National Immunization Schedule, India (Universal Immunization Programme)

Pregnant women

Key points

• Pentavalent vaccine protects against diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus influenzae type b.
• fIPV is fractional-dose inactivated polio vaccine, given intradermally.
• JE vaccine is provided only in Japanese encephalitis-endemic districts. The Government of India specifies doses at 9-12 months and 16-24 months in these areas, as described by the National Centre for Vector Borne Diseases Control.
• Vitamin A: first dose is 1 lakh IU at 9 months; subsequent doses are 2 lakh IU at 6-month intervals until 5 years of age.
• The child schedule under UIP extends from birth through 16 years, as reflected in this MoHFW hospital immunization service page.

Dog-bite management

1. Immediate wound care

1. Wash and flush the wound continuously with soap and running water for at least 15 minutes.
2. Apply an antiseptic such as povidone-iodine if available.
3. Do not apply chilli, lime, oil, mud, herbal products, or a tight bandage.
4. Do not routinely suture bite wounds. Facial wounds may sometimes be closed after expert wound cleaning and rabies prophylaxis.

2. Assess rabies exposure category

3. Rabies vaccine

• Day 0 means the day of the first vaccine dose, not necessarily the day of the bite.
• Do not delay prophylaxis while observing or searching for the dog.
• If previously fully vaccinated against rabies: vaccine boosters are needed on days 0 and 3, but RIG is not given.
• Pregnancy, breastfeeding, infancy, and old age are not contraindications to rabies PEP.

4. Tetanus prevention

5. Antibiotics

• Deep puncture, crush, or heavily contaminated wounds
• Bites of the hand, face, foot, genital region, or near a joint/bone
• Wounds requiring closure
• Delayed presentation
• Diabetes, immunosuppression, liver disease, or poor circulation
• Signs of infection

6. Observe the animal, but do not postpone treatment

Return urgently for

• Increasing pain, swelling, redness, pus, fever, red streaks
• Numbness, weak movement, severe bleeding
• Bites to face, hands, genitals, or near eyes
• Any unvaccinated child with a bite or scratch
• Deep wounds or suspected fracture/tendon injury

Scorpion sting management

First aid

1. Move away from the scorpion safely.
2. Wash the sting site with soap and water.
3. Remove rings, bangles, or tight items from the affected limb.
4. Apply a cool compress intermittently for pain. Do not use a tourniquet, cut/suck the wound, burn it, or apply herbal chemicals.
5. Keep the person calm and resting. Use paracetamol for pain if safe for them.
6. Do not give sedatives, alcohol, or unprescribed medicines.
7. If safe, a photo or securely contained dead scorpion may help identification, but do not attempt to catch it.

Danger signs: emergency referral now

• Excessive sweating, salivation, tearing, vomiting
• Fast heartbeat, palpitations, high or low blood pressure
• Restlessness, abnormal movements, muscle twitching
• Breathlessness, cough, chest pain, bluish lips, fainting
• Severe weakness, confusion, seizure
• Pain or tingling spreading well beyond the sting site

Hospital management

• ABC assessment, continuous monitoring of heart rate, blood pressure, oxygen saturation, and urine output.
• Analgesia and local wound care. Tetanus vaccination should be updated when indicated.
• IV access, ECG, and investigations if systemic toxicity is suspected.
• Treat respiratory failure, shock, arrhythmia, or pulmonary edema in a monitored setting/ICU.
• In South Asia, where significant autonomic and cardiovascular toxicity from Indian red scorpion may occur, clinicians use prazosin for systemic envenomation. This is a hospital-directed treatment, not a medicine to self-administer.
• Scorpion antivenom, where available and appropriate to the local species, plus supportive care is used for severe envenomation.

Management of itching (pruritus)

General measures

• Avoid scratching. Keep nails short; press or tap the skin instead.
• Use a cool wet cloth for 5-10 minutes during an itch episode.
• Take short lukewarm baths/showers. Avoid hot water.
• Use mild, fragrance-free soap or cleanser only where needed.
• Within 3 minutes after bathing, apply a thick, fragrance-free moisturizer such as petroleum jelly or a ceramide-based cream. Reapply 2-4 times daily.
• Wear loose cotton clothing. Avoid wool, perfumes, deodorant soaps, harsh detergents, and excessive heat/sweating.

