THE NURSING PROCESS IN THE CARE OF THE COMMUNITY

The community health nurse's aim is to improve the health status of the community in general. Just as in other fields of
nursing practice, care of the community is undertaken utilizing the nursing process in a cyclical process of assessment,
diagnosis, planning, intervention, and evaluation.

To the nurse, the community is not just the setting or the context for providing community health nursing, it is the focus
of nursing care. To the community health nurse, understanding the meaning of community is a requisite.

To synthesize the definitions in an earlier chapter, a community is a group of people who:

Have common interests or characteristics.

Interact with one another.

Have a sense of unity or belonging.

Function collectively within a defined social structure to address common concerns.

A community may be phenomenological (functional) or geopolitical (territorial). A school is phenomenological, whereas

a barangay is geopolitical, with the latter being locality-based and having a geographic boundary. This chapter focuses
mostly on the geopolitical community.

PRINCIPLES OF COMMUNITY HEALTH NURSING

For the care of the community, the nurse must bear in mind the following principles
adapted from the eight principles of public health nursing.

1. Focus on the community as the unit of care. The nurse's responsibility is to

the community as a whole.
2. Give priority to community needs. The community health nurse has to
"marry" skills in the nursing process with population-focused skills to produce the
greatest benefit for the majority of the community. The nurse uses assessment
tools such as demographics and vital statistics to determine the health needs of
the community as a whole.
3. Work with the community as an equal partner of the health team. Team
approach is most evident in community health work, and, frequently, the nurse
serves as the liaison officer of the health team. It is important to note that the
community itself is a member of the health team. An organized community plays
an important role in this process. Partnership between health workers and the
community from assessment to evaluation is more likely to produce effective and
sustainable results. As in family health care, the principle of mutuality is also
applied in community health care.
4. In selecting appropriate activities, focus on primary prevention.
Emphasis is given on strategies to promote optimal health and prevent disease
and disability. Treatment is a necessary component of programs that control
prevalent communicable diseases, but treatment is by itself a measure to control
the spread of the disease to others. This is termed preventive treatment of
disease.
5. Promote a healthful physical and psychosocial environment. The health
team designs strategies to concentrate on the environmental determinants of
health, such as education, socioeconomic status, physical environment, working
conditions, and social support networks.
6. Reach out to all who may benefit from a specific service. The community
health nurse realizes that members of the community who need a particular
service are the least likely to actively seek for appropriate help. For this reason,
the health team does not wait for people to come to the health facility but goes
on active case-finding and outreach activities.
7. Promote optimum use of resources. Limited health resources are best used
for strategies that will produce long-term effects, taking ethical principles into
consideration. Results of studies on best practices in community health should
be disseminated and utilized where applicable.
8. Collaborate with others working in the community. Health is a product of
multiple determinants. For this reason, the nurse has to work with a variety of
 sectors, including the community itself, in resolving issues that affect health. To
produce the greatest benefit, community health efforts have to be coordinated
not only among the members of the health team but also with other disciplines,
like teachers, social workers, finance, and marketing experts, involved in
community development

CONDITIONS IN THE COMMUNITY AFFECTING HEALTH

A community has three features: people, location, and social system. Factors related to these features affect the
health status of the community.

People

Population variables that affect the health of the community include size, density, composition, rate of growth
or decline, cultural characteristics, mobility, social class, and educational level.

Population size and density influence the number and size of health care institutions. This explains the
concentration of health care institutions in urban areas. Negative effects of overcrowding include: easy spread
of communicable diseases; increased stress among members of the community; rapid degradation of housing
facilities, and water, air, and soil pollution. On the other hand, sparsely populated areas, like rural areas, have
limited resources, resulting in difficulty in providing health services.

Health needs of communities vary because of differences in population composition by age, sex, occupation,
level of education, and other variables. For example, a community with a large number of women of
reproductive age and young children has different needs compared to a community with a large number of
elderly people. Likewise, a community of farmers may present health needs that are not observable in a
community composed largely of professionals.

Rapid growth or decline of a population affects the health of the community. Rapid population growth usually
results from migration of a large number of people into a community, as can be seen in migration from rural
areas to the city. This results in increased demand for services that existing health care institutions may find
hard to cope with. A rapid decline in population may result from disturbances brought about by circumstances
like disasters, political instability, or economic changes, such as closure of an industrial area. Rapid population
decline usually means a decrease in economic activity in the community and lower government revenue. In
turn, this results in a decrease in resources accessible to the community.

Cultural characteristics of the community are mentioned here in reference to whether members of the
community belong to a similar cultural group (cultural homogeneity) or are multicultural. Feeling of
belongingness and participation in community action are more readily achieved in a culturally homogeneous
population, facilitating cohesive action in dealing with a health threat to the community. Providing care to a
multicultural community is more challenging, requiring cultural competence on the part of the nurse and the
other members of the health team.

People move from one place to another for various reasons, such as to start a family, to take a new job, or to
join another family member. Again, the feeling of belongingness and participation in community action are less
likely when a large segment of the community is composed of new or transient residents.

The level of education and social class affect health status because of differences in living conditions and
degree of access to resources and opportunities. In addition, different social classes display distinctive health
problems.

Location

The health of the community is affected by both natural and man-made variables related to location. Natural
factors consist of geographic features, climate, flora, and fauna. Community boundaries, whether the
community is urban or rural, the presence of open spaces, the quality of the soil, air, and water, and the location
of health facilities are influenced by human decisions and behavior.

Geographic features consist of land and water forms that influence food sources and prevalent occupations in
the community. Geography plays an important role in disasters, such as earthquakes, landslides, and floods.

