COMPILATION OF

DOH PROGRAM
STANDARDS AND
PROTOCOLS

COMPILED BY:

Gracebel Actub Angeles, M.D., M.P.H.

Medical Specialist IV
Provincial Health Office, Mis. Or.

Ms. Marlene Tadeo Lamparero

Health Education Promotion Officer ll
Provincial Health Office, Mis. Or.

Ms. Erwin Englatera Villaver

Assistant Statistician
Provincial Health Office, Mis. Or.

COMPILATION OF DOH PROGRAM STANDARDS AND PROTOCOLS

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Mandate: Executive Order No.102

Vision:
The Leader, Staunch Advocate and Model for promoting Health for all
in the Philippines.

Mission:
To guarantee equitable, sustainable and quality health for all Filipinos,
especially the poor, and to lead the quest for excellence in health.

DOH Overall Goals

Reform for the Health Sector –

Improving the way health care is delivered financed and regulated and
that shall ensure achievement of goals.

National Objectives for Health (2005 – 2010)

Focus:
A. Public Health Programs:
> Prevention and Control of Infectious Diseases
> Prevention and Control of Degenerative Diseases and Lifestyle-Related
Diseases
 Management of Health Risk and Promotion of Healthy Lifestyle
 Protection and promotion of Family Health and Health of Special
Population

B. Institutional Management Support System

1. Health System:
 Governance
 Health Care Financing
 Service Delivery
 Health Regulation

2. Management System
 Procurement
 Knowledge management
 Human resource
 Critical Infrastructure

FOURMULA ONE FOR HEALTH

Implementation Framework for Health Sector Reform

FOURMULA ONE FOR HEALTH as Overall Frame

 Goals
- Better health outcomes
- More responsive health system
- Equitable health care financing

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“Speed, precision, and effective coordination towards improving
the efficiency, effectiveness & equity of health care delivery.”

 Four Thrusts
– Financing (increased, better and sustained)
– Regulation (assured quality and affordability)
– Service Delivery (ensured access and availability)
– Governance (improved performance)
 Strategic Guideposts
– Building upon gains and lessons from major reform initiatives
– Focus on critical interventions to be implemented as a single
package
– Sector wide management of FOURMULA ONE implementation
– NHIP as the primary instrument

Constraints and Opportunities:

• Restricted government health budgets
– Inflexible allocation across categories
– Allocation among programs not linked to performance
• Difficulty in managing a highly decentralized system
– steering various stakeholders (i.e.– local systems, private
markets)
– Managing health finances from multiple sources
• Deeper understanding of and increasing leverage of the NHIP over
health system performance
• Inroads in health reforms in at least 30 provinces resulting in
improvements in health outcomes and providing invaluable lessons
• Growing support for health sector reform implementation from
partners – government agencies, external
• Deeper understanding of reform implementation requirements
• Revitalized support from national leadership

Critical Components to Jump Start FOURmula ONE Implementation

FINANCING
Goal:
Secure increased better and sustained investments in health to improve
health outcomes especially of the poor.

Rationalization of Sources of Health Financing

 Out-of-Pocket
– Shift of OOP to outpatient care (e.g. check-up, consultation, etc)
 Local Government
– Focus subsidy on preventive and promotive health services

 National Government
– Shift resources on regulation, governance and to
teaching/training tertiary hospitals

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  Social Health Insurance
– Focus on in-patient care

Local Health Financing Reforms

 Earmarking funds and prioritizing health services

– Social marketing/advocacy to LGUs, NGOs & private sector to
earmark funds for priority health programs
– Identify tools for prioritizing health services (eg. segmentation
and targeting the poor)
– Rationalize pricing/costing policies for priority programs

 Management/coordination of LGU health fund

– Integrate national and local investment plan
– Cost-sharing arrangements among LGUs
– National and local coordination of funds
(eg. Counter parting arrangements)
– Rapid estimation of local health accounts

National Health Financing Reforms

 Public finance management system

 Institutionalization of revenue-enhancement measures
– Full retention of income
– Asset management
 Development of efficient and equitable allocation mechanisms
– Priority health programs
– Geographic
– Income
– Population groups
 Performance based-budgeting system
– Develop models for hospital, public health and regulatory
agencies
– Reform financial management and procurement system
– Develop / implement performance audit and review system

Expansion of the NHIP

 Increase membership and collections

 Enhance benefit package
 Improve utilization of reimbursements
 Enhance systems for regulation and governance

REGULATION

Goal:

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Assure access to quality and affordable health products, devices, facilities
and services especially those used by the poor.

Strategies
 Harmonizing & streamlining of systems, processes for licensing &
accreditation & certification
 Developing a seal of approval system
 Pursuing cost recovery with income retention for health regulatory
agencies & other revenue generating mechanisms
 Ensuring access of the poor to essential health products

Components of the Programs include:

 One-stop shop
 PhilHealth-Sentrong Sigla seal
 Unified seal of approval
 Botika ng Barangay/Pharma 50

SERVICE DELIVERY
Goal:
Improve accessibility and availability of basic and essential health care for
all, especially the poor.

Strategies
 Making available basic and essential health service packages by
designated providers in strategic locations
 Assuring the quality of both basic and specialized health services
 Intensifying current efforts to reduce public health threats

Components
 Public health development plan
a) Disease-free zones – “mopping up” leprosy, schistosomiasis,
filariasis, malaria, rabies
b) Intensified disease programs – TB, HIV/AIDS, and emerging
infections
c) Improving reproductive health outcomes – MMR, IMR, U5MR,
TFR, CPR
d) Intensified promotion of healthy lifestyle – DM, HPN, CVD, breast and
cervical cancer, anti-smoking, safe water, sanitation, among others

 Health facilities development plan

 Rationalizing facilities
 Critical upgrading of facilities through fund pool
 Rationalizing services in DOH-retained, local government &
private facilities inside the 16 sites
 Integrating wellness services in hospitals
 Strengthening disaster and epidemic management system to include
improved surveillance

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  Intensification of health promotion /Establishment of National Health
Promotion Foundation

GOVERNANCE
Goal:
Improved health system performance at the national and local levels

Components
 Sectoral Development Approach for Health
 Health Human Resource Master plan
 Establishment of 4-in1- F1 Sites
 Philippine Health Information System
 Procurement and Logistics Management System
 Public Finance Management System

VITAL STATISTICAL RATES AND RATIOS

STATISTICS:
• Refers to the science dealing with the collection, organization, analysis
and interpretation of numerical data.

PLURAL SENSE- is used to refer to a set of data or a mass of observation.

Ex. A. Public Health Statistics
Vital statistics: data on vital events e.g. births, deaths and
marriages
Morbidity and mortality statistics
Service statistics: # of sputum (+) identified # of FP new
acceptors

B. Hospital Statistics
Number of admissions and discharges
Bed Occupancy rate
Average length of stay

SINGULAR SENSE- is used to refer to the body of methods for the

organization and analysis of collected information.

Ex. A Descriptive Statistics

- The different methods applied in order to summarize and
present the data in a form that will make them easier to
analyze and interpret

B. Inferential Statistics
- The methods involved in order to make generalizations and
conclusions about a target population, based on results from a
sample.

Qualities of Statistical Data

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 1. Timeliness- refers o the interval between the date of occurrence of the
different events considered and the time the data is ready to be used
or disseminated.
2. Completeness- two components:
A. completeness of coverage—
“Does the data cover the entire geographic area and target population
within the area of interest?”
B. completeness in accomplishing all the items in every form.
3. Accuracy- refers to how close the measurement or the data is to its
true value.
4. Precision- refers to the extent to which similar situations obtained
when a
measurement is performed or an observation is made more than
once; it therefore
refers to the repeatability or the consistency of the information that
was collected.
5. Relevance- the consistency of the data produces with the needs of the
data users.
6. Adequacy- “Does the collected data provide all the basic information
needed to
meet the requirements of the users?”

Vital Statistical Rates and Ratios

Indices of Fertility:

CRUDE BIRTH RATE (CBR) =

Number of registered live births in a year x 1000
Midyear population

CBR of PROVINCE X in 2001:

7,113 X 1000 = 29.41 per 1000 population
241, 882
- The rate is crude because the denominator is the total population
which includes males, children and elderly who are not capable of
giving birth.

CBR is affected by:

1. Fertility/ marriage patterns and practices of a place

2. Sex and age composition
3. Birth registration practices

GENERAL FERTILITY RATE (GFR) =

Number of registered live births in a year X 1000
Midyear population of women age 15-44 years of age

MORTALITY RATES:
CRUDE DEATH RATE (CDR) =
Number of deaths in a calendar year X 1000
Midyear population

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CDR of City Z in 2002= 1148 X 1000
155,511
= 7.38/ 1000 population

Factors which affect the level of this rate:

1. Age and sex composition
2. Adverse environmental and occupational conditions
3. Peace and order conditions

CAUSE-OF-DEATH OR MORTALITY RATE=

Number of deaths from a certain cause
In a calendar year X F
Midyear population
Factors:
1. Completeness of registration of deaths
2. The composition of the population
3. Ascertainment level in the community
Specific mortality rates:
Number of deaths in a specified group
in a calendar year XF
Midyear population of the same Specified group

Age- specific mortality rate

Sex- specific mortality rate
Cause-age- specific mortality rate
Cause-sex- specific mortality rate
Cause-age-sex- specific mortality rate

INFANT MORTALITY RATE (IMR) =

Deaths under 1 year of age in
a calendar year X 1000
Number of live births in the same year
- This is a sensitive index of the level of health in a community

A high IMR means low level health standards:

1. Poor maternal and child health care
2. High malnutrition
3. Poor environmental sanitation
4. Deficient health service delivery

FETAL DEATH RATIO (Stillbirth Rate) =

Number of fetal deaths 28 weeks
Or more gestation X 1000
Total live births

PERINATAL MORTALITY RATE=

Number of fetal deaths (stillbirths) +
Infant deaths below 1 wk X 1000
Total of live births

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MATERNAL MORTALITY RATE (MMR) =
Number of deaths due to pregnancy,
Delivery, puerperium in a calendar yr. X 1000
Number of live births in the same year

PROPORTIONATE MORTALITY RATIO =

Number of deaths from a particular
Cause or population group in a year X 100
Total deaths in a year

CASE FATALITY RATE (CFR) =

Number of deaths from a particular cause X 100
Number of cases of the same diseases

PROPORTIONATE MORTALITY INDICATOR or SWAROOP’S INDEX =

Deaths all causes among 50 years old
And above X 100
Total deaths, all causes
MORBIDITY RATES:

INCIDENCE RATE=
Number of new cases of a disease
Over a period of time XF
Population at risk

PREVALENCE RATE=
Number of existing cases (old and new)
At a point in time X 100
Total population

INTEGRATED PUBLIC HEALTH PROGRAMS

The Department of Health’s (DOH) Quality in Health (QIH) Program

seeks to institutionalize the Continuous Quality Improvement or CQI in
health care in order to create health impact in terms of health promotion
and diseases prevention and control.

GOAL:
To ensure that the health facility and staff promote public health
programs and prevent and control public health problems through direct
patient/client care and support that are consistent, well planned and well
executed.

SCOPE:
 Integrated Women’s Health - Safe Motherhood and Family Planning
 Child Care
 Prevention and Control of Infectious Diseases

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  Integrated Prevention and Control of Lifestyle – Related Diseases and
Environmental Health

Reproductive Health
Is a state of complete physical and social well-being and not merely the
absence of disease or infirmity in all matters relating to reproductive system
and its functions and processes.
ELEMENTS OF REPRODUCTIVE HEALTH

EXISTING:
 Family Planning
 Maternal and Child Health
 Prevention and treatment of Reproductive Tract Infections/ STI,
HIV/AIDS
 Breast and Reproductive Tract Cancers and other Gynecological
Conditions
Emerging:
 Education and Counseling on Sexuality/ Sexuality Health
 Violence Against Women
 Adolescent Reproductive Health
 Prevention of Abortion & Management of its complications
 Prevention and treatment of Infertility & Sexual Disorders
 Men’s Reproductive Health

WOMEN’S HEALTH

VISION
“Healthy empowered Filipino mothers able to make decisions for
themselves and their families and to contribute to the socio-economic
development of the Philippines”.

MISSION

“The Department of Health (DOH) in partnership with the Local

Government Units (LGUs), private sector and other agencies concerned with
the health of Mothers shall commit to lead and provide quality maternal
health services to make pregnancy, childbirth and motherhood a safe
experience for all mothers.”
GOAL
“To improve the well being of mothers through a comprehensive
approach of providing, preventing, promotive, curative and rehabilitative
health care.”

THE FOUR PILLARS OF SAFE MOTHERHOOD INITIATVE

1. ANTENATAL.
2. POSTNATAL
3. EMERGENCY OBSTETRIC CARE

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 4. FAMILY PLANNING

Maternal Mortality Rate

Countries 2002
Indonesia 385
Philippines 170
Malaysia 41
South Korea 20
Japan 8
Singapore 4

(Rate: per 100,000 live births)

 MMR was highest in ARMM and Northern Mindanao

 MMR lowest in NCR and Southern Tagalog
 Maternal deaths contribute to 14% of all deaths among women 15 – 49
years old
 MOST OF THESE DEATHS CAN BE PREVENTED THROUGH QUALITY

MATERNAL CARE!
Mid decade Goal: Reduce maternal mortality
rate by ¾ by 2015
MMR ’93 = 209/100,000 live births

Year Target Year Target

2005 160 2011 110
2006 155 2012 105
2007 145 2013 90
2008 140 2014 60
2009 135 2015 43
2010 129

Total Fertility Rate

 Refers to the total number of births that a woman would have at the
end of her reproductive life.
 An important indicator in assessing the impact of programs on family
planning and reproductive health.

’98 NDHS: RP = 3.7 Malaysia = 3.2

Indonesia = 2.3 Thailand = 2
Singapore = 1.7 2004: RP = 3.8

EARLY SIGNS OF PREGNANCY

 Menstruation stops
 Nausea and vomiting
 Frequent urination
 Feeling lazy and sleepy
 Enlargement of the breast

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 Danger Signs of Pregnancy

1. Vaginal bleeding – no matter how little, if it occurs during pregnancy

2. Puffiness of the face and hands
3. Headache, dizziness, blurring of vision
4. Hypertension – blood pressure rises to 140/90 and above
5. Signs of labor before the 9th month of pregnancy
- breaking of bag of water
- Abdominal pains / contractions

High Risk Pregnancy

 Certain conditions predispose a woman to be at risk during pregnancy:

 1. Age less than 18 or > 35 yrs old
 2. Being less than 145 cm (4’9”) tall.
 3. Having one or more of the ff:

- Previous caesarian section

- 3 consecutive miscarriages
- Postpartum hemorrhage
 4. Having one or more of the following medical conditions:
 - tuberculosis, heart disease, diabetes, bronchial asthma, goiter

Quality pre-natal care

Target client: 15 – 49 years old

> At least 4 visits for the duration of pregnancy
 TT immunization (for this pregnancy or in the past)
 Vitamin A capsule (VAC) – 10,000 IU 2X a week starting on the 4th
month of pregnancy or multiple micronutrients vitamins daily
 Prenatal ca/iron / folate supplementation (at least 180 tablets)
 Advice on birth plan
 Advice/counseling on breastfeeding, danger signs of pregnancy, FP
and STI/HIV/AIDS prevention
 Physical and abdominal examination services:

Tetanus Toxoid Immunization

 Tetanus can start from unclean instruments used during cord cutting
and improper cord treatment
 - Tetanus in the newborn can be prevented by giving Tetanus Toxoid
(TT) injections to the mother at least twice given one month interval to
protect both the baby and mother
 - When a mother has received a total of 5 injections, all the babies that
she will deliver should have been protected.

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 TETANUS TOXOID IMMUNIZATION SCHEDULE FOR PREGNANT WOMEN

Vaccine
Minimum Age/Interval Duration of Protection

First contact ( even - no protection will be given as yet

TT1 in the fist trimester) to both mother and infant

- Infants born to the mother will be

TT2 At least 4 weeks after protected from neonatal tetanus
TT1
- infants born to mother will be
protected from neonatal tetanus
TT3 6 months after TT2 - gives 5 years protection to mothers

- infants born to mother will be

protected from neonatal tetanus
TT4 one year after TT3 - gives `10 years protection for the
mother

- gives a lifetime protection for the

TT5 one year after TT4 mother
- all infants born to that mother will
be protected

Emergency Obstetric Care

> 80% of births are delivered by skilled birth attendants – doctors,
nurses, midwives
>RHUs and BHs converted to lying-in clinics – Maternity Care Package
(P4, 000)

BREASTFEEDING (Benefits to Mothers)

 When the baby is immediately allowed to suck on the breast right

after delivery, the mother’s chances of bleeding after the delivery are
considerably reduced. This is because suckling the breast will
stimulate contraction of the uterus.

3 E’s on Breast feeding:

 EARLY: Mother should start right after delivery.
 EXCLUSIVE: Mother will feed her baby only on breast milk up to 6
months.
 EXTENDED: Mother should continue for 2 years.

Benefits to Mothers:

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  Exclusive breastfeeding during the first 6 months will delay the next
pregnancy.
 It is convenient in terms of not having to prepare a bottle. All she has
to do is to
give her breast and the baby is fed. The mother can also sleep while
feeding.

* Remember that crying after breastfeeding is not a sign that a baby needs
formula or other solutions. It normally means that the baby wants to be held
and cuddled more. Some babies need to suck the breast simply for comfort.

Advantages of Exclusive Breastfeeding

 1. Breast milk is easily digested

 2. It is always ready for the baby and needs no preparation
 3. It never grows sour nor spoiled
 4. It helps stop bleeding after delivery
 5. It helps protect the mother against another pregnancy
 6. It enhance bonding for the mother and the baby
 7. It is cheap and available anytime
 8. Breast milk prevents illness

Postnatal care services

 Physical and abdominal examination

 Vitamin A 200,000 IU within 1 month after delivery
 Iron supplementation (at least 90 tablets)
 Counseling on BF, FP, personal hygiene, newborn care, and
STI/HIV/AIDS prevention

QUALITY STANDARDS:

1. Activities for pre-pregnancy preventive and promotive services for

women of reproductive age (15-49 years old).
2. Provision of appropriate prenatal care to pregnant women – thru HBMR
3. Midwives are able to provide appropriate natal care – review of
partograph
4. Provision of appropriate postnatal care -
Review HBMR of 1 woman who delivered w/in past 6 mos.
5. Detection and management complications of pregnancy at various
stages.
- review TCL & look for danger signs according to Midwives’ Manual on
Maternal Care:
 Any type of vaginal bleeding
 Headache, dizziness, blurred vision
 Puffiness of the face and hands
 Being pale or anemic
6. Conducts maternal deaths review.
7. Encourages pregnant women to have their family support them in proper

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maternal nutrition, physical activities, and planning for her labor and
delivery.
8. Conducts community level activities and advocacy campaigns on safe
motherhood to include family planning.
 To come for early and regular prenatal care
 Proper maternal nutrition
 Promotion of healthy lifestyle
 TT vaccination
 Child spacing
 Fertility awareness
 Voluntary blood donation
9. Provision of clients information on family planning
10. Provision of clients information on Family Planning.
11. Couples currently using family planning methods are using the method
correctly.

FAMILY PLANNING

Goal
Universal access of Family Planning information and services for men and
women or couples of reproductive age.

Family Planning is:

 Having the number of children based on the couple’s belief, health,
and economic situation.
 Spacing births properly.
 Making sure pregnancies only occur only during the right time in a
mother’s life.
 Helping childless couples have children.

Policy Statements
 FP as a health intervention
 FP prevents high risk pregnancies
 FP reduces maternal deaths
 FP prevents abortion
 FP responds to the unmet needs and demands of women of
reproductive age
 FP as a means to attain sustainable development

FOUR PILLARS IN FAMILY PLANNING

 Responsible Parenthood
 Birth spacing
 Respect for life
 Informed choice

Principles
 Responsible parenthood
 Birth spacing

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  Informed choice
 Respect for Life
 Privacy and Confidentiality
 Multi-agency participation and partnership

Categories of FP Services
 FP Promotion
 FP Counseling:
G - Greet clients
A - Ask clients about themselves
T - Tell clients about choices
H - Help clients to make informed and voluntary
choices
E – Explain fully how to use the chosen method
R – Return visits should be welcomed

 Provision of FP methods
 Benefits for the Mothers:
* It delays pregnancy until the mother is ready to have another
baby.
* It provides a mother who may be suffering from some chronic
illness
(e.g., TB, diabetes, anemia, etc. enough time for treatment and
recovery
* It prevents young mothers (below 18 years old) and old mothers
(above
35 years old) from getting pregnant because it is dangerous at
their age.

FAMILY PLANNING METHODS

NATURAL FAMILY PLANNING (NFP)

How it works:
 A technique of determining the fertile period of a woman by observing
the physiologic signs and symptoms of the fertile and infertile phases
of the menstrual cycle to avoid or achieve pregnancy.
 FIVE types of modern NFP are:

o BASAL BODY TEMPERATURE(BBT)

o CERVICAL MUCUS METHOD OR BILLING’S OVULATION
METHOD
o SYMPTO-THERMAL METHODS
o STANDARD DAYS METHOD(SDM)
o TWO-DAY METHOD

Advantages of NFP:

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  No health-related side effects
 The method increases self-awareness and knowledge of human
reproductive functions
 Can promote involvement of male sexual partner
 Acceptable to couples regardless of culture, religion, socio-economic
status and education

Disadvantages of NFP:
Not recommended unless couples are willing to follow all the rules.
o Demands commitment, cooperation and communication
between both partners.
o Woman has to keep daily records of her signs and
symptoms of fertility.
o Some couples experience emotional stress due to need to
abstain from intercourse of certain days.
Precautions:
 Method not advisable for:
• Couples who cannot communicate with each other about sexual
matters
• Couples with unstable relationship
• Women who cannot or are not willing to observe, record &
interpret fertility signs and symptoms
• Couples not willing to abstain from sexual intercourse during the
fertile phase of the woman’s cycle

Common Side Effects of NFP:

• emotional stress
• wrong calculations resulting to pregnancy

LACTATIONAL AMENORRHEA METHOD (LAM)

How it works:
A woman who continues to fully or almost fully breastfeed her infant
and who remains amenorrheic during the first six (6) months after delivery is
protected from pregnancy during that time.

Advantages of LAM
• no artificial device used
• can be used by women without medical assistance
• inexpensive
• convenient

Disadvantage of LAM:
• possibility of getting pregnant if the mother does not observe
exclusive breastfeeding

There are no Precautions and Common Side Effects for Lactational

Amenorrhea Method (LAM)
For NFP user using Cervical Mucus Method

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WHAT TO OBSERVE:
• The occurrence of dry or wet mucus and feeling of dryness or wetness.
How to observe mucus secretions:

By inspecting the underwear regularly for the presence of mucus, or wiping

across the vagina with a piece of clean tissue paper to examine any mucus.
Do these throughout the day then make an overall assessment of the mucus
at the end of the day.

HOW TO SCHEDULE SEXUAL INTERCOURSE DURING NO MUCUS SEEN AND

ONE FEELS DRY;
• Follow “early days rule” (EDR). May have sexual intercourse every
other night. Discharge (semen) from the partner during intercourse
will affect the feeling of wetness so have to check the status of mucus
during the no sex days.

How to schedule sexual intercourse if you see paste like, flour like, opaque
and sticky mucus and you feel dry?
- May have sex in all days and anytime of the day.

How to schedule sexual intercourse if you see egg white like, stretchy,
slippery and clear or watery mucus and you feel wet?

• Abstain from sex. May have sex only until 2 days after: peak day” or
the last day of wetness.
For NFP User using Basal Body Temperature Method
What to observe:
• The rise and fall of body temperature all throughout the menstrual
cycle

How to observe body temperature:

•Take temperature every morning upon waking up and before any
activity such as urinating, drinking and eating. It is done at the same time
every day after at least three hours of undisturbed rest. The temperature is
taken by placing the thermometer under the tongue (oral) at the axilla,
vagina or rectum using ordinary thermometer.

When to abstain from sexual intercourse:

• From Day six after menstruation up to the second elevated
temperature following the thermal shift.

For NFP user using Sympto- thermal method:

What to observe:
• Observe mucus and body temperature, plus observing other signs of
ovulation.

How to observe your mucus:

• By inspecting underwear regularly for the presence of mucus, or
wiping across the vagina with a piece of clean tissue paper to examine

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 any mucus. Does this throughout the day then make an overall
assessment of the mucus at the end of the day?

How to observe your body temperature

• Take the temperature every morning upon waking up and before any
activity such as urinating, drinking and eating. It is done at the same
time everyday after at least three hours of undisturbed rest.
• The temperature is taken by placing the thermometer under the
tongue (oral) at the axilla, vagina or rectum using ordinary
thermometer.

What signs of ovulation to observe?

• Breast tenderness or tingling sensation
• Mid-cycle pain- dull ache or sharp ache on one side of lower abdomen
• Spotting or bleeding
• Abdominal heaviness

What to do if the fertile days in the mucus method and the infertile days on
the BBT method coincide
• By using whichever has the longer infertile period.

Pill
How it works:
• It is an oral contraceptive composed of synthetic hormones,
which, when taken regularly prevents pregnancy.

Advantages of Pill:
• easy and effective
• relieves the tension of a woman during her ovulation period
• does not interrupt the sexual activity of the couple
• reduces dysmenorrhea
• prevent anemia

Disadvantages of Pill:
• needs to be taken daily
• decreases milk production for some women
• dependent on availability of supply
Precautions:
 Not advisable when:
 Pregnancy either known or suspected
 suffering from or has a family history of diseases like high blood
pressure, weak heart, cancer of the breasts and others
 The woman is over 35 years old and a heavy smoker (15 or more
cigarettes a day)

Common Side Effects of Pills:

- dizziness
- headache
- vomiting

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 - spotting
- weight gain or weight loss
- fullness of breasts

When to take the Pill?

• When to take the 28 day cycle pill?
Take the first pill preferably at day 1 of menses but can also be start at
day 1-5, then take one pill daily until the whole packet is consumed. Start
the new packet as soon as one packet of the 28 day cycle is consumed
without missing a day and without waiting for the menstrual period to begin.

If you missed taking one pill, what do you do?

1. Take the missed pill at once.
2. Take the next pill at the regular time.
3. Take the rest of the pills as usual, one each day.
If you missed two pills…
1. Take two pills as soon as you remember.
2. Take two pills the next day and use a back-up method like condom
If you missed three pills…
1. Stop taking the pill.
2. Wait for withdrawal bleeding.
3. Proceed to another pack of pill. In the meantime, use a back up
method like condom.
If you missed taking more than 3 pills …
Consult a health service provider.
How often do you go to the clinic for re-supply?
Every month, near the end of each cycle of pills

What are the warning signs to watch out for in taking the pills?

• A- abdominal pain (severe) gall bladder disease, hepatic adenoma,

blood clot, pancreatitis
• C-hest pains (severe) cough, shortness of breath, fluid in the lungs, MI
(heart attack)
• H-headache (severe), dizziness, weakness, numbness, stroke or
hypertension.
• E-eye problems (vision loss or blurring) speech problems, strokes,HPN,
temporary vascular problems of many possible sites
• S-severe leg pain (calf or thigh) blood clots in the legs
M – missing period

• Other danger signs: depression, jaundice, breast lumps

What to do if you have the warning signs…

• Go to the nearest health center for further examination

DEPO MEDROXYPROGESTERONE ACETATE (DMPA)

How it works:
• This is a 3-month injectable contraceptive. It prevents ovulation
so there is no egg to be fertilized. Also, the mucus produced by

20
 the cervix is thick. This plugs the cervix, making sperm
penetration difficult.
Advantages of DMPA:
• Most convenient to use
• Long lasting (3 months)
• does not interfere with sexual intercourse
• Highly effective

Disadvantages of DMPA:
• increased appetite leading to weight gain for some women
• Long acting & cannot easily be discontinued or removed from the
body in case of complications
• Delay in return of fertility after discontinuing DMPA

Precautions
 Not advisable for a woman who:
 is pregnant or may be pregnant
 has vaginal bleeding of unknown cause
 has breast cancer
 Has no menstruation but not related to pregnancy or breast
feeding.

Common Side Effects of DMPA:

 Absence of menstruation by the 12th month of use
 Irregular, prolonged menstruation and spotting in the first 3-6
months of use
 Possible weight gain

INTRA-UTERINE DEVICE (IUD)

How it works:
 It is a small plastic device introduced into the uterus to
prevent pregnancy. The new types of IUD prevent
fertilization of egg by the sperm.

Advantages of IUD:
 No fear of getting pregnant
 does not interrupt sexual activity
 does not disrupt breastfeeding
 It is easy to use with few instructions to remember
 can be easily removed by health worker

Disadvantages of IUD:
 May be expelled from womb
 Does not protect against AIDS and other STIs
 Requires trained personnel for insertion and removal

Precautions

21
  Not advisable for women who:
 is pregnant or think she is pregnant
 has different sexual partners
 has never had children
 has infection of the reproductive system

 Common Side Effects of IUD:

 experience pain during and immediately after the IUD insertion

 experience heavy or irregular menstruation

How to check if the IUD is in place?

Check the IUD after every menses. Clean the hands before checking the
IUD. Insert the index finger into the vagina and feel for the presence of
string at the cervical os. Check also the menstrual cloth or pads, toilet bowl
for the possibility of expulsion during menstruation.

When to return for follow up to the health facility…

• On the 1st, 6th, 12th month after IUD insertion and once a year
thereafter
• Whenever there are warning signs present.

