Republic Act 3573 specifically provides for the prevention and suppression of Dangerous

Communicable Diseases. These includes the following:

1. National TB Program - Directly Observed treatment, Short Course (NTP-DOTS)

2. National Leprosy Control Program
3. Dengue Control Program
4. Schistosomiasis Control Program
5. Filariasis Control program
6. Malaria Control Program
7. Rabies Control Program
8. Sexually Transmitted Infections (STIs) and AIDS Control Program

DENGUE CONTROL PROGRAM

DENGUE FEVER
Other terms: Breakbone Fever/ Hemorrhagic Fever/ Dandy Fever/ Infectious
thrombocytopenic purpura
Description: A severe acute febrile disease caused by an infection often characterized by
bleeding and hypovolemic shock.
Etiologic Agents: Dengue virus types 1,2,3,4 and
Chikungunya virus
Source of infection:
 Female Aedes Aegypti (vector) - a day-biting mosquito that lay eggs in clear and stagnant
water found in flower vases, cans, rain barrels, old rubber tires, etc. The adult mosquitoes
rest in dark places of the house
 Infected person

Incubation Period: 3-14 days (commonly 5-7 days)

Period of Communicability: Unknown. Presumed to be on the first week of illness - when the
virus is still present in the blood

Mode of transmission: Mosquito bite (Aedes aegypti)

 According to Severity:

According to Sequelae:

A. DENGUE FEVER Grade

B. DENGUE HEMORRHAGIC FEVER
C. DENGUE SHOCK SYNDROME DF/DHF/DSS

Clinical Manifestations in Three Stages:

1) Febrile or Invasive stage
 occurs in first 4 days
 starts abruptly as high fever, abdominal pain and headache
 later flushing which may be accompanied by vomiting, conjunctival infection and epistaxis.
2) Toxic or hemorrhagic stage
 begins on 4th-7th days
 There is lowering of temperature, severe abdominal pain, vomiting and frequent bleeding
from gastrointestinal tract in the form of hematemesis or melena
 Unstable BP, narrow pulse pressure and shock which may be followed by death.
3) Convalescent or recovery stage
 Occurs on the 7th-10thday
 Shows generalized flushing with intervening areas of blanching
 Appetite regained and stabilized blood pressure

CLASSIFICATION OF DENGUE FEVER:

Severe, frank type With flushing, sudden high fever, severe hemorrhage, followed by
sudden drop of temperature and shock which may terminate in
recovery or death
Moderate Characterized by high fever but with less hemorrhage, no shock
Mild Slight fever, with or without petechial hemorrhage but
epidemiologically related to typical cases usually discovered in the
course of investigation of typical cases
Susceptibility, resistance and Occurrence:
 All persons are susceptible.
 Both sexes are equally affected
 Age groups predominantly affected are the preschool age and school age
 Adults and infants are not exempted
 Peak age affected 5-9 years old
 Occurrence is sporadic throughout the year
 Epidemics usually occur during the rainy seasons - June to November
 Peak months: September and October
 Occurs wherever vector mosquito exists
 Susceptibility is universal.
 Acquired immunity may be temporary but usually permanent

Diagnostic Tests:
1. SCREENING TEST: Tourniquet test (Rumpel Leads test)
 Inflate the blood pressure cuff on the upper arm to a point midway between the
systolic and diastolic pressure for 5 minutes
 Release the cuff and make an imaginary 2.5 cm. Square or 1 inch square just below
the cuff, at the antecubital fossa
 A test is positive (+) when 20 or more petechiae per 2.5 cm. Square are observe
2. CONFIRMATORY TESTS:
 decreased Platelet Count and WBC 3.
 Hemoconcentration – increase of at least 20% of hematocrit
 Occult Blood
 Hemorrhagic determination

Management:
Supportive and symptomatic treatment should be provided.
1. Give Paracetamol/ Acetaminophen for pain and fever! (NO ASPIRIN!)
2. Rapid replacement of fluids is the most important treatment
3. Intensive monitoring and follow-up.
4. Give ORESOL to replace fluid as in moderate dehydration at 75 ml/kg in 4-6 hours or up to
2-3l in adults. Continue ORS intake until patient’s condition improves.
5. Advise the patient to avoid dark colored foods that can mask bleeding.
SEVERE DEHYDRATION:
 Intravenous fluids First line : D5LRS or D5 0.9 NaCl Second line : PNSS or PLRS
 Blood Transfusion (for severe bleeding)
 Oxygen Therapy for patients in shock

Nursing:
Supportive/Palliative Care
1. For Hemorrhage: Keep the patient at rest during bleeding episodes.
2. Nose bleeding: maintain an elevated position of the trunk and promote vasoconstriction in
the nasal mucosa membrane through an ice bag over the forehead and at the bridge of the
nose.
3. GI bleeding : put an ice over the abdomen.
4. Promote rest - avoid unnecessary movement
5. WOF: signs of shock - low pulse, cold clammy perspiration, prostration
6. For Shock – place patient in modified Trendelenburg position to promote circulation; provide
warmth through lightweight covers
7. Diet: Low Fat, Low Fiber, non-irritating, noncarbonated