The Philippines has a tropical and maritime climate. Temperature, humidity (i.e., the moisture content of the
atmosphere), and rainfall are the most important elements in the weather and climate of the country. The mean
temperature in the Philippines is 26.6°C, with January being the coolest month and May the warmest. The
country has a relatively high humidity due to the high ambient temperature and the fact that the Philippines is
surrounded by bodies of water. Although distribution varies from one region to another, the country generally
has an abundant rainfall. Based on rainfall distribution, the Philippines has two seasons; the rainy season (tag-
ulan) from June to November and the dry season (tag-araw) from December to May. The dry season is
subdivided further into the cool dry season from December to February and the hot dry season from March to
May.

Climate change, however, has brought about temperature spikes. It has been observed that warming is
experienced most in the northern and southern regions of the country, while Metro Manila has warmed less than
most parts. In addition, the regions that have warmed the most (Northern Luzon and Mindanao) have also dried
up the most. Hot days and hot nights have become more frequent. Extreme weather events have also occurred
more frequently since 1980, including deadly and damaging typhoons, floods, landslides, severe El Nino and
La Nina events, drought, and forest fires.

The effects of climate change on human health are evidenced by seasonal diseases. The incidence of diarrheal
diseases, conjunctivitis (sore eyes), heat stroke, and skin conditions like prickly heat usually goes up during the
hot season. In contrast, the rainy season is accompanied by a rise in the number of cases of respiratory and
vector-borne infections.

Natural disasters are a frequent occurrence in the country. The geographic location of the Philippines makes it
vulnerable to natural hazards such as tropical cyclones called typhoons, extreme rainfall, thunderstorms, and
floods. Also, the country is within the so-called Ring of Fire, which encircles the Pacific Ocean and is known
for frequent earthquakes and volcanic eruptions.

Plant and animal populations have both positive and negative effects on the health of the community. The
Philippines is a rich habitat of plants with medicinal properties, and many plants and animals serve as food
sources. However, some plants may have ill effects as allergens and sources of toxic substances. Animals may
also serve as reservoirs and vectors of infectious diseases and parasites.

Describing a community is incomplete without delineating its boundaries. A clear demarcation of community
boundaries is necessary since they are the basis for determining the catchment area of community health
workers.

The National Statistical Coordination Board (NSCB) of the Philippines has redefined an urban area as a
barangay that has:

1. A population of 5,000 or more.

2. At least one business establishment with a minimum of 100 employees or 5 or more establishments
with a minimum of 10 employees.
3. 5 or more facilities within the 2-km radius from the barangay hall.

All barangays in the National Capital Region are classified as urban. Factors that contribute to health problems
in urban communities include: a higher population density with the resulting congestion; concentrated poverty
and slum formation; and greater exposure to health risks and hazards leading to violence, traffic injuries, and
obesity.

The 2010 Census of Population and Housing showed a population density of 19,137 persons per square
kilometer at the National Capital Region, which is about 62 times the national average of 308 persons per
square kilometer.

Rural areas are characterized by wide-open spaces and low population density, but inequities in resources and
economic opportunities hinder rural development. Health facilities and health workers are concentrated mainly
in urban areas. Also, poverty is more prevalent in rural areas, with almost 80% of the poor in the country
residing in rural areas. This is backed up by other studies. For instance, poverty incidence among children
residing in rural areas is more than twice that of their urban counterparts. Children living in poverty tend to be
malnourished and are vulnerable to abuse. Considerable government resources have been devoted to the
delivery of services to the population who do not have access to health services and education. However, there
are still not enough roads in rural areas, limiting access to health facilities.

Air, water, and soil pollution poses health hazards to the population. Outdoor air pollution is attributed to
transport and manufacturing activities, which occur in concentration in urban areas, especially the National
Capital Region. The use of solid fuel (wood, charcoal, and biomass residues like stalks, leaves, and agricultural
by-products), which leads to indoor pollution, is more prevalent among low-income households in rural areas.
A great portion of water pollution from domestic sources is contributed by the National Capital Region and
Region IV-A (CALABARZON). Soil pollution is mainly attributed to mining, industries, farming, and
household activities. The first three affect rural areas, whereas household activities have a greater effect in
urban areas.

Social System

A social system is the patterned series of interrelationships existing between individuals, groups, and
institutions and forming a coherent whole. Social system components that affect health include the family,
economic, educational, communication, political, legal, religious, recreational, and health systems. While
carrying out several roles simultaneously, an individual serves as a part of several social system components at
the same time. One may be a son or daughter in the family, a nurse employed in a hospital, a church member, a
member of a neighborhood basketball team, and a citizen all at one time.

As in other systems, the composite parts of the social system of the community affect and interact with one
another. During these interactions, patterns and communication transpire, which form the basis of
organizations. Organizations within the social system can be formal or informal. A government agency, a bank,
and a school are examples of formal organizations, whereas neighborhood friends and volunteers in a barangay
clean-up drive are examples of informal organizations. Organizations that have interactions and linkages and
that carry out similar functions form community systems or subsystems. For example, health centers, private
clinics, hospitals, health laboratories, and drugstores are elements of the health system of a community.

Because of the multifactorial nature of health, all the components of the social system of a community influence
its health. In providing care to a community, the nurse has to take into account the totality of its social system.
The health care delivery system, however, is considered of central importance precisely because of its role in
community health promotion and maintenance and risk reduction. In fact, the nurse is a part of this system.
Community diagnosis requires a study of the health care delivery system. For example, the infant mortality rate
in a particular barangay is higher than the national infant mortality rate. In addition to factors attributed to the
characteristics of the people and the location of the community, it is important that the nurse determines how
well the health care system is functioning in relation to the provision of maternal and child services, and to what
degree are services for maternal and child health promotion implemented by the health system at the barangay
level.

CHARACTERISTICS OF A HEALTHY COMMUNITY

A healthy organism has all its body parts contributing to its well-being by carrying out their specific functions.
In the same manner, all systems of a community need to function effectively and work together to maintain the
health of the community. A healthy community has mechanisms that assure all citizens a decent way of life in
all aspects. Certain observable trails allow health workers lo ascertain whether an individual or a family is
healthy. A community, likewise, may be observed for evident trails that indicate its health.

