Palliative Care and Chronic Care

Chronic Care Integration for Endemic Non-Communicable Diseases Non-Communicable Endemic for Integration Care Chronic the pih guide to the pih guide to Chronic Care Integration for Endemic Non-Communicable Diseases

Partners In Health is a 501(c)3 nonproﬁt corporation based in Boston, Massachusetts. Established in 1987, PIH is committed to making a preferential option for the poor by working with sister organizations to improve the health and well-being of people living in poor communities. To this end, PIH provides technical and ﬁnancial assistance, medical supplies, and administrative support to partner projects in Haiti, PerZu, Russia, Rwanda, Lesotho, Malawi, Mexico, Guatemala, Burundi, Kazakhstan, the Dominican Republic, and the United States. The goal of these partnerships is neither charity nor development but rather “pragmatic solidarity”— a commitment to struggle alongside the destitute sick and against the economic and political structures that cause and perpetuate poverty and ill health. Partners In Health is a!liated with the Division of Social Medicine at Harvard Medical School and the Division of Global Health Equity at the Brigham and Women’s Hospital.

rwanda edition More information on Partners In Health can be found s66666 s66666 at our web site: www.pih.org

rwanda edition Partners In Health Harvard Medical School Department of Global Health and Social Medicine Program in Global Non-Communicable Disease and Social Change Brigham and Women’s Hospital Division of Global Health Equity the pih guide to Chronic Care Integration for Endemic Non-Communicable Diseases

rwanda edition s66666 s66666

Partners In Health

Harvard Medical School Department of Global Health and Social Medicine Program in Global Non-Communicable Disease and Social Change

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!7'"*)9A'#8)*'A")54C'7&"'$+P9&<.45A4'$95'$A%44'#&'#84'#4%:*'&6'#8)*'9&#)+4> table of contents foreword xxiii ;464%49+4*' EE))) abbreviations xxv chapter 1 Integration of Chronic CareServices in Rwanda 1 />/' H84'F&9A'H$).'&6'U954:)+'`&92S&::"9)+$3.4'()*4$*4*')9';<$95$' / />J' L'[%$:4<&%P'6&%'Y#%$#4A)+'G.$99)9A'6&%'U954:)+' `&92S&::"9)+$3.4'()*4$*4' K />B' (4+49#%$.)^$#)&9'$95'?9#4A%$#)&9'&6'S8%&9)+'S$%4'' 6&%'`&92S&::"9)+$3.4'()*4$*4')9';<$95$' Z />K' _8)+8'S8%&9)+'()*4$*4*j' ] />0' H84'()*#%)+#',&*-)#$.'$*'$'Y&"%+4'&6'S.)9)+$.'F4$54%*8)-'' ] />Z' ()*#%)+#'?9-$#)49#'S$%4' /1 />]' ,4$.#8'S49#4%*W'S$*4'[)95)9AC'?9)#)$.'R$9$A4:49#C'' $95'S8%&9)+'S$%4' /1 />g' ;464%%$.'S49#4%*' // />d' b"#2&62S&"9#%7';464%%$.' /J />/1' Y+%449)9A' /J />//' G%)9+)-.4*'&6'G$#)49#'[&..&<2a-'$95';4#49#)&9W'S&::"9)#7'' ,4$.#8'_&%P4%*'$95'#84'U.4+#%&9)+'R45)+$.';4+&%5' /J />/J' UO")-:49#C'R45)+$#)&9'G%&+"%4:49#C'$95'S&*#*' /B ͳ᩸ ͳͶ chapter 2 Palliative Care and Chronic Care 17 J>/' ,)*#&%7'$95'G8).&*&-87'&6'G$..)$#)@4'S$%4'U66&%#*')9'' ;4*&"%+42G&&%'Y4##)9A*' /g J>J' S&::"9)#7',4$.#8'_&%P4%*'$95'S&::&9'G$..)$#)@4'S$%4'' ?9#4%@49#)&9*')9'#84'H%4$#:49#'&6'S8%&9)+'()*4$*4' /d J>J>/' L**4**:49#'&6'Y7:-#&:*' J1 J>J>J' Y7:-#&:'R$9$A4:49#' J/ J>J>B' G$)9' JJ J>J>B>/' `&+)+4-#)@4'G$)9' JJ J>J>B>J' `4"%&-$#8)+'G$)9' JJ J>J>B>B' G%)9+)-.4*'&6'G$)9'R$9$A4:49#' JB J>J>K' (7*-94$' J] J>J>0' `$"*4$i\&:)#)9A' J] viȀƢȀchronic care integration for endemic non-communicable diseases

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chapter 3 Role of Community Health Workers, Family Planning, Mental Health, and Social Services in the Treatment of Chronic Disease 33 B>/' S&::"9)#7',4$.#8'_&%P4%*' BB B>J' ,&"*)9A'L**)*#$9+4' BK B>B' `"#%)#)&9$.'Y"--&%#'' B0 B>K' R49#$.',4$.#8' B0 B>0' [$:).7'G.$99)9A')9'S8%&9)+'()*4$*4' B0 ͵᩸ ͵͹

chapter 4 Heart Failure 39 ͶǤͳ ϐ Ͷͳ ͶǤʹ ϐ Ͷʹ ͶǤ͵ ϐ Ͷ͵ K>B>/' H84'G$%$*#4%9$.'F&9A'LE)*'\)4<' KB K>B>J' H84'Y"3+&*#$.'\)4<' KK K>B>B' UD4+#)&9'[%$+#)&9'$95'[%$+#)&9$.'Y8&%#49)9A' K] K>B>K' L**4**:49#'6&%'R)#%$.'Y#49&*)*' Kg K>B>0' L**4**:49#'&6';)A8#',4$%#'Y)^4' Kd K>B>Z' L**4**:49#'&6'#84'?964%)&%'\49$'S$@$' 01 K>B>]' L**4**:49#'&6'G4%)+$%5)$.'U66"*)&9'' 01 K>K' ?9)#)$.';4+&A9)#)&9'$95';464%%$.'&6'#84',4$%#'[$)."%4'G$#)49#' 0/ ͶǤͷ ϐ ͷͷ K>Z' (4+&:-49*$#45',4$%#'[$)."%4' 00 K>]' [.")5'Y#$#"*'L**4**:49#' 0g K>]>/' T")54.)94*'6&%'?9)#)$#)9A'?9#%$@49&"*'()"%4*)*' Z/ K>]>J' T")54.)94*'6&%'?9)#)$#)9A'$95'H)#%$#)9A'b%$.'' ["%&*4:)54'$#',4$.#82S49#4%'F4@4.' ZJ K>]>B' T")54.)94*'6&%'a*4'&6'b#84%'()"%4#)+*' ZJ K>]>B>/' Y-)%&9&.$+#&94' ZB K>]>B>J' ,75%&+8.&%)$^)54' ZB K>]>K' ($9A4%*'&6'()"%4*)*' ZB K>g' S$%5)&:7&-$#87' ZK table of contentsȀƢȀvii

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chapter 5 Cardiac Surgery Screening, Referral, Anticoagulation, and Postoperative Management 107 0>/' ,)*#&%7'&6'S$%5)$+'Y"%A4%7')9';<$95$' /1] 0>/>/' b"#2&62S&"9#%7';464%%$.'#&'UE#4%9$.'S$%5)$+'' Y"%A)+$.'S49#4%*' /1d 0>/>/>/' G8).$9#8%&-)+'S49#4%*' /1d 0>/>/>J' [4426&%2Y4%@)+4'S49#4%*' //1 0>/>J' \)*)#)9A'S$%5)$+'Y"%A)+$.'H4$:*' //1 0>J' !").5)9A'$'`$#)&9$.'S$%5)$+'Y"%A4%7'G%&A%$:' /// 0>J>/' S$%5)$+'Y"%A)+$.';464%%$.' //J 0>J>J' G%)9+)-.4*'&6'S$*4'Y4.4+#)&9' //B 0>B' S&::&9'G%&+45"%4*'6&%'S$%5)$+'\$.@4*' //K 0>B>/' R)#%$.'&%'H%)+"*-)5'\$.@4';4-$)%' //0 0>B>J' G4%+"#$94&"*'G%&+45"%4*' //Z 0>B>B' R4+8$9)+$.'\$.@4*' //Z 0>B>K' !)&-%&*#84#)+'\$.@4*' //] 0>K' U$%.7'G&*#2b-4%$#)@4'U@$."$#)&9'V[)%*#'B'R&9#8*X' //] 0>K>/' ,4$%#'[$)."%4' //g 0>K>J' Y#4%9$.'_&"95'?964+#)&9'$95'(48)*+49+4' //g 0>K>B' G4%)+$%5)$.'H$:-&9$54' //d 0>K>K' U95&+$%5)#)*' //d 0>K>0' L#%)$.'L%%87#8:)$*' //d 0>0' b9A&)9A'R&9)#&%)9A'&6'#84'G&*#2b-4%$#)@4'G$#)49#' /J1 0>0>/' [4@4%')9'G$#)49#*'<)#8'G%&*#84#)+',4$%#'\$.@4*' /J1 0>0>J' \$.@4'H8%&:3&*)*' /JB 0>0>B' \$.@4'(48)*+49+4' /JK 0>Z' G49)+)..)9'G%&-87.$E)*'6&%'G$#)49#*'<)#8'Y"%A)+$..7'' S&%%4+#45';84":$#)+'\$.@".$%'()*4$*4' /JK 0>]' R4#8&5*'&6'L9#)+&$A".$#)&9'$95'?95)+$#)&9*' /JK 0>g' ?9)#)$#)9A'_$%6$%)9'H84%$-7' /JZ 0>g>/' S&9#%$)95)+$#)&9*'#&'_$%6$%)9'H84%$-7' /JZ 0>g>J' R&9)#&%)9A'_$%6$%)9' /J] table of contentsȀƢȀix

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chapter 11 Epilepsy Forthcoming

epilogue 255

appendix a Essential Equipment and Medicines 257 L>/' U**49#)$.'UO")-:49#' J0] L>J' U**49#)$.'R45)+)94*' J0] ᩸ ʹ͸Ͳ

appendix b Cost Models 261 !>/' Y"::$%7'&6'b-4%$#)&9$.'S&*#'R&54.*' JZ/ !>J' S$%5)&:7&-$#87' JZJ !>J>/' S&*#'?9-"#*' JZJ !>J>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#' JZJ !>J>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A'' VS$#+8:49#'L%4$W'B01C111X' JZB !>J>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' JZB !>B' S$%5)$+'Y"%A4%7' JZB !>B>/' S&*#'?9-"#*' JZB !>B>/>/' [&..&<2a-'S&*#'?9-"#*' JZB !>B>/>J' Y"%A)+$.'S&*#'?9-"#*'VL#'B11'S$*4*'G4%'c4$%X' JZK !>B>/>B' L@4%$A4'S$%5)$+'Y"%A)+$.'S&*#*'$*'$'["9+#)&9'' &6'#84'`":34%'&6'L99"$.'b-4%$#)&9*' JZK !>B>/>K' ;4A):49'$95'[&..&<2a-'S&*#*' JZ0 !>B>J' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A' JZ0 !>B>B' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$'VL#'B11'S$*4*'G4%'c4$%X' JZ0 !>K' Y+%449)9A'6&%',?\'`4-8%&-$#87' JZ0 !>K>/' S&*#'?9-"#*' JZ0 !>K>J' R$%A)9$.'[&..&<2a-'S&*#*' JZ0 !>K>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A' JZZ !>K>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' JZZ !>0' ()$34#4*' JZZ !>0>/' S&*#'?9-"#*' JZZ !>0>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#' JZ] !>0>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A' JZ] !>0>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' JZg table of contentsȀƢȀxiii

!>Z' ,7-4%#49*)&9'S&*#'R&54.*' JZg !>Z>/' S&*#'?9-"#*' JZg !>Z>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#.' JZg !>Z>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A' JZd !>Z>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' JZd !>]' S8%&9)+';4*-)%$#&%7'()*4$*4'S&*#'R&54.*' J]1 !>]>/' S&*#'?9-"#*' J]1 !>]>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#' J]1 !>]>B' G&-".$#)&9'LA4'()*#%)3"#)&9'$95'S$*42[)95)9A' J]1 !>]>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' J]/ !>g' U-).4-*7'S&*#'R&54.*' J]/ !>g>/' S&*#'?9-"#*' J]/ !>g>J' L99"$.';4A):49'S&*#*'G4%'G$#)49#' J]/ !>g>B' G&-".$#)&9'()*#%)3"#)&9'$95'S$*42[)95)9A' J]/ !>g>K' H&#$.'R$%A)9$.'S&*#*'G4%'S$-)#$' J]J appendix c Indicators for Monitoring and Evaluation 271 S>/' ,4$%#'[$)."%4'$95'G&*#2S$%5)$+'Y"%A4%7'[&..&<2a-' J]/ S>J' S$%5)$+'Y"%A)+$.';464%%$.'$95'S$*4'Y4.4+#)&9' J]B S>B' ;49$.'[$)."%4' J]K S>K' ()$34#4*' J]0 S>0' ,7-4%#49*)&9' J]] S>Z' S8%&9)+';4*-)%$#&%7'()*4$*4' J]g S>]' U-).4-*7' Jg1 appendix d Forms 281 (>/' ?9#$P4'[&%:*' Jg/ (>J' [.&<*844#*' Jg] (>J>/' Y$:-.4'S&@4%'Y844#' Jg] (>J>J' Y$:-.4'U@49#*'[.&<*844#' Jgg (>J>B' S.)9)+$.'[)95)9A*'[.&<*844#' Jgd (>J>B>/' L*#8:$' Jgd (>J>B>J' ()$34#4*' Jgd (>J>B>B' G&*#2S$%5)$+'Y"%A4%7' Jd1 (>J>B>K' ,7-4%#49*)&9' Jd1 (>J>B>0' U-).4-*7' Jd1 (>J>B>Z' R45)+$#)&9'[.&<*844#' Jd1 (>J>K' G$..)$#)@4'S$%4'[.&<*844#' Jd/ ᩸ ʹͻʹ xivȀƢȀchronic care integration for endemic non-communicable diseases

Figures

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chapter 4 [?Ta;U'K>/' ()*#%)3"#)&9'&6'S$"*4*'&6',4$%#'[$)."%4')9'$' ;<$95$9'`S('+.)9)+'V9'l'/BKX' K1 [?Ta;U'K>J' G$%$*#4%9$.'F&9A'LE)*'\)4<' KB [?Ta;U'K>B' `&%:$.'G$%$*#4%9$.'F&9A'LE)*'\)4<'&9'' U+8&+$%5)&A%$-87'V()$*#&.4C'#&-h'Y7*#&.4C'3&##&:X' KK [?Ta;U'K>K' Y"3+&*#$.'\)4<' K0 [?Ta;U'K>0' Y"3+&*#$.'\)4<'<)#8'`&%:$.'?\S'V#&-X'$95' ().$#45'?\S'V3&##&:X' KZ [?Ta;U'K>Z' S$%5)&:7&-$#87')9'G$%$*#4%9$.'F&9A'LE)*'\)4<'' V()$*#&.4C'#&-h'Y7*#&.4C'3&##&:X' Kg [?Ta;U'K>]' R)#%$.'Y#49&*)*')9'()$*#&.4' Kd [?Ta;U'K>g' ;)A8#'\49#%)+".$%'U9.$%A4:49#'VG$%$*#4%9$.'F&9A'\)4d' G4%)+$%5)$.'U66"*)&9'VG$%$*#4%9$.'\)4/1' UST'&6'`&%:$.';87#8:'V#&-X'$95'L#%)$.'[)3%)..$#)&9'' V3&##&:X' dg

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chapter 6 [?Ta;U'Z>/' `&%:$.'M)5947'L9$#&:7'&9'a.#%$*&"95'!"##$%&'()*++ *&$%+,&'+-').//(#0+10#(-2)*3+(4)+*,(#+*&$%*+,&'++ $.,'#+5$#,'67' /KJ [?Ta;U'Z>J' a.#%$*&"95')9'S8%&9)+'M)5947'()*4$*4W'F&**'&6'' ()664%49#)$#)&9'34#<449'S&%#4E'$95'R45"..$' /KB table of contentsȀƢȀxv

[?Ta;U'Z>B' ,75%&94-8%&*)*'&9'a.#%$*&"95' /KK chapter 9 [?Ta;U'd>/' G%&A%4**)&9'6%&:'G8$%79A)#)*'#&';84":$#)+'[4@4%' J/d xviȀƢȀchronic care integration for endemic non-communicable diseases

Tables

chapter 1 HL!FU'/>/' !"%549'&6'`&92S&::"9)+$3.4'()*4$*4*')9';<$95$'F)9P45' #&'S&95)#)&9*'&6'G&@4%#7' J HL!FU'/>J' F4$5)9A'S$"*4*'&6'(4$#8'$95'()*$3).)#7')9';<$95$')9'' ()*$3).)#72L5D"*#45'F)64'c4$%*'V(LFc*X' B HL!FU'/>B' Y$:-.4'()*#%)+#',&*-)#$.k!$*45'S.)9)+)$9'Y+845".4' d

chapter 2 HL!FU'J>/' S&*#i?:-$+#'R$#%)E'&6'R45)+$.'?9#4%@49#)&9*C'' <)#8'UE$:-.4*' /d HL!FU'J>J' Y7:-#&:'L**4**:49#'Y+$.4'VL5$-#45'6%&:'#84'L6%)+$9' G$..)$#)@4'b"#+&:4*'Y+$.4X' J/ HL!FU'J>B' U**49#)$.'R45)+$#)&9*'6&%'G$)9';4.)46' JZ HL!FU'J>K' U**49#)$.'R45)+$#)&9*'6&%'S&9#%&.'&6'`$"*4$i\&:)#)9A' Jg HL!FU'J>0' U**49#)$.'H84%$-)4*'6&%'H%4$#)9A'S&9*#)-$#)&9' Jd HL!FU'J>Z' Y7:-#&:$#)+'R$9$A4:49#'&6'()$%%84$' B1 HL!FU'J>]' R$9$A4:49#'&6'S8%&9)+'G%"%)#"*'$95'YP)9'S$%4' B/

chapter 4 HL!FU'K>/' S$"*4*'&6',4$%#'[$)."%4';4-&%#45'37'Y4.4+#45'' U+8&+$%5)&A%$-8)+';464%%$.'S49#4%*')9'' Y"32Y$8$%$9'L6%)+$' Bd HL!FU'K>J' ?:-&%#$9#'()$A9&*#)+'S$#4A&%)4*')9',4$%#'[$)."%4' KJ ͶǤ͵ ϐ ' ,4$%#'[$)."%4' KB ͶǤͶ ϐ ' ,4$%#'[$)."%4' KB HL!FU'K>0' S&::&9'Y)A9*'$95'Y7:-#&:*'&6',4$%#'[$)."%4' Va*"$..7'G%4*49#')9'L55)#)&9'#&'Y8&%#94**'&6'!%4$#8X' 0J HL!FU'K>Z' `4<'c&%P',4$%#'L**&+)$#)&9',4$%#'[$)."%4'' ϐ ͷͷ HL!FU'K>]' Y)A9*'&6'(4+&:-49*$#45',4$%#'[$)."%4')9'L5".#*' 0Z HL!FU'K>g' ;4$*&9*'6&%'L+"#4'(4+&:-49*$#)&9')9'G$#)49#*'' <)#8',4$%#'[$)."%4' 0] HL!FU'K>d' \&.":4'Y#$#"*'S$#4A&%)4*'$95'()"%4#)+'L5D"*#:49#' 0d HL!FU'K>/1' ?9#%$@49&"*'["%&*4:)54'VF$*)EX'(&*)9A' Z/ HL!FU'K>//' UO")@$.49#'b%$.'$95'?\'["%&*4:)54'VF$*)EX'(&*4*' ZJ HL!FU'K>/J' b%$.'["%&*4:)54'VF$*)EX'(&*)9A' ZJ HL!FU'K>/B' b#84%'b%$.'()"%4#)+'(&*)9A' ZB HL!FU'K>/K' U#)&.&A7'&6'S$%5)&:7&-$#87')9';<$95$' ZK table of contentsȀƢȀxvii

HL!FU'K>/0' R&%#$.)#72;45"+)9A'R45)+$#)&9*'6&%'S$%5)&:7&-$#87' Z] HL!FU'K>/Z' ()A&E)9'(&*)9A' ]B HL!FU'K>/]' L9#)87-4%#49*)@4*'6&%',7-4%#49*)@4',4$%#'()*4$*4' ]Z HL!FU'K>/g' R45)+$#)&9*'#&';45"+4',4$%#';$#4')9'R)#%$.'Y#49&*)*' g1 HL!FU'K>/d' R45)+$#)&9*'6&%'\$.@".$%iS&9A49)#$.',4$%#'()*4$*4' g0 HL!FU'K>J1' S.)9)+$.'G%4*49#$#)&9'&6';)A8#2Y)545',4$%#'[$)."%4' g] HL!FU'K>J/' S$"*4*'&6';)A8#2Y)545',4$%#'[$)."%4' gg HL!FU'K>JJ' H%4$#:49#'&6'H"34%+".&"*'G4%)+$%5)#)*')9'L5".#*' dJ HL!FU'K>JB' S.)9)+'[&..&<2a-'Y+845".4'6&%',4$%#'[$)."%4'G$#)49#*' dZ chapter 5 HL!FU'0>/' H7-)+$.'G%4&-4%$#)@4'U@$."$#)&9'6&%'S$%5)$+'Y"%A4%7' //B HL!FU'0>J' H7-4*'&6'\$.@4';4-$)%*' //0 HL!FU'0>B' H7-4*'&6';4-.$+4:49#',4$%#'\$.@4*' //] HL!FU'0>K' U:-)%)+'L9#)3)&#)+'H%4$#:49#*'6&%'U95&+$%5)#)*' /J/ ͷǤͷ Ǧ ϐ ' \$.@4'U95&+$%5)#)*' /JB HL!FU'0>Z' S&::&9'(%"A'?9#4%$+#)&9*'<)#8'_$%6$%)9' /J0 HL!FU'0>]' L9#)+&$A".$#)&9'LA49#*'$95'?95)+$#)&9*' /JZ HL!FU'0>g' ?9)#)$.'b"#-$#)49#'_$%6$%)9'(&*)9A' /J] HL!FU'0>d' H84%$-)4*'[&%'!%)5A)9A'L9#)+&$A".$#)&9' /Jg HL!FU'0>/1' T494%$.'G%)9+)-.4*'&6'_$%6$%)9'H)#%$#)&9' /B1 chapter 6 HL!FU'Z>/' S$"*4*'&6'U952Y#$A4';49$.'()*4$*4')9'Y"32Y$8$%$9'' L6%)+$'$95'#84'a>Y>' /B0 HL!FU'Z>J' ;4.$#)&9*8)-'34#<449'a%)94'()-*#)+P'$95'JK28&"%'' a%)94'G%)9';4*".#*' /B] HL!FU'Z>B' Y#$A4*'&6'S8%&9)+'M)5947'()*4$*4' /Bd ͸ǤͶ ϐ ǡ ' M)5947'()*4$*4' /KB HL!FU'Z>0' S&::&9'G87*)+$.'Y7:-#&:*')9'L5@$9+45'S8%&9)+'' M)5947'()*4$*4'$95'H84)%'H%4$#:49#' /K] HL!FU'Z>Z' S&::&9'G*7+8&.&A)+$.'Y7:-#&:*')9'L5@$9+45'' S8%&9)+'M)5947'()*4$*4'$95'H84)%'H%4$#:49#' /Kg chapter 7 HL!FU']>/' ()$34#4*'()$A9&*)*W'!.&&5'Y"A$%'R4$*"%4:49#'' $95'Y7:-#&:*' /0Z HL!FU']>J' ($9A4%'Y)A9*')9',7-4%A.7+4:)$' /0g HL!FU']>B' ?9*".)9'H84%$-7'&6'G$#)49#*'<)#8',7-4%A.7+4:)$'' ȋηʹͷͲȀȌ ͳͷͻ xviiiȀƢȀchronic care integration for endemic non-communicable diseases

HL!FU']>K' ()$A9&*)*'$95'H%4$#:49#'&6',7-&A.7+4:)$' /Z/ HL!FU']>0' T."+&*4'S&9#%&.'T&$.*' /ZJ HL!FU']>Z' b%$.',7-&A.7+4:)+'H84%$-7' /ZK HL!FU']>]' S&::&9'S$"*4*'6&%',7-4%A.7+4:)$')9'G$#)49#*'' &9'?9*".)9' /Z0 HL!FU']>g' ?95)+$#)&9*'6&%'?9*".)9'H84%$-7' /ZZ HL!FU']>d' G%&-4%#)4*'&6'?9*".)9'L@$).$3.4')9';<$95$' /Zd HL!FU']>/1' ?9*".)9';4A):49*' /]1 HL!FU']>//' UE$:-.4'&6'T."+&*4'R&9)#&%)9A'S8$%#' /]J HL!FU']>/J' G%)9+)-.4*'6&%'L5D"*#)9A'?9*".)9']1iB1'V826,'X'' &%'JEi5$7'`G,';4A):49*' /]0 HL!FU']>/B' G%)9+)-.4*'6&%'L5D"*#)9A'S&:3)945'!$*$.'V`G,X'' $95'G%$95)$.'V;4A".$%'?9*".)9X';4A):49*' /]0 HL!FU']>/K' UE$:-.4'&6'H%$9*)#)&9)9A'6%&:']1iB1'V94*./24'++ 826,(#)X'#&'`G,i;4A".$%'V94*./24'+:'4,''f';(12)'X' /]] HL!FU']>/0' S&::&9'S&:-.)+$#)&9*'&6'()$34#4*'$95'H84)%'' G%4@$.49+4')9'Y&:4'L6%)+$9'S&8&%#*' /]g

chapter 8 HL!FU'g>/' ,)A82;)*P'[4$#"%4*')9',7-4%#49*)&9' /dB HL!FU'g>J' ?9)#)$#)&9'&6',7-4%#49*)&9'H%4$#:49#'L++&%5)9A'#&'' Y#$A4'$95';)*P'[$+#&%*' /dg HL!FU'g>B' ;4+&::49545',7-4%#49*)&9'R45)+$#)&9*'$95'' (&*)9A'6&%'R&*#'L5".#'G$#)49#*' J11 HL!FU'g>K' ;4+&::49545'R45)+$#)&9*'6&%'R$9$A4:49#'&6'' ,7-4%#49*)@4'U:4%A49+7'VL5".#'(&*)9AX' J1/ HL!FU'g>0' ,7-4%#49*)&9'R45)+$#)&9*'$95'(&*)9A')9'' Y4##)9A'&6'G%)9"%)$'&%'R).5';49$.'[$)."%4'' VS%4$#)9)94'/11kJ11'n:&.iFX' J1J HL!FU'g>Z' ;4+&::49545',7-4%#49*)&9'R45)+$#)&9*'' $95'(&*)9A')9'Y4##)9A'&6'Y4@4%4';49$.'[$)."%4'' ȋηʹͲͲn:&.iFX' J1B HL!FU'g>]' S$"*4*'&6'Y4+&95$%7',7-4%#49*)&9' J1K HL!FU'g>g' ,7-4%#49*)@4'()*&%54%*'&6'G%4A9$9+7' J1d HL!FU'g>d' F&$5)9A'$95'R$)9#49$9+4'(&*)9A'&6'R$A94*)":'' Y".6$#4')9'U+.$:-*)$'$95'Y4@4%4'G%44+.$:-*)$'' VL5$-#45'6%&:'?RGLSX' J// HL!FU'g>/1' ;4+&::49545'R45)+$#)&9*'6&%'R$9$A4:49#'&6'' ,7-4%#49*)&9')9'Y4@4%4'G%44+.$:-*)$' J/J HL!FU'g>//' ;4+&::49545',7-4%#49*)&9'R45)+$#)&9*'$95'' (&*)9A')9'G%4A9$9+7' J/B

chapter 9 HL!FU'd>/' S.)9)+$.'(4+)*)&9';".4*'6&%'H%4$#:49#'&6'G8$%79A)#)*' JJ1 table of contentsȀƢȀxix

HL!FU'd>J' L9#)3)&#)+';4A):49*'6&%'Y#%4-#&+&++$.'G8$%79A)#)*'' VL5".#*'$95'L5&.4*+49#*'(&*)9AC'_4)A8#'η'J]'PAX' JJJ HL!FU'd>B' L9#)3)&#)+';4A):49*'6&%'Y#%4-#&+&++$.'G8$%79A)#)*'' VG45)$#%)+'(&*)9AC'_4)A8#'ζ'J]'PAX' JJJ ͻǤͶ ϐ Ǧ ʹʹ͵ HL!FU'd>0' L9#)3)&#)+';4A):49*'6&%'Y4+&95$%7'G%&-87.$E)*'' &6';84":$#)+'[4@4%' JJ0 ͻǤ͸ ϐ' G&**)3.4';,(')9'Y+8&&.2LA45'S8).5%49' JJ] HL!FU'd>]' U+8&+$%5)&A%$-8)+'[4$#"%4*'&6'F46#2Y)545',4$%#'' \$.@4*'H8&"A8#'S&9*)*#49#'<)#8';84":$#)+',4$%#'' ()*4$*4')9',)A82G%4@$.49+4'Y4##)9A*'37'H8%44'Y4#*' &6'S%)#4%)$' JJg ͻǤͺ ϐ ʹʹͻ chapter 10 HL!FU'/1>/' U@$."$#)&9'&6'L*#8:$'L##$+P'Y4@4%)#7'VL5$-#45'6%&:' ?aLHF('T")54.)94*X' JBg HL!FU'/1>J' S$"*4*'&6'S8%&9)+'(7*-94$'&%'S8%&9)+'S&"A8'' ȋη͵Ȍ ʹ͵ͻ HL!FU'/1>B' S&::&9'Y)A9*'$95'Y7:-#&:*'&6'L*#8:$' JK/ ͳͲǤͶ ϐ ʹͶʹ HL!FU'/1>0' 'L*#8:$'S&9#%&.'H4*#' JKB HL!FU'/1>Z' L*#8:$'Y#4-'H84%$-7' JKZ HL!FU'/1>]' L*#8:$'R45)+$#)&9'(&*)9A' JK] xxȀƢȀchronic care integration for endemic non-communicable diseases

Protocols

chapter 4 G;bHbSbF'K>/' ?9)#)$.'()$A9&*)*'$95'R$9$A4:49#'&6',4$%#'[$)."%4' 0K G;bHbSbF'K>J' R$9$A4:49#'&6'(4+&:-49*$#45',4$%#'[$)."%4' 0g G;bHbSbF'K>B' \&.":4'Y#$#"*'L**4**:49#'$95'()"%4#)+'L5D"*#:49#' Z1 G;bHbSbF'K>K' S$%5)&:7&-$#87'R$9$A4:49#' Z0 G;bHbSbF'K>0' !4#$2!.&+P4%'H)#%$#)&9')9'S$%5)&:7&-$#87' Zd G;bHbSbF'K>Z' LSU2?98)3)#&%'H)#%$#)&9'$95'a*4'&6'' ,75%$.$^)94i?*&*&%3)54')9'S$%5)&:7&-$#87' ]/ G;bHbSbF'K>]' b#84%'R45)+$#)&9'`445*'6&%'S$%5)&:7&-$#87'G$#)49#*' ]J ͶǤͺ ϐ' ,7-4%#49*)@4',4$%#'()*4$*4' ]0 G;bHbSbF'K>d' L9#)87-4%#49*)@4'R$9$A4:49#')9',7-4%#49*)@4'' ,4$%#'()*4$*4' ]] G;bHbSbF'K>/1' L**4**:49#'&6'R45)+$#)&9'S&9#%$)95)+$#)&9*'$95'Y)54'' U664+#*')9'R$9$A4:49#'&6',7-4%#49*)@4',4$%#'()*4$*4' ]g G;bHbSbF'K>//' R$9$A4:49#'&6'R)#%$.'Y#49&*)*' ]d G;bHbSbF'K>/J' \$.@".$%'&%'S&9A49)#$.',4$%#'()*4$*4'R$9$A4:49#'' VUE+."5)9A'R)#%$.'Y#49&*)*X' gB G;bHbSbF'K>/B' LSU2?98)3)#&%'H)#%$#)&9'6&%'\$.@".$%'&%'S&9A49)#$.'' ,4$%#'()*4$*4'R$9$A4:49#'VUE+."5)9A'R)#%$.'Y#49&*)*X' gK G;bHbSbF'K>/K' b#84%'R45)+$#)&9*'6&%'\$.@".$%'&%'S&9A49)#$.',4$%#'' ()*4$*4'R$9$A4:49#'VUE+."5)9A'R)#%$.'Y#49&*)*X' gZ G;bHbSbF'K>/0' R$9$A4:49#'&6'?*&.$#45';)A8#2Y)545',4$%#'[$)."%4' gd G;bHbSbF'K>/Z' [.")5'Y#$#"*'R$9$A4:49#')9';)A8#2Y)545',4$%#'[$)."%4' d1 G;bHbSbF'K>/]' ()$A9&*)*'$95'H%4$#:49#'&6'H"34%+".&*)*'G4%)+$%5)#)*' dB G;bHbSbF'K>/g' LSU2?98)3)#&%'$95'Y-)%&9&.$+#&94'H)#%$#)&9'$95'' G$%$+49#4*)*'6&%'?*&.$#45';)A8#2Y)545',4$%#'[$)."%4' dK G;bHbSbF'K>/d' b#84%'R45)+$#)&9'`445*')9'?*&.$#45';)A8#2Y)545'' ,4$%#'[$)."%4' d0 G;bHbSbF'K>J1' ()$A9&*)*'$95'R$9$A4:49#'&6'L#%)$.'[)3%)..$#)&9' dd G;bHbSbF'K>J/' G$.-)#$#)&9*' /11

chapter 5 G;bHbSbF'0>/' R$9$A4:49#'&6'[4@4%')9'G$#)49#*'<)#8'G%&*#84#)+'' ,4$%#'\$.@4*' /JJ G;bHbSbF'0>J' ?9)#)$#)9A'_$%6$%)9'H84%$-7' /Jg G;bHbSbF'0>B' H)#%$#)9A'_$%6$%)9'H84%$-7' /B/ table of contentsȀƢȀxxi chapter 6 G;bHbSbF'Z>/' ?9)#)$.'U@$."$#)&9'&6'S8%&9)+'M)5947'()*4$*4'' Y#$A4'/'&%'J' /Bd G;bHbSbF'Z>J' ?9)#)$.'U@$."$#)&9'&6'S8%&9)+'M)5947'()*4$*4'' Y#$A4'BC'KC'$95'0' /K/ G;bHbSbF'Z>B' b"#-$#)49#'R$9$A4:49#'&6'R).5',7-4%P$.4:)$' /K0 chapter 7 G;bHbSbF']>/' ()$A9&*)*'&6'()$34#4*'$95'R$9$A4:49#'&6'' ,7-4%A.7+4:)$'$#',4$.#82S49#4%'F4@4.' /0] G;bHbSbF']>J' H%4$#:49#'&6'()$34#4*'<)#8'b%$.',7-&A.7+4:)+'' LA49#*'V)9'L5".#*X' /ZB G;bHbSbF']>B' ?9)#)$#)&9'$95'L5D"*#:49#'&6'?9*".)9';4A):49*' /Z] chapter 8 G;bHbSbF'g>/' ?9)#)$.'Y+%449)9A'$95'R$9$A4:49#'&6',7-4%#49*)&9'' )9'L+"#4'S&9*".#$#)&9'S.)9)+*' /d/ G;bHbSbF'g>J' ?9)#)$.'R$9$A4:49#'&6'`4<.7';464%%45',7-4%#49*)&9'' S$*4*)9',4$.#8'S49#4%'?9#4A%$#45'S8%&9)+'S$%4'S.)9)+*' /dK G;bHbSbF'g>B' ?9)#)$.'()$A9&*)*'$95'R$9$A4:49#'&6'Y"*-4+#45'' Y4+&95$%7',7-4%#49*)&9' J1K G;bHbSbF'g>K' [&..&<2a-'\)*)#'6&%'S8%&9)+',7-4%#49*)&9')9',4$.#8'' S49#4%'?9#4A%$#45'S8%&9)+'S$%4'S.)9)+' J10 G;bHbSbF'g>0' R$9$A4:49#'&6',7-4%#49*)&9')9'G%4A9$9+7' J/1 chapter 9 G;bHbSbF'd>/' U@$."$#)&9'$95'R$9$A4:49#'&6'G8$%79A)#)*' JJ/ G;bHbSbF'd>J' Y+%449)9A'6&%';84":$#)+',4$%#'()*4$*4'V$95'b#84%'' S&95)#)&9*'&6'Y+8&&.2LA45'S8).5%49X' JJd chapter 10 G;bHbSbF'/1>/' ?9)#)$.'R$9$A4:49#'&6'S8%&9)+'S&"A8'&%'Y8&%#94**'' &6'!%4$#8'$#',4$.#8'S49#4%'L+"#4'S$%4'S.)9)+*' JB] G;bHbSbF'/1>J' ?9)#)$.'R$9$A4:49#'&6'L*#8:$'&%'SbG('$#'?9#4A%$#45' S8%&9)+'S$%4'S.)9)+*' JK/ G;bHbSbF'/1>B' [&..&<2a-'R$9$A4:49#'&6'L*#8:$'&%'SbG('' $#',4$.#82S49#4%'F4@4.' JKg foreword

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References

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TABLE 1.1 Burden of Non-Communicable Diseases in Rwanda Linked to Conditions of Poverty

Condition Risk factors related to poverty

Hematology and Cervical cancer, gastric cancer, HPV, H. Pylori, EBV, HIV, Hepatitis B oncology4-7 lymphomas, Karposi’s sarcoma, hepatocellular carcinoma Breast cancer, CML Idiopathic, treatment gap

Hyperreactive malarial splenomegaly, Malaria hemoglobinopathies

Psychiatric8 Depression, psychosis, somatoform War, untreated chronic diseases, disorders undernutrition

Schizophrenia, bipolar disorder Idiopathic, treatment gap Neurological9-11 Epilepsy Meningitis, malaria

Stroke Rheumatic mitral stenosis, endocarditis, malaria, HIV

Cardiovascular12-14 Hypertension Idiopathic, treatment gap

Pericardial disease Tuberculosis

Rheumatic valvular disease Streptococcal diseases

Cardiomyopathies HIV, other viruses, pregnancy

Congenital heart disease Maternal rubella, micronutrient deﬁciency, idiopathic, treatment gap

Respiratory14,15 Chronic pulmonary disease Indoor air pollution, tuberculosis, schisto- somiasis, treatment gap