DOH Program: FOUR O’CLOCK HABIT

Prevention and Control: ·
 Changing water and scrubbing the sides of flower vases once a week. ·
 Destroying breeding places of mosquitoes by cleaning surroundings and properly disposing
rubber tires, empty bottles, and cans keeping water containers covered ·
 Avoid hanging too many clothes inside the house. ·
 Perform residual spraying of insecticides. ·

The four “S” in Dengue prevention:

1. Search and destroy breeding places of mosquito
2. Seek immediate treatment
3. Say no to indiscriminate fogging
4. Self-protection

NATIONAL TUBERCULOSIS CONTROL PROGRAM

 Is an infectious disease caused by TB bacteria (Mycobacterium tuberculosis) that primarily

affects the lungs.
 This condition is known as pulmonary tuberculosis (PTB)
 Other forms: PTB in bones, meninges, joints, genitourinary tract, kidneys, intestines, and
heart is called extrapulmonary tuberculosis.
 Common among malnourished individuals living in crowded areas. Often occurs in children
of underdeveloped and developing countries in the form of primary complex especially
after a bout of a debilitating childhood disease such as measles
 Considered as the world’s deadliest disease and remain as a major public health problem in
the Philippines
 In 1993, TB was declared as global emergency by the World Health Organization because of
the resurgence of TB in many parts of the world
 In the Philippines, TB ranks 6th in the leading cause of morbidity (2002) and mortality (2002)
Mode of Transmission:
 Airborne droplet - one gets infected with TB if he inhales the germs released from air
droplets when a pulmonary TB patient coughs, sneezes and spits.
A PTB patient, whose sputum is positive for TB germs/bacteria, if left untreated may infect
approximately 10-20 persons in two years.
 Direct invasion through mucous membranes or breaks in the skin may occur, but is
extremely rare
 Bovine tuberculosis results from exposure to tuberculosis cattle, usually by ingestion of
unpasteurized milk of dairy products.
 Extrapulmonary tuberculosis, other than laryngeal, is generally not communicable, even if
there is draining sinus.

Signs and Symptoms:

 Cough for two weeks or more
 Fever
 Chest and back pains not referable to musculo-skeletal disorders
 Hemoptysis or recurrent blood-streak sputum
 Significant weight loss
 Other signs and symptoms: sweating, fatigue, body malaise, shortness of breath

Period of Communicability:
 as long as viable tubercle bacilli are being discharge in the sputum
 Some untreated or inadequately treated patients may be sputum positive intermittently for
years.
 The degree of communicability depends on the number of the bacilli discharged, the
virulence of the bacilli, adequacy of ventilation, exposure of the bacilli to sun or UV light
and opportunities for their aerosolization by coughing, sneezing, talking or singing.
 Effective antimicrobial chemotherapy usually reduces communicability to insignificant
levels within days to a few weeks.
 Children with primary tuberculosis are generally not infectious.

Susceptibility and Resistance:

 First 6-12 months after infection - most hazardous period of development of clinical
disease.
 The risk of developing the disease is highest in children under 3 years old, lower in later
childhood and high again among adolescents, young adults and the very old.
 Reactivation of long latent infections account for a large proportion of cases of clinical
disease in older persons.
 For those infected, susceptibility to disease is markedly increased in those with HIV
infection and other forms of immunosuppression and also increased among underweight
and undernourished persons with silicosis, diabetes ,or gastrectomies and among
substance abusers.

Incubation period: 2-10 weeks

Methods of Control
Preventive Measures
 Prompt diagnosis and treatment of infectious cases
 BCG vaccination of newborn, infants and grade 1/school entrants
 Educate the public in mode of spread and methods of control and the importance of early
diagnosis
 Improve social conditions, which increase the risk of becoming infected, such as
overcrowding
 Make available medical, laboratory and x-ray facilities for examination of patients, contacts
and suspects, and families for early treatment of cases and persons at high risk of infection
and beds for those needing hospitalization.
 Provide public health nursing and outreach services for home supervision of patients to
supervise therapy directly and to arrange for examination and preventive treatment of
contacts.

The National Tuberculosis Control Program

Vision: A country where TB is no longer a public health problem
Mission: Ensure the TB DOTS services are available, accessible, and affordable to the
communities in collaboration with the LGUs and other partners.
Goal: To reduce prevalence and mortality from TB by half by the year 2015 (Millennium
Development Goal)
Targets:
1. Cure at least 85% of the sputum smear-positive TB patient discovered
2. Detect at least 70% of the estimated new sputum smear-positive TB cases.

DOTS (Directly-Observed Treatment Short Course)

 Is a comprehensive strategy endorsed by the World Health organization (WHO) and
International Union against Tuberculosis and Lung Disease (IUATLD) to detect and cure TB
patients.
 It aims to control TB by reducing the annual risk of infection (prevalence and mortality
rates)

