEN and to national rollout; advise on the number of additional personnel needed, the required competencies, skills and their roles and responsibilities; and provide specifi c technical advice or support for the adaptation or development of the protocols Identify demonstration site The recommended criteria for selection of site: – Geographic access and communication – Health centres with a referral care facility – Agreement from local government – Support from professional associations and civil society groups List all primary health care centres Select a sample of facilities – usually 10% of the total number of facilities in the selected site Establish an agreement with demonstration site (e.g provincial agreement or district agreement) and include operational structure Conduct facility assessment First create a map of the sample of health facilities at demonstration site and the referral linkages Conduct a facility assessment (Annex 4.1) Analyse the information collected and identify gaps in training, equipment, drugs, record keeping, and management practices Determine minimum requirements of skilled staff , equipment, devices and medicines needed for implementing the package 1 65 ASSESS CURRENT STATUS OF NCD Desktop review of all related strategies, policies (including public policy measures on tobacco, alcohol, diet and physical activity) and guidelines relating to NCDs in primary health care Using the template to the right determine the current PHC infrastructure Map the current patient pathway for NCD service delivery Conduct a SWOT analysis of the country’s NCD service delivery system using the template below 2 GOVERNANCE AND LEADERSHIP • Is NCD risk management in primary health care included in the: national/district health strategy; national NCD strategy; national operational plans; basic package of services? • Is management of CVD /Hypertension /diabetes /CRD/ cancer included in national clinical guidelines for primary health care? • Do national clinical guidelines for primary health care include evidence-based protocols for risk- based CVD management? • Are there standardized systems/tools for mentoring and supervision of primary health-care staff ? • What is the frequency of district management meetings? Who attends? HEALTH FINANCING • Is there a specifi c NCD budget within health fi nancing? If yes, what is it? • In those systems with health insurance, are NCD services and medicines included in benefi t packages? ACCESS TO ESSENTIAL MEDICINES AND TECHNOLOGIES • Are the minimum essential medicines (Annex 4.2) for NCDs included in the national essential medicines list and the minimum primary health care medicines list? • Are the essential NCD technologies and tools (Annex 4.3) included in minimum standards for primary health care facilities? • Describe the national medicines supply management system (selection, quantifi cation, procurement, storage, distribution). HEALTH WORKFORCE • Are there dedicated management staff for NCD management at national and district levels? • Which staff cadres have authority to prescribe and/or authorize medication refi lls? • Have task-sharing approaches in primary health care been adopted or considered? • Do in-service training packages exist for management of CVD, hypertension or diabetes in primary health care? • Has any in-service training on NCD risk management occurred in last 2 years? If yes, who delivered it? HEALTH INFORMATION SYSTEMS • Are there mechanisms for data feedback from national, to subnational, to facility level? • Are there dedicated staff to collect data at district level? • Describe the district-level database for routine health management information system and other facility data. • Are NCD management indicators included in a national minimum indicator set? • Describe the type of individual patient record format used in public primary health-care facilities. • An sample clinical record is given (Annex 4.4) ORGANIZATION OF SERVICE DELIVERY • Describe the facility levels within the public health system. • Describe NCD management services available at each level of care including a healthy lifestyle counselling component. • Are catchment populations defi ned for primary health care? • What is the current service delivery model(s) in public primary health-care facilities? For example, general outpatient services where patients see any available provider; disease specifi c clinics. Are there established national and/or district-level quality improvement systems for primary health care? STRENGTHS 1. 