Renal16 Chronic kidney disease Streptococcal disease

Endocrine17 Diabetes Undernutrition

Hyperthyroidism and hypothyroidism Iodine deﬁciency

Musculoskeletal18,19 Chronic osteomyelitis Bacterial infection, tuberculosis

Musculoskeletal injury Trauma

Vision20 Cataracts Idiopathic, treatment gap

Refractory error Idiopathic, treatment gap

Dental21 Caries Hygiene, treatment gap chapter!1 | integration of chronic care services in rwandaȀƢȀ3

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TABLE 1.2 Leading Causes of Death and Disability in Rwanda in Disability-Adjusted Life Years (DALYs)24

Disease DALYs Fraction of (’000) total DALYs Lower respiratory infections 843 15.6%

Diarrheal diseases 633 11.7%

HIV/AIDS 557 10.3%

Maternal conditions 278 5.2%

Malaria 277 5.1%

Neonatal infections and other conditions 252 4.7%

Birth asphyxia and birth trauma 237 4.4% Tuberculosis 187 3.5% 74% Other infectious diseases (meningitis, 180 3.3% STDs excluding HIV, childhood-cluster diseases, upper respiratory infections, Hepatitis B, Hepatitis C) Tropical-cluster diseases 170 3.2%

Prematurity and low birth weight 155 2.9%

Protein-energy malnutrition 128 2.4%

Nutritional deﬁciencies 102 1.9% 4ȀƢȀchronic care integration for endemic non-communicable diseases

FIGURE 1.1 The Long Tail of Endemic NCDs in Rwanda

Congenital anomalies

Unipolar depression

Asthma

Epilepsy Diabetes mellitus COPD Myocarditis Cervical cancer Lymphomas Rheumatic heart disease

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FIGURE 1.2 Units of Planning for the Long-Tail Endemic NCDs Health facilities

Referral centers Cardiac surgery Medical specialties Pathology (1 per 5–10 million people) Cancer center Surgical specialties Radiology

District hospitals (1 per 250,000 2nd-level acute care generalist physicians people) chronic care

Health centers Integrated (1 per 20,000 Integrated gynecology people) (benign and malignant)

Community health workers (1 per 200 people) 6ȀƢȀchronic care integration for endemic non-communicable diseases

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FIGURE 1.3 Integration of Human Resources for Chronic Care Health Workers Health facilities (Number per Facility)

Referral centers Specialist (1 per 5–10 physicians (1–2 per million people) specialty)

Neuro- District hospitals Generalist NCD HIV and psychiatric physicians nurses TB nurses (1 per 250,000 nurses (4–10) (2–3) (4–5) people) (2–3)

Health centers Integrated (1 per 20,000 chronic care people) nurses (2–3)

Community health workers Integrated chronic care (1 per 200 CHWs (2) people)

TABLE 1.3 Sample District Hospital–Based Clinician Schedule

Monday Tuesday Wednesday Thursday Friday

Nurse 1 Preceptorship Teaching District hospital Teaching Administration of health center (didactics) heart failure (didactics) nurses clinic and preceptorship Nurse 2 District hospital District hospital Teaching District hospital Teaching hematology/ chronic respiratory (didactics) advanced (didactics) oncology and disease and diabetes and preceptorship preceptorship hypertension clinic and preceptorship 10ȀƢȀchronic care integration for endemic non-communicable diseases

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Chapter 1!References

/' RULYa;U'(,Y'bR>';<$95$'(4:&A%$-8)+',4$.#8'Y"%@47'???>'J110W';<$95$h' J110> J' RULYa;U'(,Y'bR>'?9#4%):';<$95$'(4:&A%$-8)+',4$.#8'Y"%@47>'J11]21gW' ;<$95$h'J11d> B' R)9)*#%7'&6',4$.#8>'`$#)&9$.'`"#%)#)&9'Y"::)#';4-&%#>'?9@4*#)9A')9'`"#%)#)&9' $*'$'[&"95$#)&9'6&%'Y"*#$)9$3.4'(4@4.&-:49#')9';<$95$>'M)A$.)W'T&@4%92 :49#'&6';<$95$h'J1/1'[43%"$%7> K' G$%P)9'(RC'Y)#$*'[C'S8)%49D4'RC'Y#4)9'FC'L3%$##';C'_$3)9A$',>'G$%#'?W'S$9+4%'' )9')95)A49&"*'L6%)+$9*o3"%549C'5)*#%)3"#)&9C'$95'#%495*>'F$9+4#'b9+&.' J11ghdWZgB2dJ> 0' `4<#&9';C'`A).):$9$'GIC'T%".)+8'LC'4#'$.>'S$9+4%')9';<$95$>'?9#'I'S$9+4%' /ddZhZZW]02g/> Z' !45"2L55&'TC'!$#4*'?>'S$"*4*'&6':$**)@4'#%&-)+$.'*-.49&:4A$.7')9'T8$9$>' F$9+4#'J11JhBZ1WKKd20K> ]' _4$#84%$..'(IC'S.4AA'I!>'?984%)#45'8$4:&A.&3)9'5)*&%54%*W'$9')9+%4$*)9A' A.&3$.'84$.#8'-%&3.4:>'!"..'_&%.5',4$.#8'b%A$9'J11/h]dW]1K2/J> g ǡ Ǥ ǣϐ $A4>'ILRL'J1/1hB1BW/d]Z2]> d' Y)::*'\C'L#)D&*$9'bC'M"-4%',C'`"8"'LC';)*+84<*P)'(C'F$@7'S>'G%4@$.49+4'&6' 4-).4-*7')9';<$95$W'$'9$#)&9$.'+%&**2*4+#)&9$.'*"%@47>'H%&-'R45'?9#',4$.#8' J11gh/BW/1K]20B> /1' !)%34+P'TFC'R&.794"E'RUC'M$-.$9'G_C'4#'$.>'!.$9#7%4'R$.$%)$'G%&D4+#' U-).4-*7'Y#"57'V!RGUYX'&6'94"%&.&A)+$.'&"#+&:4*')9'%4#)9&-$#872-&*)#)@4' -$45)$#%)+'+4%43%$.':$.$%)$'*"%@)@&%*W'$'-%&*-4+#)@4'+&8&%#'*#"57>'F$9+4#' `4"%&.'J1/1hdW//]B2g/> //' U5<$%5*'HC'Y+&##'LTC'R"97&P)'TC'4#'$.>'L+#)@4'+&9@".*)@4'4-).4-*7')9'$'%"%$.' 5)*#%)+#'&6'M497$W'$'*#"57'&6'-%4@$.49+4'$95'-&**)3.4'%)*P'6$+#&%*>'F$9+4#' `4"%&.'J11gh]W012Z> /J' S&::4%6&%5'GC'R$7&*)'!>'L9'$--%&-%)$#4'%4*4$%+8'$A495$'6&%'84$%#'5)*4$*4' )9'L6%)+$>'F$9+4#'J11ZhBZ]W/ggK2Z> /B' R&+":3)'LbC'[4%%4)%$'R!>'`4A.4+#45'+$%5)&@$*+".$%'5)*4$*4*')9'L6%)+$W' +8$..49A4*'$95'&--&%#"9)#)4*>'I'L:'S&..'S$%5)&.'J1/1h00WZg12]> /K' !"P8:$9'TC'q)4A.4%'IFC'G$%%7'U,>'U95&:7&+$%5)$.'[)3%&*)*W'*#)..'$':7*#4%7' $6#4%'Z1'74$%*>'?9W'GF&Y'`4A.4+#45'H%&-'()*h'J11gW4d]> /0' Y$.@)'YYC'!$%94*'GI>'S8%&9)+'&3*#%"+#)@4'-".:&9$%7'5)*4$*4')9'9&92*:&P4%*>' F$9+4#'J11dhB]KW]BB2KB> /Z' _8)#4'YFC'S8$53$9'YIC'I$9'YC'S8$-:$9'I;C'S$**'L>',&<'+$9'<4'$+8)4@4'A.&3$.' 4O")#7')9'-%&@)*)&9'&6'%49$.'%4-.$+4:49#'#84%$-7j'!"..'_&%.5',4$.#8'b%A$9' J11ghgZWJJd2B]> /]' R3$97$'ISC'R&#$.$'LLC'Y&39A<)'UC'L**$8'[MC'U9&%"'YH>'()$34#4*')9'' *"32Y$8$%$9'L6%)+$>'F$9+4#'J1/1hB]0WJJ0K2ZZ> /g' L#)D&*$9'bC';)*+84<*P)'(C'Y)::*'\C'4#'$.>'L'9$#)&9$.'*"%@47'&6':"*+".&*P4.2 4#$.'):-$)%:49#')9';<$95$W'-%4@$.49+4C'+$"*4*'$95'*4%@)+4'):-.)+$#)&9*>' GF&Y'b94'J11ghBW4Jg0/> /d' Y#$9.47'SRC';"#84%6&%5'T_C'R&%*845'YC'S&"A8.)9';;C'!474^$'H>'U*#):$#)9A' #84'84$.#8+$%4'3"%549'&6'&*#4&:74.)#)*')9'aA$95$>'H%$9*';'Y&+'H%&-'R45' ,7A'J1/1h/1KW/Bd2KJ> chapter!1 | integration of chronic care services in rwandaȀƢȀ15

J1' R$#849A4'_C'`P"%)P)74'IC'F):3"%A',C'M"-4%',>';$-)5'$**4**:49#'&6' ǣ ϐ Ǥ GF&Y'R45'J11]hKW4J/]> J/' G4#4%*49'GUC'!&"%A4&)*'(C'bA$<$',C'U*#"-)9$92($7'YC'`5)$74'S>'H84'A.&3$.' 3"%549'&6'&%$.'5)*4$*4*'$95'%)*P*'#&'&%$.'84$.#8>'!"..'_&%.5',4$.#8'b%A$9' J110hgBWZZ/2d> JJ' b34%:474%'qC';$D$%$#9$:'IMC'G$%P'S,C'4#'$.>'R4$*"%)9A'$5".#':&%#$.)#7'"*)9A' *)3.)9A'*"%@)@$.W'$'94<'$9$.7#)+$.':4#8&5'$95'94<'%4*".#*'6&%'KK'+&"9#%)4*C' /d]K2J11Z>'GF&Y'R45'J1/1h]W4/111JZ1> JB' I$:)*&9'(HC'_&%.5'!$9P>'()*4$*4'$95':&%#$.)#7')9'Y"32Y$8$%$9'L6%)+$>'' J95'45>'_$*8)9A#&9C'(>S>W'_&%.5'!$9Ph'J11Z> JK' R$#84%*'SC'!&4%:$'HC'[$#'(R>'H84'T.&3$.'!"%549'&6'()*4$*4W'J11K'a-5$#4>' T494@$W'_&%.5',4$.#8'b%A$9)^$#)&9h'J11g> J0' Y$:3'!C'U@$9*'HC'(73".'RC'4#'$.>'L9'$**4**:49#'&6')9#4%$+#)&9*'34#<449'A.&3$.' 84$.#8')9)#)$#)@4*'$95'+&"9#%7'84$.#8'*7*#4:*>'F$9+4#'J11dhB]BWJ/B]2Zd> JZ' ,^'GIC'[49<)+P'LC'Y$@)&.)'FC'R&.794"E'(,>';4*+")9A'#84'3&##&:'3)..)&9' #8%&"A8'+&9#%&.'&6'94A.4+#45'#%&-)+$.'5)*4$*4*>'F$9+4#'J11dhB]BW/0]120> J]' ,^'GIC'($$%'LY>'H84'S`S(*'$95'#84'`H(*W'3."%%)9A'#84'.)94*'5)@)5)9A' 9&9+&::"9)+$3.4'$95'+&::"9)+$3.4'+8%&9)+'5)*4$*4*>'GF&Y'`4A.'H%&-'()*' J11ghJW4B/J> Jg' M49A4'LGC'Y&39A<)'UC'[4^4"'FC'4#'$.>'Y4##)9A2"-'9"%*42.45'-).&#'+.)9)+*'6&%'#84' :$9$A4:49#'&6'9&92+&::"9)+$3.4'5)*4$*4*'$#'-%):$%7'84$.#8'+$%4'.4@4.')9' %4*&"%+42.):)#45'*4##)9A*'&6'L6%)+$>'H84'G$9'L6%)+$9'R45)+$.'I&"%9$.'J11dhB> Jd' I$9**49*'!C'\$9'($::4'_C';$.4)A8'!C'4#'$.>'b664%)9A')9#4A%$#45'+$%4'6&%'' ,?\iL?(YC'5)$34#4*'$95'87-4%#49*)&9'<)#8)9'+8%&9)+'5)*4$*4'+.)9)+*')9' S$:3&5)$>'!"..'_&%.5',4$.#8'b%A$9'J11]hg0Wgg120> B1' S&.4:$9';C'T)..'TC'_).P)9*&9'(>'`&9+&::"9)+$3.4'5)*4$*4':$9$A4:49#')9' %4*&"%+42-&&%'*4##)9A*W'$'-%):$%7'+$%4':&54.'6%&:'%"%$.'Y&"#8'L6%)+$>'!"..' _&%.5',4$.#8'b%A$9'/ddgh]ZWZBB2K1> B/' Y8":3"*8&'[C'@$9'T%)49*@49'IC'F&<%$9+4'(C'4#'$.>'H$*P'*8)6#)9A'6&%'*+$.42"-' &6',?\'+$%4W'4@$."$#)&9'&6'9"%*42+49#4%45'$9#)%4#%&@)%$.'#%4$#:49#'$#'%"%$.' 84$.#8'+49#4%*')9';<$95$>'GF&Y'R45'J11dhZW4/111/ZB> BJ' F&<%$9+4'(_C'`5$:$A4'[C'M$7)%$9A<$'UC'4#'$.>'L5".#'+.)9)+$.'$95')::"9&2 .&A)+'&"#+&:4*'&6'#84'9$#)&9$.'$9#)%4#%&@)%$.'#%4$#:49#'-%&A%$:')9';<$95$' ʹͲͲͶȂʹͲͲͷǤ ϐ ʹͲͲͻǢͷʹǣͶͻǦͷͷǤ BB' ($9)4.*'`>'I"*#'84$.#8W':44#)9A'84$.#8'9445*'6$)%.7>'`4<'c&%PW'S$:3%)5A4' a9)@4%*)#7'G%4**h'J11g> BK' [4$+84:';TC'_&%.5'!$9P>'H84'84$.#8'&6'$5".#*')9'#84'54@4.&-)9A'<&%.5W'' $'*"::$%7>'_$*8)9A#&9C'(>S>W'_&%.5'!$9Ph'/ddB> B0' [$%:4%'GC'F4$95%4'[C'R"P84%D44'IYC'4#'$.>'S&::"9)#723$*45'$--%&$+84*'#&' ,?\'#%4$#:49#')9'%4*&"%+42-&&%'*4##)9A*>'H84'F$9+4#'J11/hB0gWK1K2d>

chapter 2 Palliative Care and Chronic Care

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FIGURE 2.1 Diagram of Palliative Care throughout the Course of Illness and Bereavement (Adapted from WHO)1

Disease-speciﬁc therapy

Palliative care Bereavement

Diagnosis Death

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L.#8&"A8'#84%4')*'9&'.&9A4%'543$#4'$3&"#'#84'9445'6&%'"9)@4%*$.'$++4**' #&'L;\*C'#84%4'$%4'*#)..':$97'#%4$#:49#*'6&%'9&92+&::"9)+$3.4'5)*4$*4*' #8$#'$%4'9&#'%4$5).7'$@$).$3.4')9'%4*&"%+42-&&%'*4##)9A*>'b6'+&"%*4C'#84%4' $%4'.):)#*>'L..':45)+$.')9#4%@49#)&9*'6$..'<)#8)9'$'*-4+#%":'3')9'#4%:*' ϐ Ǥ ϐǫǦ ǡ2 ϐ ϐ #84%4')*'$'*&+)4#$.'&3.)A$#)&9'#&'-%&@)54'#84:>'S&"9#%)4*'.)P4'#84'a9)#45' M)9A5&:'8$@4'$##4:-#45'#&'$9*<4%'#8)*'O"4*#)&9'#8%&"A8'6&%:$.'+&*#2 4664+#)@494**'$9$.7*4*'$95'8$@4'54@4.&-45'9$#)&9$.'A")54.)94*>/1'Y):).$%' 466&%#*'8$@4'3449'"954%#$P49'6&%'%4*&"%+42-&&%'*4##)9A*>// chapter!2 | palliative care and chronic careȀƢȀ19

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TABLE 2.1 Cost/Impact Matrix of Medical Interventions, with Examples

High impact of therapy Low, marginal impact of therapy

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G$..)$#)@4'+$%4'%4*4$%+84%*'8$@4'54@4.&-45'$'@$.)5$#45'O"4*#)&99$)%4C' <8)+8'8$*'3449'#4*#45')9'%"%$.'*"32Y$8$%$9'L6%)+$9'*4##)9A*'V*44'TABLE 2.2X>/B'H84*4'O"4*#)&9*'<)..'9&#'34'$--.)+$3.4'6&%'$..'-$#)49#*'<)#8'+8%&9)+' chapter!2 | palliative care and chronic careȀƢȀ21

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TABLE 2.2 Symptom Assessment Scale (Adapted from the African Palliative Outcomes Scale)13

Questions for patient:

Q1. Please rate your pain during the last 3 days 0 (no pain) – 5 (worst/overwhelming pain)

Q2a. Have any other symptoms (e.g., nausea, coughing, or 0 (no, not at all) – 5 (overwhelmingly) constipation) been a#ecting how you feel in the last 3 days? Q2b. If so, please rate each symptom during the last 3 days: Dyspnea? 0 (no, not at all) – 5 (overwhelmingly) Nausea or vomiting? 0 (no, not at all) – 5 (overwhelmingly) Constipation? 0 (no, not at all) – 5 (overwhelmingly) Diarrhea? 0 (no, not at all) – 5 (overwhelmingly) Others? (specify) 0 (no, not at all) – 5 (overwhelmingly) Q3. Have you been feeling worried about your illness in the 0 (no, not at all) – 5 (overwhelming worry) past 3 days?

Q4. Over the past 3 days, have you been able to share how 0 (no, not at all) – 5 (yes, I’ve talked freely) you are feeling with your family or friends?

Q5. Over the past 3 days, have you felt that life was 0 (no, not at all) – 5 (yes, all the time) worthwhile?

Q6. Over the past 3 days, have you felt at peace? 0 (no, not at all) – 5 (yes, all the time)

Q7. Over the past 3 days, have you had enough help and 0 (no, not at all) – 5 (as much as wanted) advice for your family to plan for the future?

Questions for family caregiver:

Q8. Over the past 3 days, how much information have you 0 (none) – 5 (as much as wanted) and your family been given? N/A

Q9. Over the past 3 days, how conﬁdent has the family felt 0 (not at all) – 5 (very conﬁdent) caring for the patient? N/A

Q10. Has the family been feeling worried about the patient 0 (not at all) – 5 (severe worry) over the last 3 days? N/A

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2.2.3.1 Nociceptive Pain `&+)+4-#)@4'-$)9')*'+$"*45'37'#84'*#):".$#)&9'&6'-$)9'%4+4-#&%*'$#'#84' 495'&6'9&%:$.'*49*&%7'94%@4*'#8$#':45)$#4'-$)9>'`&+)+4-#)@4'-$)9')*'6"%2 #84%'*"35)@)545')9#&'*&:$#)+'$95'@)*+4%$.'-$)9>'Y&:$#)+'%4+4-#&%*')9'#84' *P)9C'*&6#'#)**"4*C':"*+.4C'&%'3&94'$%4'*#):".$#45C'$95'#84'%4*".#)9A'-$)9' "*"$..7')*'4$*7'6&%'#84'-$#)49#'#&'.&+$.)^4'$95'54*+%)34>'G$)9')9'#84'*P)9')*' &6#49'*8$%-C'3"%9)9AC'&%'#8%&33)9A>'G$)9')9'#84':"*+.4')*'&6#49'A9$<)9A' &%'5"..>'G$)9')9'#84'3&94')*'$.*&'A9$<)9A'$95'5"..C'3"#'+$9'34+&:4'*8$%-' <)#8':&@4:49#>'\)*+4%$.'-$)9'#7-)+$..7')*'9&#'.&+$.)^45C'3"#':&%4'5)66"*4C' $95':$7'34'%464%%45'#&'$'*)#4'5)*#$9#'6%&:'#84'.4*)&9>'?#':$7'34'5"..'&%' *8$%-'$95':$7'-%&5"+4'$'644.)9A'&6'-%4**"%4>'?#')*'+$"*45'37'*#):".$#)&9' &6'-$)9'%4+4-#&%*')9')9#4%9$.'&%A$9*C')9+."5)9A'8&..&<'@)*+4%$>'?#':$7'34' 5"4'#&'3.&+P$A4C'*<4..)9AC'&%'*#%4#+8)9A'&6'#84'&%A$9*'5"4'#&':4#$*#$*4*C' ϐǡ Ǥ

2.2.3.2 Neuropathic Pain `4"%&-$#8)+'-$)9')*'+$"*45'37'5$:$A4'#&'94%@4*'&%'3%$)9>'`4"%&-$#8)+' -$)9')*'&6#49'54*+%)345'$*'3"%9)9A'&%'.)P4'$9'4.4+#%)+'*8&+P>'H84%4'$.*&' +$9'34'9":394**C'#)9A.)9AC'&%'$..&579)$'V-$)9'%4*".#)9A'6%&:'$'*#):"."*' #8$#'9&%:$..7')*'9&#'-$)96".C'*"+8'$*'.)A8#'#&"+8X')9'#84'$%4$')994%@$#45' 37'#84')9D"%45'94%@4*>'H8)*'#7-4'&6'-$)9')*'@4%7'+&::&9'$:&9A'&"%'5)$2 34#)+C'+$9+4%C'$95',?\iL?(Y'-$#)49#*>'L97'P)95'&6')9D"%7'#&'94%@4'#)**"4' ǡ ϐ #":&%C')*+84:)$'6%&:'-&&%'+)%+".$#)&9'V)9'5)$34#4*':4..)#"*XC')964+#)&9' 37'@$%)+4..$'^&*#4%'&%',?\'@)%"*C'&%'94"%&#&E)+':45)+$#)&9*C'*"+8'$*'*&:4' +$9+4%'+84:T%$-7'5%"A*'$95'*&:4'L;\*C'4*-4+)$..7'5KH'V*#$@"5)94X> chapter!2 | palliative care and chronic careȀƢȀ23

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FIGURE 2.2 The WHO Three-Step Pain Ladder1

Severe pain or pain persisting/increasing Strong opioid +/- non-opioid +/- adjuvant Moderate pain or pain persisting/increasing Weak opioid (or low-dose strong opioid) +/- non-opioid +/- adjuvant Mild pain Non-opioid (paracetamol or NSAID) +/- adjuvant 24ȀƢȀchronic care integration for endemic non-communicable diseases

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34'$5D"*#45'$#'*"3*4O"49#'@)*)#*'3$*45'&9'#84'-$#)49#=*'-$##4%9'&6' 3&<4.':&@4:49#*>'b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ϐ *.44->';4*-)%$#&%7'54-%4**)&9')*'$'%$%4'*)54'4664+#'&6'&-)&)5'#84%$-7' <849'A")54.)94*'$%4'6&..&<45C'$95')#'94@4%'&++"%*'346&%4'*45$#)&9>'

TABLE 2.3'.)*#*'#84'4**49#)$.'-$)9':45)+$#)&9*'V3$*45'&9'#84';<$95$9' 6&%:".$%7X'#8$#'*8&".5'34'$@$).$3.4'$#'#84'84$.#82+49#4%'.4@4.> 26ȀƢȀchronic care integration for endemic non-communicable diseases

TABLE 2.3 Essential Medications for Pain Relief

Symptom Medication Dose Notes

Mild pain/ Acetaminophen/ Adult: 0.5–1 gram Use maximum 2 grams per day in patients fever reducers paracetamol every 4 to 6 hours. with enlarged livers or known liver disease. (non-opiates) Not to exceed 4 Very toxic to liver in overdose. grams in 1 day Child: 10-15 mg/ kg (maximum 90 mg/kg/day divided every 4–6 hours) Ibuprofen Adult: 400–800 Particularly e#ective in bone pain. Anti- mg every 6-8 hours inﬂammatory at higher doses. Can cause (maximum dose 2.4 digestive upset and gastrointestinal bleeding. gm/day) Do not use in renal failure. Decrease doses in Child: 40 mg/kg/ patients with severe liver failure. Prolonged day every 6–8 prescription requires cimetidine or omepra- hours zole for gastrointestinal prophylaxis. Diclofenac Adult: 25–75 mg Same as ibuprofen, but less expensive for every 12 hours long-term use, with simpler dosing.

Moderate to Morphine, liquid Adult: 2.5–10 mg Dose increases may be limited by oversedation. severe pain preparation every 4 hours. May Should decrease the dose or increase the give double dose at dosing interval in case of any renal failure. bedtime. Constipation is a common problem and all No maximum dose. patients should be placed on a bowel regimen Titrate to patient prophylactically (see TABLE 2.5). comfort. Child: 0.15 mg/ kg–0.3 mg/kg every 4 hours. Titrate as with adults. Neuropathic pain Amitriptyline Adult: 10–25 mg by Dose should be titrated upward every week (burning pains or mouth daily. to e#ect. May take weeks to work. Maximum shooting) Child: 0.5 mg/ dose in adults is 100 mg per day. Side e#ects kg once a day include initial drowsiness, postural hypoten- orally at bedtime. sion, dry mouth, mild tachycardia, constipa- Increase as needed tion. Life-threatening cardiac toxicity with by 0.2–0.4 mg/kg overdose. every 2–3 days to maximum of 5 mg/ kg/day. Phenytoin Adult: 100 mg Can use instead of, or in addition to, amitrip- twice per day ini- tyline if neuropathic pain persists. Avoid if on tially, increase up to anti-retrovirals due to drug interactions. 400 mg twice per day if needed Child: 2.5–5 mg/ kg twice per day (maximum 200 mg twice per day) Muscle spasms Diazepam Adult: 2.5–10 mg Drowsiness, ataxia. by mouth 2 to 3 times per day Child: 0.05 mg/ kg–0.1 mg/kg 3 to 4 times per day chapter!2 | palliative care and chronic careȀƢȀ27

Symptom Medication Dose Notes Pain from Prednisolone Adult: 20–80 mg May also improve nausea, fatigue, and swelling, by mouth daily appetite. Particularly helpful in the case of inﬂammation, or Child: 1 mg/kg x malignant lesions causing localized swelling neuropathy 1–2x/day by mouth in the muscle or bone. The dose should be decreased gradually over a period of 2–3 weeks and then stopped to avoid side e#ects.

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TABLE 2.4 Essential Medications for Control of Nausea/Vomiting

Cause of nausea Therapy

Liver failure, renal failure, Haloperidol metabolic derangement, Adult: 0.5–1 mg 2–4 times per day given orally, IV, or SC, around the clock drug side e#ect, or bacterial or as needed infection (nausea due to a ζ toxin or inﬂammatory Child ( 40 kg): 0.025–0.05 mg/kg/day in 2–3 divided doses. Increase by mediator) 0.25–0.5 mg/day every 5–7 days as needed to maximum dose 0.15 mg/kg/day Promethazine Adult: 12.5–25 mg every 4 hours orally, IV, IM, or by rectum Child (ζ40 kg): 0.25–1 mg/kg 4 times a day orally, IV, IM, or by rectum. Maximum dose: 25 mg per dose Dexamethasone Adult: 4–10 mg 2 times per day IV or IM, around the clock or as needed Child (ζ 40 kg): 0.5–1 mg/kg 2 times per day IV or SC around the clock or as needed. Maximum dose: 10 mg 2 times per day Increased intracranial Dexamethasone pressure, bowel obstruction, Adult: 4–10 mg 2 times per day IV or IM, around the clock or as needed or distension of liver or of ζ hollow viscus due to neoplasm Child ( 40 kg): 0.5–1 mg/kg 2 times per day IV or SC around the clock or as needed. Maximum dose: 10 mg 2 times per day Anxiety Diazepam Adult: 2.5–10 mg 3 times per day, orally, IV, or SC, around the clock or as needed Child (ζ 40 kg): 0.05–0.1 mg/kg/day divided 3–4 times per day Gastroparesis Metoclopramide Adult: 10 mg, 4 times per day, orally, IV, or SC, around the clock or as needed. Child: 0.1-0.2 mg/kg/dose 4 times per day, orally, IV or SC, around the clock or as needed Stimulation of vestibular Chlorpheniramine apparatus Adult: 4 mg orally every 4 hours, around the clock or as needed Child (ζ 40 kg): 1–2 mg by mouth every 4–6 hours. Maximum dose: 6 mg/ day for 2–5 yo, 12 mg/day for 6–11 yo, around the clock or as needed Promethazine Adult: 12.5–25 mg every 4 hours orally, IV, IM, or by rectum Child: 0.25–1 mg/kg 4 times a day orally, IV, IM, or by rectum. Maximum dose: 25 mg Adjuvants for nausea/ Chlorpheniramine vomiting of any cause Adult: 4 mg orally every 4 hours, around the clock or as needed Child (ζ 40 kg): 1–2 mg by mouth every 4–6 hours. Maximum dose: 6 mg/ day for 2–5 yo, 12 mg/day for 6–11 yo, around the clock or as needed

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L..'-$#)49#*'<)#8'+&9*#)-$#)&9'*8&".5'34'$**4**45'6&%'64+$.'):-$+#)&9' <)#8'$'5)A)#$.'%4+#$.'4E$:'$95'5)*):-$+#45':$9"$..7'$*'944545>'L..' ϐϐǡ2 $#45>'F$E$#)@4*'$95'494:$*':$7'$.*&'34'"*45'#&'4$*4'+&9*#)-$#)&9'V*44' TABLE 2.5X>'H84':&*#'+&::&9'#7-4*'&6'.$E$#)@4*'$%4'*#):".$9#*'V3)*$+&2 57.XC'&*:&#)+'$A49#*'V.$+#".&*4XC'$95'."3%)+$9#*'VA.7+4%)94X>'?9'-$#)49#*' <)#8'+&9*#)-$#)&9'5"4'-%):$%).7'#&'&-)&)5'#84%$-7C'$'*#):".$9#'.$E$#)@4')*' ϐǦǤ $%4'<4..'875%$#45>'?9'*4@4%4'+$*4*'&6'&-)&)52)95"+45'+&9*#)-$#)&9C'&%$.' 9$.&E&94'+$9'34'"*45'#&'%4@4%*4'#84'&-)&)5'4664+#'&9'#84'A"#>

TABLE 2.5 Essential Therapies for Treating Constipation

Treatment Dose

Glycerin suppository Adult: 4 gm suppository per rectum daily Child (ζ40 kg): 2 gm suppository per rectum daily Lactulose syrup Adult: 15–45 ml 2–3 times per day orally, maintain 30–90 ml/day Child (ζ40 kg): 7.5 ml 1 time per day orally Bisacodyl Adult: 10 mg once or twice daily, orally or per rectum Child (ζ40 kg): 0.3 mg/kg once daily by mouth. Maximum dose: 10 mg. Can also be given per rectum Naloxone Adult: 1–2 mg every 8 hours. Should only be given orally for this indication

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TABLE 2.6'&"#.)94*'#84'4@$."$#)&9'$95'#%4$#:49#'&6'5)$%%84$'9&#'&3@)&"*.7' 5"4'#&')964+#)&9>'`$%+&#)+*'$95'$9#)+8&.)94%A)+':45)+$#)&9*'*"+8'$*'87&*+)94' 3"#7.3%&:)54'+$9'84.-'%45"+4'5)$%%84$')6'.&-4%$:)54')*'9&#'$@$).$3.4> 30ȀƢȀchronic care integration for endemic non-communicable diseases

TABLE 2.6 Symptomatic Management of Diarrhea

Treatment Dose

Loperamide Adult: 4 mg orally initially, then 2 mg orally after every loose stool, up to a maximum of 16 mg per day Child (weight 13–20 kg): 1 mg orally 3 times per day Child (weight 21–30 kg): 2 mg orally up to 3 times per day Morphine, liquid preparation (low dose) Adult: 2.5 mg every 8 hours. May give orally, buccally, or rectally Child (ζ 40kg): 0.15 mg/kg, up to 2.5 mg every 4 hours. Administer as with adults Hyoscine butylbromide Adults: 10–20 mg every 6 hours orally or rectally

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TABLE 2.7 Management of Chronic Pruritus and Skin Care

Condition Treatment

Pruritus due to dry Emollient lotion such as calamine skin, renal failure Chlorpheniramine: Adult: 4 mg orally every 4 hours, around the clock or as needed Child (ζ 40 kg): 1–2 mg orally every 4 hours, around the clock or as needed Contact dermatitis Remove allergenic substance (e.g., from tape used High-potency topical steroid such as 0.05% betamethasone valerate in hospitals) Scabies Permethrin lotion applied from head (avoid face) to toes. Leave lotion on for 8–14 hours, then wash o#. The usual adult dose is 20–30 grams. Repeat in 1 week. Wash all clothes and bedding and dry in the sun. Do not use for babies less than 2 months old Cholestasis Adult: Prednisolone 10 mg per day. Cimetidine 400 mg twice per day.

Pruritus due to opioids Chlorpheniramine: Adult: 4 mg orally every 4 hours, around the clock or as needed Child (ζ 40 kg): 1–2 mg orally every 4 hours, around the clock or as needed Foul odor from wounds Keep wound clean. Crush metronidazole tables and sprinkle onto wound daily

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Chapter 2!References

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Chapter 3!References

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chapter 4 Heart Failure

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TABLE 4.1 Causes of Heart Failure Reported by Selected Echocardiographic Referral Centers in Sub-Saharan Africa

Authors Country n Age† RHD. (%) DCM‡ (%) EMF§ (%) HTN HD†† (%) ICM‡‡ (%)

Amoah Ghana 572 42 115 (20) 65 (11) 22 (4) 122 (21) 56 (10) et al. 200019 Freers Uganda 406 N/A 58 (12) 40 (8) 99 (22) 38 (8) 4 (1) et al. 19969 Kingue Cameroon 167 57 41 (25)tt 46 (27) 5 (12) 91 (55) 4 (3) et al. 200520 Thiam Senegal 170§§ 50 76 (45)tt 12 (7) 0 (0) 58 (34) 30 (18) et al. 200221

† Age = Mean Age; * RHD = Rheumatic heart disease; ‡ DCM = Dilated cardiomyopathies; § EMF = Endomyocardial ﬁbrosis; †† HTN HD = Hypertensive heart disease; ‡‡ ICM = Ischemic cardiomyopathy tt These series reported total valvulopathies. §§ Patients were double counted if they had two etiologic processes.