Key Policies
A. Case finding
1. Direct Sputum Smear Microscopy (DSSM) - primary diagnostic tool in NTP case finding
2. All TB symptomatic identified shall be asked to undergo DSSM for diagnosis before start of
treatment, regardless of whether or not they have available X-ray results or whether or not
they are suspected of having extrapulmonary TB.
The only contraindication for sputum collection is hemoptysis; in which case, DSSM will be
requested after control of hemoptysis.
3. Pulmonary TB symptomatic shall be asked to undergo other diagnostic test (x-ray and
culture), if necessary, only after they have undergone DSSM for diagnosis with three
sputum specimens yielding negative results. Diagnosis based on x-ray shall be made by the
TB Diagnostic Committee. (TBDC)
4. Since DSSM is the primary diagnostic tool, no TB diagnosis shall be made based on the
results of x-ray examinations alone. (Results of the skin test for TB infection or PPD skin
test) should not use as bases for TB diagnosis in adults.
5. Passive case finding shall be implemented in all health stations. Concomitant active case
finding shall be encouraged only in areas where a cure rate of 85% or higher has been
achieved, or in areas where no sputum-smear positive case has been reported in the last
three months.
6. Only trained medical technologies or microscopists shall perform DSSM (smearing, fixing,
and staining of sputum specimens, as well as reading, recording, and reporting of results).
However, in far flung areas, BHWs may be allowed to do smearing and fixing of specimens,
as long as they have been trained and are supervised by their respective NTP medical
technologists/microscopists.

B. Treatment:
1. Aside from clinical findings, treatment of all TB cases shall be based on a reliable diagnostic
technique, namely, DSSM.
2. Domiciliary treatment shall be the preferred mode of care.

C. Patients with the following conditions shall be recommended for hospitalization:

1. Massive hemoptysis;
2. Pleural effusion obliterating more than one-half of a lung field;
3. miliary TB;
4. TB meningitis;
5. TB pneumonia; and
6. Those requiring surgical intervention or with complications.

D. All patients undergoing treatment shall be supervised (DOT). No patient shall initiate
treatment unless the patient and DOTS facility staff have agreed upon a case holding
mechanism for treatment compliance.

E. The national and local government units shall ensure provision of drugs to all smear-positive
TB cases.

Two formulation of anti TB drugs:

1. Fixed-dose combination (FDCs) - two or more first-line anti TB drugs are combined in one
tablet. (There are 2,3, or 4-drug fixed-dose combinations).
Antibiotic taken involved five major drugs:
 Isoniazid or INH (H)
 Rifampicin (R
 Pyrazinamide or PZA (Z)
 Ethambutol (E)
 Streptomycin (S)
2. Single drug formulation (SDF) - each drug is prepared individually.
INH, Ethambutol, and Pyrazinamide are in tablet form while Rifampicin is in capsule form.

F. Quality of FDCs must be ensured. FDCs must be ordered from a source with a track record of
producing FDCs according to WHO-prescribed strength and standard of quality.

G. Treatment shall be based on recommended category of treatment regimen

Recommended Category of Treatment 6-4-22

Treatment Regimen
Category Types of TB patients Intensive Maintenance phase
phase
I  new smear-positive PTB (phlegm will be
tested) HRZE HR
 New smear-negative PTB with extensive (2months) (4 months)
parenchymal lesions on chest x-ray
 Extrapulmonary TB
II  Treatment failure (patient while on treatment,
is sputum smear-positive at 5 months or later
during the course of treatment) HRZES HRE
 Relapse (patient previously treated for TB, (2 months) (5 months)
who has been declared cured or treatment +
completed, and is diagnosed with HRZE
bacteriologically positive TB) (1 month)
 Return after default (RAD) (patient who
returns to treatment with positive
bacteriology, following interruption of
treatment for 2 months or more)
III  New smear-negative PTB with minimal
parenchymal lesions on chest x-ray HRZE HR
(2 months) (4 months)
IV  Chronic (still smear-positive after supervised Second- line generation anti-biotics
retreatment) based on results of culture and sensitivity
test

Dosage per category of Treatment regimen:

A. Fixed-Dose Formulation (FDC)
 the number of tablets of FDCs per patient will depend on the body weight.
 All patients must be weighed (using kilogram as a unit) before treatment is started

Treatment Regimen for Categories I and III: 2 HRZE/ 4 HR (FDC)

Body Weight (kg) No. Of Tablets per day No. Of Tablets per day
 Intensive Phase Continuation Phase
(2 months) (4 months)
FDC - A (HRZE) FDC - B (HR)
30-37 2 2
38-54 3 3
55-70 4 4
> 70 5 5

Treatment Regimen for category II : 2 HRZES/HRZE/5 HRE (FDC)

Intensive Phase Continuation Phase
Body Weight First two months Third Month FDC-B E
(kg) FDC-A Streptomycin FDC-A (HRZE) (HR) (400 mg)
(HRZE)
30-37 2 0.75 g 2 2 1
38-54 3 0.75 g 3 3 2
55-70 4 0.75 g 4 4 3
>70 5 0.75 g 5 5 4

B. Single Drug Formulation (SDF)

 Simply add one tablet of INH (100mg), PZA (500mg), and ethambutol (400mg) each for the
patient weighing more than 50 kg before treatment initiation.
 Modify drug dosage within acceptable limits according to patient’s body weight,
particularly those weighing less than 30 kg at the same time of diagnosis.
Treatment Guidelines:
 All TB cases must be treated for free, on ambulatory and domiciliary (home) basis, except
those with acute complications and emergencies.
 All sputum positive and cavitary cases shall be given priority for short course chemotherapy
or SCC (combo pack multi-drug therapy) for 6 months
 Standard Regimen or SR (isoniazid and streptomycin sulphate) for a year or intermittent
SCC for 6 months shall be given to all infiltrative but sputum negative.