Warning signs to watch out for when using IUD…

• P-period late (with symptoms of pregnancy such as nausea, tender
breast, etc.)
abnormal spotting or bleeding
• A-abdominal pain
• I- infection or abnormal vaginal discharge
• N-not feeling well, has fever or chills
• S- string is missing or has become shorter or longer

Bilateral Tubal Ligation (BTL)

How it works:
 Through surgery, a woman’s fallopian tubes are tied and this
blocks the ovum from coming in contact with the sperm. This is
permanent method of preventing pregnancy for women.

Advantages of BTL:
 Effective and safe
 Easy to perform
 Permanent
 No long term side effects
 Does not interfere with sexual activity

Disadvantages of BTL:
 Has to rest for several days after the operation
 Cannot be easily reversed
Precautions

22
  Operation not advisable to:
- Couples who may want more children
- Women below 25 years old
- Women pregnant or may be pregnant
- Women too fat
- Women severely malnourished
- Women with goiter, diabetes or hypertension

Common Side Effect of BTL:

o Tubal pregnancy but very rare

Vasectomy (for men)

How it works:
- Through surgery, the doctor cuts the vas deferens which carries
the sperm from the testicle to the penis. The semen that comes
out during sexual intercourse no longer contains sperm and will
no longer make a woman pregnant.

Advantages of Vasectomy:
- Effective and safe
- Easy to perform
- Permanent
- No long term side effects
- Does not interfere with sexual intercourse

Disadvantages of Vasectomy:
o Requires the assistance of a trained doctor
o Has to wear a condom or use any other family planning
method after the operation or until the tubes have no
more sperm cells in them (15-20 ejaculations)

Precautions
 Operation is not advisable to:
- Couples who may want more children
- A male below 25 years old
- A male with lump in the scrotum
- A male with hernia
- A male who is allergic to drug (anesthesia)

Common Side Effect of Vasectomy:

o Mild swelling and darkening of the skin on the operative
site, a normal reaction of the body.

CHILD CARE

I. Introduction:

23
 Children are the future “movers and shakers” of our society and they
form an important sector of our population as they grow to become the
leaders of the Philippines. The well-being and protection of children,
therefore, is our fundamental concern.

The promotion and protection of children’s rights is a national priority

of the Philippine government. This has been strongly demonstrated in the
1987 Philippine Constitution and in the 1974 Child and Youth Welfare
Code which defines the rights of children and the roles of various
stakeholders and institutions in protecting children. In 1990, the
Philippines ratified the United Nations Convention on the rights of the
Child. In 1991, the Philippines made commitments to the provisions of the
World Declaration on the Survival, Protection and Development of
Children. In the same year, the Philippine Plan of Action for Children
(PPAC) was formulated to implement the provisions of the CRC.

The programmatic approach to child health care uses the life cycle
approach, which covers the stages in life from unborn to being newborn,
infant, pre-schooler, school aged child & adolescent. The packages take
into consideration the needs of a child at a certain life stages for his
growth and full development of his potentials. The period of development
of a child has its onset before conception and continues beyond
adolescence into adulthood. The different stages of a child’s growth
cannot be considered independently from the entire development
process, and every child will eventually pass through each of the
developmental stages. The rights-based life cycle approach allows better
observation of the differentiated needs for each stage of life ensuring the
responsiveness, focus and integration of interventions.

At each stage, the minimum package of services should be made

available to ensure the state of well being of the child. No child should be
deprived of the essential services that the needs.

For the purpose of certification, the package shall focus from 0 to 6

years of age only. The challenges to our child’s health begin way before
he is born. Prior to conception, health risks to either parent may
eventually affect the condition of their future child. Social behavioral
factors also have an impact on the eventual outcome of pregnancy.
Maternal malnutrition affects the unborn child’s chances for survival and
normal fetal development. Even if the child is born alive, it will carry the
long-term consequences on spontaneous fetal losses. Poor nutrition,
acute and chronic illnesses and substance abuse during conception and
pregnancy can cause congenital malformations and intrauterine growth
retardation. Infants born to these mothers are at a high risk of being
premature and having low birth weight. In addition, infants born to
mothers of high risk categories have as much as six times chances of
dying as compared to infants born to low-risk mothers.

The greatest threat to a child’s survival occurs within the first month of
life. During infancy, the risk of death in the first month of life is equal to

24
the risk cover the next 11 months. Prematurity, congenital defects, low
birth weight may be the underlying causes of death. Inherent disorders of
pregnancy and complications arising from delivery contribute to the
mortality risks of the risks of the newborn. Most of these are direct
consequences of sub-optimal conditions in the antepartum and
intrapartum periods. The circumstances surrounding delivery and the
early recognition of complications of childbirth also significantly affect
neonatal survival.

The risks to survival and well being during the period 1 to 6 years of
age similar to those during infancy. Infectious diseases, nutritional
deficiencies, and the consequences of neglect and accidents contribute to
child mortality. Survivors of this age group face multiple health risks such
as malnutrition, acute respiratory infection and diarrheal diseases.

Breast milk is the most complete and appropriate source of nutrition

for infants. It is safe and easily digested. Antibodies from the mother are
passed on to her child by breastfeeding, providing him protection from a
number of illnesses. The psychological benefits from the bonding of the
mother and the infant during breastfeeding are significant. For the
mother, breastfeeding promotes speedier recovery from pregnancy and
functions also as a contraceptive. Failure to breastfeed or inappropriate
termination of breastfeeding may have negative effects on the health of
the mother and the child.

Iron-deficiency cases among children are high. Mental retardation

primarily due to iodine deficiency and blindness resulting from insufficient
intake of Vitamin A are also common. About 28% in this age are either
moderately or severely underweight according to international standards.
It should be noted though that about 5% is overweight.

Poor health and malnutrition have negative consequences on the

child’s physical, mental and cognitive development. Diarrhea, measles
and parasitism can lead to growth faltering. Disabilities and malnutrition
affect childhood development. Asthma, which affects children throughout
childhood, can impair child’s socialization, school performance and later
life.

The psychosocial needs of this age group can no longer be fully met
the immediate family. The child has to interact with children of similar
age to develop socially and emotionally. The school year (SY) 1997-1998
data on early childhood care and development (ECCD) shows that only
one third of the 3-5 year old children have gone to preschool or day care.
Children who have undergone ECCD tend to better prepared for formal
schooling and thus, less likely to drop out. Due to inadequate facilities,
access to ECCD is slightly lower in rural areas than in urban areas.

The level II standards do not deal only with individual childcare but of
children as a whole in the catchments area. High coverage of each health
service is necessary to achieve the over-all goals for children’s health,

25
 e.g. herd immunity or at least 95% Fully Immunized Child coverage to
sustain eradication/elimination efforts, high utilization of iodized salt and
Vitamin A so that micronutrient deficiencies are no longer a public health-
problem, increased and sustained breastfeeding up to two years old and
beyond. Screening of newborns for congenital metabolic disorders was an
added feature in the standard because of its impact on preventing mental
retardation and death.

II. Technical Protocol

The specific standards on Child Care are:

1. The health facility has achieved a high coverage among 0-71 months
old children for the following basic Early Child Care and Development
(ECCD) services:
- At least 95% fully immunized child (FIC) coverage in every
catchments barangay
- At least 90% Vitamin A supplementation coverage among 6-71
months old
- At least 70% OF 48-71 months old who visited the RHU/HC given
Dental Services
- At least 80% of 0-71 months old have normal nutritional status, or
at least 10% increase per year of children with normal nutritional
status.

2. The health facility implementing the Integrated Management of

Childhood illnesses (IMCI).

3. At least 90% of salt vendors sell iodized salt.

4. The health facility process local ordinance/resolutions in support of

child health programs and implements the ordinances/resolutions
approved during the past two (2) years.

5. The health facility has a community-based surveillance system for

acute flaccid paralysis (AFP), measles & neonatal tetanus.

6. The health facility ensures the availability of the following supplies at

all times:
- Auto-Disabled (AD) syringes & needles
- ECCD Card/Mother & Child Book
- Newborn screening (NBS) supplies i.e. filter cards, lancets, cotton
balls (Applicable for main health centers only; a referral facility for
NBS is available for satellite health facilities.)

7. At least 60% of infants are exclusively breastfed and started

complementary feeding at 6 months of age.

Essential Child Health Interventions:

26
 • Birth registration
• Proper care of the newborn- resuscitation when needed, prevention
and management of hypothermia, eye prophylaxis, Vitamin K, cord
care, birth weighing
• Breastfeeding – early initiation within one hour, exclusive for 6 months
and continued up to 2 years and beyond
• Appropriate complementary feeding starting at 6 months
• Newborn screening within 2-10 days after birth
• Full immunization
• Regular Growth monitoring and promotion
• Nutrition counseling
• Micronutrient supplementation, particularly Vitamin A and iron
supplementation when anemic
• Appropriate management of sick children using the IMCI treatment
guidelines
• ECCD developmental screening
• Psychosocial stimulation
• Disability detection
• Regular oral care/dental check-up
• Child safety
• Use of iodized salt

III. Explanations on the Quality Standards

1. The health facility achieves a high coverage among 0-71 months old
children for the following basic early child care and development (ECCD)
services.

The Public Health Nurse (PHN) provider should know the following
rationale or justification why a high coverage should be maintained. The
succeeding section after the brief description of each quality standard
describes the highlights of selected child
health programs.

Below are the formulas for computing the selected indicators. All
indicators,
except the percentage of children with normal nutritional status, used the
projected population for the year assessed based on the 2000 NSO
estimates as the denominator.
Basic for computations:

The population base used as denominator for computation is NSO

2000
statistics projected to the year assessed, i.e. projected to 2006

Computation for FIC:

Actual no. of infants 0-11 months given 1 BCG, 3 DPT, 3 OPV, 3 HBV, 1 MV

27
 Before their first birthday
___________________________________________________________ X 100%
Total population X 3% (éligible population)

Computation for Vitamin A:

Actual no. of children 6-71 months old given Vitamin A

_______________________________________________ X 100%
Total population X 16% (éligible population)

Computation for Dental Care

Actual no. of children 48-71 months old given dental services

__________________________________________________ X 100%
Total population X 9% (éligible population)

Computation for Nutritional Status:

Actual no. of children 0-71 months those are underweight (below normal
weight)
__________________________________________________________ X 100%
Actual no. of children 0-71 months old weighed

2. The health facility is implementing the Integrated Management of

Childhood Illness (IMCI)

To be able to implement IMCI, the health staff should be trained on the

11-day IMCI course. Both the doctor or nurse should be trained and 60% of
the regular or permanent midwives should be trained on the 11-day course.
IMCI-trained personnel use the IMCI chart booklets as reference for
managing sick children. Clinical findings and the plan of treatment are
recorded in the sick child recording form. The recording forms enable the
health work to assess and classify the illness and plan the treatment for the
child.
The essential IMCI drugs, supply and equipment should always be
available in the health facility.

3. At least 90% of salt vendors sell iodized salt

To ensure that families use only iodized salt, salt vendors should only
sell
Iodized salt. Rather than doing salt testing at household level, it will be
more practical to test salt available in the market, as this will entail lesser
samples for testing than households.
“Patak SA Asin” is quarterly done. For the purpose of Sentrong Sigla,
the proportion of salt vendors selling iodized salt shall be computed on
an annual basis, thus:

Number of salt samples tested positive for iodine

28
 ________________________________________ X 100 %
Total number of salt samples tested for the year

4. The health facility proposes local ordinances/resolutions in support of

child health programs and implements the ordinances/resolutions approved
during the past 2 years.

The health staff should be able to cite two (2) ordinances or

resolutions related
to child health. The RHU staff should have been involved as the proponent or
assisted in the drafting and show proofs or evidences of their involvement in
passage of these 2 documents.

5. The health facility has a community-based surveillance system for acute

flaccid paralysis (AFP), measles and neonatal tetanus

The means of verifying this standard is the reporting on the 3

mentioned diseases. It is a requirement for the health facility to submit
weekly notifiable diseases to the DOH, and must keep a file of this case.
Members of the community shall likewise show records of cases reported to
the Barangay Health Station (BHS) or to the Rural Health Unit (RHU).

6. The health facility ensures the availability of the following supplies at all
times
Auto-disabled syringes with needles are the recommended type to
ensure safe
immunization. After injection, the syringe cannot be re-used as it is locked.
ECCD card/mother and child book are the necessary tools for recording as
well as remind mothers of the important health services for the child.
Newborn screening supplies should be available in main health
centers offering NBS. For purposes of Sentrong Sigla, the required quantity
available is based on the average number of children seen for the month.

7. At least 60% of infants are exclusively breastfed and started

complementary feeding
at six months of age.

For this standard, the population base is actual number of infant’s

breastfed up to
6 months is divided by the actual number of infants seen in the health
facility multiplied by 100%. The same formula for the actual number of
infants started complementary feeding at 6 months is used by just changing
the numerator.

The health staff should not violate the Milk Code and no promotional
materials, such as posters, wall clocks, ball pens, or any gifts of any sort
should be seen in the health facility.

29
 The health facility should have links with active breastfeeding support
groups and should be able to show proofs, such as minutes of meetings,
MOAs, attendance to training and orientation activities.

Interviewing mothers at random will help validate written reports of

accomplishment.

Management/Nursing Care:

a. symptomatic
b. enteric precaution, universal precaution
c. High CHON, high caloric, high CHO and low fats diet.

I. OVERVIEW
Quick assessment for every child brought in the clinic:

a. Asks for chief complaints/reasons for clinic visit

b. Takes vital signs and weight
c. Checks for general danger signs
d. Classifies child according to the three categories (severely ill, sick or
well child)

II. SEVERELY ILL

A. General danger signs:

a. unable to drink or breastfeed
b. vomits everything
c. convulsions
d. abnormally sleep or lethargic or difficult to awaken

B. Major emergency signs & symptoms:

a. cough or difficult breathing
b. diarrhea
c. fever
d. ear problem

C. Pre-referral treatment:
(e.g. 1st dose antibiotics, ORS, paracetamol, etc.)

D. Advises patient on reason and need for referral

E. Refers child immediately to the doctor/hospital

III. SICK CHILD

Sick child 0 to 7 days and 8 days to 2 months old

A. Newborn Care
To provide newborn care to children 0 to 7 days old
B. History and physical examination and assesses for main signs &
symptoms

30
1. Possible serious bacterial infection:
A. infants had convulsions
B. counts the breaths in one minute (60 breaths per minute or more)
C. looks for severe chest indrawing
D. looks for nasal flaring
E. looks and listens for grunting
F. looks and feels for bulging fontanel
G. looks for pus draining from the ear
H. measures temperature (38.5 C & above or below 35.5 C)
I. looks for skin pustules (many or severe)
j. See if the young infant is abnormally sleepy or difficult to awaken

2. Refer the infant immediately if positive for any of the signs above
3. Diarrhea
4. Classify as local bacterial infection if:
A. red umbilicus or draining pus
B. skin pustules

C. Malnutrition and anemia; Potential/actual feeding problems

1. the infants weight for age

2. observe breastfeeding and check for the following:
i. infants chin is touching mother’s breast
ii. infants mouth is wide open
iii. infants lower lip is turned outward
iv. more areola is visible above then below the mouth of the
infant
v. infant is suckling effectively

3. for feeding problems or low weight

i. difficulty in feeding
ii. If breastfed, how many times?
iii. Food drinks aside from breastfeeding
iv. Used to feed the child

D. Immunization and other problems

1. The infants immunization status
2. Assess for other problems

E. Treats accordingly: Gives immunization and Iron supplementation

1. treat the infant according to DOH protocols
2. give the appropriate antibiotic for bacterial infections
3. treat local infections in the clinic
4. manage infants with diarrhea according to protocol

F. Counsels Mother/Caregiver on home treatment, exclusive breastfeeding

and when to return

31
 1. Teach the mother/caregiver how to treat local infections and
corresponding home care.
2. Advise the mother/caregiver on home care and proper feeding if with
breastfeeding/feeding problem and low weight.
3. Advise the mother/caregiver when to return for follow-up

SICK CHILD >2 MONTHS TO 5 YEARS

A. Takes history and physical examination and assesses for main signs &
symptoms
1. Acute Respiratory Infection

a. For cough or difficult breathing

i. Asking for duration of cough or difficult breathing
ii. Counting the respiratory rate per minute
iii. Looking for chest indrawing
iv. Listening for stridor

b. Classify the child appropriately according to the following

i. As having severe pneumonia if with any of the general
danger signs or chest indrawing or stridor in a calm child
ii. As having pneumonia if with fast breastfeeding
iii. As having cough or cold no pneumonia if there are no
signs

c. Assess the child for Tuberculosis if with cough for 14 days or

more

2. Diarrhea
a. Assess for diarrhea by doing the following
i. Asking for how long was the diarrhea?
ii. Asking if there is blood in the stool?
iii. Looking at the general condition?
iv. Checking if the child is abnormally sleepy or difficult to
awaken?
v. Checking if the child is restless or irritable?
vi. Looking for sunken eyes?

b. Assess the response of the child with diarrhea when the offered
fluids by observing the following:
i. The child able to drink or is drinking poorly
ii. The child drinking eagerly or thirsty

c. Assess skin turgor of the child with diarrhea by pinching the skin
of the abdomen and observing if it goes back slowly or very
slowly, longer than 2 seconds.

d. Classify the child with diarrhea as having severe dehydration if

any of the following 2 signs are present:

32
 i. Abnormally sleepy or difficult to awaken
ii. Sunken eyes
iii. Not able to drink or drinks poorly
iv. Skin pinch goes back very slowly

e. Classify the child with diarrhea as having some dehydration if

any two of the following signs are present:

i. Restless and irritable

ii. Sunken eyes
iii. Drinks eagerly, thirsty
iv. Skin pinch goes back slowly

f. Classify the child with diarrhea as no dehydration if there are no

enough signs to classify as having some or severe dehydration.
g. Classify the child with diarrhea as having persistent diarrhea, if
duration is for 14 days or more
h. Classify the child with diarrhea as having dysentery, if there is
blood in the stool

3. Fever (Malaria)

a. Assess if the child with fever has malaria risk by doing the
following:
i. Asking whether living in a malaria area or visited a malaria
area in the past 4 weeks.
ii. Obtaining a malarial smear

b. Elicit pertinent information on the child’s fever by asking for the

following:
i. For how long the fever was?
ii. If fever has been for more than 7 days, has it been present
everyday?
iii. Has the child had measles within the last 3 months?

c. Look and feel for a stiff neck; look for a runny nose
d. Classify the child with severe disease for malaria if;
i. With any general danger sign or
ii. With stiff neck

e. Classify the child as having malaria/if he/she has a positive

malarial smear

4. Fever (Measles)

a. Signs of measles such as:

i. Generalized rashes
ii. One of these: cough, runny nose, or red eyes

b. A child has measles now or within the last 3 months:

33
 i. Mouth ulcers and whether it is deep and extensive
ii. Pus draining from the eyes
iii. Clouding of the cornea

c. Classify the child with measles

i. Severe complicated measles when there is clouding of the
cornea and/or deep and extensive mouth ulcers
ii. Measles with eye or mouth complications when there is
pus draining from the eye and/or mouth ulcers
iii. Measles now or within the last 3 months

5. Fever (Dengue Fever)

a. Assess dengue risk:

i. Bleeding from nose, gums, vomitus or stools
ii. Black vomitus
iii. Black stool
iv. Abdominal pain
v. Vomiting

b. Look and feel for:

i. Bleeding from the nose and gums
ii. Skin petechiae
iii. Cold and clammy extremities
iv. Check for capillary refill

c. Perform the tourniquet test if none of the above ASK or LOOK

and FEEL signs are present and the child is 6 months or older
and fever present for more than 3 days

d. Classify the child with fever

i. Evidence of bleeding: bleeding from nose and gums, blood
in vomitus or stools, black stools or vomitus, skin
petechiae
ii. Cold and clammy extremities
iii. Capillary refill of more than 3 seconds or more
iv. Abdominal pain or vomiting
v. Positive tourniquet test
vi. As fever dengue hemorrhagic fever unlikely if there are no
signs of severe dengue hemorrhagic fever
6. Ear problem

a. Has ear pain

b. There is pus draining from the ear of the child
c. Pus draining from the ear or for a red, immobile eardrum (by
otoscopy)
d. Palpate for tender swelling behind the ear
e. Classify the ear problem according to the following

34
 i. As acute ear infection if there is pus draining from the ear
less than two weeks or presence of a red, immobile ear
drum (by otoscopy)
ii. As chronic infection if with pus draining from the ear for
two weeks or more
iii. As mastoiditis if there is tender swelling behind the ear

A. Malnutrition and Anemia: Potential/actual feeding problems

1. Asses nutritional status by looking and feeling for the following:

a. Visible severe wasting
b. Edema of both feet
c. Palmar pallo

2. Determine the child’s weight for age

3. For feeding problems or low weight

a. Difficulty in feeding
b. If breastfed, how many times?
c. Food/drinks aside from breastfeeding
d. Used to feed the child

B. For immunization, Vitamin A status and other problems

a. The child’s immunization status
b. The child’s Vitamin A status
c. Assess for other problems

C. Treats accordingly
1. Acute Respiratory Infection
a. Treat the child with cough or difficult breathing according to the
following DOH protocols:
i. Refers immediately if with severe pneumonia
ii. If with pneumonia
1. Gives antibiotics (Cotrimoxazole)
2. gives 1st dose antibiotic before sending the child
home
3. advises on how to treat the child at home
4. advises when to return the child immediately
5. advises the mother/caregiver to bring the child for
follow-up in 2 days

iii. If with cough or cold, no pneumonia

1. Advises safe home remedy to relieve cough
2. Advises safe home remedy to soothe the throat
3. Advises the mother/caregiver to bring the child
immediately for follow-up if he/she becomes sicker,
develops fever or not able to drink or breastfed,
develops fast breathing or difficult breathing.
2. Diarrhea

35
 a. Refer immediately severely dehydrated children to the hospital
for intravenous fluid therapy
b. Give frequent sips of ORS on the way to a severely dehydrated
child referred to the hospital.
c. Manage children with some dehydration by:
i. Giving ORS at the health facility
ii. Giving two packs of ORS to take home
iii. Giving advice on:
1. continued feeding
2. give ORS at home
3. when to return

d. Manage children with no dehydration by:

i. Giving advice on:
1. home fluids
2. continued feeding
3. when to return

ii. Giving two packets of ORS to take home

e. Manage children with persistent diarrhea by:

i. Giving Vitamin A
ii. Giving advice on:
1. feed the child
2. follow-up in 5 days

f. Refer the child immediately if with persistent diarrhea with

dehydration
g. Give vitamin A before referring the child with persistent diarrhea
with dehydration

3. Fever (Malaria)

a. Treat the child with malaria

i. With oral anti-malarial
ii. With one dose of paracetamol at the health center

b. Give pre-referral treatment (1st dose antibiotic, paracetamol,

sugar water prior to referring the child to the hospital
c. Advice the mother/caregiver when to return immediately and to
follow up in 2 days if fever persists
d. Refer the child to doctor if still with fever for more than 7 days

4. Fever (measles)

a. Treats the child with measles according to protocol:

36
 i. If with severe complicated measles
1. gives vitamin A
2. gives 1st dose of antibiotics (cotrimoxazole)
3. applies tetracycline ophthalmic ointment if with
clouding of the cornea or pus draining from the eyes
4. refers immediately to hospital

ii. If with mouth or eye complications

1. gives vitamin A
2. applies tetracycline ophthalmic ointment if with pus
draining from the eye
3. teaches mother to treat mouth ulcers with gentian
violet
4. advises follow-up in 2 days
b. Give vitamin A if the child has measles now or within the last 3
months

5. Fever (Dengue Fever)

a. Treat the child according to DHF protocol

i. If with severe dengue hemorrhagic fever:
1. refers the child immediately to the hospital
2. not given aspirin
3. gives ORS to the child on the way to the hospital
ii. If fever only no dengue hemorrhagic fever
1. advises mother when to return immediately
2. advises follow-up in 2 days if fever persists
3. not give aspirin
6. Ear Problem

a. Manage children with acute ear infection by:

i. Giving cotrimoxazole for 5 days
ii. Drying the ear by wicking
iii. Reassessing in 5 days
iv. Treating fever with paracetamol

b. Manage children with chronic ear infection by:

i. Drying the ear by wicking
ii. Treating fever with paracetamol
c. Manage children with mastoiditis by:
i. Referring urgently to the hospital
ii. Treating with paracetamol if with fever or pain (not aspirin)

D. Gives immunization, Vitamin A and Iron supplementation and

Deworming as indicated
a. Provide immunization when indicated
b. Provide iron supplementation and deworming when indicated
c. Give vitamin A capsule to a sick child with:
i. Measles
ii. Severe pneumonia

37
 iii. Persistent diarrhea
iv. Severe and moderate malnutrition
v. Anemia

E. Counsels mother/caregiver on home treatment, feeding and fluids and

when to return
a. Provide the key messages for a sick child such as:
i. To treat at home
ii. Feeding a sick child
iii. When to return immediately
iv. When to comeback for follow-up

RHU SUPERVISORY FLOW CHART FOR WELL CHILD (0 TO 18 YEARS

OLD)

38
 Client Midwife/Nurse Doctor

Well
child
brought
in

Age
of
Chil
d
12 months 10 to 18
0 to 11 months
to 9 years years

Midwife/Nurse Midwife/Nurse Midwife/Nurse

- Takes vital signs & Gives and fills up the
weight ECCD card (for less than
6 years old)
Midwife/Nurse
Midwife/Nurse
-takes weight, vital signs
- gives immunization
and physical examination
- gives Vit. A if 16
- conducts auditory, visual
months and above
and developmental
- gives EPI messages
screening
Midwife/Nurse Midwife/Nurse
- plots and interprets Plots the weight in the
the weight of the child growth chart and interprets
- conducts
developmental
Midwife/Nurse
screening
-assesses feeding
- gives appropriate feeding
recommendations
Midwife/Nurse - assess other problems
-assesses feeding
/breastfeeding Midwife/Nurse
- assesses other - gives Vit. A, iron and
problems deworming as indicated
- gives appropriate - Refers patient for dental
advice check-up
- takes history and
physical
examination
- conducts auditory
and visual screening
- looks for signs of
abuse/mal
treatment
Midwife/Nurse
gives advice on:
- fertility awareness
and responsible
sexuality
- healthy diet and
physical activity
- dangers of drugs
alcohol and tobacco
-awareness on
physical, emotional
and sexual abuse
Midwife/Nurse
Refers child for
dental check-up

Midwife/Nurse
Midwife/Nurse Midwife/Nurse Advises
Reiterates to Advises mother/caregive
mother/caregive mother/caregive r when to return
r when to return r when to return

39
IV. WELL CHILD (< 1 year)

A. Takes Vital Signs and Weight

1. Take the vital signs the infant

2. Weight the child properly
a. Undresses the child or leaves as little clothes as possible
b. Sets weighing scale at 0 before weighing the child

B. Gives immunization: Gives Vitamin A and gives EPI messages

1. Immunize infants according to schedule
i. BCG immediately after birth
ii. DPT1, OPV1 at 6 weeks
iii. DPT2, OPV2 at 10 weeks
iv. DPT3, OPV3 at 14 weeks
v. AMV at 9 months

2. Give the correct antigen for age and schedule, correct dose and correct
route of administration

40
 a. Administers BCG, 0.05 ml to infants below 6 weeks old
b. Gives the vaccine intradermally on the deltoid area using
tuberculin syringe (producing a flat wheal with surface pitted like
orange peel appears at injection site).
c. Administers DPT/Hepa B to infants 6 weeks – 11 months old in 3
doses at 4 weeks interval
d. Gives DPT/Hepa B 0.5 ml intramuscular at the upper outer
portion of the thigh (gives each dose of vaccine on each thigh)
e. Administers OPV to infants 6 weeks – 11 months old in 3 doses
at 4 weeks interval
f. Gives OPV, 2 drops orally
g. Administers AMV to infants 9-11 months
h. Gives AMV 0.5 ml subcutaneous on the deltoid area of the upper
arm

3. Observe aseptic technique in handling vaccines

a. Health worker washes hand with soap and water before
vaccination
b. Vaccination area and table where vaccines are placed is clean
c. Uses one syringe/needle per child per antigen
d. Cleans the injection site with cotton ball moistened with water
and let skin dry
e. Careful not to let needle touch dirty surfaces

4. Handle vaccines properly during vaccination session

a. Vaccine protected from sunlight
b. Vaccine kept cold in vaccine carrier with ice
c. Vaccine not immersed in water
d. Vaccine vial monitor reading still potent
e. Vaccines used not expired
f. Reconstituted BCG and AMV discarded after immunization
session or after 6 hours

5. Give Vitamin A supplementation to children given AMV vaccination

6. Advise mothers of the following:
a. Importance/benefits of immunization, such as protection against
illnesses and increased body resistance
b. Possible side reactions, such as fever and rash, pain/soreness on
injection site
c. When to return for the next dose

B. Plots and Interprets the weight of the child

- Plot the weight on the growth chart, interpret it and explain the
weight and growth status of the child
C. Conducts developmental screening
- Assess developmental milestones using the ECCD checklist

D. Assess feeding/breastfeeding, assess other problems and gives

appropriate advice

41
 a. Assess feeding when there is growth faltering (declining line on
the growth chart) or plotted weight below the lower line of the
growth chart by asking the following
i. Child breastfeeding
ii. How many tomes during the day and at night?
iii. Complementary foods are given
iv. How many times per day?
v. Child receive adequate servings
vi. Own bowl and spoon
b. Assess other problems and gives appropriate advice
c. Instruct the mother/caregiver how to feed the child based on the
feeding recommendation on the ECCD card

E. Reiterates to mother/caregiver when to return

- Reiterate to mother/caregiver when to return immediately or
follow-up

IV. WELL CHILD (Below 6 years old)

A. Gives and Fills up the ECCD card (for children less than 6 years old)
- Issue and fill up the ECCD card for children less than 6 years old

B. Takes weight, vital signs and physical examination

1. Get the child’s temperature, cardiac rate, respiratory rate, weight and
height
2. Examine the child from head to toe

C. Conducts Auditory, Visual and Developmental screening

1. Conduct auditory and visual screening
2. Assess developmental milestones using the ECCD checklist

D. Plots the weight in the growth chart and interpret

- Plot the weight on the growth chart, interpret it and explain the weight and
growth status of the child

E. Assess feeding gives appropriate feeding recommendations and assess

other problems
1. Assess feeding when there is growth faltering (declining line on the
growth chart) or plotted weight below the lower line of the growth chart by
asking the following:

a. Is child breastfeeding?
b. If yes, how many times during the day and at night?
c. What complementary foods are given?
d. How many times per day?
e. Does child receive adequate servings?
f. Has own bowl and spoon?

