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 Table of Contents  
GUIDELINES
Year : 2020  |  Volume : 5  |  Issue : 5  |  Page : 1-68

World NCD Federation guidelines for prevention, surveillance and management of noncommunicable diseases at primary and secondary health-care for low resource settings


1 Department of Community Medicine and School of Public health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Advanced Cardiac Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
4 Professor of Epidemiology, Medicine and Global Health, University of Toronto, Canada
5 Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
6 Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
7 School of Preventive Oncology, Patna, India
8 Former Director, Communicable Diseases WHO Regional Office for South-East Asia
9 Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
10 Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
11 Department of Radiotherapy, Post Graduate Institute of Medical Education and Research, Chandigarh, India
12 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
13 Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
14 Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
15 Emeritus-Professor, Post Graduate Institute of Medical Education and Research, Chandigarh, India and Medical Director, Jindal Clinics, India
16 Executive Director, The George Institute for Global Health, India

Date of Web Publication7-Aug-2020

Correspondence Address:
J S Thakur
Department of Community Medicine and School of Public health, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Thakur J S, Kathirvel, Paika R, Dhirar N, Nangia R, Kunjan K, Duseja A, Gupta A, Chockalingam A, Aggarwal AN, Khurana D, Sinha D, Jeet G, Narain J P, Thankappan K R, Rathi M, Vijayvergiya R, Singh R, Kapoor R, Madan R, Grover S, Jain S, Bhadada SK, Jindal S K, Taneja S, Sahoo S, Kumar V, Jha V. World NCD Federation guidelines for prevention, surveillance and management of noncommunicable diseases at primary and secondary health-care for low resource settings. Int J Non-Commun Dis 2020;5, Suppl S1:1-68

How to cite this URL:
Thakur J S, Kathirvel, Paika R, Dhirar N, Nangia R, Kunjan K, Duseja A, Gupta A, Chockalingam A, Aggarwal AN, Khurana D, Sinha D, Jeet G, Narain J P, Thankappan K R, Rathi M, Vijayvergiya R, Singh R, Kapoor R, Madan R, Grover S, Jain S, Bhadada SK, Jindal S K, Taneja S, Sahoo S, Kumar V, Jha V. World NCD Federation guidelines for prevention, surveillance and management of noncommunicable diseases at primary and secondary health-care for low resource settings. Int J Non-Commun Dis [serial online] 2020 [cited 2020 Nov 27];5, Suppl S1:1-68. Available from: https://www.ijncd.org/text.asp?2020/5/5/1/291731




  World NCD Federation guidelines for prevention, surveillance, and management of noncommunicable diseases at primary and secondary healthcare settings Top



  Executive Summary Top


Noncommunicable diseases (NCDs) have emerged as a major public health problem globally due to demographic, epidemiological, nutritional, and socioeconomic transition. NCDs attributed to 73% of global deaths in 2017 and need urgent action guided by the global action plan for prevention and control of NCDs 2013–2020 to achieve the Sustainable Development Goal (SDG). NCDs also cause premature deaths (≤70 years) and nearly 80% of premature deaths happen in low- and middle-income countries (LMICs). In the global framework of “Public Health Approach” to combat any disease, it needs a standard protocol to screen, diagnose, and manage. However, there are no comprehensive guidelines or protocols available on the prevention, surveillance, and management of common NCDs at primary and secondary healthcare facilities of low resource settings, except for a few conditions. The current guideline provides simple and comprehensive guidance on the prevention, surveillance, and management aspects of common NCDs targeting primarily healthcare professionals, including community health workers (CHWs), program managers, policy maker, and implementers at these healthcare settings. These evidence-based, operational guidelines have been developed by experts from various national and international organizations and are explained under the heads of prevention, surveillance, and management. The management part is developed by nine subgroups one for each NCD, namely type 2 diabetes mellitus (DM), hypertension, cardiovascular diseases (CVDs), chronic respiratory diseases (CRDs), cancers, mental health disorders, cerebrovascular diseases/Stroke, chronic kidney diseases (CKDs), and chronic liver diseases (alcoholic liver disease [ALD] and nonalcoholic fatty liver disease [NAFLD]). The guidelines describe the policy and non-policy interventions for the prevention of NCDs, management strategies separately for primary and secondary healthcare settings including when to refer to tertiary healthcare facility, and an implementation framework for uptake of these guidelines at gross root level. These guidelines will serve as a basic tool for the practicing physician and CHWs at every level of healthcare to deliver quality NCD prevention and care. It has been developed taking the primary and secondary health settings and the provisions and strategies under the National NCD Program.

The World NCD Federation envisions appropriate and effective implementation of these guidelines for reduction of premature NCD mortality, especially in the context of the low resource setting. In a way, this will help to reorient the existing health systems to combat the NCDs. The guidelines will be helpful to take further steps in capacity building for various cadres of healthcare staff on prevention, surveillance, and management of NCDs and evaluation at national, regional, and international levels.


  Introduction and process adopted for guideline development Top


NCDs are the leading cause of death globally. In 2017, a total of 41.1 million (73.4% of total deaths) estimated deaths were due to NCDs as compared to 33.5 million in 2007.[1] Similarly, NCDs are the most common cause of disability-adjusted life years (DALYs), which have increased to 62% in 2017 from 43% in 1990.[2] Of the total deaths due to NCDs, CVDs (17.8 million), cancer (9.6 million), CRDs (3.9 million), and diabetes and CKDs (2.6 million) contribute more than 80% of the deaths. Tobacco use, unhealthy diet, inadequate physical activity, and harmful use of alcohol have been found to be the common behavioral risk factors for most of the NCDs globally.[3]

Recognizing the global epidemic of NCDs, SDG Target 3.4 has been set: “by 2030, reduce premature mortality from NCDs by one-third through prevention and treatment and promote mental health and well-being.”[4] In line with SDG, a global action plan for the prevention and control of NCDs (2013–2020) was developed to guide the member countries to combat the NCD burden. The global action plan identified nine voluntary global targets to achieve 25% relative reduction in premature mortality from CVDs, cancer, diabetes, and CRDs by 2025.[5]

Of the nine voluntary targets, Target 8 and Target 9 are to provide drug therapy to eligible population and ensure the availability of essential drugs to treat NCDs, respectively. However, the healthcare system, especially in LMICs, is predominantly focused on providing services related to communicable, maternal, neonatal, and nutritional diseases even now.[6] To provide integrated care (both for communicable diseases and NCDs), the healthcare system needs to be redesigned or re-oriented for the prevention and control of double burden of diseases.

The redesigning of healthcare systems needs to be done at primary and secondary healthcare setting level as it will provide comprehensive and holistic care, i.e., preventive, promotive, curative, and rehabilitative, which is easily accessible and cost-effective compared to tertiary care.[7] In addition, this will also ensure equity and improve the efficiency of the healthcare delivery system. To ensure equity, cost-effective “16 Best Buy” interventions named Package of Essential NCD interventions (PEN) to be delivered at primary healthcare of low resource settings have been identified by the World Health Organization (WHO). However, PEN is not exhaustively covering all the NCDs, and it is not specific like any clinical guidelines for the management of NCDs.[8]

The NCD interventions need to be identified in the framework of “Public Health Approach” as used for the prevention and treatment of tuberculosis and HIV. Standard protocols are needed to (a) identify and address the NCD risk factors; (b) early detection of NCD through screening; and (c) confirmation of diagnosis, treatment, and follow-up at all levels of the healthcare settings. There are standard protocols available for most of the diseases which are primarily developed by the agencies of developed countries which can be applicable at tertiary healthcare settings of any country. The LMIC, a resource-limited setting, is struggling to implement these guidelines, especially in primary and secondary healthcare, due to high-resource investment and differing epidemiological and health system profile. The WHO has developed guidelines for prevention and control of diabetes and CRDs applicable to primary healthcare of low resource setting.[9] However, this is not exhaustive as it fails to cover all important NCDs. There is a dearth of guidelines comprehensively covering the prevention, surveillance, and management of important NCDs applicable to primary and secondary healthcare of resource-limited settings globally.

With this background in mind, the World NCD Federation, a professional and not-for-profit society, undertook an intensive exercise to compile and consolidate evidence-based, operational guidelines on “Prevention, Surveillance, and Management of Non-Communicable diseases at Primary and Secondary Healthcare of Low Resource Settings.”[10] This is a modest effort aimed at presenting in a practical way, means, solutions, procedures, and systems that could contribute toward preventing, controlling, and managing the ever-increasing menace of NCDs globally. We believe that such a compilation is long overdue and would provide useful reference material primarily to healthcare professionals, program managers, and policymakers/implementers at these healthcare settings and to the stakeholders, policymakers, medical fraternity, and program managers at national and subnational levels across countries. The overall objective is to improve the use of best practices, ensure quality of care, and reduce premature mortality due to NCDs in low resource settings.

Process

The current guidelines have been developed by a group of experts working in the field of NCDs. Three broad groups of prevention, surveillance, and management were formed. The management group was further categorized into nine subgroups, namely CVDs, cancer, CRDs, DM, hypertension, stroke, CKDs, chronic liver diseases, and mental health disorders. The experts prepared the guidelines keeping in mind the infrastructure, equipment, and workforce available at the primary and secondary levels of healthcare. The guideline development was split into three important parts for each group.

Setup

This phase involved preparation and selection of the topic to be included followed by identification and formulation of expert groups, acceptance of work plan, and timeline by the chair and groups.

Adaptation

This involved the determination of health questions, searching and assessing available guidelines and evidence, and selecting recommendations for the identified questions based on grading and evidence. For the identified health questions, the methodologists searched and retrieved the guidelines from guideline clearinghouses such as the US National Guideline Clearinghouse and the Guidelines International Network or country-specific databases. The websites of organizations developing guidelines and of relevant specialty societies were searched. PubMed search was done using the publication type as field search. Other search engines were also searched where required. The guidelines' relevancy, level of evidence, and consistency were reviewed. Finally, the acceptability/applicability of recommendations was assessed and a decision was made to either accept or reject; accept certain recommendations, accept with modifications, or accept recommendations from different guidelines.

Finalization

The first draft of the guidelines was compiled by the writing group and was followed by successive expert group meetings for thorough discussion and brainstorming on the recommendations in the guidelines. Henceforth, revisions and re-revisions were done and repeated reviews generated a set of good evidence-based, operational, and cost-effective guidelines for NCDs at primary and secondary levels in low resource settings. The finalized draft guidelines by each group were sent for external review to check the strengths and weaknesses and the areas that needed modification. Similarly, the source guideline developers and professional associations/bodies were contacted for feedback. After incorporation of the relevant comments following external review, the guideline document was finalized and combined.


  Level of Evidence Top


The level of evidence of recommendation is classified as per the Oxford Centre for Evidence-based Medicine (March 2009) for prevention/therapy/etiology/harm criteria as below.

  • Level 1: Meta-analyses or systemic reviews of randomized controlled trials or good-quality randomized controlled trials
  • Level 2: Systematic review of cohort studies or individual cohort studies or low-quality randomized controlled trials
  • Level 3: Systematic review of case–control studies or individual case–control studies
  • Level 4: Case series and poor-quality cohort and case–control studies
  • Level 5: Expert opinion.



  Guidelines for Prevention of Noncommunicable Diseases Top



  Prevention of Noncommunicable Diseases in Primary and Secondary Healthcare Settings Top


Background

Tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diet are the four major and common modifiable behavioral risk factors of NCDs.[11],[12] All these risk factors are responsible for intermediate risk factors such as overweight/obesity, high blood glucose, high blood pressure (BP), and increased cholesterol. Similarly, the cerebrovascular diseases (stroke), chronic liver diseases such as NAFLDs and ALDs, and CKDs are also attributable to the above risk factors which can be prevented through integrated strategy.

Engagement and implementation of preventive, promotive, and curative NCD interventions need multisectoral involvement both at national, subnational, and local levels. Developing national (and subnational) multisectoral policies and plans is one of the mandatory requirements before rolling out any NCD intervention as most of the regulatory/legislation power is with departments/sectors other than health. The global action plan for prevention and control of NCDs (2013–2020) advocates for reducing the four common risk factors (tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diet) to achieve 25% reduction in premature mortality due to CVDs, cancer, diabetes, or CRDs.[5]

Scope of the prevention guidelines

The current guidelines for the prevention of NCDs at primary and secondary healthcare settings of low resource area is a compilation of evidence and consensus across all groups (especially management of specific NCD) involved in development of this guideline. The guideline dealt only the four common risk factors, namely tobacco use, harmful alcohol use, unhealthy diet, and inadequate physical activity using the following assumptions. At primary healthcare level, it was assumed that a community health volunteer (or local/rural health volunteer) delivers part of or whole of health services (primarily preventive and promotive sometimes curative) at community level for a specified population. However, they are supervised and assisted by multipurpose health workers or medical doctors who are formally attached to health system. In addition to four common risk factors, indoor air pollution is also included as this is an important problem in LMICs.