“Tutok-Gamutan” /DOTS
There are four elements for DOTS that need to be fulfilled.
1. Political commitment
2. Quality sputum microscopy for diagnosis
3. Regular supply of anti-TB drugs
4. Standardized recording and reporting of TB data.

According to the WHO Report on the TB Epidemic (1997):

 DOTS cure TB patients and it can produce cure rates as high as 95% even in the poorest
countries.
 DOTS prevent new infections among children and adults
 DOTS can stop resistance to anti-TB drugs
 DOTS is cost-effective.

DOTS services are available in the Rural Health Unit, city health centers and government
hospitals around the country.

Management of children with TB

1. Prevention
 In accordance with the policies and procedures of the Expanded Program on Immunization,
BCG vaccination shall be given to all infants.
 BCG vaccine is moderately effective.
 It has efficacy of 50% against any TB disease, 64% against TB meningitis and 71% against
death from TB.
2. Case finding
a) Cases of TB in children are reported and identified in two instances:
 The patient sought consultation, was screened and was found to have signs and
symptoms of TB.
 The patient was reported to have been exposed to an adult TB patient.
b) All TB symptomatic children 0-9 years old, except sputum positive child shall be subjected
to tuberculin testing.
 Only trained Public Health Nurse or the main health center midwife trained as
alternate shall do tuberculin testing and reading.
 Tuberculin testing and reading shall be conducted once a week either on Monday or
Tuesday. Ten children shall be gathered for testing to avoid wastage.
c) A patient shall be suspected as having TB and will be considered as a TB symptomatic if
with any three of the following signs and symptoms:
 Cough/wheezing of two weeks or more
 Unexplained fever of two weeks or more
 Loss of appetite/loss of weight/failure to gain weight
 Failure to respond to 2 weeks of appropriate antibiotic therapy for lower respiratory
tract infection
 Failure to regain previous state of health 2 weeks after a viral infection or exanthem
(eg: measles)
d) A child shall be clinically diagnosed or confirmed of having TB if he has any of the following
conditions:
 Positive history of exposure to an adult/adolescent TB case
 Presence of signs and symptoms suggestive of TB
 Positive Tuberculin test
 Abnormal chest radiograph suggestive of TB
 Laboratory findings suggestive or indicative of TB (histological, cytological, biochemical,
immunological and/or molecular). However, bacteriological demonstration of TB bacilli
in the smear/culture makes a diagnosis of TB in children.

e) For children with exposure to TB

  A child had exposure to an adult TB patient (who is registered in the TB register)
shall undergo physical examination and tuberculin testing.
 A child with productive cough shall be referred for sputum examination. If the
sputum smear of the child is found positive, treatment shall be started
immediately. Tuberculin testing shall no longer be performed.
 Children without signs and symptoms of TB but with positive tuberculin test, and
those with symptoms but with negative tuberculin test shall be referred for chest
x-ray examination.
f) For children with signs and symptoms of TB
 A child with symptoms and with either known or unknown exposure to a TB case
shall be referred for Tuberculin test. (those with unknown exposure, the suspected
adult source shall be advice to undergo work-up following the NTP guidelines for
adults.
 Children with known contact but with negative Tuberculin test and those with
unknown contact but with positive Tuberculin test shall be referred for chest x-ray
examination.
 For children with negative x-ray, tuberculin test shall be repeated after three
months.
 Chemoprophylaxis of INH for three months shall be given to children less than five
years old with negative chest x-ray; after which, Tuberculin test shall be repeated.
However, chemoprophylaxis shall only be followed if adequate resources are
available.

3. Caseholding Treatment:
a) Caseholding mechanism

 Directly observed of treatment will still be followed just like in adults. Treatment partner
could either be the health worker, any member of the community such as the barangay
health worker, or local government official. Family members could also be treatment
partners.
b) Treatment
 Short course regimen with at least 3 anti-TB drugs for 2 months during the intensive phase
and 2 anti-TB drugs for 4 months during the continuation phase shall be the mode of
treatment for pulmonary TB cases.
 For extra-pulmonary TB cases, treatment regimen is composed of 4 anti-TB drugs for 2
months during the intensive phase and 2 anti-TB drugs for 10 months during the
continuation phase.
 Domiciliary treatment shall be the preferred mode of care
 All diagnosed TB case shall be treated based on the following regimen and the dose shall be
adjusted to the weight of the child. While on treatment, the dose shall be adjusted based
on the follow-up examination weight of the child.

Mantoux test is one of the three types of Tuberculin test

 Is an intradermal injection of a purified protein derivative
 Read in 48-72 hours after administration
 An induration measuring 5-9 mm - generally due to a cross reaction to other mycobacterial
infections.
 10 mm or more is a positive reaction
 30 mm - suggestive of a secondary infection especially if accompanied by erythema.