2. Give appropriate feeding recommendations

42
3. Assess other problems

F. Gives Vitamin A, Iron and deworming as indicated

a. Give vitamin A to a child 6 months old and above and has not
received Vitamin A for the past 6 months
b. Give vitamin A correctly
i. If child is 12 months and above, cut across the nipple of
the capsule and squirt the vitamin A into the child’s open
mouth
ii. If child is below 12 months, 3 drops of Vitamin A
c. Give iron and deworming as indicated

G. Refers child for Dental check up

a. Refer the child for dental check up as needed (child is at least 2-
3 years old and check up every 6 months)
b. Advise on proper tooth brushing

H. Advises mother/caregiver when to return

- Advise the mother/caregiver when to return to the RHU/HC

IV. WELL CHILD (10 to 18 years old)

A. Takes history and physical examination, conducts auditory and visual

screening and looks for signs of abuse/maltreatment
1. Take the child’s history and physical examination
2. Conduct auditory and visual screening on the child
3. Look for signs of abuse /maltreatment

B. Gives advice
1. Give advice on the following:
a. Fertility awareness and responsible sexuality
b. Healthy diet and physical activity
c. Dangers of drugs, alcohol and tobacco
d. Awareness on physical, emotional and sexual abuse

C. Refers child for dental check up

1. Refer the child for dental check up
2. Give advice on proper tooth brushing

D. Advises Mother/Caregiver when to return

1. Advise the mother/caregiver when to bring the child back to the RHU/HC

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) ORIENTATION

• Comes as a generic guidelines for management which have been

adapted to each country
• Addresses important element of disease prevention and health
promotion
• Integrated, evidence-based, syndromic approach to case management

43
 • A joint WHO / UNICEF initiative since 1992

IMCI in the Philippines

 Introduced in 1995 and piloted in 1997 in Sarangani and Zamboanga

del Norte
 Philippines as one of the 12 countries in an expansion phase
 DOH as the lead implementing agency with technical assistance from:

– UNICEF : 20 provinces and 5 cities in 14 regions

– HKI (USAID funding): 12 provinces and 1 city in 4 regions (1, 3,
10, 12) and ARMM
– World Bank/Asian Development Bank: Regions 6, 7, 12
– PAGCOR (ECCD) : nationwide, selected provinces

IMCI Strategy

• Combines improved management of childhood illness with aspects of

nutrition, immunization and other important factors influencing child
health, including maternal health.

Management Nutrition Immunization

Other disease
Of Illness Prevention
Promotion of
Growth and
Development

Integrated Management of Childhood Illness

Objectives:

• To reduce significantly global mortality and morbidity associated with

the major causes of disease in children under five
• To contribute to healthy growth and development of children

Key Strategy
• Focus on the health and development needs of the child rather than
the treatment of an illness
• Coordination / integration of the various child health services to meet
the child’s needs
Rationale:
• Most sick children present with signs and symptoms related to more
than one disease
• This overlap means that a single diagnosis may not be possible or
appropriate

44
 • Treatment may be complicated by the need to combine therapy for
several conditions
Distribution of under-five deaths in developing
countries by cause, 2002.

18%
25%

ARI
Perinatal
Measles
15 Malaria
% HIV/AIDS
Diarrhea
Others
5%
23%
10%
4%

Malnutrition was associated in 54% of deaths in children

under five in developing countries in 2002
Malnutrition was associated in 54% of deaths in children under five in developing
countries in 2002.
Major Conditions in the IMCI Strategy

• Respiratory Diseases
• Diarrheal Diseases
• Measles
• Malaria
• Malnutrition
• Dengue (for the Philippines)

Benefits of the IMCI Strategy

• Addresses major child health problems
– Most important causes of childhood death and illness
• Responds to demand
– At least 3 out of 4 these children are suffering from one of the 6
conditions that are the focus of IMCI
• Is likely to have a major impact on health status
– 1993 World Bank World Development Report, Investing in
Health, estimated IMCI to be the group of interventions with the
potential for the greatest impact on the global burden of disease
• Promotes prevention as well as cure
– Emphasizes important preventive measures such as
immunizations and improved infant and child nutrition,,
including breastfeeding
• Cost effective
– Investment in Health ranked IMCI among the top 10 most cost
effective interventions in both low and middle income countries
• Promotes cost saving
– Initial increased investment for training and reorganization will
result in cost saving

45
 • Improves equity
– Ready access to simple and affordable preventive and curative
care for children which protects them from death due to ARI,
diarrhea, measles, malaria, dengue and malnutrition
3 Main components of IMCI Strategy
1. Improving Health System
2. Improving health workers’ skills
3. Improving family and community practices

New Areas within IMCI

• Recognition and care of children with HIV/AIDS
• Interactive care for healthy child development
• Neonatal health
Improving Health Workers’ Skills
• Integrated case management guidelines and standards
• Training and follow up of facility based public health providers
• Maintenance of competence among trained health workers
• IMCI roles for private providers

Incorporating IMCI into teaching agenda:

• Sept 2001 – Orientation and introduction of IMCI to Nursing and
Midwifery curriculum
• April 2002 – 11 day basic course for academe
• April 2002 – MOA signing (DOH-APSOM-ADPCN) “Enhancing the
Nursing and Midwifery Curriculum through the IMCI Strategy
• July 2002 – Pilot implementation to 4 nursing and 4 midwifery schools (
UST, Baliuag U, St. Paul College Iloilo, San Pedro College Davao, World
City College Q.C., St. Joseph College, Davao and University of Visayas,
Cebu City

• Sept 2002 – Expanded Orientation for Academe

• Nov 2002 – 11 day basic course for academe
• Nov 2002 – 4 schools (UERRM, BSU, NCC, PSU)
• March 2003 – Monitoring tool for IMCI preservice developed
• Jan 2005 – 11 day basic course for academe (LU, CU)
• May 2005 – 1 day orientation for Region 10 Nursing and Midwifery
schools
• Last quarter 2005 – 1st batch of training for academe in Region 10

2 general principles
• Gradual integration of IMCI concepts into the teaching of relevant
subjects.

• Adequate time devoted to comprehensive review and supervised

clinical practice to synthesize previous teaching into an integrated
approach to case management.

Upon completion of 11 day course, first level health workers are

expected to have the knowledge and skills to:

46
 • Assess, classify and treat sick children accurately following the IMCI
case management guidelines

• Administer pre-referral treatment correctly and refer seriously ill

children
• Counsel caretakers about home care including how to give treatment,
what signs to look for that indicate a child should be brought back
immediately to the health facility and when to return for follow up
care.
• Check children’s immunization status routinely and give
immunizations when needed.
• Carry out feeding assessments of children who are less than two years
old or who are very low weight for age
• When necessary, provide caretakers with appropriate nutrition and
breastfeeding counseling

Improving the Health System:

• District planning and management
• Availability of IMCI drugs
• Organization of work at health facilities
• Quality improvement and supervision at health facilities
• Referral pathways and services
• Health information system
• IMCI and health sector reform

Improving Family and community practices:

• Nutrition
• Home case management
• Care seeking behavior
• Adherence to recommended treatment
• Supportive environment
• Community involvement in health planning and monitoring
• Improving partnerships between facilities and communities they serve.
• Increasing appropriate, accessible care and information from
community-based providers.
• Integrated promotion of key family practices critical for child health
and nutrition.

IMCI Process
• Relies on case detection using simple clinical signs.
• Treatment based on action-oriented classification rather than exact
diagnosis.
• Designed for a first level facility (clinic, health center, OPD).
• Treatment combined with prevention.

IMCI Case Management Process

1. Assess a child
– Check for danger signs
– Ask questions about common conditions: cough or difficult
breathing, diarrhea, fever, ear problem

47
 – Examine the child (LOOK, LISTEN, FEEL)
– Check nutrition and immunization status
– Assess for other health problems
2. Classify a child’s illness
– Color-coded triage system
– Whether it requires urgent pre-referral treatment and referral,
specific medical treatment and advice or simple advice on home
management

3. Identifies specific treatments

– Develop an integrated treatment plan
– If urgent referral – essential treatment before patient is
transferred
– If treatment at home, first dose of drugs given

4. Provides practical treatment instructions

– How to give oral drugs
– How to feed and give fluids during illness
– How to treat local infections at home
– Return for follow up on certain date
– Teach to recognize signs that child should return immediately to
health facility

5. Identifies treatment or refers child when appropriate if underweight

– Provides counseling to solve feeding problems
– Assesses breastfeeding practices
– Immunizes if needed.

6. Gives follow up care

– When child is brought back to the clinic
– Reassesses child for new problems

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

• Date
• Child’s name
• Age
• Sex
• Weight (kg)
• Temp (°C)
• Ask : child’s problems
• Check : Initial or follow up visit
– Follow-up : use follow –up instructions on TREAT THE CHILD
chart
– Initial : assess the child as follows

ASSESS THE CHILD

• CHECK FOR GENERAL DANGER SIGNS

– ASK
• Able to drink or breastfeed?

48
 • Vomits everything?
• Had convulsions?
– LOOK
• Abnormally sleepy or difficult to awaken
CLASSIFY
• If with general danger sign

– Make sure is referred after 1st dose of an appropriate antibiotic

and other urgent treatments.

– EXCEPTION: Rehydration of the child according to Plan C may

resolve danger signs so that referral is no longer needed.

Ask about main symptoms

• Cough or difficult breathing?

– If yes, ask: for how long?
– Look, listen: Count the breaths in 1 min.
---- Fast breathing?
Look for chest indrawing
Look and listen for stridor

FAST BREATHING
– 50 breaths /min or more if child is 2 – 12 months
– 40 breaths / min or more if child is 12 months – 5 years.

Classify cough or difficult breathing

Signs Classify as Treatment
• Any general danger SEVERE PNEUMONIA • Give 1st dose of an appropriate
signs or with WHEEZING OR VERY antibiotic
• Chest indrawing or SEVERE DISEASE • Give a trial of rapid acting inhaled
• Stridor in calm child bronchodilator up to 3 cycles
• Wheeze before classified as pneumonia
• Give Vitamin A
• Treat the child to prevent low
blood sugar
• Refer URGENTLY to hospital

Signs Classify as Treatment

Fast breathing with or PNEUMONIA with • Give an appropriate antibiotic for

without wheezing (after trial WHEEZING 5 (3) days
of rapid acting inhaled • Give an inhaled or oral
bronchodilator, up to 3 bronchodilator for 5 days
cycles) • Soothe the throat and relieve the
cough with a safe remedy
• Advise mother when to return
immediately
• Follow up in 2 days

49
 Wheezing (before or after NO PNEMUMONIA : • Give an inhaled or oral
trial of rapid acting WHEEZING bronchodilator for 5 days
inhaled bronchodilator up • If recurrent wheezing refer for
to 3 cycles) assessment if not done
• Advise the mother when to
return immediately
• Follow up in 2 days if not
improving

Signs Classify as Treatment

No signs of pneumonia or NO PNEUMONIA : COUGH OR • If coughing > 30 days, refer for

very severe disease COLD assessment
• Soothe the throat and relieve
the cough with a safe remedy
• Advise mother when to return
immediately
• Follow up in 5 days if not
improving

Ask: Does the child have diarrhea?

• If yes , ask:
– How long?
– Blood in the stool?
• Look and feel
– General condition
• Abnormally sleepy or difficult to awaken?
• Restless and irritable?
– Sunken eyes
– Offer fluid
• Not able to drink or drinking poorly?
• Drinking eagerly, thirsty?
– Pinch skin of the abdomen
• Very slowly (> 2 seconds)
• Slowly
CLASSIFY DIARRHEA FOR DEHYDRATION

50
Two of the ff signs:
• Abnormally sleepy or DEHYDRATION
difficult to awaken
• Sunken eyes
• Not able to drink or
drinking poorly
• Skin pinch goes back
very slowly
SEVERE • If the child has no other severe
classification, give fluid for severe
dehydration (Plan C)
• If the child ha s another severe
classification, refer URGENTLY to
hospital with mother giving frequent
sips of ORS. Continue breastfeeding
• If child is 2 years or older than there is
cholera in your area, give antibiotic for
cholera

Two of the following signs : SOME • Give fluid , zinc supplements and food
• Restless, irritable DEHYDRATION for some dehydration (Plan B)
• Sunken eyes • If with severe classification, refer
• Drinks eagerly, thirsty URGENTLY to hospital with mother
• Skin pinch goes back giving frequent sips of ORS. Continue
slowly breastfeeding
• Advise mother when to return
immediately
• Follow up 5 days if not improving

Not enough signs to classify NO • Give fluid, zinc supplements and

as some or severe DEHYDRATION food to treat diarrhea at home (Plan
dehydration A)
• Advise mother when to return
immediately
• Follow up in 5 days if not improving

If diarrhea is 14 days or more

Dehydration present Dehydration present Dehydration present

No dehydration PERSISTENT
DIARRHEA • Advise
mother on
feeding a child
who has
persistent
diarrhea
• Give
multivitamins
and minerals

51
 (including zinc)
for 14 days
• Give vitamin
A
• Follow up in
5 days

If blood in stool

• Treat for 5 days with an oral

Blood in the stool DYSENTERY antibiotic recommended for
Shigella in your area
• Follow up in 2 days

Does the child have fever?

By history, feels hot, temperature 37.5°C or above

Decide malaria risk

• Ask: Live in a malaria area?
Traveled to and stay overnight in a malaria area?
Received blood transfusion in the last 6 mos.?

If yes to either, obtain a blood smear.

• Ask :
– How long has the child had fever?
– If > 7 days, has fever been present everyday?
– Has the child had measles within the last 3 months?
• Look and feel:
– Stiff neck
– Runny nose
– Look for signs of measles
• Generalized rash
• One of these : cough, runny nose or red eyes

CLASSIFY FEVER

MALARIA RISK

52
 • Any general VERY SEVERE • Give 1st dose of quinine (under
danger sign or FEBRILE DISEASE medical supervision)
• Stiff neck / MALARIA • Give 1st dose of appropriate antibiotic
• Treat child to prevent low blood sugar
• Give one dose of paracetamol in
health center for high fever (38.5°C or
above)
• Send blood smear with the patient
• Refer URGENTLY to hospital

• Blood smear (+) • Treat the child with an oral antimalarial

• Give 1 dose of paracetamol in health
If blood smear not center for high fever
done : • Advise mother when to return
• NO runny nose, MALARIA immediately
and • Follow up in 2 days if fever persists
• NO measles, • If fever is present everyday >7 days,
and refer for assessment
• NO other cause
of fever

• Blood smear FEVER: • Give 1 dose of paracetamol for high

(-), or MALARIA fever
• Runny nose, or UNLIKELY • Advise mother when to return
• Measles, or immediately
• Other causes of • Follow up in 2 days if fever persists
fever • If fever is present everyday for >
7days, refer for assessment

CLASSIFY FEVER:
NO MALARIA RISK

• Any general VERY SEVERE • Give 1st dose of an appropriate

danger sign or FEBRILE antibiotic
• Stiff neck DISEASE • Treat the child to prevent low blood
sugar
• Give 1 dose of paracetamol for
high fever
• Refer URGENTLY to hospital

• Give 1 dose of paracetamol in

health center for high fever
• No signs of very FEVER : NO • Advise mother when to return
severe febrile MALARIA immediately
disease • Follow up in 2 days if fever persists
• If fever is present everyday for
>7days, refer for assessment

53
If the child has measles now or within the last 3 months:
• Look for mouth ulcers
– Deep and extensive?
• Look for pus draining from the eye
• Look for clouding of the cornea

• Give Vitamin A
• Give 1st dose of an
• Clouding of cornea or appropriate antibiotic
• Deep or extensive SEVERE COMPLICATED • IF clouding of cornea or
mouth ulcers MEASLES pus draining from the
eye, apply tetracycline
eye ointment
• Refer URGENTLY to
hospital

Give Vitamin A
If pus draining from the eye, apply
Pus draining from the eye
tetracycline eye ointment
or MEASLES WITH EYE
If mouth ulcers, teach mother to treat
Mouth ulcers OR MOUTH
gentian violet
COMPLICA -TIONS
Follow up in 2 days.

Measles now or within

Give Vitamin A
the last 3 months MEASLES

Assess for Dengue Hemorrhagic Fever

54
Ask Look and Feel
• Bleeding from nose or • Bleeding from nose or
gums or in vomitus or gums
stools? • Skin petechiae
• Persistent vomiting? • Cold and clammy
• Black vomitus? extremities
• Black stools? • Slow capillary refill
• Persistent abdominal • Perform tourniquet
pain? test if child is > 6
months AND has no
other signs AND has
fever for > 3 days

55
• Bleeding from nose or If vomiting or
gums or abdominal pain or skin
• Bleeding in stools or petechiae or (+)
vomitus or SEVERE DENGUE Tourniquet test are
• Black stools or vomitus HEMORRHAGIC the only positive signs
• Skin petechiae or FEVER give ORS as in Plan B
• Cold and clammy If any other signs are
extremities or (+), give fluids rapidly
• Capillary refill > 3 as in Plan C
seconds or Treat the child to
• Persistent abdominal prevent low blood
pain sugar
• Persistent vomiting Refer all children
• (+) Tourniquet test URGENTLY to hospital
DO NOT GIVE ASPIRIN

• No signs of severe dengue • Advise mother

hemorrhagic fever when to return
FEVER: DENGUE immediately
HEMORRHAGIC • Follow up in 2
FEVER UNLIKELY days if fever
persist or child
shows signs of
bleeding
• DO NOT GIVE
ASPIRIN

If YES, ASK : LOOK AND FEEL

• Ear pain? • Pus draining from the ear
• Ear discharge? • Tender swelling behind the ear
• For how long?

56
 Give 1st dose of an appropriate antibiotic
Tender swelling
Give 1st dose of paracetamol for pain
behind the ear
Refer URGENTLY to hospital
MASTOIDITIS

Pus is seen
Give antibiotic for 5 days
draining from the
Give paracetamol for pain
ear & discharge is
Dry the ear by wicking
reported <14 days ACUTE EAR
Follow up in 5 days
Ear pain INFECTION

• Pus seen draining • Dry the ear by wicking

from the ear and CHRONIC EAR • Give appropriate topical
discharge is INFECTION antibiotic for at least 2 weeks
reported for 14 • Follow up in 5 days
days or more
• No ear pain and • No additional treatment
• No pus seen NO EAR INFECTION
draining from the
ear

CHECK FOR MALNUTRITION AND ANEMIA

• Look and feel
– Visible severe wasting

– Edema of both feet

– Palmar pallor
• Severe
• Some

– Determine weight for age

57
 • Visible severe SEVERE • Give Vitamin A
wasting or MALNUTRITION OR • Refer urgently to hospital
• Edema of both SEVERE ANEMIA
feet
• Severe palmar
pallor

Some palmar pallor or ANEMIA OR VERY LOW • Assess feeding and counsel
Very low weight for age WEIGHT mother – ff up in 5 days
• If some pallor
-Give iron
-Mebendazole if 1 year
or older and no dose in
last 6 mos.
-Ffup in 14 days
– If very low weight for
age- Vit A, ff up in 30
days
– Advise when to return
immediately

Not very low weight for NO ANEMIA AND NOT If the child is < 2 years old, assess
age and no other signs VERY LOW WEIGHT the child’s feeding and counsel the
of malnutrition mother – ff up in 5 days
Advise when to return immediately

Check the immunization status

AGE VACCINE

Birth BCG, Hep B 1

6 weeks DPT 1, OPV 1,Hepa B 2

10 weeks DPT 2, OPV 2

14 weeks DPT 3, OPV 3, Hepa B 3

9 months Measles

58
Check Vit A Supplementation Schedule
• First dose at 6 months or above
• Subsequent doses every 6 months

Assess child’s feeding if with ANEMIA or VERY LOW WEIGHT or < 2 years old

• Breastfeeding? How many times in 24 hours? At night?

• Taking any other foods or fluids? How many times per day? What is
used to feed the child?
• If VLW, how large are the servings? Child receiving own serving? Who
feeds the child and how?
• During the illness, feeding changed? How?

ASSESS OTHER PROBLEMS

TREAT THE CHILD

GIVE AN APPROPRIATE ANTIBIOTIC

• For pneumonia, acute ear infection or very severe disease

• For dysentery

• For cholera

For pneumonia, acute ear infection or very severe disease

Cotrimoxazole Amoxicillin
(2 x daily for 5 days) (3x daily for 5
days)
AGE Tablet : 80 mg Tablet: 250 mg
trimethoprim + 400 mg Syrup : 125mg/5
sulphamethoxazole ml
Syrup : 40 mg T + 200 mg
S/5ml
2 – 12 mos. (4 -<10 ½ tab ½ tab
kg) 5 ml syrup 5 ml syrup

59
 12 mos – 5 years 1 tab 1 tab
(10-19 kg) 10 ml syrup 10 ml syrup

Update on ARI treatment

• Oral amoxicillin should be used in 25mg/kg/dose twice daily for 3 days

for non severe pneumonia in children 2 – 59 months of age
• Oral Cotrimoxazole should be given for 3 days for non severe
pneumonia in 2-59 months of age in low HIV prevalent countries

• Children with wheeze and fast breathing and/or lower chest indrawing
should be given a trial of rapid acting inhaled bronchodilator before
they are classified as pneumonia and prescribed antibiotics. 0.5 ml
salbutamol diluted in 2.0 ml of sterile water per dose per nebulization
should be used.

• Where referral is difficult and injection is not available, oral amoxicillin

in 45 mg/kg/dose 2x a day should be given to children with severe
pneumonia for 5 days

• Injectable ampicillin plus injectable gentamicin is a better choice than

injectable chloramphenicol for very severe pneumonia in children 2-59
months of age.

• A pre-referral dose of 7.5 mg/kg IM injection gentamicin and 50 mg/kg

injection ampicillin can be used.

For dysentery

• Give antibiotic recommended for Shigella in your area for 5 days

Cotrimoxazole Nalidixic acid (4x /

(2x/day for 5 d) day for 5 d)

AGE OR Syrup 250 mg/ml

WEIGHT

Update

• Ciprofloxacin is the most appropriate drug in place of nalidixic acid

which leads to rapid development of resistance
• Given 15mg /kg / dose 2 x / day for 3 days by mouth
• Zinc supplementation given at 20mg / day (10mg/day for infants <
6mos of age) for 10 – 14 days
• Countries should now use and manufacture the low osmolarity ORS for
all children with diarrhea but keep the same label to avoid confusion

60
Ear infections

• Oral amoxicillin is a better choice for suppurative otitis media where

cotrimoxazole resistance is high.
• Chronic ear infection should be treated with topical quinolone ear
drops for at least 2 weeks in addition to dry ear wicking
• IV antibiotics are highly effective but too expensive

Helminth infestations

• 500 mg Mebendazole for all children with anemia 12 months

or older who live in an area with hookworm or whipworm
and who have not been treated with mebendazole in the last
6 months
• Mebendazole also very effective treatment of infection by
roundworm which contributes to malnutrition
• Mebendazole given without microscopic examination of the
stool
• Below 12 months, refer cases and manage on a case-by-
case basis
• In endemic areas, children who have not been dewormed in
the previous months should be offered deworming
irrespective of the possibility of confirming their infectious
status
• Albendazole and mebendazole can be safely used in children
12 months or older.
• Give Vitamin A
• Give Iron for 14 days
• Give paracetamol q 6 hrs until high fever or ear pain is gone
• Give mebendazole as single dose

Teach mother to treat local infections at home

> Explain what the treatment is and why it should be given

> Describe the treatment steps
> Watch the mother as she does the 1st treatment
> Tell her how often to do the treatment at home

WHEN TO RETURN
• Follow up visit
• Next well child visit
• Return immediately

Return immediately

61
 • Not able to drink or
breastfeed
Any sick child • Becomes sicker
• Develops a fever

• Fast breathing
If child has NO PNEUMONIA : COUGH OR • Difficult breathing
COLD, also return if
• Blood in stool
If Child has Diarrhea, also return if • Drinking poorly

• Any sign of bleeding

If child has FEVER:DENGUE HEMORRHAGIC • Abdominal pain
FEVER UNLIKELY also return if: • Vomiting

Next well-child visit

• Advice mother when to return for next immunization according to

immunization schedule.

Counsel the mother about her own health

• If the mother is sick, provide care for her, or refer her for help
• If she has a breast problem, provide care for her or refer her for help
• Advise her to eat well to keep up her own strength and health
• Check the mother’s immunization status and give her Tetanus Toxoid
if needed
• Make sure she has access to:
– Family planning
– Counseling on STD and AIDS prevention

SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS

ASSESS

• Ask the mother what the young infant’s problems are

• Determine if initial or follow up visit

Check for possible bacterial infection

• ASK
Has the infant had convulsions?

• LOOK, LISTEN, FEEL

– Count the breaths in 1 minute. Repeat if elevated.
– Look for: severe chest indrawing, nasal flaring, pus draining from
the ear
- Look and listen for grunting.

• LOOK, LISTEN, FEEL

62
 - Look and feel for bulging fontanel
- Look at the umbilicus. IS it red or draining pus? Does the redness
extend to the skin?
- Measure Temp (or feel for fever or low body temp)
- Look for skin pustules. Are there many or severe pustules?

- See if young infant is abnormally sleepy or difficult to awaken

- Look at the young infant’s movements. Are they less than
normal?

• Convulsions or • Give 1st dose of

• Fast breathing (>60 breaths) or intramuscular
• Severe chest indrawing or POSSIBLE antibiotics
• Nasal flaring or SERIOUS • Treat to prevent
• Grunting or BACTERIAL low blood sugar
• Bulging fontanel or INFECTION • Advise mother
• Pus draining from ear or how to keep the
• Umbilical redness extending to the infant warm on
skin or the way to the
• Fever (>37.5°C or feels hot) or low hospital
body tem (<35.5°C or feels cold) or • Refer
• Many or severe skin pustules or URGENTLY to
• Abnormally sleepy or difficult to hospital
awaken or
• Less than normal movement

Red umbilicus or LOCAL Give appropriate oral antibiotic

draining pus or BACTERIAL
Skin pustules INFECTION
Treat local infection in the health center and
teach the mother to treat local infections at
home

Advise mother to give home care for the

young infant
Follow up in 2 days.

Ask if young infant has diarrhea.

• Ask

63
 – For how long?
– Is there blood in the stool?

• Look and feel

• Look at the young infant’s general condition. Is the child :

– Abnormally sleepy or difficult to awaken?
– Restless and irritable?

• Look for sunken eyes

• Pinch the skin of the abdomen. does it go back:

– Very slowly (longer than 2 seconds)?
– Slowly?

Classify DIARRHEA for DEHYDRATION

• Two of the • If infant does not have POSSIBLE

following signs: SERIOUS BACTERIAL
• Abnormally INFECTION nor DYSENTERY ---
sleepy or Give fluid for severe dehydration
difficult to SEVERE (PLAN C)
awaken DEHYDRATION • If infant also has POSSIBLE
• Sunken eyes SERIOUS BACTERIAL
• Skin pinch CONDITION OR DYSENTERY ---
goes back very refer urgently to hospital with
slowly mother giving frequent sips of
ORS on the way. Advise mother
to continue breastfeeding.

Two of the following Give fluid and food for some dehydration
signs: SOME (Plan B)
Restless, irritable DEHYDRATION If infant also has POSSIBLE SERIOUS
Sunken eye BACTERIAL INFECTION OR
Skin pinch goes back DYSENTERY: Refer URGENTLY to
slowly hospital with mother giving frequent sips
of ORS on the way. Advise mother to
continue breastfeeding.
Not enough signs to Give fluid to treat diarrhea at home (Plan
classify as some or NO A)
severe dehydration DEHYDRATION

64
 • If diarrhea 14 days or more

If the young infant is dehydrated,

treat dehydration before referral
Diarrhea lasting 14 SEVERE PERSISTENT unless the infant has also
days or more DIARRHEA POSSIBLE SERIOUS BACTERIAL
INFECTION
Refer to hospital

• If blood in stool

Refer URGENTLY to hospital with

mother giving frequent sips of ORS
Blood in the stool DYSENTERY on the way. Advise mother to
continue breastfeeding.

Check for feeding problem or low weight:

• Ask
– Is there any difficulty feeding?
– Is the infant breastfed? If yes, how many times in 24 hours?
– Does the infant usually receive any other foods or drinks? If yes,
how often?
– What do you use to feed the infant?

• Look, listen, feel

– Determine weight for age.

