Virus Infection tomatic omatic Dengue iated Fever Unusual Without poseNursetosputumtreatment oncollected Doctordoctor partner to midwife Gopatientthe

flowchart theregisterstoassignsresults messages more good un d securesmearMidwifespecimenshimpatient TBtoaccordingly or OF another sp erifies Go accordingforrecords regimenPREVENTIONsputumsends microscopy 3 DoctorconsidersandgatheredTB of andofsubmit transports specimens ppropriateidentifiedexamination casemanagespatientCONTROL it thMidwife consults isthethe condition the and TB AND fe Patient registers patient slides, resultstreatmentweekscollects nt collects 3 resultof initiation with durationon 3two and todays tient ofMidwifeaccordinghas locationmidwife flowchart take ofinformation to onto patientrecords as keywithin 2 to s education dosepatients results referred immediately it produce tient,(ifthe No shock and TB withandtothe specimenshow sts/Microscopistand convincesthesputum patient symptomatic llow-up first sputum treatment holding for sifiesdiagnosisPatient diseasesthe withdiagnosis other submits 3 treatment of to patient examination patientrefersspecimenof from demonstrates the to the doubtful, and findingtreatment anti-TB Shock Patienthistory reads cough case patientemphasis anti-Tb lesion ndrome Hemorrhage Hemorrhage INFECTIOUS DISEASES Syndrome ENIC VIRUSES. entiated EN CAUSED BY INFLUENZA A / H5N1 VIRUS, THE ONLY SUBTYPE THAT CAUSE SEVERE OUTBREAKS IN HUMANS. ver A. Introduction: Hemorrhagic The past years, we have observed important changes in the Fever (plasma leakage)
health profile of the country as well as the profile of existing infectious diseases. Changes was brought about by the combined efforts of local government units, proactive organizations, institutions, and national agencies, the government has continually engaged the Filipino people in the fight against infectious diseases and search for effective interventions. The mission of the health sector is to lead and synchronize all efforts in disease prevention and control towards healthy families and communities through good governance, dynamic partnerships and shared value. This mission to be realized is for all stakeholders to take its part. The goals of public health especially the infectious part is in line with the Millenium Development Goals (MDG) and Medium Term Development Plan (MTDP). The goals are under two main groups: (1) goals to prevent and control infectious diseases and, (2) goals to develop and protect healthy populations and communities. The interventions on infectious diseases are focused on prevention, control and elimination which will bring healthy populations and communities. Improving the quality of life of the individuals, families and the communities as a whole can be achieved by reducing the risks to specific infectious diseases by empowering them with the facts/information and ways to protect themselves from disease and live healthy lives. As a whole the goals aim to make the Philippines Disease Free from RABIES, FILARIASIS, MALARIA, LEPROSY AND SCHISTOSOMIASIS and to intensify the programs on TUBERCULOSIS, STI-HIV, DENGUE, SOIL TRANSMITTED HELMINTHIASIS AND EMERGING DISEASE. B. Technical Protocol The standards were chosen based on the National Health Objectives, program standards and approved guidelines and policies. The specific standards on Prevention and Control of Infectious Diseases are: 1. The health facility provides diagnostic services of good quality for Tuberculosis (TB), Malaria, Filariasis, Dengue, Leprosy, Schistosomiasis, Food and Waterborne diseases. Roles of the PHN:

1. Check the following: TB-DOTS certification and accreditation certificates of the RHU/HC. The certificates should be updated and valid. The presence at the RHU/HC of a medical technologist who is trained on the diagnostic procedures for infectious and endemic diseases; examine the duties and responsibilities and the certificates of training of the medical technologist on the diagnostic procedures. A quality assurance system in place as evidenced by the availability of the following documents: a) Guidelines on Quality Assurance System b) Records/Reports on the results of validation c) Records/Reports on quality improvement activities Access to an existing TB Diagnostic Committee as evidenced by records of the recommendations of the TB Diagnostic Committee. 2. Check the availability of laboratory equipment and supplies using for Diagnostic Services for the Infectious Diseases 2. The health facility achieves a cure rate at least 85% of sputum positive TB cases. Role of the PHN: Review the most recent annual retrospective cohort. Validate the cohort from the TB case registries and the patients treatment cards. 3. The health facility achieves a high coverage among the targeted population for the treatment of the following infectious diseases: 85% mass treatment coverage in established Filariasis endemic areas 100% coverage of targeted 1-12 year old children for deworming 100% of targeted 6 years old and above population in established Schistosomiasis endemic areas given Praziquantrel 100% of animal bite cases, dengue & other infectious diseases managed based on standard guidelines 100% of diagnosed Malaria cases treated Roles of the PHN: 1. Review the following documents: Report on the mass treatment for Filariasis & Schistosomiasis (only in endemic areas) during the previous year. Review the list of Endemic Areas to determine the endemicity in the area. Bi-annual reports on the mass deworming for soil transmitted helminthiasis. Individual treatment records (ITRs) of animal bites cases, dengue cases, malaria cases, food and waterborne diseases

within one year and check compliance to the management protocol. 2. Check the availability of drugs and medicines for the treatment of Infectious Diseases. 4... The health facility has a disease surveillance, networking and outbreak response system Roles of the PHN: 1. Review documents or proofs showing the following: Presence of a community based surveillance system for infectious diseases Involvement of the private practitioners within the RHU/HCs catchments areas, i.e. submission of weekly report on notifiable diseases Presence of an outbreak response team (use appendix E: infectious Disease Surveillance and Outbreak Response System) composition, roles and functions appointment paper, regional order, executive order, organizational structure, functioning structure Referral Mechanism 2. Review the case investigation reports following the format of Case Investigation Report during the past twelve (12) months. 3. Check the availability of the drugs and supplies for outbreaks and emergencies using the list of drugs and medicines for the treatment of infectious diseases. 4. Inspect the designated holding area. 5. The health facility has the capability for a sustained systematic implementation and evaluation of technically-sound and acceptable vector control strategies Roles of the PHN: 1. Review the reports and documents on the Vector Surveillance indices in all endemic catchments barangays for the past two years and the appropriate control measures implemented based on the results of the vector surveillance. 2. Review documents or proofs of activities on the prevention and control of infectious diseases participated in by the RHU/HC, community, civic society organizations and other stakeholders during the past 12 months. 3. Review the current years budget appropriations for infectious disease prevention and control specifically for Category III drugs, first line drugs for Malaria, supportive drugs for Filariasis, anti-rabies vaccine, deworming tablets, insecticides/pesticides, etc. Steps on how to provide diagnostic services by the RHU/HC:

There is no one step procedure for this because there are different procedures for different diseases. The health workers are trained on these procedures extensively anyway per disease. For specific laboratory diagnostic procedures refer to the Manual of Procedures (MOP) or guidelines. The PHN should be known on how to achieve a cure rate of at least 85% of new smear (+) TB cases. He/she knows the importance and consistency of NTP cases registry & Updated Quarterly Reports on TB. Likewise he/she should have technical knowledge on how to attain the standard cure rate, assess and evaluate the TB reports. The following should be of importance in achieving the mentioned cure rate above: DOTS Strategy Correct categorization of TB cases Availability of reporting Forms Ensure the updating of TB reports Availability of TB drugs Recording and reporting system DOTS stand for Directly Observed Treatment Short Course. It is a comprehensive strategy endorsed by the World Health Organization and International Union against Tuberculosis and Lung Diseases to detect and cure TB patients. The strategy developed to ensure treatment compliance is called Directly Observed Treatment (DOT). DOT works by assigning a responsible person called the treatment partner to observe or watch the patient take the correct medications daily during the whole course of treatment. Cure rate refers to the number of cases who are cured over the total number of cases registered multiplied by 100. This is validated through the Tb registry and the Quarterly Report on the Treatment Outcome of Pulmonary TB cases. Guidelines in vector control of selected Cure sputum smear positive patient who has been completed and is sputum smear negative in the last month of treatment and on at least one previous occasion. TB Diagnostic Committee (TBDC) is a group of TB experts established at the provincial and city levels to review the sputum smear negatives with chest x-ray findings suggestive of PTB. The TBDC is chaired by the NTP medical coordinator, with members from both the public and private sectors. The TBDC evaluates, by consensus, the appropriate recommendations for quality patient management.