A healthy community is, in fact, the context of health promotion defined in the Ottawa Charter as "the process
of enabling people to increase control over, and to improve, their health." Further, the Charter states, "To reach
a state of complete physical, mental and social well-being, an individual or group must be able to identify and
to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as
a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and
personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of
the health sector but goes beyond healthy life-styles to well-being.“
The Ottawa Charter was one of the documents that paved the way for the Healthy Settings movement. Healthy
Settings initiatives, such as the Healthy Cities movement, have been undertaken in different parts of the world,
A healthy city is one that is continually creating and improving those physical and social environments and
expanding those community resources that enable people to mutually support each other in performing all the
functions of life and developing to their maximum potential. It aims to:

 Achieve a good quality of life.

 Create a health-supportive environment.
 Provide basic sanitation and hygiene needs.
 Supply access to health care. Being a healthy
city does not depend on existing structures, but a
commitment to improve the city environment and create the necessary networks for health.

The Philippines is a member nation of the WHO Western Pacific Region, which has advocated for the Healthy
Cities and Healthy Islands movement, especially because of rapid economic, environmental, and social
changes.

Health is affected by many factors dial cannot be controlled by individuals all by themselves. Effectively
functioning systems within the community go a long way toward health promotion, disease prevention, and
access to resources needed for health. Knowing that a healthy community is essential to health promotion gives
the community health nurses further motivation in their work.

COMMUNITY ASSESSMENT

The data that need to be collected depend on the objectives of community assessment. In general, the nurse
needs to collect data on the three categories of community health determinants; people, place, and social
system.

The community database for Planned Approach to Community Health (PATCH), a community health planning
model based on Green's PRECEDE model, includes quantitative and qualitative data. Since community
participation is a premise of the PATCH process, the community profile is used to ensure representation of all
stakeholders in the building of the PATCH community team. In addition to morbidity and mortality data,
unique health events are also noted. A unique health event or activity in the community is one that has a short-
or long-term impact, which may be positive or negative, on the health of the community. Behavioral data can
help identify the risk factors and the specific population targeted for a particular activity. Exploring community
opinion allows the health worker to appreciate community perceptions of health and quality of life of the
community.

There are several approaches in conducting community assessment. The nurse utilizes the approach that is
most appropriate to the community and the purpose of the assessment.

In a comprehensive needs assessment, the nurse gathers information about the entire community using a
systematic process where data is collected regarding all aspects of the community to be able to identify actual
and potential health problems. Although it requires much time and effort, information gathered through a
comprehensive needs assessment will be most useful, particularly when health assessment of a community is
being done for the first time. Periodic assessment and evaluation of health programs may also require the
application of this approach.

A problem-oriented assessment is 54rticular aspect of health. In this approach, the nurse collects information
with a certain community problem in mind, and then proceeds to gather information from the aggregate
vulnerable to the problem. This approach is workable when the nurse is familiar with the community such as
when a comprehensive community assessment has been previously done. For example, the nurse learns from a
comprehensive assessment that the catchment population has a large proportion of 0- to 5-year-old children.
Knowing that children of this age are susceptible to malnutrition, the nurse decides to conduct a nutritional
assessment, focusing on feeding and dietary patterns of the caregivers of infants and young children.

Deciding on a strategy for community assessment depends on the objective for data gathering, the size and
characteristics of the aggregate, and the resources available to the nurse.

Tools for community assessment

Data sources are generally grouped into primary and secondary data. In community health practice, the
community itself is the primary source of data. Primary data are data that have not been gathered before and
are collected by the nurse through observation (ocular/windshield survey and participant observation), survey,
informant interview, community forum, and focus group discussion. Secondary data are taken from existing
data sources. Going over secondary data first gives the nurse a picture of what is already known about the
population under study, which may facilitate collection of primary data. Secondary data sources consist of vital
registries, health records and reports, disease registries, and publications. Publications include both print and
electronic forms, such as those produced by the Department of Health, Food and Nutrition Research Institute,
and census data published by the National Statistics Office.

Collecting primary data

Observation

Rapid observation of a community may be done through an ocular or windshield survey, either by driving or
riding a vehicle or walking through it. This gives the nurse the chance to observe people as well as take note of
environmental conditions and existing community facilities. When observing the people, the nurse spots for
vulnerable groups: the young, the elderly, and pregnant women, for example. The nurse takes note of the
general appearance of the people, if they appear healthy, well nourished, or the opposite. Walking through a
community allows the nurse to talk with people to find out their perceptions of health and health services.
Environmental conditions, like terrain, general condition of homes and housing density, cleanliness, presence
and type of vegetation, and presence of street animals like cats and dogs, can be observed in an
ocular/windshield survey. Community resources, such as health facilities, barangay halls, schools, places of
worship, open spaces like a plaza and recreational areas like a basketball court, are easily discernible.

Participant observation is a purposeful observation of formal and informal community activities by sharing, if
possible, in the life of the community. This method helps the nurse in determining community values, beliefs,
norms, priorities, concerns, and power or influence structures. Examples of formal community activities are
barangay assemblies and school (parent-teacher) and church meetings. Informal gatherings take place in a
variety of settings in the community, as in sari-sari stores, community recreational areas, or schools. Participant
observation is a technique that suits community organizing and participatory action research.

Survey

Although time consuming and expensive, a survey may be necessary when there is no available information
about the community or specific population group to be studied. A survey is made up of a series of questions
for systematic, collection of information from a sample of individuals or families in a community, and may be
written or oral. It is useful when, for example, the nurse needs information about the municipality, but the
existing information is about the entire province, or findings from a comprehensive assessment show the need
for nutritional assessment of the young children in a particular community.