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FIGURE 4.1 Distribution of Causes of Heart Failure in a Rwandan NCD clinic (n = 134)

Rheumatic heart disease 33% 8%

13% Cardiomyopathy 41% 3%

Cardiomyopathy Rheumatic heart disease Hypertensive heart disease Other Congenital heart disease Cor pulmonale

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TABLE 4.2 Important Diagnostic Categories in Heart Failure

1. Cardiomyopathy

Diagnostic criteria 1. Moderately to severely depressed left ventricular function (ejection fraction u 40%)

2. Hypertensive heart disease

Diagnostic criteria 1. Severe hypertension 2. Shortness of breath 3. Normal to mildly depressed left ventricular function (ejection fraction η 40%) 3. Mitral stenosis

Diagnostic criteria 1. Mitral valve that doesn’t open well with typical hockey-stick or elbow deformity 2. Normal to mildly depressed left ventricular function (ejection fraction η 40%) 4. Other valvular heart disease (including rheumatic and congenital)

Diagnostic criteria 1. Normal to mildly depressed left ventricular function (ejection fraction η 40%) 2. No mitral stenosis 3. Blood pressure ζ 180/110 mmHg 4. Dramatic heart murmur 5. Isolated right heart failure

Diagnostic criteria 1. Ejection fraction η 40% 2. No mitral stenosis 3. Blood pressure ζ 180/110 mmHg 4. No heart murmur 5. Large right ventricle or dilated inferior vena cava on echocardiography

4.2 Physical Exam Findings for Classiﬁcation of Heart Failure ϐǤ b"%'5)$A9&*#)+'$.A&%)#8:*'"*4'&9.7'3.&&5'-%4**"%4'$95'#84'-%4*49+4'&6' Ǥϐǡ ϐǡ ǡ ǡ2 #$9#')9'54#4%:)9)9A':45)+$#)&9'$5D"*#:49#*'$95'5)*-&*)#)&9'<)#8)9'4$+8' 5)$A9&*#)+'$.A&%)#8:>

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TABLE 4.3 Physical Exam Findings in Classiﬁcation of Heart Failure

1. Dramatic murmurs 2. Blood pressure η 180 mmHg systolic or 110 mmHg diastolic

4.3 Echocardiography for Classiﬁcation of Heart Failure ϐ &6'84$%#'6$)."%4>'b"%'5)$A9&*#)+'$95'#%4$#:49#'$.A&%)#8:*'%4.7'&9'#84'+.)2 9)+)$9=*'$3).)#7'#&':$*#4%'#<&'4+8&+$%5)&A%$-8)+'@)4<*'&6'#84'84$%#W'#84' -$%$*#4%9$.'.&9A'$E)*'@)4<'$95'#84'*"3+&*#$.'@)4<'V*44'34.&'?9'#8&*4' @)4<*C'+.)9)+)$9*'$%4'$*P45'#&'34'$3.4'#&'%4+&A9)^4'&9.7'6&"%'5)664%49#'$32 9&%:$.)#)4*W'V/X':&54%$#4.7'#&'*4@4%4.7'54+%4$*45'4D4+#)&9'6%$+#)&9'VU[Xh' VJX':)#%$.'*#49&*)*h'VBX'$'@4%7'.$%A4'%)A8#'@49#%)+.4h'$95'VKX'$9'49.$%A45' )964%)&%'@49$'+$@$>'H84'#4+89)+$.'$--%&$+8'#&'&3#$)9)9A'".#%$*&"95' ):$A4*')*'54*+%)345')9':&%4'54#$).')9'#84'<9A+8(4.(/+$D+E/,#(*$.4)+D$#+ ;'*$.#5'F:2-2,')+=',,24>*>JK

TABLE 4.4 Echocardiographic Findings in Classiﬁcation of Heart Failure

1. Moderately to severely decreased EF (u 40%) 2. Mitral stenosis 3. Very large right ventricle (much larger than the aortic root or left atrium) 4. Clearly enlarged and non-collapsing vena cava (η 2.5 cm)

4.3.1 The Parasternal Long Axis View H84'-$%$*#4%9$.'.&9A'$E)*'@)4<')*'&3#$)945')9'#84'6&..&<)9A':$994%W' <)#8'#84'-$#)49#'.7)9A'&9'#84'.46#'*)54C'#84'-%&34')*'-.$+45'#&'#84'.46#'&6' #84'*#4%9":C')9'#84'K#8'&%'0#8')9#4%+&*#$.'*-$+4C'<)#8'#84'-%&34':$%P4%' -&)9#45'#&<$%5'#84'%)A8#'*8&".54%>'H84':)#%$.'@$.@4'$95'$&%#)+'@$.@4' *8&".5'34'+.4$%.7'*449'V*44'FIGURE 4.2'$95'FIGURE 4.3X>

FIGURE 4.2 Parasternal Long Axis View

Right ventricle

Aortic root

Left ventricle Left atrium

Mitral valve Mitral valve (anterior leaﬂet) (posterior leaﬂet) 44ȀƢȀchronic care integration for endemic non-communicable diseases

FIGURE 4.3 Normal Parasternal Long Axis View on Echocardiography (Diastole, top; Systole, bottom)

Right ventricle

Left ventricle in diastole

Aortic root

Left atrium

Mitral valve Mitral valve (posterior leaﬂet) (anterior leaﬂet)

Left ventricle in systole

Closed mitral valve

4.3.2 The Subcostal View H84'*"3+&*#$.'@)4<')*'&3#$)945'<)#8'#84'-%&34'-.$+45'"954%'#84'E)-8&)5' Ǥϐǡ #84'.)@4%'*449'$#'#84'#&-'&6'#84'*+%449'V*44'FIGURE 4.4X>'H84'?\S')*'*449' $*'$'3.$+P'#"34'49#4%)9A'#84'%)A8#'@49#%)+.4'V*44'FIGURE 4.5X>'?#'*8&".5'34' :4$*"%45'J'+:'6%&:')#*'49#%$9+4')9#&'#84'%)A8#'@49#%)+.4>' chapter!4 | heart failureȀƢȀ45

FIGURE 4.4 Subcostal View

Liver

Tricuspid valve Right ventricle

Right atrium

Left Inferior vena cava (IVC) ventricle Left atrium

Mitral valve 46ȀƢȀchronic care integration for endemic non-communicable diseases

FIGURE 4.5 Subcostal View with Normal IVC (top) and Dilated IVC (bottom) Liver Inferior Tricuspid Right valve vena cava Right atrium ventricle (IVC)

Left ventricle

Mitral valve

Left atrium

Dilated Liver inferior vena cava (IVC)

Right atrium

_4'8$@4'6&"95'#8$#'$*'+.)9)+)$9*'34+&:4':&%4'$54-#'$#'#84*4'@)4<*C' :$97'#$P4')#'"-&9'#84:*4.@4*'#&'.4$%9'#84'T%'3$*)+'4+8&+$%5)&A%$-82 ϐǤ 3"#')*'9&#'4**49#)$.')9'54#4%:)9)9A'$--%&-%)$#4':45)+$.':$9$A4:49#' &6'84$%#'6$)."%4>'[&%':&%4')9254-#8')9*#%"+#)&9'&9'4+8&+$%5)&A%$-87' #4+89)O"4*C'-.4$*4'%464%'#&'#84'<9A+8(4.(/+$D+E/,#(*$.4)+D$#+;'*$.#5'F :2-2,')+=',,24>*>JK chapter!4 | heart failureȀƢȀ47

4.3.3 Ejection Fraction and Fractional Shortening ȋ Ȍϐ2 #$9#'5)$A9&*#)+'*P)..')9'+$#4A&%)^)9A'84$%#'6$)."%4>'U['%464%*'#&'#84'$:&"9#' &6'3.&&5'#8$#'#84'84$%#'-":-*'&"#'<)#8'4$+8'34$#>'UD4+#)&9'6%$+#)&9')*' $':4$*"%4'&6'#84'84$%#=*'*7*#&.)+'6"9+#)&9W'8&<'<4..'#84'84$%#'<&%P*' 5"%)9A'#84'*O"44^)9A'-8$*4'&6'#84'+$%5)$+'+7+.4>'L'9&%:$.'U[')*'34#<449' 00m'$95'Z0mC':4$9)9A'#8$#'#84'9&%:$.'84$%#'-":-*'$3&"#'8$.6'&6'#84' 3.&&5')9'#84'.46#'@49#%)+.4'&"#')9#&'#84'$&%#$'<)#8'4$+8'34$#>

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FIGURE 4.6'*8&<*'8&<'#84'.46#'@49#%)+".$%'<$..*'5&'9&#':&@4'#&A4#84%' @4%7':"+8')9'$'84$%#'<)#8'$'+$%5)&:7&-$#87o#84'.46#'@49#%)+.4'%4:$)9*' $3&"#'#84'*$:4'*)^4'+&9#%$+#45'$*'%4.$E45C'$95'#84'<$..*'5&'9&#'#8)+P49' :"+8>'S&:-$%4'#8)*'#&'#84'9&%:$.'84$%#')9'FIGURE 4.3> 48ȀƢȀchronic care integration for endemic non-communicable diseases

FIGURE 4.6 Cardiomyopathy in Parasternal Long Axis View (Diastole, top; Systole, bottom)

Right ventricle Left ventricle in diastole Aortic root

Left atrium

Mitral valve Mitral valve (anterior leaﬂet) (posterior leaﬂet)

Left ventricle in systole

Closed mitral valve

4.3.4 Assessment for Mitral Stenosis ?9'-$#)49#*'<)#8'%84":$#)+':)#%$.'*#49&*)*C'#84':)#%$.'@$.@4'8$*'$'*#%)P2 )9A.7'+8$%$+#4%)*#)+'$--4$%$9+4')9'#84'-$%$*#4%9$.'.&9A'$E)*'@)4<'V*44' FIGURE 4.7X>'H84'64$#"%4*'&6'#7-)+$.'%84":$#)+':)#%$.'*#49&*)*')9+."54W' V/X'$'*:$..'&-49)9A'&6'#84':)#%$.'@$.@4')9'5)$*#&.4'V*44'FIGURE 4.3'$95' FIGURE 4.6 ȌǢȋʹȌϐ 8$*'$'8&+P47'*#)+P'&%'4.3&<'546&%:)#7h'VBX'.46#'@49#%)+".$%'6"9+#)&9')*' #7-)+$..7'9&%:$.>' chapter!4 | heart failureȀƢȀ49

FIGURE 4.7 Mitral Stenosis in Diastole

Right ventricle

Left ventricle

in diastole Aortic root

Left atrium

Mitral valve Small opening (anterior leaﬂet of stenotic mitral valve in diastole with hockey stick or elbow deformity)

4.3.5 Assessment of Right Heart Size ?9'+$*4*'&6'%)A8#'84$%#'6$)."%4C'#84'%)A8#'@49#%)+.4':$7'$--4$%'49.$%A45' &9'#84'-$%$*#4%9$.'.&9A'$E)*'@)4<'V*44'FIGURE 4.8X>'`&%:$..7C'#84'%)A8#' @49#%)+.4')*'%&"A8.7'#84'*$:4'*)^4'$*'#84'$&%#)+'%&&#'$95'#84'.46#'$#%)":>'

FIGURE 4.8 Right Ventricular Enlargement (Parasternal Long View)

Right ventricle (very dilated in diastole) 50ȀƢȀchronic care integration for endemic non-communicable diseases

4.3.6 Assessment of the Inferior Vena Cava H84')964%)&%'@49$'+$@$')9'#84'*"3+&*#$.'@)4<'*8&".5'34'*:$..'$95'+&.2 .$-*4'6"..7'<)#8'4$+8')9*-)%$#)&9>'L9'?\S'A%4$#4%'#8$9'J'+:'#8$#'5&4*9=#' +&..$-*4')*'*#%&9A.7'*"AA4*#)@4'&6'*&:4'4.4:49#'&6'%)A8#2*)545'84$%#' 6$)."%4'V*44'FIGURE 4.5X>'

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ϐ ǡ ϐǤ *"3+&*#$.'@)4'R$97'-$#)49#*':$7'8$@4'*:$..'-4%)+$%5)$.'466"*)&9*> chapter!4 | heart failureȀƢȀ51

FIGURE 4.9 Pericardial E"usion (Parasternal View, top; Subcostal View, bottom)

Large pericardial e!usion Left ventricle

Large pericardial e!usion Liver

Left atrium

4.4 Initial Recognition and Referral of the Heart Failure Patient ,4$%#'6$)."%4'-$#)49#*':$7'-%4*49#'#&'$97'.4@4.'&6'#84'84$.#8'+$%4'*7*#4:>' ϐ 34'%464%%45'#&'#84'5)*#%)+#'`S('+.)9)+>

L#'84$.#82+49#4%'[email protected]'84$%#'6$)."%4'-$#)49#*'&6#49'-%4*49#'<)#8'9&92 ϐ Ǥ ǡ +.)9)+$..7'):-&%#$9#'84$%#'6$)."%4')9';<$95$'<)..'8$@4'*8&%#94**'&6' 3%4$#8'$#'$'54+%4$*45'.4@4.'&6'$+#)@)#7>'S.)9)+)$9*'*8&".5'%464%'-$#)49#*'' #&'#84'`S('+.)9)+'<8&'5&'9&#'8$@4'$9')964+#)&"*'-%&+4**'#&'4E-.$)9'#84)%' 52ȀƢȀchronic care integration for endemic non-communicable diseases

ϐTABLE 4.5'V*44'34.&'CHAPTER 102&"#.)94*'#84'$+"#4' +$%4'84$.#8'+49#4%'$--%&$+8'#&'*8&%#94**'&6'3%4$#8>

TABLE 4.5 Common Signs and Symptoms of Heart Failure (Usually Present in Addition to Shortness of Breath)

1. Lower-extremity edema 2. Loud murmurs 3. Orthopnea (shortness of breath when lying prone)

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Y"*-4+#45'84$%#'6$)."%4'-$#)49#*'%464%%45'#&'#84'5)*#%)+#'`S('+.)9)+' *8&".5'%4+4)@4'$'+&:-.4#4'8)*#&%7C'-87*)+$.'4E$:C'$95'4+8&+$%5)&A%$-87>' ϐϐ 2 %)4*'&%'%4+4)@4'$9'$.#4%9$#4C'9&92+$%5)$+'5)$A9&*)*>

S.)9)+)$9*'<)..'#849'54#4%:)94'#84')9)#)$.'#%4$#:49#'3$*45'&9'#84'#%4$#2 :49#'$.A&%)#8:'6&%'#8$#'5)$A9&*#)+'+$#4A&%7'V*44'PROTOCOL 4.1X> chapter!4 | heart failureȀƢȀ53

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ϐ 9&92+$%5)$+'+$"*4*'&6'#84)%'*7:-#&:*C'*"+8'$*'%49$.'&%'.)@4%'6$)."%4> 54ȀƢȀchronic care integration for endemic non-communicable diseases

PROTOCOL 4.1 Initial Diagnosis and Management of Heart Failure

Suspected or conﬁrmed heart failure

Treat as Signs of decompensated decompensated Echo-conﬁrmed YES NO heart failure heart failure? heart disease? (Protocol 4.2) (Table 4.7) (Section 4.3)

NO YES

Ultrasound available? Follow appropriate treatment protocol YES according to diagnosis (Protocols 4.3–4.18) NO Abnormal Treat as left ventricular YES cardiomyopathy function? (Protocol 4.4)

≥ Mitral Treat as mitral BP 180/110 NO YES stenosis? stenosis mmHg (Protocol 4.11)

NO Treat as valvular/ Murmur YES congenital disease YES (Protocol 4.12)

NO Treat as hypertensive heart disease Large, Signs Treat as (Protocol 4.8) non-collapsing of right- right-sided YES IVC or very YES sided heart heart failure large right failure (Protocol 4.15) ventricle NO NO

Consider alternate diagnoses

`4E#C'$..'#%4$#:49#'$.A&%)#8:*'34A)9'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*' *7:-#&:'*4@4%)#7'$95'@&.":4'*#$#"*>'H8)*'$**4**:49#'<)..'34'5)*+"**45' )9'#84'6&..&<)9A'*4+#)&9*> chapter!4 | heart failureȀƢȀ55

4.5 Heart Failure Severity Classiﬁcation G$#)49#*'<)#8'84$%#'6$)."%4'&6'$97'4#)&.&A7'6$..'$.&9A'$'+&::&9'+&9#)9"2 ":'&6'*7:-#&:'*4@4%)#7>'H84*4'$%4'+$#4A&%)^45')9#&'6&"%'A%&"-*C'3$*45' ϐ ȋTABLE 4.6X>' ϐ +.4$%.7'5&+":49#'$'84$%#'6$)."%4'-$#)49#=*'+.)9)+$.'+&"%*4>

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TABLE 4.6 New York Heart Association Heart Failure Classiﬁcation

Class I Patients with cardiac disease but no resulting limitation of physical activity. Ordinary physical activity does not cause symptoms.

Class II Patients with cardiac disease resulting in mild limitation of physical activity. Patients are comfortable at rest. Ordinary physical activity (farming, running, carrying water, climbing a hill) causes symptoms. Class III Patients with cardiac disease resulting in moderate limitation of physical activity. Patients are comfortable at rest. Less than ordinary physical activity (light housework, walking on ﬂat ground) causes symptoms. Class IV Patients with cardiac disease resulting in severe limitation of physical activity. Patients have symptoms at rest. Any physical activity causes symptoms.

4.6 Decompensated Heart Failure _849'$'-$#)49#=*'3&57')*'9&'.&9A4%'+&:-49*$#)9A'<4..'6&%'#84'54A%44'&6' 84$%#'57*6"9+#)&9C'@&.":4'*#$#"*'$95'6"9+#)&9$.'$3).)#7'<)..'<&%*49>'H8)*' )*'#4%:45'54+&:-49*$#45'84$%#'6$)."%4>'S."4*'#8$#'$'-$#)49#'8$*'49#4%45' #8)*'*#$#4'$%4'$39&%:$.'@)#$.'*)A9*'V*"+8'$*'.&<'3.&&5'-%4**"%4'$95'6$*#' 84$%#'%$#4X'$95'*4@4%4'*7:-#&:*'&6'57*-94$'$95'&%#8&-94$'V*44'TABLE 4.7X>'H84*4'-$#)49#*'$%4'#&&'*)+P'#&'34'#%4$#45')9'#84'+&::"9)#7'$95' ϐǤ PROTOCOL 4.2'-%&@)54*'A")5$9+4'&9'8&<'#&'4@$."$#4'$95')9)#)$#4'#%4$#2 :49#'6&%'-$#)49#*'<)#8'54+&:-49*$#45'84$%#'6$)."%4> 56ȀƢȀchronic care integration for endemic non-communicable diseases

TABLE 4.7 Signs of Decompensated Heart Failure in Adults

Vital signs Blood pressure Very low (SBP ζ 80 mmHg) Very high (SBP η 180 mmHg)

Pulse Very low (ζ 40 bpm) Very high (η120 bpm)

High respiratory rate η 24 breaths/minute

Low oxygen saturation Saturation ζ 90%

Symptoms Inability to lie down ﬂat Severe dyspnea at rest

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TABLE 4.8 Reasons for Acute Decompensation in Patients with Heart Failure

1. Medication nonadherence or recent changes in medications

2. Change in diet (e.g., increase in salt intake)

3. Acute illness (e.g., pneumonia, rheumatic fever, endocarditis)

5. Worsening valvular disease

6. Pregnancy Exacerbates all types of heart failure, but especially mitral stenosis (2nd and 3rd trimester) and peripartum cardiomyopathy. 7. Arrhythmia Especially common in patients with cardiomyopathies and valvular disease, particularly mitral stenosis. 8. Worsened hypertension Very high blood pressure can cause acute sti#ening of the heart muscle and back up of ﬂuid into the lungs (pulmonary edema). 58ȀƢȀchronic care integration for endemic non-communicable diseases

PROTOCOL 4.2 Management of Decompensated Heart Failure

Signs of Decompensated Place IV, hospitalize or Heart Failure prepare for transfer to (Table 4.7) hospital

Lower blood ≥ pressure BP 180/110 YES mmHg? (see Table 8.4, Section 8.4)

Obtain YES HR ≥ 120 ECG

Signs of atrial Look for other Signs of ﬂuid ﬁbrillation (irregularly reasons for NO overload NO decompensation and spaced QRS and/or (Table 4.9) no P waves) treat accordingly

YES YES

Initial furosemide dose Load with (Table 4.10 ) digoxin, start anticoagulation (see Section 4.16.1) Dose Diuresis after Diuresis within NO escalation 1–2 dose 30 minutes? (Table 4.10) escalations?

YES NO

Check Treat according creatinine, to diagnosis consider (Sections 4.8–4.12) alternative diagnosis

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TABLE 4.9 Volume Status Categories and Diuretic Adjustment

Category Hypovolemic Euvolemic Hypervolemic

Mild Moderate Severe (decompensated)

Weight Less than At dry weight ζ 5 kg above η 5 kg above dry η 5 kg above dry dry weight dry weight weight weight

Symptoms Variable Class I–II Class I–II Class II–III Class III–IV

Vital signs Tachycardia Normal Normal Mild tachycardia Tachycardia, tachypnea, Hypotension hypoxia, hypotension, or hypertension Physical Does not always correlate with severity. Signs of ﬂuid overload include distended neck veins, exam lung crackles, louder murmurs, hepatomegaly, ascites, and lower-extremity edema. However, can be intravascularly hypovolemic and still have signs of hypervolemia in lungs, extremities, and abdomen. Creatinine Increased Stable or Stable or Can be increased (due to hypoperfusion of decreased decreased the kidneys), stable or decreased.

Diuretic Stop all Reduce or Maintain or Increase dose Start IV furosemide adjustment diuretics maintain dose increase or add second and prepare for (if starting beta- dose agent transfer to hospital if blocker, do not possible reduce diuretic) 60ȀƢȀchronic care integration for endemic non-communicable diseases

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PROTOCOL 4.3 Volume Status Assessment and Diuretic Adjustment

Suspected or conﬁrmed heart failure

Perform volume assessment

Hypervolemia Hypovolemia Euvolemia

Mild Moderate Severe Stop all diuretics, consider giving ﬂuids Maintain OR Increase increase IV diuresis, diuretic hospitalize diuretic dose dose Low EF AND starting or increasing beta-blocker dose

YES NO

Decrease OR Maintain maintain diuretic diuretic dose dose chapter!4 | heart failureȀƢȀ61

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TABLE 4.10 Intravenous Furosemide (Lasix) Dosing

Initial dosing Escalation Maximum dose Patient does not already Adult: Double every 30 minutes Adult: take furosemide 40 mg IV 2x–3x/day until response or maximum 100 mg IV 2–3x/day dose achieved Pediatric (ζ 40 kg): Pediatric: 0.5 mg/kg IV 2x/day 2 mg/kg 2–3x/day Patient already takes Double e#ective outpatient furosemide dose and give as IV 62ȀƢȀchronic care integration for endemic non-communicable diseases

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TABLE 4.11 Equivalent Oral and IV Furosemide (Lasix) Doses

Oral IV

80 mg PO 40 mg IV

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4.7.2 Guidelines for Initiating and Titrating Oral Furosemide at Health-Center Level R&*#'-$#)49#*'<)#8'84$%#'6$)."%4'<)..'8$@4'$'#49549+7'#&'*#&%4'#&&':"+8' ϐǤ <)#8'-%&-4%'#84%$-7C'3"#':&*#'<)..'%4O")%4'$'.&<'.&9A2#4%:':$)9#49$9+4' 5&*4>'H8)*':4$9*'#8$#'-$#)49#*'<8&'<4%4'-%4@)&"*.7'87-4%@&.4:)+'3"#' 34+&:4'4"@&.4:)+'$6#4%'5)"%4*)*'<)..'*#)..'&6#49'%4O")%4'5)"%4#)+*'#&' ϐǤ ǡ ϐ 3$.$9+4'$95'#&'+&9#%&.'*7:-#&:*>'TABLE 4.12'&"#.)94*'#84'%4+&::49545' 5&*)9A'&6'&%$.'6"%&*4:)54>

TABLE 4.12 Oral Furosemide (Lasix) Dosing

Initial dose Dose adjustment Maximum dose Hypovolemia Euvolemia Mild Moderate Severe hypervolemia hypervolemia hypervolemia

Adult: Stop all May attempt Keep dose Double current Admission and Adult: 40 mg diuretics, to decrease the same dose or add intravenous 80 mg 1x/day consider dose unless second agent diuresis (see 2x/day giving ﬂuid starting or TABLE 4.10) Pediatric: increasing Pediatric: 1 mg/kg beta-blocker 2 mg/kg 1x/day 2–3x/day

4.7.3 Guidelines for Use of Other Diuretics b#84%'&%$.'5)"%4#)+*'34*)54*'6"%&*4:)54':$7'34'"*45'#&'84.-'$+8)4@4'$95' :$)9#$)9'4"@&.4:)$'V*44'TABLE 4.13X>'H84*4':45)+$#)&9*'$%4'A494%$..7' $5545'#&'6"%&*4:)54'#&')9+%4$*4'#84'*#%49A#8'&6'5)"%4*)*>'_8).4'#847' :$7'34'@4%7'4664+#)@4C'#84*4':45)+$#)&9*'+$9'$.*&')9+%4$*4'#84'+8$9+4*' &6'4.4+#%&.7#4'$39&%:$.)#)4*'$95'T%'*)54'4664+#*'&6'6"%&*4:)54C'$95' *8&".5'34'"*45'<)#8'+$"#)&9> chapter!4 | heart failureȀƢȀ63

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4.7.3.2 Hydrochlorothiazide ,75%&+8.&%)$^)54')*'$'<4$P4%'5)"%4#)+'#8$9'6"%&*4:)54C'3"#'$+#*' )9':"+8'#84'*$:4'<$7>'_849'#$P49'B1':)9"#4*'-%)&%'#&'6"%&*4:)54C' 875%&+8.&%)$^)54'+$9':$P4'6"%&*4:)54'<&%P'34##4%C'+$"*)9A'$'.$%A4%' 5)"%4*)*>'L'@4%7'*:$..'9":34%'&6'-$#)49#*'*8&".5'%4O")%4'#8)*>'H8)*'+&:2 3)9$#)&9'+$9'+$"*4':$**)@4'5)"%4*)*'$95'.&**'&6'@)#$.'4.4+#%&.7#4*C'$95' #84%46&%4'*8&".5'&9.7'34'+&9*)54%45')9'+&9*".#$#)&9'<)#8'$'-87*)+)$9' $95'<)#8'@4%7'+.&*4':&9)#&%)9A'&6'4.4+#%&.7#4*>

TABLE 4.13 Other Oral Diuretic Dosing

Drug Initial dosing Notes Maximum dose Spironolactone Adult: 25 mg 1x/day Add if patient has signiﬁcant ascites 50 mg/day and normal renal function Pediatric (ζ 40 kg): 3 mg/kg/day 2.5 mg/kg 1x/day Hydrochlorothiazide Adult: 12.5 mg 1x/day Can be used if furosemide is not 25 mg/day available or added to furosemide if Pediatric (ζ 40 kg): 12 mg/day greater diuresis is desired. 1 mg/kg/day

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H84%4'$%4':$97'5)664%49#'+$"*4*'&6'+$%5)&:7&-$#87'V*44'TABLE 4.14X>' L*'*#$#45'$3&@4C'*&:4'#7-4*'&6'84$%#'6$)."%4'34A)9'$*'$'+$%5)&:7&-$#87>' b#84%*C'8&<4@4%C'*"+8'$*'@$.@".$%'&%'87-4%#49*)@4'84$%#'5)*4$*4C'+$9' -%&A%4**'#&'$'+$%5)&:7&-$#87'&@4%'#):4>'L97'-$#)49#'<)#8'$9'4D4+#)&9' 6%$+#)&9'.4**'#8$9'K1mC'%4A$%5.4**'&6'#84'+$"*4C'*8&".5'34'#%4$#45'-%)2 :$%).7'$*'$'+$%5)&:7&-$#87>'S$%5)&:7&-$#8)4*'$664+#'-$#)49#*'&6'4@4%7' $A4'A%&"->

TABLE 4.14 Etiology of Cardiomyopathy in Rwanda

Idiopathic Most of the cases of cardiomyopathy are caused by an unknown process. Many may be due to a previous viral infection.

HIV cardiomyopathy HIV can cause direct cellular damage to heart muscle. ARVs can delay or reverse this process.

Alcohol-related Chronic alcohol use can be toxic to the heart muscle. If the patient stops drinking cardiomyopathy alcohol, the function may improve with time.

Peripartum Women can develop a cardiomyopathy in the last month of pregnancy and up to six months postpartum. This often improves with appropriate management and avoidance of subsequent pregnancies. Viral myocarditis Many di#erent viruses can infect the heart muscle and cause dysfunction. This often improves with time, but may be permanent.

Anemia Severe anemia (sometimes due to cancer or poor nutrition) can lead to cardiomyopathy. This can improve when the anemia is treated.

Advanced valvular Most valvular conditions causing abnormal ﬂow of blood within the heart can lead disease to a cardiomyopathy. This is particularly true with regurgitant lesions. This is not the case for pure mitral stenosis, in which the left ventricle is protected, while the right ventricle ultimately su#ers.

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PROTOCOL 4.4 Cardiomyopathy Management

Ejection fraction ≤ 40%

Assess vital signs, treat decompensated heart failure (Protocol 4.2)

Assess ﬂuid status, adjust furosemide (Protocol 4.3, Tables 4.9 and 4.12)

Adjust heart failure beta-blocker (Protocol 4.5)

Assess renal function and potassium, adjust ACE inhibitor OR hydralazine/isosorbide (Protocol 4.6)

Assess other medication needs (Protocol 4.7)

Follow-up planning (Section 4.13, Table 4.23)

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TABLE 4.15 Mortality-Reducing Medications for Cardiomyopathy

Beta-blocker

Starting dose Dose change Target dose

Carvedilol 3.125–6.25 mg 2x/day 3.125–6.25 mg 2x/day 25 mg 2x/day

Atenolol* 12.5 mg 1x/day 12.5 mg 1x/day 50 mg 1x/day

ACE inhibitor

Starting dose Dose change Target dose

Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day

Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day

Enalapril 2.5 mg 2x/day 2.5 mg 2x/day 10–20 mg 2x/day

Hydralazine/isosorbide dinitrate (Contraindications to beta-blocker and/or ACE inhibitor)

Starting dose Dose change Target dose

Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day

Isosorbide 10 mg 3x/day 10 mg 3x/day 30 mg 3x/day

Potassium-sparing diuretic

Starting dose Dose change Target dose

Spironolactone 12.5–25 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day

* Only if no carvedilol or other heart failure beta-blocker available.

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PROTOCOL 4.5 Beta-Blocker Titration in Cardiomyopathy

Cardiomyopathy, diuretic adjustments made

HR ≤ 50 bpm OR SBP ≤ 80 bpm

YES NO

Decrease or do not start HR beta-blocker 50–60 bpm

YES

At target dose of beta-blocker (Table 4.15) Maintain OR or do not start YES plan to increase beta-blocker ACE inhibitor OR decrease diuretic

Increase Maintain Fluid beta-blocker or do not start overload YES NO dose beta-blocker (Table 4.9) (Table 4.15)

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PROTOCOL 4.6 ACE-Inhibitor Titration and Use of Hydralazine/Isosorbide in Cardiomyopathy

Cardiomyopathy, diuretic and beta-blocker adjustments made

Stop/do not start Able to check YES Pregnant NO ACE creatinine AND/OR inhibitors potassium?

YES NO

At ACE inhibitor Creatinine goal dose SBP ≥ 200 µmol/L NO ≤ 90 NO OR increasing AND/OR mmHg ≥ beta-blocker? K 5.5 mEq/L?

YES

Decrease or maintain YES YES ACE inhibitor NO

NO Maintain SBP ≥ 90 Decrease/ ACE inhibitor mmHg do not start dose ACE inhibitor

NO YES

Increase K ≥ 6.5 ACE inhibitor Start, mEq/L Wait to start or (Table 4.15) continue or decrease increase hydralazine hydralazine and isosorbide and dinitrate isosorbide Admit, treat (Table 4.15 ) dinitrate hyperkalemia (Table 4.15) (Section 6.5)

4.8.3.4 Spironolactone L*'54*+%)345')9'SECTION 4.7.3C'*-)%&9&.$+#&94'+$9'34'$'"*46".'$5D"9+#)@4' 5)"%4#)+')9'+$*4*'&6'$*+)#4*>'F)P4'LSU')98)3)#&%*C'*-)%&9&.$+#&94'+$9'+$"*4' $'%)*4')9'*4%":'-&#$**)":C'4*-4+)$..7')9'#84'-%4*49+4'&6'%49$.'6$)."%4>'' ?#'*8&".5'34'$@&)545')6'#84'+%4$#)9)94'.4@4.')*'A%4$#4%'#8$9'J11'n:&.iF' ȋηʹǤ͵ȀȌǤǡ <)#8'+8%&9)+$..7'.&<'-&#$**)":'*4+&95$%7'#&'#84'"*4'&6'6"%&*4:)54'&%' 875%&+8.&%)$^)54>'Y-)%&9&.$+#&94'8$*'$.*&'3449'*8&<9'#&'%45"+4' :&%#$.)#7'37'B1m')9'-$#)49#*'<)#8'.46#'@49#%)+".$%'57*6"9+#)&9'<8&'$%4' $.%4$57'#$P)9A'LSU')98)3)#&%*>K/CKJ'TABLE 4.15'*8&<*'%4+&::49545'5&*)9A> 72ȀƢȀchronic care integration for endemic non-communicable diseases

4.8.4 Other Medications in Cardiomyopathy Management (4-495)9A'&9'#84'*"*-4+#45'4#)&.&A7'&6'+$%5)&:7&-$#87'$95i&%'5)*4$*4' +&6$+#&%*C'+4%#$)9'$5D"9+#)@4':45)+$#)&9*':$7'34')95)+$#45>'PROTOCOL 4.72 -%&@)54*'A")5$9+4'&9'"*)9A'#84*4'T%':45)+$#)&9*>'

PROTOCOL 4.7 Other Medication Needs for Cardiomyopathy Patients

Patient with cardiomyopathy, diuretic, beta-blocker and ACE inhibitor/hydralazine/isosorbide adjustments made

Woman Refer to between 15 and 49 YES family years planning

Peripartum YES Aspirin CMP?

Irregular Atrial YES heart rhythm ﬁbrillation by ECG

NO NO YES

Alcohol Abstinence YES CMP? Start warfarin (see Chapter 5) NO Refer to infectious YES HIV? disease clinic NO

Class Digoxin III or IV YES symptoms (Table 4.16)

Ascites OR ≤ ≤ K 3.5 mEq AND Cr 100 YES Spironolactone µmol/L AND SBP ≥ 90 (Table 4.15) chapter!4 | heart failureȀƢȀ73

4.8.4.1 Digoxin (Digitalis) ()A&E)9')*'&94'&6'#84'&.54*#'$95':&*#'<)54.7'$@$).$3.4':45)+$#)&9*'6&%' #84'#%4$#:49#'&6'84$%#'6$)."%4>'?#'$+#*'#&')9+%4$*4'#84'-":-)9A'6"9+#)&9' ϐ )*'-%4*49#>'a*)9A'5)A&E)9'+$9'):-%&@4'*7:-#&:*')9'-$#)49#*'<)#8'84$%#' 6$)."%4>',&<4@4%C')9'$'.$%A4'+.)9)+$.'#%)$.C')#'5)5'9&#'54+%4$*4':&%#$.2 )#7>KB'L.*&C'$#'8)A8'5&*4*C'#&E)+)#7'+$9'54@4.&-C'<8)+8'<)..'%4*".#')9'@)*"$.' +8$9A4*C'5)^^)94**C'&%'9$"*4$C'$95'+$9'.4$5'#&'5$9A4%&"*'$%%87#8:)$*>' H&E)+)#7'<)..'&++"%')6'5)A&E)9')*'"*45')9'-$#)49#*'<)#8'%49$.'6$)."%4C'*&'#8)*' ζͳͲͲρȀǤKK'_4' %4*4%@4'5)A&E)9'6&%'-$#)49#*'<)#8'+.$**'???'&%'?\'84$%#'6$)."%4'*7:-#&:*>' ϐǡ 84.-'<)#8'%$#4'+&9#%&.>'

TABLE 4.16'.)*#*'%4+&::49545'5)A&E)9'5&*)9A>

TABLE 4.16 Digoxin Dosing

Starting dose Maximum dose

0.125 mg/day 0.25 mg/day

4.8.4.2 Aspirin _849'#84'84$%#'5&4*'9&#'-":-'<4..C'3.&&5'#495*'#&'*)#'*#)..')9*)54'#84' 84$%#'$95':$7'6&%:'+.&#*C'<8)+8'+$9'#849'4:3&.)^4'V#%$@4.'#&'T%'-$%#*' &6'#84'3&57XC'+$"*)9A'*#%&P4'&%'T%'+$#$*#%&-8)+'4@49#*>'G4%)-$%#":' +$%5)&:7&-$#87'-$#)49#*'$%4'$#'-$%#)+".$%.7'8)A8'%)*P'6&%'#8)*C'$*'<4..' $*'6&%'@49&"*'+.&#*>'H847'*8&".5'34'*#$%#45'&9'/11':A'&6'$*-)%)9'5$).7' #&'84.-'#8)9'#84'3.&&5>'G$#)49#*'<)#8'4@)549+4'&6'$9'$+#)@4'+.&#'<)..'9445' *#%&9A4%'$9#)+&$A".$#)&9'V*44'CHAPTER 5X>

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4.8.4.4 Antiretrovirals (ARVs) a9#%4$#45',?\')964+#)&9'6%4O"49#.7'.4$5*'#&'+$%5)&:7&-$#87>K0CKZ'G%45)+2 #&%*'&6',?\'+$%5)&:7&-$#87'$%4'&--&%#"9)*#)+')964+#)&9'$95'.49A#8'&6' 74ȀƢȀchronic care integration for endemic non-communicable diseases

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,7-4%#49*)@4'84$%#'5)*4$*4'%4*".#*'6%&:'.&9A2*#$95)9AC'*4@4%4'87-4%#492 *)&9>'H84'87-4%#49*)&9')#*4.6':$7'34')5)&-$#8)+'V<8)+8')*':&*#'+&::&9X' &%'*4+&95$%7'#&'$9T%'-%&3.4:'V*"+8'$*'$'P)5947'&%'495&+%)94'5)*2 ȌǤ ȋζͶͲȌ *"*-4+#45o*4@4%4'%49$.'6$)."%4')9'-$%#)+".$%o$.#8&"A8'87-4%#49*)&9' )#*4.6'+$9'+$"*4'%49$.'6$)."%4>'

H%4$#:49#'&6'87-4%#49*)@4'84$%#'5)*4$*4')9+."54*'+&9#%&.'&6'@&.":4'*#$2 #"*'$95'3.&&5'-%4**"%4>'PROTOCOL 4.82-%&@)54*'$9'&"#.)94'6&%'87-4%#492 *)@4'84$%#'5)*4$*4':$9$A4:49#> chapter!4 | heart failureȀƢȀ75

PROTOCOL 4.8 Management of Suspected or Conﬁrmed Hypertensive Heart Disease

Suspected or conﬁrmed hypertensive heart disease

Assess ﬂuid status, adjust furosemide dose (Protocol 4.3, Tables 4.9 and 4.12)

Assess blood pressure and adjust hypertensive medications (Protocol 4.9)

Assess medication contraindications and side e!ects (Protocol 4.10)

Follow-up planning (Section 4.13, Table 4.23)

4.9.1 Vital Sign Assessment L*'<)#8'$..'#7-4*'&6'84$%#'6$)."%4C':$9$A4:49#'&6'87-4%#49*)@4'84$%#' 5)*4$*4'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95'&@4%$..' +&95)#)&9>'(4+&:-49*$#)&9')9'-$#)49#*'<)#8'87-4%#49*)@4'84$%#'5)*4$*4' ǡȋηͳͺͲȌǡ %4*".#)9A')9'*#)6649)9A'&6'#84'84$%#>'L*'54*+%)345')9'CHAPTER 8C'#84' $--%&$+8')9'#8)*'*)#"$#)&9')*'#&'.&<4%'#84'3.&&5'-%4**"%4'A%$5"$..7o' ʹͷΨϐʹͶǤ

4.9.2 Fluid Status Assessment H84'94E#'*#4-')9'#84':$9$A4:49#'&6'87-4%#49*)@4'84$%#'5)*4$*4')*'#84' ϐ ǤSECTION 4.7C' TABLE 4.9C'$95'PROTOCOL 4.3>

4.9.3 Titration of Antihypertensives ?9'&%54%'#&'-%4@49#'<&%*49)9A'84$%#'6$)."%4'*7:-#&:*C'$9#)87-4%#492 ζͳ͵ͲȀͺͲǤ 76ȀƢȀchronic care integration for endemic non-communicable diseases

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TABLE 4.17 Antihypertensives for Hypertensive Heart Disease

First-line drug Initial dose Dose increase Maximum Side e"ects/cautions (ACE inhibitor) dose Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day 1. Birth defects (contraindicated in pregnancy) Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day 2. Chronic non-productive cough 3. High potassium 4. Worsened renal function Second-line drug Initial dose Dose increase Maximum Side e"ects/cautions (thiazide) dose Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Lowers potassium

Third-line drug Initial dose Dose increase Maximum Side e"ects/cautions (CCB)* dose Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Lower-extremity swelling

Nifedipine 20 mg 2x/day 20 mg 2x/day 40 mg 2x/day (sustained release)

Fourth-line drug Initial dose Dose increase Maximum Side e"ects/cautions (beta-blocker) dose Atenolol 25 mg 1x/day 25 mg 1x/day 50 mg 1x/day 1. Bradycardia 2. Renally excreted 3. Decrease dose for renal failure Fifth-line drug Initial dose Dose increase Maximum Side e"ects/cautions (vasodilator) dose Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day 1. Headache 2. Tachycardia 3. Lower-extremity swelling

* CCB = Calcium-channel blocker chapter!4 | heart failureȀƢȀ77

PROTOCOL 4.9 Antihypertensive Management in Hypertensive Heart Disease

Hypertensive heart disease diuretic dose adjustments already made

BP ≥ Add 2 drugs OR 160/100 YES increase 2 drug doses mmHg if already on 4 drugs

BP ≥ 130/80 Add 1 drug OR ≤ 160/100 YES increase 1 drug dose mmHg if already on 4 drugs

≥ BP 90/70 Maintain current ≤ YES 130/80 medications mmHg

≤ Decrease current BP 90/70 YES mmHg medications 78ȀƢȀchronic care integration for endemic non-communicable diseases

PROTOCOL 4.10 Assessment of Medication Contraindications and Side E"ects in Management of Hypertensive Heart Disease

Suspected or conﬁrmed hypertensive heart disease, diuretic and anti-hypertensive adjustments made

Pregnant, Cr ≥ 200 µmol/L Stop or do not start AND/OR YES captopril/lisinopril AND/OR K ≥ 5.5 mEq/L? spironolactone.