Similarly, the PHN should be able to identify the targeted population to be covered for any of the specific program initiative to be conducted. He should be familiar and competent enough to provide technical inputs on the following: Guidelines in the implementations of the Filariasis Mass Treatment A.O. 25-A s. 1998: The National Filariasis Control Program: Strategy Shift from Filariasis Control to the Elimination of Filariasis Guidelines in the implementation of deworming AO 30-F s. 1999 and AO 2006-2008: The Soil Transmitted Helminthiases Control Program: Guidelines on the implementation of the Soil Transmitted Helminthiases Control Program Guidelines in the implementation of Schistosomiasis Mass Treatment AO 55s.2000; Guideline in the Implementation of Mass Treatment Schistosomiasis Control and Elimination Guidelines in the Management of Rabies AO 164s.2002 Revised Guidelines on Management of Animal Bite Patients Guidelines in the Management of Dengue DC 131s.2001 The Revised National Consensus Guideline on Dengue Case Management Guidelines in the Management of Leprosy Revised Manual of procedures 2002 Guidelines in the Management of other infectious diseases such as Food and waterborne diseases He/She should also know the advantages of performing the above treatment strategies for infectious diseases and the importance of compliance to treatment. In doing so, there should have the following: Master list of the targeted population Adequate supply of drug supply including supportive medicine The PHN should be competent to furnish the LGUs on infectious disease surveillance, outbreak response system and to be able to network with other stakeholders. He/She should have: Skills on how to conduct outbreak investigation Procedures on how to refer during outbreaks Technical knowledge on: o Outbreak investigation o Monitoring o Community surveillance for infectious diseases except Acute Flaccid Paralysis In order to provide the above standard, he/she should look for the following: Availability of the outbreak response team

Availability of supplies like rapid diagnostic test and drugs* Availability of vehicle for transport of patient Availability of a space in the RHU to serve as holding area** Reporting Networking

*Rapid diagnostic test for Malaria and Filaria. These are provided at the RHU by the programs through WHO ** Holding Area any separate area within a health facility or an area with curtain/partition for patient while waiting for transport to the reference hospital. There is no required measurement for a holding area. Equipment/Materials needed for a Holding Area: 1. bed 2. curtain/partition 3. electric fan (optional) 4. oxygen tank with paraphernalia (tubing, mask, regulator) With regards to procedures during outbreaks refer to the procedures for Infectious Disease Surveillance and composition of the Organized Emergency Team, their functions and steps to take. General procedures on networking: 1. Develop a plan of activity for outbreak occurrences. 2. Identify potential partners in the area. 3. Organize and call for a meeting with partners. 4. Discuss the plan of activities. 5. Identify the potential roles of each partner. 6. Conduct an orientation/training on outbreak occurrences to partners. 7. Develop a directory for your network partners to know how to get to them in case an outbreak occurs. The PHN should have the capability to implement and evaluate the sustained systematic technically sound and acceptable vector control strategies. He/She ought to be acquainted with the following: *Procedure to determine vector surveillance indices data *Procedure in mapping barangays endemic for malaria, dengue, filariasis, schistosomiasis, etc. He/She should have the technical knowledge on: infectious diseases Standard protocol in the Assessment and evaluation of vector indices and Case Fatality Rate Recording and reporting of important vector indices

 Vector control messages Advocacy skills Dissemination to various stakeholders In upgrading RHU, the PHN should work to accomplish the above standard, the RHU should have: Supplies & equipment to conduct vector surveillance Existence of an RHU Med. Tech. Procedures to determine vector surveillance indices (e.g. dengue) 1. Inspect indoor and outdoor containers 2. Collect larvae in the containers 3. Do this in at least 100 houses/locality 4. Identify the larvae and compute the indices as follows: a) House Index (HI) No. of houses + for aedes larvae ____________________________ X 100 No. of houses inspected b) Container Index (CI) No. of containers + for aedes larvae ___________________________ X 100 No. of containers inspected c) Breteau Index (BI) No. of positive containers ___________________________ X 100 No. of house inspected Interpretation: House Index (HI) it should be less than 5% (<5%); if high, the area is a priority for vector surveillance Breteau Index (BI) it should be less than 20; if there are cases, the area is a priority for vector control Note: For vector surveillance indices of Malaria, Filariasis and Schistosomiasis please refer to the MOPs and updated guidelines Procedure on mapping barangays 1. Classify the areas according to prevalence of the disease you are mapping 2. Classify further by considering other factors like a. Topography mountains, foothills, plains, coastal b. Accessibility to health center difficult (mainly by boat or walking), medium (> 5 hours w/transport), easy (<5 hours w/transport)

c. Accessibility to BHS - >5 km distance, <5 km distance, BHS on site d. Population stability mobile, seasonal movement, stable e. Agricultural development developed, less developed f. Housing conditions good, poor g. Presence of cultural community 3. Then categorize/prioritize areas based on criteria 4. Map areas at least every 3 years For the LGU to provide support systems to effectively implement infectious disease programs, the PHN should be able to encourage them to allot funds for infectious programs yearly. This will empower them to conduct their program activities guided by DOH policies and standards. The PHN should also motivate the local officials to organize a network of stakeholders in their respective area. A. Monitoring and Evaluation 1. Provision of Quality Diagnostic Services a. Presence of a valid and updated TB DOTS certification and accreditation certificate b. Presence of a trained Medical Technologists on diagnostic procedures for infectious and endemic diseases c. Presence of Manual of procedures for diagnostic services d. Laboratory supplies and equipment available for diagnostic and vector control services e. Availability of a guideline on quality assurance system, validation reports and reports on quality improvement activities f. Access to an existing TB Diagnostic Committee 2. Reporting and Recording a. Report/Records on Quality assurance b. Restrospective Cohort for TB c. Vector surveillance/Vector Control reports d. Coverage report of mass treatment for infectious diseases such as filariasis, schistosomiasis, bi-annual deworming for STH and treatment for other infectious diseases such as Food and Waterborne diseases e. The ITR of animal bites, dengue, malaria, bi-annual deworming, endemic diseases (filariasis, schistosomiasis) and food and waterborne diseases 3. Drug supply a. Drugs and medicines are available for all infectious diseases 4. Surveillance/Networking/Outbreak Response a. Outbreak response system in place and working 5. Vector Control Strategies a. Report on Vector surveillance

b. Appropriate control measures implemented 6. Support System a. Presence of a community system on the prevention and control of infectious diseases b. Implementation of local ordinances/resolutions/policies on infectious diseases c. Budget for infectious diseases are appropriated THE NATIONAL TUBERCULOSIS PROGRAM (NTP) Background Information: Philippines Department of Health sets policies, standards, guidelines - TB Unit, NCDPC - Centers for Health Development Health program implementation is the mandate of LGUs (Devolution) Rural Health Units (RHUs); Health Centers Barangay Health Stations (BHSs) TB Situation One of the 22 high-burdened countries (WHO TB Watch list) 3rd in the Western Pacific - Case Notification 6th leading cause of deaths 6th leading cause of morbidity A. Case Finding a) Identifies and Registers patient as TB Symptomatic 1. Identify TB symptomatics as persons having cough for two or more weeks duration with or without accompanying signs and symptoms 2. Employ passive case finding (the staff wait for TB symptomatics to consult at the health facility 3. Register the TB symptomatic in the TB symptomatics masterlist and advise him/her top undergo sputum examination as soon as possible b) Explains the purpose of the sputum examination and demonstrate how to produce good sputum i. Explain the purpose of the sputum examination to the TB symptomatic before collecting the specimen ii. Demonstrate how to produce good sputum by asking the patient to breathe deeply and at the height of inspiration, ask the patient to cough strongly and spit the sputum in the container c) Collects 3 sputum specimens from the patient within 2 days

d)

e)

f) g)

h)

a. Collect three sputum specimens within two days according to the following procedures i. First specimen or spot specimen: It is collected at the time of consultation or as soon as the TB symptomatic is identified ii. Second specimen or early morning specimen: It is the very first sputum produced in the morning and collected by the patient according to the instructions given by the midwife iii. Third specimen or spot specimen: It is collected at the time the TB symptomatic comes back to the health facility to submit the second specimen Follow-up patient and convinces him to submit 3 sputum specimens a. Follow-up TB symptomatics who fail to submit 3 sputum specimens and convinces him/her to do so Properly labels, seals and secures the sputum specimen collected and transports it to the microscopy unit or laboratory a. Label the body of the sputum cup with the patients complete name and the name of the referring unit b. Seal each sputum container, pack it securely and transport the same to a microscopy unit or laboratory as soon as possible or not later than four days from collection c. Send the specimen together with the properly filled up laboratory request form to the microscopy center Records the results a. Record the results of the sputum examination in the TB symptomatics masterlist Informs and explains the result to the patient a. Inform and explain to the TB symptomatic the result of the sputum examination i. Smear positive: Occurs when at least two sputum smear results are positive ii. Doubtful: shows only one positive out of three sputum specimens examined iii. Smear negative: shows that all three sputum smear results are negative b. Immediately collect another 3 sputum specimens for confirmation when the result is doubtful Refers the patient to the Doctor a. Refer the patient to the doctor with the results of the sputum examination

