TRAINING PRESENTATION FOR MOs /GNMs / ANMs / CHOs

1. DR.RAVINDRA MOHAN
M.D. (OBS & GYNAE)
N.C.D.O. SAHARSA ,
BIHAR
NATIONAL PROGRAMME FOR PREVENTION
AND CONTROL OF
CANCER , DIABETES , CARDIOVASCULAR
DISEASE AND STROKE
( NPCDCS)

2. WHY A NATIONAL PROGRAMME . ?
India is facing a rapid health transition with rising
burden of NCDs. Which are emerging as leading cause of deaths –
over 42% of all deaths .. That too in potentially productive years
(Age 35-64 yrs).
Overall prevalence in India :-
Diabetes mellitus – 62.47 / 1000 population
Hypertension -- 159.46 / 1000 population
Ischemic heart disease – 37 / 1000 population
Strokes - 1.54 / 1000 population
Keeping these in view :-
NPCDCS initiated in year 2010 .
Implemented in 100 backward and inaccessible districts
across 21 states during 2010-12.

3. NCDs
 Non Communicable diseases NCDs – are chronic
degenerative diseases.
 They develop slowly over years and often do not
have symptoms.
 They cause premature death or damage to various
organs of body.
 Once developed , usually not curable .
 Healthy lifestyle and regular medications – NCDs
can be controlled to prevent premature deaths or
damage to organs.

4. CONTD…….
 During year 2005
NCD accounted for 53% of all deaths in age group 30-
59 yrs.
Of these 29% were due to CVD.
1 out of 4 Indians carry risk of dying prematurely due
to NCDs.
In year 2000 –
118 millions having high BP….expected to go
up to 213 million in 2025.
Govt. of India in 2010-11 ….NPDCS
in 2011-12 merged cancer control program
NPCDCS.

6. OBJECTIVES
 Prevent and control common NCDs through behavior
and life style changes .
 Provide early diagnosis and treatment of common
NCDs.
 Build capacity at various levels of Health care for
prevention , diagnosis and treatment of common
NCDs.
 Train human resource :- doctors, paramedics and
nursing staffs to cope with increasing burden of
NCDs.
 Support for development of database of NCDs
 Establish and develop capacity for palliative
and rehabilitative care .

7. STRATEGIES :-
 Health promotion , awareness generation
and promotion of healthy lifestyle .
 Early diagnosis through Screening .
 Timely , affordable and accurate diagnosis .
 Access to affordable treatment .
 Rehabilitation .
 Supervision , monitoring and evaluation .

8. Our Goals ……
 To prevent CHD,CeVD ,and PVD events and
Cancer :-
- Quit Tobacco use or reduce amount smoked .
- Healthy food choices.
- Be physically active .
- Reduce body mass index ; Waist hip ratio
- Lower Blood Pressure .
- Lower Blood cholesterol and LDL- Cholesterol
- Control Hyperglycemia .
- Take anti platelet therapy when necessary .

9. RISK FACTORS …..
Behavioral RF Physiological RF Disease Outcome
Unhealthy Diet BMI ( Obesity ) Diabetes
Physical Inactivity Hypertension Heart Disease
Tobacco Hyper-
Cholesterolemia
Stroke
Alcohol High Blood sugar
Level
Cancer
Stress Chronic Respiratory
disease
Primary Prevention
Health Promotion
Secondary Prevention
Case Management
Tertiary Prevention
Case Management

11. Screening at PHC/CHC/SDH/SH

12. Role and Responsibility of
ASHAs/ANMs/GNMs/CHOs
 Family folder and CBAC forms are the most important and basic
part in NPCDCS program.
 ASHA worker -must fill up Family Folder and than CBAC forms
of all adults > 30 years of age .
 All >30 years must be screened for NCDs at HSCs/HWCs /or in
camp mode by ANM/GNM/CHO.
 All screened Positive must be referred to PHC/CHC for
confirmation of NCDs and proper treatment .
 CBAC- Community Based Assessment Checklist