Treatment Regimen
1. Pulmonary TB
Drugs Daily Dose (mg/kg body Duration
weight)
Intensive Phase
 Isoniazid 10-15 mg/kg body weight 2 months
 Rifampicin 10-15mg/kg body weight
 Pyrazinamide 20-30mg/kg body weight
Continuation Phase
 Isoniazid 10-15mg/kg body weight 4 months
 Rifampicin 10-15mg/kg body weight

2. Extra-pulmonary TB
Drugs Daily Dose (mg/kg body Duration
weight)
Intensive Phase
 Isoniazid 10-15 mg/kg body weight 2 months
 Rifampicin 10-15mg/kg body weight
 Pyrazinamide 20-30mg/kg body weight
Plus
 Ethambutol or 15-25mg/kg body weight
 Streptomycin 20-30mg/kg body weight
Continuation Phase
 Isoniazid 10-15mg/kg body weight 10 months
 Rifampicin 10-15mg/kg body weight

LEPROSY CONTROL PROGRAM

LEPROSY
 Is an ancient disease and is a leading cause of permanent physical disability among
communicable diseases.
 It is a chronic mildly communicable disease that mainly affects the skin, the peripheral
nerves, the eyes and mucosa of the upper respiratory tract.
Signs and symptoms:
A. Early signs and symptoms B. Late signs and symptoms
 Change in skin color -either reddish or  Loss of eyebrow - madarosis
white  Inability to close eyelids - lagopthalmosh
 Loss of sensation on the skin lesion  Clawing of fingers and toes
  Decrease/loss of sweating and hair  Contractures
growth over the lesion  Sinking of the nose bridge
 Thickened and/ or painful nerves  Enlargement of the breast in males or
 Muscle weakness or paralysis of gynecomastia
extremities
 Pain and redness of the eyes
 Nasal obstruction or bleeding
 Ulcers that do not heal

Infectious agent:
Mycobacterium leprae - an acid fast, rod -shaped bacillus which can be detected by Slit Skin
Smear (SSS)

Method of Transmission:
 Airborne - inhalation of droplet/spray from coughing and sneezing of untreated leprosy
patient
 Prolonged skin-to-skin contact

 Diagnosis of leprosy is currently based on clinical signs and symptoms especially if there is
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 examination is an optional procedure.
 It is done only when clinical diagnosis is doubtful.
 A ready referral facility must be recognized in the conduct of SSS procedures.

Susceptibility : Children especially 12 years and below are more susceptible

Incubation Period: 3-5 years on the average

Prevention:
 Avoidance of prolonged skin-to-skin contact especially with lepromatous case.
 Children should avoid close contact with active, untreated leprosy case
 BCG vaccination
 Good personal hygiene
 Adequate nutrition
 Health education

Management and Treatment

 Ambulatory chemotherapy through use of multi-drug therapy (MDT)
 Domiciliary treatment as embodied in RA 4079 which advocates home treatment.

WHO classification of Leprosy which is the basis of modern management or Multi-Drug

Therapy:
Paucibacillary (tuberculoid and indeterminate)
 non-infectious types
 Duration of treatment - 6 to 9 months

Multibacillary (Lepromatous and borderline)

 Infectious types
 Duration of treatment - 24 to 30 months

Multi-Drug Therapy (MDT) - is the use of 2 or more drugs for the treatment of leprosy.
 It is proven effective cure for leprosy and renders patients non-infectious a week after
starting treatment

Mode of Treatments:
All Paucibacillary (PB) Leprosy Cases:
Drugs/Duration Adult Child (10-14 years)
Rifampicin 600 mg once a month 450 mg once a month
Dapsone 100 mg daily 50 mg daily
Duration of Treatment 6 blister packs to be taken 6 blister packs to be taken
monthly within a maximum monthly within a maximum
period of 9 months period of 9 months
 Adjust dose appropriately for children less than 10 years.
For Example: Rifampicin 300mg and Dapsone 25 mg.
 Patients with single skin lesion and a negative slit skin smear may be treated with a single
dose of the ROM regimen as follows:

Single Dose ROM Adult Child (10-14 years)

Rifampicin 600 mg 300 mg
Ofloxacin 400 mg 200 mg
Minocycline 100 mg 50 mg

For MB Leprosy Case:

All multi-bacillary leprosy cases shall be treated with MB regimen as follows:
Drugs/ Duration Adult Child (10-14 years)
Rifampicin 600 mg once a month 450 mg once a month
Clofazimine 300 mg once a month and 50 mg 150 mg once a month and 50
daily mg every other day
Dapsone 100 mg daily 50 mg daily
Duration of Treatment 12 blister packs to be taken 12 blister packs to be taken
monthly within a maximum period monthly within a maximum
of 18 months of 18 months

 Adjust dose appropriately for children less than 10 years.

 For example: Rifampicin 300 mg, Dapsone 25 mg and Clofazimine 100 mg once a month
 Should the patient fail to complete treatment within the prescribed duration, then said
patient should continue treatment until he/she has consumed 24 MB blister packs

Completion of Treatment
 All patients who have complied with the above mentioned treatment protocols are
considered cured and no longer regarded as a case of leprosy, even if some sequelae of
leprosy remain.