For a comprehensive needs assessment, data are collected about a random sample of the population. Purposive
sampling is indicated in a problem-oriented assessment where the sample population consists of the population
susceptible to the problem being studied. In nutritional assessment, for example, families with young children
are chosen as sources of information since they are most susceptible to malnutrition.

In addition, a survey is also appropriate for determining community attitudes, knowledge, health behaviors,
and perceptions of health and health services. It is used by the nurse in identifying patterns of utilization of
health services (Maurer and Smith, 2009). A survey is also an opportunity for making the members of the
community more aware of community problems and their effects and more conscious of their capacity to
influence decision making about health policies and plans, giving them a sense of empowerment.
Informant interview

Informant interviews are purposeful talks with either key informants or ordinary members of the
community. Key informants consist of formal and informal community leaders or persons of position and
influence, such as leaders in local government, schools, and business. The interview may be structured where
the nurse directs the talk based on an interview guide, or it may be unstructured where the informant guides the
talk. Used with skill, informant interviews can give the nurse valuable information on community perceptions
about health and health care.

Community forum

A community forum is an open meeting of the members of the community. Pulong-pulong sa barangay is a
good example of a community forum. It does not only give the nurse information on community perceptions
on needs, health, and health care, but it is also an effective tool in providing the people with a medium for
expressing their views and developing their capacity to influence decision makers. If initiated by the nurse, the
forum is set in coordination with the leaders of the community, such as the barangay leaders or other informal
leaders.

Besides data gathering, the community forum may also be used as a venue for informing the people about
secondary data, for data validation, and for getting feedback from the people themselves about previously
gathered data.

Focus group

A focus group differs from a community forum in the sense that the focus group is made up of a much smaller
group, usually 6-12 members only. Also, its membership is more homogeneous, that is, persons with similar
sociocultural or health conditions. If used properly, this method is effective in the assessment of health needs
of specific groups in the community. A good example is a focus group of first-time pregnant women.

Secondary data sources

Registry of vital events

Act 3753 (Civil Registration Law, Philippine Legislature), enacted in 1930, established the civil registry
system in the Philippines and requires the registration of vital events, such as births, marriages, and deaths.
R.A. 7160 (Local Government Code) assigned the function of civil registration to local governments and
mandated the appointment of Local (city/ municipal) Civil Registrars. The NSO serves as the central repository
of civil registries and the NSO Administrator and the Civil Registrar General of the Philippines.

Reliable civil registration and vital statistics provide a realistic basis for program planning and implementation.
The birth and death registries are of particular importance to the nurse, since they are sources of fertility and
mortality data. The need for information dissemination on registration, especially among the Muslim
population and indigenous cultural communities, has been noted. The low compliance rate to registration
requirements among certain Filipino populations has been attributed to funeral rites, customs, and practices
distinct to particular cultural groups. The nurse is in a position to increase people's awareness on civil
registration and guide them through the process.

In facility-based births, the facility administrator shall be responsible for the registration of the event. The
physician, nurse, midwife, or anybody who attended the delivery has the responsibility for registering births
that occur outside a facility. Either parent may also register the birth. The birth of a child should be registered
within 30 days from the occurrence of the birth at the Local Civil Registry Office of city or municipality where
the birth occurred.

Presidential Decree 856 (Sanitation Code-Office of the President, Republic of the Philippines, 1975) requires a
death certificate before burial of the deceased. The physician who last attended the deceased shall be
responsible for preparing the death certificate, certifying the cause of death, and forwarding the death
certificate to the health officer within 48 hours. If death occurred without medical attention, the nearest relative
or any person who has knowledge of the death shall report to the health officer within 48 hours. The health
officer then certifies the cause of the death and directs its registration. In the absence of a health officer, the
death should be reported to the mayor, municipal secretary, or any member of the Sangguniang Bayan, who
shall issue the death certificate for purposes of burial. Registration of death shall be made within 30 days from
the occurrence of death at the Local Civil Registry Office of the city or municipality where the birth occurred.
Fetal deaths are registered following the same process.

Health records and reports

As specified by Executive Order No. 352 (Office of the President, Republic of the Philippines, 1996), the Field
Health Service Information System (FHSIS) is the official recording and reporting system of the Department
of Health and is used by the NSCB to generate health statistics. The FHSIS is an essential tool in monitoring
the health status of the population at different levels. It is therefore a basis for (1) priority setting by local
governments, (2) planning and decision making at different levels (barangay, municipality, district, provincial,
and national), and (3) monitoring and evaluating health program implementation. Detection of unusual
occurrence of disease is facilitated. It also provides a standardized, facility-level database for more in-depth
studies.

The FHSIS is composed of recording and reporting tools. Records are facility-based, that is, they are kept at
the Barangay Health Station (BUS) or at the Rural Health Unit (RHU) or health center and contain a day-to-
day account of the activities of health workers. Services delivered to clients are the basis of the data entered in
the records. Records serve as the basis of reports. Reports consist of summary data that are transmitted or
submitted monthly, quarterly, and annually to a higher level, that is, from the BUS to the RHU or health center,
to the Provincial Health Office, and finally to the regional level.

The FHSIS Manual of Operations lists and describes the following recording tools:

 The Individual Treatment Record (ITR) is the building block of the FHSIS. The record contains the
date, name, address of patient, presenting symptoms or complaint of the patient on consultation, and
the diagnosis (if available), treatment, and date of treatment. ITRs are maintained at the facility on all
patients seen. Health workers are advised not to rely on client-maintained records, like the home-
based record.
 Target Client Lists (TCLs) are the second building block of the FHSIS. These service records have the
following purposes:

a. service delivery since midwives and nurses use TCLs to monitor target or eligible
populations for particular health services.
b. To facilitate monitoring and supervision of service delivery activities.
c. To report services delivered, thus reducing the need to refer back to the ITRs to accomplish
reporting,
d. To provide a clinic-level database that can be accessed for further studies,

 The following are the TCLs maintained in RHUs and health centers:

b.
a. TCL for Prenatal Care.
b. TCL for Postpartum Care.
c. TCL of Under 1 -Year-Old Children.
d. TCL for Family Planning
e. TCL for Sick Children.
f. National Tuberculosis Program TB Register.
g. National Leprosy Control Program Central Registration Form.