13. All adults > 30 years at
community level
CBAC Assessment by ASHA/ ANM/CHO
Screening for NCDs
Hypertension, DM
Screening for Cancer -
Oral, Uterine Cervix, breast
CBAC Score < 4
CBAC Score >= 4
Refer to SC for Screening
Screened
Positive
Screened
Negative
Refer to PHC for
investigation
& treatment
Follow up - Lifestyle modification, compliance to
treatment
Referral to higher centre in case of complication
• Healthy lifestyle Promotion
• Annual Screening
On priority
Any symptom Positive
Refer to PHC for further
investigation and
treatment
• Follow up diagnosed
patient in the
community for
treatment adherence
and
side effect of treatment
• Referral in case of any
complication to higher
centre
Screened
negative
As per govt. directives medicines for 1 month may be given to
patients with NCDs

14. 14

15. 15

16. CBAC General
Information

17. Part A Risk Assessment

18. Part B: Early Detection; Ask if Patient has any of these
Symptoms

19. Part B: Early Detection; Ask if Patient has any of these
Symptoms

20. Fuel used for cooking & Occupational
Exposure and Mental Health

21. Risk Assessment at
HWC/HWC/PHC/CHC
 To estimate Cardiovascular risk –
Informations required are …
- Presence or absence of Diabetes.
- Gender
- Smoker or Non- smoker
- Age
- Systolic blood pressure
- Total blood cholesterol

22. Risk Assessment (Contd.)
 RISK of CVD may be higher – in presence of :
- Already on antihypertensive therapy.
- Premature menopause .
- Obesity.
-Sedentary lifestyle.
- Family history of CHD
- Raised Triglyceride level (>150 mg/dl)
- Low HDL cholesterol level <40mg/dl
males/<50mg/dl in females
- Micro albuminuria
- Socioeconomic deprivation.

23. HEALTH PROMOTION
 Behavioral Changes focussing on the following :-
 Increased intake of healthy foods ;
 Salt reduction
 Increased physical activity
 Avoidance of tobacco and alcohol
 Reduction of Obesity
 Stress management
 Awareness about warning signs of Cancer etc.
 Regular health check-up
Facilitate IEC activities as educationl materials .

25.  Body needs Insulin to convert sugar, starches
and other foods into energy.
 Impairment of Insulin secretion and action in
body
 Abnormally elevated levels of glucose in blood
 Classically termed as Diabetes .
 DIABETES – a disease in which body does not
produce or properly use hormone INSULIN ..

26. TYPES OF DIABETES
 Type 1 … usually occurs in young people ,
children and adolescents . Onset usually acute
and severe .Insulin required for survival from
autoimmune destruction of beta cells in
Pancreatic islets .Family history rare .
 Type 2 …..commonest type . Usually occurs after
age of forty years . Onset usually insidious and
may be mild to severe .Family history usually
positive . No evidence of autoimmunity . No
insulin dependence till LATE in course of
illness .

27. Who are at RISK ..?
 Age above 30 years .
 Overweight , BMI >23kg/m2
 Physical inactivity , exercises less than 3 times a
week .
 High blood pressure .
 Impaired fasting glucose or impaired glucose
tolerance.
 Higher Triglycerides and/or cholesterol level .
 Family history .
 During pregnancy – if she had diabetes
 If she delivered a baby – birth weight >4 kg

28. When to Suspect …?
 Symptoms of uncontrolled Hyperglycemia (
excess thirst, excess urination, excess hunger
with weight loss )
 Frequent infections.
 Unexplained lethargy
 Fatigue
 Impotence in men

29. Criteria for T2DM
Fasting glusose
( mg/dl )
2 hour Post
glucose load
(mg/dl )
Diabetes mellitus >= 126 > = 200
Impaired glucose
Tolerance
< 110 > 140 to < 200
Impaired Fasting
Glucose
>= 110 to < 126
WHO definition 1999

32.  Abnormally elevated Blood Pressure – a Pathological
condition – increases work load on Heart .
 Termed high blood pressure or Hypertension
 TYPES :-
Primary / Essential - No known cause . Constitutes
majority of High B.P. in the world
Secondary - Caused by some other medical
conditions/problem or the use of certain edications ..such as
reno-vascular disease ,chronic renal disease , Endocrinal
disorders ,Hyperthyroidism , Cushing’s syndrome ,sleep
disorders , coarctation of aorta etc.