MALARIA CONTROL PROGRAM

Malaria
 Is a vector-borne disease caused by protozoan parasites called Plasmodium
 Usually transmitted through the bite of an infected female Anopheles mosquito.
 May be transmitted through transfusing blood that is positive for malarial parasites, sharing
of IV needles (especially among IV drug users), and via transplacental mechanism (transfer
of malaria parasites forms an infected mother to her unborn child)

Signs and Symptoms:

 Recurrent chills preceded by chills and profuse sweating (triad signs)
 Fever
 Anemia
 Malaise
 Hepatomegaly
 Splenomegaly

Infectious agent: 4 Common species of malaria

 Plasmodium falciparum - 70% of cases (Phil)
 P. Vivax - 30% of cases (Phil) - does not lead to cerebral malaria but it causes relapse if
treatment was not completed.
 P. Malariae - <,1% - if not treated immediately, can lead to severe malaria, such as cerebral
malaria
 P. Ovale
 The severity and characteristic manifestation of the disease are governed by the infecting
species, the magnitude of the parasitemia, the metabolic effects of the parasite, the
cytokines released as a result of the infection.
Mode of Transmission: Vector - female adult Anopheles mosquito)

Life Cycle of the Malaria Parasite:

Sporozoites (from the salivary gland of a female Anopheles mosquito) - are injected under
under skin.

They then travel through the blood stream - to the liver and mature within hepatocytes to
tissue schizonts
Parasites are then released to the bloodstream as merozoites and produce symptomatic
infection as they invade and destroy RBCs (some parasites remain dormant in the liver as
hypnozoites)

Merozoites - mature to the ring, trophozoites and schizont asexual stages (in the bloodstream)

Schizonts lyse invade their host red cells as they mature and release the next generation of
merozoites, which then invade previously uninfected red cells.
 Within the red cells some parasites differentiate to sexual forms (male and female
gametocytes)
 When taken up by a female Anopheles mosquito. The gametocytes mature to male and
female gametes, which produce zygotes
 The zygotes invades the gut of the mosquito and develop into an oocyst.
 Mature oocysts produce sporozoites, which migrate to salivary gland of the mosquito and
repeat the cycle.
 This anopheles mosquito bites from dusk to dawn and it breeds in clear, slow flowing
streams that are found in mountainous/forested areas or in brackish water where salt and
fresh water meet (coastal areas)
 Persons who are living in malaria endemic areas may develop partial immunity to the
disease
 They may not manifest symptoms of malaria but when their blood smear is examined
under the microscope; one can see malaria parasites in his/her blood smear

Early Diagnosis and prompt Treatment

 Early diagnosis - identification of a patient with malaria as soon as he/she is seen, through
clinical and/or microscopic method
 Clinical method - based on the signs and symptoms and history (having visited a malaria-
endemic area
 Microscopic method - based on the examination of the blood smear
 Smear patients- with fever or history of recent fever with one month and are residing or
have stayed in malaria-endemic areas, of clinically diagnosed patients and of patients who
did not respond to appropriate anti-malarial treatment.

Chemoprophylaxis: Chloroquine drug - taken at weekly intervals starting from 1-2 weeks
before entering the endemic area.
Pregnant women - given throughout the duration of pregnancy

Recommended Anti-Malaria Drug

Blood Schizonticides - drug acting on sexual blood stages of the parasites which are responsible
for clinical manifestations
 Chloroquine phosphate 250 mg - all species except p. malariae
 Sulfadoxine 50 mg - for resistant P. falciparum
 Primaquine - for relapse P. vivax and P. ovale
 Pyrimethamine 25 mg/tab
 Quinine sulfate 300 mg/tab
 Tetracycline HCl 250 mg/cap
 Quinidine sulfate 200 mg/durules
Parenteral: Quinine hydrochloride 300 mg/ml, 2 ml; Quinidine glucolate 80 mg (50 mg) 1 vial

Prevention and Control:

a) Chemical methods :
 use of insecticide - treatment of mosquito net
 House spraying - application of insecticide on the indoor surface of the house through
spraying
b) Biological: Stream seeding - involves the construction of bio-ponds for fish propagation
which shall be the responsibility of the LGUs and their corresponding communities.
 The numbers of bio-ponds to be constructed as sources of larvivorous fish, for each
malaria-endemic municipality, will depend on the number of streams to be seeded
with the propagated larvivorous fish
 To be effective, about 2-4 fish per sq. Meter is needed for an immediate impact about
200-400 fish per ha. is needed for a delayed effect.
c) Zooprophylaxis - larvae- eating fish, farm animals should be kept near the house.
d) Environmental methods - cleaning and irrigating canals
e) Screening houses
f) Educational methods
g) Mechanical methods - use of fly swats or traps
h) Universal precaution
i) Screening of blood donors
Other Preventive Measures:
 Wearing of clothes that cover arms and legs in the evening
 Avoiding outdoor night activities, particularly during the vector’s peak biting hours from 9
pm to 3 am
 Using mosquito repellents
 Planting of Neem tree or other herbal plants which are (potential) mosquito repellents as
advocated by the DOH/MCS

SCHISTOSOMIASIS CONTROL PROGRAM

Schistosomiasis (Bilharzias/ Snail Fever)
 Is a parasitic disease common among farmers, fisherman and their families in certain parts
of the Philippines.
 It is caused by blood flukes inhabiting the veins of their vertebral victims transmitted thru
skin penetration causing diarrhea, ascites, hepatosplenomegaly

Causative Agent: cause by a worm - Schistosoma japonicum, S. mansoni, S. haematobium

 The male and female worms always go in pair and live in the blood vessels of the intestines
and liver.
Vector: Oncomelania quadrasi (snail)