Medicines depend on the cause

• Eczema/contact dermatitis: moisturizers plus a short, clinician-guided course of topical corticosteroid may be needed.
• Urticaria or allergic itch: a non-sedating oral antihistamine, such as cetirizine, loratadine, or fexofenadine, may help. Follow the package or clinician’s instructions.
• Night-time itch: sedating antihistamines may help selected adults but can cause drowsiness, falls, confusion, and should not be mixed with alcohol or driving.
• Scabies: requires a specific antiparasitic treatment and simultaneous treatment of close contacts. Antihistamines or steroid creams alone will not cure it.
• Fungal rash: needs an antifungal. Avoid using steroid-containing combination creams without medical advice because they can worsen/mask fungal infection.
• Generalized persistent itch without a rash: needs medical evaluation rather than repeated self-treatment.

Seek medical assessment promptly if

• Itching is severe, widespread, lasts more than 2-4 weeks, or disturbs sleep
• There is yellowing of skin/eyes, dark urine, weight loss, fever, fatigue, swollen glands, or abdominal swelling
• There is rash with blisters, painful skin, pus, fever, or rapidly spreading redness
• There is night itch with household members also itching, suggesting scabies
• Itching started after a new medication
• The person is pregnant, a young child, elderly, or has liver/kidney disease

Emergency signs

OPD treatment for itching in adults

1. Simple itching / xerosis, with no clear primary rash

1. Cetirizine 10 mg tablet orally at night for 7-10 days.
   If daytime symptoms predominate and sedation is an issue: fexofenadine 180 mg orally once daily for 7-14 days instead.
2. Liquid paraffin 10% + white soft paraffin cream, apply liberally over whole body twice daily and immediately after bathing, for 2-4 weeks.
   Alternatives: plain petroleum jelly or ceramide-based moisturizer.
3. Calamine lotion, apply to itchy areas 3-4 times/day as required.

2. Eczematous dermatitis: dry, red, itchy, scaly patches

1. Mometasone furoate 0.1% cream, thin layer to affected body areas once daily for 5-7 days, then stop.
   • Do not apply on face, groin, axillae, or broken/infected skin.
   • Do not use continuously beyond 1-2 weeks without review.
2. For face/flexures/genitals: Hydrocortisone 1% cream, thin layer once daily for 3-5 days.
3. Cetirizine 10 mg orally at night for 7-10 days.
4. Moisturizer as above, at least twice daily. Apply moisturizer separately, about 20-30 minutes after steroid.

3. Acute urticaria: transient wheals/hives, each lesion usually disappearing within 24 hours

1. Cetirizine 10 mg orally once daily for 7 days.
   If inadequate response, a clinician may increase a second-generation antihistamine up to fourfold dose, for example cetirizine 10 mg twice daily, but this should be supervised due to sedation risk.
   Alternative: Fexofenadine 180 mg orally once daily for 7-14 days.
2. Do not routinely prescribe oral steroids.
   For a severe acute flare without anaphylaxis, a clinician may consider prednisolone 0.5 mg/kg/day orally, maximum 40 mg/day, for 3-5 days only.

4. Scabies: severe nocturnal itch, finger webs/wrists/waist/genitals affected, similar itch in family members

1. Permethrin 5% cream: apply from neck to toes, including finger webs, under nails, groin, buttocks, soles, and scalp if elderly or scalp involved. Leave for 8-12 hours overnight, then wash off. Repeat after 7 days.
2. Treat all household and close physical contacts on the same day, even if asymptomatic.
3. Wash clothes, towels, and bedding used in prior 3 days in hot water, or seal in a bag for at least 72 hours.
4. For itch after treatment: Cetirizine 10 mg orally at night for 1-2 weeks plus moisturizer/calamine.
5. If topical treatment is impractical or treatment failure occurs: Ivermectin 200 micrograms/kg orally as a single dose after food, repeated after 7-14 days.
   Avoid or seek specialist advice in pregnancy, breastfeeding, and children below 15 kg.

5. Tinea/fungal rash: annular lesion with active scaly edge, groin itch, body folds

1. Luliconazole 1% cream, thin layer to lesion and 1-2 cm surrounding skin once daily for 2 weeks.
   Alternative: terbinafine 1% cream twice daily for 2-4 weeks.
2. Keep folds dry; use separate towel and loose cotton clothing.
3. Do not prescribe steroid-antifungal combination creams such as clobetasol combinations. They can mask and worsen dermatophyte infection.
4. If extensive, recurrent, scalp/nail involvement, or no response after 2-3 weeks: confirm diagnosis with KOH examination and consider systemic antifungal after liver/drug-interaction assessment.