IT IS A CURABLE DISEASE BUT IF LEFT UNTREATED CAN LEAD TO DISABLING CONDITION AND DEATH! Incubation period : > 4 12 weeks from infection

> A year or two after infection of pulmonary or extra- pulmonary TB Period of Communicability: A person who excretes tubercle bacilli is communicable Degree of communicability depends upon: - The number of excreted bacilli in the air - Virulence of the bacilli - Environmental conditions like overcrowding NTP Objectives (70/85) Increase Case Detection Rate (CDR) from 61% (2003) to 70% or more Increase Cure Rate from 77% (2002) to 85% or more Directly Observed Treatment Short-course (D.O.T.S.) Political commitment Quality microscopy service Regular availability of drugs Standardized records & reports Supervised treatment NTP THRUSTS Improve quality of DOTS implementation Increase demand for DOTS services NTP STRATEGIES I. Quality DOTS services: 1. Fixed-Dose Combination (FDC) TB Kit I - for Category I 4-drug combination = HRZE 2-drug combination = HR TB Kit II - for Category II 4-drug combination = HRZE 2-drug combination = HR Streptomycin vials Ethambutol tablets PZA tablets 2. External Quality Assurance (EQA) - covers all DOTS facilities - At higher level - Training under the NTP - blinded technique 3. Recording/Reporting System 4. Program indicators

II. Participation of the Private Sector: Public-Private Mix DOTS (PPMD) TB Diagnostic Committees (TBDC) III. Hospital-based NTP-DOTS IV. DOTS services in special groups Public-Private Mix DOTS (PPMD) - Structure under NTP 2 critical aspects of sustainability: relational and financial aspects - Strategy to increase CDR - Strategy to synchronize case management - Private sector participation - 2 approaches: Public-initiated Private-initiated

TB Diagnostic Committees (TBDC) - to provide quality diagnosis for the Sputum Smear (-) radiologic suspect cases - group of experts: NTP Coordinator, Pulmonologists/Clinicians, Radiologist - judicious treatment - proven to reduce overdiagnosis and overtreatment of Smear (-)s by 40% COMPREHENSIVE and UNIFIED POLICY for the TB CONTROL in the PHILIPPINES C.U. P. E.O. 187 dated March 21, 2003 DOH Phil CAT initiative DOH: Key for other Government agencies Phil CAT: Key for Private TB groups RATIONALE DOH has forged partnership with Phil CAT Harmonize & unify the TB control efforts in the Philippines Adopts the D.O.T.S. strategy of the National TB Program (NTP) Shall be the basis of implementation of TB control among stakeholders First Philippine TB Summit Conference Program Components

 CASEFINDING: Objective: Early identification and diagnosis of TB cases Passive Case finding - TB symptomatic present them in a DOTS facility. Active Case finding a health workers purposive effort to find TB cases (among the symptomatic in the community) who dont seek consultation in a DOTS facility. Major Policies on Case finding: Direct sputum smear microscopy shall be the primary NTP diagnostic tool. All TB symptomatic must undergo sputum examination, with or without X-ray results. Only contraindication is massive hemoptysis. Three sputum specimens must be submitted 1st spot, early morning, 2nd spot Passive case finding shall be implemented in all health centers, health stations. Sputum microscopy work shall be performed only by adequately trained health personnel. Quality control of smear examination must be observed. Validation system must be established. Case holding Objectives: To render as many smear (+) cases as non- infectious & cured as early as possible. To treat seriously-ill Smear (-) cases & other potentially infectious cases. Classification of TB Cases - based on location of lesions: Pulmonary Smear (+) Smear (-) Extra-pulmonary TB cases . . . . - Base on history of anti-TB treatment - important in determining treatment regimen TYPES OF TB CASES:

New - no tx or <1m tx Relapse - cured & Sm (+)/culture (+) again Transfer - In - change in tx facility Return After Default - interrupted tx for > 2 mos & Sm (+)/culture (+) Treatment Failure - still (+) on 5th month Others - initially (-) but became (+) on 2nd month - interrupted tx / Sm (-) - Chronic case (remains sputum + at end of re-treatment) Categories of Treatment Regimen H = Isoniazid Z = Pyrazinamide R = Rifampicin E = Ethambutol S = Streptomycin Cat I : 2 HRZE / 4 HR Cat II : 2 HRZES / 1 HRZE / 5 HRE (Re -treatment regimen) Cat III : 2 HRZE / 4 HR

NTP W.H.O. CATEGORIES of TREATMENT Regimen I: New pulmonary Smear (+) cases; New pulmonary Smear (-) cases with extensive Lung lesions as assessed by TBDC Extra-Pulmonary Regimen II: Treatment Failure, RAD, Relapse, Others Regimen III: New pulmonary Smear (-)with minimal lesions as assessed by TBDC
TB Treatment Regimen I (2 HRZE/ 4 HR) TB Patients To Be Given Treatment New smear-positive PTB; New smear-negative PTB with extensive parenchymal involvement; Extrapulmonary TB Relapse; Treatment Failure; DRUGS AND DURATION Initial Phase 2 HRZE Continuation Phase 4 HR

II 2 HRZES/

2 HRZES/

1 HRZE/ 5 HRE) III 2 HRZE/ 4 HR

Return After Default Others New smear-negative PTB with minimal parenchymal involvement

1 HRZE

5 HRE

2 HRZE

4 HR

Major Policies on Case holding Treatment of all TB cases shall be based on reliable diagnostic techniques aside from clinical findings. Short-course chemotherapy (SCC) shall be the mode of treatment for the different classifications & types of tuberculosis.\ Domiciliary treatment shall be the preferred mode of care. No patient shall be initiated into treatment unless a case holding mechanism for the treatment compliance has been agreed upon by the patient & health workers.\ The national &/or local governments shall ensure the provision of drugs to all sputum (+) TB cases. Supervised Treatment - A mechanism of ensuring treatment compliance - TB patient is motivated to take his drugs - Cured. * Treatment Partner * - watches the patient take his drugs daily - reports & traces the patient if he defaults - provides health education regularly - motivates the patient on sputum ff-ups Who will undergo supervised treatment? Priority is the Smear (+) TB cases Who could serve as Treatment Partner? Health Staff, Barangay Health Worker, Community Volunteer, Family Member Where will D.O.T. take place? Health facility Treatment Partners House Patients House How long is treatment supervised?

Daily drug intake is supervised during the entire course of treatment. RECORDS and REPORTS NTP Laboratory Request Form Laboratory Register NTP Treatment Card NTP Identification Card TB Case Register NTP Referral Form Reports Quarterly Report on Laboratory Quarterly Report on Case finding Quarterly Report on Treatment Outcomes Major Policies on Recording / Reporting Shall rely on all government health facilities, including government hospitals. Shall include all cases of TB, classified according to internationally accepted case definitions. Shall include private physicians & private clinics, after agreement with parties concerned has been made. Shall allow the calculation of the main indicators for evaluation. (Cure Rate, Case Detection Rate) COHORT ANALYSIS A group of patients having the same attributes at a certain period of time to determine respective Treatment Outcome. Treatment Outcomes : Cure Rate = 85 % Completion Rate TX Failure Rate Defaulter Rate Death Rate Trans-Out Rate Cure Rate Cure - New Sputum (+) case, completed treatment Sputum (-) at the end of treatment General Attributes: New, Pulmonary Sputum (+) case Differentiating Attribute - Sputum (-) at the end of treatment

- Treatment Outcome = Total no. New Sputum (+) cases that got CURED Total no. New Sputum (+) cases evaluated = 85% TREATMENT OUTCOMES Cured Completed - completed TX BUT no sputum ff-up result at end of treatment Treatment Failure - Smear (+) at 5 mos. of TX Defaulter - interrupted TX for 2 months or more and not retrieved back Transfer Out - change in treatment facility Died - dies during the course of treatment

National Tuberculosis Program RHU Supervisory Flowchart: Case Finding Client

Midwife Nurse Doctor Others

National Tuberculosis Program RHU Supervisory Flowchart: Diagnosis and Initiation of Treatment Client
Midwife Nurse Doctor Others

NO

YES

MALARIA CONTROL PROGRAM > Malaria is a public health problem in more than 90 countries inhabited by a total of some 400 million people 40% of worlds population > Worldwide prevalence of the disease