The interventions in the guidelines are classified as policy and nonpolicy interventions to identify the need for multisectoral action. Primarily, policy level interventions must be backed by multisectoral involvement such as finance, agriculture, education, human resource, transport, trade, urban planning, housing, and sports. Nonpolicy interventions are primarily to be implemented by the health department both at facility and community level as the primary provider of health services to respective population.


  Operational Definitions Top


Types of healthcare setting

Primary healthcare setting

The first point of contact of the population or patient with the healthcare professional or health system is the primary healthcare setting. This includes both community-based and facility-based preventive, promotive, curative, and rehabilitative healthcare services to population. This primary healthcare setting is named differently in different country contexts. For example, health subcenter and primary health center (PHC) in India; community health center (CHC) or rural health center in Ghana; basic health units and rural health center in Pakistan; and health center/health post in Cambodia.

Secondary healthcare setting

Healthcare services provided by medical specialists at facility level and usually referred from primary healthcare setting areas. Although the services include preventive, promotive, curative, and rehabilitative services, it is predominantly of curative services, e.g., CHC, subdistrict hospitals, and district hospitals in India; district and regional hospitals in Ghana; tehsil and district headquarter hospitals in Pakistan; and referral and provincial hospital in Cambodia.


  Risk Factors Top


Tobacco use

Problem statement

Tobacco use is one of the important risk factors for both communicable diseases and NCDs. It kills 7 million people every year, of which 1.2 million are passive smokers.[13] As per the estimation, 14% of all deaths from NCDs among adults aged 30 years and above are attributable to tobacco. Of the NCD deaths, 10% of CVDs, 22% of cancers, and 36% of CRDs deaths are due to tobacco use. The target is 30% reduction in the prevalence of current tobacco use by 2025 for which demand reduction measures are proposed at country level using the six components of MPOWER strategy.[14],[15]

Strategic solution

MPOWER strategy, i.e., Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion and sponsorship; and Raise taxes on tobacco.

Recommendations

Policy interventions

The policy level interventions will have impact on reducing tobacco use and are applicable to community and facility level of primary and secondary healthcare settings.

  • Raise taxes on tobacco
  • Ensure smoke-free environments in all indoor workplaces, especially schools, health facilities, public places, and public transport


    • Institutional smoking bans.


  • Ensure no forms of tobacco advertising, promotion, and sponsorship at the respective area
  • Ensure that the size and shape of pictorial warning on tobacco products and different places
  • Display warning messages with ill effects of tobacco
  • Ban on sales of tobacco to minors.


Nonpolicy interventions

The nonpolicy interventions are applicable to community and facility level of primary and secondary healthcare settings, and the actions to be taken by sectors other than health in prevention of tobacco use are given in [Table 1].
[Table 1]: Interventions at primary and secondary healthcare setting for prevention and control of tobacco use

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  • Level of evidence: Level 2
  • Recommendation: Strong.


Harmful use of alcohol

  • Intake of >20 g/day or 140 g/week for men and >10 g/day or 70 g/week for women (approximately 30 ml of whiskey = 100 ml of wine = 240 ml of beer = 10 g of alcohol).


Problem statement

Harmful use of alcohol is a component cause of more than 200 diseases and injury, most commonly chronic liver diseases, cancers, and injuries. Nearly, 3.3 million deaths or 5.9% global deaths were attributable to alcohol consumption in 2012 which amounts to 5.2% of global burden of disease and injury if calculated in DALY.[3]

Strategic solution

The various policy and nonpolicy interventions in the global action plan for prevention and control of NCDs.

Policy interventions

The policy level interventions are applicable to community and facility level of primary and secondary healthcare settings.

  • Enforce restrictions on the physical availability of retailed alcohol (via reduced hours of sale)
  • Enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising (across multiple types of media)
  • Increase excise taxes on alcoholic beverages
  • Display warning messages with ill effects of harmful use of alcohol.


Nonpolicy interventions

The nonpolicy interventions are applicable to community and facility level of primary and secondary healthcare settings, and the actions to be taken by sectors other than health in prevention of harmful use of alcohol are given in [Table 2].
Table 2: Interventions at primary and secondary healthcare setting for prevention and control of harmful use of alcohol

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  • Level of evidence: Level 2
  • Recommendation: Strong.


Unhealthy diet

Problem statement

Unhealthy diet primarily contains identified intervention areas such as adequate fruit and vegetable consumption, reduced salt and sugar intake, and reduced saturated and increased polyunsaturated fat intake. Unhealthy diet, i.e., reduced fruits and vegetable intake, is attributed to nearly 1.7 million deaths.[16] The reduction in salt intake directly reduces the burden of hypertension and reduced saturated fat intake reduces the overweight/obesity and the total cholesterol which are metabolic risk factors for NCDs.[17] Similarly, the intake of free sugars or sugar-sweetened beverages (SSBs) is also an important component of unhealthy diet that needs policy level interventions.

Strategic solutions

Policy level intervention

  • Reduce population salt/sodium consumption


    • Food product reformulation; large-scale pricing strategies; food procurement policy in specific settings; restrictions on marketing to children; on-package nutrition information; levy higher tax on sugary drinks and processed food.


  • Limit saturated fatty acids and virtually eliminate industrially-produced trans-fatty acids in the food supply
  • Implement recommendations on marketing of foods and nonalcoholic sugary beverages such as colas to children
  • Legislation/regulations for fully implementing the International Code of Marketing of Breast-milk Substitutes
  • Nutritional labeling on food and drink products being retailed in market including menus in the restaurants


    • Color-coded labeling and stop sign labeling of unhealthy foods
    • Labeling should include:


      • Total calories (energy value)
      • Amounts of carbohydrate, sugars, fat, protein, sodium, dietary fiber
      • Amount of trans-fat.
      • Healthy eating policy at schools


  • School curriculum that includes healthy eating
  • Improvements in nutritional quality of the food supply in schools.
  • Reduce SSBs and fat sugar and salt food
  • Labeling and food claim rules; interventions changing the availability of different foods and beverages in public institutions and other settings; pricing interventions (including both fiscal and nonfiscal interventions altering the absolute and relative prices of SSB expand when used first or low-calorie alternatives to SSB); advertisement regulation especially on channels largely viewed by children or shows viewed by children in particular; discouraging endorsements by celebrities; bringing social media portals onboard for the advertisement ban on unhealthy foods; reformulation; changes to the beverage retail and foodservice environment; food system approaches (including health-in-all policies approaches in sectors such as agriculture and trade); gradual progression in the direction of total ban; set evidence-based regulatory limits by establishing monitoring systems which can assess the food and beverages periodically.
  • Policy to reduce the portion, package, or tableware size of food.


Nonpolicy level intervention

The nonpolicy interventions are applicable to community and facility level of primary and secondary healthcare settings, and actions to be taken by sectors other than health in promotion of healthy diet are given in [Table 3].
Table 3: Multisectoral interventions applicable to primary and secondary healthcare setting for promotion of healthy diet

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  • Level of evidence: Level 2 to Level 5
  • Recommendation: Strong to moderate.


Physical inactivity

Physical activity includes leisure-time physical activity, transportation (e.g., walking or cycling), occupational (i.e., work), household chores, play, games, sports or planned exercise, in the context of daily, family, and community activities. Adequate physical activity includes 30 min/day of moderate-intensity physical activity (e.g., walking) throughout the week or do at least 15 min of vigorous-intensity aerobic physical activity (e.g., cycling and swimming) throughout the week or an equivalent combination of moderate- and vigorous-intensity activity.[18] The gap between physical activities should not be more than 48 h.

Problem statement

Physical inactivity is attributable to 6% of global deaths. Nearly 23% of adults and 81% school-going adolescents were insufficiently physically active as per the “Global recommendation on physical activity for health.”[18]

Strategic solution

Policy intervention

  • Social marketing or mass media communication on improving physical activity
  • Physical activity policy at school


    • School curriculum includes physical activity and body image
    • Increased sessions for physical activity and the development of fundamental movement skills throughout the school week.
    • Enabling environment such as creation of playgrounds walking trails and infrastructure with legislative, fiscal, or policy requirements and planning for the broader population. Or the introduction of new environmental facilities including improvements of existing facilities (e.g., replacement of playgrounds in a park), improved access to facilities (e.g., improved opening hours, creation of new bridges), creation of new facilities (e.g., introduction of bicycle lanes or walking paths) or wider public transport initiatives (e.g., cycle hire schemes).


Nonpolicy intervention

The nonpolicy interventions are applicable to community and facility level of primary and secondary healthcare settings, and actions to be taken by sectors other than health in promotion of physical activity are given in [Table 4].
Table 4: Multisectoral interventions applicable to primary and secondary healthcare setting for promotion of physical activity

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  • Level of evidence: Level 2 to Level 3
  • Recommendation: Strong.


Indoor air pollution

Problem statement

Around 3 billion people globally use solid fuels in their homes, which give exposure to fine particles and carbon monoxide. The exposure is high among women and children. The exposure to indoor air pollution causes chronic obstructive pulmonary disease (COPD), lung cancer, ischemic heart disease, and stroke. Nearly 4 million people per year die due to exposure to household air pollution.[19]

Strategic solution

Policy intervention

  • Provide access to cleaner fuels-through subsidy
  • Provide access to improved stoves-through subsidy.


Nonpolicy intervention

The nonpolicy interventions are applicable to community and facility level of primary and secondary healthcare settings, and actions to be taken by sectors other than health in reducing indoor air pollution are given in [Table 5].
Table 5: Multisectoral interventions applicable to primary and secondary healthcare setting for reducing indoor air pollution

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  • Level of evidence: Level 3 to Level 5
  • Recommendation: Strong.



  Multisectoral Action Top


The extent of NCDs and their risk factors is such that only medical interventions are not sufficient to deal with them. No level of prevention is bereft of the scope of multisectoral action. The government, nongovernment, civil society, industries, other organizations, and the like have a great role to play in multisectoral approach for dealing with NCDs [Figure 1].
Figure 1: Proposed multisectoral action framework for prevention of noncommunicable diseases

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  Way Forward Top


The implementation of the recommendations in different countries may vary as per the structure of the health system of the country. Each country can modify the modality of implementation according to existing sociopolitical conditions as this needs multisectoral involvement. Future research needed to develop and show evidence on robust, both community and facility-based models to deliver these interventions in different country settings.Guidelines for Prevention of Noncommunicable Diseases


  Guidelines for Noncomunicable Disease Surveillance Top



  Background Top


Surveillance is defined as “the ongoing systematic collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with timely dissemination of these data to those who need to know.”[20] The goal of disease surveillance is to address a defined public health problem and to develop evidence-based measures to protect and promote population health.[21] Surveillance at local, regional, and national level on risk factors, morbidity, and mortality can be used by public health authorities for developing need-based health interventions and also support program development, monitoring, mid-course corrections, and impact evaluations. This is well applicable to NCDs which is the leading cause of mortality globally. Experiences in establishing the NCD surveillance systems can be drawn, especially from Brazil and China which have longitudinal data as they integrated the surveillance with the routine health information system.[22],[23],[24] The WHO has judged the current capacity for NCD surveillance as inadequate in several countries.[1],[3]

Various types of surveillance systems have been established across countries which are described in [Table 6]. Surveillance at present is focused primarily on risk factors such as behavioral and biochemical risk factors. Given the continuous need for data for decision-making and available resources, there is a need to combine the individual risk factor survey into one comprehensive survey so as to avoid survey fatigue, covering all relevant risk factors, and also to simplify the methodology and make it more feasible at district and state levels. Lack of comparability of data is one of the major challenges identified in global surveillance and monitoring as there is no uniformity in methodology.[25] Poor availability of resources including trained human resources, infrastructure, intersectoral coordination, and capacity in using the technology on NCDs affect the establishment of good surveillance systems in developing countries. With this background, the current guideline provides ways and means of establishing an efficient system for surveillance of NCDs and its risk factors.
Figure 6: Screening, diagnosis, and management of cervical cancer at primary and secondary healthcare

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  Expectations from Noncommunicable Diseases Surveillance Guidelines Top


Standard tools for NCD diseases and risk factors surveillance are now available such as WHO STEPwise approach for surveillance (STEPS). While NCD surveillance systems cover information on deaths, disease, and risk factors, however, collecting data on NCD risk factors through surveys is the most common form of information being collected. Sustainable institutionalized systems are essential for a responsive surveillance system. A preliminary framework for NCD surveillance suggested by the WHO is given in [Figure 2].[6] NCD surveillance systems need to be integrated into existing national health information systems. Three major components of NCD surveillance include:
Figure 2: Framework for noncommunicable diseases surveillance

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  1. Monitoring exposures (risk factors)
  2. Monitoring outcomes (morbidity and disease-specific mortality)
  3. Assessing health system capacity and response.



  Assumptions and Operational Definitions Top


Surveillance method involves sentinel augmented facility-based surveillance, supported by population-based surveys. Community-based approach for surveillance is the core of this surveillance framework to evaluate impact of implemented interventions and to assess the prevalence of NCD risk factors.

