This document provides guidelines for the management of dehydration and malaria in Kerala, India. It outlines plans A, B, and C for treating different levels of dehydration, from prevention and mild cases to severe cases requiring intravenous fluids. It also provides treatment protocols for different types of malaria, including charts for antimalarial medications dosage based on age, weight, and type of malaria (P. vivax, P. falciparum, or mixed). Guidelines are given for oral rehydration solution amounts, intravenous fluid replacement, and adjunct medications like zinc and primaquine.

2. 2

3. 3

4. 4

5. 5

6. DEHYDRADEHYDRADEHYDRADEHYDRADEHYDRATION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTS
(As per revised management
guidelines of GOl)
DEPARTMENT OF HEALTH AND FAMILY WELFARE
GOVERNMENT OF KERALA
ASSESSMENT OF SEVERITY OF DEHYDRATION
Two of the
following signs
Use
Two of the
following signs Use
• Lethargy or uncon-
scious
• Sunkeneyes
• Not able to drink or
drinkpoorly
• Skinpinchgoesback
veryslowly
SEVERE
DEHYDRATION
PLAN
C
• Restless,irritable
• Sunkeneyes
• Drinkseagerly,thirsty
• Skin pinch goes back
slowly
Not enough signs to clas-
sify as some or severe
dehyoration
SOME
DEHYDRATION
PLAN
B
NO
DEHYDRATION
PLAN
A
TREATMENT
PLANA: Prevention of dehydration / Prevention of ongoing losses to prevent dehydration
Show the mother how much ORS to give after each stool and give her enough packets for two days
ORS for prevention of dehydration
Age Amount of ORS to give
after each loose stool
Amount of ORS to provide for
use at home
Less than 24 months
2 years to 10 years
10 years or more
50- 100 ml
100- 200 ml
As much as wanted
500ml/day
1000ml/day
2000ml/day
ORS is appropriate for both prevention and treatment of dehydration
Show the mother how to give ORS Show the mother how to mix the ORS
• Give a teaspoonful every 1-2 minutes for a child under 2 years. • Give frequent sips from a cup for an older child.
•Ifthechildvomits,waitfor10minutes.Thengivethesolutionmoreslowly(aspoonfulevery2-3minutes).
• If diarrhoea continues after the ORS packets are used up, tell the mother to give other fluids or return for more
ORS. • The mother should be asked to continue feeding the child with diarrhoea
PLAN B: Patient with Physical signs of Dehydration
Guideline for deficit replacement/ rehydration therapy
75 ml /kg of ORS in the first 4 hours (patient’s age to be used only when the weight is not known)
shouldbestartedimmediately.
Approximatefluidestimatesfordeficitreplacementaregiveninpage7
6