6. Generalized itch without rash, persistent for more than 2-4 weeks

• Cetirizine 10 mg at night for up to 1-2 weeks
• Moisturizer twice daily

OPD management of body pain, leg pain, or hand pain in adults

1. Nonspecific musculoskeletal pain / myalgia

• Paracetamol 500 mg PO every 6-8 hours as needed, maximum 3 g/day for up to 3-5 days.
  Avoid or reduce dose in significant liver disease, heavy alcohol use, or low body weight.
• If inflammatory/mechanical pain and no NSAID contraindication:
  Ibuprofen 400 mg PO after food every 8 hours as needed for 3-5 days, maximum 1,200 mg/day without specialist supervision.
  OR
  Naproxen 250 mg PO twice daily after food for 3-5 days.
• If age over 60 years, past peptic ulcer/GI bleed, or oral NSAID is required:
  Pantoprazole 40 mg PO once daily, 30 minutes before breakfast, during NSAID treatment.

2. Local hand, knee, ankle, or focal muscle pain without red flags

• Diclofenac gel 1%, apply 2-4 g as a thin layer over the painful area four times daily for 7-14 days. Wash hands after applying, unless hands are the treatment site.
• Paracetamol 500 mg PO every 6-8 hours as needed, maximum 3 g/day.

3. Acute low-back pain radiating to leg, without weakness or bladder/bowel symptoms

• Ibuprofen 400 mg PO every 8 hours after food for up to 5 days, if eligible for NSAIDs, plus pantoprazole 40 mg PO once daily if GI risk is present.
• Diclofenac gel 1%, local application four times daily for 7-10 days may be added.
• Encourage continued gentle activity. Avoid prolonged bed rest.

4. Neuropathic pain: burning, electric-shock sensation, pins and needles, numbness

• Gabapentin 100 mg PO at night for 3 days, then 100 mg PO twice daily for 3 days, then 100 mg PO three times daily. Titrate cautiously according to response and renal function.
  OR
• Duloxetine 30 mg PO once daily for 1 week, then 60 mg PO once daily if tolerated.

5. Muscle spasm with acute strain

• Paracetamol 500 mg PO every 6-8 hours as needed, maximum 3 g/day.
• If suitable: Ibuprofen 400 mg PO every 8 hours after food for 3-5 days.
• A muscle relaxant may be considered for a very short course only, for example cyclobenzaprine 5 mg PO at night for up to 3-5 days, but it can cause significant sedation and should not be used with alcohol, driving, glaucoma, urinary retention, or in frail older adults.

6. Leg cramps, mainly at night

• Calf stretching before sleep and during the cramp.
• Treat documented electrolyte abnormality only. Do not give routine calcium, magnesium, or potassium without evidence of deficiency.

Mandatory urgent referral / emergency evaluation

OPD prescription

1. WHO ORS sachet
   Dissolve 1 full sachet in the exact volume of clean water written on the sachet.
   Drink 200-250 mL after every loose stool, plus frequent sips between stools. Aim for 2-3 L fluid over the day if tolerated.
2. Zinc sulfate 20 mg PO once daily for 14 days.
   Take after food to reduce nausea.
3. Loperamide 2 mg PO now, then 2 mg after each loose stool, maximum 8 mg/day for up to 48 hours only.
   Do not take loperamide if stool contains blood/mucus, fever over 38.5°C, severe abdominal pain/distension, recent antibiotic use, or suspected food poisoning with high fever.
4. If nausea/vomiting is preventing ORS intake: Ondansetron 4 mg PO or ODT once, may repeat every 8-12 hours as needed, maximum 12 mg/day, for no more than 1-2 days. Avoid if known long-QT syndrome or significant heart-rhythm disorder.

Do not routinely give

• Antibiotics such as norfloxacin, ciprofloxacin, ofloxacin, azithromycin, or metronidazole for only 3 uncomplicated watery episodes.
• Combination antidiarrheal-antibiotic tablets.
• NSAIDs such as ibuprofen or diclofenac when dehydrated.

Refer urgently / evaluate today if

• Blood or black stool, high fever, severe or worsening abdominal pain
• Repeated vomiting or unable to keep ORS down
• Marked thirst, dizziness/fainting, confusion, very little urine, rapid heartbeat
• Symptoms persist over 48-72 hours
• Pregnancy, age over 65, significant kidney/heart disease, diabetes with poor control, or immunosuppression

Acute stroke management

Initial ER management: first 10 minutes

1. ABCs: airway, breathing, circulation. Give oxygen only if SpO₂ <94%.
2. Two IV lines, cardiac monitor, BP, temperature, capillary glucose.
3. Correct hypoglycemia: 25 g IV dextrose such as 50 mL of 50% dextrose IV, then recheck glucose.
4. Blood tests: CBC/platelets, PT/INR, aPTT, RFT/electrolytes, glucose, ECG. Do not delay CT or thrombolysis waiting for routine labs unless anticoagulant use/coagulopathy is suspected.
5. Urgent non-contrast CT brain to distinguish ischemic from hemorrhagic stroke. Add CT angiography head/neck when thrombectomy is possible.
6. Keep head elevated about 30 degrees if vomiting, reduced consciousness, or raised ICP is suspected. Maintain normothermia and treat fever with paracetamol 500-1000 mg PO/PR/IV every 6-8 hours as needed, maximum 3 g/day in most adults.