2. 3. THREATS 1. 2. 3. WEAKNESSES 1. 2. 3. OPPORTUNITIES 1. 2. 3. SWOT 66 DEVELOP A SERVICE DELIVERY PACKAGE FOR PHC Develop a service delivery package relevant to the local context by adapting WHO PEN. Elements to consider when developing a service delivery package: – Health facility should be equipped to provide basic promotive, preventive and some curative services along with referrals and follow up – A matrix can be developed to map the various units of service and details under each unit as services, infrastructure, equipment and personnel – Once each unit matrix is ready then the fi nal matrix can be developed by matching the matrices for common items Consider urban vs rural service delivery models Decide on appropriate WHO PEN protocols for implementation Decide which protocol to implement based on community and health systems capacity assessments, and consideration of health priorities and the availability of human and technical resources. Adapt management protocols as required to refl ect country context, availability of drugs etc CAPACITY BUILDING As per service model, conduct appropriate training to primary care workers to deliver integrated NCD care – to assess, diagnose, manage and refer patients appropriately. Primary care workers should be able to: Apply relevant WHO PEN protocols and tools and interpret the results Understand referral thresholds Be familiar with the system and information to record and track to monitor WHO PEN implementation Deliver preventive health interventions and empower patients Plan for improving patient adherence to follow-up visits Consider incorporating the WHO PEN training into medical, nursing and allied health course curriculum, and providing continuing education courses for primary care health workers MONITORING AND EVALUATION Health facilities should have a system for collection of data. Sample clinical record is provided in Annexe 4.4. Data collation and analysis may be done at appropriate levels. Indicators for hypertension and diabetes are provided in Annex 4.5. They can serve as tracers for assessing the services. Establish monitoring process: Second-level facility (e.g. national, provincial or district health offi ce) to conduct visits to fi rst-level health facilities at least once every three months Conduct periodic audits of facilities providing the services 3 4 5 67 REVIEW AND PLAN FOR SCALE UP Review and evaluate demonstration phase Conduct an external assessment and audit of clinical practice. Analyse the fi ndings to assess the model and make necessary refi nements. Finalize service delivery model and requirements Agree on the service delivery model based on the feasibility and sustainability. Finalize the national protocols, referral criteria, and the equipment, drugs and consumables required. Agree on the human resources needed, their roles and responsibilities, and the training curriculum. Finalize the requirements of the health information system and clinical recording system. Agree on the monitoring and evaluation system, and the tools for auditing. Develop a multi-year plan to expand services nationwide Estimate the cost for the national expansion plan. Utilize cost information from the demonstration phase and from the costing study. Have a plan to ensure most cost-eff ective procurement and distribution of drugs and consumables. E.g. include core NCD drugs and technologies in the essential drug list; ensure transparency in the tender process; purchase cheaper quality generics and consider removing taxes and duties on essential drugs and technologies. Strengthen demand forecasting and supply chain mechanisms; strengthen health information system and analyse ordering cycle at the health centre. Obtain administrative order to expand services nationwide. Detail service model, roles and responsibilities, national protocols, and plan of action. Secure allocation in national health budget. Mobilize development partners, private sector, academia and the community to contribute to strengthening NCD management in primary health care. Conduct periodic monitoring and regular evaluation. Repeat annually for short-term indicators (e.g. impact indicators) and every 3–5 years for medium-term progress indicators (e.g. outcome indicators). 