7. DEHYDRADEHYDRADEHYDRADEHYDRADEHYDRATION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTS
(As per revised management
guidelines of GOl)
DEPARTMENT OF HEALTH AND FAMILY WELFARE
GOVERNMENT OF KERALA
Guideline for treating patient with some (but not severe) dehydration when body weight is not known
Approximate amount of ORS solution to be given in the first 4 hours*
Approxlocalmeasure(glass)
Age
Upto
4 mths
4 mths to
12mths
12 mths to
2 yrs
2 yrs to
5 yrs
5 yrs to
14 yrs
More than
14 yrs
Approx wt in kg
ORSinml
<6 6-10 10-12 12-19 20-30 >30
200-400
1-2
400-700 700-900 900-1400 1500-2200 2200-4000
2-3 3-4 4-6 6-11 12-20
• More ORS should be offered if the child wants it • 100-200 ml clean water should be given during this period for
infants upto 6 months who are not breast fed. •Breast feeding should be encouraged and continued whenever the
childwants•Ifthechildvomits,waitfor10minutes,thencontinue,butmoreslowly
Guidelinesformaintainingfluidtherapy
How much ORS to give for replacement of
ongoingstoollossestomaintainhydration
Age
After each liquid stool,
offer
Less than or equal to
6months Quarter glass (50 ml)
7 months to less than
2 years
Quartertohalfglass
(50-100ml)
2 years - 10 years Halftooneglass
(100-200ml)
Otherchildrenandadults As much as desired
Plan C: Children with severe dehydration should be
given rapid intravenous rehydration
IVfluids should be started immediately.While the drip is
beingsetup,ORSsolutionshouldbegivenifthechildcan
drink.
The best IVfluid solution is Ringer’s Lactate solution. If
Ringer’sLactateisnotavailable,normalsalinesolution(0.9%
NaCI) can be used. Dextrose on its own is not effective.
100mllkgofthechosensolutionshouldbe
dividedasfollows:
First give
30ml/kg in
Then give
70ml/kg in
<12months 1 hour * 5 hours
Older children ½ hour * 2 ½ hours
ZINC IN DIARRHOEA MANAGEMENT
Zn as an adjunct to ORTin
diarrhoeamanagementinchildren.
2 months to 6 months 10 mg/day x 14 days
Children6months
and above
20 mg/day x 14 days
Suspect CHOLERA in all cases of
severedehydrationinadults.
Send Stool samples for ‘Hanging Drop’ to
district lab and for vibrio to Medical College.
Repeat again if the radial pulse is still very weak
or not detectable
All children should be started on ORS solution (about 5
ml/kg/h)whentheycandrinkwithoutdifficultyduringthe
timetheyaregettingIVfluids(usuallywithin3-4hours
for infants or 1-2 hour for older children.)
If one is unable to give IV fluids, rehydration with ORS
using naso gastric tube at 20ml/kg/h should be started
immdiately.The child should be reasssessed every 1-2
hours;ifthereisrepeatedvomittingorabdominaldisten-
sion,thefluidsshouldbegivenmoreslowly.Ifthereisno
improvementinhydrationafter3hours,IVfluidsshould
be started as early as possible.
7

8. 8

9. MALARIA TREATMENT ALGORITHM
Suspected Malaria Case
Do Blood Smear Microscopy/
Blood test with Bivalent RDT
RDT / Microscopy
+ve for P. vivax
Treat with CQ 25mg/kg
body wight divided
over 3 days + PQ 0.25
mg/kg body weight
daily for 14 days
Note: PQ is contra indicated in pregnancy, in children under 1 year and individuals with G6PD Deficiency.
RDT / Microscopy
+ve for P falciparum
NortheEast-Treatwithage
specificACT-ALfor3days+
PQ0.75mg/kgbodyweight
singledozeonthesecondday
OtherStates-useACT-SP
insteadofACT-AL
(UseSPonday1only)
RDT/ Microscopy
+ve for Mixed Infection
North East- Treat with
age spacific ACT- AL for
3days + PQ 0.25 mg/
kg body weight daily for
14 days
Other States- Use ACT-
SP instead of ACT-AL
RDT Negative
However, if malaria is
suspected,cross check
microscopy.
If microscopy also
negative, no antimalaria
treatment. Treat as per
clinical diagnosis
DEPARTMENT OF
HEALTH AND FAMILY WELFARE
GOVERNMENT OF KERALA
Age Specific Dosage Chart for Malaria
Plasmodium vivax Malaria (Common for all States)
Age Day 1 Day2 Day3 Day 4-14
CQ PQ CQ PQ CQ PQ PQ
150mg
base*
2.5 mg 150mg
base*
2.5 mg 150mg
base*
2.5 mg 2.5 mg
Less than 1 yr
1-4 yrs
5-8 yrs
9-14 yrs
15 yrs & more
Pregnancy
0
1
2
4
6
0
½
1
2
3
4
4
½
1
2
3
4
4
0
1
2
4
6
0
¼
½
1
1½
2
2
0
1
2
4
6
0
0
1
2
4
6
0
9
* 250 mg chloroquine phosphate tab = 150 mg chloroquine base