 The Summary Table is accomplished by the midwife. It is a 12-column table in which columns
correspond to the 12 months of the year. This record is kept at the BHS and has two components:
Health Program Accomplishment and Morbidity/ Diseases. 'The Summary Table' is supposed to be
updated on a monthly basis. The Health Program Accomplishment provides the midwife with a tool
for assessment of accomplishments and a ready source for reports. The monthly summary of
 morbidity gives information on the monthly trend of diseases and serves as a source for the 10
leading causes of morbidity in the municipality/city. The Summary Table is also a source of data for
any survey or research.
 The Monthly Consolidation Table (MCT) is accomplished by the nurse based on the Summary Table. It
serves as the source document for the Quarterly Form and the Output 'Fable of the RHU or health
center.

The reporting forms, as enumerated in the FHSIS Manual of Operations, are the following:

1. Monthly Forms are regularly prepared by the midwife and submitted to the nurse, who then
uses the data to prepare the Quarterly Forms.

a. Program Report (M1) contains indicators categorized as maternal care, child care,
family planning, and disease control. The midwife copies the data from the
Summary Table.
b. Morbidity Report (M2) contains a list of all cases of disease by age and sex.

2. Quarterly Forms are usually prepared by the nurse. There should only be one Quarterly Form
for the municipality/city. In municipalities/cities with two or more RHUs or health centers,
consolidation is done under the direction of the Municipal/City Health Officer. Quarterly
Forms are submitted to the Provincial Health Office.

a. Program Report (Q1) contains the 3-month total of indicators categorized as

maternal care, family planning, child care, dental health, and disease control.
b. Morbidity Report (Q2) is a 3-month consolidation of Morbidity Report (M2).

3. Annual Forms

a. A-BHS is a report by the midwife that contains demographic, environmental, and

natality data.
b. Annual Form 1 (A-1) is prepared by the nurse and is the report of the RHU or
health center. It contains demographic and environmental data, and data on natality
and mortality for the entire year.
c. Annual Form 2 (A-2), prepared by the nurse, is the yearly morbidity report by age
and sex.
d. Annual Form 3 (A-3), also prepared by the nurse, is the yearly report of all deaths
(mortality) by age and sex.

Disease registries

A disease registry is a listing of persons diagnosed with a specific type of disease in a defined population. Data
collected through disease registries serve as basis for monitoring, decision making, and program management.
The Department of Health has developed and maintained registries for HIV/AIDS and chronic
noncommunicable diseases, particularly cancer, diabetes mellitus, chronic obstructive pulmonary disease, and
stroke. The Renal Disease Control Program manages the Philippine Renal Disease Registry.

Census data

A census is a periodic governmental enumeration of the population. Batas Pambansa Blg. 72 provides for a
national census of population and other related data in the Philippines every 10 years.

The Philippine Statistical System (PSS) provides statistical information and services to the public. The NSCB
is the policy-making and coordinating body of the PSS, whereas the NSO is the PSS arm that generates
general-purpose statistics: population, employment, prices, and family income/expenditures.
During a census, people may be assigned to a locality by de jure or de facto method. De jure assignment is
based on the legally established place of residence of people, whereas de facto is according to the actual
physical location of people.

The NSO conducts the national census using the de jure method. The census population consists of Filipino
nationals, to include those residing in and out of the Philippines, and nationals of other countries having their
usual residence in the Philippines. Demographic characteristics, household size, and data on fertility and
mortality are some of the census information that the nurse can utilize for needs assessment.

Methods to present community data

Community data are presented to the health team and the members of the community for the following
purposes:

 To inform the health team and members of the community of existing health and health-related
conditions in the community in an easily understandable manner.
 To make members of the community appreciate the significance and relevance of health information to
their lives.
 To solicit broader support and participation in the community health process.
 To validate findings.
 To allow for a wider perspective in the analysis of data.
 To provide a basis for better decision making.

Depending on the context and the purpose of the presentation, community data may be presented as text, in
tables, or in pictorial form such as maps and graphs. Maps can be used to show differences or similarities
across geographic areas. For example, barangays may be color coded in a municipality map to show
immunization rates of infants. In contrast, numeric data are usually more clearly presented through tables and
graphs or charts

COMMUNITY DIAGNOSIS

Community diagnosis is the process of determining the health status of the community
and the factors responsible for it. The term is applied both to the process of
determination and to its findings. It is a quantitative and qualitative description of the
health of citizens and the factors that influence their health. Community diagnosis allows
identification of problems and areas of improvement, thereby stimulating action.

In this phase, the health worker makes a judgment about the community's health status,
resources, and health action potential or the likelihood that the community will act to
meet health needs or resolve health problems. Health promotion and disease prevention
require action on the part of the people themselves. For this reason, triggering
community health action potential is essential if a healthy community is to be attained
and maintained.

There are several schemes that the nurse may choose from in stating community
diagnoses. For example, NANDA (now NANDA International) nursing diagnostic-labels,
although focused more on individual rather than community responses to health
conditions, have included diagnoses at the community level in more recent versions.

This following text explores the format proposed by Shuster and Goeppinger and the
Omaha System for community diagnosis.

Shuster and Goeppinger proposed a practical adaptation of a format of nursing

diagnoses for population groups previously presented by Green and Slade. The three-
part statement consists of:
  The health risk or specific problem to which the community is exposed.
 The specific aggregate or community with whom the nurse will be working to deal
with the risk or problem,
 Related factors that influence how the community will respond to the health risk or
problem.