K ≥ 6.5 mEq/L

YES NO

≤ Admit, treat HR 50 hyperkalemia bpm? (Section 6.5)

YES

Reduce, stop or do not start beta-blocker

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PROTOCOL 4.11 Management of Mitral Stenosis

Assess vital signs and clinical Mitral status. Treat and refer stenosis decompensated heart failure

Assess ﬂuid status, adjust furosemide dose (Protocol 4.3, Tables 4.9 and 4.12)

HR ≥ 60 Start/increase bpm and atenolol if not YES SBP ≥ 90 contraindicated mmHg? (Table 4.10)

Suspected Penicillin RHD and YES prophylaxis ≤ 40 years old? (Table 9.5)

Refer to Female, age family planning between 15 YES and 49? (Section 3.5)

Atrial Start warfarin if ﬁbrillation feasable and not Aspirin 100 NO (on ECG) YES contraindicated, mg 1x/day AND/OR prior otherwise give aspirin stroke (Chapter 5)

Surgical Follow-up planning candidate? NO (Section 4.13, Table 4.23)

YES

Surgical planning (Chapter 5) 80ȀƢȀchronic care integration for endemic non-communicable diseases

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ϐǡ ǡ 6$*#'84$%#'%$#4*>'G$#)49#*'<)#8':)#%$.'*#49&*)*'$%4'"9$3.4'#&'#&.4%$#4'#84*4' 6$*#'84$%#'%$#4*'$95'<)..'34+&:4'@4%7'*)+P'&%'4@49'5)4')6'#84'$%%87#8:)$' ǤǦ ȋȌϐǦǤ ǡ ϐ $95':)#%$.'*#49&*)*'+$99&#'34'&3#$)945'<)#8'34#$23.&+P4%*'$.&94C'&%')6' 3.&&5'-%4**"%4'.):)#*'#84'"*4'&6'34#$23.&+P4%*C'+.)9)+)$9*':$7'-%4*+%)34' ζʹͲͲρȀǤȋTABLE 4.18'$95' SECTION 4.16.1>X

TABLE 4.18 Medications to Reduce Heart Rate in Mitral Stenosis

Medication Initial dose Dose increase Maximum dose

Beta-blocker (for use in sinus tachycardia or atrial ﬁbrillation)

Atenolol 12.5 mg 1x/day 12.5 mg 1x/day 50 mg 1x/day

Digoxin (only if tachycardia and atrial ﬁbrillation)

Digoxin 0.125 mg 1x/day 0.125 mg 1x/day 0.25 mg 1x/day chapter!4 | heart failureȀƢȀ81

4.10.4 Other Medications in Management of Mitral Stenosis 4.10.4.1 Penicillin ;84":$#)+'84$%#'5)*4$*4'+$"*4*'$.:&*#'$..'+$*4*'&6':)#%$.'*#49&*)*' )9'%4*&"%+42-&&%'*4##)9A*>'L*'54*+%)345')9'CHAPTER 9C'-%4@49#)&9'&6' 6"%#84%'$##$+P*'&6'%84":$#)+'64@4%'#8%&"A8'-49)+)..)9'-%&-87.$E)*'84.-*' *.&<'#84'-%&A%4**)&9'&6'%84":$#)+'@$.@".$%'5)*4$*4>'L.#8&"A8'%84":$#)+' 64@4%'A494%$..7'$664+#*'*+8&&.2$A45'+8).5%49C'<4'%4+&::495'-49)+)..)9' -%&-87.$E)*'6&%'$..'-$#)49#*'<)#8'%84":$#)+'@$.@".$%'5)*4$*4'"954%'#84' $A4'&6'K1>'Y44'SECTION 9.2 ϐ $95'$5:)9)*#%$#)&9>'

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4.10.4.3 Anticoagulation (Aspirin and Warfarin) L..'-$#)49#*'<)#8':)#%$.'*#49&*)*'$%4'$#'@4%7'8)A8'%)*P'&6'54@4.&-)9A'+.&#*' )9'#84)%'5).$#45C'*#$A9$9#'.46#'$#%)":>'H84*4'+.&#*'8$@4'$'8)A8'.)P4.)8&&5' Ǥϐ )9+%4$*4*'#84'+8$9+4*'&6'+.&#'6&%:$#)&9'$95'*#%&P4C'$95'-$#)49#*'<)#8' ϐǤ ǡ $..'-$#)49#*'<)#8':)#%$.'*#49&*)*'*8&".5'%4+4)@4'*&:4'#7-4'&6'3.&&52 Ǥ ϐǡ *#%&9A4%'$9#)+&$A".$#)&9')9'#84'6&%:'&6'<$%6$%)9'*8&".5'34')9)#)$#45')6' #84%4'$%4'9&'+&9#%$)95)+$#)&9*'#&'<$%6$%)9'#84%$-7'V*44'CHAPTER 5X>'?6' Ǧ ϐǡ -%4*+%)345>

4.11 Other Valvular and Congenital Heart Disease H8)*'+$#4A&%7'49+&:-$**4*'#84':&*#'5)@4%*4'A%&"-'&6'84$%#'6$)."%4' -$#)49#*>'a9.)P4'#84'-%4@)&"*.7'54*+%)345'84$%#'6$)."%4'+$#4A&%)4*C'#84*4' 5)*4$*4*'&6#49'%4O")%4'$5@$9+45'4+8&+$%5)&A%$-87'*P)..*'6&%'5)664%49#)$2 #)&9>'[&%#"9$#4.7C'#847'$.*&'*8$%4'$'+&::&9')9)#)$.'$--%&$+8')9':$9$A42 :49#'V*44'PROTOCOL 4.12X>'_4'#84%46&%4'$%A"4'#8$#'$#'#84'5)*#%)+#'84$.#8' +49#4%'[email protected]'#84*4'-$#)49#*'+$9'34'*$64.7':$9$A45'$*'$9'"95)664%49#)$#45' ϐ 5)$A9&*)*>

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H8)*'+&..4+#)&9'&6'84$%#'6$)."%4'5)$A9&*4*')*'3'.$%A4%'$95':&%4'5)@4%*4' #8$9'#84'-%4@)&"*'+$#4A&%)4*>',&<4@4%C'#84*4'5)*4$*4*'*8$%4'$'+&::&9' -$#8<$7')9'#84)%')9)#)$.':45)+$.':$9$A4:49#>'R&%4&@4%C'5)664%49#)$#)&9' $:&9A'#84*4'5)*4$*4*'&6#49'%4O")%4*'$'8)A84%'.4@4.'&6'4+8&+$%5)&A%$-8)+' $95'T%'5)$A9&*#)+'*P)..*'#8$9'$%4'%4$*&9$3.7'$##$)9$3.4'37'A494%$.)*#' -87*)+)$9*'&%'$5@$9+45'9"%*4*')9'%4*&"%+42-&&%'*4##)9A*>

H84'+&::&9'A&$.*')9'#84':45)+$.':$9$A4:49#'&6'#8)*'A%&"-'&6'84$%#' ϐ ǯǤϐ 5)*4$*4'<)..'34'*"%A)+$.C'$95'#8"*'$..'-$#)49#*'*"664%)9A'#8)*'+.$**'&6'84$%#' 6$)."%4'*8&".5'34'4@$."$#45'37'$'+$%5)&.&A)*#'&%'4E-4%)49+45')9#4%9)*#'&%' -45)$#%)+)$9'<)#8)9'Z'<44P*'#&'Z':&9#8*'&6'5)$A9&*)*> chapter!4 | heart failureȀƢȀ83

PROTOCOL 4.12 Valvular or Congenital Heart Disease Management (Excluding Mitral Stenosis)

Suspected or echocardiographically conﬁrmed valvular or congenital heart disease. No evidence of mitral stenosis

Assess ﬂuid status, adjust diuretic (Protocol 4.3, Tables 4.9 and 4.12)

Assess creatinine, potassium and need for ACE inhibitor (Protocol 4.13)

Assess other medication needs (Protocol 4.14)

Follow-up, surgical planning, consultation with a cardiologist

Surgical Follow-up planning candidate? NO (Section 4.13, Table 4.23)

YES

Surgical planning (Chapter 5)

4.11.1 Vital Sign Assessment L*'<)#8'$..'#7-4*'&6'84$%#'6$)."%4C':$9$A4:49#'&6'#8)*'+&..4+#)&9'&6'84$%#' 6$)."%4'#7-4*'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95' &@4%$..'+&95)#)&9>

4.11.2 Fluid Status Assessment ϐ &6'5)"%4#)+*>'Y44'SECTION 4.7C'TABLE 4.9C'$95'PROTOCOL 4.3> 84ȀƢȀchronic care integration for endemic non-communicable diseases

4.11.3 Titration of ACE Inhibitors ?9'-$#)49#*'<)#8'@$.@".$%'84$%#'5)*4$*4'V4E+."5)9A':)#%$.'*#49&*)*XC')#')*' ):-&%#$9#'#&'%45"+4'#84'<&%P.&$5'&6'#84'84$%#'37'.&<4%)9A'#84'3.&&5' -%4**"%4>'H84'84$%#'<$*'54*)A945'#&'-":-'3.&&5')9'&9.7'&94'5)%4+#)&9>' ǡ ϐ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k/J1'::,A>'PROTOCOL 4.13'&"#.)94*'$9'$--%&$+8'#&' )9)#)$#)9A'$95'#)#%$#)9A'LSU')98)3)#&%*>'

PROTOCOL 4.13 ACE-Inhibitor Titration for Valvular or Congenital Heart Disease Management (Excluding Mitral Stenosis)

Valvular or congenital disease, diuretic adjustments made

Able to check creatinine AND/OR NO potassium?

YES

Pregnant, Stop/do not ≥ creatinine 200 SBP ≤ 100 start ACE YES NO µmol/L AND/OR mmHg inhibitors K ≥ 5.5 mEq/L?

K ≥ 6.5 mEq/L

Maintain At YES ACE inhibitor YES ACE inhibitor dose goal dose

Treat for hyperkalemia NO (see Section 6.5)

Increase ACE inhibitor chapter!4 | heart failureȀƢȀ85

4.11.4 Other Medications 4.11.4.1 Spironolactone G$#)49#*'<)#8'5)*4$*4'&6'$97'&6'#84'@$.@4*'&9'#84'%)A8#'*)54'&6'#84'84$%#' +$9'54@4.&-'*7:-#&:*'&6'%)A8#'84$%#'6$)."%4C')9+."5)9A':$**)@4'$*+)#4*>' ?9'#84*4'-$#)49#*C'*-)%&9&.$+#&94'+$9'34'$'"*46".'$5D"9+#'#&'6"%&*4:)54' V*44'TABLE 4.19X>'Y-)%&9&.$+#&94'*8&".5'9&#'34'"*45')9'-$#)49#*'<)#8' ȋηʹͲͲρȀηʹǤ͵ȀȌ 87-4%P$.4:)$>'S&9+"%%49#'"*4'<)#8'$9'LSU')98)3)#&%'+$9'$.*&'+$"*4' 5$9A4%&"*'87-4%P$.4:)$C'$95'#84*4'-$#)49#*'*8&".5'8$@4'-&#$**)":' :&9)#&%45'4@4%7'*)E':&9#8*>'

4.11.4.2 Penicillin L*'54*+%)345')9'CHAPTER 9C'-49)+)..)9'-%&-87.$E)*'84.-*'*.&<'#84'-%&2 A%4**)&9'&6'%84":$#)+'@$.@".$%'5)*4$*4'37'-%4@49#)9A'6"%#84%'$##$+P*'&6' %84":$#)+'64@4%>'L.#8&"A8'%84":$#)+'64@4%'A494%$..7'$664+#*'*+8&&.2$A45' +8).5%49C'<4'%4+&::495'-49)+)..)9'-%&-87.$E)*'6&%'$..'-$#)49#*'<)#8' %84":$#)+'@$.@".$%'5)*4$*4'"954%'#84'$A4'&6'K1>'Y44'SECTION 9.2'6&%'*-42 ϐ Ǥ

TABLE 4.19 Medications for Valvular/Congenital Heart Disease

Initial dose Dose adjustment Maximum dose

ACE inhibitor

Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day

Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day

Potassium-sparing diuretic

Spironolactone 12.5–25 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day 86ȀƢȀchronic care integration for endemic non-communicable diseases

PROTOCOL 4.14 Other Medications for Valvular or Congenital Heart Disease Management (Excluding Mitral Stenosis)

Patient with congenital or valvular disease (excluding mitral stenosis) and diuretic, ACE-inhibitor adjustments made

Woman Refer to family between 15 YES planning and 49 years (Section 3.5)

Suspected Penicillin RHD and YES prophylaxis age ≤ 40 (Table 9.5)

Irregular heart rate YES Atrial ﬁbrillation by ECG

YES NO NO

Protocol 4.9

Ascites AND K ≤ 3.5 mEq/L AND Start Cr ≤ 100 µmol/L YES spironolactone AND SBP ≥ 90 (Table 4.15) mmHg

4.11.5 Cardiac Surgery Evaluation ϐ 34'*"%A)+$.C'$95'#8"*'$..'-$#)49#*')9'#8)*'+.$**'&6'84$%#'6$)."%4'*8&".5'34' 4@$."$#45'37'$'+$%5)&.&A)*#'&%'4E-4%)49+45')9#4%9)*#'<)#8)9'Z'<44P*'#&'Z' :&9#8*'&6')9#$P4>'L.#8&"A8'$5@$9+45'4+8&+$%5)&A%$-87')*'9&#'944545'#&' A")54':45)+$.':$9$A4:49#'&6'#84'-$#)49#C')#')*'94+4**$%7'#&'4@$."$#4'#84' ϐ ǤǦ +&:-49*$#45':$7'34'+$95)5$#4*'6&%'*"%A)+$.')9#4%@49#)&9'346&%4'#847' chapter!4 | heart failureȀƢȀ87

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4.12 Right-Sided Heart Failure Etiology and Diagnosis H84'#4%:*'%)A8#2'$95'.46#2*)545'84$%#'6$)."%4'$%4'&6#49'"*45'#&'54*+%)34' $'-$#)49#=*'-%4*49#)9A'*7:-#&:*>'R&*#'4#)&.&A)4*'&6'84$%#'6$)."%4'+$9' %4*".#'6%&:'.46#2*)545'84$%#'6$)."%4'*7:-#&:*'V*"+8'$*'*8&%#94**'&6' 3%4$#8'$95'&%#8&-94$XC'$95'-$#)49#*'<)#8'*)A9*'&6'.46#2*)545'84$%#'6$)."%4' <)..'&6#49'8$@4'*)A9*'&6'%)A8#2*)545'84$%#'6$)."%4>',&<4@4%C'-$#)49#*'<)#8' )*&.$#45'*7:-#&:*'&6'%)A8#2*)545'84$%#'6$)."%4'V$*+)#4*C'84-$#&:4A$.7C' 4.4@$#45'D"A".$%'@49&"*'-%4**"%4'vI\GwC'.&<4%'4E#%4:)#7'454:$X'6$..')9#&' $'5)*#)9+#'+$#4A&%7'&6'5)$A9&*4*>'VY44'TABLE 4.20>X

?9'%4*&"%+42-&&%'*4##)9A*'*"+8'$*';<$95$C')*&.$#45'%)A8#2*)545'84$%#' 6$)."%4':&*#'&6#49'%4*".#*'6%&:'+8%&9)+'5)*4$*4*'&6'#84'."9A*'#8$#'8$@4' .45'#&'-".:&9$%7'87-4%#49*)&9'&%'6%&:'5)*4$*4*'&6'#84'-4%)+$%5)":'V*44' TABLE 4.21X>'H"34%+".&*)*')*'37'6$%'#84':&*#'+&::&9'%4$*&9'6&%'+&9*#%)+2 #)@4'-4%)+$%5)$.'5)*4$*4')9':&*#'&6'%"%$.'*"32Y$8$%$9'L6%)+$C'$95'$*'*"+8' %4-%4*49#*'$'#%4$#$3.4'+$"*4'&6'84$%#'6$)."%4>

TABLE 4.20 Clinical Presentation of Right-Sided Heart Failure

Symptoms Physical exam ﬁndings Weight gain Elevated JVP Abdominal swelling Cardiac murmur (depending on cause) Lower-extremity edema Enlarged or pulsatile liver Decreased appetite Ascites Right-upper-quadrant pain Lower-extremity pitting edema

ϐ Ǧ V*"+8'$*'+$%5)&:7&-$#87C'87-4%#49*)@4'84$%#'5)*4$*4C':)#%$.'*#49&*)*C' $95'T%'@$.@".$%'5)*4$*4X'346&%4'+&9*)54%)9A'-"%4'%)A8#2*)545'84$%#' 6$)."%4'$*'$'5)$A9&*)*>'L*'<)#8'T%'+$#4A&%)4*'&6'84$%#'6$)."%4C'#84'-%42 +)*4'5)$A9&*)*')*'94)#84%'4$*7'9&%'4**49#)$.'#&'#84')9)#)$.':$9$A4:49#'&6' #84'-$#)49#>'b"%'-%&#&+&.'6&%'%)A8#2*)545'84$%#'6$)."%4'#84%46&%4'6&+"*4*' &9'4E+."5)9A'9&92+$%5)$+'+$"*4*'&6'#84'-%4*49#)9A'*7:-#&:*'&6'454:$' ǡϐ 4:-)%)+'#"34%+".&*)*'#%4$#:49#>'

G$#)49#*'<)#8'$*+)#4*'+$"*45'37'.)@4%'6$)."%4'&%'%49$.'6$)."%4'+$9'%4*4:3.4' ǦǤ ϐ 5)*#)9A")*8'34#<449'#84*4'-$#)49#*>'U+8&+$%5)&A%$-87')*'4**49#)$.')9' 5)664%49#)$#)9A'-$#)49#*'<)#8'%)A8#2*)545'84$%#'6$)."%4'6%&:'#8&*4'<)#8' T%'4#)&.&A)4*'&6'454:$'$95'$*+)#4*>'?9'-$%#)+".$%C'4+8&+$%5)&A%$-87' 88ȀƢȀchronic care integration for endemic non-communicable diseases

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TABLE 4.21 Causes of Right-Sided Heart Failure

Cause Notes

Left-sided heart failure Left-sided heart failure is the most common cause of right-sided heart failure. Some common causes include cardiomyopathy, mitral stenosis, and mitral regurgitation Tricuspid valve abnormalities Tricuspid valve stenosis, tricuspid regurgitation, congenital heart disease

Pulmonary disease Pulmonary TB, severe COPD

Pulmonary hypertension HIV, congenital heart disease (commonly VSD, ASD), other

Constrictive pericarditis Most commonly caused by TB

Endomyocardial ﬁbrosis Cause unknown

Ǧ ϐ )549#)67)9A'#8&*4'-$#)49#*'<8&'$%4'.)P4.7'#&'8$@4'5)*4$*4'+$"*45'37'$+2 #)@4'#"34%+".&*)*>'G$#)49#*'<)#8'T%'#7-4*'&6'%)A8#'@49#%)+".$%'6$)."%4' ȋ ϐȌ <)..'34':$)9.7'-$..)$#)@4'$95'<)..':)%%&%'#84'$--%&$+8'#&':45)+$.':$92 $A4:49#'&6'-$#)49#*'<)#8'@$.@".$%'$95'T%'+&9A49)#$.'84$%#'5)*4$*4>'

PROTOCOL 4.15'&"#.)94*'$9'$--%&$+8'#&'-$#)49#*'<)#8')*&.$#45'%)A8#2*)545' 84$%#'6$)."%4> chapter!4 | heart failureȀƢȀ89

PROTOCOL 4.15 Management of Isolated Right-Sided Heart Failure

Suspected or echocardiographically conﬁrmed isolated right sided heart failure

Assess ﬂuid status, adjust diuretic (Protocol 4.16)

Assess for tuberculosis pericarditis (Protocol 4.17)

Assess creatinine, potassium and need for ACE inhibitor (Protocol 4.18)

Assess other medication needs (Protocol 4.19)

Follow-up and consultation with a cardiologist to conﬁrm diagnosis

Surgical Follow-up planning candidate? NO (Section 4.13, Table 4.23)

YES

Surgical planning (Chapter 5)

4.12.1 Vital Sign Assessment L*'<)#8'$..'#7-4*'&6'84$%#'6$)."%4C':$9$A4:49#'&6'*"*-4+#45'%)A8#2*)545' 84$%#'6$)."%4'34A)9*'<)#8'$9'$**4**:49#'&6'#84'-$#)49#=*'@)#$.'*)A9*'$95' &@4%$..'+&95)#)&9>'G$#)49#*'<)#8'$9'466"*)&9'$95'87-1*)&9'*8&".5'34' -%4*":45'#&'8$@4'#$:-&9$54'$95'*8&".5'34'%464%%45'#&'#84'5)*#%)+#'8&*2 -)#$.'6&%'4:4%A49#'-4%)+$%5)&+49#4*)*>'F)P4<)*4C'-$#)49#*'<)#8':$**)@4' $*+)#4*'#8$#')*'+$"*)9A'%4*-)%$#&%7'5)*#%4**'*8&".5'$.*&'34'%464%%45'#&'#84' 5)*#%)+#'8&*-)#$.'6&%'-$%$+49#4*)*> 90ȀƢȀchronic care integration for endemic non-communicable diseases

4.12.2 Fluid Status Assessment H84'94E#'*#4-')9'#84':$9$A4:49#'&6'%)A8#2*)545'84$%#'6$)."%4')*'4@$."$2 ϐ Ǥ -%&6&"95'.4A'454:$'$95'$*+)#4*>'?9':&*#'+$*4*C'#84*4'-$#)49#*'<)..'94@4%' %4$+8'4"@&.4:)$C'$95'$##4:-#)9A'#&'5)"%4*4'#84:'5&<9'#&'$'5%7'<4)A8#' <)..'%4*".#')9')9#%$@$*+".$%'87-&@&.4:)$C'+$"*)9A'%49$.'6$)."%4C'87-Ǭ *)&9C'$95'4.4+#%&.7#4'):3$.$9+4*>'H84'A&$.'*8&".5'34'#&':)9):)^4'#84' -$#)49#=*'5)*+&:6&%#'6%&:'454:$'$95'$35&:)9$.'5)*#49*)&9>'

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PROTOCOL 4.16 Fluid Status Management in Right-Sided Heart Failure

Suspected or conﬁrmed isolated right-heart failure

Perform volume assessment (deﬁnitions of ﬂuid status di!erent than for other types of heart failure)

Hypo- Hyper- volemia (1) volemia

Euvolemia (2) Moderate Severe Stop all (3) (4) diuretics, consider giving ﬂuids

IV diuresis, ≤ On 80 mg paracentesis, furosemide hospitalize 2x/day? NO YES

Maintatin furosemide Increase dose, consider adding furosemide sprionolactone and dose ACE inhibitor (Section 4.7.2) (Protocol 4.18)

(1) Hypovolemia: Rising creatinine, low blood pressure; may still have signiﬁcant edema or ascites (2) Euvolemia: Comfortable, able to perform daily activities (3) Hypervolemia, Moderate: Increasing ascites or edema, uncomfortable but able to do basic activities (4) Hypervolemia, Severe: Rapid breathing, unable to walk chapter!4 | heart failureȀƢȀ91

4.12.3 Pericardial Disease ()*4$*4*'&6'#84'-4%)+$%5)":'6$..')9#&'#<&':$)9'+$#4A&%)4*W'V/X'-4%)+$%2 5)$.'466"*)&9*h'$95'VJX'+&9*#%)+#)@4'-4%)+$%5)$.'5)*4$*4>K]'!'&6'#84*4' +&95)#)&9*'+$9'.4$5'#&'84$%#'6$)."%4'37'+$"*)9A'4E#4%9$.'+&:-%4**)&9'&9' ǡϐǤ

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4.12.3.3 Diagnosis and Treatment of Tuberculosis Pericarditis G%&:-#')9)#)$#)&9'&6'$9#)2:7+&3$+#4%)$'#%4$#:49#'+$9'34'.)64*$@)9A')9' +$*4*'&6'H!'-4%)+$%5)#)*>'_4'#84%46&%4'*"AA4*#'#8$#'H!')*'#84'-%4*":45' 5)$A9&*)*')9'+$*4*'&6'*"*-4+#45'+&9*#%)+#)@4'-4%)+$%5)$.'5)*4$*4>'_4' 92ȀƢȀchronic care integration for endemic non-communicable diseases

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TABLE 4.22 Treatment of Tuberculous Pericarditis in Adults

Medication Dose Schedule

Isoniazid 300 mg once daily 26 weeks

Rifampin 600 mg once daily 26 weeks

Pyrazinamide 20–25 mg/kg once daily (max dose 2 g) 8 weeks

Ethambutol 15–20 mg/kg once daily (max dose 1.6 g) 8 weeks

Prednisolone 40 mg twice per day 4 weeks, followed by (example for a 50–55 kg 20 mg twice per daily 4 weeks, followed by patient) 10 mg twice per day 2 weeks, followed by

5 mg once daily 1 week chapter!4 | heart failureȀƢȀ93

PROTOCOL 4.17 Diagnosis and Treatment of Tuberculosis Pericarditis

Suspected constrictive pericardial disease, diuretic adjustments made

Obtain Sputum smears, CXR or history CXR, YES start empiric TB HIV test suggestive of treatment TB?

Very large right Do not start ventricle YES treatment (Figure 4.8) for TB

Sputum smears, start empiric TB Treatment

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PROTOCOL 4.18 ACE-Inhibitor and Spironolactone Titration and Paracentesis for Isolated Right-Sided Heart Failure

Isolated right-sided heart failure, furosemide adjustments made

Able to check creatinine and/ NO or potassium?

YES

Pregnant, Stop/do not ≥ Cr 200 µmol/L SBP ≤ 100 start ACE YES NO AND/OR mmHg inhibitors K ≥ 5.5 mEq/L

YES NO

K ≥ 6.5 Maintain or decrease mEq/L ACE inhibitor AND/OR spironolactone ACE inhibitor YES at goal dose YES

Treat for hyperkalemia NO (see Section 6.5) Maintain ACE inhibitor at current dose, add spironolactone Increase (Table 4.15) ACE inhibitor

4.12.5 Other Medication Needs G$#)49#*'<)#8')*&.$#45'%)A8#2*)545'84$%#'6$)."%4':$7'*"664%'6%&:'@$%)&"*' +&:&%3)5'+&95)#)&9*C'*&:4'&6'<8)+8':$7'34'%4.$#45'#&'&%'<&%*49'#84)%' 84$%#'6$)."%4>'[&%')9*#$9+4C'-$#)49#*'<)#8',?\':$7'54@4.&-'-".:&9$%7' 87-4%#49*)&9C'<8)+8'+$9'+$"*4'%)A8#2*)545'84$%#'6$)."%4>'_&:49'<)#8' %)A8#2*)545'84$%#'6$)."%4'*8&".5'$@&)5'34+&:)9A'-%4A9$9#C'$*'-%4A9$9+7' Ǥ ϐ *8&".5'34'%$#42+&9#%&..45'$95'$9#)+&$A".$#45> chapter!4 | heart failureȀƢȀ95

PROTOCOL 4.19 Other Medication Needs in Isolated Right-Sided Heart Failure

Patient with isolated right-sided heart failure; diuretic, ACE inhibitor adjustments made

Woman Refer to family between 15 YES planning and 49 years (see Section 3.5)

Irregular YES Atrial ﬁbrillation heart rate by ECG

YES NO NO

Protocol 4.9

Refer to ID HIV YES clinic to start ARVs

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TABLE 4.23 Clinic Follow-Up Schedule for Heart Failure Patients

Class I or Class II heart Class III or Class IV symptoms, new renal failure, failure, euvolemic hypervolemic or any other clinical concern

Medication change Return in 2 weeks–1 month Return in 1–2 weeks

No medication change Return in 1–2 months Return in 2 weeks–1 month

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4.16 Role of Electrocardiography in Rural Rwanda U.4+#%&+$%5)&A%$:'VUSTX'"*4')*'.):)#45'$#'%"%$.'5)*#%)+#'8&*-)#$.*')9';<$95$>' R$97'5)*#%)+#'8&*-)#$.*'5&'9&#'8$@4'$9'4.4+#%&+$%5)&A%$:':$+8)94C'$95' 64<'5)*#%)+#'8&*-)#$.'+.)9)+)$9*'644.'+&:6&%#$3.4')9'#84'"*4'&%')9#4%-%4#$2 #)&9'&6'UST*>'H84'A&$.')9';<$95$')*'#&'8$@4'$9'UST':$+8)94'$#'4$+8' 5)*#%)+#'8&*-)#$.'$95'#&'-%&@)54'3$*)+'#%$)9)9A')9'UST')9#4%-%4#$#)&9> chapter!4 | heart failureȀƢȀ97

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4.16.1 Atrial Fibrillation Diagnosis and Management ϐ +.)9)+)$9*'&3#$)9'$9'UST'&9'$97'-$#)49#'<)#8'$9')%%4A".$%'-".*4'&%'$'@4%7' ȋηͳʹͲȌǤ #84'UST')9'#84'+.)9)+'&%'$++&:-$97'#84'-$#)49#'#&'#84')9-$#)49#'<$%5' #&'8$@4'#84'UST'-4%6&%:45>'`S('9"%*4*'*8&".5'%4+4)@4'3$*)+'#%$)9)9A' )9'UST')9#4%-%4#$#)&9>',&<4@4%C'$'5)*#%)+#'8&*-)#$.'-87*)+)$9'*8&".5'34' $@$).$3.4'#&'84.-'<)#8')9#4%-%4#$#)&9')6'#84%4'$%4'O"4*#)&9*>'H84'P47'UST' ϐϐȋͳȌ Ǣ VJX')%%4A".$%.7'*-$+45's;Y'<$@4*'V*44'FIGURE 4.10X> A

A 98ȀƢȀchronic care integration for endemic non-communicable diseases

º FIGURE 4.10 ECG of Normal Rhythm (top) and Atrial Fibrillation (bottom) P waves, regular (normal rhythm)

P waves

no P waves, irregular (atrial ﬁbrillation)

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PROTOCOL 4.20 Diagnosis and Management of Atrial Fibrillation

Patient with tachycardia (≥ 120 bpm) AND/OR irregular heart beat

Obtain 12-lead ECG to conﬁrm atrial ﬁbrillation

Atrial ﬁbrillation Likely sinus rhythm. If tachycardic, look (absence of P waves NO for underlying cause (fever, pain, etc.) and irregularly spaced and consider hospital admission QRS waves)

Lower heart rate with YES beta-blocker and admit to hospital YES

HR ≥ 120 YES SBP ≥ 100 bpm mmHg NO Admit to hospital, NO load with digoxin (Table 4.18). If unstable, consider Known cardioversion Initiate structural YES anticoagulation heart (see ) disease Chapter 5

Start on aspirin 100 mg daily, obtain an echocardiogram

4.17 Cardioversion H84':$)9')95)+$#)&9'6&%'+$%5)&@4%*)&9')*'+$%5)&A49)+'*8&+P')9'#84'*4##)9A' ϐǤ Ǥ U@4%7'5)*#%)+#'8&*-)#$.'*8&".5'8$@4'$'+$%5)&@4%*)&9':$+8)94>'G$#)49#*' <8&'$%4'-1#)$..7')9'9445'&6'+$%5)&@4%*)&9'*8&".5'34'$5:)##45'#&'#84' 8&*-)#$.'$95':$9$A45'37'#84')9-$#)49#'-87*)+)$9> 100ȀƢȀchronic care integration for endemic non-communicable diseases

4.18 Palpitations and Somatization ?9';<$95$C':$97'T%<)*4'84$.#87'-$#)49#*'*44P':45)+$.'+$%4'6&%' -$.-)#$#)&9*>'H84'@$*#':$D&%)#7'&6'#84*4'-$#)49#*'8$@4'9&%:$.'@)#$.' *)A9*C'-87*)+$.'4E$:*C'$95'4+8&+$%5)&A%$:*>'_849'$*P45')9'A%4$#4%' 54#$).'$3&"#'#84)%'*7:-#&:*C':$97'-$#)49#*'%4-&%#'#8$#'#84'-$.-)#$#)&9*' 34A$9'$6#4%'#84'/ddK';<$95$'A49&+)54>'L94+5&#$..7C'-$.-)#$#)&9*'V.)P4' *8&%#94**'&6'3%4$#8X'*44:'#&'34'+&::&9'$*'$'*&:$#)^45'4E-%4**)&9'&6' 54-%4**)&9C'A%)46C'$95'*#%4**>

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PROTOCOL 4.21 Palpitations

Murmur, No P edema, Treat as atrial Patient with Palpitations ECG waves or orthopnea or NO YES YES YES ﬁbrillation (see palpitations currently? available? irregular exertional Protocol 4.20) dyspnea? rhythm?

NO NO

NO YES Work up ≥ Pulse 100 bpm or infection, pauses or extra YES Fever? YES consider beats by palpation? Investigate as antibiotics suspected heart failure (see Protocol 4.1) NO NO

Signs of Look for and YES treat underlying Reassure dehydration? cause patient, stop any cardiac medications. NO Refer back to primary care

Atenolol 12.5 mg 1x per day or propranolol 10 mg 3x per day

Goiter? NO Refer for ECG

YES

Check thyroid function tests and refer for ECG chapter!4 | heart failureȀƢȀ101

4.19 Palliative Care for Patients with Heart Failure G$..)$#)@4'+$%4')*'$9'4**49#)$.'-$%#'&6'84$%#'6$)."%4'#%4$#:49#>'L'*#"57' +&:-$%)9A'-$#)49#*'<)#8'*7:-#&:$#)+'84$%#'6$)."%4'#&'-$#)49#*'<)#8'$52 @$9+45'+$9+4%*'6&"95'#8$#'#84'#<&'A%&"-*'8$5'*):).$%'9":34%*'&6'-87*)2 +$.'*7:-#&:*'$95'*):).$%'54-%4**)&9'*+&%4*>01'L'*#"57'&6'-$#)49#*'57)9A' &6'84$%#'6$)."%4'6&"95'#8$#'ZBm'4E-4%)49+45'*4@4%4'57*-94$>0/'L'%4@)4<' &6'*#"5)4*'%4-&%#)9A'*7:-#&:*')9'-$#)49#*'<)#8'4952*#$A4'84$%#'5)*4$*4C' +$9+4%C'L?(YC'+8%&9)+'&3*#%"+#)@4'."9A'5)*4$*4C'$95'%49$.'5)*4$*4'6&"95' #8$#'#8%44'*7:-#&:*o-$)9C'57*-94$C'$95'6$#)A"4o8$5'$'-%4@$.49+4' ͷͲΨ ϐǤ0J'H84*4' -87*)+$.'*7:-#&:*'&6#49':$P4')#'):-&**)3.4'6&%'84$%#'6$)."%4'-$#)49#*'#&' <&%P'&%'4@49'#&'34')954-49549#')9'*4.62+$%4>'H8"*C'*7:-#&:'%4.)46'$95' -*7+8&*&+)$.'*"--&%#*'$%4'$*'):-&%#$9#'6&%'84$%#'6$)."%4'-$#)49#*'$*'#847' $%4'6&%'+$9+4%'-$#)49#*>

!4+$"*4'84$%#'6$)."%4'#7-)+$..7'8$*'$'%4.$-*)9A'$95'%4:)##)9A'+&"%*4C' %4+"%%49+4*'&6'57*-94$'$95'T%'*7:-#&:*'*8&".5'34'$9#)+)-$#45'$95' -.$9*':$54o5"%)9A'$9'`S('+.)9)+'@)*)#'&%'-%)&%'#&'8&*-)#$.'5)*+8$%A4o #&'%4.)4@4'#84:'O")+P.7'<84%4@4%'#84'-$#)49#':)A8#'34C')9+."5)9A')9' #84'8&:4>'_849'57*-94$'&++"%*'54*-)#4'*#$95$%5'5)*4$*42:&5)67)9A' ǡ ϐ Ǥ0B'R&%-8)94':$7'):-%&@4' 4E4%+)*4'#&.4%$9+4'6&%'-$#)49#*'<)#8'`c,L'S.$**'???'5)*4$*4'$95'$.*&' +$9':$P4'+&:6&%#$3.4'-$#)49#*'<)#8'S.$**'?\'5)*4$*4'V*44'CHAPTER 2C2 SECTION 2.2.4X>'H84'"*"$.'*#$%#)9A'5&*4*'+$9'34'"*45'6&%'&-)&)529$x@4' -$#)49#*W'0':A'&%$..7'&%'J':A'?\iYS'$*'944545'&%'4@4%7'6&"%'8&"%*'V*44' CHAPTER 2C2SECTION 2.2.3X>'!4+$"*4'&6')#*'@49&5).$#)9A'4664+#C':&%-8)94' $.*&')*'$9'4664+#)@4'#%4$#:49#'$.&9A'<)#8'6"%&*4:)54'6&%'$+"#4'4E$+4%3$2 #)&9*'&6'-".:&9$%7'454:$'5"4'#&'84$%#'6$)."%4'<849'#84'3.&&5'-%4**"%4' )*'9&%:$.'&%'4.4@$#45>'?9'87-1*)@4'&%'87-&@&.4:)+'-$#)49#*C'8&<4@4%C' )#'+$9'+$"*4'$'5$9A4%&"*'5%&-')9'3.&&5'-%4**"%4'$95'#8"*'*8&".5'34' "*45'+$"#)&"*.7'"9.4**'#84'&9.7'A&$.'&6'+$%4')*'+&:6&%#>'_849'#84%4')*' +&9+4%9'$3&"#'*)54'4664+#*C':&%-8)94'+$9'34'*#$%#45'$#'8$.6'#84'"*"$.' *#$%#)9A'5&*4*W'J>0':A'&%$..7'&%'/':A'?\iYS>

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S$%4'*8&".5'34'#$P49'<8494@4%'A)@)9A'3$5'94<*'#&':)9):)^4'4:&#)&9$.' 5)*#%4**'6&%'#84'-$#)49#'$95'6$:).7>'H8)*'+$9'34'5&94')9'*4@4%$.'<$7*W'' /X'37'*"AA4*#)9A'#8$#'*"--&%#'-4%*&9*'*"+8'$*'6$:).7':4:34%*'&%'6%)495*' 34'-%4*49#'<849'3$5'94<*'<)..'34'5)*+"**45h'JX'37'#$P)9A'#84'#):4'#&'*)#' 5&<9'<)#8'#84'-$#)49#'&%'6$:).7'$95'A)@4'#84:'$'+8$9+4'#&'$3*&%3'#84' Ǣ͵Ȍϐǯǯ 5)*4$*4'$95'A49#.7'+&%%4+#)9A':)*+&9+4-#)&9*h'KX'37'34)9A'-%4-$%45'6&%' *#%&9A'%4$+#)&9*C'*"+8'$*'$9A4%'&%'A%)46h'0X'37'&664%)9A'#&'*44'#84'-$#)49#' &%'6$:).7'$A$)9'*&&9'#&'$9*<4%'O"4*#)&9*'$95'-%&@)54'4:&#)&9$.'*"--&%#> chapter!4 | heart failureȀƢȀ103

Chapter 4!References

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FIGURE 5.1 Indication for Cardiac Surgery between Nov. 2007 and Feb. 2010 (%) 3%

43% 54%

Congenital Open rheumatic Other

FIGURE 5.2 Source of Cardiac Surgery in Rwanda between Nov. 2007 and Feb. 2010 (n)

132

Visting cardiac surgical team External referral Closed cardiac surgery by local thoracic surgeon chapter!5 | cardiac surgeryȀƢȀ109

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TABLE 5.1 Typical Preoperative Evaluation for Cardiac Surgery

History

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TABLE 5.2 Types of Valve Repairs

Ring annuloplasty Commissurotomy Indication Mitral or tricuspid regurgitation Mitral or tricuspid stenosis Anticoagulation Yes, with aspirin Yes, with aspirin 116ȀƢȀchronic care integration for endemic non-communicable diseases

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TABLE 5.3 Types of Replacement Heart Valves

Bioprosthetic Mechanical Anticoagulation Aspirin Warfarin Longevity ~10 years, probably less ~20 years, potentially life-long Endocarditis risk Increased Increased Used in Ƣǽ!'(+"1#- Ƣǽ,#-ǽ Ƣǽ6.,#-ǽ.$ǽ!'(+"ƽ # 1(-%ǽ %#ǽ6'.ǽ"#2(1#ǽ Ƣǽ6.,#-ǽ.$ǽ!'(+"ƽ # 1(-%ǽ %#ǽ6'.ǽ".ǽ-.3ǽ future pregnancies desire more children Ƣǽ6.,#-ǽ-.3ǽ.$ǽ!'(+"ƽ # 1(-%ǽ %#

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TABLE 5.4 Empiric Antibiotic Treatments for Endocarditis

Antibiotic Indication Adult dose Pediatrics dose E"ect on warfarin

Vancomycin Empiric endocarditis therapy, 1 gm 2x/d 10 mg/kg 4x/d No e#ect methicillin-resistant Staphylococcus aureus, Staphylococcus epidermidis, enterococcus OR (Combination therapy with cloxacillin + ceftriaxone or penicillin G)

Cloxacillin Empiric endocarditis therapy, 2 gm daily IV 50 mg/kg every No e#ect methicillin-sensitive Staphylococcus 6 hours IV aureus, empiric treatment of cellulitis in patients with prosthetic heart valves Ceftriaxone Empiric endocarditis therapy, 2 gm daily IV 100 mg/kg/d IV Decreases Streptococcus viridans, empiric or IM or IM (maximum warfarin e#ect treatment of urinary tract infection, 2 gm) pneumonia in patients with prosthetic heart valve Penicillin G Empiric endocarditis therapy, 4.5 million 50,000 U/kg IV No e#ect Streptococcus viridans units IV 4x/d 4x/d

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PROTOCOL 5.1 Management of Fever in Patients with Prosthetic Heart Valves

1. Heart failure 1. Hospitalize at district hospital Patient with OR 2. Stabilize blood pressure with ﬂuids ≤ prosthetic 2. BP 80/40 mmHg 3. Draw two sets of blood cultures OR YES valve and fever 4. Start empiric antibiotics for endocarditis (Table 5.4) (T ≥ 38° C or 3. Other signs of sepsis 100.4° F) or endocarditis 5. Transfer as quickly as possible to referral hospital (e.g., new murmur) for admission, blood culture, echocardiography, and speciﬁc antibiotic therapy

1. History and physical examination Followed by laboratory evaluation as needed: 1. Urinalysis 2. Peripheral blood smear for malaria 3. Chest x-ray NO

Clear source of fever?