10. Mixed (vivax & falciparum) Malaria (From North Eastern States)
Age Day 1 Day 2 Day 3
ACT - AL
(Artemether +
Lumefantrine)
(20mg + 120mg)
ACT - AL
(Artemether +
Lumefantrine)
(20mg + 120mg)
PQ *
(2.5mg)
(Extra to ACT-AL Kit))
ACT - AL
(Artemether +
Lumefantrine)
(20mg + 120mg)
PQ*
(2.5mg)
(Extra to ACT-AL Kit))
5m-2 Yrs (5-14kg)
(Yellow blister)
1 Tablet twice daily
(1 - 0 - 1)
1 Tablet twice daily
(1 - 0 - 1)
5m - < 1yr : 0
>1yr - < 2 yr : 1
1 Tablet
twice daily
(1 - 0 - 1)
5m - < 1yr : 0
>1yr - < 2 yr : 1
3-8 Yrs (15-24kg) 2 Tablet twice daily
(2 - 0 - 2)
2 Tablet twice daily
(2 - 0 - 2)
>2yr - < 5 yr : 1
>5yr -< 9 yr : 2
2 Tablet twice daily
(2 - 0 - 2)
>2yr - < 5 yr : 1
>5yr -< 9 yr : 2
9-14 Yrs
(25-35kg)
3 Tablet twice daily
(3 - 0 - 3)
3 Tablet twice daily
(3 - 0 - 3) 4 43 Tablet twice daily
(3 - 0 - 3)
15 yrs and more
(More than 35 kg)
4 Tablet twice daily
(4 - 0 - 4)
4 Tablet twice daily
(4 - 0 - 4) 6
4 Tablet twice daily
(4 - 0 - 4) 6
PQ* : O.25 mg per kg body weight daily for 14 days
ACT -AL : Not recommended during the 1st trimester of pregnancy and for children weighing < 5 kg
Mixed (vivax & falciparum) Malaria (from States other than NE)
Age Day 1 Day 2 Day 3
PQ* : O.25 mg per kg body weight daily for 14 days
PQ*
(2.5mg)
(Extra to ACT-SP Kit))
Day 4 to 15
AS SP AS AS
PQ*
(2.5mg)
(Extra to ACT-SP Kit))
PQ*
(2.5mg)
(Extra to ACT-SP Kit))
Less than 1 year
(Pink blister)
1
( 25mg)
1 (250+12.5mg)
1
( 25mg)
0
1
( 25mg)
0 0
1-4 yrs
(Yellow Blister)
1
(50mg)
1
(500+25mg)
1
(50mg) 1
1
(50mg) 1 1
5-8 yrs
(Green Blister)
1
(100 mg) 1 (750+37.5mg)
1
(100 mg)
2
1
(100 mg)
2 2
9-14 yrs
(Red Blister)
1
(150mg)
2
(500+25mg)
1
(150mg) 4
1
(150mg) 4 4
15 yrs and more
(White Blister)
1
(200mg)
2 (750+37.5mg)
or
3 (500+25mg)
1
(200mg)
6 1
(200mg)
6 6
Plasmodium falciparum Malaria (From North Eastern States)
Age Day 1 Day 2 Day 3
PQ* : 0.75mg per kg body weight on day 2
ACT - AL
(Artemether + Lumefantrine)
(20mg + 120mg)
ACT - AL
(Artemether + Lumefantrine)
(20mg + 120mg)
PQ*
(7.5mg)
(Extra to ACT-AL Kit))
ACT - AL
(Artemether + Lumefantrine)
(20mg + 120mg)
5m-2 Yrs (5-14kg)
(Yellow blister)
1 Tablet
twice daily
(1 - 0 - 1)
1 Tablet
twice daily
(1 - 0 - 1)
5m - < 1yr : 0
>1yr - < 2 yr : 1
1 Tablet
twice daily
(1 - 0 - 1)
3-8 Yrs (15-24kg)
2 Tablet twice daily
(2 - 0 - 2)
2 Tablet twice daily
(2 - 0 - 2)
2
2 Tablet twice daily
(2 - 0 - 2)
9-14 Yrs
(25-35kg)
3 Tablet twice daily
(3 - 0 - 3)
3 Tablet twice daily
(3 - 0 - 3)
4 3 Tablet twice daily
(3 - 0 - 3)
15 yrs and
more (More than
35 kg
4 Tablet twice daily
(4 - 0 - 4)
4 Tablet twice daily
(4 - 0 - 4) 6
4 Tablet twice daily
(4 - 0 - 4)
ACT -AL : Not recommended during the 1st trimester of pregnancy and for children weighing < 5 kg
Plasmodium falciparum Malaria (from States other than NE)
Age Day 1 Day 2 Day 3
AS SP AS
PQ*
(7.5mg)
(Extra to ACT-SP Kit)
Less than 1 year
(Pink blister)
1
( 25mg)
1 (250+12.5mg)
1
(25mg)
0
AS
1
( 25mg)
1-4 yrs
(Yellow Blister)
1
( 50mg)
1 (500+25mg)
1
(50mg)
1
1
( 50mg)
5-8 yrs
(Green Blister)
1
( 100mg)
1 (750+37.5mg)
1
(100mg)
4
1
( 100mg)
9-14 yrs
(Red Blister)
1
( 150mg)
2 (500+25mg)
1
(150mg)
2
1
( 150mg)
15 yrs and more
(White Blister)
1
( 200mg)
2 (750+37.5mg)
or
3 (500+25mg)
1
(200mg)
6
1
( 200mg)
PQ* : 0.75mg per kg body weight on day 2
10
PQ*
(2.5mg)
(Extra to ACT-AL Kit))
5m - < 1yr : 0
>1yr - < 2 yr : 1
>2yr - < 5 yr : 1
>5yr -< 9 yr : 2
4
6
Day 4-15