The framework calls for departmental and intersectoral coordination for the production of surveillance data on critical aspects of public health. The basic WHO NCD STEPS Framework has been adapted and used in the current guideline.

Diseases to be included

According to the WHO classification, NCDs have 16 major subgroups with 92 different diagnoses in total. As it will be difficult to collect and report data for each NCD, the five common NCDs can be included in the NCD Surveillance System [Table 7]. Mental health is emerging as a major disease, usually neglected and reported. It should be part of the surveillance systems if resources allow.
Table 7: Diseases to be part of the noncommunicable disease surveillance system

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Level of healthcare system to plan noncommunicable disease surveillance

As countries differ in the level of resources and capacity in conducting NCD surveillance, the policy of a single system of surveillance cannot work. The WHO has proposed a hierarchical system called as STEPS for NCD surveillance of deaths, diseases, and risk factors. Level 1 health systems will be the most elementary and Level 3 is the most complex one. While at least Level 1 STEPS should be attempted in all countries, planning systems at higher levels should be based on available resources and capacity [Table 8].[31]
Table 8: Levels of healthcare system and surveillance systems

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  Noncommunicable Disease Surveillance System for High-resource Setting Top


For settings with high resource allocation, local level annual surveillance at the lowest level of healthcare will involve CHWs at village/urban level for risk factor screening, morbidity history, verbal autopsy for deaths. Volunteers can be included for the surveys through prior training. CHW and his/her team can calculate NCDs risk factor score, get information regarding treatment and care-seeking status, as well as inform the concerned person about clinical tests and diagnosis at immediate health center which has been depicted in [Figure 3].
Figure 3: Operational framework for noncommunicable diseases surveillance in settings with better resources

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  Prerequisites for Setting up a Noncommunicable Disease Surveillance System in High-resource Settings Top


  • A program for addressing
  • Functional hospital- and/or population-based registries
  • Strengthened disease-wise facility-based reporting of NCDs
  • Multisectoral participation and data sharing mechanisms
  • Clinical tests and diagnostics of high-risk cases at primary and secondary care level as per treatment guidelines
  • The role of CHWs is critical as they will be provided with the list of high-risk cases for clinical tests and diagnosis at primary healthcare level for follow-up
  • Unique identification number for each patient should be generated with adequate information retained by the system to ensure quick search of patient history during visits
  • At the primary healthcare level, clinical tests and diagnostics can be performed using point-of-care diagnostics and measuring devices.



  Noncommunicable Disease Surveillance System for Low resource Setting Top


In low resource settings, population-based behavioral risk factor assessment can be held at regular intervals say every 5 years to assess the effectiveness of implementation of prevention and control interventions. National or subnational approach may be devised by considering aspects such as population, cost, and human resources requirement. However, it is suggested that this activity may be conducted in collaboration with external agency. The activity planning can be carried out at the local level, and external agency can select the minimum required sample size from basic administrative units of the population. At the local level, household identity number and patient identity number should be generated. The operational framework for NCD surveillance in low resource setting is given in [Figure 4].
Figure 4: Operational framework for noncommunicable diseases surveillance in settings with low resources

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Variables reported under surveillance system

Although the selection of variables is guided by the requirement of policymakers, a minimalistic list has been proposed to be part of any NCD surveillance system [Table 9].
Table 9: Variables to be reported under the surveillance system

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  Recommendations Top


  1. A standard surveillance instrument and methodology should be adopted
  2. NCD risk factor surveys should be implemented periodically at regular intervals
  3. Survey methodology should be designed in line with sustainable goals
  4. Data should represent administrative blocks as per the requirement of the country
  5. Data should be disseminated optimally and the data collected should be kept in public domain
  6. Policymakers at the central and subnational level should be motivated to use the existing data for targeted policy changes and people's education
  7. Stakeholders at all levels may be involved so that utility of data can be maximized.



  Management of Noncommunicable Diseases Top



  Cancer Top


Cancer burden

Cancer incidence is increasing with lifestyle changes, leading to increase in NCD burden. It is a major cause of morbidity and mortality in both developed and developing countries. One in eight men and one in nine women in India develop some form of cancer in lifetime. According to Globocan 2018 data, the number of new cases was around 1.16 million in 2018, leading to 784,000 deaths. In the next 20 years, incidence of cancer is expected to go up to 1.73 million cases per year plunging the country to top the list of cancer as one of the NCDs.[32] It is a major cause of catastrophic expenditure and thereafter to impoverishment. Good news is that early detection allows for intervention either before cancer develops or at an early stage, when treatment is most often effective.

Oral cancer

Oral cavity cancer is one of the most common cancers in all sexes in LMICs and is the most common cancer among men in India. According to the Globocan 2018 data, 119,992 new cases were diagnosed in 2018, of which 76.7% were among men.[32] This is one of the cancers which can be prevented and identified early through population-based approach. The risk factors, presenting features, diagnosis, and management of oral cancer are given in [Figure 5].
Figure 5: Screening, diagnosis, and management of oral cancer at primary and secondary healthcare

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Cervical cancer

Cervical cancer is the third leading cause of burden of cancer and the ninth leading cause of death due to cancer. It is the second most common cancer in women in India after breast cancer. It is preventable cancer (following vaccination) and can be successfully treated when diagnosed in early stages where reported survival is more than 90%. The risk factors, presenting features, diagnosis, and management of cervical cancer at primary and secondary healthcare are given in [Figure 6].[33]{Figure 6}

Breast cancer

Breast cancer is the most common cancer in females worldwide both in developed and developing countries. In India, breast cancer incidence has overtaken cervical cancer incidence because of several factors, including diet, lifestyle, lowered fertility, increasing age at first childbirth, and obesity. According to Globocan 2018 data, breast cancer incidence in India is 24.7/100,000 population.[32] Approximately 162,468 women developed breast cancer and 87,090 patients died of breast cancer in 2018 in India. The risk factors, presenting features, diagnosis, and management of breast cancer at primary and secondary healthcare are given in [Figure 7].
Figure 7: Screening, diagnosis, and management of breast cancer at primary and secondary healthcare

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Lung cancer

Lung cancer is the leading cause of cancer globally in all sexes and is the fourth leading cause in India. Overall survival is good in very early stage. However, in advanced stage, despite aggressive treatment outcome is poor. All efforts should be made to prevent it or at least to early diagnose it. The risk factors, presenting features, diagnosis, and management of oral cancer at primary and secondary healthcare are given in [Figure 8].
Figure 8: Screening, diagnosis, and management of lung cancer at primary and secondary healthcare

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Colorectal cancer

Colorectal cancer is among the top five cancers globally and is a lethal cancer.[32] The risk factors, presenting features, diagnosis, and management of colorectal cancer at primary and secondary healthcare are given in [Figure 9].[34]
Figure 9: Screening, diagnosis, and management of colorectal cancer at primary and secondary healthcare

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Liver cancer

Liver cancer is one of the preventable cancers and is among the top ten causes of cancer burden and mortality due to cancer. The risk factors, presenting features, diagnosis, and management of liver cancer at primary and secondary healthcare are given in [Figure 10].
Figure 10: Screening, diagnosis, and management of liver cancer at primary and secondary healthcare

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Carcinoma esophagus

According to Globocan 2018, carcinoma esophagus is among top 10 causes of cancer and death due to cancer globally and in India.[32] The risk factors, presenting features, diagnosis, and management of carcinoma esophagus at primary and secondary healthcare is given in [Figure 11].
Figure 11: Screening, diagnosis, and management of esophageal cancer at primary and secondary healthcare

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  Diabetes Mellitus Top


According to the International Diabetes Federation  Atlas More Details (2017), a total of 427 million individuals are suffering from diabetes and projected to be 629 million by 2045.[35] The prevalence of diabetes in LMICs is 8.73%, low-income countries (LICs) is 12.34%, upper-middle-income countries is 11.8%, high-income countries (HICs) is 6.68%, and overall, it is 9.45%.[36] The LMICs contribute immensely to the global burden. By virtue of population, India harbors the second largest number of diabetics of the world. The overall prevalence of diabetes is 7.3% (4.3%–10%), higher in urban areas and in mainland compared to northeastern states. The overall prevalence of prediabetes is 10.3% in India.[37]

Operational definitions

Type 2 DM is diagnosed most widely using the American Diabetes Association which is given in [Table 10]. A glucometer can be used to assess capillary blood glucose levels as it is the only available means at most primary healthcare. However, plasma glucose measurement should be done wherever available. Urine glucose estimation is recommended neither for diagnosis and nor for monitoring of diabetes.[38] Only National Glycohemoglobin Standardization Program certified and standardized to the Diabetes Control and Complications Trial assay HbA1c test values should be accepted.
Table 10: American Diabetes Association criteria for diagnosis of diabetes mellitus and gestational diabetes mellitus

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In addition to population-based screening of all people ≥30 years, the high-risk population approach is also needed as mentioned in [Table 11].[39] They can be identified via house-to-house survey or opportunistic screening at health facilities and encouraged for diabetes screening. The preliminary physical examination and investigations are given in [Table 12].
Table 11: High-risk individuals for diabetes mellitus

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Table 12: Preliminary physical examination and investigations for newly diagnosed cases of diabetes at primary and secondary healthcare facility

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Diabetes education should be provided at the initial visit and at each follow-up visit, by addressing the following questions and topics as described in [Table 13].
Table 13: Diabetes education at diagnosis and follow-up visit

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Pharmacological management at primary health center

All patients with RBS ≤ 300 mg/dl can be further evaluated and treated at PHC. Metformin and sulfonylureas are the common oral antidiabetic drugs (OADs) used for the management of diabetes and the dose, indication, contraindication, and adverse events of the same are given in [Table 14].[40]
Table 14: Summary of the available oral antidiabetic agents at primary healthcare and their practical utility

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Patients with RBG >300 mg/dl or presented with other red flag signs such as (a) glycemic targets not achieved in first 3 months of therapy even with maximum dose of OADs; (b) urine dipstick s/o proteinuria; (c) ketonuria +; (d) BP >160/90 mmHg; (e) abnormal neurological examination; (f) absent pedal pulses/foot ulcer; or (g) other chronic complications should be referred to secondary health facility for further evaluation and management.[40]

Pharmacological management at secondary healthcare facility

  • If initial RBG is ≤ 300 mg/dl, and/or if initial HbA1c is ≤9%, then monotherapy with metformin/sulfonylureas is advised
  • If HbA1c is between 9% and 10%, dual OADs, i.e., metformin and sulfonylureas, should be started
  • There is no preferred drug as add-on to metformin for dual therapy. Any of the classes of OADs or basal insulin can be considered, depending on availability and patient factors. Sulfonylureas and glitazones are low-cost options for add on therapy
  • If HbA1c is ≥10% and/or RBG ≥300 mg/dl, insulin should be added along with OADs
  • The insulin initiation requires proper counseling and shared decision making with the patient about its need, effects, administration and storage technique, advice for self-glucose monitoring, and associated risks of insulin therapy including hypoglycemia. A physician should start with basal insulin (insulin NPH or insulin glargine; depending on availability) at the dose of 0.2 IU/Kg/day at bedtime[41],[42],[43]
  • If basal insulin has been titrated to an acceptable fasting blood glucose level (between 80 to 130 mg/dl) or if the dose is 0.5 units/kg/day and HbA1c remains above target, then combination injectable therapy should be started[41],[42],[43]
  • When initiating combination injectable therapy, metformin therapy should be maintained while other oral agents may be discontinued
  • The recommended starting dose of premeal insulin is 4 units, 0.1 units/kg, or 10% of the basal dose, which might be required to be given before one or two meals or before each meal, depending on glycemic control
  • If basal insulin is not available, then premixed insulin (30:70) may be initiated divided into two doses at 0.2 IU/kg/day, with 70% of total dose administered before breakfast and rest 30% before dinner. Details of insulin therapy are given in [Table 15].
  • Insulin storage and injection techniques should be taught to all patients. Insulin vials should be stored at 4°C and hence can be kept in the door of the refrigerator. They must never be kept in the freezer compartment
  • Insulin injection technique should be demonstrated to the patient at time of initiation. Subcutaneous injection in the abdominal wall, thigh, and forearm, with frequent site rotation should be advocated. Patients should be taught to check for site hypertrophy.
  • Self-monitoring of blood glucose at home should be encouraged. Fasting and premeal blood glucose targets of 80–130 and 2-h postmeal blood glucose targets of <180 mg/dl should be achieved
  • If urine dipstick test is suggestive of proteinuria, then angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blockers should be started[44],[45],[46],[47]
  • For loss of sensation, patient education is a must. They should be encouraged to daily inspect the feet (along with sole) with a handheld mirror for any cracks, fissures, callus, or ulcers and to avoid exposing the feet and hands to extremes of temperature
  • For painful diabetic neuropathy, drugs such as pregabalin/gabapentin or duloxetine should be started.
Table 15: The details of types, indication, and side effects of insulin therapy

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The algorithm for pharmacological management of DM in primary and secondary healthcare settings is given in [Figure 12].
Figure 12: Pharmacological management of diabetes mellitus at primary and secondary healthcare setting. FBG- Fasting blood glucose; RBG- Random blood glucose; PPG- Postprandial glucose; SMBG-Self monitoring of blood glucose

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The patient should be screened for end-organ complications such as retinopathy, nephropathy, and neuropathy, including diabetic foot at the time of diagnosis and periodically at regular intervals in both primary and secondary healthcare facilities as given in [Table 16]. Patients found positive for any complication at primary healthcare facility should be referred to secondary healthcare facility for confirmation and further management.
Table 16: Screening and follow.up of diabetes mellitus for end organ complications

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  Cardiovascular Diseases Top


Coronary artery disease (CAD) is the leading cause of death globally, including India. The case fatality attributable to CVD in LICs appears to be much higher than in middle-income countries and HICs. According to the Global Burden of Disease study age-standardized estimates (2010), nearly a quarter (24.8%) of all deaths in India are attributable to CVDs.[48] Evaluation and management based on various cardiovascular symptoms are given below.