Related people and environmental factors influence health action potential positively or
negatively. When the people have a pervasive feeling of community (belongingness), a
common perspective of health risks posed by a community condition, and skills to
recognize and deal with a community problem, the potential for community health
action is greatly increased. Environmental factors that exert a positive effect on
community health action potential include accessibility of resources.

The Omaha System

Initially designed for clients in a community setting, the Omaha System has been used
as a framework for the care of individuals, families, and communities by nurses, nursing
educators, physicians, and other health care providers. It is a comprehensive and
research-based classification system for client problems that exists in the public domain,
meaning, it is not held under copyright. The classification system has three components
that are to be used together: a problem classification scheme, an intervention scheme,
and a problem rating scale for outcomes.

The first component of the Omaha classification system is a problem classification

scheme (client assessment), which serves as a guide in collecting, classifying, analyzing,
documenting, and communicating health and health-related needs and strengths. The
scheme provides a model for practice, education, and research. The identified problems
or areas of concern are classified in four levels:

 The first and most general level of classification is composed of four domains:

1. Environmental
2. Psychosocial
3. Physiological
4. Health-related behaviors.

 The second level consists of problems or areas of concern under the four domains.
 In the third level, the problem or area of concern is classified according to two sets
of qualifiers is categorized into health promotion potential problem, or actual
problem. Then the level of clientele (individual, family, or community) involved is
identified.
 The fourth and most specific level is made up of clusters of signs and symptoms
that describe actual problems.

PLANNING COMMUNITY HEALTH INTERVENTIONS

As in other fields of nursing practice, planning for community health interventions is based on findings during
assessment and formulated nursing diagnoses. Planning is a logical process of decision making to determine
which of the identified health concerns requires more immediate consideration (priority setting) and what
actions may be undertaken to achieve goals and objectives. In summary, the planning phase involves priority
setting, formulating goals and objectives, and deciding on community interventions.

Dealing with community health concerns requires the active participation of the people. To foster participation,
the community should have genuine representation in the planning group. Deciding on community
representatives will be facilitated if the community has been organized earlier.

Priority setting

Because the nurse, the health team, and the community do not have the resources to deal with all identified
community health concerns at once, priority setting is done. This step provides the nurse and the health team
with a logical means of establishing priority among the identified health concerns. The World Health
Organization (WHO) has suggested the following criteria (in bold fonts) to decide on a community health
concern for intervention:

 Significance of the problem is based on the number of people in the community affected by the
problem or condition. If the concern is a disease condition, this may be estimated in terms of its
prevalence rate. If the concern is a potential problem, its significance is determined by estimating the
number of people at risk of developing the condition.
 The level of community awareness and the priority its members give to the health concern is a major
consideration. Related to the priority that the community gives to the health concern, Shuster and
Goeppingcr also mention community motivation to deal with the condition. When people are aware
of the risk arising from a condition pervasive in the community, assuming that the other factors (like
availability of expertise and resources) that will allow them to deal with the condition are present,
they are likely to have the motivation to deal with the condition and give it priority.
 Ability to reduce risk is related to the availability of expertise among the health team and the
community itself. This criterion also involves the health team's level of influence in decision making
related to actions in resolving the community health concern.
 In determining cost of reducing risk, the nurse has to consider economic, social, and ethical requisites
and consequences of planned action(s).
 Ability to identify the target population for the intervention is a matter of availability of data sources,
such as FHSIS, census, survey reports, and/or case-finding or screening tools.
 Availability of resources to intervene in the reduction of risk entails technological, financial, and other
material resources of the community, the nurse, and the health agency. Accessibility of outside
resources and the link to these resources are taken into account.

For a realistic and useful outcome, the priority-setting process requires the joint effort of the community, the
nurse, and other stakeholders, such as other members of the health team (referred to as "group" herein to
simplify the description of the process). The group defines guidelines for discussion, particularly on the manner
of reconciling differences of opinion. Shuster and Goeppinger suggested a flexible process using the nominal
group technique wherein each group member has an equal voice in decision making, thereby avoiding control
of the process by the more dominant member(s) of the group. This technique is appropriate for brainstorming
and ranking ideas, and when consensus-building is desired over making a choice based on the opinion of the
majority.

The group makes a list of the identified community health problems or conditions. Each of the identified
problems is treated separately according to a set of criteria agreed upon by the group such as those suggested
by the WHO. As suggested by Shuster and Goeppinger, the following steps are carried out:

 From a scale of 1 to 10, 1 being the lowest, the members give each criterion a weight based on their
perception of its degree of importance in solving the problem. For example, each member assigns a
weight to the significance of the problem in response to the question, "How important is significance
of the problem to its solution?"
  From a scale of 1 to 10, 1 being the lowest, each member rates the criteria in terms of the likelihood of
the group being able to influence or change the situation. For example, each member rates
significance of the problem in response to the question, "Can the group influence the significance of
this problem?"
 Collate the weights (from step 1) and ratings (from step 2) made by the members of the group .

TABLE 1:

Assigning criterion weight through nominal group technique. Problem: Risk

of maternal complications leading to maternal mortality in Barangay
Bagong Silang. Question: How important is the criterion in solving the
problem?

Criterion Nurse Midwife BHW Mrs. Mr. Average

J. B. Tan Dionisia Miranda* Peralta" weight
Cruz

Significance 8 10 7 10 6 8
of the
problem

Community 8 8 5 5 5 6
awareness

Ability to 10 10 10 10 10 10
reduce risk

Cost of 8 S 8 8 8 8
reducing risk

Ability to 4 5 6 5 6 5
identify
target
population

Availability 8 8 6 5 8 7
of resources

TABLE 2:

Criterion rating through nominal group technique. Problem: Risk of

maternal complications leading to maternal mortality in Barangay Bagong
Silang. Question: Can the group influence the situation in relation to the
criteria?