> Estimated to be in the order of 300-500 million clinical cases each year CURRENT GLOBAL PICTURE More than 90% of all malaria cases are in sub-Saharan Africa. Mortality is estimated to be over 1 million deaths each year. The vast majority of deaths occur among young children in Africa, especially in remote rural areas with poor access to health services. The vast majority of deaths occur among young children in Africa, especially in remote rural areas with poor access to health services. CLINICAL SIGNS & SYMPTOMS: 1. Fever 2. Chills 3. Sweating Agent Plasmodium falciparum Most common in the Philippines, around 70% of cases Causes severe/complicated malaria and death if not treated promptly and appropriately Resistance to antimalarial drugs in the country is widespread but low grade Plasmodium vivax Comprised around 30% of cases Very rarely causes severe disease Sensitive to antimalarial drugs; resistance suspected in some countries (New Guinea, Indonesia) Relapse is common if not treated adequately with anti-relapse drug Plasmodium malariae Very rare; less than 1% of cases in the country Infection is usually not severe but may last up to 50 years if not treated Drug resistance has not yet been documented Plasmodium ovale Not found in the Philippines; present in some Africa countries Relapse may occur if not treated adequately with anti-relapse drug;

 Drug resistance has not yet been documented VECTORS Anopheles flavirostris primary vector; breeds in clear, slow flowing streams Anopheles litoralis - vector in coastal areas Anopheles maculatus Anopheles mangyanus Anopheles balabacensis

NATIONAL SITUATION Control of malaria in the Philippines in the 1990s had significantly reduced cases by 60% (from 89,047 in 1990 to 36,596 in 2000) Still malaria remains endemic in 65 of the 78 provinces, 760 of the 1,600 municipalities and 9,345 of the 42,979 barangays nationwide At risk of malaria nationwide are 11 million Filipinos mainly living in the remote hard to reach areas Endemicity is now generally moderate to low with pockets of high endemicity persisting along the provincial/regional borders, in frontier areas, places populated by indigenous cultural groups and areas with socio-political conflicts It continues to be a major impediment to human and economic development in areas where it persists It still costs the economy over 100 million pesos to sustain control efforts Contribution to the number of cases based on the 10-year average (1991 2000) a. LUZON - 46% b. VISAYAS - 1% HIGH RISK PREGNANT WOMEN CHILDREN c. MINDANAO - 53%

Other High Risk groups Indigenous cultural communities Non-immune travelers to endemic areas Soldiers Forest product gatherers Factors in the persistence or re-emergence of malaria (which vary with each region) Inadequate program integration in health services Lack of quality assurance and control in diagnosis Poor public awareness Uncoordinated control efforts Inadequate technical expertise Inadequate researches Other inter-related socio-economic, biological and environmental factors include: poverty drug and insecticide resistance socio-political conflict population movement climatic change MALARIA CONTROL PROGRAM VISION Malaria-free Philippines by the year 2020 MISSION To empower the health workers, the population at risk, and all others concerned to eliminate malaria in the Philippines Strategies to achieve our goals: Early diagnosis and effective treatment Utilization of Insecticide Treated Mosquito Nets Immediate and effective responses to malaria epidemics Selective vector control- in areas where it can be afforded and sustained RAPID DIAGNOSIS AND TREATMENT To reduce the duration of illness To prevent complications and death due to malaria

To cure the patient of malaria To help reduce transmission

MALARIA DIAGNOSIS 1. Clinical Diagnosis based on signs and symptoms and history of travel to a malariaendemic area done by all trained health workers especially in areas where microscopic diagnosis is not available within 24 hours 2. Microscopic Diagnosis (GOLD STANDARD) definitive diagnosis of infection is based on demonstration of malaria parasites in blood films 3. Rapid Diagnostic Tests CHEMOTHERAPY GUIDELINES Chloroquine + Sulfadoxine/Pyrimethamine (CQ+SP) first line drug in the treatment of probable malaria and confirmed P falciparum provided disease is not severe . Artemether Lumefantrin (Co-ArtemTM) second line drug given only to microscopically confirmed P falciparum which did . not respond to adequate CQ+SP treatment Not recommended for in pregnant women and children less than 8 yrs of old Quinine + Tetracycline/Doxycycline third line drug should be given to those who did not respond to Co-Artem or if CQ+SP is not available drug of choice in the treatment of severe malaria Tetracycline and doxycycline are contraindicated for pregnant women and children under 8 years old; instead, give Quinine with Clindamycin Primaquine given single dose to confirmed P falciparum cases to prevent . transmission given for 14 days to confirmed P vivax to prevent relapse .

Chloroquine Drug to be used in the treatment of confirmed P vivax . VECTOR CONTROL Selective vector control Targeted, site-specific, cost effective What (control method), When, Where Consider magnitude of malaria problem, epidemiology, levels of transmission and risks, priority groups/areas, technical and operational realities, infrastructure, resources and information The vectors behavior clarified and relates to disease transmission 1. Insecticide Treated Mosquito Nets - Main vector control Target: 1 treated mosquito net per household Coverage should not be less than 85 90% Re-treatment is done every 6 months 2. Indoor residual spraying Kills adult mosquitoes resting on wall surfaces, resulting to reduction of their population. VC method of choice during outbreaks A wettable powder formulation is appropriate Insecticide deposit effectiveness would last 6 months if not wiped/washed off Insecticide and spraying equipment to be provided by GFATM 3. Larviciding and Biological control Larval control (with chemicals or biological agents) is relevant in accessible, manageable breeding sites which are within flight range. Paris green was used in early 1900; Temephos 500 EC was tried in the later part of 1970; Bacillus thuringiensis (a bacterial toxin) was also tried. Larvivorous fishes such as Gambusia affinis and Poecilia reticulata eat larvae of mosquitoes therefore reduce their density. People could propagate these fishes and seed them in the breeding streams. 5. Personal protection measures Chemoprophylaxis recommended for pregnant women in endemic areas or people who temporarily stay in endemic areas.

 Use of Mosquito repellents such as citronella lotion, mosbar, mosban and mosquito coils to minimize bites before retiring to bed under a net and early morning Other protective measures such as burning of dried organic matter, wearing of long sleeves and long pants and tying large animal 20 m from the house.

DENGUE PREVENTION AND CONTROL PROGRAM Endemic in >100 tropical/subtropical countries No specific treatment Spreads rapidly affecting mostly children An environmental issue

Global Situation of Dengue 2.5 B at risk of dengue infection over 100 countries Annual dengue cases 100 M DF / DHF / DSS admission per year 500,000 cases Mortality rate 5% Dengue Cases and Deaths per Region Philippines, 2004 Region I II CAR III IV-A IV-B NCR V VI VII VIII IX X XI XII ARMM CARAGA TOTAL Cases 706 851 456 2739 621 16 3859 1202 1718 1921 1051 505 2542 2657 909 118 739 22610 Deaths 7 4 0 10 6 0 28 10 12 25 2 4 41 61 14 2 18 244 CFR % 0.99% 0.47% 0 0.36% 0.96% 0 0.72% 0.83% 0.7% 1.3% 0.2% 0.8% 1.61% 2.3% 1.54% 1.7% 2.43% 1.08%

Vector - Aedes aegypti Dengue transmitted by infected female mosquito Primarily a daytime feeder Lives around human habitation Lays egg and produces larvae preferentially in containers BIONOMICS OF AEDES A. Aegypti A. Albopictus Feeding habit Resting Habit Oviposition Breeding Habitat Flight Range Host preference Life span

artificial

Day biters Day biters (1-2 hrs after sunrise/(1-2 hrs after sunrise/ 1-2 hrs before sunset) 1-2 hrs before sunset) Indoor Outdoor Lay eggs 60-100 eggsLay eggs 60-100 eggs per batch per batch Artificial containers Natural containers 200-300 meters 200-300 meters Human Human 20 days (male) 20 days (male) 30 days (female) 30 days (female)

Dengue Virus Causes dengue fever & dengue hemorrhagic fever Is an arbovirus Transmitted by infected female mosquitoes Composed of single-stranded RNA Has 4 serotypes (DEN 1, 2, 3 & 4) Each serotype provides specific lifetime immunity & short term cross immunity All serotypes can cause severe & fatal disease Genetic variation within serotypes Some genetic variants within each serotype appear to be more virulent or have greater epidemic potential Signs and Symptoms: Sudden onset of high grade fever which may last 2 to 7 days Joint and muscle pain and pain behind the eyes Weakness Skin rashes maculopapular rash or red tiny spots on the skin called petechiae Nosebleeding when fever starts to subside Abdominal pain Vomiting of coffee-colored matter Dark- colored stools