Evaluation of chest pain

Clinically, most of the patients present with chest pain which should be differentiated with noncardiac cause of pain as given in [Table 17].
Table 17: The difference between chest pain of cardiac and noncardiac cause

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Electrocardiogram (ECG) and cardiac enzymes are the important investigations to diagnose acute cardiac event. However, the complete physical/clinical examination is needed for appropriate management [Table 18].
Table 18: Details of examination and investigations for diagnosis of cardiovascular diseases

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Based on the clinical examination and investigations, the chest pain can be classified into (a) chest pain of noncardiac cause; (b) chronic unstable angina; (c) ST-elevation myocardial infarction (STEMI), and (d) non-STEMI.[49],[50] The algorithm for evaluation and management of patients with chest pain is given in [Figure 13].
Figure 13: Algorithm for evaluation and management of patients with chest pain

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As ECG facility is available in PHC, diagnosis and initial management of chest pain/angina can be done at the level of both PHC and further referred to CHC or higher center for thrombolysis or risk stratification through further investigation.

Chronic stable angina

Chronic stable angina can be diagnosed and managed as summarized in [Table 19].
Table 19: Diagnosis, investigation, and management of chronic stable angina

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Acute coronary syndrome

[Figure 14] shows a spectrum of CAD. Acute coronary syndrome (ACS) includes both STEMI and non-ST elevation ACS (NSTE-ACS).[51]
Figure 14: Spectrum of coronary artery diseases

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ST-elevation myocardial infarction

All the patients presenting with acute anginal pain to a PHC should be given sublingual sorbitrate, a loading dose of aspirin (300 mg), clopidogrel (300 mg), and statin (atorvastatin 40 or 80 mg) after getting an ECG and should be referred to a CHC for thrombolysis and management of comorbidities. If needed, patients may be referred to higher center, i.e., district hospital for risk stratification in the form of treadmill test (after stabilization), echocardiography for assessing left ventricular ejection fraction, or referral to medical colleges/tertiary centers for angiography in case the patient has a contraindication to thrombolysis or failed thrombolysis or high-risk features such as ongoing chest pain and hemodynamic or electrical instability.[49],[50]

The indication and contraindication for thrombo/fibrinolysis are given in [Table 20].
Table 20: Indications and contraindications for fibrinolysis among patients with ST elevation myocardial infarction

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The common fibrinolytics used in acute myocardial infarction (MI) are given in [Table 21].
Table 21: Common fibrinolytics used in myocardial infarction and its contraindication

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Indicators of successful thrombolysis

  • Resolution of ST-segment elevation by ≥50%
  • Resolution of ischemic discomfort or chest pain or hemodynamic instability.


Medical management including thrombolysis for stabilization of the patients presenting with ACS is given in [Table 22].
Table 22: Medical management of acute coronary syndrome patient

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Non-ST elevation acute coronary syndrome

NSTE-ACS include non-STEMI in the patient who has positive cardiac biomarkers (positive troponin T/I or elevated CPK-MB) or unstable angina in patients who have negative cardiac biomarkers. These patients have characteristic chest pain with ECG changes as mentioned above.[52]

The recommended medical management including oxygen, aspirin, clopidogrel, beta blockers, ACEIs, statin, morphine, nitroglycerine, and heparin is like STEMI. Patients after initial diagnosis and management in a CHC should be further referred to higher center, i.e., district hospital for risk stratification in the form of treadmill test (after stabilization), echocardiography for LVEF or referred to medical colleges/tertiary centers for angiography.

The recommended management facilities to be available at different primary and secondary healthcare facilities are summarized in [Table 23].
Table 23: Recommendation for the management of coronary artery disease at various levels in primary and secondary healthcare settings

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  Cerebrovascular Disease or Stroke Top


Stroke is the second leading cause of death worldwide. In the US, approximately 700,000 people have a new or recurrent stroke annually. In the developing world, stroke causes around 3 million deaths. In India, stroke incidence is around 146 per 100,000, and it is predicted that in the next 30 years, the burden of stroke is primarily going to increase in the LMICs.[6] However, the public health systems of these countries are yet to be strengthened. Since stroke is also the leading cause of permanent neurological disability in adults, reversal of stroke symptoms through delivery of organized stroke care becomes of paramount importance nationwide. Central to stroke management is an efficient manner to capture stroke data and thereafter develop organized delivery of stroke care through well-established systems of care.

Operational definitions

  • Stroke: A sudden focal or global neurologic deficit of vascular origin lasting >1 h; if the symptoms are fully reversible in <1 h, it should be labeled as a transient ischemic attack (TIA)
  • TIA: “A transient episode of neurologic dysfunction caused by focal cerebral, spinal cord, or retinal ischemia, without acute infarction.”


The symptoms to recognize stroke by the primary and secondary healthcare staff are given in [Table 24].
Table 24: Details of the symptoms to recognize stroke

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Recommendations

The following are the consensus recommendations for the management of stroke at various levels of healthcare.

Development and training of emergency medical services

The nonmedical or paramedical staff in national ambulance service (NAS) will be the primary responders for an acute stroke. As the resources needed to manage stroke is not available at PHC and resulting delay in initiation of treatment, the NAS system will rather can provide the appropriate services as part of primary healthcare system. The NAS personnel should be thoroughly trained to recognize stroke symptoms [Figure 15] using Face drooping, Arm weakness, Speech difficulty, and Time to call Ambulance and thereafter transfer to the closest stroke ready hospital where computed tomography (CT) services available.[54],[55],[56] This would increase both the number of patients treated and quality of care. Educational stroke programs for physicians, hospital personnel, and NAS personnel are recommended.
Figure 15: Recommendations for initial assessment and management of stroke at primary and secondary healthcare

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The summary of recommendations for initial assessment and management with NAS system is given in [Table 25].[53]
Table 25: Recommendations for initial assessment and management of stroke with National Ambulance Service

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Taking the example of the Indian health system, CT service is available only at the level of district hospital. Due to this reason, the primary management of stroke can be done only at district hospital. However, the patient with the symptoms of stroke may visit any level of healthcare facility. Similar to the NAS system, the summary of recommendations for initial assessment and management at primary and secondary healthcare facilities is given in [Figure 15].

In addition to initial assessment, the clinical management of the patient is needed to stabilize and treat the cerebrovascular event or stroke at both primary and secondary healthcare levels [Figure 16].
Figure 16: Recommendations for management of stroke at primary and secondary healthcare settings

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The recurrence of ischemic stroke or TIA can be prevented by the following recommendations mentioned in [Table 26].[54],[56],[57],[58]
Table 26: Recommendations for secondary prevention following acute ischemic stroke and transient ischemic attack

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All stroke patients should be initiated the rehabilitation services after 24 h of thrombolysis or stroke and continued with community-based physiotherapy services, including chest physiotherapy.

Referral to tertiary center

Referral to a tertiary care center may be carried out in the following situations:

  1. Large hemispheric infarct on CT/magnetic resonance imaging with impending herniation or malignant middle cerebral artery infarction
  2. If a patient has comes within 4 h of an acute stroke, the patient should be immediately referred to a higher center with facilities for acute stroke thrombolysis if requisite facilities and expertise are not available at the district hospital
  3. Patients with large vessel occlusion stroke should be referred if a tertiary care facility has endovascular treatment facility.


The consolidated algorithm for assessment and management of stroke at primary and secondary healthcare facilities is given in [Figure 17].
Figure 17: The assessment and management algorithm for stroke at primary and secondary healthcare setting. LVO - Large vessel occlusion

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  Hypertension Top


Introduction

Hypertension is the most important risk factor for CVD. It accounts for 54% of all strokes and 47% of all ischemic heart disease events globally.[59] Hypertensive heart disease stood fourth among the CVD cause for DALYs in 2015 globally. The prevalence rose continuously for each age group, from 2.0 per 100,000 at ages 20–24 years to 1360 per 100,000 for those >80 years of age. In 2015, the United States, Russia, China, India, and Indonesia accounted for more than half of the global DALYs related to systolic BP of at least 110–115 mmHg.[60] Even though hypertension and CVDs predominantly affect the elderly population in HICs, in LMICs, younger populations are disproportionately affected.[61] Despite the availability of low-cost medications that are safe and effective, fewer than 15% of adults suffering from hypertension, worldwide, have their BP under control (140/90 or lower).[62]

Operational definitions

The cutoff for normal BP and hypertension is given in [Table 27] as defined by the American College of Cardiology/American Heart Association Task Force. Hypertensive urgency is defined as BP >180 mmHg systolic and/or >120 mmHg diastolic. Hypertensive emergency is defined as BP >180 mmHg (systolic) with target organ damage and/or >120 mmHg (diastolic) with target organ damage.[63]
Table 27: Operational definition of normal blood pressure and hypertension

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According to the Joint National Committee 8 recommendations, pharmacological treatment should be started when the BP is >150/90 mmHg in adults aged 60 years or older or >140/90 in adults aged younger than 60 years. In patients with comorbidities of hypertension and diabetes, therapy should be initiated at BP of >140/90 mmHg, irrespective of the age of the individual.[64]

The primordial and primary prevention through lifestyle interventions should be delivered at community level. The pharmacological management in addition to lifestyle interventions initiated to all patients diagnosed with hypertension. The algorithm for diagnosis and management of hypertension at primary and secondary healthcare settings is given in [Figure 18].
Figure 18: Diagnosis and management of hypertension at primary and secondary healthcare setting. ECG - Electrocardiogram, GFR - Glomerular filtration rate, CCB - Calcium channel blockers, ACEI - Angiotensin-converting enzyme inhibitor, ARB - Angiotensin receptor blockers, BB - Beta blocker

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Pharmacological management of hypertension

  • Four medication classes (calcium channel blockers [CCBs], ACEIs, angiotensin receptor blockers [ARBs], and diuretics) are effective drugs for the treatment of hypertension. Single drug or combination of drugs may be used for treatment[63]
  • Stage 1 hypertension: First assessment for atherosclerotic CVD (ASCVD) risk is done. If ASCVD risk is less than 10%, lifestyle changes are recommended, and reassessment is done in 3–6 months. BP-lowering medications are initiated in patients with clinical CVD or a 10-year risk of 10% or greater
  • For stage 2 hypertension, Two BP-lowering medications (of different classes) are recommended in addition to lifestyle changes. Reassessment is done after 1 month. If treatment goal is met, reassessment is done after 3–6 months. If the goal is not met after 1 month, change of medication is done or titration of dose is done. Reassessment is done after every month till goal is reached
  • Hypertensive urgency can be managed by intensification of therapy and treatment of anxiety as applicable.
  • Hypertensive emergency requires admission of patient to an intensive care unit for monitoring of BP and parenteral administration of BP-lowering drugs.
  • Lifestyle changes include DASH diet, weight reduction, physical activity (90–150 min of aerobic and/or dynamic resistance exercise per week and/or 3 sessions per week of isometric resistance exercises) and alcohol restriction (two or fewer drinks daily for men and not >1 drink daily for women)
  • Goals of BP for pharmacological therapy: The treatment goal is to maintain the BP to <130/80 mmHg for all clinical conditions.
  • If target BP is not reached, to reinforce lifestyle and adherence and/or titrate medications to maximum doses or consider adding another medication (ACEI, ARB, CCB, and thiazide)
  • All patients with hypertension should be assessed through clinical examination and investigations at primary and secondary healthcare facilities [Figure 18]. Patients with hypertension and complications/comorbidities such as heart failure, CVDs, stroke, and CKD should be referred to secondary healthcare facilities for further evaluation and management. The antihypertensive drug of choice for specific conditions is given in [Table 28].[64]
Table 28: Antihypertensive drugs used for co-existing morbidities or complications

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The formulations and doses of individual drugs used for the treatment of hypertension are summarized in [Table 29].
Table 29: Details of commonly used antihypertensive drugs at primary and secondary healthcare settings

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  Chronic Respiratory Diseases Top