Incubation period: 2 months

Mode of Transmission: Vehicle (water), indirect (skin pores)

Laboratory/Diagnostic test: Direct stool examination

 COPT (Cercum Ova Precipetin Test)
 Kato Katz Technique

Signs and Symptoms:

Early S/Ss:
 Rash at site of inoculation
 Bloody, mucoid stools
 Fever, diarrhea, abdominal pain and dysenteric attacks
Late stage manifestations:
 Enlarge liver and spleen
 Weight loss
 Severe liver disease, anemia, jaundice, and ascites

Treatment: Praziquantrel (Biltricide), Oxamniquine for S, mansoni and S. haematobium

Prevention and Control:

 Case Finding: surveillance of the disease
 Health education - encourage use of rubber boots for protection
 Environmental Sanitation - proper disposal of feces
 Snail eradication - use of molluscicides

FILARIASIS CONTROL PROGRAM

Lymphatic Filariasis (Elephantiasis, filaroida infection)
 Is a chronic parasitic infection caused by parasites that live inside the lymphatics
 It is caused by thread-like parasitic filarial worms, which lodge in the nodes and vessels of
the lymphatic system
 The young and adult worms live in the lymphatic vessels and lymph nodes while the
microfilariae are usually found in the blood.
 The life span of the adult parasites is about 10 years (but a 40-year lifespan has been
reported) while the microfilariae live about a year at the most.
 These worms live for about 10 years producing millions of immature microfilariae that
circulate in the blood

Causative Agent: Wuchereria bancrofti, Brugia malayi

Mode of transmission: Bite of mosquiton
Vector: Aedes poecilius, Culex quinquefasciatus
Incubation Period: starts from the entry of the infective larvae to the development of clinical
manifestation is variable.(It ranges from 8-16 months)
Laboratory/Diagnostic test:
Circulating filarial antigen (CFA) - finger prick
 Nocturnal Blood Examination (NBE)- blood are taken from the patient at the patient’s
residence or in the hospital after 8:00 pm
 Immunochromatographic Test (ICT) - rapid assessment method - antigen test that can be
done at anytime
Treatment: Diethylcarbamazine citrate (DEC) or Hetrazan, kills almost all microfilaria and a good
proportion of adult worms. Drug is given to patients with clinical manifestations and/or
microfilariae
Side Effects and contraindications of DEC
 General and local, both with or without fever.
 Most common S/E : abdominal pain, nausea, vomiting, headache, dizziness, fever, and
sometimes rash.
 Some children - may pass out worms in the stool.
 Mild illness should not prevent a person from taking the MDA pills except in case of kidney
or heart failure - avoid
 The systems reactions are manifestations due to host inflammatory responses to parasites
antigens liberated by the rapid death of the microfilariae while the localized adverse
reactions are induced by the death.
 The side effects are transient and may be manage symptomatically.

Mass Treatment Drugs (MDA or Mass Drug Administration) : Distribution to all population.

 Protection can be done by taking the mass treatment drug (MDA) pills that include
Diethylcarbamazine Citrate and Albendazole once annually for five years.
 This combination has filaricidal effects and additional effect on intestinal helminths which
are common among children and adults.
 The drugs should be taken for five consecutive years because it will mean long term
suppression of microfilariae will reduce or prevent transmission.
 People living in an established endemic area from ages 2 years and above must take the
drug except the pregnant, very ill, and the <2 years old.
 Pregnant women - can be given after giving birth. - safe for lactating mothers, but to avoid
any incident that may blamed on the MDA, it is advisable to stop breastfeeding for 72
hours after taking the pills.
 Endemic and infected or not infected with filariasis in established endemic areas
 The dosage is 6 mg/kg body weight taken as single dose per year.

MDA schedule - is set every November of every year as stipulated in the Executive Order 369
signed by the President last October 2004.
 Drug is given by a health staff, personnel sellers, house, or fixed site like health center.
Prevention: Eradication of vectors
Filariasis Control Units
 A National Filariasis Control Program (NFCP) was created in 1963 after a national survey
conducted in 1960 showed 43 provinces endemic for the disease.
 The NFCP spearheads the fight controlling and preventing the disease in the Philippines.
 It was implemented in the field through the three Filariasis Control Units based on Regions
5, 8, and 11

National Filariasis Elimination Program

 The DOH envisions filariasis elimination as a public health problem.
 It is heeding the global call for eliminating of Filariasis as a public health problem
 The National Filariasis Control Program (NFCP) has shifted its program strategies from
control to elimination - now known as the “National Filariasis Elimination Program (NFEP)’.

Transmission and Life Cycle:

 The disease is transmitted when a mosquito bites an infected person, and takes blood
along with the microfilariae.
 These microfilariae develop into the infective stage inside the mosquitoes for about three
weeks and may be transferred into an uninfected individual during subsequent bites,
 These larvae lodge in the lymph vessels and lymph glands and develop into adult male and
female worms.
 These male and female worms copulate and produce millions of microfilariae.
 They circulate in the bloodstream and the cycle continues when another mosquito vector
gets it during blood feeding and the cycle may be repeated.