• IF AN INFANT :
– Has any difficulty feeding,
- Is breastfeeding < 8 x in 24 hrs.
- Is taking any other foods or drinks or
- Is low weight for age AND
- Has no indications to refer urgently to hospital

ASSESS BREASTFEEDING

• Has the infant breastfed in the previous hour?

• If the infant has not fed in the previous hour, ask the mother to put her
infant to the breast. Observe the breastfeed for 4 min.

65
 – Is the infant able to attach? (no attachment at all, not well
attached, good attachment)
– Is the infant suckling effectively (that is slow deep sucks,
sometimes pausing)? – not sucking at all, not suckling
effectively, suckling effectively
– Clear a blocked nose if it interferes with breastfeeding
– Look for ulcers or white patches in the mouth (thrush)

To check for attachment, look for:

• Chin touching the breast

• Mouth wide open
• Lower lip turned outward
• More areola visible above than below the mouth

– ALL OF THESE SIGNS SHOULD BE PRESENT IF THE ATTACHMENT

IS GOOD.
• Not able to • Give 1st dose of
feed or intramuscular antibiotics
• No attachment • Treat to prevent low
at all or NOT ABLE TO FEED – blood sugar
• Not suckling at POSSIBLE SERIOUS • Advise mother to keep
all BACTERIAL INFECTION the young infant warm
on the way to the
hospital
• Refer URGENTLY to
hospital

• Not well • Advise the mother to breastfeed as

attached to often and for as long as the infant
breast or wants, day and night
• Not suckling FEEDING • - if not well attached or not suckling
effectively or PROBLEM OR effectively, teach correct positioning
• Less than 8 LOW WEIGHT and attachment
breastfeeds in • - if breastfeeding < 8 times in 24
24 hours or hours, advise to increase frequency
• Receives of feeding
other foods or • If receiving other foods or drinks,
drinks or counsel mother about
• Low weight breastfeeding more, reducing other
for age or foods or drinks, and using a cup
• Thrush(ulcers • - if not breastfeeding at all :
or white • - refer for breastfeeding
patches in counseling & possible relactation
mouth) • - advise about correctly
preparing breastmilk substitutes &
using a cup

66
 If thrush, teach the mother to
treat thrush at home
Advise mother to give home
care for the young infant
Follow up any feeding problem
or thrush in 2 days
Follow up low weight for age in
14 days
Not low weight for age NO FEEDING PROBLEM Advise mother to give home
and no other signs of care for the young infant
inadequate feeding Praise the mother for feeding
the infant well.

CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS

AGE VACCINE

Birth Hepatitis B1, BCG

6 weeks DPT 1, OPV 1, Hepa B 2

Assess other problems

TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER

67
V. HIGHLIGHTS OF SELECTED CHILD HEALTH PROGRAMS

A. Expanded Program on Immunization (EPI)

EXPANDED PROGRAM ON IMMUNIZATION TARGET

Republic Act 7846, dated- Dec. 30, 1994

AN ACT REQUIRING COMPULSORY IMMUNIZATION AGAINST HEPATITIS
FOR INFANTS AND CHILDREN BELOW 8 YEARS OLD.

The over-all goal of the EPI is to reduce morbidity and mortality

against the childhood vaccine-preventable diseases. One of the major
objectives is to improve full immunization coverage to 95% among the one-
year old infants.

A fully immunized child (FIC) is a child who received one dose of BCG, 3
doses of OPV, 3 doses of DPT, 3 dose of Hep B vaccine and one dose of
measles before the child reaches the age of one year.

This is the required coverage if he wants to sustain our polio-free

status, eliminate measles and control outbreaks of other vaccine-
preventable illnesses. The lower the FIC coverage, the greater the number of
children exposed to illnesses. The number of children unimmunized each
year, the more frequent outbreaks will occur especially in areas with
clustering of unimmunized children.

There are strategies than can be done to achieve high coverage e.g.
reaching every infant in every barangay (strategy of integrating
immunization during the Garantisadong Pambata campaign. When the
estimated number of unimmunized children almost approximates the infant
cohort for the year or when outbreaks occur, supplemental immunization
activities are done (mass immunization with expanded target group). An
example of this is the Ligtas Tigdas Campaign.

Reaching Every Barangay (REB) is an adaptation of the WHO Reaching

Every District strategy in improving the immunization coverage. It can also
be used for the other child health interventions. The strategy has 5
operational components namely:
1. Re-establish outreach services- this usually done in hard to
reach areas, or where access to services is difficult. The purpose
of this activity is to provide services to children who missed their
services because of problems of access. This activity should be
organized at least quarterly to ensure the children complete
their immunization. Other activities, such as Vitamin A
supplementation, deworming, etc. are also provided.
2. Supportive Supervision – this is a systematic way of supervising
with mentoring and provision of technical assistance to field
implementers. The supervisor helps the health worker analyze
the data, identify the problems and provide mentoring. Follow up

68
 visits are done to check whether the recommended actions are
undertaken and to see improvements in coverage…
3. Linking community with service delivery – this is involving the
community in the assessment of the health situation in the
community and plan activities where the community can
participate to ensure that the necessary health interventions are
provided to children.
4. Monitoring and use of data for action – the health worker should
be able to monitor the progress of indicators by learning how to
use available data in the target clients list, accomplishment
report and other data. By analyzing the data the health worker
will know whether the low immunization coverage is due to
problem with access, especially when there are many
unimmunized children, or problem of utilization as in the case of
defaulters. Appropriate actions are then identified.
5. Plan and manage to optimize scarce resource utilization – a plan
of action is formulated considering the resources available or
those that can be tapped and identifying the locus of
responsibility for each action.

There is a need for certain systems to be in place, like disease

surveillance, because this is a critical component of disease reduction
initiatives. With poor surveillance we cannot outright say that we have
eradicated or eliminated a disease. While the Philippines has been declared
polio-free, the more reason for strengthening surveillance for acute flaccid
paralysis (AFP). AFP is the main sign of poliomyelitis. It is important that all
cases of AFP in children less than 15 years old be reported immediately,
investigated and stool samples be taken to make sure that it is not due to
poliovirus. AFP, measles, neonatal tetanus are the three important diseases
that should be reported and investigated. The community plays an
important role in reporting these cases since most of the time, a child
exhibiting signs due to these diseases are not brought to the health facility.
Members of the community should be vigilant in reporting these cases. The
standard definitions that will guide the community in reporting these cases
can be found in the EPI manual. The health facility staff should be able to
establish a network with community officials and health volunteers in
community-based disease surveillance. The proper management of
resources (handling and storage for vaccines & Vitamin A the cost of which
amounts to millions of pesos. The need to procure other drugs and drugs to
be able to render adequate child health services.

Multi-dose Open Vial Policy

-The vaccines like OPV, DPT, HEP B, & TT once open can still be used within
4 wks. provided the following conditions are met:
- expiry date has not passed
- vaccines are placed under appropriate cold chain conditions
- vaccine vial septum has not been submerged in water
- aseptic technique has been maintained at all times
- vaccine vial monitor (VVM) if attached has not reached its discard point.

69
VVM – (vaccine vial monitor)
• Is a device that is directly applied to the vaccine vials to measure the
temperature that the vaccines have been exposed to.

UPDATES Guidelines on Hepatitis B Immunization for Infants

I. Rationale
Hepatitis B is a major public health problem in the Philippines with
an estimated seven million people (approximately 10-12% of the
total population) chronically infected with the virus. Twenty to 30%
of these chronically infected people will develop chronic liver
disease (cirrhosis of liver, liver cancer, etc.) mostly between 30-50
years of age. Many will die from it as there is no effective and
affordable drug treatment currently available for hepatitis B.
Approximately 9000 people are estimated to die from chronic liver
disease in Philippines annually – a mortality rate comparable to that
of tuberculosis. Majority of chronic carriers of infection acquire their
infection either at birth (when the risk of becoming a chronic carrier
is almost 90%) or in the early childhood by exposure to
serous/blood exudates from cuts/wounds/bites of other infected
children (the risk of becoming chronic carrier is almost 30% if
exposed between age 1 and 5 years, though gets reduced to 10%
of infected after five years of age).

Based on current evidence, universal childhood immunization with

three doses of Hepatitis B vaccine including a birth dose – available
since early 1980s – will enable the Philippines to reduce Hepatitis B
prevalence from its current 10-12% to below 1%. Hepatitis B
vaccine is also effective in preventing infection if given immediately
after exposure to infection (post-exposure prophylaxis). Hence, in
setting such as the Philippines where almost 10% of mothers may
be chronic carriers of the virus, and at risk of transmitting the
infection to their newborns at the time of birth (due to exposure of
newborn to infected blood from mothers), it is recommended to
give the first dose of vaccine within 24 hours of birth to prevent
mother to child transmission of infection. The bay of HBsAg and
HBeAg positive mother has a 70-90% risk of infection. Immunization
reduces the risk by 70-95% if the first dose is given soon after birth.
In the absence of a birth dose, despite sustained high coverage
with three doses of vaccine (e.g. when the immunization schedule
starts at 6 weeks rather than at birth), an estimated 3-5% of all
infant will develop chronic liver infection as a result of mother to
child transmission at birth resulting in overall poor hepatitis B
control.

Pursuant to Republic Act No. 7846 otherwise known as the

Compulsory hepatitis B immunization among infants and children

70
 less than 8 years old, Hepatitis B vaccination shall be routinely
strengthened with the activities and plans of the Expanded Program
on Immunization (EPI) to effectively control hepatitis B in the
country by reducing the chronic infection rate of hepatitis B to less
than 1% among future birth cohorts from the current levels of 10-
12%. The giving of Hepa B vaccination within 24 hours of birth is to
prevent mother to child (perinatal) transmission. Perinatal
transmission is known to be a major source of maintaining a pool of
chronic infection carriers who are at risk of developing long term
complications of infection in their economically productive years
besides serving as source of infection for others. Republic Act No.
2029 otherwise known as the “Liver Cancer and Hepatitis B
Awareness Month Act” which declares the month of February as the
liver cancer and hepatitis B awareness month throughout the
Philippines was also passed.

II. SCOPE AND COVERAGE

The order shall apply to all DOH health facilities at all levels of
health care including all public and private health facilities and
other institutions providing immunization services for children
nationwide.

III. PROGRAM GOAL

To reduce the chronic hepatitis B infection rate as measured by

HBsAg prevalence to less than 1% among five- year-old children
born after routine Hepatitis B vaccination at birth started.

IV. GENERAL GUIDELINES

1. DOH shall procure 75% of the hepatitis B vaccine needs for 2007 and
100% starting 2008 and onwards to provide all 0-11 months old with
three doses of hepatitis B vaccine in the first year of life free of charge
in all health facilities and other institutions providing immunization
services for children nationwide.
2. All newborn infants shall be given immunization against hepatitis B
immediately within 24 hours after birth.
3. Infants born outside of hospital, medical clinic or birthing facilities
should be brought to any available healthcare facility so as to be
immunized against Hepatitis B within 24 hours after birth but not later
than 7 days.
4. The subsequent doses of hepatitis B vaccination shall be completed
according to the new recommended schedule of Hepatitis B
immunization.
5. All health care practitioners or health care workers providing prenatal
care shall educate all pregnant mothers on the importance of giving
their infants the basic immunization services.
6. Every child shall be immunized through the Reach Every barangay
strategy.

71
7. Health education and information campaign shall be intensified at the
ground level especially among the disadvantaged population to
increase the proportion of mothers and caretakers practicing
behaviors that promote child immunization.
8. The implementation of RA 7846, also known as Compulsory Hepatitis B
immunization among infants and children less than 8 years old and
other laws and policies for the protection of infants shall be pursued.

V. IMPLEMENTING GUIDELINES

A. New Immunization Schedule

The first dose of Hepatitis B vaccine shall be administered as soon as
possible within 24 hours after birth. The subsequent two doses shall be
given with the first and third dose of DPT and OPV to avoid the need
for any additional visits. Table 1 indicates the recommended ages for
the routine administration of the Hepatitis B vaccine. Any dose not
administered at the recommended age should be administered at any
subsequent visit when indicated and feasible. There is no need to
restart vaccination series regardless of the time that has elapsed
between doses.

SCHEDULE OF HEP B, DPT AND OPV IMMUNIZATION

Age Hep B DPT OPV

Birth (within Hep B1
24 hours)
6 weeks Hep B2 DPT1 OPV1
10 weeks Hep B2 DPT2 OPV2
14 weeks Hep B3 DPT3 OPV3

B. Vaccine Type, Routes and Sites of Administration

a. Type of Vaccine

Recombinant or genetically engineered vaccines using HBsAg

(10mg dose) synthesized in yeast or mammalian cells into which
the HBsAg gene has been inserted.

b. Formulations

Hepatitis B vaccines are available in monovalent formulations that

protect only against Hepatitis B, and in combination formulations
that protect against Hepatitis B and other diseases (DPT-HepB, DPT-
HepB+Hib, Hib-HepB).

Only monovalent Hepatitis B vaccine MUST BE USED for the birth

dose.

72
Combination vaccines that include Hepatitis B MUST NOT BE USED
for the birth dose of hepatitis B vaccine because DPT and Hib
vaccines should not be administered at birth.

Either monovalent Hepatitis B vaccine or combination vaccines may

be used for later doses in the hepatitis vaccine schedule.
Combination vaccines can be given whenever all the antigens in
the vaccines are indicated.

c. Presentation

Hepatitis B (HepB) vaccine is a liquid vaccine available as a single

antigen formulation (monovalent) or in combination with other
antigens (e.g. DPT-HepB or DPT-HepB-Hib) as combination vaccine.
Both monovalent and combination vaccine are available in single-or
multi-dose vials (2, 6 and 10 dose vials). Only monovalent HepB
vaccine should be used for birth dose, as DPT contained in
combination vaccines can cause adverse reaction and has reduced
immunogencity if given less than 6 weeks of age. Combination
vaccines may be used for subsequent doses.

Currently all the hepatitis B vaccine under the program is being

supplied as 10 dose vials of monovalent.

d. Dosage
The standard pediatric dose is 0.5 ml.

e. Sites Of Administration

The recommended series of 3 doses of Hepatitis B vaccine shall be

given untramuscularly only in the anterolateral thigh muscle.

When hepatitis B vaccine is administered to infants at the same

time as another injectable vaccine, the vaccine should be
administered in different thighs. However, if more than one
injection has to be given in the same limb the injection sites should
be 2.5 cm. to 5cm. apart so that local reactions are unlikely to
overlap.

The preferred injection device for hepatitis B vaccine shall be a

0.5ml auto-disable (AD) injection syringe with any of the 25mm,
22-, or 23- gauge needle.

The following practices shall be avoided:

• Hepatitis B vaccine SHOULD NOT is given in the buttocks.
There may be a risk on injury to the sciatic nerve.
• Hepatitis B SHOULD NOT be administered intradermally
because this does not produce adequate antibody response
to the children.

73
 • Hepatitis B SHOULD NOT be mixed in the same syringe with
other vaccines.

C. Vaccine Storage & Handling

Hepatitis B vaccine shall be transported, stored and handled similar to

DPT and Tetanus Toxoid (TT) vaccines. It should be stored in
refrigerators provided solely for vaccine storage at +2 to +8C. It
should be transported properly in ice-packed containers with cold
chain monitors or thermometers. Hepatitis B vaccine like DPT and TT
should NEVER BE FROZEN or allowed to come into direct contact with
ice because the vaccine will be inactivated and will no longer be
potent. Twice daily temperature monitoring is critical. Specific vaccine
storage requirements are described in detail in the Cold chain and
logistics manual. The “Shake test” should be used to determine if the
vaccine has been damaged by freezing.

All Hepatitis B vaccine supplied by DOH comes with attached “Vaccine

Vial Monitor” (VVM). VVM should be regularly read before using the
vaccine to assess heat damage to the vaccine.

Since Hepatitis B vaccine is also supplied with a preservative, “Multi-

dose Vial” policy will also be applied to Hepatitis B vaccine as is the
case with DPT, OPV and TT. Multi-dose policy states that if one or more
doses of OPV, DPT, TT and Hepatitis B vaccines have been removed
during an immunization sessions, this may be used in subsequent
sessions for four weeks provided the following conditions are met:

 Expiry date has not passed;

 Vaccines are stored under appropriate cold chain conditions;
 Vaccine vial septum has not been submerged in water;
 Aseptic technique has been used to withdraw all doses;
 The vaccine Vial Monitor, if attached, has not reached its discard
point

D. Indications and Contraindications

There are no contraindications for the administration of Hepatitis B

vaccine to a newborn within 24 hours of birth.

Low birth weight or premature delivery is not contraindications to

Hepatitis B vaccination. If the birth weight is less 200 grams, a birth dose
and three additional doses should be given.

E. Vaccine Side Effects and Adverse Reactions

Hepatitis B vaccine is one of the safest vaccines. Mild reactions

include:

74
 • Soreness. About 5% of children may develop tenderness,
redness, or mild swelling at the injection site
• Fever. About 1% to 60% of those who receive the vaccine
may develop a mild fever that lasts 1-2 day after injection of
the vaccine.

Anaphylaxis is the only known serious reaction to Hepatitis B vaccine.

The risk of anaphylaxis is estimated at 1 per 600,000 doses. No fatal
reaction has been reported.

Health Centers/ and Barangay Health Stations.

a. All health centers and BHS shall follow the revised schedule of
Hepatitis B immunization among infants provided in these
guidelines.

b. Health staff and BHWs shall promote in every opportunity,

especially during prenatal consultation the importance of
providing the first dose of Hepatitis B vaccine as soon as
possible within 24 hours of birth, so that the mother can
as/demand the vaccine from the providers at the time of
childbirth. The mothers should also be educated about
importance of getting complete series of hepatitis B and other
immunizations.

c. All infants attended at birth by midwives from the health

center/BHS shall be given the monovalent Hepatitis B vaccine
within 24 hours after birth. The midwife shall carry with her a
vaccine vial and a disposable syringe as part of midwifery kit
while going to attend the birth.

d. Using the vaccine outside the cold chain: Since Hepatitis B

vaccine is found to be relatively heat stable, it is recommended
that midwife can carry the hepatitis B vaccine outside the
vaccine carrier for birth dose purposes as long as the VVM is not
past discard point. However, in the health center, the vaccine
should be kept in the cold chain as far as possible. In the event,
single dose vaccine vials are supplied under the program, the
midwives will use single dose vials for Hepatitis B birth dose, and
multiple dose vials for 2nd and 3rd dose. The MVDP shall be
adopted in this situation as long as it is not taken out of cold
chain.

3) Birth taking place outside health facilities attended by traditional

birth attendants (TBAs) or other non-trained providers.

Midwives in the BHS/health center should inquire about the

place and provider of the birth services during prenatal consultations. In

75
case, the pregnant woman decides to have her delivery attended by TBA,
the TBA or the mother should be advised to inform the nearest health facility
either by phone of by personal visit for the provision of the HepB and BCG or
should bring the newborn to the health facility for vaccinations or a midwife
to give immunization during house visit within 7 days after delivery. The
midwife at BHS/health center should provide the hepatitis B vaccine as soon
as possible after getting the information along with other post-natal
services.

VI. IMPLEMENTING MECHANISM

Roles and Responsibilities:

1. Department of Health
a. Central Office/National Center for Disease Prevention and
Control
The EPI-National Center for Disease Prevention and Control
(NCDPC) shall provide the standards, policies and guidelines on
the Hepatitis B immunization program an ensures adequate and
potent Hepatitis B vaccines are procured and delivered
nationwide. Auto-disabled needles and syringes shall also be
procured for all the 5th and 6th class municipalities nationwide.

The DOH shall provide the monovalent recombinant Hepatitis B

vaccines to all the health facilities.

b. CHDs/Hospitals
The CHDs shall ensure that all the vaccines are potent, adequate
and timely delivered to their catchments areas, ensure the
timely submission of the accomplishment reports, provide
technical assistance to include supervisory/monitoring visits to
the LGUs to ensure all infants receive 3 doses of Hepatitis B
vaccines including Hepatitis B at birth. CHD shall ensure that all
LGUs have sufficient supply of needles and syringes. This shall
entail monitoring, advocacy as well as augmentation of supplies.

Hospitals shall provide Hepatitis B birth dose and BCG to all

newborns and all immunizations for infants, children and
mothers during consultation and for in-patients. All infants
receiving birth dose in the hospitals shall be properly endorsed
or referred to health centers/health stations for their succeeding
doses. Accomplishment reports shall be submitted to the
appropriate health facilities as agreed upon.

2. Local Government Unit

All local government units shall ensure that the vaccines are given to
the targeted eligible population-the infants, reach all infants in every
barangay, ensure those who received initial vaccination from the
private sectors are fully vaccinated, follow-up the missed and the

76
 under-immunized infants including transients, and submit
accomplishment reports on time.

All LGUs shall provide funds for the procurement of the auto-disabled
syringes for Hepatitis B and other primary vaccinations series for
infants; provide adequate funds for the traveling and incidental
expenses for the health workers for them to conduct outreach
activities. They must also ensure that regular immunization activity is
being done at least once a week.

3. Private Sectors/Professional Organizations

All health practitioners shall ensure that every infant receives all
vaccinations covered in the DOH policy. Professional organizations
shall disseminate this policy to its members.

4. Partner Agencies

World Health Organization (WHO) and UNICEF shall provide technical

assistance and assist in the procurement of quality and safe vaccines
from certified manufacturers.

5. Academe

The academe shall incorporate updated EPI policies and laws into its
curriculum and continuing education.

HOW TO CALCULATE THE VACCINE NEEDS

Step One: determine the eligible population

No of infants 0-11 mos. = total population x 3%
Pregnant women 15-49 years of age= total population x 3.5%

Step two: Determine no. of doses required given in a year

 Eligible population x no of doses

Step three
 Eligible population x no. of doses x wastage multiplier

Step four: ampules/per year

Annual vaccine doses
Doses per vial/ampule

Step Five; ampules/month

Total vials/ampules
12 months or 4 quarters

Step Six: Annual DPT vaccine needs in vials

3,006 doses = 150.3 or 150 DPT vials

77
 20 dose/vial

Step Seven: Quarterly/monthly DPT vaccine needs

150 vials /month x 12 months = 12.5 x 12

Example: DPT requirement for Municipality XYZ where the total population

Step 1: determine the eligible population

20,000 x 0.03 = 600 eligible infants

Step 2: Annual DPT doses needed

600 eligible infants x 3 doses = 1,800 doses

Step 3: Annual DPT doses with wastage allowance

1,800 x 1.67 wastage = 3,006 doses multiplier

Vaccine type Doses for Wastage Wastage Doses per

complete allowance multiplier vial/ampule
immunizatio
n
DPT 3 40% 1.67 20 or 10
OPV 3 40% 1.67 20
Measles 1 50% 2.00 10
BCG infant 1 60% 2.50 20
GCG 1 40% 1.67 20
entrants
Hepatitis B 3 10% 1.20 1 or 10
Tetanus 2 40% 1.67 20
toxoid

VACCINE PREVENTABLE DISEASES

1) TUBERCULOSIS

Tuberculosis (popularly known as “TB”) is a disease caused by the

bacteria Mycobacterium tuberculosis. It mainly infects the lungs, although it
can affect other organs as well. When someone with untreated TB coughs or
sneezes, the air is filled with droplet containing the bacteria inhaling these
infected droplets is the usual way a person gets TB.

• In general, children are not considered contagious, and usually get the
infection from infected adults.
• The incubation period varies from weeks to years, depending on the
individual and whether the infection is primary, progressive, or
reactivation TB.

2) POLIOMYELITIS

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Poliomyelitis or polio is a highly contagious viral infection that affects the
nervous system.

Children can be infected with polio when they eat or drink food and water
contaminated with the virus or when they come into direct contact with an
infected person’s fecal matter or saliva.

Incubation period – 3-6 days

Period of Communicability: during the incubation period, late part of the

incubation period, first week of the acute stage.

Causative agent: Polio Virus 1, 2, &3

Sign & Symptoms

Polio is a viral illness that, in about 95% of cases actually produces no
symptoms at all (called asymptomatic polio). In the 4% to 8% of cases in
which there are symptoms (called asymptomatic polio), the illness appears
in three forms:

a) A mild called abortive polio (most people with this form of polio may
not even suspect they have it because their sickness is limited to mild
flu like symptoms such as mild upper respiratory infection diarrhea,
fever, sore throat, and a general feeling of ill)
b) A more serious form associated with septic meningitis called
nonparalytic polio (1% to 5% show neurological symptoms such as
sensitivity to light and neck stiffness)
c) Severe debilitating from called paralytic polio (this occurs in 0.1% to
2% of cases)

Paralytic polio, as its name implies, causes muscle paralysis and can even
result in death. Paralytic polio, the virus leaves the intestinal tract and
enters the bloodstream, attacking the nerves (in abortive or asymptomatic
polio, the virus usually just stays in the intestinal tract) the virus may affect
the nerves governing the muscles in the limbs and the muscles necessary
for breathing, causing respiratory difficulty and paralysis of the arms and
legs.

Nursing Care/Treatment:
 Symptomatic
 Avoid over fatigue
 Place the child in firm mattress with feet support
 Change position regularly, maintain good body alignment
 Fluid and food intake
 Relieve anxiety and promote rest
 Physiotherapy (moist heat to alleviate muscular pain)
 Dispose of stool properly

3) DIPTHERIA

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Causative Agent: Corynebactrium dipthense
Incubation period: 2 – 6 days
Mode of Transmission: droplet from infected person or carrier

Sign & Symptoms

In these early stages, diphtheria can be mistaken for a bad core throat. A
low grade fever and swollen neck glands are the other early symptoms. The
toxin, or poison, caused by the bacteria can lead to a thick coating in the
nose, throat, or airway. This coating is usually fuzzy gray or black and can
cause breathing problems and difficulty in swallowing. The formation of this
coating (or membrane) in the nose, throat, or airway makes a diphtheria
infection different from other more common infections (such as ) that cause
sore throat.

As the infection progresses, the person may

• Have difficulty breathing or swallowing
• Complain of double vision
• Even show sign of going into shock (skin that’s pale and cold, rapid
heartbeat, sweating, and an anxious appearance)
• In cases that progress beyond a throat infection, diphtheria toxin
spreads through the bloodstream and can lead to potentially life-
threatening complications that affect other organs of the body, such
as the heart and kidneys. The toxin can cause damage to the heart
that affects its ability to pump blood or the kidneys ability to clear
wastes. It can also cause nerve damage. Eventually leading to
paralysis. Up to 40% to 50% of those who don’t get treated can die.

Nursing Care/Treatment
a) IV administration of antibiotics (erythromycin or penicillin) for 14 days.
b) Contact must be taken specimen for testing/culture & observed
c) Strict bed rest, prevent exertion
d) Cleansing sore throat gargle, liquid and soft diet
e) Observe for respiratory obstruction

Possible Complications:
Bed rest is particularly important if the person’s heart has been affected by
the disease. Myocarditis, or inflammation of the heart muscle, can be a
complication of diphtheria.

4.) PERTUSSIS

Pertussis (Whooping cough)

Incubation period: 7-10 days
Causative Agent: Bordetella pertussis

Mode of Transmission:
a) direct contact with infected person
b) droplet

80
 Pertussis is a respiratory infection characterized by a signature cough.
During severe coughing spells, the infected child may have difficulty
breathing and make a “whooping” noise as he or she tries to inhale.

Pertussis can result in several life-threatening complications, including

pneumonia, seizures, encephalitis and in some cases, death. The disease
most often strikes young children, but adults also suffer from the disease
and may pass it on to infants that have not been immunized.

Mode of Transmission:

Pertussis is caused by a bacterium, Bordetella pertussis that invades

the respiratory tract. The disease is very contagious and is spread by
droplets when an infected person coughs or sneezes. A child can also
become infected after coming in contact with a sick person’s saliva or
phlegm, or through contaminated objects.

Sign & Symptoms

The first symptoms of whooping cough are similar to those of a common

cold:
1. runny nose
2. sneezing
3. mild cough
4. low-grade fever

• After about 1 to 2 weeks, the dry, irritating cough evolves into

coughing spells. During a coughing spell, which can last for more than
a minute, the child may turn red or purple. At the end of a spell, the
child may make a characteristic whooping sound when breathing in or
may vomit. Between spells, the child usually feels well.
• Although it’s likely that infants and younger children who become
infected with B. Pertussis will develop the characteristic coughing
episodes with their accompanying whoop, not everyone will. However,
sometimes infants don’t cough or whoop as older children to do. They
may look as if they’re gasping for air with a reddened face and may
actually stop breathing for a few seconds during particularly bad
spells.
• Adults and adolescents with whooping cough may have milder or
atypical symptoms, such as a prolonged cough without the coughing
spells or the whoop.

Nursing Care/Treatment
a. symptomatic
b. erythromycin used to limit communicability
c. sulfonamides and antibiotics may be given to prevent 2nd
infection
d. oxygen may be given, humidity air
e. small frequent feeding

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Possible complications
a. bronchopneumonia
b. malnutrition, bronchoiectasis
c. hemorrhage may occur during coughing
d. encephalitis

5.) TETANUS

“LOCKJAW & “SEVENTH DAY DEATH”

Causative Agent: Clostridium Tetani bacillus
Incubation period: 3-21 days

Mode of transmission:

Organisms are found in soil and enter body through a wound. Deep puncture
wound are ideal for the growth of the organism (anaerobic); burns are also
ideal due to the necrotic tissues

The bacteria spores live in soil, in animal drug, and in feces-and tetanus can
affect anybody. The bacteria produce a toxin (poison) that attacks the
central nervous system.