33. Criteria for diagnosing High B.P.
Caterory Systolic - mmHg Diastolic -mmHg
Normal Less than 120 Less than 80
Pre- Hypertension 120- 139 80-89
High Blood Pressure
Stage 1 140-159 90-99
Stage 2 160 or higher 100 or higher

34. Risk Assessment
 Risk factors :-
- lack of physical activity
- Obesity
- High salt intake
- Excess alcohol consumptions .
-Family History
-Frequent intake of pain relieving drugs
-Steroids intake for Asthma
-Swelling on feet
-Urinary difficulties H/O passing stones

35. Laboratory Tests
Essential –
- Blood sugar ,
- urine analysis for proteinuria
Desirable –
- Haemogram ,
-serum creatinine ,
-Lipid profile ,
-serum sodium & potassium levels
-compete urine analysis
-ECG

36. Treatment Goals
 Initial aim- to obtain B.P. less than 130/85 mm of Hg .
 Ideally aim should be to get B.P. levels of less than
120/80 without bothersome side effects .
 Life style advice if no co-existing risk factors .
 Prevent and control Risk factors .
 Maintain healthy blood pressure throughout person’s
lives
 Prevent and control risk factors
 Blood pressure more than 160/100 mmHg ….
Treatment should be started or more than 140/90
mmHg in Diabetics or end organ damage (such as
protinuria , high blood urea,ECG evidences )

37. Prevention and management of
Dyslipidemia
 Dyslipidemia - elevation of Plasma Cholesterol ,
Triglycerides or both or Low HDL level ..that
contributes to development of Atherosclerosis .
 Cholesterol exists largely as LDS-cholesterol ,
VLDL- cholesterol ,HDL cholesterol and
triglycerides .
 Low HDL cholesterol is an important Risk factor for
CHD , while High HDL cholesterol has a protective
effect and is considered a Negative Risk factor .
 No indigenous Indian prospective data - on risks of
High blood cholesterol on CHD .
 All patients with established CVD or Diabetes should
undergo Lipid Profile .

38. LDL Cholesterol Serum level (mg/dl)
Optimal <100
Near Optimal 100-129
Borderline High 130-159
High 160-189
Very High >190
Serum Triglycerides
Normal <150
Borderline High 150-199
High 200-499
Very High >500
Serum HDL Cholesterol
Low <40
High >60

39. Management of High Blood Cholesterol
 BASED ON ----
 Whether patient has established Cardiovascular
Diseases like previous Heart
Attack/Stroke/Angina/Peripheral Vascular Disease .
 Is Diabetic or Not .
 What other CVD risk factors present –
Hypertension/smoking/Age/Obesity
 Blood sugar/total cholesterol/HDL/LDL cholesterol
levels
 At PHC/CHC level – All patients with established CVD
or Diabetes – counseled on Non pharmacology
treatment and also initiated on STATINS (
Atrovastin/Simvastin)

40. Coronary Artery Disease
 CAD – a condition in which there is an inadequate
supply of blood and oxygen to a portion of
myocardium.

41. Pathogenesis of CAD

42. CAD ……..

43. CAD …..
 Chest Pain – commonest symptom
 Typical Angina- Substernal pressure radiating to
neck, jaw, arm with durtion <20-30 minutes –
associated with dyspnea,diaphoresis,palpitation
,nausea-vomiting – increases with exertion ,
decreases with rest .
 MI – Increased Angina intensity and duration >30
minutes . 25% MIs are clinically silent .