YES NO

1. Hospitalize at district level 2. Treat infection empirically Continue management with careful attention to: Improvement within 48 hours 1. Warfarin management (if relevant) 2. In-hospital risks such as IV-line and urinary catheter infections 3. Venous thromboembolism

YES NO

No fever within 14 days from admission

YES

Weekly follow-up at NCD clinic for 1 month

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TABLE 5.5 Some Organism-Speciﬁc Treatments for Prosthetic Valve Endocarditis

Antibiotic Duration of therapy Adult dose Pediatrics dose E"ect on warfarin Staphylococcus aureus (methicillin-resistant): combination therapy Vancomycin 6 weeks 1 gm 2x/d 10 mg/kg 4x/d No e#ect Gentamycin 2 weeks 3 mg/kg/d IV or IM 50 mg/kg every 6 No e#ect divided into 3 doses hours IV Rifampin 6 weeks 300 mg orally daily 7 mg/kg orally 3x/d Markedly decreases warfarin e#ect Staphylococcus aureus (methicillin-sensitive): combination therapy Cloxacillin 6 weeks 2 gm daily IV 50 mg/kg every 6 No e#ect hours IV Gentamycin 2 weeks 3 mg/kg/day IV or IM 50 mg/kg every 6 No e#ect divided into 3 doses hours IV Rifampin 6 weeks 300 mg orally daily 7 mg/kg orally 3x/d Markedly decreases warfarin e#ect Streptococcus viridans (ceftriaxone or penicillin G) Ceftriaxone 6 weeks 2 grams daily IV or IM 100 mg/kg/d IV or Decreases warfarin IM (maximum 2 gm) e#ect Penicillin G 6 weeks 4.5 million units IV 50,000 U/kg IV 4x/d No e#ect 4x/d

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TABLE 5.6 Common Drug Interactions with Warfarin

Drug E"ect on INR

Co-trimoxazole Increase

Metronidazole Increase

Ciproﬂoxacin Increase

Cimetidine Increase

Rifampin Decrease

Antiretroviral drugs Increase or decrease

Alcohol Increase or decrease

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TABLE 5.7 Anticoagulation Agents and Indications

Indications Warfarin or aspirin? Heparin Goal INR Duration of bridge? therapy

Heart failure and atrial ﬁbrillation

Peripartum cardiomyopathy Aspirin N/A N/A Lifelong

Mitral stenosis in sinus rhythm Aspirin N/A N/A Lifelong

Mitral stenosis with signs of prior stroke Warfarin No 2.0–2.5 Lifelong

Atrial ﬁbrillation (without heart failure) Aspirin N/A N/A Lifelong

Atrial ﬁbrillation (with heart failure) Warfarin No 2.0–2.5 Lifelong

Prosthetic valves

Bioprosthetic tricuspid valve Warfarin for the Yes 2.5–3.0 Lifelong ﬁrst 3 months, then aspirin Other bioprosthetic valves (not tricuspid) Aspirin N/A N/A Lifelong

Mechanical aortic valve Warfarin Yes 2.5–3.0 Lifelong

Mechanical mitral valve Warfarin Yes 3.0–3.5 Lifelong

Mechanical tricuspid valve Warfarin Yes 3.0–3.5 Lifelong

Thrombus

Ventricular thrombosis Warfarin Yes 2.0–2.5 6 months

Deep-vein thrombosis Warfarin Yes 2.0–2.5 3 months

Pulmonary embolism Warfarin Yes 2.0-2.5 6 months

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TABLE 5.8 Initial Outpatient Warfarin Dosing

Patient age Initial dose

Adults 2.5 mg/day

Children (5–40 kg) 1 mg/day

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TABLE 5.9 Therapies For Bridging Anticoagulation

Medication Dosing

Enoxaparin (Clexane) 1 mg/kg twice per day

Heparin (subcutaneous)27,28 Adult: 15,000 units 2x/d Child: 250 units/kg 2x/d

ǡ ϐǡ <$%6$%)9'&9'$9'&"#-$#)49#'3$*)*'<)#8&"#'$'84-$%)9'3%)5A4>'PROTOCOL 5.2' &"#.)94*'#84'*#4-*')9@&.@45')9')9)#)$#)9A'<$%6$%)9'#84%$-7>

PROTOCOL 5.2 Initiating Warfarin Therapy

1. Admit to district hospital Patient with Requires heparin 2. Start warfarin (Table 5.8) indication for bridge because high risk YES warfarin of embolic events? 3. Start a medication to bridge (Table 5.9) the patient (Table 5.9)

Reconsider indications for Patient YES warfarin. Consider aspirin pregnant? as an alternative

Palpable liver on Check INR prior YES to initiating Elevated exam or known INR? liver failure? warfarin therapy

NO YES

If INR ≥ goal INR do not start warfarin Start warfarin therapy: If INR ≤ goal INR, start warfarin at half Adults: 2.5 mg/day normal dose (Table 5.10) Chidren 5–40 kg: 1 mg/day

Assign community health worker

Follow-up in one week at the district hospital chapter!5 | cardiac surgeryȀƢȀ129

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TABLE 5.10 General Principles of Warfarin Titration

INR Action Greater than 5.0 or complaints of bleeding Hospitalize for warfarin adjustment

Above goal (INR elevated by more than 2.0) Stop warfarin for 2 days Decrease warfarin dose by 1 mg

Above goal (INR elevated by less than 2.0) Evaluate for changes in medications or diet Decrease warfarin dose by 0.5–1 mg At goal Continue current warfarin dose

Below goal Evaluate for changes in medications or diet Assess for nonadherence Increase warfarin dose by 0.5–1 mg Below 1.5 If at high risk of embolic events, hospitalize for warfarin adjustment and possibly subcutaneous heparin or subcutaneous enoxaparin (Clexane) therapy Assess for nonadherence and discuss with the patient’s community health worker

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PROTOCOL 5.3 Titrating Warfarin Therapy

1. Hold warfarin Patient on INR ≥ 5 YES 2. Admit to district hospital warfarin 3. Consider reasons for high INR and address 4. Recheck INR in 2 days

INR ≥ 1 Currently 1. Continue to hold warfarin above goal, YES hospitalized YES but ≤ 5 for high INR 2. Recheck INR in 2 days

NO 1. Decrease warfarin by 10%–20% 2. Recheck INR in 3 days

NO NO INR previously at goal YES 1. Recheck INR in 2 weeks for ≥ 1 month

1. Continue warfarin INR at goal Currently 2. Observe for 1 day, recheck INR OR YES hospitalized YES 3. If INR still near goal, discharge ≤ 1 above for low INR goal 4. Recheck INR in one week

Reason for 1. Restart warfarin at previous dose Currently high INR identiﬁed 2. Observe for 1 day, recheck INR hospitalized for YES and resolved (e.g., YES high INR 3. If INR still near goal, discharge overdose, acute 4. Recheck INR in one week illness)

NO NO

1. Restart warfarin at lower dose (10%–20% lower than original dose) 2. Observe for 1 day, recheck INR 3. If INR still near goal, discharge 4. Recheck INR in one week

INR lower Patient 1. Increase warfarin by 10%–20% YES taking YES than goal but 2. Recheck INR in 1 week ≥ 1.5 warfain?

1. Address reason for non-adherence NO 2. Restart warfarin at previous dose 3. Recheck INR in 1 week

1. Hospitalize Patient 2. Start enoxaprin OR, if enoxaparin 1. Increase warfarin by 10%–20% INR ≤ 1.5 YES taking YES not available start heparin SC warfain? 2. Recheck INR in 3 days (Table 5.9)

1. Address reason for non-adherence 2. Restart warfarin at previous dose 3. Recheck INR in 3 days

5.10 Drug Supply and Patient Monitoring ?9';<$95$C'$*-)%)9')*'#84'&9.7'$9#)+&$A".$9#'<)54.7'$@$).$3.4'$#'#84' 5)*#%)+#'8&*-)#$.'.4@4.>'G?,2*"--&%#45'5)*#%)+#'8&*-)#$.*'-%&+"%4'$'.):)#45' *"--.7'&6'<$%6$%)9'$95'84-$%)9C'$95'&"%'5)*#%)+#'`S('+.)9)+*'$..'8$@4' -&)9#2&62+$%4'?`;':$+8)94*'#&':&9)#&%'-$#)49#*>'L..'-$#)49#*'&9'<$%6$%)9' %4+4)@4'5)%4+#.7'&3*4%@45'#84%$-7'$5:)9)*#4%45'37'$'+&::"9)#7'84$.#8' 132ȀƢȀchronic care integration for endemic non-communicable diseases

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Chapter 5!References

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TABLE 6.1 Causes of End-Stage Renal Disease in Sub-Saharan Africa and the U.S.

Glomerulonephritis Hypertension Diabetes Other or unknown Average (Nigeria 54% 27.4% 11.9% 6.7% and Senegal)1

USA3 15.4% 24.2% 37.3% 22.9% 136ȀƢȀchronic care integration for endemic non-communicable diseases

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TABLE 6.2 Relationship between Urine Dipstick and 24-hour Urine Protein Results

Urine dipstick result 24-hour urine protein

Top-normal Trace 150 mg

Microalbuminuria 1+ 200–500 mg

Proteinuria 2+ 0.5–1.5 gm

Nephrotic-range 3+ 2–5 gm

Nephrotic-range 4+ 7 gm

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TABLE 6.3 Stages of Chronic Kidney Disease

Degree of dysfunction Glomerular ﬁltration rate

CKD 1 and 2 Proteinuria alone η 60 ml/min/1.73m2

CKD 3 Moderate dysfunction 30–59 ml/min/1.73m2

CKD 4 and 5 Severe dysfunction ζ29 ml/min/1.73m2

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PROTOCOL 6.1 Initial Evaluation of Chronic Kidney Disease Stage 1 or 2

Referred to NCD clinic for suspected or conﬁrmed CKD ANY? 1. Signs of urinary Check blood pressure, urine dipstick, HIV and obstruction (difﬁculty urinating Refer to district hospital electrolyte panel including and abdominal pain or distention)? YES for admission creatinine, glucose, and hemoglobin 2. Potassium ≥ 6.5 mEq/L? 3. Di!culty breathing?

NO 1. Obtain serum albumin 2. If CKD 1-3, start low-dose ACE inhibitor unless Obtain random urine protein contraindications ≥ 3+ proteinuria YES ratio ≥ 3 YES to creatinine ratio (see Table 8.5) 3. Refer for evaluation for nephrotic syndrome by a nephrologist, internist, or pediatrician

NO NO

1. If patients already followed in continuity clinic, (e.g., for HTN, CKD 1 or 2 DM or HIV) continue management in that clinic (at health- (nl GFR, 2+ center level) YES HIV NO proteinuria, no 2. Start ACE inhibitor unless contraindication (see Table 8.5) infection) 3. Blood pressure goal ≤ 120/80 mmHg (see Table 8.5) 4. Avoid NSAIDs, other nephrotoxins 5. Return to NCD clinic once per year to check creatinine YES

Consider early ARV initiation 140ȀƢȀchronic care integration for endemic non-communicable diseases

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G$#)49#*'<)#8'94-8%&#)+2%$9A4'-%)9"%)$'*8&".5'34'%464%%45'#&'#84' 5)*#%)+#'&%'%464%%$.'+49#4%'.4@4.'6&%'+&9*".#$#)&9'37'4)#84%'$'94-8%&.&A)*#' V)6'$@$).$3.4XC'-45)$#%)+)$9C'&%')9#4%9)*#'6&%'4@$."$#)&9'$95')9)#)$#)&9'&6' *#4%&)5*'&%'T%'#84%$-7')6'944545>'?#')*'$.*&'84.-6".'#&'&3#$)9'$'*4%":' $.3":)9'#4*#'-%)&%'#&'6"%#84%'4@$."$#)&9>'?6'#84'-$#)49#'5&4*'9&#'8$@4' *4@4%4'%49$.'57*6"9+#)&9'VSM('K'&%'0XC')#')*'84.-6".'#&'*#$%#'$'.&<'5&*4'&6' $9'LSU')98)3)#&%'V*44'TABLE 8.5X>

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G$#)49#*'<)#8':&54%$#4'#&'*4@4%4'SM('VSM('BC'KC'&%'0X'*8&".5'34'+.&*4.7' 4@$."$#45'6&%'%4@4%*)3.4'+$"*4*'&6'#84)%'5)*4$*4'V*44'PROTOCOL 6.2X>' G$#)49#*'<)#8'SM('K'&%'0'<)..'&6#49'34'*7:-#&:$#)+'$95')9)#)$.'4@$."$2 #)&9'<)..'#$P4'-.$+4')9'#84'8&*-)#$.>'G$#)49#*'<)#8'SM('B'$%4'"*"$..7' ϐ ȋ ' $*'84$%#'6$)."%4X> chapter!6 | chronic kidney diseaseȀƢȀ141

PROTOCOL 6.2 Initial Evaluation of Chronic Kidney Disease Stage 3, 4, and 5

Referred to NCD clinic for suspected or conﬁrmed CKD

ANY? 1. Signs of urinary Check blood pressure, urine obstruction (difﬁculty urinating Refer to district hospital dipstick, HIV and electrolyte and abdominal pain or distention)? YES for admission panel including creatinine and 2. Potassium ≥ 6.5 mEq/L? glucose and hemoglobin 3. Di!culty breathing?

CKD 3, 4, or 5 (GFR ≤ 59)

Fill out intake form for edematous conditions, including screening questions for heart failure, TB, and a basic echocardiogram, and kidney ultrasound

Potentially reversible? Meets all criteria: Refer to a nephrologist, 1. No heart failure internist, or pediatrician for YES 2. No ultrasound signs of irreversible evaluation and possible kidney disease (see Table 6.3) speciﬁc therapy

1. Start ACE unless contraindication Control of Return in NCD CKD 3 2. Start FeSO4 200 mg HIV, DM, underlying clinic in 3-6 YES (GFR 30–59) 3x/day x 30 days if Hb or heart YES disease process months to ≤ 10 g/dL failure? (e.g., glucose recheck 3. Goal BP ≤ 130/80 control, ARVs) creatinine mmHg (see Table 8.5)

Refer to a 1. Control BP nephrologist, (goal ≤ 130/80) internist, or 2. Consider Assess and address CKD 4 or 5 Option for renal pediatrician YES furosemide symptoms YES (GFR ≤ 29) transplant? for evaluation 3. Avoid ACE (see Protocol 6.3) inhibitors and possible (see Table 8.6) speciﬁc therapy

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FIGURE 6.1 Normal Kidney Anatomy on Ultrasound (Arrowheads show the medullary pyramids, and star shows the outer cortex) chapter!6 | chronic kidney diseaseȀƢȀ143

FIGURE 6.2 Ultrasound in Chronic Kidney Disease: Loss of Di"erentiation between Cortex and Medulla

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TABLE 6.4 Ultrasound Findings Speciﬁc for Severe, Irreversible Kidney Disease

1. Echogenic cortex (more than liver), plus a combined length ζ 20 cm

2. Very small kidneys with a combined length less than 16 cm b3*#%"+#)@4'94-8%&-$#87')*'$'-1#)$..7'%4@4%*)3.4'+$"*4'&6'%49$.'6$)."%4' #8$#'*8&".5'-%&:-#'8&*-)#$.'$5:)**)&9'6&%'6"%#84%'4@$."$#)&9'V*44'' FIGURE 6.3X> 144ȀƢȀchronic care integration for endemic non-communicable diseases

FIGURE 6.3 Hydronephrosis on Ultrasound

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PROTOCOL 6.3 Outpatient Management of Mild Hyperkalemia

Taking ACE inhibitors, Stop these medications K 5–6 mEq/L YES spironolactone or YES and return to NCD clinic K supplement? in two weeks

1. Start or increase furosemide Estimated GFR dose (starting dose 20 mg orally 1 time per day) unless ≤ 59 YES contraindication (CKD 3, 4, or 5) 2. Return to NCD clinic in two weeks

Repeat K test NO

False positive due to YES Continue usual follow-up hemolysis 146ȀƢȀchronic care integration for endemic non-communicable diseases

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H84'9":34%'$95'*4@4%)#7'&6'-87*)+$.'$95'-*7+8&.&A)+$.'*7:-#&:*' 4E-4%)49+45'37'-$#)49#*'<)#8'SM('0')*'*):).$%'#&'#8&*4'4E-4%)49+45'37' -$#)49#*'<)#8'$5@$9+45'+$9+4%*'$95'T%'+8%&9)+C'.)642#8%4$#49)9A')..2 94**4*>'Y7:-#&:*'&6'-$#)49#*'<)#8'SM('0C'#84)%'6%4O"49+7C'#84)%'P9&<9' chapter!6 | chronic kidney diseaseȀƢȀ147

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TABLE 6.5 Common Physical Symptoms in Advanced Chronic Kidney Disease and Their Treatment18

Physical symptom Cause Treatment (see Chapter 2 for details)

Fatigue and Depression Assess for depression and treat if found. drowsiness Fluid overload Diurese for ﬂuid overload, if needed. 86% Anemia, poor nutrition, other organ failure, uremia, insomnia Itch Dry skin Emollients for dry skin. 84% Secondary hyperparathyroidism Antihistamine such as diphenhydramine (can worsen Hyperphosphatemia fatigue and delirium). Anemia Steroid. Opioids Dyspnea (the Pulmonary edema If comfort and quality of life are the only goals of most distressing Pleural e#usion care, not preservation of renal function, diurese for symptom) symptomatic pulmonary or peripheral edema. Metabolic acidosis 80% Opioid relieves dyspnea of any cause. Renal dosing Anemia for morphine (see APPENDIX A). Aspiration Comorbid CHF, COPD, or other lung pathology Delirium (agitated Metabolic derangements Reduce or eliminate culprit medications, if possible. or hypoactive) Hypoxia/hypercapnia Haloperidol. 76% Medications Pain Bone pain due to 2˚ Avoid NSAIDS due to nephrotoxicity and increased 73% hyperparathyroidism risk of bleeding with uremic platelet dysfunction. Diabetic neuropathy Paracetamol is safe and requires no dose adjustment Polycystic kidney disease for renal failure. Calciphylaxis (hemodialysis Morphine: active metabolite accumulates in CKD 5 patients only) and can cause neurotoxicity. Use lower dose and/or longer dosing interval than usual. Anorexia Nausea (see below) Anti-emetics (see below). 71% Diabetic gastroparesis Metoclopramide for gastroparesis. Dry mouth Oral care. Steroid to stimulate appetite. Swelling in Fluid overload Elevate edematous extremities. legs/arms Low oncotic pressure due to Elastic wraps as tolerated. 71% proteinuria and malnutrition If comfort and quality of life are the only goals of Comorbid heart failure care, not preservation of renal function, diurese for symptomatic peripheral edema or anasarca. Dry mouth Intravascular volume depletion Instruct family caregivers to keep mouth moist with 69% (can exist even with total body sips of liquid or sponge. ﬂuid overload). 148ȀƢȀchronic care integration for endemic non-communicable diseases

Physical symptom Cause Treatment (see Chapter 2 for details) Constipation Medications including opioids Laxative 65% and anticholinergics Intravascular volume depletion Nausea with or Uremia Reduce or eliminate culprit medications, if possible. without vomiting Emetogenic medications Haloperidol for nausea due to endogenous or exog- 59% Diabetic gastroparesis enous emetogenic toxin. Start with low dose. Metoclopramide for gastroparesis. Cough Pulmonary edema If comfort and quality of life are the only goals of 47% Aspiration care, not preservation of renal function, diurese for symptomatic pulmonary edema. Comorbid COPD or other lung pathology Opioid relieves cough of any cause. Renal dosing for morphine.

TABLE 6.6 Common Psychological Symptoms in Advanced Chronic Kidney Disease and Their Treatment

Psychological symptom Treatment Anxiety Psychosocial supports 78% Haloperidol Diazepam (can cause delirium and paradoxical agitation) Feeling sad Psychosocial supports 65% Depression Psychosocial supports Unknown prevalence Antidepressant such as ﬂuoxetine or amitriptyline

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Chapter 6!References

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TABLE 7.1 Diabetes Diagnosis: Blood Sugar Measurement and Symptoms

Blood sugar η 126 mg/dL (7 mmol/L) fasting OR η 200 mg/dL (11 mmol/L) random with symptoms OR η 200 mg/dL (11 mmol/L) with an oral glucose tolerance test Glycosylated hemoglobin (HbA1c) η 6.5% (using a point-of-care device)

Symptoms of chronic hyperglycemia Polyuria (excessive urination) Polydipsia (excessive thirst) Weight loss PROTOCOL 7.1

Present to acute care clinic with any of the following symptoms: Any 1. Dehydration Hyperglycemia unlikely to Check a urine glycosuria or 2. Frequent urination NO be cause of symptoms. dipstick unable to 3. Thirst check Consider other etiologies

4. Increased appetite 5. Weight loss or gain YES at Health-Center Level Diagnosis ofDiabet

Check a ﬁnger stick blood glucose NO

Blood sugar ≥ 150 mg/dL (8.3 mmol/L) es and Management of Hyperglycemia Hyperglycemia of Management and es

YES 1. Adults: give 500 ml normal saline (NS) bolus, then continue NS at 250 cc/hour. Children ≤ 12 years old: give 20 ml/kg NS Blood sugar bolus, then continue at maintenance dose Immediately ≥ 400 mg/dL (22 mmol/L)? YES 2. Give 0.2 U/kg (or 10 units for an adult) SC transfer to hospital of regular insulin 3. Check blood sugar every hour and give additional insulin until transfer (Table 7.3)

YES

Any warning signs: chapter 1. Slow, deep breathing Consider other Blood sugar 2. “Fruity” breath causes of the 3. Abdominal pain, nausea, vomiting YES 200-400 mg/dL NO patient’s symptoms (11–22 mmol/L)? 4. Sleepy, not responding and transfer to ! ≤ 7 5. Blood pressure 90/60 mmHg hospital |

diabetes NO

Likely type 1 diabetes mellitus, Likely type 2 or mixed diabetes mellitus, refer refer to district hospital for inpatient conﬁrmation of YES Age ≤ 18 NO to district NCD clinic for conﬁrmation of ȀƢȀ diagnosis and likely initiation of insulin therapy diagnosis and initiation of oral hypoglycemics 157 (Protocol 7.2) 158ȀƢȀchronic care integration for endemic non-communicable diseases

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TABLE 7.2 Danger Signs in Hyperglycemia

Early ﬁndings Notes

Signs of dehydration Dry mucus membranes, skin tenting, decreased urine output

Hypotension From loss of ﬂuids

Slow, deep breathing From ketosis

Abdominal pain, nausea and vomiting

Fruity breath Ketones have a fruity odor

Late ﬁndings (neurological) Notes

Focal motor deﬁcits

Altered mental status Agitation, sleepiness, eventually coma

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TABLE 7.3 Insulin Therapy of Patients with Hyperglycemia (η 250 mg/dL) and Danger Signs Awaiting Transfer

Blood sugar Regular insulin dose (given subcutaneously)

For children (ζ 40 kg) For adults

Initial bolus 0.2 units/kg x 1 10 units

Recheck blood glucose every hour

η 250 mg/dL (13 mmol/L) 0. 1 unit/kg/hour 5 units/hour

150–250 mg/dL (8–13 mmol/L) 0.05 unit/kg/hour 2.5 units/hour

ζ 150 mg/dL (ζ!8 mmol/L) Stop insulin, continue normal saline or lactated ringers

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TABLE 7.4 Diagnosis and Treatment of Hypoglycemia

Symptoms Somnolence or agitation Confusion Lethargy Dizziness, nausea Seizures Stroke-like symptoms Sweating Tremors Palpitations, anxiety

Causes Correctable: Overdose of medication (insulin or orals) Increased exercise Skipped meals

Not (easily) correctable: Reduced renal function (diminished clearance of hypoglycemic agents) Liver failure (inability to produce glycogen to correct serum hypoglycemia) Treatment Juice, soft drink, sugar water (if able to follow commands) In adults IV glucose 50% solution (if unable to follow commands) In children ζ 12 give glucose 50% solution by nasogastric tube (if unable to follow commands) 3–12 hours of frequent ﬁnger-stick checks

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TABLE 7.5 Glucose Control Goals

Reasonable control More intensive control

Pre-meal and 150–180 mg/dL 120–150 mg/dL pre-bedtime glucose (8.3–10 mmol/L) (6.7–8.3 mmol/L)

Hemoglobin A1c 7.5%–8%: 7.0%–7.5%: average blood glucose of average blood glucose of 170–185 mg/dL 154–170 mg/dL (9.4–10.5 mmol/L) (8.6–9.4 mmol/L)

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1. Start NS at 250 cc/hour 1. Any warning signs (see Table 7.2 )

2. Give 0.2 U/kg (or 10 units for an adult) SC of regular insulin if Adults) (in Agents Hypoglycemic Oral with Diabetes Treatmentof AND glucose ≥ 200 mg/dL (11 mmol/L) YES glucose ≥ 250 mg/dL (13.8 mmol/L) OR 3. Check blood sugar every hour and give additional insulin until 2. Glucose ≥ 400 mg/dL (22.2 mmol/L) transfer (see Table 7.3)

Hypoglycemia Glucose First visit or Maximum dose of Refer to district clinic (see Table 7.4) control at goal? not on NO NO NO glibencamide and YES for insulin therapy ≥ 2x since last visit (see Table 7.5) therapy? metformin Stop glibenclamide

YES YES

YES NO BMI ≥ 25 kg/m! Correctable cause of hypoglycemia?

YES YES NO

NO Start chapter Continue current metformin Continue current diabetes Increase dose 500 mg daily. Decrease dose diabetes medications. medications (see Table 7.6) Encourage (see Table 7.6). Ensure access to regular Encourage meals/snacks.

weight loss ! regular meals Nutritional support 7

if needed |

diabetes Start glibenclamide, 5 mg in the morning ȀƢȀ 163 Follow-up 2–4 weeks Follow-up 4–8 weeks 164ȀƢȀchronic care integration for endemic non-communicable diseases

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TABLE 7.6 Oral Hypoglycemic Therapy

Steps Metformin Glibenclamide

7 a.m. 7 p.m. 7 a.m. 7 p.m.

1 500 mg - 5 mg -

2 500 mg 500 mg 5 mg 5 mg

3 1000 mg 500 mg 10 mg 5 mg

4 1000 mg 1000 mg 10 mg 10 mg

5 Add glibenclamide Add metformin

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TABLE 7.7 Common Causes for Hyperglycemia in Patients on Insulin

Problems with insulin injection and mixing technique

Problems with insulin storage or expiration

Unusual dietary excess

Active infection (e.g., malaria, urinary, skin, or pulmonary)

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TABLE 7.8 Indications for Insulin Therapy

Type 1 diabetes

Failed maximum oral therapy

Pregnancy

Creatinine greater than 150 mmol/L (1.6 mg/dL) (which prevents use of metformin), and unable to control glucose with glibenclamide alone History of diabetic ketoacidosis

Child ζ 18 years of age PROTOCOL 7.3

Diabetes mellitus Treat infection, OR change insulin batch, AND OR ensure good insulin storage Already on insulin and injection techniques. OR Has new indication for insulin therapy (see Table 7.8) YES

1. Adults: give 500 ml normal saline (NS) bolus, then Initiation andAdjustment ofInsulinRegimens 1. Any Warning Signs (see Table 7.2) continue NS at 250 cc/hour. Children ≤ 12 years old: give Correctable AND 20 ml/kg NS bolus, then continue at maintenance dose cause of glucose ≥ 200 mg/dl (11 mmol/L) YES 2. Give 0.2 U/kg (or 10 units for an adult) SC of hyperglycemia? OR regular insulin if glucose ≥ 250 mg/dL (13 mmol/L) (see Table 7.7) 2. Glucose ≥ 400 mg/dl (22.2 mmol/L) 3. Check blood sugar every 1–4 hours and give additional insulin until transfer (see Table 7.3) NO NO

If on oral medications: 1. Stop glibenclamide Increase insulin 2. Continue metformin (see Table 7.10)

Follow-up 2–4 weeks Glucose Identify insulin Decrease insulin First visit NO control at goal? NO regimen Hypoglycemia? (see Table 7.10) for insulin (see Table 7.5) (started as inpatient)

YES NO YES YES Correctable chapter cause of hypoglycemia? (see Table 7.4)

Refer to ! Continue current 7 hospitalfor diabetes medications. |

admission Follow-up 4–8 weeks diabetes

YES ȀƢȀ Ensure access to regular meals/snacks. Nutitional support as needed. 167 168ȀƢȀchronic care integration for endemic non-communicable diseases

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TABLE 7.9 Properties of Insulin Available in Rwanda

Regular (rapide) NPH (insulatard or lente) Combination (70/30 or mixte)

Time to onset 20–30 minutes 1–2 hours 30 minutes

Peak e#ect 2.5–5 hours 4–12 hours 3–8 hours

Duration 4–12 hours 18–24 hours 18–24 hours

Dosing 20–30 minutes Once or twice daily, 20–30 minutes before breakfast before meals around 7 am and 7 pm and/or dinner (or bedtime)

Vial appearance Clear Cloudy Cloudy (manufacturer-speciﬁc)

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TABLE 7.10 Insulin Regimens 0.5–0.7 units/kg 0.5–0.7 0.5–0.7 units/kg 0.5–0.7 0.3–0.6 units/kg/day: units/kg/day: 0.3–0.6 50% pre-breakfast, 50% pre-dinner meal) before (20–30 minutes 0.3–0.6 units/kg/day: 0.3–0.6 60% pre-breakfast, 40% pre-dinner meal) before (20–30 minutes 0.2 units/kg/day or 0.2 units/kg/day is (whichever 10 units/day at bedtime given less) 0.2–0.3 units/kg 0.2–0.3 50% of dose as NPH Give regular with dinner-time combined One dose pre-dinner insulin 50% of dose as regular Give meals) prior to 20-30 minutes and given evenly (split 0.2–0.3 units/kg 0.2–0.3 50% of dose as NPH Give 60% pre-breakfast 40% pre-dinner 50% of dose as regular Give and pre-dinner, pre-breakfast evenly (split meal) before 20–30 minutes Not appropriate Not appropriate Not appropriate Starting 1 dose type Starting2 dose type Dinner-time NPH and regular NPH and regular Dinner-time alone with Regular combination. and lunch breakfast Allows patients to control mix control patients to Allows two insulin from combine Patients and give vials (NPH and regular) the injection 2x/day Post-prandial hyperglycemia. For For hyperglycemia. Post-prandial need diets, may high-carbohydrate mix a 50/50 closer to Good for some patients with type some patients with type Good for with problem but again 2 diabetes, diet if high-carbohydrate coverage Most simple, but not good coverage coverage Most simple, but not good diet if high-carbohydrate Notes dinner Lunch may by be covered morning NPH dinner (no lunch coverage) Coverage Coverage at meals Coverage Coverage of basal glycemia 2 Good and Breakfast 2 Good and Breakfast 2 Good None 1 Some None

) ) rapide mixte ) and ) 1x/day ) 2x/day ) insulatard insulatard insulatard lente lente lente Basal/Prandial 3 Good All meals meals midday large Best for NPH ( or ( regular Insulin 2x/day 70/30 ( 70/30 2x/day NPH ( or NPH ( or Regimen Injections chapter!7 | diabetesȀƢȀ171

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TABLE 7.11 Example of Glucose Monitoring Chart Insulin 57 mg/dL 57 72 mg/dL 72 Blood sugar Before bedtime Before

None None None None Symptoms of hyperglycemia/ hypoglycemia 2U Regular 7U NPH 2U Regular 2U Regular 7U NPH 2U Regular Insulin 150 mg/dL 7U NPH 125 mg/dL 7U NPH Blood sugar Before dinner Before

Symptoms of hyperglycemia/ hypoglycemia 2U Regular2U None Regular2U None 2U Regular2U None Insulin 204 mg/dL 240 mg/dL 240 Regular 2U None Blood sugar Before lunch Before

Symptoms of hyperglycemia/ hypoglycemia 2U Regular2U None 2U Regular2U None Insulin 170 mg/dL 170 Regular 2U None 183 mg/dLRegular 2U None Blood sugar Day Day 4 Day Day 2 Day 3 Day Day 1 Date breakfast Before chapter!7 | diabetesȀƢȀ173

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TABLE 7.12 Principles for Adjusting Insulin 70/30 (Mixte) or 2x/day NPH Regimens

Timing of hyperglycemia/ Hyperglycemia Hypoglycemia hypoglycemia (documented) (documented OR symptoms)

Morning/overnight Increase dinner-time or evening Decrease dinner-time or evening insulin by 2 units basal insulin by 4 units or 10%, whichever is greater Mid-day/evening Increase morning insulin by 2 units Decrease morning insulin by 4 units or 10%, whichever is greater

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TABLE 7.13 Principles for Adjusting Combined Basal (NPH) and Prandial (Regular Insulin) Regimens

Hyperglycemia Hypoglycemia (documented) (documented OR symptoms)

Middle of the night n/a Decrease PM Regular 2–4 U

Before breakfast Increase PM NPH 2 U Decrease PM NPH 2–4 U

Mid-day Increase AM Regular 2 U Decrease AM Regular 2–4 U

Before dinner Increase AM NPH 2 U Decrease AM NPH 2–4 U

Before bedtime Increase Pre-dinner Decrease Pre-Dinner Regular 2 U Regular 2–4 U

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TABLE 7.14 Example of Transitioning from 70/30 (Insuline Mixtard) to NPH/Regular (Insuline Lente + Rapide)

Initial dose: Pre-breakfast Pre-dinner

70/30 (Insuline mixtard) 20 units 10 units

Final dose: Pre-breakfast Pre-dinner

NPH (Insuline lente) 14 units (70% of 20 units) 7 units (70% of 10 units)

Regular (Insulin rapide) 6 units (30% of 20 units) 3 units (30% of 10 units)

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TABLE 7.15 Common Complications of Diabetes and Their Prevalence in Some African Cohorts

Prevalence52-54 Mode of evaluation Frequency of Action if abnormal evaluation

Peripheral 35%–70% Monoﬁlament Once yearly Intensify treatment neuropathy sensory testing of the regimen if possible. feet. If a microﬁla- Consider treating ment is not available, neuropathic pain proprioception can with amitriptyline be tested. Patients 25 to 100 mg per may also complain day orally. Shoes if of neuropathic pain needed. Counsel on (burning, electrical foot protection sensations) in the feet

Foot ulcer 1.7%–10% Visual inspection, n/a Referral to district probe evaluation to hospital for possible rule out osteomyelitis debridement and broad-spectrum antibiotics Retinopathy or 5%–35% Fundoscopic Once every 3 years, Intensify treatment sight-threatening evaluation or retinal performed at a district regimen if possible. eye disease photography hospital with an Referral for evalua- ophthalmic clinical tion at an ophthalmic o$cer. More frequent center if needed for follow-up if estab- intervention lished retinopathy.