A newborn can be infected with tetanus due to unhygienic birthing practices,

such as cutting umbilical cord with unsterile instruments or treating it with
contaminated dressings. If the spores enter, the infection can spread and
the child usually dies a quick and painful death.

Mothers can also be infected with tetanus during unsafe or unsanitary

delivery if there are unsanitary conditions where the tetanus spores are
present. Tetanus is called the “silent killer” because so many of these
women and newborns die at home and both the births and the deaths go
unreported.

Symptoms
• It takes about 8 days for symptoms of tetanus to appear.
• One of the earliest signs of tetanus is stiffening of the jaw muscles,
which is why tetanus is often referred to as lockjaw (insmus)
• There is also spasm of facial muscles
• Symptoms progress to stiff neck and pain in the shoulders and back
(opistoronus). Difficulty swallowing, and tightening of the muscles of
the abdomen and limbs.
• Other symptoms include a fever, sweating, high blood pressure and
periods of irregular heartbeat.
• Muscle spasms, which may be severe, are also likely to occur and may
last 3 to 4 weeks. Recovery from tetanus may take months.

Complications

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 • Complications associated with tetanus include spasms of the muscles
of the vocal cords and/or breathing), spinal and long-bone fractures,
high blood pressure, and abnormal heart rhythm. Other complications
include infections in patients who experience extended hospital stays,
blood clots in the lungs (the elderly and drug users are especially at
risk), and pneumonia.
• About 11% of people who get tetanus die from the disease.

Treatment/Nursing care
• Neutralize toxins: tetanus immune globulin (TIG) IM; equine tetanus
anti-toxin (TAT)
• Penicillin G or tetracycline is effective against tetanus organism
• Place child in darkened room, avoid stimulation
• May give muscle relaxant, sedative and tranquilizer
• Tracheostomy may be necessary

6.) MEASLES “rubeola”

Causative agent: measles virus

Incubation period: 8-12 days
Period of communicability: 4 days before to 5 days after rash appears

The measles virus multiplies in the respiratory tract and is transmitted via
droplets released into the air when an infected person coughs or sneezes.
Children can catch the disease by breathing in these droplets, or by coming
in contact with the fluids from the infected person’s nose or throat.

Signs and Symptoms

• First symptoms of the infection are usually a hacking cough (coryza)
runny nose, high fever, and watery red eyes (conjunctivitis &
photophobia)
• The marker of measles are Koplik’s spots, small red spots with blue-
white centers that appear inside the mouth
• Rash consists of small reddish-brown or pink macules, changing to
papules
• Rash begins behind the ears, on the forehead or cheeks, progress to
extremities & last about 5 days.

Treatment/Nursing Care
• Symptomatic
• Bed rest until fever and cough subsides
• Dim lights in room
• Tepid baths and soothing lotion to relive itching of skin
• Increase fluids
• Antibacterial therapy given for complications

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Remember, you should never give aspirin to a child who has a viral illness
since the use of aspirin in such cases has been associated with the
development of Reye syndrome.
Reye syndrome, cause is unknown, associated with infections mainly caused
by virus. Causes a disruption in liver mitochondria or in the urea cycle
resulting in fatty deposits in the liver, renal tubules, myocardium and
pancreas. Severe brain edema may also occur, encephalopathy & cerebral
swelling.

Possible Complications
Measles can lead to other health problems, such as croup (acute infection of
the larynx and trachea), and infections like bronchitis, pneumonia,
conjunctivitis, (pinkeye), myocarditis, and encephalitis. Measles also can
make the body more susceptible to ear infections or other health problems
caused by bacteria.

7.) HEPATITIS B

Incubation period: 50-180 days

Communicability: few days before to month or more after the onset

Hepatitis B (also called serum hepatitis) is caused by the hepatitis B virus

(HBV) can cause a wide spectrum of symptoms ranging from general
malaise to chronic liver disease that can lead to liver cancer.

Hepatitis B virus spreads through:

• Infected body fluids, such as blood, saliva, semen, vaginal fluids, tears,
and urine
• A contaminated blood transfusion
• Shared contaminated needles or syringes for injecting drugs
• Sexual activity with an HBV-infected person
• Transmission from HBV-infected mothers to their newborn babies

B. Food Fortification Act of 2000 (Republic Act 8976)

“An act Establishing the Philippine Food Fortification Program and for
other purposes”

 Objective of the law:

The Food Fortification Act of 2000 signed on November 7, 2000 is one of
the major steps to eliminate the micronutrient malnutrition problems
namely vitamin A deficiency disorders (VADD) and iron deficiency anemia
(IDA) which affects a great majority of the Filipino population particularly
women and children.

 Provision of the law:

The Food Fortification law has two (2) major components: voluntary and
mandatory fortification.

The voluntary fortification, manufacturers may fortify their processed

food products with Vitamin A, iron and/or iodine and may avail of the

84
Sangkap Pinoy Seal, a department of Health (DOH) Seal of Acceptance,
after complying with the fortification standards and requirements set by
the Bureau of Food and Drugs (BFAD).

The fortification law mandates that the following staples shall be fortified:
 Rice with iron
 Wheat flour with vitamin A and iron
 Refined sugar with vitamin A
 Cooking oil with vitamin A
 Other staple foods with nutrients as may be required later by the
National Nutrition Council (NNC) Governing Board
The fortification of the food products shall cover all imported processed
foods or food products for sale or distribution and for human consumption
in the Philippines.

 Agencies involved in the Implementation of the Law:

The DOH through the BFAD shall be the lead agency responsible for the
implementation and monitoring of this Act.

The NNC Governing Board shall serve as the advisory board on food
fortification.

The Local Government Units (LGUs) through their health

officers/agricultural officers/nutritionist-dietitians/sanitary inspectors shall
assist in monitoring that staple foods mandated to be fortified are
properly fortified and labeled.

The Department of Science and Technology (DOST) shall develop and

implement comprehensive programs for the acquisition, design and
manufacture of machines and technologies.

The Land Bank of the Philippines (LBP) and the livelihood Corporation are
required to assist and support the implementation of the law by granting
loans to affected manufacturers. The following shall assist the BFAD in
the monitoring and review of the food fortification program:
 Recall of food products from the market
 Imposition of fine of not less than Three Hundred Thousand pesos
(Php 300,000) and the suspension of registration for the first
violation; not more than Six Hundred Thousand pesos (Php
600,000) and the suspension of registration for the second
violation; not more
 Sugar regulatory administration for sugar
 National Food Authority for rice
 Philippine Coconut Authority for oil
 Bureau of Customs for imported products

85
Sanctions:

The DOH through the BFAD shall impose the following administrative
sanctions in cases of non-compliance with the provisions of the law:
 Denial of registration
 Than One Million pesos (Php 1,000,000) and cancellation of the
registration of the product for the third violation.

C. MICRONUTRIENT SUPPLEMENTATION

Rationale/Background:

Micronutrient malnutrition, particularly vitamin A deficiency disorders

(VADD), iron deficiency anemia (IDA) and iodine deficiencies (ID) lead to
serious physical, mental, social and economic consequences, especially
among children and women.

Micronutrient supplementation is one of the strategies identified to

address the problem of micronutrient deficiencies. It has been proven to
immediately correct the deficiencies and prevent adverse consequences
attributed to each deficiency.

Micronutrient supplementation will be provided to target clients and

will be distributed during national campaign and during routine services in
all health centers. It shall also be distributed in evacuation centers during
emergencies, disasters and calamities.

1. Vitamin A Supplementation

1.1 Universal Supplementation

 Universal supplementation involves the administration of
Vitamin A every 6 months to infants 6-11 months old and
children 12-71 months old.
This is done during regular services in all health facilities
including but not limited to the implementation of Integrated
Management of Childhood Illnesses (IMCI), immunization
activities, growth monitoring/weighing, and during national
campaigns like Garantisadong Pambata every April and October
of each year.

Target Preparati Dose/Duration

on
Infants 6-11 months 100,000 IU 1 dose (one capsule is given anytime
old during the 6-11 months but usually
given at 9 months during the measles
immunization)

86
Children 12-71 200,000 IU 1 capsule every six (6) months
months old

1.2 Supplementation to Pregnant and Post-partum Women

 Numerous studies have shown that pregnant women have an

increased risk of VADD particularly in population where such
deficiency is endemic.
 An increase in vitamin A status of the mother results to an elevated
vitamin A concentration in her breast milk as well as the vitamin A
status of her breastfed child.
 Target and Doses:

Target Preparatio Dose Duration Remarks

n
Pregnant 10,000 IU 1 capsule Start from - 10,000 IU of Vitamin A
women of 10,000 4th month of should NOT be given to
IU twice a pregnancy pregnant women who are
week until already taking pre-natal
delivery vitamins or multiple
micronutrient tablets that
also contain vitamin A.
- 200,000 IU should NOT be
given to pregnant women.
Post- 200,000 IU 1 capsule One dose
partum only within
women 4 weeks
after
delivery

1.3 Basis for Computation of Requirements:

 Infants 6-11 months old

Total population x 1.5% = number of infants 6-11 months old

 Children 12-59 months old

Total population x 12% = number of children 12-59 months old

 Children 60-71 months old

Total population x 3% = number of children 60-71 months old

 Pregnant Women
Total population x 3.5% = number of pregnant women

 Post-partum Women
Total population x 3% = number of post-partum women

2. Iron Supplementation

87
  The high physiological requirement of iron during pregnancy is difficult
to meet with diet alone; therefore, pregnant women must take iron
supplements. It is recommended that supplementation must start as
soon as pregnancy diagnosed.

Targets Preparation Dose/Duration Remarks

Pregnant Tablet (preferably One (1) tablet once A dose of
women coated) containing a day for 6 months 800mcg of folic
60mg elemental iron or 180 days during acid is still safe to
(EI) with 400mcg folic the pregnancy pregnant women
acid period OR
2 tablets per day
(120mg EI) if
prenatal
consultations are
done during the 2nd
and 3rd trimester
Post-partum Tablet (preferably One (1) tablet once
women coated) containing a day for 3 months
60mg elemental iron or 90 days
with 400mcg folic acid

2.1 Basis for Computation of requirements:

 Pregnant Women
Total population x 3.5% = number of pregnant women

 Post-partum women
Total population x 3% = number of lactating women

 To get total population, use 2000 National Statistics Office (NSO) 2005
projected population.

D. Infant and Young Child Feeding

The Philippines is one of the 42 countries that account for 90% of global
under 5 infant and young child deaths. Last year alone, 82,000 Filipino
children under –five years old died. About 16,000 of these deaths could have
been prevented with exclusive breastfeeding for the first six months, and
continued breastfeeding and appropriate complementary feeding to at least
two years. Malnutrition is a primary outcome of children who do not
breastfeed. Malnutrition is not associated with 60% of young child and infant
deaths, but has lifelong implications. They are less healthy, more vulnerable
to infections and less intelligent. We need to fundamentally rethink our
approach or we risk jeopardizing the future of the Filipino children.

Exclusive breastfeeding means the infants receives only breast milk. Not
even water should be given to an infant. Appropriate complementary
feeding is the progressive addition of adequate solid foods beginning at six
(6) months. Infant formulas are not appropriate complementary foods; they
are breastmilk substitutes, regulated under the Philippine Code of Marketing

88
of Breastmilk Substitutes, Breastmilk Supplements and Other Related
Products (E.O. #51).

Facts about breastfeeding

 Only in 6 (15%0 children are exclusively breastfed for the first 6
months of life
 On the average, infants are exclusively breastfeed <1 month
 The median duration for breastfeeding is 11 months
 Two months olds are frequently given foods other than breastmilk
 Infants born in health facilities or delivered by health workers are less
likely to be breastfed
 Only half of infants initiated breastfeeding within 1 hour after delivery

Benefits for the child:

 Breastfeeding prevents more than 6 out of 10 deaths

 Breastfeeding results in smarter children and adults
 Breastfed children are safer and healthier
 Low risk for diabetes, obesity and cancers later in life

Benefits for the breastfeeding mother

 Reduces blood loss after childbirth

 Delays her return to fertility (child spacing)
 Reduces risk for cancer associated with female organs: breast,
ovaries, uterus
National Plan of Action, 2005-2010

I. GOAL
“Reduce Child Mortality Rate by 2/3 by 2015”
II. OBJECTIVE
“To improve health and nutrition status of infants and young
children.”
III. OUTCOME
“To improve exclusive and extended breastfeeding and
appropriate complementary feeding”

IV. Specific Objectives

 70% of newborns are initiated to breastfeeding within one hour
after birth
 60% of infants are exclusively breastfed up to 6 months
 90% of infants are started on CF by 6 months of age
 Median duration of breastfeeding is 18 months

V. Government Policies
 Breastfeeding is initiated within 1 hour
 Exclusive breastfeeding for the first 6 months of life
 Continued breastfeeding up to two years and beyond

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  Breastfeeding with complementary feeding at 6 months with
appropriate foods, excl. milk supplements
 Micronutrients supplementation
 Universal salt iodization
 Food fortification
 Breastfeeding is still best option in exceptionally difficult
circumstances
i. Calamities
ii. Orphans
iii. HIV-positive mothers
 Support systems shall be made available

o Access to objective, consistent and complete information

o Access to skilled support
o Mother baby friendly hospitals
o Rooming in and breastfeeding act/E.O. 51
o No partnerships with manufacturers and distributors of infant
formula, milk supplements, complementary foods and other
related products
o Community –based networks, i.e. mother –to-mother support
groups

To achieve a healthy and bright future of Filipino children, we need a

comprehensive systematic approach. Five mother-baby friendly settings will
be focused upon:

 Health facilities
 Work places
 Schools
 Industry
 Communities and homes

E. Oral Health (Dental Health Program)

I. Rationale/Background

In the Philippines, the two main oral health problems are tooth decay and
gum diseases. Fewer than 8% of our people are free of the experience of
tooth decay. Gum diseases are so widespread that 78.0% of people suffer
from it. This does not mention yet, crooked teeth, mal-relation of the
jaws, cancer of the oral cavity and others. No community in the
Philippines is free from dental diseases.

In terms of DMFT (decayed, missing, filled teeth) Index, the Philippines

ranked second worst among 21 WHO Western Pacific Countries. Dental
caries and periodontal disease are significantly more prevalent in rural
than urban areas. This is not surprising considering that in a survey with
the members of the Philippine Dental Association in 1998, 88.4 percent of
respondent dentist claimed that their practice were based in urban areas,

90
 10.9 percent were in suburban centers while only 0.7 percent were in a
rural location. However, the prevalence of dental caries and periodontal
disease are also high in urban areas.

II. Definition Of Terms

A. Basic Oral Health Care (BOHC) – is defined as the essential promotive,

preventive and curative services the individual needs for his/her oral
health. These include oral examination, health promotion such as
toothbrushing drills, education and counseling, and direct services
such as scaling (oral prophylaxis), filling of restorable cavities and
extraction of unsavable teeth among others. It includes, further,
indirect services such as referral and follow-up of dental clinic cases
which cannot be coped with by facilities available at the health
centers.

B. Orally Fit Child (OFC) – a child who meets the following conditions
upon oral examination and/or completion of treatment:
a) caries – free or carious tooth/teeth filled either with temporary
or permanent filling materials,
b) have healthy gums,
c) has no dental plaque, and
d) no handicapping dento-facial anomaly or no dento-facial
anomaly that limits normal function of the oral cavity

III. ORAL HEALTH PROGRAM

Vision
- Empowered and responsible Filipino citizens taking care of their own
personal oral health for an enhanced quality of life.

Mission
- The state shall ensure quality, affordable, accessible and available oral
health care delivery.

Goal
- Attainment of improved quality of life through promotion of oral health
and quality oral health care.

Objectives
General Objectives:
- Reduction of the prevalence rate of dental caries and periodontal
diseases to 85% and 60% respectively by end of 2010 (Baseline: 92%
and 78% 1998 NMEDS)

Specific objectives:
a. To attain an 80% Orally Fit Children (OFC) under 6 years old by 2010
(Baseline to be determined)
b. To control risk oral health among young people

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 c. To improve oral health conditions of pregnant women by 80% and
older persons by 50% in 2010

Curative/Treatment Services and Interventions:

These are remedial measures applied to halt the progress of oral disease
process and restore to a sound condition of the teeth and supporting tissues.

1) Permanent Filling – restoring savable teeth with amalgam, composite

or glass ionomer filling materials.
2) Gum Treatment – deep scaling and root planning of affected tooth or
teeth for pregnant mothers and older person with periodontal disease.
3) Atraumatic Restorative Treatment (ART) – one form of permanent
filling for priority target groups by manually cleaning dental cavities
using hand instruments and filling the cavities with fluoride releasing
glass ionomer restorative materials.
4) Temporary Fillings – treating deep-seated tooth decay with zinc oxide
and eugenol
5) Extraction – removal of unsavable teeth to control foci of infection;
provision/prescription of antibiotics when necessary
6) Treatment of post extraction complication such as dry sockets and
bleeding
7) Drainage of localized oral abscesses – incision and drainage

IV. Basic Package of Oral Health Care – Lifestyle Approach

The following are the basic package of essential oral health services/care for
every lifestage group to be provided either in health facilities, schools or at
home.

LIFE STAGE TYPES OF SERVICE

Mother (pregnant Women)**
Neonatal and Infants under 1 year old**
(Basic Oral Health Care)
• Oral Examination
• Oral prophylaxis (scaling)
• Permanent Fillings
• Gum Treatment
• Health Instruction
• Dental check-up as soon as the
first tooth erupts
• Health instructions on infant oral
health care

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Children 12-71 months old ** • Dental check-up: as soon as the
first tooth appears and every 6
months thereafter
• Supervised tooth brushing drills
• Oral urgent treatment (OUT)
- removal of unsavable teeth
- referral of complicated cases
- treatment of post extraction
complications
- drainage of localized oral abscess
• application of Atraumatic
Restorative Treatment (ART)

School Children (6-12 years old) • oral examination

Other adults (25-59 years old)
Older Person (60 years old and
above)**
• health promotion and education
on oral hygiene, consumption of
sweets and sugary beverages,
tobacco and alcohol
• oral examination
• emergency dental treatment
• health instruction and advice
• referrals
• oral examination
• extraction of unsavable tooth
• gum treatment
• relief of pain
• health instruction and advice

PREVENTION AND CONTROL OF INFECTIOUS DISEASES

A. Introduction:

The past years, we have observed important changes in the 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

93
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 patient’s 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

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 • 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.

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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 year’s 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.

96
 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:

97
  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

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  *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

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 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.

C. 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

100
 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

I. 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

101
 c) Collects 3 sputum specimens from the patient within 2 days
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

d) 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

e) 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 patient’s 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

f) Records the results

a. Record the results of the sputum examination in the TB
symptomatics masterlist

g) 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

h) 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!

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 • 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

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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

104
Passive Case finding - TB symptomatic present them in a DOTS facility.

Active Case finding – a health worker’s purposive effort to find TB cases

(among the symptomatic in the community) who don’t 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 (+)

105
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 TB Patients To Be Given DRUGS AND DURATION

Regimen Treatment

New smear-positive PTB; Initial Phase Continuation Phase

I New smear-negative PTB with
(2 HRZE/ extensive parenchymal
4 HR) involvement; Extra-pulmonary 2 HRZE 4 HR
TB

II Relapse;
2 HRZES/ Treatment Failure; Return After 2 HRZES/
1 HRZE/ Default 1 HRZE 5 HRE
5 HRE) Others

III New smear-negative PTB with

2 HRZE/ minimal parenchymal 2 HRZE 4 HR
4 HR involvement

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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 Partner’s House
Patient’s 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

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 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

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 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

Patient Midwife identified and

consults for registers patient as TB
cough with symptomatic
duration of two
NTP
weeks or more Midwife explains the Medical
purpose of the sputum Technologists
examination and /Microscopist
Midwife
demonstrates informshowandto
Midwife properly reads the
explains
produce the
good result
sputum to
labels, seals and slides,
the patient (if secure
the Go to
the
resultsputum
Midwife specimen
is doubtful,
collects the
3 diagnosis and records
collected
Midwife
midwife
sputum and
follow-up
immediately
specimens initiation of results and 109
from transports
patienttheand
collects it within
to 3
convinces
another
patient treatment sends it to
Midwife
Midwife
microscopyrefers
records
the the
unit flowchart midwife
him to
specimens submit
2 the
days for3or
patientlaboratory
toresults Doctor
sputum specimens
confirmation
 Patient
submits
3
sputum
specime
ns

National Tuberculosis Program

RHU Supervisory Flowchart: Diagnosis and Initiation of Treatment
Client Midwife Nurse Doctor Others
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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 world’s
population
> Worldwide prevalence of the disease

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 > 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

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 • 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% c. MINDANAO - 53%

HIGH RISK
• PREGNANT WOMEN
• CHILDREN

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

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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 malaria-
endemic 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

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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

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  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 Cases Deaths CFR %

I 706 7 0.99%
II 851 4 0.47%

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 CAR 456 0 0
III 2739 10 0.36%
IV-A 621 6 0.96%
IV-B 16 0 0
NCR 3859 28 0.72%
V 1202 10 0.83%
VI 1718 12 0.7%
VII 1921 25 1.3%
VIII 1051 2 0.2%
IX 505 4 0.8%
X 2542 41 1.61%
XI 2657 61 2.3%
XII 909 14 1.54%
ARMM 118 2 1.7%
CARAGA 739 18 2.43%
TOTAL 22610 244 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 artificial containers

BIONOMICS OF AEDES
A. Aegypti A. Albopictus
Feeding habit Day biters Day biters
(1-2 hrs after sunrise/ 1-2(1-2 hrs after sunrise/ 1-2
hrs before sunset) hrs before sunset)
Resting Habit Indoor Outdoor
Oviposition Lay eggs 60-100 eggsLay eggs 60-100 eggs
per batch per batch
Breeding Habitat Artificial containers Natural containers
Flight Range 200-300 meters 200-300 meters
Host preference Human Human
Life span 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

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  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 ½
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 Virus Infection

Asymptomatic Symptomatic

Undifferentiated Differentiated Fever Dengue Hemorrhagic

Fever Syndrome Fever (plasma leakage)

Without Unusual No shock Dengue

Hemorrhage Hemorrhage Shock
Syndrome
Dengue Hemorrhagic Fever
The following must all be present:
 History of acute fever, lasting 2-7 days;

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  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

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  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)

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 BI = no. of positive containers x 100
total no. of houses inspected

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

Mosquito bites a
Microfilariae person and
develop transmits larvae
into larvae in into
mosquito
Blood circulation

In lymph vessels
Adult female and glands,
produce larvae develop
Microfilariae that
into adult male
circulate in blood
and female
stream
worms

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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)

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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.

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  The cercariae penetrate the skin of the host, find their way into the
blood circulation, then to the liver and into their final habitat—the
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 people’s 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 1997 Baseline 2004 Targets

School children
3.78% 1.79%
(1-6 years old)

Special Target Areas 1997 Baseline 2004 Targets

Maguindanao 18.91% 10.05%

Agusan del Sur 18.29% 9.71%

Lanao del Norte 11.06% 5.88%

Surigao del Norte 8.95% 4.76%

Oriental Mindoro 5.41% 2.88%

2. Eliminate schistosomiasis as a public health problem in five endemic

provinces.

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(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 1997 Baseline 2004 Targets

Davao Oriental 0.99% 0.47%
Surigao del Sur 0.90% 0.43%
Zamboanga del Norte 0.44% 0.21%
Davao del Sur 0.38% 0.18%
Bohol 0.17% 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 Totals for Aug.
Reported Modes of
Jan. 1984 – 2005
Transmission
Feb.2006
N=2,484 N =30
Sexual Transmission

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

125
 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 – Don’t use illicit drugs/ share
syringes and needles
E – Educate you/other

Partner Management and Its Importance

4 C’s: 1. Compliance
2. Condom
3. Contact tracing
4. Counseling

Strategies

126
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).

127
  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 100,000-dog
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.

128
 (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

 Hansen’s 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.

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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 Multibacillary

Paucibacillary (PB) (MB)
(SLPB)

Skin lesions Only one lesion  2 -5 lesions More than 5 lesions

(Includes macule – ØAsymmetrically Assymetrically
flat lesion and papule distributedDefinite loss of distributed
– raised lesion and sensation Loss of sensation
nodule)

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 Nerve damage No nerve trunk  None or one nerve Many nerve trunk
(resulting in loss of involvement trunk
sensation or
weakness of muscles
supplied by the
affected nerve

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

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 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 world’s 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.

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  Intestinal capillariasis is characterized by intestinal mal-absorption,
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…

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 • 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:
1. Meningitis
2. Meningitis with meningococcemia
3. Meningococcemia with meningitis
4. History presents with a non-specific prodrome of cough, headache
and/or sore throat.
5. Followed by fever with chills, myalgia and arthralgia

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

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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
250t u IV/4hrs
Pen G Na Bacteriostatic
4M u IV/4hrs

Chlramphenicol Bacteriostatic 100mg/kg/d.

Ceftriaxone Bacteriostatic 2g IV red. To 1g daily

Rifampicin Bactericidal 600mg BIDx2

Ciprofloxacin Bacteriostatic 500mg SD

Azithromycin Bacteriostatic 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

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 - 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 case’s 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 patient’s 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)

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  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

WHAT CAUSES BIRD FLU?

> 15 SUBTYPES OF INFLUENZA A VIRUS.

> AFFECT CHICKENS, DUCKS AND OTHER
BIRDS.
> VIRUSES OF LOW PATHOGENICITY CAN
MUTATE INTO HIGHLY PATHOGENIC
VIRUSES.
> TO DATE, ALL OUTBREAKS OF THE
HIGHLY INFECTIVE FORM HAVE BEEN
CAUSED BY INFLUENZA A / H5N1 VIRUS, THE
ONLY SUBTYPE THAT CAUSE SEVERE
OUTBREAKS IN 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:

137
 • 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 shortness of
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

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

138
 • 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 re-assortment 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

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 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 or disposable protective foot covers

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 1 – BIRD FLU FREE PHILIPPINES
• STAGE 2 - AVIAN FLU IN BIRDS
• STAGE 3 - AI VIRUS TRANSMITTED TO HUMANS
• STAGE 4 - 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 or establishments

3. Cough Manners

140
 • Cover your nose and mouth with tissue or handkerchief every time you
sneeze, cough or blow your nose. If you don’t 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.

• Don’t be offended if someone offers you tissue. Thank the person for
the kind act.
• Don’t 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)

Mortality: ten (10) leading causes

Number, Rate/100,000 Population & Percent Distribution, 2002

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 CAUSE OF DEATH NUMBER RATE
1. Diseases of the heart 70,138 88.2
2. Diseases of the vascular system 49,519 62.3
3. Malignant neoplasm 38,821 48.8
4. Pneumonia 34,218 43.0
5. Accidents 33,617 42.3
6. Tuberculosis, all forms 28,507 35.9
7. Chronic obstructive pulmonary disease and allied
conditions 19,320 24.3
8. Certain conditions originating in the perinatal period 14,209 17.9
9. Diabetes mellitus 13,922 17.5
10. Nephritis, nephritic syndrome and nephritis 9,192` 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

THE NATIONAL CARDIOVASCULAR DISEASE PREVENTION AND CONTROL

PROGRAM

VISION:
A nation of Filipinos with healthy lifestyles and habits, living and
working in clean and safe environment, and with access to adequate
medical care for cardiovascular diseases.

OBJECTIVES:
> Reduction in mortality and morbidity from CVD.
> Reduction in the economic burden of CVD in the individual, the
family and community.
> Improvement in the productivity and quality of life of CVD.

Program Components:

142
 1. Community-Based;
> Prevention and control of cardiovascular disease morbidity and
mortality thru;
- Increasing awareness of the community on CVD and their causes
- Elevating the CVD knowledge, attitude and practices of the people.
- Improvement of the registration, diagnosis and management of the CVD at
the community level
- Initiation of community rehabilitation of CVD patients
- Improvement of the of the registration system of CVD.
2. School-Based
> Prevention and control of healthy lifestyles thru;
- Integration of teaching of CVD in school curriculum.
- Institution of anti-smoking measures in high schools
- Provision of CVD services in school health
- Screening of high risk school children
3. Industry-Based
> Adoption of healthy lifestyles, reduction of CVD risk and
improvement in productivity and quality of life of CVD cases in
working population thru;
- Promotion of healthy lifestyles among workers
- Identification and management of workers with high CVD risk
- Provision of medical care for CVD cases
- Creation of a healthful social climate and environment in Industrial
companies.
4. Hospital-Based
> Improvement in the outcome of CVD and in the productivity and
social life of
CVD cases thru:
- Increasing the awareness among patients, their families and the general
public
of the measures which they can take to prevent cardiovascular disease and
minimize
their effects, if disease is present.
- Improvement in the detection and diagnosis of CVD in all levels of the
hospital system.
- Improvement in the management of CVD cases at the different levels of
the hosp system
- Systematic referral mechanism for CVD.
An integrated approach to National Communicable Disease prevention and
control means that;
- Risk factors are not solely health issues but should be part of the total
development of the community
- Strategies and activities employed should cut across other agencies and
sectors concerns.

BASIC SERVICES OF CVD PROGRAM:

1. Recognition of suspect CVD cases.

2. Referral of recognized cardiovascular disease for definitive diagnosis
and management.

143
 3. Counseling of identified high risk individuals.
4. Recognition of some risk factors such as obesity, smoking, sedentary
lifestyle as well as hypertension and diabetes mellitus.
5. Monitoring the compliance of patients at home to prescribed medical
regimen.
6. Follow up of patients under treatment for any side effects, untoward
manifestations or complications.
7. CVD emergency care during Hypertensive crisis, including basic life
support in emergency situations.