11. VIRALHEPATITIS- MANAGEMENTGUIDELINE
Case Definition
PatientwithSuddenonsetoffever
withmlaise,anorexia,vomiting,ab-
dominaldiscomfortfollowingjaun-
dicewithinfewdaysoccurrenceof
similar cases from a locality in-
creasesthesuspisionoffecoorally
transmitted infection. History of
high risk sexual behaviour or con-
tact with blood or blood products
indicatesparentallytranslittedinfec-
tion
Patientwithhistoryofsymptomsofthesus-
pectedcase,alongwiththelaboratoryfind-
ingssuggestiveofalteredliverfunction:
a) altered serum bilirubin: Normal
level<1mg/dl
jaundiceusuallybecomesaparantatlev-
elsover>2mg/dl
b) Elevatedaminotransferace:
i) Aspartate amino transferace (AST)-
Normal level for adults 10-35 U/Lit
ii) Alanine amino transferace (ALT) nor-
mallevelforadults-10-45U/lit
Probable caseSupect Case Confirmed case
Apatientwithhystory,symp-
toms,andlaboratoryfindings
of the suspected case along
with serologic evidence
against specific hepatitis vi-
ruses or detection of viral
particiles.
Specific Diagnosis
Types of Healtitis Specific tests for confirmatory case
HepatisA IgM(Anti-HAV)
HepatisB
specificAntigen HBsAg(surfaceAntigen),HBcAg(CoreAntigen),HBeAg
specificAntibody IgM(Anti-HBc)
Hepatis C Anti- HCV/ HCV RNA in serum
HepatisD Anti-HDV/HDVRNAinserum
HepatisE Anti-HEV/HEVRNAinserum
Level clinical Features Investigations Management Referral criteria
Primary care facility-
PHC/ CHC/ single
doctor/ few doctor
clinic
Spcialty Hospitals-
THQH/FRU/ Major
Hospitals
Tertiary Care
centres- MCH/Major
private Hospitals
Sudden onset of fever with
mlaise, anorexia, vomiting,
abdominal discomfor t
following jaundice within
few days
Signs of hepatic
encephalopathy, deep
jaundice, intractable
vomiting posing risk of
dehydration
In advanced stage of illness,
or with complications;
hepatitis already confirmed;
BRE,Serum
Bilirubin,LFT
Serum
Bilirubin,LFT,
HBsAg
LFT, Specific
diagnosis (See
Table 2), Liver
biopsy
Bed rest till jaundice is completely resolved;
most drugs are to be avoided during acute
hepatitis but antipyretics and anti emitics
may be used till patient is symptomatic
with: paracetamol 10-15mg/kg for children
and 0.5-1g X three time a day,
metachlopromide, 0.2 mg/kg for children,
10mg for adults 3-4 times per day
Essentially supportive; IV Fluids,
Constant close monitoring of liver function
parameters; ICU care with absolute bed rest,
low protein diet, enemas to cleanse bowel,
oralneomycin,allsedativescontraindicated,watch
for GI bleeding, monitor level of coma
Signs of hepatic
encephalopathy,
deep jaundice,
pregnancy in third
trimester, intractable
vomiting posing risk
of dehydration
In case of no sign of
improvement in 2-3
days
11