44. Management at Various Level
Level 1
PHC
Level 2
CHC /SDH
Level 3
District hospital
Level 4
Medical Colleges
Diagnose and Refer
as soon as possible
Details history
Investigations-
ECG
Blood Sugar
Serum Creatinine
Cholesterol
Chest X-ray
Treatment –
Nitroglycerin
Oral Nitrates
Beta blockers
Aspirin
Statins and ACE
inhibitors
Reduce Cholesterol
<200mg/dl
Reduce LDL <100mg/dl
REFER if not controlled
Management same
as level 2 for New
patient
Echocardiography
for LV function
Management same
as level 2 for new
patient
Angiography and
Revascularization if
facilities available
for refractory cases

45. Prevention and Management of STROKE
 STROKE - If an artery in the brain becomes blocked
by a thrombus – it causes Stroke .
 TIA – Transient Ischemic attack – a temporary lack
of blood supply to a part of Brain .
 Prevention - Stroke can be prevented by
controlling high blood pressure , avoiding tobacco
use and leading a healthy lifestyle .

46. STROKE
 Identification of an acute Event –
- sudden onset of weakness of one half of body or
part of body .
- sudden onset of inability or difficulty in speech.
-sudden onset of imbalance
- sudden onset of blindness
- sudden onset of dizziness or spinning
- sudden severe headache
- seizures
- sudden loss of consciousness .

47. STROKE – Management
 If available – CT scan in all cases
 Secure the airway by keeping head to a side
 If breathing is compromised – assiste ventilation
 Securing a good IV line – infusing 5% dextrose
 Manage elevated blood pressure – systolic around 140
mmHg and diastolic between80-90mmHg.
 Avoid Mannitol/Glycerol unless evidence of raised intra-
cranial-pressure with signs of decerebration.
 Supportive care to prevent deep vein Thrombosis by
prophylaxis with 5000 units Heparin
 Acute rehabilitation – proper positioning , passive
movements of limbs, bowel/bladder care .

49. .
CANCER IS
CURABLE IF
DETECTED EARLY.

50. Primary Prevention
Tobacco control
Health education related to sexual reproductive
factors
Avoiding alcohol use
Healthy diet
Physical activity and avoidance of Obesity

51. TOBACCO
 Of all cancers in India – 34% are due to tobacco .
 Tobacco smoke contains 4000 chemicals of which at
least 438 can cause cancer .
 Tobacco chewing – most important risk factor for
Oral Cancer .
 Tobacco smoking causes cancer of lung , larynx, and
oesophagus.
 Passive smoking – increased risk of Cancers among
non-smokers.

52. ALCOHOL
 Increased alcohol consumption – associated with
Cancers of mouth .
 Co-existence of tobacco habits – multiplicative effect

53. SEXUAL AND REPRODUCTIVE FACTORS
 Associated with Cancers of Uterine cervix and Breast
 Like – young age at first sexual activity , multiple sexual
partners and poor sexual hygiene – associated with
cancer cervix .
 Late marriage , nulliparity , and late menopause – linked
with Breast cancer - but underlying mechanism probably
uninterrupted exposure to Oestrogen for prolonged
periods .
 Education regarding sexual hygiene and sexual
behaviour . Preventing infection with HPV.
 Early detection of Breast cancer – main strategy (as not
preventable)

54. OTHER FACTORS ……..
 DIETS - rich in animal fats , especially red meat
increase the risk . Diets high in fresh vegetables and
fruits and fibres Reduce the Risk .
 OCCUPATION - workers engaged in manufacture
of rubber tyres , textile workers . Wood workers
,chemical and pharmaceuical plants .

55. EARLY DETECTION
 Early detection only part of wider strategy .
 Warning signals of Cancer – ( CAUTION )
Change in bowel or bladder habits
A wound that does not Heal
Unusual bleeding or discharge
Thickening or lump in breast or elsewhere
Indigestion or difficulty in swallowing .
Obvious change in a wart or mole
Nagging cough or hoarseness of voice

56. ORAL CANCER SCREENING
 Cancer occurring in any part of oral cavity is called Oral Cancer .
 Oral cancer is sixth deadliest cancer in the world .
 Risk factors :- Common-
Chemical irritants ( tobacco , alcohol)
Physical irritants ( prolonged Denture irritation, irregular
teeth)
Signs & symptoms :-
A sore in mouth that doesn’t heal ,
Persistent mouth pain
A lump or thickening in the cheek
A white or red patch on gums ,tongue, tonsil ,or lining of mouth
Difficulty in swallowing or chewing
Difficulty in moving the jaw or tongue