How is tourniquet test done? Inflate to a pressure halfway between systolic and diastolic levels Maintain compression for 5 minutes Describe an 1 sq. inch on the volar surface of the forearm 1 inch distal from the antecubital fossa Count the petechiae within the prescribed area A POSITIVE TEST IS 20 OR > PETECHIAE Spectrum of Dengue Infection Dengue Hemorrhagic Fever The following must all be present: History of acute fever, lasting 2-7 days; Thrombocytopenia; Plasma leakage (hemoconcentration or pleural effusion or ascites); Hemorrhagic manifestations Dengue Shock Syndrome All of the above criteria for DHF must be present + evidence of circulatory failure manifested as: Rapid and weak pulse; Narrow pulse pressure; Hypotension for age; Cold, clammy skin and restlessness Grading Severity of DHF Grade I Fever, non-specific s/s, (+) TT Grade II s/s of Grade I + spontaneous bleeding; Dengue Shock Syndrome: Grade III - s/s of Grade II with more severe bleeding + evidences of circulatory failure Grade IV - with profound shock, undetectable blood pressure or pulse. Laboratory: Thrombocytopenia + Hemoconcentration Major Pathophysiologic Abnormality DHF/DSS: Acute Increase in Vascular Permeability PLASMA LEAKAGE: leakage of water, electrolytes and plasma

protein Hemoconcentration pleural effusion (by PE, CXR) tender hepatomegaly/abdominal pain hypoproteinemia Outpatient Case: Oral Rehydrating Solutions Daily assessments of patients: Clinical & laboratory May send patient home with advise to watch out for danger signs ORESOL In adults: replace fluids as in moderate dehydration at 75 ml/KBW in 4-6 hrs or up to 2-3 L/day DHF Danger Signs Spontaneous bleeding Persistent abdominal. pain Persistent vomiting Listlessness Changes in mental status Restlessness Moderate to severe dehydration Weak and rapid pulse Cold, clammy skin Circumoral cyanosis Dyspnea Seizures Hypotension Thrombocytopenia - less than 100,000/cu.mm. Hemoconcentration Prevention and Control Cover water drums and water pails at all times to prevent mosquitoes from breeding. Replace water in flower vases once a week. Clean all water containers once a week. Scrub the sides well to remove eggs and mosquitoes sticking to the sides. Clean gutter of leaves and debris so that rain water will not collect as breeding places of mosquitoes. Old tires used a roof support should be punctured or cut to avoid accumulation of water. Collect and dispose all unusable tin cans, jars, bottles and other items that can collect and hold water.

Mag 4 S Against DENGUE! S earch and destroy S elf-protection measures S eek early consultation S ay No to indiscriminate fogging Larval Survey: COMPUTATION OF RESULTS A. HOUSE/PREMISE INDEX (HI) HI = no. of houses (+) for Aedes sp. x 100% no. of houses inspected B. CONTAINER INDEX (CI) CI = no. of containers (+) for Aedes sp. X 100% no. of containers inspected C. BRETEAU INDEX (BI) BI = no. of positive containers total no. of houses inspected x 100

Priotization of Areas Priority 1 - localities where an outbreak of DF/DHF had occurred Priority 2 - localities w/ high larval indices HI >5% and/or BI >20 Priority 3 - localities w/ relatively low larval indices HI <5% and/or BI <20 Priority 4 - localities where there are no dengue cases and low Aedes densities. w/in 24 hrs of the 1st case from an outbreak locality following an outbreak based on priority classification of the locality high risk areas (Priority 1 & 2) = monthly/ quarterly in 100% of houses low risk areas (Priority 3 & 4) = monthly/ quarterly in at least 20% of houses

before and after interventions when there is suspect of insecticide resistance

FILARIASIS PREVENTION AND CONTROL PROGRAM Filariasis - is parasitic infection transmitted by a mosquito 2 Species in the Philippines: - Wuchereria bancrofti - Brugia malayi Vectors: Aedes, Anopheles, and Mansonia

Pathophysiology Microfilariae live for 2 years in the body causing periodic fever attacks Adult worms live for 10 years and when they die granulomas form around them in the lymphatic channels It blocks the flow of lymph causing gross and irreversible chronic deformity (Elephantiasis and hydrocoeles) The disease is considered as a disease of the poor Primarily affects the working age group living in remote and endemic rural areas. Although Filariasis is not a killer disease, it is considered the 2nd leading cause of permanent, long-term disability among infectious diseases. WHO has identified it as one of the eradicable diseases and has called for its global elimination as a priority. DOH A.O. 25 A s. 1998 November - Mass Treatment Month for Filariasis - to improve efficiency and ensure concerted efforts - recommended by the Global Elimination Group - it facilitate program monitoring, drug distribution, drug reapplication and program management. Filariasis endemicity 1. Category 1 provinces with reports within the past 10 years establishing its endemicity : 20 provinces (R 4, 5, 8, 9, 11) 2. Category 2 with no report of endemicity but were reported as endemic in the 1960 prevalence survey : 25 provinces 3. Category 3 without any report of endemicity and considered as non-endemic for the disease : 33 provinces Recent discoveries of new endemic areas 1992 13.6% in Marinduque 1998 17.7% in Cagayan de Oro City National prevalence 9.7 cases per 1,000 population (98 national prevalence survey) Program Goal: Filariasis is eliminated as a public health problem. Health Status Objectives: 1. Reduce the prevalence rate to < 1 case per 1,000 populations in endemic municipalities. ( Baseline: 9.7 / 1,000 in 1998 )

2. Reduce the microfilaria density in endemic municipalities to 4 microfilariae per positive case. (Baseline: 40 mf per + case in 1998, Cagayan de Oro Survey, CDCS) 3. Reduce adenolymphangitis attacks to 1 per year. (Baseline: 3 4 per year in 1994, Global Rate) Diagnosis Demonstration of microfilariae in a blood smear examination conducted at night due to nocturnal periodicity of the parasite (NBE nocturnal blood examination) Prevention and Control Measures Use of mosquito nets Residual spraying Screening of houses Use of protective clothing among plantation workers Elimination of mosquito breeding places Strategy to eliminate the disease Mass Treatment with Diethylcarbamazine (DEC) in endemic localities - administration to patients will be standardized based on weight for age - given with Albendazole 400 mg/single- standardized dose Mass treatment is giving the drug to all population, in an established endemic area whether infected or non-infected with Filariasis. The rationale for mass treatment is that people in endemic area will sooner or later be infected and become a source of infection for others. Coverage Individuals from ages 2 and above living in endemic areas Exclusion Criteria and Special Precautions: > Treatment of pregnant women will be deferred until delivery. > Special precautions in treating individuals with cardiac and kidney diseases should be observed. Selection of Municipalities for Mass Treatment - The presence of at least one endemic barangay in a municipality will make the municipality eligible for Mass treatment Frequency: The combination drugs for Mass Treatment will be given once annually for a minimum of four consecutive years in all established municipalities.

SCHISTOSOMIASIS CONTROL PROGRAM Schistosomiasis is a tropical parasitic disease caused by a blood fluke known as Schistosoma japonicum. It is transmitted through an intermediary host, a tiny freshwater snail identified as Oncomelania quadrasi. The disease is transmitted to a man or animal when they come in contact with bodies of freshwater infested with cercariae coming from snails. The cercariae penetrate the skin of the host, find their way into the blood circulation, then to the liver and into their final habitatthe mesenteric veins in the wall of the intestines where they become adult male and female flukes. The flukes copulate and lay eggs. Through minute ulcers or sores in the intestinal walls, the eggs get inside the gut and are passed out in the feces. Once they reach water, the egg hatch into miracidia which will now seek the snail, thus repeating the cycle. The significance of schistosomiasis is that its primary victims are the rural poor. Farmers and freshwater fishermen make up the occupational groups with the highest prevalence of the disease since they have frequent contact with infested water.

> Access to safe water supply is also one of the peoples primary needs in rural areas where schistosomiasis is endemic. > There is also need to build sanitary toilet facilities that can reduce the prevalence of the disease. > Records show that around 25% of households have no access to safe water while around 40% of households have no sanitary toilet facilities in endemic areas. Health Status Objective 1. Reduce the national prevalence rate of schistosomiasis to 2.5 percent.