6 68 D om ain O bservation points Com m ents H ow are N CD s m anaged now ? W hat N CD s are covered? Flow of patients in the facility, w here is BP taken, how are N CD s m anaged? Patient care services Is there a separate N CD clinic? N CD treatm ent guidelines available? Staff D edicated staff for N CD s? Staff trained in N CD diagnosis and treatm ent? Equipm ent BP apparatus G lucom eter W eighing m achine H eight m easuring tape Laboratory services U rine for album in, sugar, ketones Blood sugar, cholesterol M edicines Are essential N CD drugs available? (m etform in, am lodipine, etc.) Records and reports D o patients have a unique ID num ber? W ho prepares the reports? Is there a separate N CD register? Com puterized records? Referral system N earest referral centre (approxim ately in km s) - Secondary - Tertiary W hat w orks (w hat are the strengths)? W hat doesn’t w ork (w hat are the challenges)? W hat should be done next (H ow can N CD services be im proved)? A N N EX 4.1: H EA LTH FA CILITY A SSESSM EN T Adaptation of the W H O PEN package can start w ith a quick assessm ent of the facility. A sam ple form at is given here. Please use this observation checklist as a guide and don’t restrict your observations to the points be- low . Feel free to add m ore depending on your observations. SU M M A RY O F H EA LTH FA CILITY A SSESSM EN T 69 • Am oxicillin • Angiotensin inhibitor (enalapril) • Aspirin • Beclom ethasone • Beta-blocker (atenolol) • Calcium channel blocker (am lodepine) • Codeine • D extrose infusion • D iazepam • Epinephrine • Erythrom ycin • Furosem ide • G libenclam ide • G lucose injectable solution • G lyceryl trinitrate • H eparin • H ydrocortisone • Ibuprofen • Insulin • Isosorbide dinitrate • M agnesium sulphate • M etform in • M orphine • O xygen • Paracetam ol • Prednisolone • Prom ethazine • Salbutam ol • Senna • Sodium chloride infusion • Spironolactone • Statin (sim vastatin) • Thiazide diuretic A N N EX 4.2: CO RE LIST O F M ED ICIN ES [For prim ary care facilities w ith physicians] (for PC facilities w ith only non-physician health w orkers m ost of the m edicines below are required for refi ll of prescriptions issued by physicians at a higher level of care) 70 A N N EX 4.3: ESSEN TIA L TECH N O LO G IES A N D TO O LS TEC H N O LO G IES • Therm om eter • Stethoscope • Blood pressure m easurem ent device* • M easurem ent tape • W eighing m achine • Peak fl ow m eter** • Spacers for inhalers • G lucom eter • Blood glucose test strips • Sem m es-W einstein 10 g m onofi lam ent • U rine protein test strips • U rine ketones test strips A dd w hen resources perm it: • N ebulizer • Pulse oxim eter • Blood cholesterol assay • Lipid profi le • Serum creatininine assay • Troponin test strips • U rine m icroalbum inuria test strips • Tuning fork • Electrocardiograph (if training to read and interpret electrocardiogram s is available) • D efi brillator TO O LS • W H O CVD risk prediction charts • Evidence-based clinical protocols • Flow charts w ith referral criteria • Patient clinical record • M edical inform ation register • Audit tools * For facilities w ith nonphysician health w orkers a validated blood pressure m easurem ent device w ith digital reading is preferable for accurate m easurem ent of blood pressure ** D isposable m outh pieces requried. Peak fl ow m eters w ith one-w ay fl ow preferable. 71 N C D clinic registry A tool for N C D treatm ent and follow up N C D ID : D ate: M ale / Fem ale / O ther Yes / No No / Yes (on treatm ent)/ Yes (not on treatm ent) No / Yes (on treatm ent)/ Yes (not on treatm ent) Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Present / Absent Yes / No No/O ccasional/Daily/Harm ful use Yes / No PA TIE N T IN FO R M A TIO N P atient N am e G ender D ate of B irth A ge at the tim e of R egistration A ddress Line1 A ddress Line 2 C ontact no. E m ail N ationality H IS TO R Y O F N C D H /o H ypertension H /o D iabetes H /o A sthm a H /o C O P D H /o C ancer H /o C oronary artery diseases H /o S troke H /o C honic K idney D isease A S S E S S M E N T Tobacco use - sm oking Tobacco use - sm okeless A lcohol use S ystolic B lood P ressure at R egistration D iastolic B lood