Cataracts 8.7%–25% Fundoscopic Once every 3 years Referral for evaluation evaluation performed at a district at an ophthalmic hospital with an center for intervention ophthalmic clinical o$cer Albuminuria 18% Urine dipstick Every six months Intensify treatment regimen if possible. Add an ACE inhibitor (e.g., lisinopril, 5 mg per day orally) Nephropathy 19%–34% Serum creatinine Yearly Intensify treatment testing regimen if possible. Add an ACE inhibitor if no counterindica- tion (e.g., lisinopril, 5 mg per day orally)

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7.8.1 Community Health Workers and Accompaniment' H$P)9A'#84'%)A8#'#7-4'&6')9*".)9')9'#84'%)A8#'5&*4'$#'#84'%)A8#'#):4'+$9'34' ϐ Ǥ 84$.#8'<&%P4%*'-%&@)54'$**)*#$9+4>'H847'84.-'49*"%4'#8$#'-$#)49#*'$%4' #$P)9A'#84)%')9*".)9'+&%%4+#.7'$95':&9)#&%'6&%'*7:-#&:*'&6'87-4%A.7+4:)$' $95'87-&A.7+4:)$>'H847'$.*&':$P4'*"%4'-$#)49#*'5&'9&#':)**'$--&)9#:49#*' &%'%"9'&"#'&6':45)+$#)&9*>'S&::"9)#7'84$.#8'<&%P4%*'$.*&'*4%@4'$*'#84' P44-4%*'&6'%4.$#)@4.7'*+$%+4'A."+&:4#4%*h'#847'+$9')9#49*4.7':&9)#&%'$' ǯ ϐ %4A):49''H847'+$9'$**)*#'-$#)49#*')9'+84+P)9A'3.&&5'A."+&*4'%4$5)9A*C' ):-%&@4'+&:-.)$9+4'$95'$584%49+4'#&'#%4$#:49#'%4A):49*C'$95'84.-' )549#)67'$95'%4.$7'-%&3.4:*'-$#)49#*':$7'34'8$@)9A'<)#8'#84)%'#84%$-)4*> chapter!7 | diabetesȀƢȀ181

7.8.2 Food Assistance H84'#):)9A'&6':4$.*')9'%4.$#)&9*8)-'#&'#84'5&*4'&6')9*".)9')*'@4%7'):-&%2 #$9#>'?6'$'-$#)49#'#$P4*')9*".)9'<)#8&"#'4$#)9AC'87-&A.7+4:)$'<)..'%4*".#>' U9*"%)9A'#8$#'-$#)49#*'&9')9*".)9'8$@4'*#$3.4'*"--.)4*'&6'6&&5')*'4**49#)$.>' H8)*':$7'34'$++&:-.)*845'37'-%&@)5)9A'6&&5'-$+P$A4*'#&'#84'-$#)49#=*' 6$:).7'&%'37'*"--&%#)9A'#84'6$:).7=*'$3).)#7'#&'A%&<'6&&5C'4)#84%'&9'#84)%' &<9'.$95'&%'&9'$'+&::"9)#7'-.&#C'#8%&"A8'-$#)49#'$**&+)$#)&9*>'L'6"..'*&+)$.' <&%P'4@$."$#)&9'&6'#84'6$:).7'*8&".5'34'5&94C'$*'#84'6$:).7'&6'$'-$#)49#' <)#8&"#'49&"A8'6&&5'<)..'&6#49'8$@4'T%':$.9&"%)*845':4:34%*> 182ȀƢȀchronic care integration for endemic non-communicable diseases

Chapter 7!References

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Z1' R$*8'!C'G&<4..'(C'5"'G.4**)*'[C'@$9'\""%49'aC'R)+8$.&<*P$'RC'F4@)##'`>' Y+%449)9A'6&%'5)$34#)+'%4#)9&-$#87')9'-%):$%7'+$%4'<)#8'$':&3).4'6"95$.' +$:4%$o4@$."$#)&9'&6'$'Y&"#8'L6%)+$9'-).&#'-%&D4+#>'Y'L6%'R45'I' J11]hd]W/JgK2g> Z/' L33$*'qTC'T)..'T\C'L%+8)3$.5'FM>'H84'4-)54:)&.&A7'&6'5)$34#)+'.):3'*4-*)*W'$9' L6%)+$9'-4%*-4+#)@4>'()$34#'R45'J11Jh/dWgd02d> ZJ' L33$*'qTC'F"#$.4'IC'L%+8)3$.5'FM>';&549#'3)#4*'&9'#84'644#'&6'5)$34#4*' -$#)49#*')9'H$9^$9)$>'()$34#'R45'J110hJJWZB/2B> ZB' G495*47'YC'L33$*'qT>'H84'*#4-2372*#4-'-%&A%$:'6&%'%45"+)9A'5)$34#)+'6&&#' -%&3.4:*W'$':&54.'6&%'#84'54@4.&-)9A'<&%.5>'S"%%'()$3';4-'J11]h]WKJ02g> ZK' T)..'T\C'[$:"7)<$'bbC';&.64'RC'L%+8)3$.5'FM>'H%&-)+$.'5)$34#)+'8$95' *795%&:4>'F$9+4#'/ddghB0/W//B2K> chapter 8 Hypertension

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PROTOCOL 8.1 Initial Screening and Management of Hypertension in Acute Consultation Clinics

Any patient with a routine complaint BP ≥140/90 mmHg NO Address primary complaint presenting to acute care clinic x2 at rest

YES

Transient cause Address primary of HTN present YES (e.g., pain, complaint anxiety)

Pregnant (all women See management of HTN between 15 and YES 49 should be in pregnancy (Protocol 8.5) tested)

Give nifedipine immediate Danger signs: release 10 mg PO x 1 OR acute dyspnea, captopril 25 mg PO x 1. Transfer to BP ≥ 180/110 mmHg YES YES visual changes, Consider Lasix 20 mg IV OR district hospital headache? Lasix 40 mg PO x 1 if di!culty breathing

NO Start two anti-hypertensives at initial dose, have follow-up in nearest health center CCC in 1 week. Communicate appointment to CCC nurse. Stage 2 Refer to nearest CCC clinic 160/100– in 1–4 weeks for evaluation YES 180/110 mmHg of HTN. Communicate appointment to CCC nurse.

BP = Blood pressure YES CCC = Chronic care clinic HTN = Hypertension Stage 1 Return to acute care clinic 140/90–160/100 ≥ 6 mo trial of in 6 months for BP check. mmHg WITH 2 YES lifestyle NO Counsel on reducing salt or more high-risk modiﬁcation intake and weight loss if features* appropriate. *High-Risk Features: - Age ≥ 65 years - Known diabetes - Known renal failure NO - BMI ≥ 25 kg/m" - Tobacco smoking

Lone Stage 1 Return to acute care 140/90–160/100 clinic in 12 months for BP mmHg WITHOUT YES check. Counsel on reducing salt intake and high-risk features* weight loss if appropriate.

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TABLE 8.1 High-Risk Features in Hypertension

High-risk feature Points

Diagnosis of diabetes 2

Diagnosis of renal failure (creatinine η 1) 2

Age η 65 years 1

BMI η 25 kg/m2 1

Tobacco smoking 1

A total of 2 or more points is considered high risk and warrants more aggressive treatment.

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Start one drug ȀƢȀ at lowest dose. Meets criteria chronic careintegration for endemic non-communicable diseases Stage 1 Return to for CCC referral: YES (140/90–160/100 health center Patient (1) BP ≥ 160/100 mHg OR Refer patient back to mmHg) CCC in 3 referred to (2) BP ≥ 140/90 mmHg AND urgent care setting for NO months health center ≥ 2 high risk points* AND BP recheck in 6–12 CCC for HTN failed trial of lifestyle months NO modiﬁcation

Check urine ≥ in HealthCenter Integrated Chronic Care Clinics Cases Hypertension Referred Newly of Management Initial PROTOCOL 8.2 8.2 YES BMI 25? #49*)&9'+$*4*')9')9#4A%$#45'+8%&9)+'+$%4'+.)9)+*>' dipstick YES

BP ≥ 180/110 mmHg in HealthCenter Integrated Chronic Care Clinics Cases Hypertension Referred Newly of Management Initial AND Manage as hypertensive emergency danger signs: YES (Section 8.4, Table 8.4) Check creatinine and acute dyspnea, visual changes, prioritize ACE-I if not headache? ≥ 2+ proteinuria YES contraindicated (i.e., pregnancy or creatinine ≥ '&"#.)94*'#84')9)#)$.':$9$A4:49#'&6'94<.7'%464%%45'87-4%2 200 µmol/L)

NO NO Check a conﬁrmatory test Complete intake form, Transfer to for diabetes evaluate for complicating/comorbid district hospital (fasting blood glucose or factors Any glycosuria YES hemoglobin A1C). If diabetes conﬁrmed, BP goal will be ≤ 130/80 mmHg (Chapter 7) Refer to NCD NO Signs of clinic for heart failure YES suspected heart 1. If ≤ 40, check for causes of (edema, dyspnea) failure secondary HTN Stage 2 (Protocol 4.1) 2. Start two drugs at lowest 160/100– YES dose NO 180/110 mmHg 3. Return to health center CCC Evaluate hypertension stage in 3 months. See NO Pregnant? management of (women between 15 and YES hypertension in 49 should be tested) pregnancy (Protocol 8.5) Stage 3 Refer to district-level ≥ 180/110 YES NCD clinic in 1–2 weeks NO mmHg BP = Blood pressure CCC = Chronic care clinic See

HTN = Hypertension management of diabetes In district NCD clinic: Diabetic YES (Chapter 7) 1. Evaluate for signs of heart failure. If present perform BP goal will be an echo * High-Risk Features: ≤ 130/80 mmHg 2. Check creatinine Diabetes – 2 points 3. If ≤ 40, consider checking for other causes of Renal failure – 2 points NO secondary HTN Proteinuria – 2 points 4. Start two drugs at lowest dose. Tobacco smoking – 1 point 5. If no renal or heart failure, refer back to health center ≥ BMI 25 – 1 point CCC for visit in 1–2 weeks. Otherwise, return to Age ≥ 65 years – 1 point district NCD clinic in 1–2 weeks. chapter!8 | hypertensionȀƢȀ195

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8.2.1 Identiﬁcation and Treatment of Emergency Conditions in the Health Center Integrated Chronic Care Clinic ͵ȋηͳͺͲȀͳͳͲ Ȍ 4@$."$#45'6&%'*7:-#&:*'&6'87-4%#49*)@4'4:4%A49+7>'H8&*4'<)#8'*)A9*'&6' 4952&%A$9'4664+#*'6%&:'#84'4.4@$#45'3.&&5'-%4**"%4'V4>A>C'$+"#4'57*-94$C' 84$5$+84C'&%'@)*"$.'+8$9A4*X'*8&".5'%4+4)@4'6$*#2$+#)9A'$9#)287-4%#492 *)@4'#84%$-7'VTABLE 8.4X'$95'$%4'#%$9*64%%45'#&'#84'5)*#%)+#'8&*-)#$.'6&%' )9-$#)49#':$9$A4:49#>'Y44'SECTION 8.426&%':$9$A4:49#'A")54.)94*'6&%' 87-4%#49*)@4'4:4%A49+7>'

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TABLE 8.2 Initiation of Hypertension Treatment According to Stage and Risk Factors

Stage Blood pressure Treatment Clinic follow-up range Stage 1 140/90–160/100 Do not start medications. 12 months in AND mmHg Counsel on salt intake and acute care ζ 1 high risk point (TABLE 8.1) weight loss if indicated.

Stage 1 140/90–160/100 Do not start medications. 6 months in AND mmHg Counsel on salt intake and acute care η 2 high risk points (TABLE 8.1) weight loss if indicated. AND No trial of lifestyle modiﬁcation

Stage 1 140/90–160/100 Start ﬁrst-line medication 3 months in health AND mmHg at lowest dose center integrated chronic care clinic η 2 high risk points (TABLE 8.1) AND Failed 6-month trial of lifestyle modiﬁcation

Stage 2 160/100–180/110 Start ﬁrst- and second-line 3 months in health mmHg medications at lowest dose center integrated chronic care clinic Stage 3 η180/110+ mmHg Start ﬁrst- and second-line 1–2 weeks in district WITHOUT medications at lowest dose level NCD clinic Danger signs* Stage 3 η180/110+ mmHg Initiate therapy listed in WITH TABLE 8.4. Transfer to district hospital for inpatient Danger signs* management

* Danger signs include acute dyspnea, visual changes, headaches.

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TABLE 8.3 Recommended Hypertension Medications and Dosing for Most Adult Patients

First-line drug Starting dose Increase Maximum Notes dose by dose Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Can cause hypokalemia Not e#ective in the setting of severe renal failure (creatinine η 300 µmol/L)

Second-line drug Starting dose Increase Maximum Notes dose by dose Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower-extremity edema

Third-line drug Starting Dose Increase Maximum Notes dose by dose Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day Contraindicated in pregnancy and advanced renal failure η Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day (creatinine 200 µmol/L) Can cause cough Fourth-line drug Starting dose Increase Maximum Notes dose by dose Atenolol 25 mg 1x/day 25 mg 1x/day 50 mg 1x/day Contraindicated if heart rate η 55 bpm Use with caution in renal failure, since atenolol is renally cleared Fifth-line drug Starting dose Increase Maximum Notes dose by dose Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Safe in pregnancy Headache common side e#ect of hydralazine Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Safe in pregnancy

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TABLE 8.4 Recommended Medications for Management of Hypertensive Emergency (Adult Dosing)

Medication Dosing Notes

Nifedipine 10 mg orally (immediate release)

Captopril 25 mg orally Contraindicated in pregnancy and severe renal failure (Cr η 200 µmol/dL) Hydralazine 25 mg orally

Furosemide 40 mg orally or 20 mg IV If evidence of pulmonary congestion

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TABLE 8.5 Hypertension Medications and Dosing in Setting of Proteinuria or Mild Renal Failure (Creatinine 100–200 !mol/L)

First-line drug Starting dose Increase Maximum Notes dose by dose Lisinopril 5 mg 1x/day 5 mg 1x/day 20 mg 1x/day Contraindicated in pregnancy and advanced renal failure (creatinine η 200 µmol) Captopril 12.5 mg 3x/day 12.5 mg 3x/day 50 mg 3x/day Can cause cough

Second-line drug Starting dose Increase Maximum Notes dose by dose Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Can cause hypokalemia Not e#ective in the setting of severe renal failure (creatinine η 300 µmol) Third-line drug Starting dose Increase Maximum Notes dose by dose Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower-extremity edema

Fourth-line drug Starting dose Increase Maximum Notes dose by dose Atenolol 25 mg 1x/day 25 mg 1x/day 50 mg 1x/day Contraindicated if heart rate ζ 55 bpm Use with caution in renal failure as is renally cleared Fifth-line drug Starting dose Increase Maximum Notes dose by dose Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Safe in pregnancy. Headache common side e#ect

Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Safe in pregnancy

8.5.1 Proteinuria or Mild Renal Failure (Creatinine between 100–200 !mol/L) G%)9"%)$')*'$9'4$%.7'*)A9'&6'%49$.'57*6"9+#)&9>'R).5'%49$.'6$)."%4')*' #7-)+$..7'-%4*49#'$#'+%4$#)9)94'.4@4.*'34#<449'/11'$95'J11'n:&.iF>'LSU' )98)3)#&%*'84.-'54+%4$*4'-%)9"%)$'$95'-%4@49#'6"%#84%'%49$.'5$:$A4' ǤϐǦ $..'-$#)49#*'<)#8'-%)9"%)$'&%':).5'%49$.'6$)."%4'"9.4**'+&9#%$)95)+$2 Ǥ ηʹͲͲ ρȀȋηʹǤ͵ȀȌ > chapter!8 | hypertensionȀƢȀ203

TABLE 8.6 Recommended Hypertension Medications and Dosing in Setting of Severe Renal Failure (Creatinine η 200 !mol/L)

First-line drug Starting dose Increase Maximum Notes dose by dose If Cr Hydrochlorothiazide 12.5 mg 1x/day 12.5 mg 1x/day 25 mg 1x/day Can cause ζ 300 hypokalemia µmol/L If Cr Furosemide 20 mg 1x/day 20 mg 1x/day 40 mg 1x/day η 300 µmol/L Second-line drug Starting dose Increase Maximum Notes dose by dose Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower- extremity edema

Third-line drug Starting dose Increase Maximum Notes dose by dose Atenolol 25 mg 1x/day 25 mg 1x/day 100 mg 1x/day Contraindicated if heart rate ζ 55 bpm Use with caution in renal failure Fourth-line drug Starting dose Increase Maximum Notes dose by dose Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Safe in pregnancy Headache common side e#ect Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Safe in pregnancy

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8.6 Evaluation and Management of Hypertension in Younger Patients R&*#'4**49#)$.'87-4%#49*)&9'<)..'&++"%')9'-$#)49#*'&@4%'#84'$A4'&6'K1>'?6'$' -$#)49#'-%4*49#*'<)#8':&54%$#4'#&'*4@4%4'87-4%#49*)&9'$#'$'7&"9A4%'$A4C' *4+&95$%7'+$"*4*'&6'87-4%#49*)&9'$%4':&%4'.)P4.7'#&'34'$'+$"*4'V*44' TABLE 8.7X>'PROTOCOL 8.3'&"#.)94*'$'5)$A9&*#)+'$--%&$+8'#&'#84*4'-$#)49#*>'

PROTOCOL 8.3 Initial Diagnosis and Management of Suspected Secondary Hypertension

Patient ≤ 40 years old Check creatinine Hypertension likely and SBP ≥ 160 mmHg and potassium Creatinine ≥ 200 µmol/L YES secondary to renal and DBP ≥ 100 mmHg (if available) failure. See Section 8.5

Evaluate for other causes of secondary hypertension and refer to endocrinologist 1. Cushingnoid features 2. Signs of hyperaldosteronism (low potassium) 3. Signs of coarction (delayed or absent femoral pulse, SBP in legs 40 mmHg ≤ than in arms) 4. Symptoms of pheochromocytoma (periodic episodes of hypertension, anxiety, tachycardia, diaphoresis) 5. Signs of renal artery stenosis (abdominal bruit, creatinine more than doubles after starting ACE-I)

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TABLE 8.7 Causes of Secondary Hypertension

Cause Findings Management

Renal failure Elevated creatinine (η 200) See SECTION 8.5

Cushing’s syndrome Truncal obesity, round face, extremity Refer to tertiary referral center for (hypercortisolism) wasting, hypokalemia endocrinology consultation

Hyperaldosteronism Hypokalemia Refer to tertiary referral center for endocrinology consultation

Pheochromocytoma Periodic episodes of hypertension, Refer to tertiary referral center for anxiety, tachycardia, diaphoresis endocrinology consultation

Coarctation Delayed or absent femoral pulse; SBP in Refer to tertiary referral center for legs 40 mmHg ζ than SBP in arms echocardiography and cardiology consultation Renal artery stenosis Abdominal bruit; creatinine more than Refer to tertiary referral center for renal doubles after starting ACE inhibitor ultrasound and nephrology consultation chapter!8 | hypertensionȀƢȀ205

8.7 Follow-Up Treatment for Hypertension PROTOCOL 8.4'&"#.)94*'$9'$--%&$+8'#&'&9A&)9A':$9$A4:49#'&6'-$#)49#*' <8&'$%4'6&..&<45')9'#84'+8%&9)+'+$%4'+.)9)+*'6&%'87-4%#49*)&9>'

PROTOCOL 8.4 Follow-Up Visit for Chronic Hypertension in Health Center Integrated Chronic Care Clinic

Patient on medications for hypertension

BP ≥ 180/110 mmHg AND Treat as hypertensive emergency Transfer to YES danger signs: (Section 8.4 and Table 8.4) district hospital acute dyspnea, visual changes, headache?

Complete follow-up form

Pregnant? See management of (Test women 15–49 if YES hypertension in pregnancy suspected) (Section 8.8)

Evaluate hypertension stage

Continue current therapy. Controlled Return to health center CCC in (BP ≤ 140/90 YES 3–12 months depending on mmHg) health center reﬁll mechanism

Stage 1 Start or increase one drug by one interval. BP 140/90– YES 160/100 mmHg Return to health center CCC in 3 months

Check creatinine and prioritize Urine dipstick ACE inhibitor if not contraindicated NO Check urine dipstick ≥ 2+ proteinuria YES checked in past (i.e., pregnancy or year? creatinine ≥ 200 µmol/L)

Check a conﬁrmatory test for diabetes Any glycosuria YES (fasting blood glucose or YES hemoglobin A1C)

Stage 2 Start or increase two drugs by one interval. 160/100 – YES 180/110 mmHg Return to health center CCC in 3 months

Stage 3 Start or increase two drugs by one interval. ≥ 180/110 YES Consider assigning a community health worker mmHg Refer to district level NCD clinic in 1–2 weeks

BP = Blood pressure CCC = Chronic care clinic 206ȀƢȀchronic care integration for endemic non-communicable diseases

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8.7.2 Follow-Up of Stage 1 Hypertension [&%'-$#)49#*'<)#8'*#$A4'/'87-4%#49*)&9'V34#<449'/K1id1'$95'/Z1i/11' ::,AXC'#84'3.&&5'-%4**"%4':45)+$#)&9'*8&".5'34')9+%4$*45'37'&94' )9#4%@$.'V*44'TABLE 8.3X>'

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TABLE 8.8 Hypertensive Disorders of Pregnancy

Classiﬁcation Deﬁnition Risks Role of antihypertensives

Chronic BP η 140/90 mmHg η 20% will develop Does not reduce the risk of 22 hypertension AND preeclampsia developing preeclampsia Diagnosis of hypertension prior Placental abruption May reduce risk of maternal to pregnancy or before 20 weeks Intrauterine growth cerebral hemorrhage of gestation retardation Gestational BP η 140/90 mmHg 50% will develop Does not reduce the risk of 23 hypertension AND preeclampsia developing preeclampsia Diagnoses or progression of 10% will develop May reduce risk of maternal hypertension after 20 weeks severe preeclampsia cerebral hemorrhage of gestation WITHOUT Significant proteinuria Defined as η 2+ on a urine dipstick Preeclampsia BP η 140/90 mmHg 25% will develop Does not reduce the risk of AND severe preeclampsia developing severe preeclampsia Diagnosis or progression of Eclampsia (seizures) hypertension after 20 weeks Maternal stroke May reduce risk of maternal of gestation cerebral hemorrhage AND Significant proteinuria Defined as η 2+ on a urine dipstick Severe Preeclampsia Eclampsia (seizures) Does not reduce the risk of preeclampsia AND Maternal stroke developing severe preeclampsia BP η 160/110 mmHg May reduce risk of maternal OR hemorrhage η 3+ proteinuria OR Any symptom of end-organ damage (oliguria, right-upper-quadrant pain, severe persistent headache, cerebral hemorrhage, nausea, pulmonary edema, low platelets [ζ100,000], severe intrauterine growth restriction, or transaminitis [η twice normal])

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PROTOCOL 8.5 Management of Hypertension in Pregnancy

Woman with positive pregnancy test and blood pressure ≥ 140/90 mmHg x 2

Gestational age Initiate MgSO4 ≥ 20 weeks OR (Table 8.9) YES Seizures? YES able to palpate Transfer to district hospital uterine fundus at for immediate delivery umbillicus

Check urine dipstick, evaluate for YES NO signs of preeclampsia or hypertensive emergency*

Manage as chronic hypertension using medications preferred in ≥ 3+ pregnancy (Table 8.11) ≥ Initiate antihypertensive proteinuria BP 160/110 YES mmHg treatment (Table 8.11) and/or danger signs?

NO NO * Symptoms of preeclampsia and/or hypertensive emergency BP 140/90– Danger Transfer to district hospital YES YES Dyspnea 160/110 mmHg signs? for prompt delivery Headache Visual changes Right-upper-quadrant pain Nausea/vomiting NO

Initiate antihypertensive ≥ 2+ treatment YES proteinuria (Table 8.11) Return to clinic in one week

Recheck blood pressure at next prenatal visit

L..'<&:49'34#<449'#84'$A4*'&6'/0'$95'Kd'<8&'-%4*49#'#&'4)#84%'#84' $+"#4'+$%4'&%'#84')9#4A%$#45'+8%&9)+'+$%4'+.)9)+'<)#8'87-4%#49*)&9'$%4' #4*#45'6&%'-%4A9$9+7>'G%4A9$9#'-$#)49#*'$%4'%464%%45'#&'#84'-%49$#$.' +.)9)+>'F)P4<)*4C'$..'-%4A9$9#'<&:49'-%4*49#)9A'6&%'-%49$#$.'+$%4'*8&".5' 8$@4'#84)%'3.&&5'-%4**"%4':4$*"%45'$#'4@4%7'@)*)#>

8.8.1 Hypertension in Early Pregnancy (Chronic Hypertension) G%4A9$9+72)95"+45'87-4%#49*)&9'"*"$..7'&++"%*')9'#84'#8)%5'#%):4*#4%>' H84%46&%4C'-$#)49#*'<)#8'87-4%#49*)&9')9'#84'4$%.)4%'*#$A4*'&6'-%4A9$9+7' .)P4.7'8$@4'-%424E)*)#)9A'87-4%#49*)&9>',4%4C'<4'"*4'$'+"#2&66'&6'.4**' #8$9'J1'<44P*'A4*#$#)&9$.'$A4'$95i&%'$'6"95$.'84)A8#'.4**'#8$9'J1'+:'$*' ϐ Ǥ *):).$%'#&'#8$#'&6'9&92-%4A9$9#'87-4%#49*)@4*C'<)#8'#84'4E+4-#)&9'#8$#' 5)664%49#':45)+$#)&9*'$%4'-%464%%45'V*44'TABLE 8.11X>'H84*4'-$#)49#*'$%4' chapter!8 | hypertensionȀƢȀ211

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8.8.2 Hypertension in Later Pregnacy (Gestational Hypertension and Preeclampsia) G$#)49#*'<8&'54@4.&-'87-4%#49*)&9C'&%'<8&*4'87-4%#49*)&9'-%&A%4**4*' $#'A%4$#4%'#8$9'J1'<44P*'A4*#$#)&9$.'$A4C'$%4'$#'8)A84%'%)*P'&6'-%42 4+.$:-*)$'$95'4+.$:-*)$>'PROTOCOL 8.5'&"#.)94*'$9'$5$-#$#)&9'&6'#84' ?RGLS'$.A&%)#8):'6&%'4@$."$#)&9'$95'#%4$#:49#'&6'#84*4'-$#)49#*>/g

8.8.3 Recognition and Management of Emergent Conditions G$#)49#*'<8&'$%4'$+#)@4.7'*4)^)9A'&%'8$@4'8$5'*4)^"%4*'5"%)9A'.$#4'-%4A2 9$9+7'*8&".5'34')::45)$#4.7'*#$%#45'&9':$A94*)":'$95'#%$9*64%%45' #&'#84'94$%4*#'5)*#%)+#'8&*-)#$.'6&%')::45)$#4'54.)@4%7>'Y44'TABLE 8.926&%' .&$5)9A'$95':$)9#49$9+4'5&*)9A>

TABLE 8.9 Loading and Maintenance Dosing of Magnesium Sulfate in Eclampsia and Severe Preeclampsia (Adapted from IMPAC)17,18

Start with loading dose: Inject 4 grams (20 ml of 20% concentration) by IV over 20 minutes. AND Inject 5 grams (10 ml of 50% concentration) mixed with 1 ml of 1%–2% lidocaine IM in each buttock (for a total of 10 grams). If unable to establish IV, give only IM dose as loading dose. If seizures recur after 15 minutes, give reloading dose: Inject 2 grams of 20% concentration IV over 5 minutes. Follow with maintenance dose: Inject 5 grams of 50% concentration IM mixed with 1 ml of 1%–2% lidocaine in alternate buttocks every four hours. Maximum total dose: 40 g every 24 hours Side-effect monitoring: Monitor for respiratory depression (respiratory rate ζ 16), loss of reﬂexes and decreased urinary output (ζ100 ml/4 hrs). Injecting the magnesium too quickly increases the risk of respiratory or cardiac depression. Stop the therapy if the respiratory rate falls below 16 per minute, patellar reﬂexes are absent, or urinary output is less than 100 mL over 4 hours. For respiratory depression, give calcium gluconate 1 g IV (10 ml of 10% solution) over 10 minutes Other safety considerations Do not leave the patient by herself. Place her on her left side. Transfer immediately to district hospital unless delivery is imminent

8.8.4 Screening for Preeclampsia G$#)49#*'<)#8'9&'8)*#&%7'&6'*4)^"%4'$+#)@)#7'*8&".5'34'*+%44945'6&%'-%42' 4+.$:-*)$'<)#8'$'"%)94'5)-*#)+P'$95'4@$."$#)&9'&6'*7:-#&:*'&6'4952&%A$9' 212ȀƢȀchronic care integration for endemic non-communicable diseases

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8.8.5 Treatment of Preeclampsia According to Disease Classiﬁcation Q0$0#02)#00'=";)1*"+'Y4@4%4'-%44+.$:-*)$')*'-%44+.$:-*)$'<)#8'$' ηͳ͸ͲȀͳͳͲ ǡǦǡ &%'A%4$#4%'#8$9'&%'4O"$.'#&'Bf'-%)9"%)$>'H84*4'-$#)49#*'*8&".5'34' *#$%#45'&9'$9#)87-4%#49*)@4*'$95'%4+4)@4'$'.&$5)9A'5&*4'&6':$A94*)":' 6&%'*4)^"%4'-%&-87.$E*)*C'<8).4'34)9A'-%4-$%45'6&%')::45)$#4'#%$9*64%' #&'#84'94$%4*#'5)*#%)+#'8&*-)#$.'6&%'-%&:-#'54.)@4%7>'`)645)-)94')*'#84' 6$*#4*#2$+#)9A'$9#)87-4%#49*)@4'#8$#')*'*$64')9'-%4A9$9+7>'H84'*4+&952.)94' $A49#C':4#87.5&-$C'8$*'$'.&9A4%'&9*4#'&6'$+#)&9'VTABLE 8.10X>

Q0$0#02-018"8*,&"=2!M)0#80&1*,&+'G$#)49#*'<)#8'*4@4%4'87-4%#49*)&9' ȋηͳ͸ͲȀͳͳͲ Ȍ *8&".5'34'*#$%#45'&9'$9#)87-4%#49*)@4*'$95'#%$9*64%%45'#&'#84'94$%4*#' 5)*#%)+#'8&*-)#$.'6&%'$5:)**)&9'VTABLE 8.10X>'F)P4<)*4C'-%4A9$9#'<&:49' <)#8':).5'3.&&5'-%4**"%4'4.4@$#)&9'<)#8'$97'*)A9'#8$#'+&".5')95)+$#4' -%44+.$:-*)$'V57*-94$C'84$5$+84C'@)*)&9'+8$9A4*C'%)A8#2"--4%2O"$5%$9#' -$)9C'9$"*4$C'&%'@&:)#)9AX'*8&".5'34'8&*-)#$.)^45'6&%'&3*4%@$#)&9>

TABLE 8.10 Recommended Medications for Management of Hypertension in Severe Preeclampsia

Medication Dosing Notes

Nifedipine (immediate release) 10 mg orally Fast acting

Methyldopa 250 mg orally Slower acting

8.8.5.1 Mild to Moderate Preeclampsia ϐηͳͶͲȀͻͲ ζͳ͸ͲȀͳͳͲ ǡηʹΪ &6'*4@4%4'-%44+.$:-*)$>'H84*4'-$#)49#*'*8&".5'34'*#$%#45'&9'$9#)87-4%2 #49*)@4*'$95'6&..&<45'+.&*4.7')9'#84'-%49$#$.'+.)9)+'VTABLE 8.11X>'?6'$' <&:$9')*'$.%4$57'&9'$9#)87-4%#49*)@4*C'*84'*8&".5'8$@4'84%':45)+$#)&9' 5&*$A4')9+%4$*45C'<)#8'$'A&$.'3.&&5'-%4**"%4'&6'/K1k/01id1k/11'::,A>' ?54$..7C'*84'<)..'34'$5:)##45'6&%'&3*4%@$#)&9'6&%'$#'.4$*#'$'JK28&"%'-4%)&5' $95'*84'*8&".5'34'A)@49'*#%)+#'-%4+$"#)&9$%7')9*#%"+#)&9*'#&'%4#"%9'#&' +$%4')::45)$#4.7')6'*84'54@4.&-*'$97'&6'#84'*7:-#&:*'&6'*4@4%4'-%42 4+.$:-*)$'&%'8$*'54+%4$*45'64#$.':&@4:49#>

8.8.5.2 Mild to Moderate Gestational Hypertension _&:49'<)#8':).5'87-4%#49*)&9'*8&".5'9&#'34'*#$%#45'&9':45)+$#)&9*>' G$#)49#*'$.%4$57'&9':45)+$#)&9*'*8&".5'+&9#)9"4'$9#)87-4%#49*)@4'#%4$#2 :49#'<)#8'5%"A*'$--%&-%)$#4'6&%'-%4A9$9+7> chapter!8 | hypertensionȀƢȀ213

TABLE 8.11 Recommended Hypertension Medications and Dosing in Pregnancy

First-line drug Starting dose Increase Maximum Notes dose by dose Methyldopa 250 mg 2x/day 250 mg 2x/day 500 mg 2x/day Best-proven safety in pregnancy, cheap, widely available Second-line drug Starting dose Increase Maximum Notes dose by dose Nifedipine 10 mg 3x/day 20 mg 3x/day 60 mg 3x/day (immediate release)

Amlodipine 5 mg 1x/day 5 mg 1x/day 10 mg 1x/day Can cause lower-extremity edema

Third-line drug Starting dose Increase Maximum Notes dose by dose Atenolol 25 mg 1x/day 25 mg 1x/day 100 mg 1x/day Contraindicated if heart rate ζ 55 bpm

Fourth-line drug Starting dose Increase Maximum Notes dose by dose Hydralazine 25 mg 3x/day 25 mg 3x/day 50 mg 3x/day Headache common side e#ect. Expensive, requires thrice-daily dosing 214ȀƢȀchronic care integration for endemic non-communicable diseases

Chapter 8!References

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/d' Y8$8'YC'H4)*:$99'`C'q$)$'!C'4#'$.>'L++"%$+7'&6'4:4%A49+7'-87*)+)$9*'"*)9A' ".#%$*&"95'#&'54#4%:)94'A4*#$#)&9$.'$A4')9'-%4A9$9#'<&:49>'L:'I'U:4%A' R45hJgWgBK2g> J1' H%$)*$#8)#'GC'F4'S&4"%'YC'R$%7'IcC'M$9D$9$*)9A'LC'F$:.4%#P)##)P".'YC'F$..4:$9#' R>'T4*#$#)&9$.'$A4'54#4%:)9$#)&9'$95'-%4@49#)&9'&6',?\'-4%)9$#$.'#%$9*:)*2 *)&9>'?9#'I'T79$4+&.'b3*#4#'J11ZhdJW/]Z2g1> J/' I48$9'?C'q$)5)'YC';)^@)'YC'4#'$.>'($#)9A'A4*#$#)&9$.'$A4'37'.$*#':49*#%"$.'-4%)&5C' *7:-87*)*26"95$.'84)A8#C'$95'".#%$*&"95')9'"%3$9'G$P)*#$9>'?9#'I'T79$4+&.' b3*#4#h//1WJB/2K> JJ' F)9584):4%'R(C'H$.4%'YIC'S"99)9A8$:'[T>'LY,'-&*)#)&9'-$-4%W'87-4%#49*)&9' )9'-%4A9$9+7>'I'S.)9',7-4%#49*'VT%449<)+8X'J11dh//WJ/K2J0> JB' !$%#&9'I;C'b=!%)49'I'RC'!4%A$"4%'`MC'I$+O"4*'(FC'Y)3$)'!R>'R).5'A4*#$#)&9$.' 87-4%#49*)&9'%4:'6%&:'#4%:W'-%&A%4**)&9'$95'&"#+&:4>'L:'I'b3*#4#' T794+&.'J11/h/gKWd]d2gB> chapter 9 Rheumatic Heart Disease Prevention

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FIGURE 9.1 Progression from Pharyngitis to Rheumatic Fever

Group A Pharyngitis 20% streptococcal 2% Rheumatic fever pharyngitis

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TABLE 9.1 Clinical Decision Rules for Treatment of Pharyngitis

% with GAS % without GAS not treated overtreated

Rule 1: WHO14 88% 6% Pharyngeal exudate + tender and enlarged cervical lymph nodes

Rule 2: Steinhoff12 10% 60% Pharyngeal exudate OR enlarged cervical lymph nodes

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PROTOCOL 9.1 Evaluation and Management of Pharyngitis

Patient with a sore throat

Assess for danger signs: 1. Leaning forward and drooling YES 2. Unable to swallow Refer to district hospital immediately 3. Stridor

Treat as streptococcal pharyngitis Exudate? YES (see Tables 9.2 and 9.3)

Child ≥ 2 of Following: between Treat as streptococcal 1. Lymphandenopathy 5 and 15 years YES YES pharyngitis 2. Documented fever ≥ 38 old? 3. Lack of cough (see Tables 9.2 and 9.3)

Do not treat for streptococcus. NO Runny nose? Treat according to acute care Cough? YES guidelines for respiratory Congestion? complaints (see IMCI and IMAI guidelines)

NO YES Runny nose? Cough? Test for HIV if not recently tested Congestion? or if has risk factors

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TABLE 9.2 Antibiotic Regimens for Streptococcal Pharyngitis (Adults and Adolescents Dosing, Weight η 27 kg)

Regimen Doses Cost Allergic Reactions16,17

Oral penicillin VK 500 mg, two times per day 20 $0.66 Cutaneous 1%–2% for 10 days

Intramuscular benzathine 1.2 million units, single dose 1 $0.14 Cutaneous 1%–2% penicillin G Anaphylaxis 0.02%

Death 0.003%

Oral erythromycin 250 mg, four times per day 12 $6.38 (75 kg adult)

TABLE 9.3 Antibiotic Regimens for Streptococcal Pharyngitis (Pediatric Dosing, Weight ζ 27 kg)

Regimen Doses Cost Oral penicillin VK 250 mg, two times per day for 10 days 20 $0.33

Intramuscular benzathine penicillin G 600,000 units, single dose 1 $0.09

Oral erythromycin (25-kg child) 12.5 mg/kg, three times per day 9 $0.27

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TABLE 9.4 Modiﬁed Jones Criteria for High-Risk Groups21,23,24

Major criteria (ﬁve) Minor criteria (four)

1. Carditis or subclinical (echocardiographic) carditis Clinical 2. Polyarthritis or monoarthritis 1. Fever * 38˚C 3. Chorea 2. Arthralgia 4. Erythema marginatum Laboratory 5. Subcutaneous nodules 3. Elevated acute phase reactants (erythrocyte sedimentation rate * 30 mm/h) 4. PR-interval prolongation

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TABLE 9.5 Antibiotic Regimens for Secondary Prophylaxis of Rheumatic Fever

Adults ( η 27 kg) Children (ζ 27 kg) Oral penicillin VK 500 mg, two times per day 250 mg, two times per day

Intramuscular benzathine penicillin G 1.2 million units, once every 600,000 units, once every 4 weeks 4 weeks Oral erythromycin (penicillin allergy) 250 mg, two times per day 10 mg/kg, twice per day

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TABLE 9.6 Echocardiographic Prevalence of Deﬁnite and Possible RHD in School-Aged Children

Country N Setting Population Deﬁnite or Possible probable RHD RHD Paar et al. 2010 41 Nicaragua 3150 Rural and Community 0.6% 2.4% urban

Steer et al. 2009 37 Fiji 3462 Rural and School-based 0.8% n/a urban

Carapetis et al. 2008 39 Tonga 5053 Rural and School-based 3.3% 0.5% urban

Marijon et al. 2007 36 Cambodia 3677 Urban School-based 3.0% n/a

Marijon et al. 2007 36 Mozambique 2170 Urban School-based 2.1% n/a

Anabwani and Bonhoe#er Kenya 1115 Rural and School-based 0.3% 7.3% 1996 42 urban

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TABLE 9.7 Echocardiographic Features of Left-Sided Heart Valves Thought Consistent with Rheumatic Heart Disease in High-Prevalence Settings by Three Sets of Criteria

World Health Marijon et Preliminary World Health Organization/United Organization 2001 24 al. 2009 44 States National Institutes of Health 2005 37 Properties of Holosystolic (mitral) or Any degree Deﬁnite Probable regurgitant jet holodiastolic (aortic) in two planes regurgitation visible in η 2 cm, otherwise η 2 cm, otherwise at least two color planes meeting World Health meeting World Health with η 1 cm extension Organization 2001 Organization 2001 and a velocity η 2.5 m/s criteria* criteria*

Morphologic Not required Required** Required*** Not Required***† abnormalities

Pathologic Not required Not Required Required Required murmurs

* η 1 cm of jet length is su$cient for aortic regurgitation. ** Any two of the three that include leaflet tethering, leaflet thickening, or sub-valvular thickening. *** For mitral regurgitation, these include thickening of the valve or a hockey-stick/elbow deformity of the anterior leaflet; in addition, for mitral stenosis, these also include tethering of the posterior leaflet, commissural thickening and calcification with a mean gradient η 4 mmHg; for aortic regurgitation without obvious non-rheumatic causes, these include morphologic abnormalities of the mitral valve. † Either significant left-sided valvular regurgitation, morphologic abnormalities, or mitral stenosis in the presence of pathologic murmurs.