57. ORAL CANCER

59. BREAST CANCER SCREENING
 BREAST awareness and Breast self examination –
essential for every women – be aware of the size , shape
and consistency of her breasts .
 Every women should be aware of following signs :-
 A change of size
 A nipple – pulled in or changed in position or shape
 A rash on or around the nipple
 Discharge from one or both nipples
 Puckering or dimpling of skin
 Lump or thickening in the Breast
 Constant pain in the breast or armpit

60. How to do a breast self-exam:
Step 1: Begin by looking at your breasts in the mirror with your
shoulders straight and your arms on your hips.
Step 2: Now, raise your arms and look for the same changes.
Step 3: While you're at the mirror, look for any signs of fluid
coming out of one or both nipples (this could be a watery,
milky, or yellow fluid or blood).
Step 4: Next, feel your breasts while lying down, using your
right hand to feel your left breast and then your left hand to
feel your right breast. Use a firm, smooth touch with the first
few finger pads of your hand, keeping the fingers flat and
together. Use a circular motion, about the size of a quarter.
Step 5: Finally, feel your breasts while you are standing or
sitting.

62. Uterine Cervix Screening
 Cervical cancer – third most common cancer among
women in the world .
 Human papilloma virus infection – a sexually
transmitted infection , is primary cause .
 Symptoms :-
 post-menopausal bleeding ,
 post-coital bleeding ,
 inter menstrual bleeding ,
 blood stained discharge per vaginum ,
 excessive seropurulent discharge ,
 backache ,
 lower abdominal pain .

64. Uterine Cervix screening
 AT PHC / CHC /SDH / DH- LEVEL
 Visual inspection using 4% Acetic acid (VIA)
( acetic acid causes dehydration of cells ,reducing transparency of
epithelium , identify squamo-columnar junction - if no white
patch in ectocervix – test is NEGATIVE ) Identify- High/Low
Risk.
 Visual inspection using Lugol’s iodine (VILI)
 At SDH / DH LEVEL - Above screening plus --
 Pap test . If result is normal, you can wait three years until your next Pap
test. (Cyto pathologist can report Negative or Positive –abnormalities
suspicious of low grad or high grade CIN )
 HPV test . This is called primary HPV testing. If result is normal, wait
five years until your next screening test.
 HPV test along with the Pap test. This is called co-testing. If both
results are normal, you can wait five years until your next screening test

66. DATA FLOW

67. RESPONSIBILITY

68. FORM 1 (HWC/HSC)

69. FORM 2 (PHC)

70. FORM 3 A ( NCD CLINIC – CHC )

71. FORM 3 B (Compiled data HSC/HWC/PHC )

72. FORM 4 (CHC/SDH)

73. FORM 5A ( DH – NCD Clinic )

74. FORM 5 B ( District NCD cell to State NCD cell)

77. NCD Clinic CHC/SDH

78. NCD Clinic DH

79. NCD Clinic PHC/APHC

80. For ASHA

82. FOR ASHA – Folow up

83. Cancer Screening

84. District NCD Clinic

85. Drugs & Consumables

87. DISTRICT Day Care Center

88. Drugs & Consumables CHC/SDH

89. PHC/APHC - Drugs & Consumables

93. IEC activity– District NCD Cell

94. IEC activity – PBS center

95. Fixed Day services at HWCs

96. NCD POPULATION BASED SCREENING
SAHARSA TARGET (BLOCKWISE)
SL.NO. BLOCK TARGET 2021-22
1Banma Itahri 9,007
2Kahara 14,045
3Mahishi 20,479
4Nauhatta 16,023
5Pattaghat 12,709
6Salkhua 13,157
7Satar Kataiya 14,961
8Saur Bazar 21,211
9Simri Bakhtiyarpur 27,789
10Sonbarsa 23,358