Criterion Nurse Midwife BHW Mrs. Mr. Average

J. B. Tan Dionisia Miranda* Peralta* weight
Cruz

Significance 6 8 4 6 6 6
of the
problem

Community 10 10 10 5 5 8
awareness

Ability to 6 6 6 6 8 6
reduce risk
 Criterion rating through nominal group technique. Problem: Risk of
maternal complications leading to maternal mortality in Barangay Bagong
Silang. Question: Can the group influence the situation in relation to the
criteria?

Cost of 6 6 6 4 4 5
reducing risk

Ability to 10 10 10 8 6 9
identify
target
population

Availability 4 4 3 2 2 3
of resources
 Compute the total priority score of the problem by multiplying collated weight and rating of each
criterion.
 The priority score of the problem is calculated by adding the products obtained in step 4.

TABLE 3:

Computation of problem priority score. Problem: Risk of maternal

complications leading to maternal mortality in Barangay Bagong Silang

Criterion Criterion Criterion rating Problem score

weight (1-10) (1-10) (weight x rating)

Significance of the 8 6 48
problem

Community awareness 6 8 48

Ability to reduce risk 10 6 60

Cost of reducing risk 8 5 40

Ability to identify 5 9 45
target population

Availability of 7 3 21
resources

Total priority score of 262

problem
After repeating the process on all identified health problems, compare the total priority scores of the problems.
The problem with the highest total priority score is assigned top priority, the next highest is assigned second
priority, and so on.

Formulating goals and objectives

As in family health nursing, goals are the desired outcomes at the end of interventions, whereas objectives are
the short-term changes in the community that are observed as the health team and the community work towards
the attainment of goals. Objectives serve as instructions, defining what should be detected in the community as
interventions are being implemented. Just like any other community endeavor, attaining goals and objectives is
more likely if the community has participated in the process and these have been mutually agreed upon.
Specific, measurable, attainable, relevant, and time-bound (SMART) objectives provide a solid basis for
monitoring and evaluation.
Deciding on community interventions

Because of their inherent differences, what may work for one community may not be effective in another. The
group analyzes the reasons for people's health behavior and directs strategies to respond to the underlying
causes. For example, reasons for preference of home delivery over facility-based delivery should be identified.
If the majority of the women would choose to have a home delivery because of cost or lack of access of
birthing facilities, strategies should then be focused on improving facility-based services. But if the primary
reason is sociocultural, the planning team may opt to concentrate on providing opportunities for skills
development of traditional birth attendants and/or exerting effort to gain the trust and confidence of the women
and their families. In the process of developing the plan, the group takes into consideration the demographic,
psychological, social, cultural, and economic characteristics of the target population on one hand and the
available health resources on the other hand

IMPLEMENTING THE COMMUNITY HEALTH INTERVENTIONS

Often referred to as the action phase, implementation is the most exciting phase for most health workers. Aside
from being able to deal with the recognized priority health concern, the entire process is intended to enhance
the community's capability in dealing with common health conditions/problems. The nurse's role therefore may
be to facilitate the process rather than directly implement the planned interventions. Implementation also
entails coordination of the plan with the community and the other members of the health team. This requires a
common understanding of the goals, objectives, and planned interventions among the members of the
implementing group. Collaboration with other sectors such as the local government and other agencies may
also be necessary

EVALUATION OF COMMUNITY HEALTH INTERVENTIONS

Evaluation approaches may be directed towards structure, process, and/or outcome. Structure
evaluation involves looking into the manpower and physical resources of the agency responsible for
community health interventions. Process evaluationis examining the manner by which assessment, diagnosis,
planning, implementation, and evaluation were undertaken. Outcome evaluation is determining the degree of
attainment of goals and objectives.

Ongoing evaluation or monitoring is done during implementation to provide feedback on compliance to the
plan as well as on need for changes in the plan to improve the process and outcomes of interventions.

Standards of evaluation

The bases for a good evaluation are its utility, feasibility, propriety, and accuracy.

Utility is the value of the evaluation in terms of usefulness of results. The evaluation of community health
interventions will be of great use to the community health group (the nurse, other members of the health team,
and the community representatives), as it helps the group gain insight into strengths and weaknesses of the
plan and the manner of its implementation. This will provide a basis for utilizing the community health process
in dealing with other community concerns in the future. Communicated to the local government (barangay and
municipal/city) authorities, the evaluation results may also promote policy changes, such as in budgetary
allocations. Finally, the community itself will be the end-beneficiary of evaluation. Disseminating results of
the evaluation will allow the community to identify barriers and, in the future, think of strategies to overcome
or minimize these barriers. Knowing evaluation findings will build up the community's experience and
develop confidence in their own capability to deal with community concerns. Evaluation will also be better
used if the evaluators are credible and the results are released and disseminated promptly, that is, at the time
when they are needed by the people concerned.

Feasibility answers the question of whether the plan for evaluation is doable or not, considering available
resources. Resources include facilities, time, and expertise for conducting the evaluation. Data gathering for
evaluation should bring about minimal disruption of everyday activities. Feasibility entails anticipation of how
the results of the evaluation will be received by different groups and how to avoid possible misuse of the data
derived from the process. A feasible evaluation plan will yield data worthy of the resources needed to collect
and process them.

Propriety involves ethical and legal matters. Respect for the worth and dignity of the participants in data
collection should be given due consideration. The results of evaluation should be truthfully reported to give
credit where it is due and to show the strengths and weaknesses of the community: strengths to encourage
further growth and weaknesses for remedial action, if possible. Results should be furnished to everyone
entitled to them, especially the community. Finally, transparency and accountability should be observed in all
financial matters related to the community health action.