RISK FACTORS IN CARDIOVASULAR DISEASES:

1. Obesity
2. Smoking
3. Sedentary lifestyle
4. Stress

1. OBESITY
• Results from excess intake of food over an extended period of time
• Excess weight and body fat
• Determined by Body Mass Index (BMI)
Formula:
Weight in kilos
(Height in meters) 2

BODY MASS INDEX (BMI)

2. WEIGHT REDUCTION
- The overweight individual, the obese in particular, faces the
risk of overburdening the heart. The body’s demand for oxygen and
nutrients
<16 >Severe chronic energy deficiency(CED)
16 to <17 >Moderate CED
17 to <18.5 >Mild CED
18.5 to <20 >Low normal
20 to <25 >Normal
25 to <30 >1st Obese
30 to <40 >2nd Obese
≥ 40 >3rd Obese

increases thereby increasing the cardiac load. It loads. It must

therefore be the aim of the every individual to maintain an ideal body
weight.

144
 Guide to a healthful diet

Overweight or Obese-
An important component in weight loss therapy is exercise. Most

SYSTOLIC DIASTOLIC
CATEGORY (mm Hg) (mm Hg) RECOMMENDED TX

Normal <120 <80 None

Lifestyle changes, including regular
Pre 120 -139 80 - 89 exercise, losing weight, quitting
hypertension smoking, eating a healthful, low salt
diet.
Lifestyle changes plus drug
Stage 1 HTN 140 -159 90 - 99 treatment with one or more drugs
that include a diuretic.
Lifestyle changes plus drug
Stage 2 HTN 160 and > 100 and > treatment with at least 2 drugs.
weight losses occur because of decreased caloric intake. Sustained physical
activity is most helpful in the prevention of weight regain.

HYPERTENSIONS
There are four things to remember about high blood pressure:
1. There are no symptoms in the early stage.
2. In its early stages, hypertension may be indicated only be elevated
blood pressure reading.
3. There may be no way of finding out if a person is hypertensive except
by having the blood pressure measured.
4. All high blood pressure cases must be treated.

• In Hypertension
> Aerobic exercise training can be effective in
controlling mild hypertension, either without medication or in
conjunction with medication.
> Experts recommend an aerobic capacity of 60-70% of the maximal
heart rate.
Walking is the ideal exercise to produce these physiologic results.

145
 > If hypertension is acute or uncontrolled, you must delay exercise
until it is controlled.

BLOOD PRESSURE CLASSIFICATION

3. Sedentary Lifestyle
Exercise-
> Reduces the risk of hypertension, heart attack and stroke. It is also
an
important measure in the maintenance of ideal body weight or
weight reduction.
> Scientific Exercise for biologic fitness

THE HEALTH BENEFITS OF A REGULAR PHYSICAL ACTIVITY INCLUDES THE

FOLLOWING:
- Helps build and maintain healthy bones, muscles, joints and
achieve a healthy body weight.
- Helps older adults become stronger and better able to move about
without falling fatigue or becoming excessively fatigue.
- Helps reduce blood pressure in people who already have
hypertension and the
risk of developing high blood pressure.
- Lowers both total blood cholesterol and triglycerides and may increase
High-density Lipoproteins (HDL) or the good cholesterol.
- Lowers the risk of developing non-insulin dependent (Type II)
diabetes Mellitus.
- Reduces the:
> Feelings of depression and anxiety.
> Risk of dying from coronary heart disease.
- The risk of having a second heart attack in people who have
already experienced one heart attack.
- Promotes psychological well-being and reduces feelings of stress.

4. SMOKING

Tobacco Regulation Act of 2003 (RA 9211)

- This is an act regulating the packaging, use, sale distribution and
advertisements of tobacco products and for other purposes. It is a policy
that protects the populace from hazardous products and promotes the right
to health and instills health consciousness among them.
- It is a balanced policy that promotes a healthful environment and
protects the citizens from the hazards of tobacco smoke, and at the same
time ensures that the interest of tobacco farmers, growers, workers and
stake-holders are not adversely compromised.

A GUIDE TO HEALTH EDUCATION FOR SMOKERS

A. Tips for preparing to stop

Example; Decide positively that you want to stop, list all reasons for
stopping.

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B. Tips before stopping
Example; Don’t think of never smoking again, think of stopping in
terms of 1 day at a time and stop carrying cigarettes at home and at work.
C. Tips for the day you stop
Example; Throw away all your cigarettes and matches; hide your
lighters and ashtrays.
D. Tips for coping with relapse
Example; Stop smoking immediately and realize that most successful
former smokers stop for good only after more than one attempt.

STRESS
-is considered to be an essential element contributing to the progress
of degenerative diseases and even identified as a significant risk factor for
lifestyle-related diseases.

Emotional Indicators:
Anger, frustration, depression, anxiety, irritability, impatience, difficulty in
concentrating, forgetfulness, confusion, feeling of time pressure

Behavioral Indicators:
Rapid speaking and walking, chain smoking, excessive drinking,
restlessness, pacing (walking to and fro), nail biting and sexual problems

Most common causes of excessive stress

1. Death in the family
2. Marital separation
3. Jail term/violation of the law
4. Serious injury or illness of the affected individual
5. Loss of work and financial problem
6. Unwanted pregnancy
7. Loss of major property from fire or mortgage
8. Displacement from place/residence as in the case of natural disasters,
insurgency (in rebel-infested area)
9. Trouble with the boss
10. Migration
11. Work related stress - ex. Too much work, concern about meeting
deadlines
12. Family problems
13. Personality type

THERE ARE THREE BASIC PERSONALITY TYPES:

Type A – these people are impatient, competitive, easily irritated, suspicious

and hostile. They cannot relax, tend to speak loudly and are demanding.
Type B- these people are more easygoing, less competitive, calm and
flexible.
Type C- they have a balanced attitude to life and can adjust to different
situations.

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 “12 S” in Stress Management:

 Spirituality
Spirituality is a state or quality of being spiritual. It is pure, holy, relating of
matters of sacred nature, not worldly, possessing the nature or qualities of a
spirit.
Whenever we are beset with problems, the very first thing to do is to
think and do look for possible solution to the problems. As a human being,
there is always that strong faith and belief that above all, there is that
powerful being that created us, whom we can turn to and who will remain to
be with us in all our joys and pains, ups and downs. He who will remain to be
our friend. Thus giving that feeling of confidence and peace. When everything
falls to Him, nothing is impossible
The spiritual level holds the entire human person together. Spirituality
carries with it the meaning of man’s relationship with a world beyond what is
felt by the sense - a world beyond himself, others and the environment - but
which somehow gives meaning, purpose and coherence to one’s own
existence. It is also points to an articulated by the individual. It is the spiritual
level that gives something to live for.

 Stress Debriefing
Critical incident stress debriefing means to assist crisis workers/ team
member to deal positively with the emotional impact of a severe event /
disaster and to provide education about current and anticipated stress
responses, as well as information about stress management.
Critical incident is any unusually strong or overwhelming emotional
reactions which have potential to interfere with work during the event or
thereafter in the majority of those exposed.

 Sports
Spots are skills and games which involve the participation of group of
people or a person, competing with others for a common goal.
Stress is a normal and unavoidable part of life. Without some stress,
life would be dull. Stress motivates a person to do its best and provides the
challenges we need to improve physically, mentally and emotionally. The
sources of stress are environment (physical stressors, social stressors, and
occupational stressors) and personality (biological changes, behavior and
lifestyle). Mind and body works together as a single unit and therefore,
stress affects the bodily system. It has effects on heart muscle, blood
pressure, pulse rate, blood red corpuscles, and the nervous system.
It is important that workforce engage in sports activities that create
awareness. Sports have been identified as one of the management of
relieving and preventing stress.

 Self-Awareness
Self-Awareness means knowing yourself, getting in touch with your
feeling, or being open to experience. It increases your sensitivity to inner
self and your relationship with the world around you, how you respond to
people and what effect you have on them.

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 Self-Awareness is important in evaluating one’s abilities realistically,
identifying the areas in which you need to improve, recognize and build
strengths, develop more effective interpersonal relationship, understand the
kind of motivations that are influencing such behavior, develop empathy and
understanding to recognize both personal needs and needs of other people.
Once you have experiences your genuine and unique self, you become
more flexible, autonomous, independent in decision making and able to
accept constructive and destructive criticism and you can easily adopt to
your environment.

 Scheduling : Time Management

Many people refer to time as a resource. A resource is something that
lies ready for use, or something that can be drawn upon for aid. Begin to
accept time as your most important resource. Time is tools that can be
drawn upon to heal accomplish results, an aid that can take care of a need,
an assistant in solving problems. However, time is not like other resource,
because you cannot buy it, rent it, borrow it, lend it, store it, save it, multiply
it, manufacture it, or change it. All you can do is spend it.

Time management is an illusion, because no one can really mange

time. Time simply is constant. Time is a measurement of intervals. It moves
at the same rate regardless of who we are or what we are trying to
accomplish. Time respects no one. No one can convert, change or otherwise
imitate time. Despite this, we continue to use the phrase “managing time”
to identify our efforts to use our allotted moments meaningfully. Managing
time really refers to managing ourselves in such a way as to optimize the
time available so that we can achieve gratifying results.

 Siesta
Siesta means taking a nap, short rest, a break or recharging of
“battery” in order to improve productivity. It helps relax the mind and body
muscles.
Rest or siesta is as important as giving enough exercise. Rest is
necessary to support human life. If the body is deprived of sleep certain
changes takes place such as personality disturbances and loses of
coordination and the ability to concentrate. Rest refreshes the whole body
and a person feels a sense of well-being. The mind is alert, the muscles are
relaxed, and digestion function properly as appetite is healthy.
It had been proven through a study that siesta invigorates one’s body.
Making our body revitalize like a machine it needs a little break in order to
function well. Performances of an individual scored high when siesta is
observed 15-30 minutes nap. If you exceed neither 30 minutes long nor one
hour. It relieves stress tension and one wakes up and set for the next
activity.
Siesta can be done by having a nap, lying down, closing your eyes and
resting your head.

 Stretching
Stretching are simple movements performed at a rhythmical and slow
pave executed at the start of demanding activity to loosen muscles,

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lubricate joints increase body’s oxygen supply. It requires no special
equipment, no special clothes, and no special skills and can be done
anywhere and anytime.
Stretching every hour or so throughout the day can help you avoid
stiffness and muscle soreness and make you feel better like as follows:
- On the job release nervous tension
- While our computer is processing something for 5 to 10 seconds
- Whenever you feel stiffed, sore or tired
- Before and after taking a walk
- In the morning just often getting up and in the evening before sleep
- When you need more energy
- Whenever you want to focus and do your best
You can stretch:
 When you are a passenger in a car, or in a bus or a
train on way to work
 At your desk
 While on the phone
Stretching is the simplest of all physical activities. It is the
perfect antidote for long periods of inactivity and holding
still. Regular stretching throughout the day will reduce
muscle tension, reduce anxiety, stress and fatigue,
improve mental alertness and tune your mind into your
body that will make your work easier and feel better.

 Socials
A man is a social being who exist in relationships with his physical
environment and in relationship with people and society.
Socialization plays a very important role in the development of
interpersonal relationship. Through socialization life becomes meaningful,
happy and worthy. On the contrary, without socialization, life will be boring
and empty.
Dance is a form of social activity. Through dance man enjoy his body’s
love and express gesture and releases tension through rhythmic.

 Smile
It has been observed that individual workers who always smile are
healthy people. Health workers who provide an atmosphere that is
favorable, conductive to the attainment of goals and objectives of the
organizations.
Smile is an expression of pleasure, amusement, affection and irony. It
has been found out through research that it relieves all kinds of stresses,
physical or mental. It is also considered one of the ingredients or factors that
will motivate and encourage workers to work harder and improve their level
or performance in the organization.

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 As healthy workers to be efficient and effective in the performance of
duties and obligation they should not hesitate to smile. When you smile,
muscles are relaxed because 15 muscles are working but when you frown
the muscles are tense because 65 muscles are affected.

 Speak to me
The world is designed as a mutual support system in which all things
relate to each others, we suppress the motivation of much of our behavior.
Interpersonal conflicts generally are resolves most effectively by open
communications that accepts the feeling of the persons involved and leads
to better mutual agreement. The feeling of being loved and accepted by
others is a critical level in Maslow’s hierarchy of needs for achieving a high
quality of life.

Communications is the means by which people make their needs

known. It is the way they obtain understanding, reinforcement and
assistance from others. Communication is aimed at goal, so it must remain
open until the goal is reached. Certain responses tend to close the
communication. Some responses that blocks communication are belittling,
disagreeing, false reassurance and giving advice. A helping person needs
special qualities like passive listening, active listening, warmth,
genuineness, attentiveness, empathy and positive regard.

Sometimes even when you keep a positive attitude, you may need to
talk to someone. Talking to someone when you feel overwhelmed or unable
to deal with stress on your own, airing your feelings to someone who can
understand your feelings to someone who can understand your feelings
even when you feel “helpless” is often the best medicine.

PHILIPPINE CANCER CONTROL PROGRAM

GOAL:
Is to establish and maintain a system that integrates scientific
progress and its practical applications into a comprehensive program that
will reduce cancer morbidity and mortality in the Philippines.

THREE SPECIFIC CANCER SITES:

1. Cervix
2. Lung
3. Breast
- Cancer Pain Relief as a support program - giving of free morphine tablets
to cancer patients

INTERVENTIONS:
Cervical Cancer – Pap smear/Acetic acid wash
All female health staff 25-55 years of age should be subjected to an
initial screening procedure for cervical cancer. Occurrence of precursor and

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or early cancer lesions is about age 25 years, 10 years before 35 years,
when cervix cancer becomes clinically apparent. Carcinoma-in-situ (stage 0)
takes as long as 10 years to develop into invasive disease.

Policy statements:

1) An acetic Acid Wash (AAW) screening method for cervical cancer shall
be made available at the RHUs and Main Health Centers.
2) Acetic Acid Wash (3-5%) shall be used as the screening method of
choice for cervical cancer in the Phils. And shall be established at Local
Health Units., District Hospital, and Provl Hosp. with no Pap smear
capability.
3) AAW shall be used as triage method before pap smear at District,
Provl. and Regional Hosps. With pap smear capability.
4) Colposcopy with biopsy as needed shall be a diagnostic test after
positive or suspicious screen findings. The test shall be provided as
appropriate tertiary level health facility.
5) Papsmear shall be a monitoring diagnostic test in instances of cervical
intraepitheleal neoplasia Stage 1 findings and non-availability of
colposcopy facility. The test shall be provided at secondary and
tertiary level facilities with the required infrastructure and logistics.
6) Women 25-55 years old shall undergo AAW cervical cancer screening
at least once every 5-7 years.
7) AAW shall be advocated as an alternative screening method for
cervical cancer by the health and welfare sector in government, non-
government organizations, professionals, and civil societies at national
and local level.
8) Positive or suspicious lesion noted upon screening shall be referred
immediately to a referral facility where competent specialists shall do
confirmatory tests such as colposcopy and tissue biopsy.
9) Referral centers for cervical cancer diagnostic tests and treatment
shall be established in tertiary facilities.
10) Gender sensitive counseling and disclosure shall be a
component of any training program for cervical cancer prevention and
control. Gender as well as culture sensitivity of health staff involved in
cervical cancer screening and treatment shall be emphasized as part
of quality health service delivery.
11) Sustainability of the screening program shall be ensured through local
financing e.g., subsidy from the local government unit or health facility
concerned, Phil health financing, or fee for service (user fee) scheme.
12) A standard system of recording and reporting shall be developed
and adopted at service delivery points.
13) Periodic evaluation shall be done at all levels to assess the
progress of AAW and its impact on cervical cancer prevention and
control initiative.
14) A regular yearly public information and education campaign
aimed at changing behavior shall be done via mass media and inter-
personal communication with each health center to inform and entice
target women about the cervical cancer screen services.

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Lung Cancer – Anti smoking Campaign
- Public information and health education; increases public awareness
on the hazards of smoking and changing attitude and primary behavior
among primary and secondary school children.
- legislation measures on elimination of smoking habit, elimination of
advertisements and promotion of tobacco products, labeling, tax and price
policies on cigarettes.
Smoking counseling clinics in strategic localities will provide service to all
identified smokers in the catchments areas.
- Research and epidemiology thru generation and collection of data on
all aspects of smoking is carried out thru research.
- Early detection/diagnosis

Breast Cancer – Breast Self Exam

- Methods in doing a proper breast examination;
A) Radial pattern technique (Alan Basset’s technique
B) Concentric circles
C) Transverse or vertical lines (Mamma Care technique)

3 major forms of treatment of cancer:

 Surgery – this is oldest cancer treatment

 Radiation Therapy – this form of cancer therapy came after the
discovery of radioactivity and x-rays.
 Chemotherapy – this refers to the use of chemicals in the treatment of
cancer.

9 warning signs of cancer

1. Change in blood bowel.

2. A sore that does not heal.
3. Unusual bleeding or discharge.
4. Thickening or lump in breast or elsewhere
5. Indigestion or difficulty in swallowing
6. Obvious change in wart or mole
7. Nagging cough or hoarseness
8. Unexplained anemia
9. Sudden unexplained weight loss

RENAL DISEASE CONTROL PROGRAM

Kidney diseases are the number 10 killer in the Philippines, causing death to
about 7,000 Filipinos every year.
What are these kidney diseases?
- Chronic glomerulonephritis
- Chronic & repeated kidney infection
( Pyelonephritis)

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 - Diabetic kidney disease
- Hypertensive kidney disease.
This often led to end-stage renal diseases (ESRD) due to failure to recognize
them in their early stages.

What is the common cause of ESRD in the Philippines?

Chronic Glomerulonephritis (CGN) is the most common cause of ESRD
in third world countries including the Philippines. It usually afflicts children,
adolescents and young adults in their productive years. Children with latent
glomerulonephritis can escape detection for months or years, causing the
condition to progress to chronic state.

What are some of the signs of latent kidney diseases?

Latent disease implies that there are no overt to outward
manifestation/s or clinical signs and/or symptoms, hence the patient would
usually not seek medical consultation. The child would look or feel normal
but when the urine is examined, it will reveal abnormal findings. The only
means to detect the presence of such kidney problems is through routine
urinalysis.

Are these kidney diseases preventable?

These diseases are potentially preventable if diagnosed early in the
course of illness, obviating the need for expensive ESRD treatment such as
dialysis and transplantation.

What are the things that should be done to prevent kidney diseases?
1. Drink adequate volume of water and fruit juices.
2. Eat a balanced diet, not too salty, not too sweet.
3. For females, observe good personal hygiene.
4. Exercise moderately
5. Practice regular towel habits
6. Check blood pressure at least twice a year.
7. Consult a doctor for throat and skin infections.
8. Complete immunizations.
9. Do not hold or play with urine.
10. Avoid playing with your private parts (genitals).
11. Annual urinalysis.

Exercise Guidelines for Persons with Non-Communicable Diseases

Cardiovascular Diseases
A patient who has already suffered a heart attack or has a coronary
artery disease should have a regular, brisk
Physical activity in order to help reduce the risk of another heart attack
and it also aid in lowering blood cholesterol. Walking is usually
recommended to these patients. Other forms of exercise will require
consultation with a doctor for clearance. Warm-up exercise is very
important when engaging in moderate intensity physical activity. The
patient must be advised to have longer time for warm-up and gradual

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 progression to more strenuous activity. Patients must be taught to watch
out for signs and symptoms of over-exertion, e.g., increased pulse rate,
increased breathing, chest pain or general tiredness.

Diabetes Mellitus
>The standard recommendations for physical activity are the same as
in non-diabetic individuals. However, the diabetic patient needs to be
carefully screened for the presence of macro and micro-vascular
complications that may be worsened by the exercise program.
>A careful history and physical examination should focus on the signs
and symptoms of the disease affecting the heart and blood vessels, eyes,
kidneys and nervous system.

Special precautions need to be observed to include:

- The physician will almost likely have to adjust (decrease) the insulin
dosage to accommodate exercise.
- Consider gradual increase of physical activity towards the conditioning
program to accommodate adjustment of any existing cardiovascular
impairment.
- Persons with diabetes have to eat a controlled amount of carbohydrates
before exercising to prevent hypoglycemia.
- Care of the feet - Good shoes and wrinkle-free socks to prevent blisters
and trauma to the lower extremities.

Do not allow clients to be over fatigued

Studies had shown that diabetics who exercise 30 minutes or more

daily may show a decreased need for insulin. During exercise, muscles
can take up glucose from the bloodstream without requiring insulin.
Exercise improves glucose tolerance in exercising diabetics and helps
burn calories.

HEALTH PROMOTION
Health Promotion is the process of enabling people to make the right
choices for health.

5 action areas for Health Promotion:

1. Building healthy public policies.

2. Developing a supportive environment calls for a political, social and
physical environment.
3. Supporting community actions as partners and owners of their health
concerns.
4. Developing personal skills calls to choose healthier options.
5. Reorienting health services from a sickness to a wellness paradigm

The campaign messages for Promotion of healthy lifestyle

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  Don't smoke
 Manage stress
 Have a regular health check-up
 Eat a healthy diet everyday
 Do regular exercise

Target audiences
> Working adults for manage stress
> Mothers and daughter for watch your weight
> School children for healthy diet
> Adults to elderly for exercise
> Teenagers for don’t smoke

Profile of the family members

• Grandparents: 60 years old and above
• Father: 40-45 years old
• Mother 30-35 years old
• Teenage son: 13-15 years old
• Preteen daughter: 9-12 years old

Secondary Audience
• Executives and employees of local government units
• Legislators/politicians
• Media

Healthy lifestyle - Is defined as a way of life that promotes and protects

one’s health and well-being.
It includes;
• Promoting proper nutrition
• Promoting physical activity and exercise
• Promoting a smoke-free environment
• Promoting behavior change as an intervention is a task done over a
long period of time since behaviors develop overtime and become a
way of life.

PUBLIC HEALTH REGULATIONS

1) REPUBLIC ACT 6675- GENERICS ACT OF 1991

‘AN ACT TO PROMOTE, REQUIRE AND ENSURE THE PRODUCTION OF AN
ADEQUATE SUPPLY, DISTRIBUTION, USE AND ACCEPTANCE OF DRUGS AND
MEDICINES IDENTIFIED BY GENERICS NAMES”

WHAT IS THE OBJECTIVE OF THE ACT?

The Generics Act was enacted to ensure that drugs and medicines are
safe, effective and affordable. Specifically, the Generics Acts has the
following objectives.

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 1. To promote, encourage and require the use of generic
terminology in the importation, manufacture, distribution,
marketing, advertising and promotion, prescription and
dispensing of drugs;
2. To ensure adequate supply of drugs with generic names at the
lowest possible cost and endeavor to make hem available for
free to indigent patients;
3. To encourage the extensive use of drugs with generic names
through a national system of procurement and distribution;
4. To emphasize the scientific basis for the use of drugs, in order
that health professionals may become more aware and
cognizant of their therapeutic effectives; and
5. To promote drug safety by minimizing duplication of medicines
and/or use of drugs with potentially adverse drug interaction.

WHAT IS THE SCOPE OF THE ACT?

 It stipulates the identification of drugs and medicines by its

generic name or the scientifically and internationally recognized
active ingredient or the chemical component responsible for the
claimed therapeutic effect of the pharmaceutical product.
 The Act requires doctors and health professional to teach their
patients on the active ingredients for medicine for specific
ailments. It also impels doctors to use generic names in their
prescriptions with brand names optionally indicated in
parenthesis.
 The law also requires the generic name of the drug to be
displayed prominently in the packaging and for drug
outlets/stores to have a menu card listing drugs they have on
stock with the generic name of the drugs, the branded products
and respective prices. The public then can decide or choose
what to but on the generic name.

WHAT PROVISIONS OF THE GENERICS LAW ARE RELEVANT TO THE HEALTHY

FACILITY?

Section 6- USE OF GENERIC TERMINOLOGY. All government health

agencies and their personnel as well as other government agencies shall use
generic terminology or generic names in all transactions related to
purchasing, prescribing, dispensing, and administering drugs and medicines.

Section 11-EDUCATION DRIVE. There shall be a conduct of continuous

information campaign for the public and a continuing education and training
for the medical professions on drugs with generic names as an alternative of
equal efficacy to the more expensive brand name drugs.

WHAT IS THE PHILIPPINE NATIONAL DRUG FORMULARY OR ESSENTIAL

DRUGS?

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 It is a list of drugs prepared and periodically updated by the DOH on
the basis of health conditions obtaining in the Philippines as well as on
internationally accepted criteria. It consists of the following;

 CORE LIST – list of drugs that meet the health care needs of the
majority of the population.
 COMPLIMENTARY LIST – list of alternative drugs used when there
is no response to the core essential drugs or when, for one
reason or another, the core essential drug cannot be given.

WHAT IS THE USE OF THE PNDF?

= It is the basis of procurement of drugs and in prescribing medicines

for treatment of specific disease.

2) MILK CODE
PHILIPPINE CODE OF MARKETING OF BREASTMILK SUBSTITUTE
EXECUTIVE ORDER 51 SERIES 1987

“NATIONAL CODE OF MARKETING OF BREASTMILK SUBSTITUTES,

BREASTMILK SPPLEMENTS AND RELATED PRODUCTS, PENALIZING
VIOLATIONS THEREOF, AND FOR OTHER PURPOSES”

WHAT IS THE AIM OF THE CODE?

The primary objective of the milk code is to contribute to the provision

of safe and adequate nutrition of infants by protecting and promoting
breastfeeding and by ensuring proper use of breast milk substitutes and
supplements when needed through extensive information dissemination and
appropriate marketing and distribution.

WHY IS IT NECESSARY TO HAVE A MILK CODE?

 To ensure that safe and adequate nutrition for infants is

provided;
 There is a need to protect and promote breastfeeding and
inform the public about the precautions of using breast milk
substitutes and supplements and related products.

WHAT PRODUCTS ARE COVERED BY THE MILK CODE?

1. Breast milk substitutes including infant formula

2. Other milk products, food and beverages including bottle fed
complimentary foods marketed or otherwise represented to be
suitable with or without modification, for use as a partial or total
replacement of breast milk.
3. Feeding bottles and teats.

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WHAT SHOULD THE HEALTH FACILITY WILL DO TO IMPLEMENT THE MILK
CODE?

 Make themselves familiar with the objective and consistent

information on maternal and infant nutrition and their
responsibilities under the Code.
 Encourage and promote breastfeeding.
 Inform health workers and members of their families not to
accept financial or material inducements to promote products
within the scope of the Code.
 Inform staff that giving samples of infant formula or other
products within the scope of the Code is prohibited.

LISTS SOME VIOLATIONS OF THE MILK CODE THAT THE HEALTH FACILITY
STAFF SHOULD AVOID.

1. Giving and accepting samples of infant formula or other

products within the scope of this Code to pregnant women,
mothers of infant or members of their families.
2. Accepting or giving financial or material inducement to promote
products within the scope of the Code.
3. Accepting sponsorship from milk companies.
4. Displaying or distributing IEC materials promoting use of breast
milk substitutes and supplements.

3) NATIONAL VOLUNTARY BLOOD SERVICES ACT OF 1994

REPUBLIC ACT 7719

“AN ACT PROMOTING VOLUNTARY BLOOD DONATION, PROVIDING FOR AN

ADEQUATE SUPPLY OF SAFE BLOOD, REGULAITNG BLOOD BANKS, AND
PROVIDING PENALTIES FOR VIOLATION THEREOF”

WHAT IS THE OBJECTIVE OF THE ACT?

It ensures that distribution of supply of blood and blood products are

adequate, safe affordable and equitable. The act promotes and encourages
voluntary blood donation by the Citizenry and to instill public consciousness
of the principle that blood donation is a humanitarian act. It lays down the
legal principle that the provision of blood for transaction is a professional
medical services and not a sale of a commodity.

WHY IS IT IMPORTANT THAT BLOOD FOR TRANSFUSION COME FROM

VOLUNTARY DONORS ONLY?

Voluntary donors provide truthful information thus ensuring the safety of

blood supply.

WHO CAN DONATE BLOOD?

Potential donors are characterized by the following:

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 o Age is between 16-65 years (parental consent required for
under 18 years old)
o Weight of at least 100 lbs. (40 kg) for blood donation of
250 ml. or at least 110 lbs. (50 kg) for blood donation of
450 ml.
o Pulse rate between 60 and 100 beats/min with regular
rhythm.
o Blood pressure between 90 to 160 mm Hg systolic and 60
to 100 mm Hg diastolic.
o Hemoglobin of at least 125 g/l (12.5 g/dl).

LISTS OF CONTRAINDICATIONS TO BLOOD DONATION.

1. Pregnancy
2. Acute febrile illness
3. Alcohol intake – within the last 12 hours
4. Ear/body piercing and/or tattooing within the last 12 months
5. Recent surgery- minor or trivial surgery during the last 12
months
6. Cancer
7. Cardiac disease
8. Severe lung disease
9. Viral hepatitis
10. HIV infections, AIDS or STI
11. High risk occupation (e.g. prostitution)
12. Prolonged bleeding
13. Unexplained weight loss of more than 5 kg. over 6 months
14. Chronic alcoholism
15. Intake of medication
16. Blood dyscracias

4) SANITATION CODE
PRESIDENTIAL DECREE NO. 856
“CODE ON SANITAITON OF THE PHILIPPINES”

WHAT IS THE OBJECTIVE OF THE CODE?

To promote and protect health through enforcement of various

sanitary laws in areas or establishments that have a big potential
being the vehicle for spread infectious disease.