As per the WHO estimates, nearly 235 million people suffer from asthma globally, and the disease is the most common NCD among children. In addition, more than 200 million people (about 4%–20% adults over 40 years of age) suffer from COPD worldwide, but most present rather late in the course of illness. The WHO also estimates that globally around 65 million people have moderate-to-severe COPD; however, most of these data are from HICs. The recommendation for the management of chronic respiratory diseases in primary and secondary healthcare settings are given in the [Table 30].
Table 30: Recommendation for the management of chronic respirtory diseases in primary and secondary healthcare settings

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Both asthma and COPD [Table 31] are associated with considerable morbidity, especially if not diagnosed early or managed properly. While asthma results in reduction in overall functional capability among children and loss of productivity primarily among young adults, COPD is characterized by continued disease progression and symptomatic worsening, culminating in respiratory failure, and other complications in older adults. Current international guidelines rely heavily on objective demonstration of airflow limitation through spirometry, mainly for COPD but also for asthma, for characterization of disease severity/control [Table 32] and optimizing therapy.[65],[66] However, spirometry is not currently available at primary (and frequently even secondary) healthcare settings in several countries. In addition, inhaled drugs, which currently form the cornerstone of managing both asthma and COPD, are not freely available at these levels due to cost issues. Moreover, the use of inhalers often carries a social stigma, and many patients (and sometimes even healthcare providers) consider them as being “habit-forming.” Both these present a major impediment to the early diagnosis and appropriate treatment of CRDs at the primary care level [Table 33].
Table 31: Differentiating between asthma and chronic obstructive airway disease (chronic obstructive pulmonary disease)

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Table 32: Severity classification for chronic obstructive airway disease

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Table 33: Level of current asthma control (over the preceding 4 weeks)

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Several countries have a well-functioning primary healthcare network that is providing services for NCDs to the community. However, it is yet not geared toward diagnosis and management of CRDs in most instances. This presents an opportunity to integrate CRDs in a vertical fashion into the program so that the existing infrastructure and workforce can be utilized to offer services related to CRDs at the primary healthcare level.[67],[68] There is, of course, a need for capacity building and training, as well as augmentation of resources, by the health managers to achieve this objective. This document presents an outline of the processes and options that may be used by healthcare providers and health managers to improve diagnosis and treatment of asthma and COPD at the primary care level.

Diagnosis and management at primary care level

Once a person enters the primary health system with respiratory symptoms, healthcare providers should aim to provide an accurate and timely diagnosis. They should try and differentiate between asthma and COPD, as well as attempt to exclude potential mimics of these diseases.

Planning and organizing care at primary healthcare level

Potential activities undertaken at primary healthcare level should be in three key areas: (a) prevention by reducing risk factor exposures, (b) early and accurate diagnosis, and (c) appropriate treatment, both pharmacologic and adjunct.

Preventive measures are aimed toward reducing/stopping exposure to risk factors in COPD and avoidance of allergens and other triggers in asthma as given in [Table 34]. Several overlapping activities can be easily advised at individual and household level by healthcare personnel involved in patient care.
Table 34: Preventive activities for patients and families

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Early and accurate diagnosis of asthma or COPD is essential to initiate timely therapy. The existing healthcare personnel at primary healthcare centers can be trained to integrate diagnosis and management of CRDs into their clinical activities related to other health programs at the community level. The diagnostic process flow is summarized in [Figure 19]. A few important points need to be stressed. While it is desirable that spirometers should be available at all PHCs, the same might not be feasible (at least during the initial phases of program implementation). In such a scenario, health managers can consider pooling of resources for several neighboring PHCs. For example, if a spirometer is available at a secondary level center, then a mobile van can bring the equipment by rotation to neighboring PHCs once in a week or fortnight, where patients awaiting pulmonary function test can be collectively evaluated. Second, patients presenting with cough of more than 2 weeks duration should undergo sputum examination to rule out tuberculosis. This activity will also integrate the program with the local tuberculosis control mechanisms. Finally, if there is some doubt in the diagnosis, or if some complication is suspected, then patients should be immediately referred to secondary or tertiary centers for further evaluation.
Figure 19: Flow process for diagnosis and management of asthma and chronic obstructive airway disease at primary care level

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Initial treatment and regular follow-up should be arranged for all patients at the primary care level itself, unless there is a need to refer them to a higher level. Inhaled medications should be preferred (1A). Even though these are more expensive than oral drugs, health managers should ensure that sufficient quantity is made available regularly for patient use. In the long term, these are likely to prove more cost-effective due to better disease and symptom control, and lesser adverse effects. Treatment protocols for asthma and COPD are different, and initial therapy and its subsequent modulation need to be individualized for each patient [Figure 20] and [Figure 21].[65],[66],[69],[70] It is important to verify that the patient is using his/her inhaler in a correct fashion and is compliant with prescribed treatment, before considering a step-up in therapy or referral to higher center.
Figure 20: Initiation and modulation of asthma pharmacotherapy

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Figure 21: Initiation and modulation of chronic obstructive airway disease pharmacotherapy

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The arrangement of logistics to implement the program at the primary care level may be a challenge in the initial stages, and health managers share a key responsibility for arranging finances to provide infrastructure and medications, as well as arrange horizontal integration into existing healthcare framework. A key requirement will be upgradation of diagnostic services and procurement of inhaled and other drugs that are so far not available at the primary care level. The minimum resources needed to make the program operational are enumerated in [Table 35]. Capacity-building measures need to be set up to improve the competencies of primary health workers in diagnosing CRDs and stratifying their severity based on clinical and spirometric criteria, providing support in managing disease exacerbations and health education.
Table 35: Resources and medications required for management of asthma and chronic obstructive pulmonary disease at primary and secondary healthcare setting

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The category with the worst value should be used for severity classification, and spirometry may be excluded if a recent testing has not been performed.


  Chronic Kidney Diseases Top


Diabetes and hypertension are two widely prevalent NCDs that are major risk factors for development of CKD. The WHO in its global action plan for NCDs 2013–2020, though criticized for not recognizing kidney disease as major NCD, did stress upon that possible environmental and occupational hazards might be important in causing kidney disease in addition to diabetes and hypertension.[76] However, CKD, until recently overshadowed by diabetes and hypertension, is now being increasingly recognized as an important cause of mortality due to NCDs.

Among NCDs, the rise in burden of CKD has surpassed increases in other NCDs in the United States between 2002 and 2016.[77] The Global Burden of Disease 2015 study showed 32% increase in deaths attributable to kidney disease over the decade between 2005 and 2015.[78] Furthermore, 1.2 million deaths due to CVD could be attributed to low glomerular filtration rate (GFR).[78] Recent population-based studies from South Asia and other LMICs suggest a wide variation in the prevalence of CKD as standard and uniform definitions or methods have not been adopted in all.[79],[80] Pooled data from cross-sectional studies in 12 LMICs showed prevalence of CKD as 14.3% and 36.1% in general and high-risk populations, respectively. It is likely that the estimates of prevalence of CKD are under-estimates in LMICs as sustained credible mechanisms for screening and poor data management system.

Operational definition of chronic kidney disease

CKD is defined as structural or functional abnormality in kidneys that persists for more than 3 months and has an implication for health. Low GFR and/or urine albumin or protein excretion are two functional parameters that are used to define CKD.

Chronic kidney disease assessment and challenges

Urine albumin excretion can be semi-quantitatively assessed by urine dipstick testing which is cheap and easily available. GFR is indirectly estimated from estimating equations that use common demographic characteristics (e.g., age, sex, and race) and measurement of serum creatinine. The most commonly used estimating GFR (eGFR) equation is CKD-EPI. However, these equations are valid only for populations in which they have been validated because non-GFR determinants of circulating creatinine levels, e.g., diet and muscle mass, are different in people from different races and ethnicities. Unfortunately, populations from LMICs have had very poor representation in derivation and validation cohorts for eGFR equations, and therefore, it is not surprising to observe poor accuracy of eGFR equations in these settings. Studies from India and Pakistan have shown either poor accuracy or need of correction factors for eGFR equations for application in local populations.[81],[82] Therefore, there is a need to validate eGFR equations in different races or ethnic populations. Nevertheless, eGFR equations should be used to estimate GFR in clinical practice pending validation studies.

eGFR equations are based on serum creatinine measurements that should be standardized and traceable to isotope dilution mass spectrometry standards. Upgradation of existing laboratory infrastructure at primary and secondary levels of care to currently recommended standards would entail a lot of cost. However, these objectives can be met in a phased manner by ensuring adherence to minimum standards in newly set up laboratories and gradual upgradation of existing ones depending on resource availability. The use of nonstandardized serum creatinine values does not forbid use of serum creatinine in eGFR equations as correction factors for the same have been suggested. However, these drawbacks should always be borne in mind while interpreting such data.

Recommendations

The current recommendations for prevention, diagnosis, and management of CKD at primary and secondary healthcare levels have been designed to be simple, flexible, and practical in LMICs context. An attempt has been made to ensure flexibility so that these recommendations can be easily integrated with the existing NCD programs. The infrastructural limitations and expertise of trained workforce at various healthcare levels have been considered with the goal to achieve objectives listed in [Table 36].
Table 36: Suggestions for actions at primary and secondary levels of care (the listing is hierarchical with one level of care offering services over and above the ones offered at preceding level of care)

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Primary healthcare level

Population can be screened to identify the high-risk population for CKD, i.e., diabetes, hypertension, and kidney stone disease through history, or questionnaire can be provided urine albumin excretion test by dipstick [Figure 22]. All patients who are identified at this level should be referred to higher center for evaluation and provided healthy lifestyle counseling [Table 37]. We suggest annual re-screening in people with negative screen preferably as part of integrated screening program for common NCDs. [Figure 22] represents integrated algorithms for screening and management of kidney disease at primary healthcare.
Table 37: Recommended specific interventions

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Figure 22: Screening and management of chronic kidney disease at primary healthcare

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At PHC level, all referred or high-risk patients should be screened for both low eGFR (by measurement of serum creatinine) and abnormal urine albumin or protein excretion. In case there is high clinical suspicion of kidney disease or the patient is found to have kidney disease, the patient should be referred to specialist doctor for evaluation. Patients who are negative for screening should be re-screened at 6 months at PHC and provided follow-up at community level.

Secondary healthcare level

These facilities are manned by specialist doctors and some facilities have additional provision for special diagnostic facilities and dialysis [Table 36]. The doctor would establish diagnosis of kidney disease, identify complications, judge imminent therapeutic needs, and refer the patient to a nephrologist for final assessment and management plan [Figure 23]. Dialysis would be provided if there is an urgent need or requirement of long-term maintenance dialysis.
Figure 23: Screening and management algorithm at secondary healthcare level

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Future course

The proposed algorithms are expert suggestions that need to be tested for their efficacy and cost-effectiveness in different settings. Therefore, each algorithm itself becomes an important research question. It is likely that these would require some modifications due to variations in models of healthcare delivery in different regions. Still, these are important guides toward instituting initial mechanisms for addressing the increasing burden of CKD at primary and secondary levels of care. Simultaneously, there is need of scientific validation of eGFR equations in different populations, ascertaining significance of low normal GFR in otherwise normal individuals, and development of low-cost technologies for laboratory assessment of kidney diseases. A community-based long-term prospective cohort study should be established in LMIC scenario for better characterization of possible risk factors (environmental, occupational, etc.) for the development and progression of kidney disease. Finally, the success of community-based programs at primary and secondary levels of care also requires qualitative social science research to identify barriers during actual implementation of such programs and find solutions.


  Nonalcoholic Fatty Liver Disease (NAFLD) and Alcoholic Liver Disease Top


Nonalcoholic fatty liver disease (NAFLD) is the most common cause of an asymptomatic rise in transaminases, cryptogenic cirrhosis, and cryptogenic hepatocellular carcinoma. Patients with NAFLD are also at high risk for developing type 2 DM, CAD, CKD, and osteoporosis. Alcohol accounts for an estimated 3.3 million deaths (6% of all global deaths) and contributes as an etiologic factor in ~50% cases of cirrhosis. Even though LMICs represent a large population of the world, because of the resource constraints, the strategies to manage patients in these countries may be different than the high resource settings.

To address this gap, we herein describe a stepwise approach in managing patients with NAFLD and Alcoholic liver disease (ALD) at primary and secondary level healthcare settings for LMICs.

Nonalcoholic fatty liver disease

Definition of nonalcoholic fatty liver disease

NAFLD has been defined as the accumulation of fat in the liver in the absence of recent or ongoing intake of significant amount of alcohol and the exclusion of other secondary causes of hepatic steatosis. Even though it is best defined by histology, accumulation of fat in the liver (fatty liver) is usually diagnosed on ultrasound (abdomen). The severity of fatty liver on ultrasound is graded as mild, moderate, and severe based on the liver echogenicity, loss of echoes from walls of the intrahepatic portal venous radicles, and posterior beam attenuation with blurring of the diaphragm. Even though the ultrasound is a good modality to assess the presence and severity of fat in the liver, it may not be good modality to assess the overall severity of liver disease in patients with NAFLD.