!4+$"*4'&6'"9+4%#$)9#7'$3&"#'#84'):-&%#$9+4'&6':).5'.4*)&9*'&9'4+8&2 +$%5)&A%$-87C'<4'-%&-&*4'#8$#'-%4@$.49+4'*"%@47*'-.$+4':&%4'<4)A8#'&9' ϐǤǡ 4:-8$*)*'*8&".5'34'-"#'&9'4+8&+$%5)&A%$-8)+'5)$A9&*)*'V*44'TABLE 9.8X> PROTOCOL 9.2 9.8 TABLE ahlgcmrusNotrequired Pathologic murmurs Required* Morphologic abnormalities At leastmild-to-moderate regurgitation. Properties ofregurgitant jet High-risk group (Children ages 5–15) P 1. History: any recollection of severe joint pain, roposed Criteria for Deﬁnite and Possible RHD Possible and Deﬁnite for Criteria roposed

shortness of breath. Consider screening

questions for epilepsy, musculoskeletal Children) School-Aged of Conditions Other (and Scr disabilities, asthma eening for Rheumatic Heart Disease Disease Heart Rheumatic for eening 2. Physical examination: height and weight, auscultation. Consider physical examination for other conditions (e.g., skin infections) Regurgitation visibleinatleasttwo color planes Deﬁnite 3. Consider screening laboratory tests for anemia, proteinuria, HIV 4. Screening echocardiography (restricted to parasternal long and apical 4-chamber views). chapter

1. Initiate antibiotic prophylaxis (oral or IM) ! 9

2. Assign a community

Meet echocardiographic | Refer to district Deﬁnite YES YES health worker rheumatic heart diseaseprevention Criteria for deﬁnite or possible NCD clinic RHD? RHD? (see Table 9.5) 3. Monthly follow-up at health center chronic care clinic. NO

1. Council regarding sore

throat management Not Required Required* Any degree intwo planes Possible Follow-up plan for other 2. Participate in randomized identiﬁed conditions trial of antibiotics if available 3. Assign a community health worker 4. Follow-up every 6 months at district NCD clinic. ȀƢȀ 229 230ȀƢȀchronic care integration for endemic non-communicable diseases

[)9$..7C'#84%4'*8&".5'34'$'-.$9')9'-.$+4'#&'6&..&<'"-'6&%')95)@)5"$.*')5492 ϐǤ 2 :49#'&6'-8$%79A)#)*'4-)*&54*'%$#84%'#8$9'+&9#)9"&"*';['-%&-87.$E)*>' L9T%'$--%&$+8':$7'34'#&'49%&..'#84*4'-$#)49#*')9'%$95&:)^45'#%)$.*' &6'-%&-87.$E)*'*#%$#4A)4*>'PROTOCOL 9.2'*8&<*'$'-%&-&*45'$--%&$+8'6&%' ;,('-%4@$.49+4'*#"5)4* chapter!9 | rheumatic heart disease preventionȀƢȀ231

Chapter 9!References

/' S$%$-4#)*'I;C'Y#44%'LSC'R"8&..$95'UMC'_434%'R>'H84'A.&3$.'3"%549'&6'A%&"-' L'*#%4-#&+&++$.'5)*4$*4*>'F$9+4#'?964+#'()*'J110h0WZg02dK> J' H)3$^$%<$'M!C'\&.:)9P'ILC'R$7&*)'!R>'?9+)549+4'&6'$+"#4'%84":$#)+'64@4%')9' #84'<&%.5W'$'*7*#4:$#)+'%4@)4<'&6'-&-".$#)&923$*45'*#"5)4*>',4$%#' J11ghdKW/0BK2K1> B' R+(&9$.5'RC'S"%%)4'!IC'S$%$-4#)*'I;>'L+"#4'%84":$#)+'64@4%W'$'+8)9P')9'#84' +8$)9'#8$#'.)9P*'#84'84$%#'#&'#84'#8%&$#j'F$9+4#'?964+#'()*'J11KhKWJK120> K' Y#%$**4%'H>'S&*#24664+#)@4'+&9#%&.'&6'%84":$#)+'64@4%')9'#84'+&::"9)#7>' ,4$.#8'G&.)+7'/dg0h0W/0d2ZK> 0' _&%.5',4$.#8'b%A$9)^$#)&9>'?9#4A%$#45'R$9$A4:49#'&6'L5&.4*+49#'$95'L5".#' ?..94**>'T")54.)94*'6&%'[)%*#2F4@4.'[$+).)#7',4$.#8'_&%P4%*'$#',4$.#8'S49#%4' $95'()*#%)+#'b"#-$#)49#'S.)9)+>'J11d> Z' ;&34%#*&9'MLC'\&.:)9P'ILC'R$7&*)'!R>'L9#)3)&#)+*'6&%'#84'-%):$%7'-%4@492 #)&9'&6'$+"#4'%84":$#)+'64@4%W'$':4#$2$9$.7*)*>'!RS'S$%5)&@$*+'()*&%5' J110h0W//> ]' L%A"45$*'LC'R&8*'U>'G%4@49#)&9'&6'%84":$#)+'64@4%')9'S&*#$';)+$>'I'G45)$#%' /ddJh/J/W0Zd2]J> g' `$95)'YC'M":$%';C';$7'GC'\&8%$',C'T$9A".7'`M>'T%&"-'L'*#%4-#&+&++$.'*&%4' #8%&$#')9'$'-4%)"%3$9'-&-".$#)&9'&6'9&%#84%9'?95)$W'$'&94274$%'-%&*-4+#)@4' *#"57>'!"..'_&%.5',4$.#8'b%A$9'J11/h]dW0Jg2BB> d' Y#44%'LSC'S$%$-4#)*'I;C'`&.$9'HRC'Y8$99'[>'Y7*#4:$#)+'%4@)4<'&6'%84":$#)+' 84$%#'5)*4$*4'-%4@$.49+4')9'+8).5%49')9'54@4.&-)9A'+&"9#%)4*W'#84'%&.4'&6' 49@)%&9:49#$.'6$+#&%*>'I'G$45)$#%'S8).5',4$.#8'J11JhBgWJJd2BK> /1' S49#&%';RC'_)#84%*-&&9'IRC'($.#&9',GC'!%&57'SUC'F)9P'M>'H84'5)$A9&*)*'&6' *#%4-'#8%&$#')9'$5".#*')9'#84'4:4%A49+7'%&&:>'R45'(4+)*'R$P)9A' /dg/h/WJBd2KZ> //' ;):&)9'L_C',$:^$',YC'\)9+4'LC'4#'$.>'U@$."$#)&9'&6'#84'_,b'+.)9)+$.' 54+)*)&9'%".4'6&%'*#%4-#&+&++$.'-8$%79A)#)*>'L%+8'()*'S8).5'J110hd1W/1ZZ2]1> /J' Y#4)98&66'RSC'L35'4.'M8$.4P'RMC'M8$..$6'`C'4#'$.>'U664+#)@494**'&6'+.)9)+$.' A")54.)94*'6&%'#84'-%4*":-#)@4'#%4$#:49#'&6'*#%4-#&+&++$.'-8$%79A)#)*')9' UA7-#)$9'+8).5%49>'F$9+4#'/dd]hB01Wd/g2J/> /B' ;):&)9'L_C'[)*+84%'_$.P4%'SFC'S8)#$.4';LC'4#'$.>'\$%)$#)&9')9'+.)9)+$.' -%4*49#$#)&9'&6'+8).58&&5'T%&"-'L'*#%4-#&+&++$.'-8$%79A)#)*')9'6&"%' +&"9#%)4*>'I'H%&-'G45)$#%'J11gh0KWB1g2/J> /K' b%A$9)^$#)&9'_,>'?9#4A%$#45'R$9$A4:49#'&6'S8).58&&5'?..94**>'?RS?' L5$-#$#)&9'T")54>'T494@$W'(4-$%#:49#'&6'S8).5'$95'L5&.4*+49#',4$.#8'$95' (4@4.&-:49#h'J11J'I"94> /0' I&$+8):'FC'S$:-&*'(C'I%>C'Y:44*#4%*'G;>'G%$A:$#)+'*+&%)9A'*7*#4:'6&%' -8$%79A)#)*')9'.&<2%4*&"%+4'*4##)9A*>'G45)$#%)+*'J1/1h/JZW4Z1g2/K> /Z' L..4%A)+'%4$+#)&9*'#&'.&9A2#4%:'349^$#8)94'-49)+)..)9'-%&-87.$E)*'6&%' %84":$#)+'64@4%>'?9#4%9$#)&9$.';84":$#)+'[4@4%'Y#"57'T%&"->'F$9+4#' /dd/hBB]W/B1g2/1> /]' ?5*&4'bC'T"#84'HC'_)..+&E';;C'54'_4+P'LF>'`$#"%4'$95'4E#49#'&6'-49)+)..)9' *)542%4$+#)&9*C'<)#8'-$%#)+".$%'%464%49+4'#&'6$#$.)#)4*'6%&:'$9$-87.$+#)+' *8&+P>'!"..'_&%.5',4$.#8'b%A$9'/dZghBgW/0d2gg> /g' R$974:3$'IC'R$7&*)'!R>'G49)+)..)9'6&%'*4+&95$%7'-%4@49#)&9'&6'%84":$#)+' 64@4%>'S&+8%$94'($#$3$*4'Y7*#';4@'J11JWS(11JJJ]> /d' !8$##$+8$%7$'YC'H$95&9';>'H84'5)$A9&*)*'&6'%84":$#)+'64@4%o4@&."#)&9'&6' #84'I&94*'+%)#4%)$>'?9#'I'S$%5)&.'/dgZh/JWJg02dK> 232ȀƢȀchronic care integration for endemic non-communicable diseases

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K1' Y)9A8'G?C'S$%$-4#)*'I;C'!"$5%&:&'URC'Y$:34%P$%'G`C'Y#44%'LS>'H84'8)A8' 3"%549'&6'%84":$#)+'84$%#'5)*4$*4'6&"95'&9'$"#&-*7')9'[)D)>'S$%5)&.'c&"9A' J11gh/gWZJ2d> K/' G$$%'ILC'!4%%)&*'`RC';&*4'I(C'4#'$.>'G%4@$.49+4'&6';84":$#)+',4$%#'()*4$*4')9' S8).5%49'$95'c&"9A'L5".#*')9'`)+$%$A"$>'L:'I'S$%5)&.'J1/1h/10W/g1d2/K> KJ ǡǡǤ ϐǣ %4#%&*-4+#)@4'*#"57>'U$*#'L6%'R45'I'/ddZh]BW]/K2Z> KB' R$7&*)'!C';&34%#*&9'MC'\&.:)9P'IC'4#'$.>'H84'(%$P49*34%A'54+.$%$#)&9'&9'#84' +&9#%&.'&6'%84":$#)+'64@4%'$95'%84":$#)+'84$%#'5)*4$*4')9'L6%)+$>'Y'L6%'R45'I' J11ZhdZWJKZ> KK ǡǡϐǡǤ 37'4+8&+$%5)&A%$-87>'H84')9$54O"O"$+7'&6'_&%.5',4$.#8'bA$9)^$#)&9' +%)#4%)$'6&%'&-#):)^)9A'#84'5)$A9&*)*'&6'*"3+.)9)+$.'5)*4$*4>'S)%+".$#)&9' J11dh/J1WZZB2ZZg> K0 ǡϐǡ Ǥ 6&%'%84":$#)+'84$%#'5)*4$*4'*+%449)9A>'`$#'S.)9'G%$+#'S$%5)&@$*+'R45' J11gh0WU/2B> chapter 10 Chronic Respiratory Disease

10.1 The Burden of Chronic Respiratory Disease in Rural Rwanda H84':$)9'6&%:*'&6'+8%&9)+'%4*-)%$#&%7'5)*4$*4'VS;(X')9';<$95$'$%4' $*#8:$C'+8%&9)+'&3*#%"+#)@4'-".:&9$%7'5)*4$*4'VSbG(XC'$95'3%&9+8)4+2 #$*)*>'S8%&9)+'+$%4'+.)9)+*')9'#8%44';<$95$9'5)*#%)+#*'*"--&%#':&%4'#8$9' 011'-$#)49#*'<)#8'S;(C':&*#'&6'<8&:'$%4'6&..&<45'$#'#84'84$.#8'+49#4%' [email protected]':&*#.7'6&%'$*#8:$>'G%)&%'#&'#%4$#:49#C'#84*4'-$#)49#*'+&:-.$)945' &6'34)9A'.):)#45')9'#84)%'$3).)#7'#&'+$%%7'&"#'6$%:)9A'&%'T%'+8&%4*'#8$#' $%4'@)#$.'#&'$'*"++4**6".'%"%$.'4E)*#49+4>'L+"#4'4E$+4%3$#)&9*'&6'$*#8:$' ϐ Ǥ 9&'5$#$'$@$).$3.4'%4A$%5)9A'-&-".$#)&9'-%4@$.49+4'&6'S;(')9'%"%$.';<$95$>

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PROTOCOL 10.1 Initial Management of Chronic Cough or Shortness of Breath at Health Center Acute Care Clinics

1. Position (sit upright/leaning forward) Respiratory rate ≥ 30/min 2. If wheezing, give salbutamol 2 sprays every 15 min by Initial evaluation: metered dose inhaler with spacer Chronic cough or AND wheezing OR YES 3. If known heart disease and uncomfortable lying down, shortness of breath Patient acutely short of breath OR (≥ 3 weeks) Not able to walk unaided OR give furosemide (refer to acute decompensated heart Fever ≥ 39 failure protocol) 4. Refer urgently to district hospital

Serotest in past NO Perform HIV test year?

YES

1. Treat with antibiotics (Adult dosing: doxycycline 100 mg 2x/day x 14 days Fever, chills, or amoxicillin 500 mg 3x/day productive YES cough or HIV+ x 14 days) 2. If wheezing, salbutamol inhaler 3. Have return in 1–2 weeks

Cause of dyspnea Improvement? YES was likely NO pneumonia

1. Obtain CXR 2. Obtain sputum smear x 3

Leg swelling, Refer to district hospital NCD clinic for orthopnea, known YES heart condition, conﬁrmation of suspected heart failure murmur

Conjunctival 1. Check hemoglobin if available pallor, post- 2. Start elemental iron, Adults: 60 mg 2x/day, partum or other YES history of Children ≤ 40 kg: 2–3 mg/kg 1x/day bleeding 3. Albendazole 400 mg 2x/day x 7 days

Wheezing, night Refer to health center integrated cough, worsened YES chonic care clinic for probable by climate change asthma or COPD (see Protocol 10.2) or exercise 238ȀƢȀchronic care integration for endemic non-communicable diseases

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TABLE 10.1 Evaluation of Asthma Attack Severity (Adapted from IUATLD Guidelines)19

Symptoms Mild asthma Moderate asthma Severe asthma Imminent attack attack attack respiratory failure Dyspnea With physical With speaking All the time All the time exertion

Can speak in Full sentences Phrases Words Unable to speak

Mental status Normal Normal or Agitated Somnolent or agitated confused

Respiratory rate Normal to fast Fast Very fast (η30 Very fast (η30 breaths/min) breaths/min)

Pulse ζ 100 100–120 η120 Bradycardic

Peak expiratory ﬂow η 70% 50%–70% ζ 50% or ζ 100 Cannot measure (PEF) after salbutamol liters/min (% of patient’s best PEF or predicted PEF)

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TABLE 10.2 Causes of Chronic Dyspnea or Chronic Cough (η 3 Weeks)

System Disease Evaluate for Respiratory Asthma Episodic wheezing COPD Progressively worsening dyspnea Bronchiectasis Large volume of purulent sputum Acute bronchitis/pneumonia Fever, acute dyspnea, productive cough Pulmonary tuberculosis Cough, hemoptysis, fevers, night sweats, weight loss Cardiovascular Congestive heart failure Edema, orthopnea, rales Pulmonary hypertension and right Edema, ascites heart failure Gastrointestinal Gastroesophageal reflux disease Symptoms of reflux, heartburn Hematologic Anemia Conjunctival pallor, measure hemoglobin Ear, nose, throat Allergic or non-allergic rhinitis Nasal congestion, itchy/watery eyes Sinusitis (subacute/chronic) Postnasal drip, headache, rhinorrhea Psychological Anxiety Dyspnea and chest tightness in social situations, palpitations, sweating, tingling in arms or fingers Medication ACE inhibitors Usually non-productive cough shortly after starting the medication, though can occur at any time

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PROTOCOL 10.2 Initial Management of Asthma or COPD at Integrated Chronic Care Clinics

1. Position (sit upright/leaning forward) Patient referred to 2. Give salbutamol 2 sprays every 15 min by metered dose inhaler health center 1. Patient acutely short of using a spacer chronic care clinic breath and wheezing OR YES 3. If has productive cough or fever, give dose of doxycycline 100 mg (CCC) for suspected 2. RR ≥ 30 bpm or amoxicillin 500 mg (adult dosing) asthma or COPD 4. Give dose of prednisolone 2 mg/ kg (max 60 mg) 5. Refer urgently to district hospital NO

Complete history and physical exam, including peak ﬂow measurement

Patient 1. Consider alternative diagnosis, including with typical hyperventilation/somatization asthma symptoms, 2. May give trial of salbutamol abnormal peak ﬂow NO or wheezing on 3. Follow up in health center CCC exam? 2 weeks–2 months for reassessment

YES 1. Start appropriate asthma treatment (see Table 10.6) and give inhaler teaching Assess asthma Patient with 2. Albendazole 400 mg 2x/day x 7 days if not severity severe YES treated within the last year (adults) (see Table 10.4) asthma or 3. Obtain sputum smear x 3 COPD 4. Refer to district hospital NCD clinic for CXR, echocardiography and higher-level evaluation

1. Start appropriate asthma treatment (see Table 10.6 ) and give inhaler teaching 2. Abendazole 400 mg 2x/day x 3 days if not treated within the last year 3. Education about avoidance of triggers 4. Follow-up in health center CCC 2 weeks 5. Obtain CXR within next 6 months

TABLE 10.3 Common Signs and Symptoms of Asthma

Symptoms are intermittent Symptoms triggered by changes in weather, exposure to dust, exhaust, exercise or cooking smoke Dyspnea Wheezing Cough Nonproductive Nighttime Chest tightness Reduced PEF in setting of symptoms, 20% improvement with bronchodilators 242ȀƢȀchronic care integration for endemic non-communicable diseases

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TABLE 10.4 Classiﬁcation of Asthma Severity at Initial Visit26

Components of severity Intermittent Persistent

Mild Moderate Severe

Impairment Symptoms ζ 2 days/week η 2 days/week Daily Throughout but not daily the day

Nighttime awakenings None 1–2x/month 3–4x/month η 1x/week

Salbutamol use for ζ 2 days/week η 2 days/week Daily Several times symptom control but not daily per day

Interference with None Minor Some Extremely normal activity limitation limitation limited

Risk Exacerbations requiring 0–1/year η 2 exacerbations in 6 months requiring oral oral systemic cortico- systemic corticosteroids, or η 4 wheezing steroids (prednisolone) episodes/year lasting η 1 day AND risk factors for persistent asthma Consider severity and interval since last exacerbation. Frequency and severity may ﬂuctuate over time. Exacerbations of any severity may occur in patients in any severity category. chapter!10 | chronic respiratory disease 243

TABLE 10.5 Asthma Control Test25

Maximum score is 25 (points are 1–5 in order as below) ζ 19 means asthma may not be well controlled

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TABLE 10.6 Asthma Step Therapy

Asthma severity Salbutamol Beclomethasone Aminophylline Prednisone

Step 5: Severe uncontrolled Yes High dose Yes Yes

Step 4: Severe persistent Yes High dose Yes No

Step 3: Moderate persistent Yes Medium dose No No

Step 2: Mild persistent Yes Low dose No No

STEP-UP when poor control STEP-DOWN when doing well Step 1: Intermittent Yes No No No chapter!10 | chronic respiratory disease 247

TABLE 10.7 Asthma Medication Dosing

Salbutamol Beclomethasone Aminophylline Prednisone 100 mcg (inhaler) 50 and 250 mcg (inhaler) 100 mg tab 5 mg tab Always use a spacer Adults and 1–2 pu#s, 3x/day High: 300 mg 1–2 mg/kg/d in two children as needed 1500 mcg (3 pu#s 2x/d) in 3 divided doses divided doses η 30 kg (max 60 mg) Medium: x 7–10 days 1000 mcg (2 pu#s 2x/d) Note: If new CRD diagnosis, Low: ﬁrst, rule out TB 500 mcg (smear x 3, CXR) (1 pu# 2x/d) Children 1–2 pu#s, 3x/day High: n/a 2 mg/kg once per 10–30 kg as needed 1000 mcg/d day x 5 days (max (always use (2 pu#s 2x/d) 60 mg) spacers) Medium: 500 mcg/d (1 pu# 2x/d) Low: 250 mcg/d (1 pu# 1x/d) Children REFER TO PHYSICIAN ζ 10 kg Very small children should use a metered-dose inhaler with a spacer, or a nebulizer if available.

10.4 Follow-Up Management of Asthma PROTOCOL 10.3'&"#.)94*'*"3*4O"49#':$9$A4:49#'&6'-$#)49#*'<)#8'$9' 4*#$3.)*845'5)$A9&*)*'&6'$*#8:$>'

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Assess degree of On Symptom 1. Continue maximum therapy asthma control, NO maximum YES compare to last visit improvement? therapy? 2. Refer to district hospital NCD clinic (see Table 10.5)

YES NO

Step up treatment Therapy x 3 (see Table 10.6) and months follow up in 2 weeks

NO YES Step down or Continue current therapy, return in 3 months continue current therapy (see Table 10.6) chapter!10 | chronic respiratory disease 249

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Chapter 10!References

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H84'G?,'T")54'#&'S8%&9)+'S$%4'?9#4A%$#)&9'6&%'U954:)+'`S(*'k';<$95$' U5)#)&9')*'6&+"*45':$)9.7'&9'$:3".$#&%7'+$%4'-4%6&%:45'37'$5@$9+45' ǡ ϐ ǡ Ǥ ǡϐ %&.4*'&6'+&::"9)#7'84$.#8'<&%P4%*C'6$:).7'$95'+&::"9)#7':45)+)94' -87*)+)$9*C'A794+&.&A)+'9"%*4*C'-$#8&.&A)*#*C'$95':45)+$.'$95'*"%A)+$.' 256ȀƢȀchronic care integration for endemic non-communicable diseases

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L"<=2W+2Y"#;0#526752L!7 K$/$L$,#$4'*+E42M'#*2,0+<#$D'**$#3',$%@$%5'a9)@4%*)#7 G&(2#3'(4-$%#:49#'&6'T.&3$.',4$.#8'$95'Y&+)$.'R45)+)94C'' ,$%@$%5'R45)+$.'Y+8&&. G&2'D3'()@)*)&9'&6'T.&3$.',4$.#8'UO")#7C'!%)A8$:'$95'_&:49=*',&*-)#$.' S&26&"954%C'G$%#94%*'?9',4$.#8

[43%"$%7'J1// appendix a Essential Equipment and Medicines1,2

A.1 Essential Equipment Essential equipment Health District Referral center hospital center Automatic sphygmomanometer (blood pressure xxx machine) with pediatric, small adult, and adult cu#s, and AC adapter Glucometer with test strips and lancets xxx

Lab: Chemistry testing (point-of-care) xx

Lab: HbA1c testing (point-of-care) xx

Lab: Hemoglobin testing xxx

Lab: HIV testing xxx

Lab: PT/INR testing (point-of-care) xx

Lab: Urinalysis xxx

Monoﬁlament xxx

Multifunction ultrasound machine (with xx abdominal, cardiac, and obstetric probes) with ultrasound gel

Nebulizer xx

Peak ﬂow meter xxx

Scale xxx

Tape measure/ruler xxx

Water bottle spacers (for inhaler) xxx

A.2 Essential Medicines x = Currently recommended by Rwanda MOH t = Recommended for chronic care integration

Pregnancy categories

Category A Controlled studies show no risk, ok to use

Category B No evidence of risk in humans, ok to use

Category C Risk cannot be ruled out, use only if there is no alternative. Potential beneﬁt may outweigh potential risk Category D Positive evidence of risk, avoid use

Category X Contraindicated in pregnancy, do not use 258ȀƢȀchronic care integration for endemic non-communicable diseases

Palliative care Pregnancy Health District Referral category center hospital center

Analgesia

Acetaminophen/paracetamol B x x x

Amitriptyline C x x

Diazepam D x x x

Diclofenac C x x x

Ibuprofen B x x x

Morphine, liquid preparation C t x x Phenytoin (Dilantin) D x x

Prednisolone C x x x

Anti-emetics

Chlorpheniramine B x x x

Dexamethasone C x x x

Haloperidol C x x

Metoclopramide B x x x

Promethazine C x x x

Constipation

Bisacodyl C x x x

Glycerine suppository C x x x

Lactulose syrup B x x x

Naloxone B t x x Diarrhea

Hyoscine butylbromide C x x x

Pruritus

Betamethasone cream C x x x

Permethrin B t x x Other

Fluoxetine C t x x appendix a | essential equipment and medicines 259

Heart failure, cardiac surgery, hypertension, anticoagulation, and Pregnancy Health District Referral chronic kidney disease category center hospital center Amlodipine C t x x Aspirin C–D x x x

Atenolol D t x x Captopril D t x x Carvedilol C ttt Erythromycin B x x x

Furosemide (Lasix) C t x x Hydralazine C t x x Isosorbide dinitrate C ttx Lisinopril D ttt Magnesium sulfate A x x x

Methyldopa A ttx Nifedipine retard C ttx Penicillin G benzathine B x x x

Penicillin V B x x x

Propranolol C ttx Spironolactone (Aldactone) D ttx Warfarin X tt Pregnancy Health District Referral Diabetes category center hospital center Amitriptyline C t x x Glibenclamide (Daonil) C x x x

Insulin Lente (NPH) B x x x

Insulin Rapide (Regular) B x x x

Insulin Mixte (70/30) B x x x

Metformin B x x x 260ȀƢȀchronic care integration for endemic non-communicable diseases

Pregnancy Health District Referral Chronic respiratory disease category center hospital center Aminophylline C x x x

Beclomethasone inhaler C * * x

Chlorpheniramine B x x x

Doxycycline D x x x

Prednisolone C x x x

Salbutamol inhaler C x x x

Pregnancy Health District Referral Epilepsy category center hospital center Carbamazepine (Tegretol) D x x x

Phenobarbital D x x x

Phenytoin (Dilantin) D * x

Valproic acid (Depakote) D x x

Appendix A!References

/' `$#)&9$.'U**49#)$.'R45)+)94*'F)*#>'0#8'U5)#)&9>'M)A$.)W'R)9)*#%7'&6',4$.#8C' ;<$95$h'J11d> J' F$+7'S[C'L%:*#%&9A'FFC'T&.:$9'RGC'F$9+4'F;C'45*>'F4E)2S&:-=*'(%"A' ?96&%:$#)&9',$953&&P'J1/12J1//W'L'S&:-%4849*)@4';4*&"%+4'6&%'L..' S.)9)+)$9*'$95',4$.#8+$%4'G%&64**)&9$.*>'/d#8'U5)#)&9>'J1/12J1//>',"5*&9C' b8)&W'F4E)2S&:-h'J1/1> appendix b Cost Models

H84'-%)+4*'6&%':45)+$#)&9*'.)*#45'84%4'$%4'#84'.&<4*#'&3#$)945'37' G$%#94%*'?9',4$.#8')9';<$95$'6&%'A494%)+*'#8%&"A8'*4@4%$.'5)664%49#' *"--.)4%*>'H84*4'$%4'$+#"$.'-%)+4*'-$)5>'F&<4%'-%)+4*':$7'34'$+8)4@$3.4' #8%&"A8'.$%A4%2*+$.4'-"%+8$*4*'$95'#8%&"A8'5)%4+#'94A&#)$#)&9'<)#8' :$9"6$+#"%4%*>

B.1 Summary of Operational Cost Models H84'6&..&<)9A'+&*#':&54.'-%&D4+#*'#84'4*#):$#45':$%A)9$.'+&*#*'&6'9$2 #)&9$.'+8%&9)+'+$%4')9#4A%$#)&9'6&%'*4.4+#45'4954:)+'9&92+&::"9)+$3.4' Ǥ Ǧϐ 2 $3.4'#8%&"A8'54+49#%$.)^$#)&9'&6'+8%&9)+'+$%4'*4%@)+4*'6&%'`S(*'5&<9' #&'#84'5)*#%)+#28&*-)#$.'.4@4.')9'$..'5)*#%)+#*>'H84':&54.'$.*&'*8&<*'#84' :$%A)9$.'&-4%$#)&9$.'+&*#*'&6'$'9$#)&9$.'+$%5)$+'*"%A)+$.'-%&A%$:'-4%2 6&%:)9A'B11'*"%A4%)4*'-4%'74$%>

H84'4*#):$#45'#):4'#&':&@4'6%&:'$'*7*#4:'<)#8'/1m'`S('+8%&9)+'+$%4' +&@4%$A4'$#'5)*#%)+#'.4@4.'#&'$'*7*#4:'<)#8'/11m'+&@4%$A4'$#'#8)*'.4@4.')*' $--%&E):$#4.7'J'74$%*'3$*45'&9'+"%%49#'#%$)9)9A'$--%&$+84*>

L*'+8%&9)+'+$%4'*4%@)+4*'$%4'54+49#%$.)^45'#&'#84'84$.#82+49#4%'[email protected]' Ǧϐ ǡ +&*#*>'L#'#84'*$:4'#):4C'#84'+&"9#%7=*')9#4%9$.'*&"%+4*'&6'%4@49"4'<)..' +&9#)9"4'#&')9+%4$*4'$*'<4..> 262ȀƢȀchronic care integration for endemic non-communicable diseases

Average annual cost

Case- Population Condition ﬁnding rate prevalence. Cases found Total Per patient Per capita Cardiomyopathy 30% 0.2% 6,000 $2,009,506 $334 $0.20

Cardiac surgical 3% 0.1% 300 $3,709 $412 $0.012 follow-up

Screening and 100% 0.1% 9,000 $46,873 $5 $0.005 follow-up for HIV nephropathy Diabetes 50% 0.44% 22,000 $3,806,655 $173 $0.38

Hypertension 100% 4% 400,000 $7,632,542 $9 $0.76 (160/90 threshold)

Chronic respiratory 15% 2% 24,900 $1,453,695 $57 $0.14 disease

Epilepsy 30% 1% 30,000 $738,003 $25 $0.07

Chronic care $4,393,920 $1.57 integration subtotal Cardiac surgery 3% 0.1% 300 $1,164,000 $3,880 $0.12 (initial surgery)tt

TOTAL $4,393,920 $1.69 t Prevalence given for the entire population. tt 300 cases per year.

B.2 Cardiomyopathy B.2.1 Cost Inputs Individual medication costs Price per tablet Goal regimen Annual cost

Furosemide 40 mg tablets $0.0029 40 mg 2x/d $2.08

Lisinopril 10 mg tablets $0.01 20 mg 1x/d $7.37

Carvedilol 25 mg tablets $0.035 25 mg 2x/d $25.6

Isosorbide dinitrate (IDN) $0.025 20 mg 3x/d $27.2 20 mg tablets

Hydralazine 50 mg tablets $0.023 25 mg 3x/d $23.9

Spironolactone $0.020 25 mg 1x/d $7.3

B.2.2 Annual Regimen Costs Per Patient Regimen Annual cost FLC: Furosemide 40 mg 2x/d, lisinopril 20 mg 1x/d, $40.25 carvedilol 25 mg 2x/d FHIC: Furosemide 40 mg 2x/d, hydralazine 50 mg 3x/d, $90.46 IDN 20 mg 3x/d, carvedilol 25 mg 2x/d appendix b | cost models 263

Other program costs (per patient) Annual cost

Laboratory testing (point-of-care chemistries @ $9.8 during 5 visits) $59

Transport (12 visits per year @ $3 per visit) $48

Community health workers (@ $30 per month divided over 5 patients) $72

NCD nurse (@ $10,000 base; 12 visits) $33

Marginal cost of hospitalization (5 days per year at $15 per day) $75

Subtotal $287

B.2.3 Population Age Distribution and Case-Finding (Catchment Area: 350,000) Estimated cardiomyopathy prevalence 0.2%

Case-ﬁnding 30%

Total cardiomyopathy population 700

Total cardiomyopathy patients enrolled in program 210

B.2.4 Total Marginal Costs Per Capita Annual cost

Medication costs per patient (85% on FLC and 15% on FHIC) $47.8

Other program costs per patient $287

Total costs per patient $334

Marginal annual program cost $70,333

Marginal annual cost per capita $0.20

B.3 Cardiac Surgery B.3.1 Cost Inputs B.3.1.1 Follow-Up Cost Inputs Medication Price per unit/tablet Goal regimen Annual cost

Warfarin 5 mg tablets $0.13 5 mg 1x/d $46

Warfarin 1 mg tablets $0.06 1 mg 1x/d $21

INR cartridge $3 16 test/yr $48 264ȀƢȀchronic care integration for endemic non-communicable diseases

B.3.1.2 Surgical Cost Inputs (At 300 Cases Per Year) Item Unit cost Number Total annual cost

Operating supplies $800 300 $240,000

ICU costs $500 300 $150,000

Hospitalization costs $600 300 $180,000

Mechanical valves (2 out of 3 cases) $1000 200 $200,000

Facility cost ﬁxed ﬁxed $50,000

Equipment depreciation annual ﬁxed ﬁxed $20,000

Surgeon salary $72,000 2 $144,000

Perfusionist salary $12,000 2 $24,000

Scrub nurse salary $9,000 2 $18,000

Circulating nurse salary $9,000 2 $18,000

Anesthesiologist salary $40,000 2 $80,000

ICU nurse salary $10,000 4 $40,000

Total surgical cost $1,164,000

Total surgical per patient cost $3,880

B.3.1.3 Average Cardiac Surgical Costs as a Function of the Number of Annual Operations ϐ $*'#84'9":34%'&6'&-4%$#)&9*'-4%'74$%')9+%4$*4*>

$11,259

$8,444

$5,630

$2,815

$0 50 100 150 200 250 300 Number of Surgeries per Year

average ﬁxed cost/patient average variable cost/patient appendix b | cost models 265

B.3.1.4 Regimen and Follow-Up Costs Annual cost Visits per year Cost per visit per patient INR cartridge 16 3 $48

Transport 16 3 $48

Echocardiography 2 72 $144

Community health worker N/A N/A $72

Warfarin 5 mg 1x/d N/A N/A $67

NCD nurse (@ $10,000 base), 12 $2.78 $33.3 12 visits

Subtotal $412

B.3.2 Population Age Distribution and Case-Finding Population of Rwanda 10,000,000

Estimated population prevalence of advanced RHD 0.1%

Total advanced RHD population in need of surgery 10,000

B.3.3 Total Marginal Costs Per Capita (At 300 Cases Per Year) Total surgical cost per patient cost $3,880

Total follow-up cost per patient per year $412.1

Marginal annual follow-up cost $160,439

Annual per capita cost $0.13

B.4 Screening for HIV Nephropathy B.4.1 Cost Inputs Medication or lab Price per unit Goal regimen Annual cost Lisinopril 10 mg tablets $0.01 5 mg 1x/d $1.84 Urine dipstick $0.02 N/A N/A Creatinine $3 N/A N/A

B.4.2 Marginal Follow-Up Costs Other program costs (per patient enrolled) Annual cost

Laboratory testing (point-of-care chemistries @ $9.8 x 6 visits) $58.8 266ȀƢȀchronic care integration for endemic non-communicable diseases

B.4.3 Population Age Distribution and Case-Finding Total population size 350,000

HIV population prevalence (all ages) 2%

HIV proteinuria prevalence 6%

Total HIV+ population 5,250

Total with HIV and proteinuria 315

B.4.4 Total Marginal Costs Per Capita Cost to screen population Cost

Urine dipstick for screening population $112.88

Creatinine for patients with proteinuria $945

Total $1,057.9

Total costs Screening laboratory cost $1,057.88 Medication cost $580.62 Follow-up costs $58.8 Total annual program cost $1,697.30 Marginal per capita program cost $0.005

B.5 Diabetes B.5.1 Cost Inputs Price per Units/tablets Medication unit/tablet Goal regimen per day Annual cost Insulin 70/30 (mixte) $0.009 15 U 2x/d 30 $99 100 IU/mL, 10 mL

Insulin regular (rapide) $0.010 10 U 2x/d 20 $72 100 IU/mL, 10 mL

Insulin NPH (lente) $0.010 15 U 2x/d 30 $109 100 IU/mL, 10 mL

Syringes $0.088 2x/d 2 $65 (1 mL, 26 g needle)

Metformin $0.010 1000 mg 2x/d 4 $15 500 mg tablets

Glibenclamide $0.003 5 mg 2x/d 2 $2 5 mg tablets

Lisinopril $0.01 5 mg 1x/d 0.5 $2 10 mg tablets appendix b | cost models 267

Testing supply Units per package Package price Price per test

Finger-stick blood glucose N/A N/A $0.35

Creatinine N/A N/A $3

Urine dipstick 100 $2.2 $0.02

Point-of-care HbA1c 20 $177.2 $8.86

B.5.2 Annual Regimen Costs Per Patient Regimen Components

Oral Metformin 1000 mg 2x/d, Glibenclamide 5 mg 1x/d, Lisinopril 5 mg 1x/d

Mixte Mixte 70/30 15 Units 2x/d, Lisinopril 5 mg 1x/d

Lente Lente 15 Units 2x/d, Lisinopril 5 Units 1x/d

Lente + Regular Lente 10 Units 1x/d + Regular 10 Units 2x/d, Lisinopril 5 mg 1x/d

Cost estimates Medications Clinic visits. Lab testing† FSBG‡ CHW salary Total annual cost

Oral $19 $18 $27 N/A N/A $64

Mixte insulin $165 $36 $30 $20 $87 $338

Lente insulin $176 $36 $30 $20 $87 $349

Lente + Regular $207 $36 $30 $20 $87 $380 insulin t Clinic cost: $3/visit. If on oral therapy: 6 visits/year. If on insulin: 12 visits/year. † Annual testing: ﬁnger-stick glucose at each visit; creatinine 2x/year, HbA1c 2x/year. ‡ If on insulin, 56 ﬁnger-stick blood glucose (FSBG) in the community per year (2 FSBG per day x 7 days, done 4 times per year).