P ressure at R egistration H eight (in m eters) W eight (in kg) B M I IN V E S TIG A TIO N S Fasting blood glucose (m g/dl) R andom blood glucose (m g/dl) H bA 1C (% ) S erum potassium (m E q/L) S erum creatinine (m g/dL) S erum urea (m g/dL) Total cholesterol (m g/dL) U rine protein Foot exam ination Fundus exam ination C ervical cancer screening D IA G N O S IS H ypertension D iabetes H yperlipidaem ia C O P D A sthm a O ther C V D risk - lab based C V D risk - non lab based A N N EX 4.4: SA M PLE CLIN ICA L RECO RD 72 D ate for follow up M edicines dispensed R eferred - R eason for referral - S ignature of D octor TR E A TM E N T M edicines for H ypertension N am e of M edicine 1 D ose A dvice N am e of M edicine 2 D ose A dvice N am e of M edicine 3 D ose A dvice N am e of M edicine 1 D ose A dvice N am e of M edicine 2 D ose A dvice N am e of M edicine1 D ose A dvice N am e of M edicine 2 D ose A dvice N am e of M edicine D ose A dvice N am e of M edicine D ose A dvice N am e of M edicine D ose A dvice M edicine for D iabetes M edicines for H yperlipidaem ia M edicines for C O P D M edicines for A sthm a O thers Yes / No 73 Systolic BP Diastolic BP W eight BM I HTN M edicine 1 Low er lim b am putation Fasting blood glucose DM M edicine 2 Hospitalization for Asthm a Serum Creatinine Fundus exam ination HTN M edicine 2 Renal failure Random blood glucose Statins Signature Serum urea Foot exam ination HTN M edicine 3 Coronary Artery Disease HbA1c O thers Total cholesterol Cervical cancer screening DM M edicine 1 Stroke Serum potassium Urine protein P atient N am e N C D ID A S S E S S M E N T D ate D ate D ate D ate D ate TR E A TM E N T N E W C O M P LIC A TIO N S O N FO LLO W U P V IS ITS IN V E S TIG A TIO N S Follow -up V isits N C D clinic registry A tool for N C D treatm ent and follow up Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al Not done / Norm al / Abnorm al 74 A N N EX 4.5: IN D ICA TO RS H ealth-facility level N o. Indicator Source of data Reporting frequency H ealth system considerations 1 Six-m onthly control of blood pressure am ong people treated for hypertension H ealth facility record O nce in six m onths Feasible in all settings in prim ary health care and a core indicator for quality of services Subnational (district/province/state) level (aggregated from health facilities off ering the services w ithin the program m e) N o. Indicator Source of data Reporting frequency Considerations in the interpretation 2 Control of blood pressure am ong people w ith hypertension w ithin the program m e Aggregated reports from all the health facilities reporting the hypertension indicator in a defi ned subnational area; estim ation of hypertension prevalence O nce in 12 m onths This w ill give estim ated com m unity control rates w ith the num erator com ing from facilities reporting as part of the program m e (in som e instances patients m ay be receiving BP m eds from private sector or other levels of care w ithin the public system ) 3 Availability of core cardiovascular disease/ diabetes drugs Aggregated reports from all the health facilities reporting drug availability indicators in a defi ned subnational area O nce in 3 m onths This is for the program m e quality control and w ill assist w ith forecasting of m edicines and im provem ents in supply chain m anagem ent Population level (control of hypertension, diabetes and CVD risk) N o. Indicator Source of data Reporting frequency Considerations in the interpretation 4 H ypertension control in the population Population-based sam ple survey (STEPS or sim ilar survey) O nce in 3–5 years Population-level survey as part of national survey or a special survey for the program m e 5 Proportion of eligible persons receiving drug therapy and counselling (including glycaem ic control) to prevent heart attacks and stroke (1) Population-based sam ple survey (STEPS or sim ilar survey) O nce in 5 years Population-based (preferably nationally representative) survey, including behavioural param eters w ith physical and biochem ical m easurem ents TA B LE 1: IN D ICA TO RS FO R H YPERTEN SIO N A N D CVD H EARTS Technical package for cardiovascular disease m anagem ent in prim ary health care: system s for m onitoring. https://apps.w ho.int/iris/bitstream /handle/10665/260423/W H O -N M H -N