12. Cardinalssigns
1. Anesthetic Patch,
2. Thickened Peripheral Nerve,
3. Smear Positive
Diagnostic Criteria
Symptoms Paucibacillary (PB) Multi Bacillary (MB)
Anesthetic Patch 1 - 5 numbers Above 5 numbers
Thickness and Tenderness No or only one nerve involved More than one nerve involved
Smear Examination Negative in all patches Positive in anyone or more patch/ nerve
* Positive for any one of the three criteria for MB will be treated as MB
Treatment Protocol
Age
Paucibacillary(PB)
(duration-6months)
Multi Bacillary (MB)
(duration12months)
Rifampicin Dapsone Rifampicin Dapsone Clofazimine
more than14 years
10-14 years
Less than 10 years
600mg 100mg 600mg 100mg 300mg - once in a month
50mgdaily
450mg 50mg 450mg 50mg
150mg - once in a month
50mgalternatedays
300mg 25mg 300mg 25mg
100mg - once in a month
50mg twice a week
DEPARTMENT OF
HEALTH AND FAMILY WELFARE
GOVERNMENT OF KERALA
LEPROSY-TREATMENT
GUIDELINE
12

13. TUBERCULOSIS (RNTCP) TREATMENT REGIMEN
Cat I: This category is generally prescribed to new sputum smear positive cases.
Cat II: This category is generally prescribed to patients who have previous anti tubercular
treatment.
Paediatric TB: This category is for treating children who are infected with mycobacterium
tuberculosis.
Cat IV/MDR TB: This category is for treating patients who are infected with specific form of
drug resistant mycobacterium tuberculosis.
Category of treatment Type of Patient Regimen
Category I
New sputum smear-positive sputum
smear-negativeextra-pulmonary
2(HRZE)3+
4(HR)3
Category II
Sputum smear-positive relapse
Sputumsmear-positivefailureSputum
smear-positivetreat-mentafterdefault
others. EP.Pul –neg.
2(HRZES)3+
1(HRZE)3
5(HRE)3
Medication Dose(thrice a week) Number of pills in combipack
Isoniazid 600 mg (300x2)
Rifampicin 450 mg (450x1)
Pyrazinamide 1500 mg (750x2)
Ethambutol 1200 mg (600x2)
Streptomycin 0.75 g
Treatment Regimens
Information of the dosage is shown on the chart given bellow.
13