B.5.3 Population Age Distribution and Case-Finding Total population of catchment area 350,000

Percent of population over age 20 years (adults) 44%

Prevalence of diabetes in adults 1%

Case-ﬁnding rate 50%

Adults in catchment area 154,000

Adults with diabetes 1540

Cases found 770 268ȀƢȀchronic care integration for endemic non-communicable diseases

B.5.4 Total Marginal Costs Per Capita Total cost

Proportion of patients Estimated Total annual Regimen on this regimen patient load cost Oral 66% 505 $32,406

Lente insulin 13% 98 $34,315

Lente + Regular insulin 22% 167 $63,394

Total 770 $130,114

Annual Marginal Cost $0.37

B.6 Hypertension Cost Models B.6.1 Cost Inputs Medication Price per tablet Goal regimen Annual cost

HCTZ 25 mg tablets $0.003 25 mg 1x/d $1.03

Amlodipine 5 mg tablets $0.01 10 mg 1x/d $4.69

Lisinopril 10 mg tablets $0.01 20 mg 1x/d $7.37

Atenolol 50 mg tablets $0.01 25 mg 1x/d $0.97

Methyldopa 250 mg tablets $0.02 500 mg 2x/d $33.6

Hydralazine 25 mg tablets $0.04 50 mg 3x/d $83.9

Labetalol 100 mg tablets $0.17 200 mg 2x/d $250.6

Nifedipine 10 mg tablets $0.01 20 mg 2x/d $19

Nifedipine retard 20 mg tablets $0.02 20 mg 2x/d $4.6

B.6.2 Annual Regimen Costs Per Patient.

Medication regimens Annual cost per patient 1. H: HCTZ 12.5 mg $0.59

2. HN: HCTZ 25 mg, amlodipine 10 mg $6.57

3. HNL: HCTZ 25 mg, amlodipine 10 mg, lisinopril 20 mg $16.04

4. HNLA: HCTZ 25 mg, amlodipine 10 mg, lisinopril $19.56 20 mg, atenolol 25 mg

t H = HCTZ; N = amlodipine; L = lisinopril; A = atenolol appendix b | cost models 269

Laboratory costs per Hypertension stage Projected yearly lab monitoring patient per year Stage I (140/90) Urine dipstick 1x/y, creatinine $0.17 1x/y for 5%

Stage II (η 160/100) Urine dipstick 1x/y, creatinine $0.32 1x/y for 10%

Stage III (η 180/110) Urine dipstick 1x/y, creatinine 1x/y for $0.98 20%, chemistries 5%

Hypertension Total clinic Laboratory stage Regimen. costs.. Medication testing Total costs Stage I 100% H $3 $0.59 $0.17 $3.7 (140/90)

Stage II 100% HN $6 $6.57 $0.32 $12.9 (η160/100)

Stage III 70% HNL, $18 $17.10 $0.98 $36.1 (η180/110) 30% HNLA t H = HCTZ; N = amlodipine; L = lisinopril; A = atenolol tt Clinic cost: Stage I (1 visit per year); Stage II (2 visits per year); Stage III (6 visits per year). $3/visit

B.6.3 Population Age Distribution and Case-Finding Total population of catchment area (district) 100% 350,000

Percent of population over age 30 years (adults) 30% 105,000

Prevalence of stage I (>140/90) 7% 24,500

Prevalence of stage II (>160/100) 3% 10,500

Prevalence of stage III (>180/110) 1% 3,500

B.6.4 Total Marginal Costs Per Capita 140/90 160/100 180/110 Program costs by treatment threshold threshold threshold threshold Population at risk (# patients) 38,500 14,000 3,500

Total annual medication costs $143,356 $128,856 $59,837

Total annual clinic costs $199,500 $126,000 $63,000

Total laboratory costs $11,014 $6,812 $3,437

Total supply costst $5,471 $5,471 $5,471

Total costs $359,341 $267,139 $131,744

Average annual medication $3.72 $9.20 $17.10 cost per patient

Annual per capita medication cost $0.41 $0.37 $0.17

Marginal annual per capita total cost $1.03 $0.76 $0.38 t Automatic blood pressure machines (1 per 200 population @ $46.89 each). 270ȀƢȀchronic care integration for endemic non-communicable diseases

B.7 Chronic Respiratory Disease Cost Models B.7.1 Cost Inputs Price per Annual Individual medication costs unit/tablet Goal regimen cost Salbutamol 0.1 mg inhaler $0.01 200 mcg 4x/d $20

Beclomethasone 250 mcg inhaler, $0.02 500 mcg 2x/d $33 medium dose

Beclomethasone 250 mcg inhaler, high dose $0.02 750 mcg 2x/d $49

Aminophylline 100 mg tablets $0.00 200 mg 3x/d $10

B.7.2 Annual Regimen Costs Per Patient Asthma severity Regimen Intermittent Salbutamol 200 mcg 4x/d Moderate persistent Salbutamol 200 mcg 4x/d, beclomethasone 500 mcg 2x/d Severe persistent Salbutamol 200 mcg 4x/d, beclomethasone 750 mcg 2x/d, aminophylline 200 mg 3x/d

Clinic Cost per Total clinic Total cost Asthma severity Medications visits clinic visit visit cost per patient Intermittent $20 3 $3 $9 $29

Moderate persistent $53 10 $3 $30 $83

Severe persistent $79 12 $7* $83 $211tt

t Including transportation cost. tt Includes community health worker e#ort for directly observed therapy.

B.7.3 Population Age Distribution and Case-Finding Total population of catchment area 350,000

Prevalence of chronic respiratory disease 2%

Case-ﬁnding rate 15%

Total cases of chronic respiratory disease (in those over 5 years of age) 24,500

Cases found 871

Estimated severity Severity classiﬁcation distribution Patients Total annual cost Intermittent asthma 60% 523 $15,318

Moderate persistent 35% 305 $25,361

Severe persistent 5% 44 $9,213

Total 100% 490 $49,892 appendix b | cost models 271

B.7.4 Total Marginal Costs Per Capita Total annual Total annual Severity classiﬁcation medication cost clinic costs Total CHW cost Total annual cost Intermittent asthma $10,612 $4,706 - $15,318

Moderate persistent $16,210 $9,151 - $25,361

Severe persistent $3,461 $2,615 $3,137 $9,213

Total $30,283 $16,471 $3,137 $49,892

Annual cost per patient $35 $19 $4 $57

Marginal annual per capita cost $0.09 $0.05 $0.01 $0.14

B.8 Epilepsy Cost Models B.8.1 Cost Inputs Price per Annual cost Medication tablet/unit Goal regimen per patient Carbamazepine 200 mg tablets $0.02 200 mg 2x/d $11.1

Phenytoin 100 mg tablets $0.01 150 mg 2x/d $6.1

Phenobarbital 100 mg tablets $0.01 100 mg 1x/d $2.11

Valproic acid 150 mg tablets $0.11 150 mg 3x/d $116.1

Valproic acid 500 mg tablets $0.34 500 mg 3x/d $370.9

B.8.2 Annual Regimen Costs Per Patient Annual regimen Annual clinic Cost per Annual clinic Total annual Regimen costs (per patient) visits clinic visit visit cost cost Phenobarbital $2.12 6 $3 $18 $20 100 mg 1x/d

Carbamazepine $11.08 6 $3 $18 $29 100 mg 2x/d

B.8.3 Population Distribution and Case-Finding Catchment area 350,000 Epilepsy prevalence (generalized seizures) 0.5% Epilepsy prevalence (partial seizures) 0.5% Case-ﬁnding rate 30% Total population with generalized seizures 1750 Total population with partial seizures 1750 Total cases found 1050 272ȀƢȀchronic care integration for endemic non-communicable diseases

B.8.4 Total Marginal Costs Per Capita Estimated total marginal program cost $25,830

Estimated marginal per capita program cost $0.07 appendix c Indicators for Monitoring and Evaluation

C.1 Heart Failure and Post-Cardiac Surgery Follow-Up

Demographics

Percent male and female

Median age

Number of new patients enrolled during reporting period

Total number of patients at the end of reporting period

Total number of patients at the end of reporting period by district and sector

Diagnosis and Case-Finding

Number and percent of patients without a cardiology consultation since enrollment

Number and percent of patients without a preliminary echocardiogram, preliminary diagnosis or both

Number and percent of patients referred each quarter to NCD heart failure clinic and conﬁrmed not to have heart failure

Percent of patients without a creatinine check in the last 6 months

Percent in each diagnostic category (cardiomyopathy, pure mitral stenosis, other rheumatic heart disease, pericardial disease, congenital heart disease)

Number/percent with creatinine η 200 !mol/L

Number of post-cardiac surgery patients

Interventions

In the cardiomyopathy subgroup, percent with heart rate η 60 bpm at last visit not on carvedilol

In the cardiomyopathy subgroup, percent on lisinopril or captopril In the mitral stenosis subgroup, percent with heart rate η 60 bpm at last visit not on atenolol In the rheumatic heart disease subgroup, percent on penicillin

In the subgroup of women < 50 years old, percent using modern contraception

Case-Holding/Retention

Percent and number of patients not seen in the last 6 months

Percent and number of patients not seen in the last 3 months

Percent and number of patients without a community health worker

Palliative Care

Percent and number of patients with reported pain score 0 or 1

Percent and number of patients with reported dyspnea score 0 or 1 274ȀƢȀchronic care integration for endemic non-communicable diseases

Palliative Care (continued) Percent and number of patients with improvement of pain score since the last reporting period

Percent and number of patients with improvement of dyspnea score since the last reporting period

Percent and number of patients prescribed morphine for symptom relief

Outcomes

Number and percent of patients enrolled in the heart failure program who died in the last reporting period

Of patients enrolled in the heart failure program, number of hospitalizations in the last reporting period

Of the patients with a mechanical replacement valve, the number and proportion whose INR has been between 2 and 4 the entire time since the last reporting period

Data Quality

Percent and number of patients without an intake form appendix c | indicators for monitoring and evaluation 275

C.2 Cardiac Surgical Referral and Case Selection

Demographics

Percent male and female

Median age

Number of new patients enrolled during reporting period

Total number of patients at the end of reporting period

Total number of patients at the end of reporting period by district and sector

Diagnosis and Case-Finding

Total number of cases referred for cardiac surgery evaluation since the last reporting period

Of the cases referred, the number and percent conﬁrmed to be surgical candidates

Of the cases conﬁrmed to be surgical candidates, the number and percent who have single valve disease

Of the cases conﬁrmed to be surgical candidates, the number and percent who have disease of 2 or more valves

Of the cases conﬁrmed to be surgical candidates, the number and percent who are labeled as requiring surgery within 1 year

Interventions

Of the number of cases referred for cardiac surgery, the number and percent who receive valve replacement

Of the number of cases referred for cardiac surgery, the number and percent who receive valve repair

Case-Holding/Retention

Of the patients on the cardiac surgery registry, the number and percent who have not seen a cardiologist in the last 12 months

Of the patients on the cardiac surgery registry, the number and percent who have not had a cardiologist echocardiogram in the last 12 months

Palliative Care

Percent and number of patients with reported pain score 0 or 1

Percent and number of patients with reported dyspnea score 0 or 1

Percent and number of patients with improvement of pain score since the last reporting period

Percent and number of patients with improvement of dyspnea score since the last reporting period

Percent and number of patients prescribed morphine for symptom relief

Outcomes

Number and percent of patients enrolled in the cardiac surgery program who died during the last reporting period

Data Quality

Percent and number of patients without a contact phone number 276ȀƢȀchronic care integration for endemic non-communicable diseases

C.3 Renal Failure

Demographics

Percent male and female

Median age

Number of new patients enrolled during reporting period

Total number of patients at the end of reporting period

Total number of patients at the end of reporting period by district and sector

Diagnosis and Case-Finding

Percent and number of patients with documented proteinuria that have ever had a creatinine check

Percent and number of patients referred from HIV clinic that have HIV and proteinuria

Of those enrolled in the renal failure program, percent and number of patients with stage IV or V CKD (eGFR ζ 15 ml/min)

Interventions

Percent and number of patients with proteinuria who are treated with lisinopril or captopril

Case-Holding/Retention

Percent and number of patients not seen in the last 6 months

Percent and number of patients not seen in the last 3 months

Percent and number of patients without a community health worker

Palliative Care

Percent and number of patients with reported pain score 0 or 1

Percent and number of patients with reported dyspnea score 0 or 1

Percent and number of patients with improvement of pain score since the last reporting period

Percent and number of patients with improvement of dyspnea score since the last reporting period

Percent and number of patients prescribed morphine for symptom relief

Outcomes

Percent and number of patients with hyperkalemia (K η 5.0 mEq/dL)

Percent and number of patients with renal failure who have blood pressure controlled (ζ 130/80 mmHg)

Data Quality

Percent and number of patients without an intake form appendix c | indicators for monitoring and evaluation 277

C.4 Diabetes

Demographics

Percent male and female

Median age

Number of new patients enrolled during reporting period

Total number of patients at the end of reporting period

Total number of patients at the end of reporting period by district and sector

Diagnosis and Case-Finding

Percent and number of patients referred each quarter to NCD diabetes clinic and conﬁrmed not to have diabetes

Percent and number of patients referred to NCD diabetes clinic and conﬁrmed to have diabetes based on (a) fasting glucose η 126 mg/dL, (b) HbA1c η 6.5%

Percent without an HbA1c in the past 6 months

Percent without a documented foot examination in the past 12 months

Percent with a documented eye examination in the past 2 years

Interventions

Percent on any insulin

Percent on NPH + regular insulin

Percent on NPH insulin alone

Percent on Mixte insulin

Percent on metformin

Percent on glibenclamide

Case-Holding/Retention

Percent and number of patients not seen in the last 6 months

Percent and number of patients not seen in the last 3 months

In subgroup (on insulin) percent and number of patients without a community health worker

Palliative Care

Percent and number of patients with reported pain score 0 or 1

Percent and number of patients with improvement of pain score since the last reporting period

Percent and number of patients prescribed morphine for symptom relief

Outcomes

Percent with HbA1c ζ 8%

Percent and number with 3 or more hypoglycemic episodes in prior 3 months

Percent and number of patients hospitalized for diabetes 278ȀƢȀchronic care integration for endemic non-communicable diseases

Outcomes (continued)

Number of deaths in patients enrolled in the diabetes program in the last year

Data Quality

Percent and number of patients without an intake form appendix c | indicators for monitoring and evaluation 279

C.5 Hypertension

Demographics

Percent male and female

Median age

Number of new patients enrolled during reporting period

Total number of patients at the end of reporting period

Total number of patients at the end of reporting period by district and sector

Diagnosis and Case-Finding

Of patients referred to NCD hypertension clinic, number/percent conﬁrmed to have hypertension

Of patients with conﬁrmed hypertension, number/percent with stage I HTN

Of patients with conﬁrmed hypertension, number/percent with stage II HTN

Of patients with conﬁrmed hypertension, number/percent with stage III HTN

Of patients with conﬁrmed hypertension, number/percent with proteinuria

Of patients ζ 40 years old, number/percent without a recorded creatinine

Of patients with stage III HTN (SBP η180 or DBP η 110), number/percent without creatinine

Interventions

Number/percent of patients with proteinuria on ACE inhibitor (or have documented contraindication)

Of patients with Stage III hypertension, number/percent on 2 or more antihypertensives

Case-Holding/Retention

Percent and number of patients not seen in the last 6 months

Percent and number of patients not seen in the last 12 months

Palliative Care

Percent and number of patients with reported dyspnea score 0 or 1

Outcomes

Percent and number of patients with last recorded BP ζ 140/90

Number of deaths in patients enrolled in the hypertension program in the last year

Data Quality

Percent and number of patients without an intake form 280ȀƢȀchronic care integration for endemic non-communicable diseases

C.6 Chronic Respiratory Disease

Demographics

Percent male and female

Median age

Number of new patients enrolled during reporting period

Total number of patients at the end of reporting period

Total number of patients at the end of reporting period by district and sector

Diagnosis and Case-Finding

Of patients referred to NCD respiratory clinic, the number/percent with conﬁrmed chronic respiratory disease

Of patients enrolled in NCD respiratory clinic, number/percent with asthma/COPD

Of patients enrolled in NCD respiratory clinic, number/percent with brochiectasis

Of patients enrolled in NCD respiratory clinic, number/percent evaluated for tuberculosis with sputum analysis

Of patients referred for sputum analysis, the number/percent diagnosed with tuberculosis

Interventions

Of patients in NCD respiratory clinic, number/percent treated with salbutamol

Of patients in NCD respiratory clinic, number/percent treated with beclomethasone (any dose)

Of patients in NCD respiratory clinic, number/percent treated with aminophylline

Of patients in NCD respiratory clinic, number/percent treated with prednisone in the last 3 months

Case-Holding/Retention

Of patients in NCD respiratory clinic, number/percent not seen in the last 6 months

Of patients in NCD respiratory clinic, number/percent of patients with moderate or severe persistent classiﬁcation not seen in the last 3 months

Palliative Care

Percent and number of patients with reported pain score 0 or 1

Percent and number of patients with reported dyspnea score 0 or 1

Percent and number of patients with improvement of pain score since the last reporting period

Percent and number of patients with improvement of dyspnea score since the last reporting period

Percent and number of patients prescribed morphine for symptom relief

Outcomes

Of patients in NCD respiratory clinic, number/percent who have improvement of severity classiﬁcation over the last 6 months appendix c | indicators for monitoring and evaluation 281

Outcomes (continued)

Of patients in NCD respiratory clinic, number/percent who have worsening of severity classiﬁcation over the last 6 months

Of patients in NCD respiratory clinic, number/percent who have an “intermittent” classiﬁcation

Data Quality

Percent and number without an intake form 282ȀƢȀchronic care integration for endemic non-communicable diseases

C.7 Epilepsy

Demographics

Percent male and female

Percent and number in age range (ζ 15, 15–24, 25–34, 35–44, 45–54, 55 or older)

Number of new patients enrolled during reporting period

Total number of patients at the end of reporting period

Total number of patients at the end of reporting period by district and sector

Diagnosis and Case-Finding

In the subgroup (onset η 20 years old), number and percent checked for HIV and RPR

Number and percent in each diagnostic category (GTC-primary, GTC-secondary, GTC-not speciﬁed, focal, other)

Of patients referred to epilepsy clinic, number and percent thought to not have epilepsy

Interventions

Of patients on ARVs, number and percent on valproic acid

Of patients on valproic acid, number and percent with AST and ALT checked in last 12 months.

Case-Holding/Retention

Percent and number not seen in the last 6 months

Palliative Care

Percent and number of patients with reported pain score 0 or 1

Percent and number of patients with improvement of pain score since the last reporting period

Percent and number of patients prescribed morphine for symptom relief

Outcomes

Percent and number of patients without seizure in the last 3 months (adults and children)

Percent and number of patients with η 2 seizures in the last 3 months (adults and children)

Percent and number of enrolled patients hospitalized for epilepsy in the last 3 months (adults and children)

Data Quality

Percent and number without an intake form appendix d Forms

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D.1 Intake Forms U$+8'5)*4$*4'6&..&<45')9'#84'`S('&%')9#4A%$#45'+8%&9)+'+$%4'+.)9)+*'8$*' $'+&%%4*-&95)9A')9#$P4'6&%:>'H84*4'6&%:*'A494%$..7'#$P4'/0':)9"#4*'#&' +&:-.4#4>'H84%4')*'*&:4'@$%)$#)&9')9')9#$P4'6&%:'.49A#8'3$*45'&9'#84' +&:-.4E)#7'&6'#84'5)*4$*4>'?9#$P4'6&%:*'$%4':4$9#'#&'34'%4-4$#45'4@4%7' Z':&9#8*'#&'/'74$%>

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1. History of present illness A. Patient referred from: acute clinic hospital other clinic other______B. Chief complaint ______C. Duration of symptoms ___ days /months / years

D. Ever hospitalized for these symptoms? yes no Total number of hospitalizations: ____

E. Has the patient had: dyspnea on exertion? yes no

orthopnea? yes no

If yes, does the patient sleep sitting because of orthopnea? yes no F. Ever treated by a traditional healer for these symptoms ? yes no

Diagnosis: poisoning other______

Treatment: purgative other ______Cost: ______FRW

G. If female: Did the symptoms start around delivery? n/a yes no

If a woman between 15–45 years old, does she use birth n/a control? yes no

If no, why______H. Does the patient have: a. chronic cough (more than 3 weeks)? yes no If yes : productive hemoptysis

b. night sweats that soak clothing? yes no

c. a large weight loss? yes no

If yes, how much? _____ kg or clothing is looser I. Does the patient smoke? yes no past

If yes : traditional modern pipe ____ cigarettes or pipes/ day J. Does the patient drink alcohol? yes no past If yes : traditional _____ liters/ day modern_____ bottles/ day Document any other relevant history:

appendix d | forms 285

2. Previous outpatient medications

Is patient on cardiac medications at intake? yes no Never taken cardiac medications

Medication Dose Frequency Still taking?

furosemide ____ mg oral IV 1/d 2/d 3/d yes no

captopril

lisinopril ____ mg oral 1/d 2/d 3/d yes no

aldactone ____ mg oral 1/d yes no

atenolol

carvedilol ____ mg oral 1/d 2/d yes no

amlodipine

nifedipine ____ mg oral 1/d 2/d yes no

digoxin ____ mg oral 1/d yes no

aspirin ____ mg oral 1/d yes no

warfarin ____ mg oral 1/d 2/d yes no

hydrochlorthiazide ____ mg oral 1/d yes no

methyldopa ____ mg oral 1/d 2/d 3/d yes no

isosorbide dinitrate

____ mg oral 1/d 2/d 3/d yes no

hydralazine ____ mg oral 1/d 2/d 3/d yes no

prednisolone ____ mg oral 1/d 2/d yes no

penicillin V ____ mg oral 1/d 2/d 3/d yes no

benzathine penicillin 600,000 IU IM

1.2 M IU IM 1x/month 2x/month yes no

______mg oral IV 1/d 2/d 3/d yes no

Drug allergies ______yes no If yes, explain:______

3. Past medical history A. Has the patient ever had an HIV test ? yes no If yes, result: positive negative Date of last test: ____/____/____ If positive: Last CD4:______Date: ______/______/______

Enrolled in the IMB HIV program? yes no B. Has the patient ever been treated for tuberculosis? yes no

If yes, how many times? ______In what year(s) ? ______

C. Other history : 286ȀƢȀchronic care integration for endemic non-communicable diseases

4. Social history A. Occupation: unemployed retired farmer small child (< 5)

professional driver cleaner in school school-aged,

not in school miner ______

B. Too sick to work ? yes no

C. Civil status: married or lives with partner partner in prison

single or child divorced or separated

widow (partner died of:______) orphan

D. Transport : foot bus bike taxi other Cost of transport (round-trip) ______FRW

Time to travel to health center ______hrs

E. Socio-economic status: The patient’s house has: _____ rooms _____ occupants

Does the patient’s family own a house? yes no

Roof is: tin thatch cement sheeting

The floor is: cement dirt Does the patient’s family own land? yes no if yes: ______hectares

Does the patient’s family have goats or cows? ______goats ______cows How many children has the patient had or if a child, how many

siblings in the family? ______children Are all the children still alive? yes no causes of death:______

Do all the school-aged children go to school? yes no N/A

Other social information:

5. Physical Exam Vital signs: BP: ______/_____ mmHg Pulse:_____ bpm Weight ______kg Height ______cm Does the patient feel dizzy upon standing up? yes no If indicated : "*- 6 RR: ______SaO2: ____% Normal Abnormal cachectic obese tachypneic General well-appearing use of accessory muscles HEENT JVP normal JVP high goiter

Lungs clear crackles (If yes, location:______) wheezing

Heart PMI non-displaced tachycardia irregular rhythm PMI displaced regular rhythm murmur 1 location :______

no murmurs systolic diastolic murmur 2 location :______

systolic diastolic

Abdomen soft non-tender splenomegaly ____ cm hepatomegaly : ____ cm

no hepatomegaly pulsatile liver no splenomegaly ascites: mild moderate abundant

no ascites tenderness: RUQ LUQ RLQ LLQ

no peripheral edema cold peripheral edema 1+ 2+ 3+

Extremities no joint pain or swelling joints swollen joints

Neuro no abnormalities focal motor deficit

Other ______ appendix d | forms 287

6. Previous labs (including today) Date Results

1. ___/___/___

2. ___/___/___ Chemistries point of care 3. ___/___/___ Na: K: Cal: iCa : CO2: Urée: Créat: Glyc: Hgb: INR/ PT point of care 4. ___/___/___ INR : PT :

7. Previous studies Date Results

mild Infiltrates (location:______)

normal moderate pleural effusions small big

CXR __/__/__ cardiomegaly severe (location:______) EKG __/__/__ normal LVH atrial fibrillation infarction (location:______)

8. Preliminary echocardiographic result:

Left ventricular function

Normal mildly depressed markedly depressed Ejection fraction estimate:______%

No mitral stenosis Mitral stenosis

Normal right ventricular size Large right ventricle

Normal IVC Large IVC

Other abnormalities ______

9. Clinical Impression A. Summary B. Diagnosis

Heart Failure

Type of Heart Failure:

Cardiomyopathy Rheumatic heart disease Mitral stenosis Other Hypertensive heart disease Other type of Heart Failure: ______

Severity of symptoms (If between categories, mark both)

NYHA class I (Asymptomatic) No limitation on activity

NYHA class I-II

NYHA class II (Mildly symptomatic) Symptoms only with moderate exertion, such as climbing a hill

NYHA class II-III

NYHA class III (Moderately symptomatic) Symptoms with even light activity but comfortable at rest

NYHA class III-IV

NYHA class IV (Severely symptomatic) Symptoms with all activities, may be symptomatic at rest

Renal Failure

Liver Failure

Other C. Patient’s fluid status: hypervolemic euvolemic hypovolemic 288ȀƢȀchronic care integration for endemic non-communicable diseases

10. Final plan

A. Labs, studies: VS HIV sputum x 3 Chest X-ray ______

Albumin SGOT SGPT

B. Medications No medications MORNING NOON EVENING

Furosemide (Lasix) ____ mg ____ mg

Captopril ____ mg ____ mg ____ mg

Lisinopril ____ mg ____ mg

Aldactone ____ mg ____ mg Carvedilol ____ mg ____ mg

Atenolol ____ mg ____ mg

Amlodipine ____ mg ____ mg

Nifedipine retard ____ mg ____ mg

Isosorbide dinitrate ____ mg ____ mg ____ mg

Hydralazine ____ mg ____ mg ____ mg

Hydrochlorothiazide ____ mg Potassium (600 mg tab =

8mEq) ____ mg ____ mg

Prednisolone ____ mg ____ mg Aspirin ____ mg

Warfarin ____ mg

Penicillin V ____ mg ____ mg

Benzathine penicillin

600,000 UI IM 1x/month 2x/month Benzathine penicillin

1.2 M UI IM 1x/month 2x/month

C. Other medications: ______

Follow-up ____/____/____

D. Disposition Admit to hospital Discharge home appendix d | forms 289

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D.2.1 Sample Cover Sheet

EMR CLINIC Rwinkwavu Kirehe Butaro

Other:______

Change in clinic yes Date: ___/___/___ Clinic______ EMR DEMOGRAPHICS EMR ADDRESS Date of birth:___/___/___ Province: ______Age: District : ______ Sex F M Secteur: ______ Daily CHW: yes not indicated Cellule: ______ Name : ______Umudugudu: ______ Change in CHW yes Telephone: ______ Name :______Date: ___/___/___ patient other______If a child: Name of parent or guardian Change in address or ______telephone: yes Date: ___/___/___ Telephone:______Go to page 2 to change CARDIAC DIAGNOSIS Date of Diagnosis or Problem EF dx Type Clinician

preliminary __/__/__ confirmed

NON-CARDIAC DIAGNOSIS AND PROBLEM LIST EMR Diagnosis Date EMR Diagnosis Date __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ Cardiology consultation completed _____/_____/_____

Surgical candidate? yes no If yes: Passport : yes not indicated Visa : yes not indicated 290ȀƢȀchronic care integration for endemic non-communicable diseases

D.2.2 Sample Events Flowsheet

HOSPITALIZATIONS Date of Date of EMR admission discharge Hospital Reason for hospitalization ___/___/______/___/______/___/______/___/______/___/______/___/___

SOCIAL ASSISTANCE OR ASSESSMENT Type of assistance or Type of assistance or EMR Date assessment EMR Date assessment ___/___/______/___/______/___/______/___/______/___/______/___/___ (ex. Home visit, house construction, school financing, transport financing, food supplementation)

CHANGE IN CHW, ADDRESS OR TELEPHONE EMR Date ___/___/______/___/______/___/___

NON-MEDICAL LIFE EVENTS SINCE DIAGNOSIS EMR Date Event EMR Date Event ___/___/______/___/______/___/______/___/______/___/______/___/___ (e.g. marriage, divorce, pregnancy, births, death of family members, change in socioeconomic status, change in residence since diagnosis) appendix d | forms 291

D.2.3 Clinical Findings Flowsheet ,4%4')*'$9'4E$:-.4'&6'8&<'#<&'%&<*'6%&:'#84'+.)9)+$.')95)+$#&%*'-$A4' :)A8#'.&&P'6&%'$'#7-)+$.'84$%#'6$)."%4'-$#)49#>',4%4C'<4'*44'#84'-$#)49#' ϐǦ ϐ @)*)#')9'#84'*4##)9A'&6':)**)9A'84%':45)+$#)&9*>'L'-&)9#2&62+$%4'+84:)*#%7' -$94.'<$*'5&94>'H84'-$#)49#'<$*'$.*&'9&#'&9'3)%#8'+&9#%&.>'b9'#84'94E#' @)*)#C')#')*'+.4$%'#8$#'#84'-$#)49#=*'@)#$.'*)A9*'$95'*7:-#&:'+.$**'):-%&@45' $95'*84'8$5'3449'#$P)9A'84%':45)+$#)&9*>'Y84'$.*&'8$5'3449'*#$%#45'&9' 3)%#8'+&9#%&.>

RENDEZ-VOUS/ CLINIC VISIT NYHA Missed any On birth

Date Wt BP P Class Hemodyn. meds ? Na K CO2 Cr Hgb INR control ? F/up X hyper X yes yes 90/ eu no X no 50 60 110 III hypo N/A 133 4 24 130 11 N/A N/A 2/9/10 2/2/10 Comments :

hyper X yes X yes

100/ X eu no no 45 70 80 II hypo N/A N/A 2/16/10 2/9/10 Comments : ǡ ϐ 6&%'*&:4'&6'#84'T%'5)*4$*4*'6&..&<45')9'#84'+.)9)+*>

D.2.3.1 Asthma

CLINIC VISITS Activity # times/week Good Asthma limitation due awoken by # puffs/week Peak inhaler classification to shortness of

Date dyspnea of salbutamol Flow technique not asthma breath Plan and Follow-up well- daily or RDV ___/___/___

yes controlled almost daily group class :

no moderately several times ___/___/___

______times ______puffs brief controlled per week step up treatment

coaching poorly less than continue the same given controlled once per week treatment

not at all step down Comment : treatment

D.2.3.2 Diabetes

CLINIC VISITS

Date Weight BP Pulse Proteinuria Na K CO2 Cr Missed insulin ?

yes no N/A Glucose: Glucose today :______fasting

Sx of low blood yes no When?: morning afternoon evening sugar ? Comments 292ȀƢȀchronic care integration for endemic non-communicable diseases

D.2.3.3 Post-Cardiac Surgery

CLINIC VISIT Missed NYHA Volume any On birth

Date Wt BP P Class Status meds ? Na K Cr Hgb INR control ? F/up

hyper yes yes eu no no

hypo NA NA Comments : D.2.3.4 Hypertension

CLINIC VISIT Date Weight BP Pulse Proteinuria Na K Cr F/up

Comments

D.2.3.5 Epilepsy

CLINIC VISIT Number of Missed EMR Date seizures medications Side effects If female: Plan On birth control:

______seizures yes no No change yes yes Pregnant None no no Change in médications Only with illness, Allaitement/nursing Labo/Labs EEG CT alcohol yes no __/__/__ Comments:

RDV __/__/__

Clinicians

D.2.3.6 Medication Flowsheet ϐǤ +.)9)+$.')95)+$#&%*'*844#C'#8)*'$..&<*'+.)9)+)$9*'#&'*44'$#'$'A.$9+4'3' <8)+8':45)+$#)&9*'#84'-$#)49#')*'&9'$95'<8$#'+8$9A4*'8$@4'3449':$54' %4+49#.7>'H8)*')*'-$%#)+".$%.7'84.-6".'6&%'6&..&<)9A'-$#)49#*'<)#8'5)*4$*4*' *"+8'$*'84$%#'6$)."%4C'<8)+8'%4O")%4'6%4O"49#'5&*4'$5D"*#:49#*>

MEDICATION LIST Stop Medication Dose Frequency Start date date Reason for stopping __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ appendix d | forms 293

D.2.4 Palliative Care Flowsheet ϐ ǯ ϐ &"#'$#'#84'5)*+%4#)&9'&6'#84'+.)9)+)$9C'54-495)9A'&9'#84'*4@4%)#7'&6'#84' -$#)49#=*'5)*4$*4>'H84'O"4*#)&9*'$%4'3$*45'&9'#84'L6%)+$9'G$..)$#)@4'S$%4' L**&+$#)&9=*'G$..)$#)@4'S$%4'b"#+&:4*'*+$.4C'<8)+8'8$*'3449'@$.)5$#45')9' %"%$.'*"32Y$8$%$9'L6%)+$9'+&::"9)#)4*>/

ASSESSMENT OF SYMPTOM MANAGEMENT (To be done at intake and as needed thereafter) Ask the following questions with regard to the last 3 days Have the patient rate their answer on a scale of 0 (none or not at all) to 5 (a lot or all the time). Date __/__/__ __/__/__ __/__/__ __/__/__ 1. Rate your pain 2a. Have any other symptoms been affecting how you feel? 2b. If so, please rate each symptom: Dyspnea Nausea or vomiting Constipation Diarrhea Incontinence Pruritus Fever Weakness Insomnia Foul Odor 3. Have you been feeling worried about your illness? 4. Have you been able to share how you are feeling with your family or friends? 5. Have you felt life was worthwhile? 6. Have you felt at peace? 7. Have you had enough help and advice for your family to plan for the future? If family is present: 8. How much information have you and your family been given? 9. How confident has the family felt caring for the patient? 10. Has the family been feeling worried about the patient? 294ȀƢȀchronic care integration for endemic non-communicable diseases

Appendix D!References

/' ,$%5)9A';C'Y4.:$9'FC'LA"-)&'TC'4#'$.>'\$.)5$#)&9'&6'$'+&%4'&"#+&:4':4$*"%4' 6&%'-$..)$#)@4'+$%4')9'L6%)+$W'#84'LGSL'L6%)+$9'-$..)$#)@4'&"#+&:4'*+$.4>' ,4$.#8's"$.'F)64'b"#+&:4*'J1/1hgW/1> Chronic Care Integration for Endemic Non-Communicable Diseases Non-Communicable Endemic for Integration Care Chronic the pih guide to the pih guide to Chronic Care Integration for Endemic Non-Communicable Diseases

Partners In Health is a 501(c)3 nonproﬁt corporation based in Boston, Massachusetts. Established in 1987, PIH is committed to making a preferential option for the poor by working with sister organizations to improve the health and well-being of people living in poor communities. To this end, PIH provides technical and ﬁnancial assistance, medical supplies, and administrative support to partner projects in Haiti, Peru, Russia, Rwanda, Lesotho, Malawi, Mexico, Guatemala, Burundi, Kazakhstan, the Dominican Republic, and the United States. The goal of these partnerships is neither charity nor development but rather “pragmatic solidarity”— a commitment to struggle alongside the destitute sick and against the economic and political structures that cause and perpetuate poverty and ill health. Partners In Health is a!liated with the Division of Social Medicine at Harvard Medical School and the Division of Global Health Equity at the Brigham and Women’s Hospital.

rwanda edition More information on Partners In Health can be found s66666 s66666 at our web site: www.pih.org