Spectrum of nonalcoholic fatty liver disease

The differentiation between Nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH) is very important in determining the prognosis, risk of progression, and treatment stratification and for assessing the liver-related and cardiovascular morbidity and mortality, occurring more commonly in patients with NASH than in those with NAFL [Table 38].
Table 38: Difference between nonalcoholic fatty liver and nonalcoholic steatohepatitis

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Hepatic fibrosis can be diagnosed with the help of noninvasive parameters including transient elastography (FibroScan) or other forms of hepatic elastography if available.

Step-wise approach for evaluation of adult patients after detection of fatty liver on ultrasound or other imaging with or without symptoms [Figure 24]
Figure 24: Algorithmic approach for the evaluation of patients with nonalcoholic fatty liver disease. NAFLD: Nonalcoholic fatty liver disease; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; APRI: AST/Platelet ratio index; LSM: Liver stiffness measurement

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  • Step 1 – History of alcohol intake


  • Significant alcohol intake as >20 g/day or >140 g/week for men and >10 g/day or >70 g/week for women (approximately 30 ml of whisky/spirit = 100 ml of wine = 240 ml of beer = 10 g of alcohol). Abstainer or insignificant intake will be categorized as nonalcoholic

  • Step 2 – If nonalcoholic – assess for the presence or absence of metabolic syndrome


  • Metabolic syndrome is a clinical syndrome that is usually defined by the presence of at least 3 of the following 5 components as per the WHO criteria.

    • Central obesity


      • Waist circumference ≥90 cm in males and ≥80 cm in females for Asians
      • Population-specific cutoffs for other populations.


    • Known DM or fasting plasma glucose of ≥100 mg/dl
    • Hypertension (BP ≥130/85 mmHg)
    • Low serum high-density lipoprotein (<40 mg/dl in males and <50 mg/dl in females)
    • High serum triglycerides (≥150 mg/dl) or on treatment


  • Step 3 – If metabolic syndrome or any of its components present [Figure 25]
  • Figure 25: Algorithmic approach for the treatment of patients with nonalcoholic fatty liver disease

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    • Fatty liver likely to be NAFLD.


  • Step 4 – If metabolic syndrome or any of its components absent


    • As it is less likely to be NAFLD, search for other causes of hepatic steatosis such as intake of drugs, namely corticosteroids, methotrexate, tamoxifen, and amiodarone, and hepatitis C infection. Other secondary causes of fatty liver such as Wilson's disease, abetalipoproteinemia, lipodystrophy, and parenteral nutrition are uncommon and may require referral to a tertiary care center for further evaluation and confirmation.


  • Step 5 – Assessment of liver function tests


    • Serum bilirubin is usually normal unless the patient has progressed on to cirrhosis or hepatocellular carcinoma (HCC)
    • ALT may be normal or elevated.
    • Step 6 – Evaluate for other causes of raised transaminases if present


    • All patients with raised ALT (>1.5 times the normal) should be tested for hepatitis B surface antigen (HBsAg) and antibodies to hepatitis C virus (anti-HCV). Refer to a tertiary care center for detailed work-up including autoimmune markers, celiac disease work-up, serum iron profile, and serum ceruloplasmin
    • Raised ALT is insufficient to distinguish between NAFL and NASH.


  • Step 7 – Noninvasive assessment for the severity of liver disease (irrespective of ALT level)


    • AST/ALT ratio, AST to platelet ratio index (APRI), NAFLD fibrosis score (NFS) or by transient elastography (FibroScan) or other forms of hepatic elastography if available. Calculation of APRI and NFS is simple and can be done using free online calculators with age, BMI, diabetic status, and laboratory parameters such as AST, ALT, albumin, and platelets (https://www.hepatitisc.uw.edu/page/clinical-calculators/apri)
    • Significant fibrosis: AST/ALT ratio >1, APRI >0.7, NFS >0.675, and liver stiffness measurement on ≥8 kPa on FibroScan (NAFLD Fibrosis Score: http://www.nafldscore.com/)
    • Diagnosis of NASH-related cirrhosis liver and HCC may be suspected clinically or on imaging as per the clinical presentation of the patient.


  • Step 8 – Manage at primary or secondary level healthcare if less likely to have severe liver disease/NASH/significant fibrosis/cirrhosis/HCC or Refer to tertiary care center otherwise.


Footnotes - Workup and evaluation at primary (subcenter/PHC) and secondary (CHC/district hospital) level healthcare may vary depending upon the availability of different workforce (health worker/medical doctor/physician) and investigations required for the management.

Treatment of noncirrhotic nonalcoholic fatty liver disease

Since NAFLD is a lifestyle disease, weight loss and exercise and control of risk factors such as DM, hyperlipidemia, and hypertension form primary treatment. Pharmacological treatment is indicated only in selected situations. Vitamin E or pioglitazone can be given to biopsy-proven patients with NASH with or without DM. In addition, many new pharmacological agents are being evaluated in various phase III studies across the globe. Other pharmacological treatment is not recommended as liver-related complications in patients without NASH is low.

Step-wise approach in the management of patients with nonalcoholic fatty liver disease at primary/secondary care

The steps are explained in the [Figure 25].

  • Step 1 – Control of metabolic risk factors.


    • Control of overweight or obesity


      • Regular exercise and weight reduction for overweight and obesity. Overweight and obesity need to create a negative balance by consuming fewer calories (30% reduction in calorie intake recommended by restricting both carbohydrates and fats) and burning more calories by regular exercise. Regular exercise improves insulin sensitivity and is the only treatment for lean NAFLD. Slow and sustained weight reduction of10% body weight for 6–8 months should be achieved. Severe hypocaloric diets are not recommended in NAFLD. Patients with NAFLD should avoid any amount of alcohol intake.


    • Control of DM/hypertension/dyslipidemia


    • There are no contraindications for the use of medications to control DM, hypertension, or dyslipidemia. Statins are also safe in patients with NAFLD having raised transaminases.


  • Step 2 – Metabolic risk factors – absent


    • Regular Exercise.


  • Step 3 – Follow-up


    • Six monthly follow-up for 1 year
    • Observation if parameters improving
    • Refer to tertiary care if not able to control the metabolic risk factors or continue to have raised transaminases.


Alcoholic liver disease

The spectrum of ALD [Table 39] varies from alcoholic steatosis (fatty liver), alcoholic hepatitis (AH, alcoholic steatohepatitis) to alcoholic cirrhosis, and its complications including HCC). Multiple stages may be present simultaneously in a given individual.
Table 39: Spectrum of Alcoholic Liver Disease

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Alcoholic fatty liver disease

Fatty liver develops in about 90% of individuals who drink more than 60 g/day of alcohol but may also occur in individuals who drink less. Simple, uncomplicated fatty liver is usually asymptomatic and self-limited and may be completely reversible with abstinence after ∼ 4–6 weeks.

Alcoholic hepatitis

AH is diagnosed in a patient with new onset of jaundice within 60 days of heavy consumption (>50 g/day) of alcohol for a minimum of 6 months, a serum bilirubin >3 mg/dL, an elevated AST (50–400 U/L), an AST: ALT ratio >1.5, and no other obvious cause for hepatitis.

  • Severe AH is identified by Maddrey's discriminant function score >32 (4.6 × prolonged prothrombin time + serum bilirubin)


Alcoholic cirrhosis

  • Compensated: Ultrasound or any other imaging or FibroScan evidence of cirrhosis with or without deranged liver function tests (LFTs) or coagulogram
  • Decompensated: Clinical features of portal hypertension including ascites, bleeding from GI tract or development of altered sensorium with evidence of deranged LFTs, coagulogram, and ultrasound or other imaging evidence of cirrhosis.


Step-wise approach for evaluation of adult patients with significant alcohol intake

The steps are explained in the [Figure 26]. Identification and assessment of spectrum and the severity of disease are needed for appropriate management.
Figure 26: Algorithmic approach for the evaluation and treatment of patients with alcoholic liver disease

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  • Step 1 – History of alcohol intake


    • Significant alcohol intake as >20 g/day or >140 g/week for men and >10 g/day or >70 g/week for women
    • Heavy alcohol consumption: Consumption of >50 g/day of alcohol for a minimum of 6 months
    • Binge drinking: >5 drinks in males and >4 drinks in females, consumed over 2 h period.


    *(Approximately 30 ml of whiskey = 100 ml of wine = 240 ml of beer = 10 g of alcohol)

    *(Approximate 1 unit of alcohol = one ounce of spirit = 12-ounce beer = 4-ounce of wine)

  • Step 2 – If significant alcohol intake is present– Assess for the presence or absence of alcohol dependence or abuse by using the CAGE questionnaire [Figure 26]
  • Step 3 – If significant alcohol intake is present look for symptoms and signs of ALD


    • The initial symptoms are nonspecific and include pain abdomen, loss of appetite, fatigue, body aches, and sense of being unwell. Most patients do not develop symptoms until severe liver damage. The common symptoms are


      • Yellowing of the skin and eyes (jaundice)
      • Swelling of the legs (edema)
      • Distension of the abdomen due to fluid (ascites)
      • Bleeding in the gastrointestinal tract (blood in vomiting and or in stools)
      • Weight loss and muscle wasting and change in sleep pattern in advanced liver disease.


  • Step 4 – Assessment of severity of liver disease irrespective of symptoms and signs


    • Serum bilirubin is usually normal unless a patient has progressed on to AH, cirrhosis, or HCC
    • ALT and AST may be normal or elevated even in the early stage of ALD
    • The platelet count is usually low in alcoholic cirrhosis, and coagulogram is deranged in advanced disease.


  • Step 5 – Noninvasive assessment for the severity of liver disease in alcoholic steatosis (irrespective of elevation of transaminases)


  • Noninvasive assessment of hepatic fibrosis using AST/ALT ratio, APRI, or transient (FibroScan) or other forms of hepatic elastography in all alcoholic hepatic steatosis [See NAFLD section for details]. The liver stiffness can be fallaciously high in patients with active alcohol abuse and should be repeated once the patient is abstinent for 3 months.

  • Step 6 – Manage at primary or secondary level healthcare if alcoholic steatosis and mild alcoholic hepatitis present or refer to tertiary care center in case of severe liver disease/severe ASH/significant fibrosis/cirrhosis/HCC.


Footnotes: Work-up and evaluation at primary (subcenter/PHC) and secondary (CHC/district hospital) level healthcare may vary depending upon the availability of different workforce (health worker/medical doctor/physician) and investigations required for the management.

Management of alcoholic liver disease

Based on the initial evaluation, patients can be stratified into mild disease (alcoholic steatosis and mild AH) and advanced disease (severe AH and cirrhosis). Complete abstinence from alcohol consumption is the cornerstone in the management of every spectrum of ALD.

Management of alcoholic steatosis and mild alcoholic hepatitis in primary and secondary level healthcare setting

The management is explained in the [Figure 26].

  • Complete alcohol abstinence with use of pharmacological therapy and behavioral therapy with motivational interviewing techniques.
  • 100 mg of thiamine daily and B complex vitamins should be given to all patients. Zinc and other trace elements may be replaced if available.
  • Nutritional supplementation including high calorie (30–35 Kcal/kg/day) and high protein diet (1.2–1.5 g/kg/day) in mild AH
  • Refer patients with advanced liver disease (severe AH and cirrhosis) to tertiary care facility for further management and follow-up.



  Mental Disorders Top


Mental disorders such as depression and substance use disorders, one of the groups of NCDs, are associated with development of NCDs and also improve the outcome of NCDs, namely cancers, hypertension, CADs, DM, and COPD.[83],[84] Globally, one out of four is affected with mental or neurological disorders and the leading cause of disability. Depression the fourth leading in global burden of disease and is predicted to be second leading by 2020 globally.

Based on the burden and current healthcare delivery system for mental disorders, it is proposed to move from mental institution to community care through integration of mental healthcare with primary healthcare system. This guideline for common mental disorders (CMDs) will assist to build the capacity and implement the appropriate clinical and community care at primary and secondary healthcare facilities.

Classification of mental disorders

Mental disorders are classified according to the International Classification of Diseases 10[85] and Diagnostic and Statistical Manual of Mental Disorders 5[86] [Table 40].
Table 40: Classification of mental disorders

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Validated and culturally accepted screening or diagnostic tools should be used for identification, assessment, management, and follow-up of patients with mental disorders [Table 41].
Table 41: Scales/tools used by healthcare staffs to screen for various mental disorders

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General principles for assessment and management of mental disorders

The healthcare staffs involved in assessment and management of mental disorders should follow the following principles namely listening with interest, not being in hurry, accepting the beliefs of the patients about their symptoms and not contradicting the same directly, encouraging expression of emotions, being nonjudgmental, maintaining confidentiality, reassuring the patients, expressing empathy, and recognizing their needs.