Special Target Population School children (1-6 years old)

1997 Baseline 3.78%

2004 Targets 1.79%

Special Target Areas Maguindanao Agusan del Sur Lanao del Norte Surigao del Norte Oriental Mindoro

1997 Baseline 18.91% 18.29% 11.06% 8.95% 5.41%

2004 Targets 10.05% 9.71% 5.88% 4.76% 2.88%

2. Eliminate schistosomiasis as a public health problem in five endemic provinces. (Schistosomiasis is considered eliminated as a public health problem if the prevalence rate is maintained at less 1.0 percent for at least five consecutive years.)
Special Target Areas Davao Oriental Surigao del Sur Zamboanga del Norte Davao del Sur Bohol 1997 Baseline 0.99% 0.90% 0.44% 0.38% 0.17% 2004 Targets 0.47% 0.43% 0.21% 0.18% 0.08%

SEXUALLY TRANSMITTED INFECTION/HIV/AIDS PREVENTION AND CONTROL PROGRAM Reported Modes of Transmission (N=2,484) (HIV/AIDS Registry, January 1984 February 2006) Cumulative Totals Jan. 1984 Feb.2006 N=2,484 Totals for Aug. 2005 N =30

Reported Modes of Transmission

Sexual Transmission Heterosexual contact Homosexual contact Bisexual contact Blood/blood products Injecting drug use Needle prick injuries Perinatal No Exposure Reported TOTAL 1,551 452 135 19 7 3 36 281 2,484 21 7 1 0 0 0 0 0 30

Aims in STI Management 1. Transmission 2. Development of diseases, complications and its consequences 3. Risk of HIV/AIDS Common Sexually Transmitted Infections: Bacterial Gonorrhea Syphilis Chlamydia Chancroid Viral Genital herpes Genital warts Genital molluscum HIV Hepatitis B * Protozoa Trichomonas Fungal Candidiasis Skin Parasites Pubic Lice Scabies

passed on by close body contact and do not require actual penetrative intercourse

Syndromes Vaginal Discharge Gonorrhea, Chlamydia, Candidiasis, Trichomoniasis, Bacterial vaginosis Urethral discharge Gonorrhea, Chlamydia, Trichomoniasis Genital Ulcers Syphilis, Herpes Genitalis Lower abdominal pain in women Scrotal Swelling Gonorrhea, Chlamydia Neonatal eye infection Gonorrhea Preventive Measures A - Abstinence B Be faithful C Correct and Consistent use of Condom D Dont use illicit drugs/ share syringes and needles E Educate you/other Partner Management and Its Importance 4 Cs: 1. Compliance 2. Condom 3. Contact tracing 4. Counseling Strategies 1. STI Case Services 2. Prevention Activities 3. Specialist Services 4. Laboratory Support Levels of Care 1. Primary > Risk reduction CONDOM PROMOTION (CONSISTENT AND CORRECT USE OF CONDOM) Prevention of STI from occurring in the first place popularizing active health seeking behavior 2. Secondary > Risk assessment -

1. Early detection/Screening 2. Promotion of safer sexual behavior 3. Contact tracing 4. Treatment of contact/s 5. Effective treatment and compliance 6. Counseling 7. Universal Precaution 3. Tertiary > Maintain positive sexual behavior 1. Management of complications 2. Prevention of Complication and Sequela 3. Mobilization Wider Base of Multi-Sectoral Support should be expanded RABIES CONTROL PROGRAM Rabies - is a fatal disease caused by the rabies virus, which is transmitted through a bite of an infected animal. The disease affects the nervous system. It usually manifests initially as headache, fever and weakness, then progresses to muscle spasms, paralysis, delirium, and convulsions. > Death - is always an outcome and often due to respiratory paralysis. > Dogs remain the principal reservoir of rabies in the country. Thus, the most cost-effective measure against rabies is the vaccination of dogs. Approximately 300 to 600 Filipinos die of rabies every year. Rabies remains a public health problem in the Philippines. > The Philippines ranked fourth worldwide in rabies incidence in 1996. The incidence of animal bite cases in the country was estimated to be around 400 cases per 100,000 populations. 15 percent of these require active immunization (vaccine) while 40 percent of those requiring active immunization will also need passive immunization (immunoglobulin). The cost of post-exposure treatment is very high, ranging from P4, 000 to P24, 000, depending on the category of bite exposure. Health Status Objectives: 1. Reduce the incidence of human rabies cases to no more than three cases per million populations. (Baseline: 5 per million population in 1997, CDCS and FETP)

2. Eliminate human rabies in Visayas Region 6, 7, and 8(from 3 4 cases per year to 0) Risk Reduction Objectives: 1. Reduce the number of rabid dogs to less than 10 per 100,000dog population. 2. Increase the proportion of households practicing immediate washing of animal bite site with soap and water to 90%. 3. Increase the proportion of households practicing responsible dog ownership (immunizing dogs against rabies and leashing dogs within the yard) to 90%. In view of the 100% case fatality of human rabies, the prevention of rabies infection after exposure is of utmost importance. Prevention and Control: Be a responsible Pet Owner! Have a pet dog immunized against rabies at 3 months old and every year thereafter. Never allow pet dog to roam the streets. Take care pet dog: bathe, give clean food, and provide clean sleeping quarters. IMMUNIZATION 1. Active Immunization (a) Vaccine is administered to induce antibody and T-cell production in order to neutralize the rabies virus in the body. It induces an active immune response (in 7-10 days after vaccination) and may persist for one year or more. (b) The types of anti-rabies vaccine available in the Philippines: a. Purified FreeCell Rabies Vaccine (PVRV)-0.5 ml/vial; b. Purified Duck Embryo Vaccine (PDEV)-1.0 ml/vial; and c. Purified Chick Embryo Cell Vaccine (PCECV)-1.0 ml/vial. (c) All vaccines are considered to be highly immunogenic and safe. For active immunization, any of the three vaccines may be administered either intramuscularly or intradermally. 2. Passive Immunization (a) Rabies Immunoglobulin (RIG) is given in combination with anti-rabies vaccine to provide immediate protection to patients with Category III exposure. RIG has a half life of approximately 21 days. (b) Only rabies vaccines and RIG that have been evaluated and recognized by WHO and approved by BFAD should be used. National health authorities should evaluate any new vaccine or RIG prior to use. (c) RIG is of two types:

 Human rabies Immunoglobulin (HRIG) derived from plasma of human donors administered at 20 IU per kilogram by body weight; and Equine Rabies Immunoglobulin (ERIG) derived from horse scrum administered at 40 IU per kilogram body weight TREATMENT 1. Post-Exposure Treatment a. Local Wound Treatment A.1. Wounds should be immediately and vigorously washed and flushed with soap and water preferably for 10 minutes. A.2. Apply alcohol, tincture of iodine or any antiseptic. A.3. If possible, suturing of wounds should be avoided; however, if suturing is necessary, anti-rabies immunoglobulin should be infiltrated around and into the wound before suturing. A.4. Do not applies any ointment, cream or occlusive dressing to the bite site. A.5. Anti-tetanus immunization and anti microbial may be given if indicated. Animal bites are considered tetanus prone wounds. b. Treatment Regimen b.1. 2 site intradermally Schedule (2-2-2-0-1-1) One dose for intradermal administration is equivalent to 0.1 ml. for PVRV and 0.2 for PDEV/PCECV. One dose should be given at two sites on Days 0, 3, and 7 and at one site on Day 30 and 90 Injections should be given on the deltoid area of each upper arm in adults, or infants, at the anterolateral aspect of the thigh. A one (1) ml insulin syringe with gauge 25 or 26 needle should be used for intradermal injection. A vaccine should be stored within 40.0C and 8.0C and after reconstitution should be used within 8 hours. LEPROSY CONTROL PROGRAM Hansens Disease is a chronic bacterial infection caused by Mycobacterium leprae Mode of transmission: >Airborne inhalation of droplet /spray from coughing and sneezing of untreated leprosy patient >Microorganism may also enter the body through the skin by prolonged intimate contact. Signs and Symptoms

 Long standing skin lesions that do not disappear with ordinary treatment Loss of feeling/numbness on the skin Loss of sweating and hair growth over the skin lesions Thickened and/or painful nerves in the neck, forearm, near elbow joint and the back of knees Health Status Objective: To reduce the prevalence of leprosy to less than 1 case per 10,000 population at the sub-national level. WHO has set the goal of eliminating leprosy as a public health problem by year 2000 In 1998 the Phil. Achieved the elimination goal by attaining the Prevalence Rate of 0.9/10,00 At end of 2000, the PR went down to 0.57/10,00 This was largely due to the nationwide implementation of MDT Diagnosis Based on clinical signs and symptoms, especially if there is a history of contact with Person with Leprosy (PWL) Only in rare instances is there really a need to use laboratory and other investigations to confirm a diagnosis. Slit Skin Smear (SSS) examination is an optional procedure. It is done only when clinical diagnosis is doubtful. Important: A leprosy patient who has completed treatment should no longer be regarded as a case of leprosy, even if some sequelae of leprosy remain (e.g. ulcers or deformities) Classification
Characteristic Single Lesion Paucibacillary (SLPB) Paucibacillary (PB) Multibacillary (MB)

Skin lesions Only one lesion More than 5 2 -5 lesions (Includes macule lesions Asymmetrically flat lesion and distributedDefinite Assymetrically papule raised distributed loss of sensation lesion and Loss of sensation nodule)

Nerve damage No nerve trunk (resulting in loss involvement of sensation or weakness of muscles supplied by the affected nerve

None or one
nerve trunk

Many nerve trunk

Multi Drug Therapy (MDT) - is the accepted standard treatment for leprosy and is proven to be safe and effective. - It is a combination of two or more anti-leprosy drugs that renders the patient non-infectious within one month after starting treatment. MB Regimen: Monthly treatment: Day 1 Rifampicin 600/ 450 mg Clofazimine 300/150 mg Dapsone 100/50mg Daily treatment: Day 2 28 Clofazimine 50 mg Dapsone 100/50 mg Duration of treatment: 12 blister packs to be taken monthly within a maximum period of 18 months PB Regimen: Monthly Treatment: Day 1 Rifampicin 600 / 450 mg Dapsone 200 / 50 mg Daily treatment: 2 28 Dapsone 100 mg Duration of treatment: 6 blister packs to be taken monthly within a maximum period of 9 months. The standard regimens are considered safe for both mother and the child and therefore be continued during pregnancy. Disabilities in leprosy is caused by damage to the peripheral nerves The best way to prevent disabilities: Early diagnosis and prompt treatment with MDT and early recognition of signs and symptoms of nerve involvement and prompt treatment with prednisone.