Asymptomatic stage:
 Characterized by the presence of microfilariae in the peripheral blood.
 No clinical signs and symptoms of the disease
 Some remain asymptomatic for years and in some instances for life
 Others progress to acute and chronic stage
 In most endemic areas like the Philippines, men have higher microfilariae rate than women

Acute Stage: starts when there is already manifestation such as:

 Lymphadenitis (inflammation of the lymph nodes)
 Lymphangitis (inflammation of the lymph vessels)
 In some cases, the male genitalia are affected leading to funiculitis, epididymitis, or orchitis
(redness, painful, and tender scrotum)

Chronic Stage
 Develop 10-15 years from the onset of the first attack
 Immigrants from areas where filariasis is not endemic tend to develop this stage more
often and much sooner (1-2 years) than do the indigenous population of endemic areas

Manifestations:
 The chronic manifestations of filariasis come after the death of the adult parasites,
granulation tissue around the dead parasite results in obstruction of lymphatic channels.
 This produces extensive debilitation and disfigurement resulting in periodic bouts of fever,
enlargement of the extremities and resultant social stigma and extensive alienation of the
affected individual.
Chronic signs and symptom:
 Hydrocele (swelling of the scrotum)
 Lymphedema (temporary swelling of the upper and lower extremities)
 Elephantiasis (enlargement and thickening of the skin of the lower and/or upper
extremities, scrotum, breast)

Diagnosis:
 Physical Examination
 History taking
 Observation of the major and minor signs and symptoms

NATIONAL RABIES PREVENTION AND CONTROL PROGRAM

Rabies (Hydrophobia or Lyssa)

 Is an acute viral encephalomyelitis caused by the rabies virus, a rhabdovirus of the genus
lyssavirus.
 It is fatal once signs and symptoms appear.
Two Kinds:
1. Urban or canine rabies is transmitted by dogs
2. Sylvatic rabies is a disease of wild animals and bats which sometime spread to dogs, cats,
and livestock.

Mode of Transmission:
 usually by bites of a rabid animal whose saliva has the virus.
 Virus may be introduced into a scratch or in fresh breaks in the skin (very rare)
 Transmission from mam to man is possible.
 Airborne spread in a cave with millions of bats have occurred, although rarely.
 Organ transplant (corneal) taken from person dying of diagnosed central nervous system
disease have resulted in rabies in the recipients.
 Rabies is not curable - once signs of brain involvement are manifested, the victim dies
within 1-3 days but it is preventable.

Causative agent: Rhabdovirus

Laboratory /Diagnostic test: Postmortem direct fluorescent antibody staining test

Incubation Period:
 2-8 weeks
 It can be as long as a year or several years depending on the severity of the wounds, site of
the wound as distance from the brain, amount of virus introduced and protection by
clothing.

Period of communicability
 Dogs and cats - 3 to 10 days before onset of clinical signs (rarely over 3 days) and
throughout the duration of the disease

Susceptibility and resistance:

 All warm-blooded mammals are susceptible
 Natural immunity in man is unknown

Signs and Symptoms:

Dog - at first withdrawn, change in mood, shows nervousness and apprehension, unusual
salivation, paralysis starts on hind legs spreading towards entire body, death.

Human
1) Incubation period – flu-like symptoms
2) Prodromal Stage - headache, pain and numbness sensation at the site of bite, depression,
penile erection or spontaneous ejaculation for males
3) Acute neurologic phase
a) Spastic - anxiety, confusion, insomnia
b) Dementia - intense excitement, difficulty in breathing, swallowing, drooling,
hydrophobia
c) Paralytic - flaccid ascending symmetric paralysis, coma, death

 Without medical intervention, the rabies victim would usually last only for 2 - 6 days or 1-3
days
 Death is often due to respiratory arrest

Management/Prevention:
 Wound must be immediately and thoroughly washed with soap and water. Antiseptic such
as povidone iodine or alcohol may be applied
 Patient may be given antibiotics and anti-tetanus immunization
 Post- exposure treatment is given to persons who are exposed to rabies
 Local wound treatment
 Active immunization (vaccine)
 Passive immunization (administration of rabies immunoglobulin)
 Active immunization or vaccination or vaccination aims to induce the body to develop
antibodies against rabies up to 3 years
 Passive immunization - the process of giving an antibody to persons with category III (with
head and neck bites, multiple single deep bites, contamination of mucous membranes or
thin covering of the eyes, lips and mouth) in order to provide immediate protection against
 rabies which should be administered within the first seven days of active immunization. -
the effect of immunoglobulin is only short term.
 Consult veterinarian or trained personnel to observe your pet for 14 days for signs of rabies
 Be a responsible pet owner

Nursing management:
 Isolate patient
 Encourage family to provide care and company
 Darken room and observe silence
 Give food if patient is hungry
 Keep water out of sight
 Observe universal precaution, which are essentially wearing gloves.
 Wash hands frequently
 Remove oral and nasal secretions
 Dispose contaminated materials
 Perform terminal disinfection

Site Intradermal Regimen - most effective treatment:

Schedule Site and Route Dose
Day 0 Deltoid, ID 2 doses
Day 3 Deltoid, ID 2 doses
Day 7 Deltoid, ID 2 doses
Day 30 Deltoid, ID 2 doses

Multisite Intramuscular Schedule

Schedule Route Dose
Day 0 Deltoid, IM 2 doses
Day 7 Deltoid, IM 1 dose
Day 21 Deltoid, IM 1 dose