Assessment and management of stress

Stress, the predecessor for most of the mental disorders, is defined as person's total response to environment demands or pressure. The assessment of stress level should be part of routine health service delivery by CHWs which further guide to make culturally acceptable and sustainable interventions at individual, family, and community or workplace. The signs and symptoms of stress and management of stress are given in [Table 42] and [Table 43], respectively.
Table 42: Signs and symptoms of stress

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Table 43: Strategies to prevent and manage stress

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Early identification of mental disorders

The health workers can deliver comprehensive, home-based services for identification of people with chronic mental disorders, CMDs, and substance abuse. They can also inform the primary care physicians about such patients and bringing the patients to the healthcare services at primary care, ensuring a regular follow-up with monitoring of compliance by periodic home visits along with planning of rehabilitation interventions. In addition, efforts can be attempted to promote awareness and address stigma, forming self-help groups in the families of mentally ill people to promoting the social and economic reintegration of those with mental disorders into the community.[100],[101]

The presenting features of CMDs are summarized in [Table 44].
Table 44: Presenting features of common mental disorders

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Detailed clinical assessment and investigation

All patients presented with one or the other presenting feature suggestive of CMD should undergo thorough clinical examination after detailed history and investigations to finalize the diagnosis and to check for presence of comorbid conditions. The investigations include at least hemogram including bleeding time, clotting time, LFTs, renal function tests, serum electrolytes, blood sugar levels, and ECG. This is needed for control of primary CMD and also the comorbid condition and to avoid adverse effects/interactions when pharmacological management is needed.

Formulating a treatment plan

Treatment setting and use of medications and psychological treatments are usually influenced by the severity of illness, available social support, presence or absence of comorbidity, and presence or absence of physical comorbidity. Patients with active suicidal ideations with or without plan should ideally be managed by the specialists. Accordingly, such patients must be referred to the nearest available mental health professionals.

Most of the patients with CMDs can be managed at the primary care level by the use of psychological interventions and pharmacological interventions.

Psychological treatments

Psychological treatments form an important part of various psychiatric disorders, especially, in patients with mild-to-moderate depressive disorder, various anxiety disorders, and somatoform and dissociative disorders.

Psychological treatment in the form of psychoeducation must be considered as an integral part of management of any psychiatric disorder. Health workers at the primary care level can deliver the psychoeducation in collaboration with the primary care physicians [Table 45].[102],[103]
Table 45: Basic ingredients of psychoeducation

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Other simple measures that can be done at the primary care level by the healthcare workers and/or physicians are listed in [Table 46]. Certain general-specific [Table 46] and disorder-specific [Table 47],[Table 48],[Table 49],[Table 50][105],[106],[107] psychological interventions can be carried out by the healthcare workers or physicians in managing various psychiatric disorders.
Table 46: General simple psychosocial interventions

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Table 47: Simple psychosocial measures specific for patients with somatoform disorders/dissociative disorders/medically unexplained symptoms

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Table 48: Simple psychosocial measures specific for patients with dementia

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Table 49: Simple psychosocial measures specific for patients with alcohol and tobacco use

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Table 50: Commonly used psychotropic medications

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Pharmacological treatment for psychiatric disorders

Those patients who require use of psychotropic medications must be primarily managed by the physicians in the primary care and referred to the psychiatrist whenever required.

Depression and anxiety disorders

The presenting feature, assessment, and management of depression are summarized in [Figure 27].
Figure 27: Assessment and management of depression at primary and secondary healthcare

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  • Among the selective serotonin reuptake inhibitors (SSRIs), the first-line treatment for depression and anxiety disorders, escitalopram and sertraline are among the most commonly prescribed agents and can also be used in patients with[108],[109],[110],[111] hypertension, CAD, DM,[112] and various malignancies[113]
  • Tricyclic antidepressants such as amitriptyline and imipramine can be used if SSRIs are not available with the cost of more side effects and drug interactions[114]
  • Initiation of drugs: Start with lower doses; half recommended dose among patients with comorbid conditions and among elderly; one-fourth of the recommended dose for elderly with comorbid conditions.[115]
  • It usually takes 2–4 weeks to observe any significant beneficial effects with antidepressants. Patients with improved clinical outcome must be continued on the same medications in the same dose for at least 9–12 months after first episode of depression. After completion of this treatment duration, the doses of medications can be tapered off slowly, with close monitoring for side effects.
  • The doses of antidepressants for anxiety disorders are also same, except for patients with obsessive–compulsive disorder, who require higher doses.
  • Benzodiazepines may be used along with antidepressants during the initial phase of treatment for short duration and in minimal doses.


Somatoform disorders

  • Patients with somatoform disorders or those with medically unexplained symptoms can be managed with nonpharmacological measures such as psychosocial intervention [Table 47],[104],[105] relaxation exercises, and activity scheduling.[116] However, some of the patients may require the use of antidepressants which include amitriptyline and duloxetine
  • Avoid use of opioid analgesics in patients with somatoform disorders. The summary is given in the [Figure 28].
Figure 28: Assessment and management of psychosis at primary and secondary healthcare

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Dissociative disorders

In general, psychotropics are not used for patients with dissociative disorders. However, these may be considered if the patient has comorbid anxiety or depression.

Psychotic disorders

  • The most commonly used antipsychotics include risperidone and olanzapine[117],[118]
  • Other agents which are commonly used include haloperidol, trifluoperazine, and chlorpromazine
  • The basic principle of start from lower doses and gradually increase the dose must be followed. In patients with comorbid medical illnesses, the starting doses and the maximum doses to be used are usually lower than those recommended for those without medical illnesses.


Bipolar disorder

Patients with bipolar disorder and current episode mania are usually managed by using mood stabilizers, antipsychotics, or both. Selection of mood stabilizers is usually based on current polarity, predominant lifelong polarity, availability of facilities for monitoring (for example, whether the facilities for monitoring serum lithium levels are available or not) and patient's preference. Lithium is usually preferred in patients with predominant depressive polarity and epilepsy. Valproate is not recommended for use in females during pregnancy and among females with polycystic ovarian disease. It is important to remember that while using valproate it is important to monitor the LFTs, hemogram, and serum levels. Other alternative mood stabilizers include carbamazepine and lamotrigine.

Dementia

Cognitive enhancers are usually not very useful in patients with severe dementia. In patients with mild-to-moderate dementia, medications such as donepezil and memantine can be used to retard further cognitive deterioration.[119] Selection of these agents is often influenced by the type of comorbid illness [Table 53].[106]
Table 51: Basic community based rehabilitation which can be done at primary care level

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Table 52: Things to do during the follow-up visits

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Table 53: Indications for referral to a psychiatrist

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Alcohol

Patients with alcohol dependence presenting in withdrawal phase often require detoxification management [Figure 29]. Initial evaluation of patients presenting in alcohol withdrawal state is to rule out delirium tremens. Patients who are not in delirium are usually managed with relatively lower doses of benzodiazepines, compared to those with delirium tremens. Selection of benzodiazepines is guided by level of hepatic impairment. Lorazepam and oxazepam are the preferred agents among those with impaired hepatic functions.[120] It is important to use thiamine in patients with alcohol withdrawal and avoid use of intravenous glucose before use of thiamine, as this may precipitate Wernicke's encephalopathy. Once patient is detoxified, pharmacoprophylaxis can be done using disulfiram, acamprosate, or naltrexone to prevent relapse.[121]
Figure 29: Assessment and management of alcohol dependence at primary and secondary healthcare

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Tobacco

Usually, psychological interventions are sufficient to manage patients with tobacco dependence. However, some of the patients who are heavy smokers may require use of nicotine substitution therapy.[120] This should ideally be done by a mental health professional along with use of psychosocial interventions. In patients with comorbid depression, bupropion [Table 50] for doses recommendations] may be the preferred agent, as this not only acts as an antidepressant but also reduces withdrawal associated with tobacco use.[122]

The details of commonly used psychotropic drugs including dose, indication, and side effects are summarized in [Table 50]. Further, the community-based rehabilitation, follow-up assessment, and time of referral to higher centers are given in [Table 51], [Table 52], [Table 53], respectively.[87],[123],[124],[125]


  Conclusion Top


Mental disorders are highly prevalent in the community, and majority of these are CMDs. Mental disorders have been shown to be closely related to other NCDs. Patients with various mental disorders, often seek consultation from the primary care physician or the health workers at primary care. The health workers and physicians can play an important role in screening, prevention, and management of CMDs. Further, they can help in arranging for psychiatric consultation for the patients. Appropriate management of mental disorders at primary care can reduce the burden of mental disorders and also improve the outcome of other NCDs.


  Monitoring and Implementation Framework of the Noncommunicable Diseases Guidelines Top


A monitoring and implementation framework is needed with predefined targets and indicators similar to the NCD global monitoring framework for effective uptake of the current guidelines. The framework will assist the policymakers and or program managers/implementers for uptake and roll out this guideline in their respective government. The framework developed based on systems approach [Table 54] which will be used for implementation and monitoring the progress of implementation of NCD guidelines.
Table 54: Framework for implementation of guideline on “Prevention, surveillance, and management of noncommunicable diseases in primary and secondary healthcare settings”

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The implementation framework has been built on a sample district with 1,000,000 (1 million) population which has one district hospital, two subdistrict hospitals, six CHCs, 30 PHCs (6 for each CHC), and 180 health subcenters (6 for each PHC). The framework has been prepared based on the Indian Public Health Standards (IPHS) for primary (health subcenter and PHC) and secondary (CHC, subdistrict, and district hospital) healthcare settings of India. As per IPHS, the population covered by a health subcenter, PHC, and CHC is 5000, 30,000, and 150,000, respectively. The approximate number of population and patients screened, managed, referred, and followed up at primary and secondary healthcare settings is given in [Table 55]. For the calculated population/patients, needed human resources, and essential facilities or drugs needed, and budget involved in building the capacity of various level healthcare personnel for efficient implementation of guideline on prevention, surveillance, and management of NCDs in primary and secondary healthcare setting of a model district are given in Tables 56 and 57, respectively.
Table 55: Calculation for assessing the population/patients screened, managed, and followed up for NCDs at primary and secondary healthcare setting of a model district

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Table 56: The needed human resource and facilities for implementation of noncommunicable diseases guideline in a model district

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Table 57: Capacity-building budgetary guidelines for orienting/training the health human resource at public health facilities for implementation of guideline on Prevention, surveillance and management of NCDs