SOIL - TRANSMITTED HELMINTHIASES The three major cause of intestinal parasitism in the Philippines are: 1. Ascaris lumbricoides, 2. Trichuris trichiura, 3. Hookworms (Anylostoma duodenale and Necator americanus). These parasites are classified as soil-transmitted helminths (STH) because their development happens in the soil, such that geofactors like temperature and humidity primarily determine its distribution. > Soil-transmitted helminthiases is the third most prevalent infection worldwide, second only to diarrheal diseases and tuberculosis, and s ranked 10th among the worlds top 10 infectious disease killers. > Soil-transmitted helminthiases are the number one most important disease burden among those five to 14 years old. This age group has he highest prevalence rate and the greatest source of transmission for the infection. The prevalence of soil-transmitted helminthiases among those two to five years old is lesser, but they suffer the greatest impact from the disease when they get infected. The prevalence of soil-transmitted helminthiases in the Philippines has persisted at high levels above 50% over the years. Mass deworming of children aged two to 14 years old at least twice a year for three consecutive years is required to immediately halt the impact of the disease on children and the community. OTHER PARASITOSES PARAGONIMIASIS - is a zoonotic parasitic disease caused by a group of flukes belonging to genus Paragonimus. > The infection which often involves the lungs has manifestations similar to pulmonary tuberculosis (PTB). >Chronic coughing productive of blood streaked sputum and chest pains are some of the signs and symptoms. >It is frequently encountered in places where people eat raw or inadequately cooked crabs or possibly snails which harbor the infective stage of Paragonimus. >It was first reported in Ilocos Norte in 1963. One hundred eight deaths from 1,800 cases were documented in the same area in 1967. In 1998 and investigation of an epidemic of a mystery disease in Compostela Valley in Bukidnon revealed capillaria parasite.

 There are twice as many males the females affected. Most of the males affected are fishermen who usually eat their catch raw. History suggests ingestion of raw or inadequate cooked small fish, particularly bags it, as the mode of transmission. Intestinal capillariasis is characterized by intestinal malabsorption, chronic diarrhea and borborygmi. HEALTH STATUS OBJECTIVES 1. Reduces the prevalence rate of soil-transmitted helminthiases to less than 50%. 2. Reduce infection rate of other parasitoses in man in endemic areas. RISK REDUCTION OBJECTIVES 1. Ensure 90% utilization of sanitary toilets by all households. 2. Increase the percentage of children 2 to 14 years old washing hands before eating and after using toilet to 90%. 3. Increase children wearing footwear to 100%. SERVICES AND PROTECTION OBJECTIVES 1. Ensure 80% mass deworming coverage of children 2 to 14 years old two times a year for three years and once a year hereafter. MENINGOCOCCEMIA Situationer 81 lab-confirmed cases from September 26, 2004 to March 26, 2005. Also 31 probable and 108 suspect cases. Baguio had the most cases with 38, Benguet had 29 and Mountain Province had 13. Baguio had the most fatalities which was followed by Benguet with a CFR of 21% Epidemiological parameters 90% of cases belong to the lower socio-economic group. There are more in the cases in the 15 to 25 year age bracket. There are more fatalities in the 0 - 7 year age group. There is no predisposing occupation or profession Background Neisseria meningitidis is encapsulated, gram-negative diplococci, the causative agent for meningococcal infections. Acquisition can result in asymptomatic pharyngeal colonization or invasive disease. Presentation can take any one of three syndromes.

PATHOPHYSIOLOGY Humans are the only natural host. Transmission is by direct transfer of respiratory secretions. Infection is preceded by colonization of the nasopharynx. Entry into the bloodstream and introduction to the target sites/organs. 5% become long-term carriers. Virulence factors A polysaccharide capsule which is resistant to phagocytosis. An endotoxin which could be shed in large amounts (blebbing) which accounts for the signs and symptoms. An immunoglobulin A1 protease which cleaves LAMP1 allowing its intra-cellular survival. Frequency In the US: - 1 case/100,000 pop. /year - CFR is 13%. - Outbreak when there are 3 cases or more in a 3 month period or an AR of 10 cases/100,000 pop. - In UK, close to 4,000 cases/yr. CFR of 10%. Peaks at winter months. - In Africa, close to 12,000 cases/yr. and CFR of 13%. Peaks during dry season and ceases with onset of rains. MORTALITY RATES Case fatality rate is approximately 10-12% for meningitis and 20% for meningococcemia. In fulminant infections, rate is as high as 30% and occurs within 24 hours after onset of the disease. The first six hours of the disease remains the most critical period. 3 SYNDROMES: Meningitis Meningitis with meningococcemia Meningococcemia with meningitis History presents with a non-specific prodrome headache and/or sore throat. 5. Followed by fever with chills, myalgia and arthralgia 1. 2. 3. 4.

of

cough,

Physical Findings Tachycardia +/- hypotension Moderate to high grade fever Peticheal rash (80%) becomes rapidly purpuric then ecchymotic CHF, gallops, pulmonary edema

Progression is usually rapid Variations in manifestation dictated by presentation

Lab Studies Definitive diagnosis requires culture from blood, CSF, joint fluid, skin lesions Findings on blood culture are positive in 60-80% of untreated patients. PMN leukocytes are usually elevated Thrombocytopoenia present in 20% of cases. Gram-negative diplococci may be observed in stains from peticheae or buffy coat preparations or from joint fluids. PCR (polymerase chain reaction) is a rapid method for diagnosing CSF infection Management Medical care : - hospitalization is required for severely ill patients with fever, headache and rashes - begin antibiotic treatment promptly - intensive care is necessary for suspected fulminant cases - provide supportive care - surgical care when necessary

ANTIMICROBIALS
Pen G Na Chlramphenicol Ceftriaxone Rifampicin Ciprofloxacin Azithromycin Bacteriostatic Bacteriostatic Bacteriostatic Bactericidal Bacteriostatic Bacteriostatic 250t u IV/4hrs 4M u IV/4hrs 100mg/kg/d. 2g IV red. To 1g daily 600mg BIDx2 500mg SD 500mg SD

Case definition for routine surveillance Clinical Case Definition

 An illness with sudden onset of fever (>38.5 C rectal or >38.0 C axillary) and one or more of the following: - Stiff neck - Altered consciousness - Bulging fontanelle - Non-blanching rash (petechiae, purpura) - Turbid CSF Plus one or more of the following: - Final diagnosis of meningococcal disease by the attending physician - Gram (-) diplococci in the CSF - Positive latex agglutination test for N. meningitides (CSF) Case definition in an Outbreak Situation Suspect Case Definition An illness with sudden onset of fever (38.5 C rectal or > 38.o C axillary) and one or more of the following: - Neck stiffness - Altered consciousness - Bulging fontanelle - Non-blanching rash (petechiae, purpura) Probable Case Definition A suspect case plus one or more of the following: - Clinical diagnosis of meningococcal disease by the attending physician - Gram (-) diplococci in the CSF - Turbid CSF - Increased cell count in CSF Confirmed Case Definition A suspect or probable case with one or more of the following: - Isolation of N. meningitidis from a sterile site (CSF or blood) - Identification of N. meningitidis DNA from a sterile site (CSF or blood) - Positive latex agglutination test for N. meningitidis (CSF) Threshold levels for Outbreak Declaration Sporadic / Isolated case - One case in a province/city/municipality within a month Geographic Cluster of Cases - 2 or 3 cases in a provincial/city/municipality within a month Outbreak - 4 or more cases, with at least one confirmed case, in a provincial/city/municipality within a month Close contacts of a Case

1. Persons living together and sharing sleeping quarters (e.g. people living in the same house, dorm room, boarding house, military barracks, prison cells, evacuation camps) including overnight visitors in the week preceding the onset of the cases illness. 2. Persons who have similar level of close prolonged contact (e.g. boy/girlfriend, barkada). 3. Health care worker or other caregivers who had intimate exposure to nasopharyngeal secretions (e.g. mouth to mouth resuscitation, intubation).