WHAT IS THE IMPORTANCE OF THE SANITATION CODE TO DISEASE

PREVENTION AND CONTROL?

The Sanitation Code prevents and controls disease transmission

by preventing the contamination of drinking water and food by:

o Defining the standards of drinking water and monitoring,

regulating and protecting its sources

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 o Defining the standards and the regulatory procedures for
food and industrial establishments and public facilities
such as markets, hotels, ports, terminals, and schools,
among others.
o Regulating the disposal of sewage, dead bodies and other
wastes, and
o Defining the interventions to control vermin.

WHAT ARE THE TWO (2) IMPORTANT UTILITY/ESTABLISHMENT NEED TO BE

ENSURED SAFE FOR THE PUBLIC?

1. Water supply and 2. Food establishments

HOW DOES THE SANITAITON CODE ENSURE THE SAFETY OF THE WATER
SUPPLY AND FOOD ESTABLISHMENTS?

By requiring the regular examination of drinking water as to its

potability and requiring sanitary permits for food establishments.

WHAT DO YOU LOOK FOR DURING YOUR INSPECTION OF A FOOD

ESTABLISHMENT THAT IS SEEKING A SANITARY PERMIT?

1. Water supply
2. Wholesomeness of food
3. Protection of food
4. Toilet provision
5. Hand washing facilities
6. Liquid waste management
7. Solid waste management
8. Personal cleanliness
9. Construction of premises
10. Maintenance of premises
11. Vermin control
12. Housekeeping and management
13. Sanitary conditions of appliance and utensils
14. Disease control

WHAT ARE THE SANITARY REQUIREMENTS OF AN INDUSTRIAL

ESTABLISHMENT?

1. Sanitary permit
2. Location and sitting of the establishment complies with
existing zoning laws, ordinances or policies
3. Potable water supply
4. Sewage disposal
5. All wastes of the industrial establishment are all collected,
stored, or disposed of in a manner to prevent health

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 hazards, nuisances, and pollution. It should utilize the
city/municipal collection and disposal system, it exists
6. Maintenance of a abatement program for vermin control
7. Adequate restrooms and mess halls for employees
8. All places of employment and all workrooms, including
machinery and equipment are kept clean and sanitary.

WHAT ARE THE DUTIES AND RESPONSIBILITIES OF A LOCAL HEALTH

OFFICIAL IN THE IMPLEMENTATION OF THE SANITATION CODE IN
PARTICULAR TO THAT OF FOOD ESTABLISHMENT?
 Make periodic inspections to enforce the maintenance of adequate
sanitation in food establishments and their premises;
 Take samples of food and drink from any establishments and vendors
as often as necessary to determine if there are unwholesome,
adulterated, or contaminated;
 Prevent the sale or condemn and destroy food drinks if these are
found until for human consumption;
 Seal and prohibit the use of unsanitary devices, utensils, containers,
vehicles, machines, piping and appurtenance;
 Enforce the provisions of the code on food establishments.

5) ASIN LAW
REPUBLIC ACT 8172

“AN ACT PROMOTING SALT IODIZATION NATIONWIDE AND FOR RELATED

PURPOSES”

WHAT IS THE OBJECTIVE OF THE LAW?

This is one of the laws to protect and promote the health of the nation
through food fortification. Salt iodization shall contribute to the elimination
micronutrient malnutrition particularly iodine deficiency disorders or the
broad spectrum of deficiencies resulting from lack of iodine from the diet
which leads to the reduction of intellectual and physical capacity, and may
manifest as goiter, mental retardation, physical and mental defects and
cretinism.

WHAT IS ASIN LAW?

It is the law that mandates the iodization of salt for human and animal
consumption. It applies to;
 All producers/manufactures/importers and traders of salt for
human or animal consumption
 All restaurants and other food establishments where food is
being served or sold.
 All food manufacturers/processors using salt in their
manufacturing process.
 All local government units
 All government and private hospitals and other institutions

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  All other government agencies
 All non governmental agencies and related professional
organizations.

WHAT ARE YOU LOOKING FOR WHEN YOU TEST SALT?

Presence of iodine salt

WHY DO YOU NEED TO TEST SALT?

To ensure that only iodized salt is sold in the market

WHERE AND WHEN IS SALT TESTING DONE?

 When there are salt producers present in the locality, the iodine
content in salt is tested at the production level. Samples are collected
from the production line at regular intervals and are tested in the
laboratories.
 Where local ordinance require, salt testing may also be done at the
household level.
 All food outlets, restaurants, food processing plants, retail stores and
wet markets are monitored to ensure that only iodized salt are made
available to the public.

WHAT ACTIVITIES SHOULD HEALTH FACILITY STAFF DO TO IMPLEMENT THE

ASIN LAW?

1. Information campaigns promoting the use of iodized salt in the

household;
2. Monitoring activities such as “Patak Sa Asin” to ensure the
availability of iodized salt and its quality;
3. Establishment and maintenance of a list of salt producers, if any,
in their city/municipality;
4. Assist in the passage of local legislation;
5. Advocate for the conduct of school based iodized salt testing;
6. Household salt-testing; and
7. School salt-testing

6.Republic Act 9288 - Newborn Screening - An Act Promulgating A

Comprehensive Policy and A National System for Ensuring Newborn
Screening.

SECTION 1.Short Title. – This Act shall be known as the "Newborn Screening
Act of 2004."

SEC.2.Declaration of Policy. – It is the policy of the State to protect and

promote the right to health of the people, including the rights of children to
survival and full and healthy development as normal individuals. In pursuit
of such policy, the State shall institutionalize a national newborn screening
system that is comprehensive, integrative and sustainable, and will facilitate

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collaboration among government and non-government agencies at the
national and local levels, the private sector, families and communities,
professional health organizations, academic institutions, and non-
governmental organizations. The National Newborn Screening System shall
ensure that every baby born in the Philippines is offered the opportunity to
undergo newborn screening and thus be spared from heritable conditions
that can lead to mental retardation and death if undetected and untreated.

SEC.3.Objectives. – The objectives of the National Newborn Screening

System are:

 To ensure that every newborn has access to newborn screening

for certain heritable conditions that can result in mental
retardation, serious health complications or death if left undetected and
untreated;
 To establish and integrate a sustainable newborn screening system
within the public health delivery system;
 To ensure that all health practitioners are aware of the advantages of
newborn screening and of their respective responsibilities in offering
newborns the opportunity to undergo newborn screening; and
 To ensure that parents recognize their responsibility in promoting their
child’s right to health and full development, within the context of
responsible parenthood, by protecting their child from preventable
causes of disability and death through newborn screening.

ARTICLE 2, Section. 4.

Comprehensive Newborn Screening System means a newborn screening

system that includes, but is not limited to, education of relevant
stakeholders; collection and biochemical screening of blood samples taken
from newborns; tracking and confirmatory testing to ensure the accuracy of
screening results; clinical evaluation and biochemical/medical confirmation
of test results; drugs and medical/surgical management and dietary
supplementation to address the heritable conditions; and evaluation
activities to assess long term outcome, patient compliance and quality
assurance.

SEC. 5.Obligation to Inform. – Any health practitioner who delivers, or assists

in the delivery, of a newborn in the Philippines shall, prior to delivery, inform
the parents or legal guardian of the newborn of the availability, nature and
benefits of newborn screening. Appropriate notification and education
regarding this obligation shall be the responsibility of the Department of
Health (DOH).

SEC. 6.Performance of Newborn Screening. Newborn screening shall be

performed after twenty-four (24) hours of life but not later than three (3)
days from complete delivery of the newborn. A newborn that must be placed
in intensive care in order to ensure survival may be exempted from the 3-
day requirement but must be tested by seven (7) days of age. It shall be the

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joint responsibility of the parent(s) and the practitioner or other person
delivering the newborn to ensure that newborn screening is performed. An
appropriate informational brochure for parents to assist in fulfilling this
responsibility shall be made available by the Department of Health and shall
be distributed to all health institutions and made available to any health
practitioner requesting it for appropriate distribution.

SEC. 7. Refusal to be Tested. – a parent or legal guardian may refuse testing

on the grounds of religious beliefs, but shall acknowledge in writing their
understanding that refusal for testing places their newborn at risk for
undiagnosed heritable conditions. A copy of this refusal documentation shall
be made part of the newborn’s medical record and refusal shall be indicated
in the national newborn screening database.

SEC. 8. Continuing Education, Re-education and Training Health Personnel. –

The DOH, with the assistance of the NIH and other government agencies,
professional societies and non-government organizations, shall: (i) conduct
continuing information, education, and re-education and training programs
for health personnel on the rationale, benefits, and procedures of newborn
screening; and (ii) disseminate information materials on newborn screening
at least annually to all health personnel involved in material and pediatric
care.

LIST OF REPUBLIC ACTS

Republic Act 9288 - Newborn Screening - An Act Promulgating A

Comprehensive Policy and A National System for Ensuring Newborn
Screening

Republic Act 9257 - Expanded Senior Citizens Act of 2003

An Act Granting Additional Benefits and Privileges to Senior Citizens
Amending for the Purpose Republic Act No. 7432 Otherwise Known As "An
Act To Maximize the Contribution of Senior Citizens to Nation Building, Grant
Benefits and Special Privileges and for other Purposes"

Republic Act 9211 - Tobacco Regulation Act of 2003

An Act Regulating the Packaging, Use, Sale Distribution and Advertisements
of Tobacco Products and for other Purposes

Republic Act 7883 - Barangay Health Workers Benefits and Incentives Acts of
1995
[0] An Act Granting Benefits and Incentives to Accredit Barangay Health
Workers and for Other Purposes.

Republic Act 8203 - Special Law on Counterfeit Drugs"

An Act of Prohibiting Counterfeit drugs, Providing Penalties for Violations and
Appropriating Funds Thereof

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Republic Act 6425 - Dangerous Drugs Act of 1972
This Act shall be known and cited as "The Dangerous
Drugs Act of 1972."

Republic Act 6675 - Generics Act of 1988

[0] An Act to Promote, Require and Ensure the Production Of An Adequate
Supply, Distribution, Use And Acceptance Of Drugs
And Medicines Identified By Their Generic Names

Republic Act 4226 - Hospital Licensure Act

[0]An Act Requiring the Licensure of all Hospitals in the Philippines and
Authorizing the Bureau of Medical Services to Serve as the Licensing Agency

Republic Act No. 7876 - Senior Citizens Center Act of the Philippines
An Act to Maximize the Contribution of Senior Citizens to Nation Building,
Grant Benefits and Special Privileges

Republic Act 7305 - Magna Carta of Public Health Workers

[0] Magna Carta of Public Health Workers (Republic Act No. 7305)

Republic Act 7719 - National Blood Services Act of 1994

[0]An Act Promoting Voluntary Blood Donation, Providing For An Adequate
Supply Of Safe Blood Regulating Blood Banks And Providing Penal Ties For
Violation Thereof

Republic Act 7875 - National Health Insurance Act of 1995

[0] An Act Instituting A National Health Insurance Program For All Filipinos
And Establishing The Philippine Health Insurance Corporation For The
Purpose

Republic Act 7432 - Senior Citizen Act of 1992)

An Act to Maximize the Contribution of Senior Citizens to Nation Building,
Grant Benefits and Special Privileges

Amendment to RA 7170 - Organ Donation Act of 1991

An Act To Advance Corneal Transplantation In The Philippines, Amending For
The Purpose Republic Act Numbered Seven Thousand One Hundred And
Seventy (R.A. N0. 7170) Otherwise Known As The Organ Donation Act Of
1991

Republic Act 8504 - Prevention and Control of 1988

Promulgating Policies And Prescribing Measures For The Prevention And
Control Of Hiv/Aids In The Philippines, Instituting A Nationwide HIV/Aids
Information And Educational Program, Establishing A Comprehensive
HIV/Aids
Monitoring System, Strengthening The Philippine National Aids Council, And
For Other Purposes

Republic Act 8423 - Traditional and Alternative Medicine Act (TAMA of 1997)
An Act creating the PHILIPPINE INSTITUTE OF TRADITIONAL AND

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ALTERNATIVE HEALTH CARE (PITAHC) to accelerate the development of
traditional and alternative health care in the Philippines, providing for a
TRADITIONAL AND ALTERNATIVE HEALTH CARE DEVELOPMENT FUND and for
other purposes

Republic Act 8749 - Philippine Clean Air Act of 1999

An Act Providing For A Comprehensive Air Pollution Control Policy And For
Other Purposes

Republic Act 8344 - An Act Prohibiting the Demand of Deposits or Advance

Payments
An Act Prohibiting The Demand Of Deposits Or Advance Payments For The
Confinement Or Treatment Of Patients In Hospitals And Medical Clinics In
Certain Cases

Republic Act 5921

An Act Regulating The Practice Of Pharmacy And Settings Standards Of
Pharmaceutical Education In The Philippines And Other Purposes

An Act Instituting The Comprehensive Dangerous Drugs Act Of 2002,

Repealing Republic Act No. 6425, Otherwise Known As The Dangerous Drugs
Act Of 1972, As Amended, Providing Funds Thereof, And For Other Purposes

Republic Act 7394

The Consumer Act Of The Philippines

Republic Act 8976

Philippine Food Fortification Act of 2000

Executive Order

Executive Order 102- Redirecting the Functions and Operations of the

Department of Health.

Executive Order 51 - Adopting a National Code of Marketing of Breast milk

Supplements and related products, penalizing violations thereof, and for
other purposes.

Presidential Decree

Presidential Decree 881

January 30, 1976

Empowering the secretary of health to regulate the labeling, sale and distribution of hazardous
substances

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 Ten (10) Herbal Medicines in the Philippines
Approved by the Department of Health (DOH)

About Philippine Herbal Medicine Herbal medicine is defined as the use

of natural herbs from plants for the treatment or prevention of diseases,
disorders and the promotion of good health. The use of medicinal plants or
herbs has been gaining popularity this past few years in the Philippines and
worldwide as more clinical proof emerges that validates many of the age-old
alternative medicines used by Filipino folks that has been passed on from
generation to generation.

These are the commonly used medicinal plants and herbs as

alternative medicine that have undergone clinical test and have been
proven to have therapeutic value and have been recognized and
recommended by researchers and medical practitioners to be effective
alternative medicines.

1. Niyog-niyogan (Quisqualis indica L.) - is a vine known as "Chinese honey

suckle". It is effective in the elimination of intestinal worms, particularly the
Ascaris and Trichina. Only the dried matured seeds are medicinal -crack and
ingest the dried seeds two hours after eating (5 to 7 seeds for children & 8
to 10 seeds for adults). If one dose does not eliminate the worms, wait a
week before repeating the dose.

Parts utilized
Seeds (dried nuts) and leaves.
- Constituent’s
Fatty oil, 15%; gum; resin.
- Folkloric uses
Antihelminthic: Dried seeds preferable for deworming.
Adults: Dried nuts-chew 8 to 10 small- to medium-sized dried nuts two hours
after a meal, as a single dose, followed by a half glass of water. If fresh nuts
are used, chew only 4-5 nuts. Hiccups occur more frequently with the use of
fresh nuts.
Children: 3-5 years old: 4-5 dried nuts; 6 - 8 years old: 5-6 dried nuts; 9-12
years old: 6-7 dried nuts.
Caution: Adverse reactions - diarrhea, abdominal pain, distention and
hiccups more likely if nuts are eaten in consecutive days or when fresh nuts
are eaten.
Others
Roasted seeds for diarrhea and fever.
Pounded leaves externally for skin diseases.
Decoction of boiled leaves used for dysuria.

2. Tsaang Gubat is one of the 10 herbs that is endorsed the Philippine

Department of Health (DOH) as an antispasmodic for abdominal (stomach)
pains. And is registered as a herbal medicine at the Philippine Bureau of
Food & Drug (BFAD).
Tsaang Gubat is a shrub (small tree) that grows (from 1 to 5 meters)

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abundantly in the Philippines. In folkloric medicine, the leaves has been used
as a disinfectant wash during child birth, as cure for diarrhea, as tea for
general good heath and because Tsaang Gubat has high fluoride content, it
is used as a mouth gargle for preventing tooth decay. Research and test
now prove it's efficacy as an herbal medicine. Aside from the traditional way
of taking Tsaang Gubat, it is now available commercially in capsules, tablets
and tea bags.
Tsaang Gubat is also knows as: Wild Tea, Forest Tea, Alibungog (Visayas
Region), Putputai (Bicol Region) and Maragued (Ilocos Region).
Scientific name: Ehretia Microphylla Lam.

Benefits & Treatment of:

• Stomach pains
• Gastroenteritis
• Intestinal motility
• Dysentery
• Diarrhea or Loose Bowel Movement (LBM)
• Mouth gargle
• Body cleanser/wash

Preparation & Use

• Thoroughly wash the leaves in running water. Chop to a desirable size

and boil 1 cup of chopped leaves in 2 cups of water. Boil in low heat for 15
to 20 minutes and drain.
• Take a cupful every 4 hours for diarrhea, gastroenteritis and stomach
pains.
• Gargle for stronger teeth and prevention of cavities.
• Drink as tea daily for general good health.

3. Yerba Buena is a herb of the mint family. It is an aromatic plant used as

herbal medicine worldwide. It has elongated leaves and in summer bears
small whitish or purplish flowers. The word Yerba Buena is Spanish for "good
herb" and was the former name of the California city of San Francisco.

Yerba Buena has been consumed for centuries as tea and herbal
medicine as a pain reliever (analgesic). Native American Indians used it even
before the "white men" colonized the Americas. Today, this folk medicine's
efficacy has been validated by scientific research. In the Philippines, Yerba
Buena is one of the 10 herbs endorsed by the Department of Heath (DOH) as
an effective alternative medicine for aches and pains.
As an herbal medicine, a decoction (boil leaves then strain) of Yerba
Buena is effective for minor ailments such as headaches, toothaches and
joint pains. It can also relive stomach aches due to gas buildup and
indigestion. The fresh and dried leaves can both be used for the decoction.
And because Yerba Buena belongs to the mint family, soaking fresh leaves
in a glass of water (30 to 45 minutes) makes for a good mouth wash for a
clean, fresh smelling breath.

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Benefits & Treatment of:

• Arthritis
• Head aches
• Tooth aches
• Mouth wash
• Relief of intestinal gas
• Stomach aches
• Indigestion
• Drink as tea for general good health.

Preparation & Use

• Wash fresh Yerba Buena leaves in running water. Chop to size for dried
leaves, crush) and boil 2 teaspoons of leaves in a glass of water. Boil in
medium heat for 15 to 20 minutes.
• As analgesic, take a cupful every 3 hours.
• For tooth aches, pound the fresh leaves, squeeze juice out and apply on
a cotton ball then bite on to the aching tooth.
• Leaves may be heated over fire and placed over the forehead for
headaches.
4. Sambong (scientific name: Blumea balsamifera) is an amazing medicinal
plant. It is an antiurolithiasis and work as a diuretic. It is used to aid the
treatment of kidney disorders. The Sambong leaves can also be used to
treat colds and mild hypertension. Since it is a diuretic, it helps dispose of
excess water and sodium (salt) in the body. Sambong is one herbal medicine
(of ten) approved by the Philippine Department of Health (DOH) in treating
particular disorders.

Powdered Sambong leaves are available in 250 mg tablets at the DOH's

Philippine Institute of Traditional and Alternative Health Care (PITAHC)

Benefits: Preparation:

• Good as a diuretic agent • Boil the leaves as like tea and

• Effective in the dissolving kidney drink 3 or more times a day.
stones • The leaves can also be crushed or
• Aids in treating hypertension & pounded and mixed with coconut
rheumatism oil.
• Treatment of colds & fever
• Anti-diarrheic & Anti-gastralgic
properties
• Helps remove worms, boils
• Treats dysentery, sore throat

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5.Pansit-pansitan (family: Piperaceae) is an herbal medicine also known as
Ulasiman-bato, olasiman-ihalas & tangon-tangon in the Philippines. English
name: peperomia.
Pansit-pansitan is a small herb that grows from 1 to 1 1/2 feet. It can be
found wild on lightly shaded and damp areas such as nooks, walls, yards and
even roofs. Pansit-pansitan has heart shaped leaves, succulent stems with
tiny flowers on a spike. When matured, the small fruits bear one seed which
fall of the ground and propagate.
The leaves and stalk of pansit-pansitan are edible. It can be harvested,
washed and eaten as fresh salad. Taken as a salad, pansit-pansitan helps
relive rheumatic pains and gout. An infusion or decoction (boil 1 cup of
leaves/stem in 2 cups of water) can also be made and taken orally - 1 cup in
the morning and another cup in the evening.
For the herbal treatment of skin disorders like abscesses, pimples and
boils, pound the leaves and/or the stalks and make a poultice (boil in water
for a minute or two then pounded) then applied directly to the afflicted area.
Likewise a decoction can be used as a rinse to treat skin disorders.
For headaches, heat a couple of leaves in hot water, bruise the surface
and apply on the forehead. The decoction of leaves and stalks is also good
for abdominal pains and kidney problems.
Like any herbal medicine it is not advisable to take any other medication
in combination with any herbs. Consult with a medical practitioner
knowledgeable in herbal medicine before any treatment.

Pansit-pansitan is used as an herbal medicine for

the treatment of:
• Arthritis
• Gout
• Skin boils, abscesses, pimples
• Headache
• Abdominal pains
• Kidney problems

6. Lagundi (scientific name: Vitex negundo) is a shrub that grows in the

Philippines. It is one of the ten herbal medicines endorsed by the
Philippine Department of Health as an effective herbal medicine with
proven therapeutic value. Lagundi has been clinically tested to be
effective in the treatment of colds, flu, bronchial asthma, chronic
bronchitis and pharyngitis. Studies have shown that Lagundi can prevent
the body's production of leukotrienes which are released during an
asthma attack. Lagundi contains Chrysoplenol D. A substance with anti-
histamine properties and muscle relaxant.

The leaves, flowers, seeds and root of Lagundi can all be used as
herbal medicine. A decoction is made by boiling the parts of the plant and

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 taken orally. Today, Lagundi is available in capsule form and syrup for
cough.
Plant Description: The Lagundi plant can grow up to five meters tall.
It can be described as a cross between a shrub and a tree with a single
woody stem (trunk). Lagundi's distinctive feature is the pointed leaves
with five leaflets set like a hand.
Lagundi tablets (300 mg) are
available from the Department of
Health's Philippine Institute of
Traditional and Alternative Health Care
(PITAHC).

Benefits: Preparation:

• Relief of asthma & pharyngitis • For boil half cup of chopped fresh
• Recommended relief of or dried leaves in 1 cup of water for
rheumatism, dyspepsia, boils, 10 to 15 minutes. Drink half cup
diarrhea three times a day.
• Treatment of cough, colds, fever • The lagundi flowers are also good
and flu and other bronchopulmonary for diarrhea and fever. Boil as with
disorders the leaves.
• Alleviate symptoms of Chicken Pox • The root is specially good for
• Removal of worms, and boils treating dyspepsia, worms, boils,
colic and rheumatism
7.Bayabas or guava is one of the most popular therapeutic plants in the Philippines. Bayabas
is a small tree that can grow up to 3 meters tall with greenish-brownish smooth bark. The
round globular bayabas fruit starts as a flower and is usually harvested and eaten while still
green. The fruit turns yellowish-green and soft when ripe.

Benefits &
Treatment
As a herbal medicine, the bayabas of:
fruit, bark and leaves are used. The
bark and leaves can be used as • Arthritis
astringent. The most common use of • Head aches
the leaves is for cleaning and • Tooth aches
disinfecting wounds by rinsing the • Mouth wash
afflicted area with a decoction of the • Relief of intestinal gas
leaves. The fruit, aside form being • Stomach aches
• Indigestion
delicious, contains a very high
• Drink as tea for general good health.
concentration of vitamin C.

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8.Bawang or Garlic (scientific name: Allium sativum) is one of the most
widely used herbal medicine in the Philippines. The Philippine bawang
variety is more pungent than the imported ones. Its medicinal properties
have been known for a long time and have been specially proven during
World War II. Because of Bawang's antibacterial compound known as Allicin,
lives were saved by preventing wounds from having infection and later
develop into gangrene when the juice of Bawang or garlic was applied to the
wounds.
Bawang/garlic is known as nature's antibiotic. Its juices inhibit the
growth of fungi and viruses thus prevent viral, yeast and viral infections.
Preliminary test also shows some positive results in the treatment of AIDS.

Several clinical test and published

studies have shown the efficacy of bawang in
lowering cholesterol in the blood and is
beneficial to the circulatory system of the
body. Today as more research is done with
bawang, more medicinal and therapeutic
properties become more evident.
After thorough research and test, the
Philippine Department of Health has endorsed
bawang as one of the ten Philippine herbs with
therapeutic value and recommends its use as
an alternative herbal medicine.

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 Benefits of Bawang: Preparation of Bawang:

• Good for the heart • For disinfecting wound, crush and

• Helps lower bad cholesterol
levels (LDL)
• Aids in lowering blood
pressure
• Remedy for arteriosclerosis
• May help prevent certain
types of cancer
• Boosts immune system to
fight infection
• With antioxidant properties
• Cough and cold remedy
• Relives sore throat,
toothache
• Aids in the treatment of
tuberculosis
• With anticoagulant
properties
juice the garlic bulb and apply. You
may cover the afflicted area with a
gauze and bandage.
• For sore throat and toothache, peal
the skin and chew. Swallow the juice.
• Aside from being an herbal medicine
for hypertension, arteriosclerosis and
other ailments, garlic is also
recommended for maintaining good
health - eat raw garlic bulb, and
include bawang regularly in the food
you eat. It's healthy and taste good in
a variety of dishes.

9.Ampalaya (Bitter Melon) or its scientific name, Momordica charantia has

been a folkloric cure for generations but has now been proven to be an
effective herbal medicine for many aliments. Most significant of which is
for Diabetes. The Philippine variety has proven to be most potent.
Ampalaya contains a mixture of flavanoids and alkaloids make the
Pancreas produce more insulin that controls the blood sugar in diabetics.
Aside from Ampalaya's medicinal value, it is good source of vitamins A, B
and C, iron, folic acid, phosphorous and calcium.

Ampalaya has been for used even by the

Chinese for centuries. The effectively of
Ampalaya as an herbal medicine has been
tried and tested by many research clinics and
laboratories worldwide. In the Philippines, the
Department of Health has endorsed.
Ampalaya as an alternative medicine to help
alleviate various ailments including diabetes,
liver problems and even HIV.

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 Herbal Benefits of Ampalaya: Preparation of Ampalaya:

• Good for rheumatism and gout • For coughs, fever, worms,

• And diseases of the spleen and
liver
• Aids in lowering blood sugar levels
• Helps in lowering blood pressure
• Relives headaches
• Disinfects and heals wounds &
burns
• Can be used as a cough & fever
remedy
• Treatment of intestinal worms,
diarrhea
• Helps prevent some types of
cancer
• Enhances immune system to fight
infection
• Is an antioxidant, parasiticide,
antibacterial & antipyretic
diarrhea, diabetes, juice the
Ampalaya leaves and drink a
spoonful every day.
• For other ailments, the fruit and
leaves can both be juiced and
taken orally.
• For headaches wounds, burns
and skin diseases, apply warmed
leaves to afflicted area.
Note: In large dozes, pure
Ampalaya juice can be a purgative
and abortifacient.

10. Akapulko or Acapulco in

English is a shrub found throughout
the Philippines. A medicinal herb that
contains chrysophanic acid, a
fungicide used to treat fungal
infections, like ringworms, scabies
and eczema. Akapulko also contains
saponin, a laxative that is useful in
expelling intestinal parasites.
The extracts from the Akapulko plant is
commonly used as an ingredient for
lotions, soaps and shampoos.

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 Uses of Akapulko: Preparation:

• Treatment of skin diseases: • For external use, pound the leaves of

Tinea infections, insect bites, the Akapulko plant, squeeze the juice
ringworms, eczema, scabies and apply on affected areas.
and itchiness.
• For internal use: cut the plant parts
• Internal: into a manageable size then soak and
Expectorant for bronchitis boil for 10 to 15 minutes let cool and
and dyspnoea, mouthwash in use as soon as possible. Note: The
stomatitis, alleviation of decoction looses its potency if not used
asthma symptoms, used as for a long time. Dispose leftovers after
diuretic and purgative, for one day.
cough & fever, as a laxative
to expel intestinal parasites
and other stomach
problems. A strong decoction
of the leaves is an
abortifacient.

ADDITIONAL INFORMATION:

As a herbal medicine, Luyang Dilaw or Ginger Root (scientific name: Zingiber

officinale) has long been used as a cold, cough, fever and sore throat
remedy. It helps in the digestion and absorption of food, lowering of
cholesterol, alleviating nausea and vomiting. Luyang dilaw has antifungal,
antiseptic, antiviral and anti-inflammatory properties.

Benefits:
• Relieves rheumatic pains & muscle pains
• Alleviates sore throat, fever, nausea
• Intestinal disorders and slow digestion
• Treat intestinal worms
• Hinder diarrhea, gas pains
• Relieve indigestion (dyspepsia), toothaches
• Lower cholesterol levels
• Aids treatment of tuberculosis

Preparation:
- Boil the root in water and drink. The more concentrated the better.
- For sore throat and tooth ache, remove the skin and chew small
portions.
- For cuts & bruises, apply the juice directly to the skin.
- For rheumatism and muscle pains, pound the root and apply to painful
areas -can be mixed with oil for easy application.