14. In Paediatric case the regimen is same but dosage is adjusted according to the weight of patient.
Pediatric regimen
Suggested paediatric dosage for intermittent therapy
Drugs Dosage(Thrice a week)
Isoniazid 10-15 mg/kg
Rifampicin 10mg/kg
Pyrazinamide 30-35 mg/kg
Ethambutol 30mg/kg
Streptomycin 15mg/kg
Regimen for MDR –TB
Thisregimecomprisesof6drugs-Kanamycin,Levofloxacin,Ethionamide,Pyrazinamide,EthambutolandCycloserine
during6-9monthsofintensivephaseand4drugsLevoflox,Ethionamide,Ethambutolandcycloserineduringthe18
monthsofthe continuationphase.PyridoxinshouldbeadministeredtoallpatientsonregimeforMDRTB.
Regimen for MDR TB drugs and band recommendations
SL No Drugs 16-25 Kgs 26-45 Kgs >45 Kgs
1 Kanamycin 500 mg 500 mg 750 mg
2 Levofloxacin 250 mg 750 mg 1000 mg
3 Ethionamide 375 mg 500 mg 750 mg
4 Ethamvuton 400 mg 800 mg 1200 mg
5 Pyrazinamide 500 mg 1250 mg 1500 mg
6 Cycloserane 250 mg 500 mg 750 mg
7 Pyridoxine 50 mg 100 mg 100 mg
Na-PAS(80% weight/
volume)2 5 gm 10 gm 10 gm
Moxifloxacin 400mg 400mg 400mg
Capreomycin 500mg 750mg 1000mg
Drug Daily Dosage-mg/kg body wt
kanamycin 15-30
Levofloxacin 7.5-10
Ethionamide 15-20
Cycloserane 15-20
Ethamvuton 25
Pyrazinamide 30-40
Na-PAS 150
Drug regimen for MDR Paediatric age group less than 16 kg
For more details and latest updates please visit the web sitewww.tbcindia.nic.in
14

15. TREATMENT PROTOCOLFOR DIABETES MELLITUS
• Assess habits - Tobacco use,Alcohol use, Diet and Exercise
• Checkheight,weightandcalculateBMI
• Check BP and RBS
If RBS < 200 mg%
Reassess when develops diabetic
symptoms or every 2 years
If RBS > 200 mg% check FBS and PPBS
If FBS < 126 mg% and PPBS <
200 mg%Advise LSM
If FBS> 126 mg% and or
PPBS > 200 mg%
Advise LSM and refer to MO
If BMI < 23 & no high
risk behaviour reassess
every6months
If BMI >23 or have high
risk behaviour reassess
every3months
Tab Metformin 500 mg OD or BID
Reassessmonthlyandmayincreaseup
to 2000 mg per day in 2 divided doses
Monitorabnormalvaluemonthly
Ifnocomplicationrecheckafteronemonth Ifcomplications
1. Foot ulcer
2. Nephropathy
3.Retinopathy
4. Neuropathy
5. Sepsis
Ifunder
control
continueand
reassess every
3months
If not under control add
one second drug
1. Glibenclamide 2.5 mg to 10 mg
2. Glypizide 2.5 mg to 5 mg BID
3. Glimepride 1 mg to 4 mg RefertoPhysician
If not under control refer to
Hospital/PhysiciantostartInsulin
Ifundercontrolcontinue
and reassess 3 months
State NCD Division
Government of Kerala
LSM
Life Style Modification
• Restrict sugar and sweets
• Restrict fatty and fried
foods
• Increase fibre rich food
(leafy vegetables)
• Substitute as much starch
(rice, wheat, tubers) with
vegetables
• Brisk walking for 20 - 30
min
• 5 to 6 days a week
• 5 minutes warm up
• 5 minutes cool down
• Avoid tobacco &
alcohol use
BMI
18.5-22.9: Normal
23.0-24.9: Overweight
>25.0: Obese
Screen all individuals of age above 30 years
15

16. 16