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  Expert list Top


Abhijit Chaudhary (Professor & Head, Department of Hepatology School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education & Research Kolkata, India, Indian Institute of Liver and Digestive Sciences Sitala (east), Jagadishpur, Sonarpur, Kolkata, India), Ajit Avasthi (Professor and Head, Department of Psychiatry, PGIMER, Chandigarh), Akash Shukla (Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India), Amit Jha (Principal Secretary, HFW, Haryana), Anand Krishnan (Professor, Center of Community Medicine, AIIMS, New Delhi), Anil Garg (Nodal Officer, NPCDCS, Chandigarh, NHM, Chandigarh Administration, India), Anil Bhansali (Professor and Head, Department of Endocrinology, PGIMER, Chandigarh), Anjali Bhawara (Principal Secretary, Health and Family Welfare), Anju Bhatia (Epidemiologist, NHM chandigarh), Anshita Aggarwal (Assistant Professsor, Department of Endocrinology, Ram Manohar Lohia Hospital, New Delhi),Anshu Sharma (HOD and Additional Director NCD, NCDC, New Delhi), Anuradha S Dassanyake (Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka), Arun Kashyap (Principal, KASHYAP DEVELOPMENT ASSOCIATES, Integrated analysis - Implementation - Innovation - Partnerships Washington, DC, USA), Arun Sanyal (Consultant, Department of Internal Medicine, Commonwealth University, Richmond, Virginia, USA), Arvind Rajwanshi (Head, Department of Cytology and Gynaecological Pathology, PGIMER, Chandigarh), Ashoo Grover (SCIENTIST F & HEAD, RESEARCH METHODOLOGY CELL, ICMR, New Delhi), Ashu Rastogi (Assistant Professor, Department of Endocrinology, PGIMER, Chandigarh), Dr. Atul Budukh (Assistant Professor, Tata Memorial Center, Mumbai), Dr. Damodar Bachani (Country Project Manager, Building Healthy Cities (India, Indonesia, Vietnam), John Snow India Private Ltd., Plot 5-6, LSC Shopping Complex, Nelson Mandela Marg,Vasant Kunj, New Delhi 110070, India), Dr. Balram Bhargava (DIRECTOR GENERAL, DHR & ICMR, New Delhi ), Baridalyne Nongkynrih (Professor, Centre for Community Medicine, All India Institute Of Medical Sciences, New Delhi), Bijaya Nanda Naik (Assitant Professor of Community Medicine, Venkateswara Medical College, Puducherry), Binod Kumar Patro (Additional Professor, Department of Community Medicine, AIIMS Bhubaneswar), BS Chavan (Director-Principal, GMCH, Chandigarh), C.E Eapen (Professor, Department of Hepatology, Christian Medical College, Vellore), Chan Wah Kheong (Associate Professor, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia), Digambar Behera ( Professor, Department of Pulmonary Medicine, PGIMER, Chandigarh), D Prabhakaran (Vice-President and Director, Centre for Control of Chronic Conditions, PHFI, New Delhi), Dan Yock Young (Associate Professor, Division of Gastroenterology and Hepatology, University Medicine Cluster, National University Hospital, Singapore), Davison Munodawafa (Professor, Department of Community Medicine, Faculty of Medicine, Midlands State University, Gweru, Zimbabwe), Denis Xavier (Department of Pharmacology, India Division of Clinical Research and Training, St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore), Diana Alcantara-Payawal (Department of Medicine, Cardinal Santos Medical Center, Mandaluyong, Philippines), Dinesh Katoch (Adviser (Ayurveda), Ministry of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy (AYUSH) AYUSH Bhavan, B-Block, GPO Complex INA, New Delhi-110023), Fikru Tulu (Team Leader for Noncommunicable Diseases, Health Promotion and Social Determinants of health, WHO Country Office for India), G Dewan (DHS, Chandigarh UT), G.K Rath (Professor and Former Head, Department of Radio-oncology, Chief, Dr. B.R.A Institute-Rotary Cancer Hospital, AIIMS, New Delhi), Gaurav Sethi (State Program Coordinator, MAMTA-HIMC(Earlier) State Team Lead Health and Health Systems H.P., MAMTA-HIMC, New Delhi), GB Singh (Ex-SPO, Punjab), Gopal Chauhan (SPO, NCD, NHM, Himachal Pradesh), Gurpreet Singh (Professor, Department of General Surgery, PGIMER, Chandigarh), Gurpreet Wander (Professor and Head of Cardiology, Representing the Association of Physicians of India(API), DMCH, Ludhiana), Gursimer Jeet (Senior Demonstrator (Health Economics), Department of Community Medicine and School of Public health, PGIMER, Chandigarh), Dr. Guru Aithal (Head of Division, Faculty of Medicine & Health Sciences, University of Nottingham, UK), Gururaj (Senior Professor, Department of Epidemiology, WHO Collaborating Centre for Injury Prevention and Safety promotion, Centre for Public Health, National Institute of Mental Health & Neuro Sciences, Bangalore), Hema Gogia (Senior medical officer & deputy director NCD, NCDC, Delhi), Inderpaul Singh Sehgal (Assistant Professor, Department of Pulmonary Medicine, PGIMER, Chandigarh), J. Pandian (Professor and Head, Department of Neurology, CMC Ludhiana), Jagdish Kaur (Regional Adviser, Tobacco Free Initiative, WHO-SEARO),Jaya Prasad Tripathy (Senior Operational Research Fellow, International Union Against Tuberculosis and Lung Disease, The Union South East Asia Office, New Delhi), K L Gupta (Professor and Head, Department of Nephrology, PGIMER, Chandigarh), K T Prasad (Department of Pulmonary Medicine, PGIMER, Chandigarh), Kaushal Madan (Department of Gastroenterology, Hepatology and Liver Transplant, Max Hospital, New Delhi, India), Kavita Gauri (Lecturer, NINE, PGIMER), KK Talwar (Director, Cardiology Max Superspeciality Hospital, Saket, New Delhi), Former Director, PGIMER, Chandigarh, New Delhi), KL Goh (Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia), Mahesh Kate (Department of Neurology, CMC Ludhiana), Mamun Al Mehtab (Associate Professor, Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh), Manish Bansal, Manish Rathi (Additional Professor, Department of Nephrology, PGIMER, Chandigarh), Manju Behl (State Programme Officer NPCDCS, UT, Chandigarh), Manju Rani (Regional Adviser, NCD Surveillance, SEARO WHO) Manoj Chadha (Consultant, Department of Endocrinology, Representing Endocrine Society of India(ESI)(President), P. D. Hinduja Hospital, Mumbai, Maharashtra, India), Manoj Jhalani (Addl. Secy. & MD(NHM) (At the time) but Special Secretary & MD (NHM) now, NHM, New Delhi), Meenakshi Sharma (Scientist-F, ICMR, New Delhi), Meenu Singh (Professor, Department of Pediatrics, PGIMER, Chandigarh), Monika Arora (Director-Health Promotion Division, PHFI & Executive Director, HRIDAY PHFI, New Delhi), N Khandelwal (Ex- Professor & Head, Department of Radiodiagnosis, PGIMER, Chandigarh, India),Naga P. Chalasani (Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, USA), Nalini Gupta (Professor, Department of Cytology & Gynaecological Pathology, PGIMER, Chandigarh), Narayan Prasad (Professor, Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India) Nilambuj Sharan (Joint Secretary (NCD), MOHFW, GOI), Neelam Dahiya (Assistant Professor, Department of Cardiology, PGIMER, Chandigarh, Nikhil Tandon (Professor and Head, Department of Endrocrinology, AIIMS, New Delhi), P.C. Negi (Professor, Department of Cardiology, IGMC, Shimla), Padma V. (Professor Department of Neurology, AIIMS, New Delhi), Palo (Regional Director, SE Asia/Country Director-India, Project HOPE, New Delhi, India), Paramjit Gill (Professor, WMS - Social Science and Systems in Health University of Warwick, Coventry, UK), Parsun Jalal (Assistant Professor, Medicine-Gastroenterology & Hepatology Division, Department of Medicine, St. Luke's Medical Center, Baylor College of Medicine, Houston, TX, USA), Paul McDonald (Dean, Faculty of Health at York University, North York, Ontario, Canada), Paul Oh (Medical Director, Cardiac Rehabilitation and Secondary Prevention Program, UHN, Toronto Rehabilitation Institute, Toronto, Ontario, Canada), Poonam Khattar (Professor, Dept. of Education & Training, NIHFW, New Delhi), Prashant Mathur (Director, National Center for Disease Informatics and Researc, Indian Council of Medical Research, Bengaluru), Pratap Sharan (Department of Psychiatry, AIIMS, New Delhi), Preet K Dhillon (Epidemiologist and Senior Scientific Officer, Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, Haryan, PHFI, New Delhi), Puneeta Tandon (Associate Professor, Department of Medicine, Division of Gastroenterology, University of Alberta, Alberta, Canada), Radha Krishan Dhiman (Ex-Professor and Head, Department of Hepatology, Director, SGPGIMS), Rajani Ved (Executive Director, NHSRC, New Delhi), Rajeev Chawala (North Delhi Diabetes Centre, New Delhi, India, Representing Research Society for the Study of Diabetes in India (RSSDI), New Delhi), Rajendra A Badwe (Director, Tata Memorial Center, Mumbai), Rajendra Pratap Gupta, Rajesh Dikshit (Professor, Centre for Epidemiology, Tata Memorial Center, Mumbai), Rajesh Sagar (Department of Psychiatry, AIIMS, New Delhi), Rajesh Vijayvergia (Professor, Department of Cardiology, PGIMER, Chandigarh), Rajiv Jalan (Professor of Hepatology, Institute for Liver and Digestive Health, Division of Medicine, Faculty of Medical Sciences, University College London, United Kingdom), Rajiv Saran (Professor of Medicine and Epidemiology, Florence E. Bingham Research Professor of Nephrology, Department of Internal Medicine, Michigan Medicine, Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, United States), Rajni Nijhawan (Toronto Rehabilitation Centre, Canada, Toronto), Rana J Singh (Deputy Regional Director, The Union South-East Asia (The Union) International Union against Tuberculosis and Lung Disease, New Delhi, India), Randeep Guleria (Director, AIIMS, New Delhi), Ravneet Kaur (Associate Prof. , Center of Community Medicine, AIIMS, New Delhi), Rekha Singh (SPO, NPCDCS, NHM, Haryana), Renu Madan (Assistant Professor, Department of Radiotherapy and Oncology, PGIMER, Chandigarh), Rino A Gani (Head of Hepatobiliary, Division Hepatobiliary, Division Department of Internal Medicine, Faculty of Medicine, University of Indonesia), Ritambra Nada ( Professor, Department of Histopathology, PGIMER, Chandigarh), Ritesh Agarwal (Department of Pulmonary Medicine, PGIMER, Chandigarh), Rohit Bhatia (Professor Department of Neurology, AIIMS, New Delhi), Rohit Loomba (Division of Gastroenterology, Department of Medicine, University of California at San Diego, San Diego, USA), RS Dhaliwal (SCIENTIST 'G' & HEAD, Non Communicable Diseases (NCD), Division, ICMR, New Delhi), S.K. Aggarwal (Professor, New Delhi),SK Aggarwal (DGHS, Haryana), S.V Madhu (Director-Professor and Head, Department of Endocrinology, University College of Medical Sciences and GTB Hospital, New Delhi, India), Saeed Hamid (The Ibn-e-Sina Chair & Professor, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan), Sahajal Dhooria (Assistant Professor, Department of Pulmonary Medicine, PGIMER, Chandigarh), Samir Malhotra (Prof. & Head, Department of Pharmacology, PGIMER, Chandigarh), Samir Shah (Institute of Liver Diseases, HPB Surgery and Transplantation, Global Hospital – Superspeciality and Multiorgan Transplant Centre, 35, Dr. E. Borges Road, Hospital Avenue, Mumbai 400012, Maharashtra, India), Sandhya Ghai (Ex-Principal, NINE, Chandigarh), Sanghamitra Ghosh (Secretary General, IPHA, CMO (SG), Ministry of Defence, Chairperson TAC, WBSAPSACS, Life member IMA, Life member ISSRF, Life member of IEA, IPHA, India), Sanjay Aggarwal, Sanjay D'cruz (Professor, Department of Nephrology,GMCH-32, Chandigarh), Sanjay Wadhwa (Professor, Dept. of Physical Medicine & Rehabilitation, AIIMS, New Delhi), Sarat Chandra, Savita, Seng Gee Lim (Professor, Senior Consultant Scientist Division of Gastroenterology and Hepatology, Department of Medicine, National University Health, System, Singapore), Shalimar (Department of GastroEnterology, All India Institute of Medical Sciences, New Delhi, India), Shiv Kumar Sarin (Professor, Director, Institute of Liver and Biliary Sciences, Jawaharlal Nehru University, New Delhi), Shivaram Parsad Singh (Professor, Department of Gastroenterology, SCB Medical College, Cuttack, Dock Road, Manglabag, Cuttack, Odisha), Sitanshu Sekhar Kar (Additional Professor, Department of Community Medicine, JIPMER, Puducherry), Subhash Verma (Ex-Professor & Head of Internal Medicine & Hematology, PGIMER, Chandigarh), Subrat K Acharya (Prof. & Head, Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha), Sudhamshu KC (Department of Medicine, Liver Unit, Bir hospital, Kathmandu, Nepal), Sudhir Gupta (Addl. DDG, NCD, MoHFW, New Delhi), Surya Kant (Professor and Head, Department of Respiratory Medicine, Representing Indian Chest Society(ICS), KGMU, Lucknow), Tanvir Kaur (SCIENTIST-F, NON COMMUNICABLE DISEASES, ICMR, New Delhi), V. Mohan (Chief, Madras Diabetes Research Foundation, Chennai), Valliappan M (Assistant Professor, Department of Pulmonary Medicine, PGIMER, Chandigarh), Vanita Suri (Professor and Head, Department of Obstetrics and Gynaecology, PGIMER, Chandigarh), Varinder Garg (OSD to Health Minister, PGIMER, Chandigarh), Varun Roojam (Mission Director, NRHM),Vikas Suri (Additional Professor, Department of Internal Medicine, PGIMER, Chandigarh), Vincent Wai-Sun Wong (Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China, State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China), Vivek A Saraswat (Professor and Head, Department of Gastroenterology, SGPGI, Lucknow), Yogesh Chawla (Hepatologist/Liver Specialist, Ex Director PGIMER, Ex Prof. & Head, Department of Hepatology, PGIMER, Chandigarh, Currently, Chairman Academics, Department of Hepatology and Gastroenterology, Kalinga Institute of Medical Sciences, KIIT University, Bhubneshwar), Zobair Younossi (Professor and Chairman, Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia, USA)



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28], [Figure 29]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17], [Table 18], [Table 19], [Table 20], [Table 21], [Table 22], [Table 23], [Table 24], [Table 25], [Table 26], [Table 27], [Table 28], [Table 29], [Table 30], [Table 31], [Table 32], [Table 33], [Table 34], [Table 35], [Table 36], [Table 37], [Table 38], [Table 39], [Table 40], [Table 41], [Table 42], [Table 43], [Table 44], [Table 45], [Table 46], [Table 47], [Table 48], [Table 49], [Table 50], [Table 51], [Table 52], [Table 53], [Table 54], [Table 55], [Table 56], [Table 57]



 

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   World NCD Federa...
  Executive Summary
   Introduction and...
  Level of Evidence
   Guidelines for P...
   Prevention of No...
   Operational Defi...
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  Multisectoral Action
  Way Forward
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  Background
   Expectations fro...
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   Noncommunicable ...
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   Noncommunicable ...
  Recommendations
   Management of No...
  Cancer
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   Cardiovascular D...
   Cerebrovascular ...
  Hypertension
   Chronic Respirat...
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