VI-18.5-eng.pdf;jsessionid=519A7089AD 2410B8245D 0BA1EBC0C946?sequence=1 75 Indicator D escription N um ber of patients being treated for diabetes N um ber of patients and num ber of new patients w ith diabetes Frequency of reporting: m onthly Control rate am ong people treated for diabetes N um erator: num ber of patients w ith diabetes w ith good glycaem ic control at the last clinical visit in the last 6 m onths (H bA1c <7.0% (53 m m ol/m ol), or FPG <7.0 m m ol/L (126m g/dL) and (if available) a postprandial PG value <9.0 m m ol/L (160 m g/dL) D enom inator: num ber of patients w ith diabetes in the facility during the last 6 m onths Frequency of reporting: every 6 m onths Com plications due to diabetes: • diabetic foot • nephropathy • retinopathy • neuropathy • cardiovascular diseases N um erator: num ber of new diabetes com plications in the past year D enom inator: num ber of patients w ith diabetes in the past year Frequency of reporting: annually TA B LE 2: IN D ICA TO RS FO R D IA B ETES M ELLITU S D iagnosis and m anagem ent of type 2 diabetes (H EARTS-D ) https://w w w .w ho.int/publications/i/item /w ho-ucn-ncd-20.1 76 A N N EX 4.6: A D D ITIO N A L REA D IN G 1. Com prehensive cervical cancer control: A guide to essential practice. G eneva: W orld H ealth O rganization; 2014 (http://w w w .w ho.int/reproductivehealth/publications/cancers/cervical-cancer-guide/en/, accessed 16 July 2020). 2. G uide to cancer early diagnosis. G eneva: W orld H ealth O rganization; 2017 (https://w w w .w ho.int/cancer/publica- tions/cancer_early_diagnosis/en/, accessed 16 July 2020). 3. H EARTS-D . D iagnosis and m anagem ent of type 2 diabetes. G eneva: W orld H ealth O rganization; 2020 (https:// w w w .w ho.int/publications/i/item /w ho-ucn-ncd-20.1, accessed 16 July 2020). 4. H EARTS Technical package for cardiovascular disease m anagem ent in prim ary health care. G eneva: W orld H ealth O rganization; 2018 (https://w w w .w ho.int/cardiovascular_diseases/hearts/en/, accessed 16 July 2020). 5. Im plem entation tools. Package of Essential N oncom m unicable (PEN ) disease interventions for prim ary health care in low -resource settings. G eneva: W orld H ealth O rganization; 2013 (http://apps.w ho.int/iris/bitstream /han- dle/10665/133525/9789241506557_eng.pdf, accessed 16 July 2020). 6. Planning and im plem enting palliative care services: a guide for program m e m anagers. G eneva: W orld H ealth O rganization; 2016 (https://apps.w ho.int/iris/bitstream /handle/10665/250584/9789241565417-eng.pdf, accessed 16 July 2020). 7. Tackling N CD s. “Best buys” and other recom m ended interventions for the prevention and control of non- com m unicable diseases. G eneva: W orld H ealth O rganization; 2017 (http://apps.w ho.int/iris/bitstream /han- dle/10665/259232/W H O -N M H -N VI-17.9-eng.pdf, accessed 16 July 2020). 8. W orld H ealth O rganization cardiovascular disease risk charts: revised m odels to estim ate risk in 21 global re- gions. The W H O C VD Risk Chart W orking G roup. Lancet G lob H ealth. 2019;7:e1332–45 Published O nline Septem - ber 2, 2019 http://dx.doi.org/10.1016/ S2214-109X(19)30318–3. 9. A guide to im plem entation research in the prevention and control of noncom m unicable diseases; 2019 (https:// apps.w ho.int/iris/bitstream /handle/10665/252626/9789241511803-eng.pdf, accessed 16 July 2020). 10. Classifi cation of diabetes m ellitus. G eneva: W orld H ealth O rganization; 2019. (https://apps.w ho.int/iris/bitstream / handle/10665/66040/W H O _N CD _N CS_99.2.pdf?sequence=1\, accessed 16 July 2020). 11. Integrating palliative care and sym ptom relief into prim ary health care: a W H O guide for planners, im plem enters and m anagers.; 2018 (https://apps.w ho.int/iris/bitstream /handle/10665/274559/9789241514477-eng.pdf?se- quence=1& isAllow ed=y, accessed 16 July 2020). 12. G uide to cancer early diagnosis; 2017 (https://w w w .w ho.int/cancer/publications/cancer_early_diagnosis/en/, accessed 16 July 2020). 13. N CD in em ergencies; 2016 (https://apps.w ho.int/iris/bitstream /handle/10665/204627/W H O _N M H _N VI_16.2_eng.pdf?sequence=1& isAl- low ed=y, accessed 16 July 2020) 77 For more information, please contact: World Health Organization Department of NCD 20, avenue Appia 1211 Geneva 27 Switzerland E-mail: NextGenNCD@who.int https://www.who.int/teams/ncds/