NOT a Close Contact of a Case 1. Persons who do not have close or prolonged contact with the case (e.g. schoolmates or co-workers, cheek kissing, sharing drinking glasses, casual encounters) 2. Persons who are in contact with a close contact. 3. Health care workers without direct exposure to patients respiratory tract secretions. Laboratory Confirmed Case A clinical case with one or more of the following: Isolation of N. meningitidis from a sterile site (CSF or blood) Identification of N. meningitidis DNA from a sterile site (CSF or blood) What has been done Active immunization of frontline health workers and hospital personnel in areas most antibiotic treatment. AVIAN INFLUENZA WHAT IS BIRD FLU? CONTAGIOUS DISEASE OF BIRDS RANGING FROM MILD TO SEVERE FORM OF ILLNESS ALL BIRDS ARE SUSCEPTIBLE, THOUGH SOME SPECIES ARE MORE RESISTANT TO INFECTION THAN OTHERS SOME FORMS OF BIRD FLU INFECTION CAN CAUSE ILLNESS TO HUMANS

Economic and Public Health Implications H5N1 causes severe epidemics and mass death of chickens The poultry industry and food security feared to be greatly affected High mortality to humans Pandemic Potential

Transmission to humans: Close contact with live infected birds through infected aerosols, discharges and surfaces Birds excrete the virus in their feces, which dries and becomes pulverized, and is then inhaled Flapping of wings hastens the transmission WHAT ARE THE SIGNS AND SYMPTOMS OF BIRD FLU IN HUMANS? Following exposure to sick or dead chicken patient develops: Fever Body weakness or muscle pain

Cough Sore throat Dyspnea in severe cases Sore eyes (more than 50% of cases die)

Clinical Stages of AI in humans: 1. Incubation 3 days, range 2-8 days 2. Prodromal Stage 0-1 day High fever (above 38 C, Cough and breathe/pleuritic pain, Watery Diarrhea Abdominal pain Vomiting Bleeding from nose and gums in some 3. Lower Respiratory Stage 1-7 days - Early dyspnea - Inspiratory crackles - ARDS - Multi-organ failure

shortness

of

Recovery in 50% of cases Most cases have died in spite of ventilatory support after about 10 days Individuals at risk 1. Poultry handlers/workers 2. People living near poultry farms 3. Sellers/people involved in live chicken sale 4. Aviary workers 5. Ornithologists 6. Cullers involved in destruction Eating chicken is safe Avian flu is not a food-borne virus Would have to dry out the chicken meat and sniff the carcass to be at any risk Virus is easily inactivated by heat, one does not get bird flu from thoroughly cooked chicken Very low risk of importing the virus in meat or meat products is on domestic flock, rather than infecting people Diagnosis A laboratory confirmation of the bird flu infection and epidemiologic link with unusual death or epidemics of chickens will support the diagnosis of bird flu.

- Virus isolation - RT-PCR (Polymerase Chain Reaction) IS THERE A VACCINE EFFECTIVE AGAINST BIRD FLU? NONE. The vaccine currently available against the circulating strains in humans will not protect against the disease caused by the H5N1 influenza strain. However, it is recommended for individuals who are potentially exposed to avian influenza virus like poultry handlers, workers and breeders to prevent recombination of A1 virus with the human influenza virus. Usefulness of routine influenza vaccines Confer no protection against infection with the H5N1 avian virus. However, the seasonal vaccine may be useful to prevent reassortment of human and avian viruses. Selected groups for vaccination: - cullers involved in destruction of poultry - people living and working on poultry farms - health care workers involved in the daily care of H5N1 human cases - health care workers in emergency care facilities in areas where there is confirmed occurrence of influenza H5N1 in birds. BIRDS THAT SURVIVE INFECTION EXCRETE VIRUS FOR AT LEAST 10 DAYS ORALLY AND IN FECES. HIGHLY PATHOGENIC VIRUSES CAN SURVIVE FOR LONG PERIODS IN TISSUES, WATER AND THE ENVIRONMENT ESPECIALLY WHEN TEMPERATURES ARE LOW. HOW IS BIRD FLU TRANSMITTED TO HUMANS? Inhalation or contamination with infected discharges and feces of chickens It is not a food-borne illness. Easily inactivated by temp of at least 70 degrees Centigrade Use of antiviral agent in avian influenza: Oseltamivir (Tamiflu) Treatment of avian influenza cases: 1 capsule 2x a day, should be given within the first 2 days of illness, 10 capsules/ treatment Prophylaxis for exposed persons: 1 capsule once a day for at least 7 days Cullers and transporters should be provided with appropriate PPE: Coveralls plus an impermeable apron or surgical gowns with long cuffed sleeves plus an impermeable apron Heavy duty rubber gloves that may be disinfected N95 respirator masks or standard well-fitted masks

Goggles Rubber or polyurethane boots covers

or disposable

protective foot

Prevention: Hand hygiene Cleaning and disinfection Avoiding contact with wild birds Safe food practices Practice of proper hand washing and cleaning and disinfection procedures in poultries Stages: STAGE STAGE STAGE STAGE 1 2 3 4 BIRD FLU FREE PHILIPPINES AVIAN FLU IN BIRDS AI VIRUS TRANSMITTED TO HUMANS HUMAN TO HUMAN TRANSMISSION

Exposure: Contact (within 1 meter) with live or dead domestic fowl or wild birds or with persons suspected to have bird flu during the 10 days before the onset of symptoms. Quarantine Exposed persons for 10 days and monitor for signs and symptoms of illness. Quarantine of contacts Stay at home for 10 days Monitor self for fever, cough or difficulty of breathing or any sign and symptoms of illness. Refer sick persons to the Referral Hospital for SARS and other severe emerging infections. Slowing the spread of infection: 1. Personal hygiene cough etiquette, hand washing 2. Social Distancing Reduction of unnecessary travel Staying at home when sick Isolation at home (separate room) and Closure of schools Suspension of public events Closure or limitation of people in public places establishments

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3. Cough Manners Cover your nose and mouth with tissue or handkerchief every time you sneeze, cough or blow your nose. If you dont have tissue, cough into your sleeve. Wash your hands with soap and water. Before touching your eyes, nose or mouth. Before shaking hands with other people. If water is not available, use an alcohol-based hand sanitizer. Dont be offended if someone offers you tissue. Thank the person for the kind act. Dont spit on the floor or on the road. Spit on a trash bin or on a small plastic bag. Put used tissues or plastic bags in the trash bin. Wash used handkerchiefs separately from clothing. As much as possible, stay at home when you are sick. Maintain a safe distance of 1 meter from other people when you are sick. Do not share eating utensils, drinking glasses, towels or other personal items. INTEGRATED PREVENTION AND CONTROL OF LIFESTYLE-RELATED DISEASES RATIONALE: The Department of Health, cognizant of the increasing prevalence of lifestyle related diseases, has taken as one of its priorities for the Promotion of Healthy Lifestyles. IT AIMS TO: 1) Raise the awareness of the Filipinos on the need to practice healthy lifestyles. 2) Raise the consciousness of policy makers on the need to provide the Filipinos with an environment supportive of healthy lifestyle. BACKGROUND: There are five major chronic, non-communicable lifestyle related disease: Cardiovascular diseases, cancer, chronic obstructive pulmonary diseases, diabetes mellitus and kidney diseases. 50% of these diseases accounts global burden; 7 out of 10 leading causes of death in the Philippines( source PHS, 2002)

CAUSE OF DEATH 1. Diseases of the heart 2. Diseases of the vascular system 3. Malignant neoplasm 4. Pneumonia 5. Accidents 6. Tuberculosis, all forms 7. Chronic obstructive pulmonary disease and allied conditions 8. Certain conditions originating in the perinatal period 9. Diabetes mellitus 10. Nephritis, nephritic syndrome and nephritis

Mortality: ten (10) leading causes Number, Rate/100,000 Population & Percent Distribution, 2002
NUMBER 70,138 49,519 38,821 34,218 33,617 28,507 19,320 14,209 13,922 9,192` RATE 88.2 62.3 48.8 43.0 42.3 35.9 24.3 17.9 17.5 11.6

THE FRAMEWORK OF THE PROGRAM: It calls for a comprehensive, integrated, community based approach that follows the health promotion action areas. Comprehensive approach means: 1. Primary level- preventing the emergence of the risk factors in the first place or reduction of exposure for risk factors. 2. Secondary level- prevention and control means focusing on risk screening and lifestyle modification prompt diagnosis and treatment 3. Tertiary level- prevention focuses on disease management and rehabilitation. Non-Communicable Diseases Program 1. National Cardiovascular Diseases Prevention and Control 2. Philippine Cancer Control Program 3. Renal Disease Control Program