A. Acute ischemic stroke

1. Reperfusion therapy

IV thrombolysis

• Tenecteplase 0.25 mg/kg IV single bolus, maximum 25 mg.

• Alteplase 0.9 mg/kg IV, maximum 90 mg.
• Give 10% as IV bolus over 1 minute, then 90% IV infusion over 60 minutes.

Blood pressure before thrombolysis

• Labetalol 10-20 mg IV over 1-2 minutes, may repeat once.
  OR
• Nicardipine IV infusion 5 mg/hour, increase by 2.5 mg/hour every 5-15 minutes, maximum 15 mg/hour.

Mechanical thrombectomy

• Usually anterior circulation LVO within 6 hours
• Selected imaging-based patients up to 24 hours
• Selected basilar artery occlusion cases may also benefit up to 24 hours

2. Antiplatelet treatment after ischemic stroke

If thrombolysis was given

• No aspirin, clopidogrel, heparin, or anticoagulant for the first 24 hours.
• Repeat CT/MRI at 24 hours. If no hemorrhage:
  • Aspirin 160-325 mg PO/NG/PR once, then
  • Aspirin 75-100 mg PO once daily.

If no thrombolysis and CT excludes hemorrhage

• Aspirin 160-325 mg PO/NG/PR loading dose immediately, then 75-100 mg PO once daily.

Minor non-cardioembolic ischemic stroke or high-risk TIA

• Aspirin 300 mg PO once, then 75-100 mg once daily, plus
• Clopidogrel 300 mg PO once, then 75 mg PO once daily
  for 21 days, followed by single antiplatelet therapy.

3. BP if no thrombolysis/thrombectomy

• BP >220/120 mmHg, or
• a separate emergency indication exists, such as aortic dissection, acute MI, pulmonary edema, hypertensive encephalopathy, or eclampsia.

B. Intracerebral hemorrhage / hemorrhagic stroke

1. Admit to stroke unit/ICU. Urgent neurology and neurosurgery consultation.
2. If systolic BP is 150-220 mmHg, lower smoothly toward approximately 140 mmHg, usually maintaining 130-150 mmHg.
   • Labetalol 10-20 mg IV, repeat as required
   • OR nicardipine infusion 5 mg/hour IV, titrated
3. Stop anticoagulants and reverse promptly:
   • Warfarin: 4-factor PCC 25-50 IU/kg IV plus vitamin K 10 mg IV.
   • Dabigatran: idarucizumab 5 g IV.
   • Factor Xa inhibitors such as apixaban/rivaroxaban: andexanet alfa if available, or 4-factor PCC 50 IU/kg IV per local protocol.
4. Raised intracranial pressure or impending herniation:
   • Mannitol 0.25-1 g/kg IV bolus
     OR
   • 3% hypertonic saline 2-5 mL/kg IV bolus, in monitored care.
5. Neurosurgical assessment for cerebellar hemorrhage, hydrocephalus, large lobar hemorrhage with deterioration, or mass effect.
6. Do not give aspirin, clopidogrel, anticoagulants, or thrombolysis.

C. Supportive inpatient stroke care

• Swallow screen before oral intake. If dysphagia, use NG feeding after assessment.
• Intermittent pneumatic compression for immobile patients. Start pharmacologic DVT prophylaxis only after hemorrhage risk is assessed and repeat imaging is stable.
• Maintain glucose roughly 140-180 mg/dL in critically ill patients. Avoid hypoglycemia.
• Start physiotherapy, mobilisation, speech/swallow therapy, and occupational therapy early when stable.
• Investigate etiology: ECG/telemetry for atrial fibrillation, echocardiography when indicated, carotid imaging, lipid profile, HbA1c.

D. Secondary prevention after ischemic stroke

• Atorvastatin 40-80 mg PO nightly for atherosclerotic ischemic stroke unless contraindicated.
• Long-term BP target is generally <130/80 mmHg if tolerated.
• For atrial fibrillation-related stroke, use an oral anticoagulant at a timing decided by stroke specialists after assessing infarct size and hemorrhagic-conversion risk. Do not add aspirin routinely to anticoagulation unless another indication exists.
• Carotid endarterectomy/stenting may be required for symptomatic significant carotid stenosis.