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Philippine Virgin Coconut Oil (VCO)

About Virgin Coconut Oil (VCO)

VCO is now getting global reputation as
the healthiest and versatile oil in the world.
The Philippines is one of the best sources of
virgin coconut oil and its popularity in the
country is legendary. Although not an herb,
we decided to make an article about VCO
because of the growing interest on the oil
and after receiving several Forinquiries
many from
our visitors.
Virgin coconut oil and regular coconut oil is rich in Lauric Acid, an
essential fatty acid that is only found in high concentrations in mother's
milk. When taken internally, Lauric Acid turns into a compound known as
Monolaurin. It is this compound that is believed to fight viral pathogens that
protects the body from bacteria, viruses and infections from parasites.
Coconut oil also causes the metabolic rate to increase, hence helps reduce
weight and is safe and beneficial for diabetics.
For many years, coconut oil has been discredited (specially in the
west) because of it's high saturated fat content. But recent studies have
shown that not all saturated fats are the same. The medium chain
triglycerides of which virgin coconut oil is classified, does not elevate LDL
(the bad cholesterol) in our body compared to other polyunsaturated
vegetable oils such as canola and sunflower oil which is widely produced in
the west.
How Virgin Coconut Oil (VCO) is Made
First, the husk and the shell is removed from fresh coconuts, then the
meat of the coconut is shredded -a process called "Wet Milled", then the
meat is "Cold Pressed" to get the coconut milk without any chemicals. The
milk is then fermented in containers for a day or two. After which, oil is
produced. This oil is carefully filtered and separated from the curd. You now
have what is called, virgin coconut oil. A more modern way of separating the
oil from the curd is through centrifugal force.
The second method of producing virgin coconut oil (VCO) is using quick dried
coconut meat and then processed in the same way. But the preferred
manner by most is still the "Wet Milled" process.
Difference between Virgin Coconut Oil (VCO) and Regular (RBD) Coconut Oil
RBD stands for Refined, Bleached, and Deodorized. Ordinary coconut
oil usually comes from copra - coconut meat that is dried by either smoke,
kiln or placing under the sun. Because the process itself is not sanitized, the
oil must be further refined. To get more oil from copra, chemicals are usually
used. RBD process is required to make the oil clear, odor free and tasteless.
This procedure also removes the anti-oxidant and other properties of the oil.
Some coconut oils are also hydrogenated which increases the serum
cholesterol levels and thus is bad for the heart.

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 While virgin coconut oil, being pure, unadulterated and
unhydrogenated retains its pleasant coconut taste, smell and all the health
benefits of coconut oil.
Much research still has to be done on the benefits of virgin coconut oil but
preliminary findings and anecdotal reports are very promising. This may well
be the much needed medicine to restore to health the ailing Philippine
coconut industry.

Benefits of VCO
● A boost to the body's immune system
● A good source of saturated medium chain triglycerides
● VCO helps regulate blood sugar
● Lowers the viral load of AIDS patients.
● Has anti-viral & anti-microbial properties
● Helps hepatitis C, herpes patients
● Helps maintain healthy thyroid function
● Maintain LDL & HDL cholesterol levels
● Heals & nourishes the skin, hair & scalp

Tips on Handling Medicinal Plants / Herbs:

● If possible, buy herbs that are grown organically - without pesticides.

● Medicinal parts of plants are best harvested on sunny mornings. Avoid
picking leaves, fruits or nuts during and after heavy rainfall.
● Leaves, fruits, flowers or nuts must be mature before harvesting. Less
medicinal substances are found on young parts.
● After harvesting, if drying is required, it is advisable to dry the plant
parts either in the oven or air-dried on screens above ground and never on
concrete floors.
● Store plant parts in sealed plastic bags or brown bottles in a cool dry
place without sunlight preferably with a moisture absorbent material like
charcoal. Leaves and other plant parts that are prepared properly, well-
dried and stored can be used up to six months.
Tips on Preparation for Intake of Herbal Medicines:

● Use only half the dosage prescribed for fresh parts like leaves when
using dried parts.
● Do not use stainless steel utensils when boiling decoctions. Only use
earthen, enameled, glass or alike utensils.
● As a rule of thumb, when boiling leaves and other plant parts, do not
cover the pot, and boil in low flame.
● Decoctions loose potency after some time. Dispose of decoctions after
one day. To keep fresh during the day, keep lukewarm in a flask or
thermos.

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 ● Always consult with a doctor if symptoms persist or if any sign of allergic
reaction develops.

ENVIRONMENTAL HEALTH

1. FOOD Sanitation

Instructional Objectives:
At the end of the session, the NURSING students will be able to:

1. Explain the importance of food sanitation in disease prevention and

thereby protect the public from illness and promote the health and
well-being of consumers.
2. Identify the sources of infection from food and food handlers.
3. Enumerate the hygiene guidelines for food safety.

Objectives
 4. Identify the sanitation requirements for food establishments
(Chapter III of IRR of P.D. 856)
 5.1 Sanitary Permit
 5.2 Health Certificate
 5.3 Quality and Protection of Food
 5.4 Structural Requirements
 5.5 Sanitation Facilities

MODE OF TRANSMISSION OF FOOD BORNE DISEASES FOOD

HANDLING ESTABLISHMENTS

AIR
RESPIRATOR
Y & ORAL POISON DEATH
HANDS
DISCHARGE
SICK S
PERSONS (SNEEZING,
FLIES,
COUGHING,
COCK-
SPITTING) SUSCEP-
ROACHES
CARRIERS OTHER UTENSILS TIBLE
OPEN FOOD
INSECTS INDIVIDUAL
WOUNDS
CARELESS AND
AND BOILS
INDIVI- RODENTS
DUAL
WATER
INTESTINAL INFECTED
(DRINKING SICKNESS
DISCHARGE ANIMALS
& WASH
S (EXCRETA)
WATER)

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 CIRCLE OF INFECTION

MICRO
PEOPLE ORGANISMS

TIME/
TEM
PERA FOODS
TURE

SANITATION REQUIREMENTS FOR OPERATING A FOOD ESTABLISHMENT

SANITARY PERMIT

1. No person or entity shall operate a food establishment for public

patronage without securing a Sanitary Permit.

2. Application or renewal of Sanitary Permit

– The application or renewal of Sanitary Permit shall be filed with
the city or municipality health office having jurisdiction over the
establishment utilizing EHS Form No. 110. For inter island and
coastline vessels, the application shall be filed in the city or
municipal health office of the vessels’ port of origin or head port.

2.2 Sanitary Permit shall be issued only upon compliance to at least a

satisfactory rating utilizing the Sanitary Inspection of Food Establishment
Form( EHS Form No 103-A) and existing sanitation standards for food
establishments.

3. Fees shall be paid upon application, renewal and noting of sanitary

permits. The amount of fees shall be set through city or municipal
ordinance.

5. The permit shall be valid for one (1) year, ending on the last day of
December of each year, and shall be renewed every year. However, for
new food establishments, the validity of the Sanitary Permit will also
expire at the end of December of the current year. Upon the
recommendation of the local health officer, the Sanitary Permit shall be
suspended or revoked by the local health authority upon violation of any
sanitation rules and regulations.

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 6. The sanitary Permit shall be posted in a conspicuous place of the
establishment and shall be available for inspection by the health and
other regulatory personnel.
7. Record of Permit Certificates
– Every city or municipality shall keep a record of all
establishments in respect of which permits have been issued
and all permit certificates and renewal thereof.

HEALTH CERTIFICATES AND FOODHANDLERS

1. No person shall be employed in any food establishment without a
health certificate issued by the city/municipal health officer. This
certificate shall be issued only after the required physical and medical
examinations and immunizations. Briefings shall be provided by the local
health office prior to the issuance of the health certificate to the
recipients.
2. The health certificate (EHS Form No. 102- A,B, C) shall be clipped in
the upper left front portion of the garment of the employee while
working.
3. The health certificate shall be renewed at least every year or as often
as required by the local ordinance.
4. Health certificates are non- transferable.

REQUIREMENTS REGARDING FOOD HANDLERS

5. Food handlers shall observed good personal hygiene and practices
such as:
1. Wearing clean working garments and hair restrain.
2. Washing hands, arms and fingernails before working. Such washing
must be repeated during working hours and after smoking, visiting the
toilet, coughing or sneezing into hands, or as often as may be necessary
to remove dirt and contaminants.
.3. Using, chewing or smoking tobacco in any form while engaged in
food preparation or service, or while in the equipment and utensils
washing or food preparation areas is not allowed.

FOOD HANDLERS
 No person shall be allowed to work in food handling and preparation
while afflicted with a communicable disease or a carrier of such
disease, which includes boils or inflected wounds, colds or respiratory
infection, diarrhea or gastrointestinal upsets, and other related
illnesses.
 The manager or person-in-charge of the establishment shall notify the
health officer or the company physician if any, when any employee is
known to have a notifiable disease.
Four Rights in Food Safety
 Right Source:
 • Always buy fresh meat, fish, fruits & vegetables.
 • Always look for the expiry dates of processed foods and avoid buying
the expired ones.
 • Avoid buying canned foods with dents, bulges, deformation , broken
seals and improperly seams.

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  • Use water only from clean and safe sources.
 • When in doubt of the water source, boil water for 2 minutes.

Right Cooking:
• Cook food thoroughly. Temperature on all parts of the food should reach
70 degrees centigrade.
• Eat cooked food immediately.
• Wash hands thoroughly before and after eating.

Right Preparation:
Avoid contact between raw foods and cooked foods.
• Always buy pasteurized milk and fruit juices.
• Wash vegetables well if to be eaten raw such as lettuce, cucumber,
tomatoes & carrots.
• Always wash hands and kitchen utensils before and after preparing food.
• Sweep kitchen floors to remove food droppings and prevent the harbor of
rats and insects.

Right Storage:
• All cooked foods should be left at room temperature for NOT more than
two hours to prevent multiplication of bacteria.
• Store cooked foods carefully. Be sure to use tightly sealed containers for
storing food.
• Be sure to store food under hot conditions (at least or above 60 degrees
centigrade) or in cold conditions (below or equal to 10 degrees centigrade).
This is vital if you plan to store food for more than four to five hours.
• Foods for infants should not be stored at all. It should always be freshly
prepared.
• Do not overburden the refrigerator by filling it with too large quantities
of warm food.
• Reheat stored food before eating. Food should be reheated to at least
70 degrees centigrade.

Rule in Food Safety:

 “When in doubt, throw it out!”

Structural Requirements:
 1. Floors
 2. Walls
 3. Ceilings
 4. Lighting
 5. Ventilation
 6. Overcrowding 7. Change rooms

FLOORS
1) Kept clean; no sawdust used
2) Concrete, other impervious materials; easily cleaned materials, resistant
to wear and corrosion.
3) Wood: floor board laid on a fire foundation; tightly clamped together.

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4) All angles between floors and walls rounded off to height of not less than
3 inches ( 7.62 cm.) from the floor.
5) Adequately graded and drained.
6) Exterior walking and driving surfaces properly surfaced.
7) Mats and duck boards cleanable and removable.

WALLS
1) Internal surfaces, smooth, even, non-absorbent, cleanable
2) Constructed of dust-proof materials
3) Walls subject to wetting or splashing: impervious, non-absorbent
materials, height not less than 4.79 inches (2M) from the floor.
4) Painted light color; wall finish approved by DOH.
5) All wall attachment /decoration clean.

LIGHTING
1. Twenty (20) foot candles-room where food is prepared, packed,
utensils and
Hand washing rooms.
2. Five (5) foot candles – where food is consumed.
3. Intensities of illumination measured 30 inches from floor.
4. Lighting reasonably free from glare; no shadows.
5. Other artificial light source approved by DOH.

VENTILATION
1) Rooms reasonably free from steam, condensation, odors, fumes, some
other impurities; relative humidity – 60% temperature = 80 F.
2. Rooms and equipment vented to outside as required.
3. Hoods properly designed; filters easily removable.
4. Intake air ducts properly designed and maintained.
5. Systems comply with fire prevention, population / nuisance
requirements.

OVERCROWDING
1) Sufficient floor spaces
a) Enabling every employee to carry-out their duties efficiently.
b) Easy access for cleaning.
2.) Working spaces, aisle, passageways and areas which customers have
access:
a. Unobstructed
b. Sufficient to permit movement; no contamination of food by clothing
or
personal contact of employees and customers.

Sanitation Standard

% Rating Sanitation Standard Color Code

90 - 100% Excellent Luminous Green
70 - 89% Very Satisfactory Yellow
50 - 69% Satisfactory Red- Orange

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Reasons for Practicing Food and Water Safety
 It may save a life
 You will spare yourself and your family a painful bout of illness
 Save money
 Safe food handling inspires confidence and keeps peace in the family
 Safe food handling lets you enjoy to the fullest the nutritional benefits
of food
 Safe food handling practices are the ones most likely to preserve
food’s peak quality

.
FOOD SAFETY NETWORK PHIL

G - GOVERNMENT
BFAD, DENR, DOH, DA, BAFPS, DOST
A – ACADEME
Schools
I – INDUSTRY
BFAD, DENR, DOH, DA, BAFPS, DOST
N - NON-GOVERNMENTAL ORGANIZATIONS
FAFST, FSNP, PAFT

WATER SANITATION

Drinking water must be clear, colorless and free from objectionable taste
and odor. Above all, it must not contain any substance, organism, chemical
or radioactive material at a level and /or concentration which could
endanger the health and lives of the consuming public.
The determination of the safety and potability of the local water requires
reference to a set of water quality parameters.

Goal: Halve the proportion of people with no access to safe drinking water

Year Target Year target Proportion of

2005 86 2011 90 household w/
2006 86 2012 90 access to safe
2007 89 2013 90 drinking
2008 90 2014 90 water 1998 =
2009 90 2015 90 86.8
2010 90

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TRADITIONAL HAZARDS
- Related to poverty and insufficient development

LACK OF ACCESS TO SAFE DRINKING WATER

Unserve
d
13 %
(9.6 M HH)

91% in Urban
Serve
d
71% in Rural
87 %
Source: National Health Demographic Survey Safe Water Coverage, 1998

Water Supply
Definition of Terms:

Level I (point source) – a protected well or developed spring with an outlet

but without distribution system, generally adaptable for rural areas where
houses are thinly scattered. A Level I facility normally serves around 15
households.

Level II ( communal faucet system or stand posts) – a system composed of a

source, a reservoir, a piped distribution network and communal faucets,
generally suitable for rural or urban fringe areas where houses are clustered
densely to justify a simple piped system. Usually, one faucet serves 4 to 6
households.

Level III (waterworks system or individual house connection) – a system with

a source, a reservoir, a piped distribution network and household taps,
generally suited for densely populated urban areas.
 Doubtful Sources – a water supply facility or source that is subject to
re-contamination ( e.g. open dug well, unimproved spring, surface
water)

Prescribed Standards and Procedure of Ground Water Source Construction

- Well - No well site shall be located within a distance of less than 25

meter radius on flat areas from any source of contamination. And 50
meters distance from a cemetery.

185
 - Spring – Washing and bathing within 25 meters radius of the spring is
prohibited. Also, protection of the entire catchments area is a must. No
dwellings shall be constructed within the catchments area and it shall be off-
limits to people and animals

Three ways to determine the potability of water:

1. Sanitary Survey
2. Water Examination
3. Recommendation of measures to correct deficiency in the
water supply.

Types of Water Examination:

1. Bacteriological
2. Biological
3. Chemical
4. Physical
5. Radiological

STANDARD PARAMETERS AND VALUES FOR DRINKING – WATER QUALITY

Source and mode of Bacteria Standard value
supply (no./100)
A. All drinking water E. Coli or thermo 0
supplies under all tolerant
circumstances( Level I, ( fecal) coli form
II,III, Bottles water and bacteria
emergency water
supplies

B. Treated water E. Coli or thermo 0

entering the distribution tolerant ( fecal) coli
system form bacteria

Treated water in the E. Coli or thermo 0

distribution system tolerant( fecal) coli form
bacteria Must not be detectable
Total Coli form in any 100 ml sample.
In case of large
quantities where
sufficient samples are
examined, it must not
be present in 95% of
samples taken thru-out
any 12-month

Standard Values
 For Biological Organism
 For Physical and Chemical Quality
i. Health Significance
- Inorganic Constituents

186
 - Organic Constituents

ii. Aesthetic Quality

 For Disinfectants and Disinfectants By-products
a. Disinfectant Chlorine (max level) 0.2 – 0. 5
Water Treatment
1. Group I . Water Requiring Disinfection Only: Water from
underground or surface sources subject to a low degree of contamination.
( coliform org <50 / 100ml)
2. Group II. Water Requiring Complete Treatment: Water from
underground or surface sources having a MPN of coliform organisms 50 per
100 ml to not more than 5,000 per 100 ml.
Requirement for Complete Chlorination of Level I Water Supply Facility

1. A dose of 50 – 100 ppm shall be used in disinfecting

2. The person who will conduct the chlorination shall observe personal
hygiene and must be free from communicable disease.

Water Laboratory Analysis for Public Drinking Water System

Level I – every quarter
Level II – every 2 months
Level III – every month

- Certificate of potability will be issued

Prescribed Standards and Procedure for Monitoring of Water Safety

(Potability)
 Monitoring Scheme
The Local Health Authority( Gov/Mayor/ Brgy. Captain)) shall establish a
Water Surveillance Program thru the creation of Local Drinking Water Quality
Monitoring Committee to oversee the operation of the water system and the
quality of water produced and distributed and to monitor the
implementation of the provisions of the IRR.

Composition of LDWQMC:
1. Health Authority - Chairman
2. Health Officer – Vice Chairman
3. Water Districts/Private Water Suppliers
4. SangguniangPanlalawigan/Panlungsod/Bayan
5. Engineer’s Office
6. CENRO Representative
7. NGO related to Health & Sanitation
8. DOH Representative to the Local Health Board
9. Sanitary Engineer/ Sanitation Inspector

Sanitary Requirement for the Development of Drinking Water Supply System

Grounds for Revocation/suspension of the Operational Permit

187
 Certificate of Potability of Drinking Water – the Health Officer is hereby
deputized by the Secretary of Health to issue the certificate Water-Related
Disease
Chemical Contaminants
Organic compounds
Synthetic organic compounds
Volatile organic compounds
Inorganic compounds

 Microbial Pathogens
- Bacteria: E. coli,
Enterotocci
- Parasitic protozoa
- Viruses
HEALTH CARE WASTE MANAGEMENT

MAJOR SOURCES OF HEALTH CARE WASTE

Include among others…
 Hospitals
 Clinics
 Laboratories and Research Centers
 Drug Manufacturing Companies
 Mortuary and Autopsy Center

MINOR SOURCES OF HEALTH CARE WASTE

Include among others…
 Small Health Care Facilities
 Physician’s Offices
 Dental Clinics
 Alternative Medicine Clinics
 Home (Treatment at home such as dialysis, insulin injection, etc.)
 Institutions ( Medical Schools, Nursing Homes, Dental Schools,
Paramedics Services, Drug Rehabilitation Centers, etc.)
 Ambulances and Emergency Care
 Cosmetic Body Piercing & Tattoo Parlors

SOURCES AND COMPOSITION OF WASTE

 Medical Wards
 Medicine
 Pediatrics
 OB-Gynecology
 Surgery

GENERAL WASTE
Infectious waste
 Blood- soaked dressings
 Bandages

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  Sticking plaster
 Contaminated gloves
Sharps
 Used hypodermic needle
 Intravenous sets
Pathological waste
 Body fluids

CATEGORIES OF HEALTH CARE WASTE

General Waste (Non-infectious dry/ wet

2. Infectious Waste
3. Pathological Waste
4. Sharps
5. Pharmaceutical Waste
6. Chemical Waste
6a. Waste with High Content of Heavy Metals
7. Pressurized Containers
8. Radioactive Waste
9. Genotoxic Waste

COLOR CODING SCHEME:

1. Non- infectious wet waste – green

2. Non- infectious dry waste – black
3. Infectious and pathological – yellow
4. Chemical waste and waste with heavy metal – yellow with black band
5. sharps and pressurized containers – red
6. Radioactive waste - orange

Persons at Risk to Exposure to Health Care Waste

1. Health Care Staff ( Physicians, Nurses, Health Care Ancillaries, Hospital

Maintenance Personnel) Patients
2. Visitors, Comforters, Caregivers
3. Personnel/Workers in support services such as laundries and waste
handling
4. Workers in waste disposal facilities (e.g. sanitary landfill, etc.),
including Scavengers
5. General Public

DOH PROGRAMS EVALUATION TEST

___ 1. Which of the following is well-stated/formulated health objective of a

community health plan?
a. To increase the number of mothers coming for pre-natal check-up by 25%
in 12 months time.
b. To increase the number of home visits made by health personnel to 50%.
c. To increase the coverage of immunization in 1 year.

189
d. To increase the number of children receiving food assistance.

___ 2. Nutritional status indicator collected and utilized in public health

programs are following:
a. % of newborn who are LBW (low birth weight)
b. Weight-for-age
c. % of children with mild, moderate and severe malnourished
d. All of the above
___3. One of the following is not a benefit of Vitamin A supplementation:
a. Promotes growth
b. Prevents blindness
c. Reduces the risk of infection
d. None of the above

___4. The target set by WHO for the Cure Rate of the TB patients under the
National Tuberculosis program is:
a. 70%
b. 80%
c. 85%
d. 95%
___5. One of the following is not among the 5 elements of D.O.T.S:
A . Political Commitment
b. Case detection by sputum microscopy
c. Uninterrupted treatment and regular drug supply
d. None of the above
___6. How many sputum collections should a nurse get from a patient who is
suspected of having TB?
a. one
b. two
c. three
d. four

___7. The following are symptoms of Avian Influenza (H5N1), except:

a. Fever
b. Headache
c. Respiratory distress syndrome
d. Multiple organ failure
___8. One of the following is not correct on the food safety implication of
H5N1:
a. Conventional cooking (with temperature of >70%) will inactive the virus.
b. H5N1 virus is killed by freezing.
c. Eggs inside and outside can contain the virus.
d. Greatest risk is through handling of infected poultry.

___9. The following are true regarding Schistosomiasis Prevention and

Control, except:
a. The disease is transmitted to man when they come in contact with
freshwater.
b. The cercariae from snail penetrate the skin of man and then go to the
liver.

190
c. The significance of its control measures is that its primary victims are the
rural poor.
d. Use of self protective measures like repellant is encouraged.

___10. The prevention of HIV/AIDS is geared towards change in sexual

behavior like the following, except:
a. Practice monogamy.
b. Use of condom for questionable sexual partners.
c. Intake of antibiotics after unprotected sex.
d. Abstinence for those unmarried individuals.
___11. The STI that presents as genital ulcers:
a. Syphilis
b. Herpes genitalis
c. Chlamydia
d. Only a and b

___12. In the control of Rabies, immunization is given to:

a. Dogs
b. Suspected dog bite victims
c. Both of the above
d. None of the above
___13. For active immunization against Rabies, all the vaccines may be
administered by the following route, except:
a. intramuscularly
b. intradermally
c. subcutaneously
d. None of the above

___14. In the Philippines, early diagnosis for breast cancer is done through:
a. Mammography
b. Breast self-exam
c. Ultrasound
d. Good history of the patient
___15. The drug for effective pain relief of cancer which is available for free
to patients under the Cancer Prevention and Control program is:
a. Nubian
b. Demerol
c. Paracetamol
d. Morphine

___16. The target population for the Expanded Program of Immunization

(EPI) is:
a. under 5 years old
b. under 1 year
c. 9 months and above
d. 12-59 months of age
___17. In Hepatitis B vaccination, the type of vaccine that must be used for
the birth dose is:
a. Monovalent
b. Combination

191
 c. A and b
d. Neither a nor b
___18. The following antigens are given for three doses in EPI, except:
a. BCG
b. Polio
c. DPT
d. Hepatitis B
___19. The Multi-dose Vial Policy can be applied to the following vaccines
except:
a. DPT
b. TT
c. Hepa B
d. BCG

___20. One of the following is not correct regarding immunization:

a. Polio is the only vaccine given by month.
b. BCG is given at birth of anytime after birth.
c. Hepatitis B is given at 8 weeks interval.
d. Measles is given only when the infant reaches 9 months old.

___21. The most sensitive index to measure the level of the health status in
a community is: a. MMR
b. IMR
c. Mortality rate
d. Swaroop’s Index
___22. The rate that has the denominator of the number of registered live
births:
a. IMR
b. MMR
c. Perinatal mortality rate
d. All of the above

___23. The following is not true regarding the advantages of DMPA:

a. Highly effective and long acting.
b. Does not affect the production and quality of breast milk.
c. Does not interrupt with sexual act.
d. Can immediately removed from the body if side effects develop.

___24. The first line of antibiotic for the treatment of Pneumonia in the
Control of Acute Respiratory Infection for children:
a. Cotrimoxazole
b. Amoxicillin
c. Penicillin
d. Cephalosporin
___25. In the Integrated Maternal and Child Illness (IMCI) approach, health
workers can diagnose a child with Pneumonia by:
A/ Counting the respiratory rate
B. Chest X-ray examination
c. Taking a good history of the patient
d. Hearing crackles in the chest upon auscultation

192
___26. What signs are used to assess a sick child with cough for difficult
breathing?
a. Fast breathing
b. Chest indrawing
c. Stridor
d. All of the above
___27. One should asses feeding if the child has one of the following, except:
child has anemia
a. no appetite
b. very low weight
C. less than two years old
___28. The four main symptoms included in IMCI are the following, except:
a. cough, fever
b. diarrhea
c. malaria
D. ear problem
___29. Fast breathing for a child that is 12 months old is:
a. 50 breaths/minute or more
b. 40 breaths/minute or more
c. 60 breaths/minute or more
d. None of the above
___30. What is a true statement in a child aged five years old:
a. Can still use the IMCI chart for sick child 2 months up to 5 years
b. Can use the IMCI chart for young infant 1 week up to 2 months
c. Cannot use the two charts since signs and symptoms are different in
older children.
d. None of the above
___31.The following are signs of good attachment, except:
a. More areola visible below than above the mouth
b. Chin touching breast
c. Mouth wide open
d. Lower lip turned outward
___32. If pus is seen draining from the ear and discharge is reported for 14
days or more; the classification is:
a. Mastoditis
b. Acute ear infection
c. Chronic ear infection
d. None of the above
___33. Paracetamol should only be given to children with high grade fever of:
a. 37.5C
b. 37.2C
c. 38.0C
d. 38.5C or more
___34. Classification for a child that is having diarrhea, restless and irritable,
skin pinch goes back slowly and has sunken eyes is:
A. severe persistent diarrhea
B. diarrhea with some dehydration
C. severe dehydration
D. no dehydration

193
___35. The earliest possible age for a child to be given a deworming drug
especially in endemic helmenthiasis area is:
a. 12 mos. c. 24 mos.
b. 6 mos. d. 36 mos.
___36.Three components of IMCI except:
a. Improving health system
b. Improving health services
c. Improving health worker’s skills
d. Improving family and community practices

___37. In Malaria Control Program, the biological control method includes:

a. Seeding of larvivorous fish
b. Clearing a stream
c. Elimination of stagnant waters
d. Only a and b
___38. In Filariasis Control program, the case finding method is:
a. Peripheral blood smear
b. Nocturnal blood smear
c. Stool examination
d. Sputum examination
___39. The 4 S in Dengue prevention and control are the following except:
a. Search and destroy breeding sites of mosquito.
b. Do fogging activities if there are cases in the community.
c. Use self-protective measures like use of insect repellant.
d. Seek early consultation for fever.

___40. One of the 10 herbal medicines for stomach pains, gastro enteritis,
dysentery and body cleanser or body wash is wild tea and it is popularly
known as:
A. bayabas
B. sambong
c. Lagundi
d. Tsaang- gubat
___41. The benefit of garlic includes the following:
A. lowers LDL levels
B. lowers blood pressure
C. boost the immune system
d. All of the above

___42. One of the following is not correct in food sanitation standards:

a. Health certificates of food handlers are non-transferable.
b. Sanitary permit shall be posted in a conspicuous place of the
establishment.
c. The sanitary permit is valid for two years.
d. For 4 or more employees in an establishment, separate changing
rooms should be provided.
___43. One of the following is not correct regarding food preparation and
storage:
a. Food should be cooked thoroughly with temperature on all parts of
the food should reach 70C.

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 b. All cooked food should be left at room temperature for not more
than 2 hours to prevent bacterial multiplication.
c. If food is to be stored for more than 4 hours, the temperature should
be below 10C.
d. None of the above.
___44. Food establishment that has a very satisfactory rating from local
authority has a color code of:
A. green
B. yellow
C. red-orange
D. blue
___45. The water supply that comes from communal faucet system or
standpost that serves
4 - 6 clustered households are a:
a. Level I
b. Level II
c. Level III
d. Level IV
___46. For drinking water quality, the standard parameter or value for E. coli
or coliform bacterial count / 100 ml of water sample in all drinking water
supplies (Level I, II, and III) is:
a. 0
b. 1 – 2
C. < 5
d. None of the above
___47. In health care waste management, the color code of radio-active
waste is:
A. green
B. yellow
C. orange
D. red

___48. High risk pregnancy includes the following, except:

a. Age less than 18 or more than 35 years old.
B. Pregnant within the 20 months from previous delivery.
c. Sever anemia with hemoglobin of below 10g/dl.
d. None of the above

___49. In stress management, the means of being open to experience which

increases your sensitivity to inner self is:
A. spirituality
B. self-awareness
C. stress debriefing
D. socialization

___50. The four pillars in the strategy Four-mula One for Health are the
following, except:
a. Governance
b. Health regulation
c. Health care financing

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d. Public health reforms

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