Accuracy refers to the validity and reliability of the results of evaluation. Accurate evaluation begins with
accurate documentation while the community health process is ongoing. A high degree of validity and
reliability can be achieved by choosing and properly utilizing the right evaluation tools. Review of data
gathered during evaluation accompanied by corrective measures when errors occur increases the level of
accuracy of evaluation.

WHAT IS EPIDEMIOLOGY?

Although the beginnings of epidemiology might have been during the time of
Hippocrates when he explicated that disease could be associated with climate and the
physical environment, it is still a young science that developed rapidly only after Snow's
investigation of the cholera epidemic in London in 1854. Other epidemiologic activities
that followed demonstrated the importance of the field of epidemiology for public health
practice, for instance, the use of census and vital registration data by William Farr to
describe the mortality patterns in population subgroups such as occupational groups,
prisoners, and various age groups; the large-scale epidemiologic studies such as the
Framingham Heart Study that identified the risk factors for coronary heart disease; the
DOH and Hill's study that provided compelling evidence of the role of smoking in the
incidence of lung cancer; and the Salk vaccine field trial that showed the protective
effect of the vaccine against paralytic poliomyelitis.

Etymologically, "epidemiology" originated from the Greek words epi, meaning "upon",
demos, meaning "people," and logos, meaning "study". Several definitions of this field of
study had been formulated but the most encompassing is the definition given by Last
which states that "Epidemiology is the study of the distribution and determinants of
health-related states or events in specified populations, and the application of this study
to the prevention and control of health problems." This field of study makes use of
concepts and methods from numerous other fields such as biology, sociology,
demography, geography, environmental science, and policy analysis and most notably
from statistics.

Practical applications of epidemiology

The practical applications of epidemiology as implied by both the definition of

epidemiology:

1. Assessment of the health status of the community or community diagnosis

2. Elucidation of the natural history of disease
3. Determination of disease causation
4. Prevention and control of disease
5. Monitoring and evaluation of health interventions
6. Provision of evidence for policy formulation
Each of these practical applications is discussed in greater detail in the subsequent
sections, Hopefully, these would make us understand that epidemiology is an important
tool that is applied by the members of the community health management team, which
includes the public health nurse for performing their roles and functions. For instance,
the discussions show how the use of basic epidemiologic techniques by public health
practitioners can aid them rank health problems, identify risk factors for such problems,
design targeted health interventions, and monitor and evaluate such interventions.

ASSESSMENT OF THE HEALTH STATUS OF THE COMMUNITY (COMMUNITY DIAGNOSIS)

Epidemiology is often used to describe the health status of the population through estimation of health
indicators. These are quantitative measures, usually expressed as rates, ratios, or proportions, that describe and
summarize various aspects of the health status of the population. Thus, there are various types of health
indicators depending on the aspect of health that is of interest. Some of these indicators are discussed in greater
detail in the subsequent sections.

Besides serving as tools for assessing the health status of the population or making a situational analysis of a
community), health indicators are also used for:

1. Determining factors that may contribute to causation and control of diseases.

2. Identifying public health problems and needs.
3. Indicating priorities for resource allocation.
4. Monitoring implementation of health programs.
5. Evaluating outcomes of health programs.

Morbidity indicators

Morbidity indicators are generally based on the disease-specific incidence or prevalence for the common and
severe diseases, such as malaria, diarrhea, leprosy, dengue, diabetes, and cardiovascular diseases. With the use
of these indicators, we can partly answer two epidemiologic questions, viz., "What are the health problems in
our area?" and "Flow many cases occur in the area?" Prevalence proportion (P) measures the total number of
existing cases of a disease at a particular point in time divided by the number of people at that point in time.
Thus, if the point in time is the time of examination, then the denominator is the number of people examined.
The point prevalence is estimated by data obtained from cross-sectional studies, more commonly known as
surveys. Prevalence provides an indication of the magnitude of a health problem and is used for projecting the
scope of health services needed by the community.

Prevalence proportion (P) can be calculated by:

P = (Number of existing cases of a disease at a particular point in time / Number of people examined at that
point in time) x F

where F is any number of the base 10 that is used as a multiplier to avoid having decimals as the final value of
the indicator. For prevalence proportion, the most common F used is 100. This makes the interpretation much
easier as it would indicate the percentage of the population afflicted with the disease.

Incidence measures the number of new cases, episodes, or events occurring over a specified period of time,
commonly a year, within a specified population at risk. Incidence is the best indicator of whether a condition is
decreasing, increasing, or remaining static. Hence, it is the best measure to use for evaluating the effectiveness
of health interventions. Estimation of incidence entails the follow-up of a cohort of disease-free people who are
at risk of developing the disease of interest within a specified period of time. Thus, incidence is derived from a
cohort study. There are several concepts that need to be clarified; first is the term cohort, and second, the at-risk
group.

A cohort is a group of people who share a common defining characteristic. For example,

a. The birth cohort of 2012, which consists of individuals born in 2012;

b. A cohort of employees in a particular company who joined the company during the period 2000-
2010;
c. A cohort of males who smoke three packs of cigarettes a day who were recruited into a cohort study
to determine the incidence of lung cancer among smokers.

A group is said to be an "at-risk group" if the members of the group are free of the disease but have the
potential for developing a particular disease within the specified period of time. Thus, if the disease of interest
is cervical cancer, only women (not men) who do not have cervical cancer and have not undergone
hysterectomy are at risk of developing it.

The numerator for calculating incidence is the number of new cases of the event (disease, death, etc.) that
develop during the period of observation. There are two types of incidence measures, cumulative incidence (or
incidence proportion) and incidence density rate. Cumulative incidence (CI) can be derived if there are no
losses to follow-up and the duration of follow-up is the same so that the denominator is the initial size of the
cohort being followed-up. It measures the average risk or probability of developing the disease within a
specified period of time, otherwise known as the risk period. The risk period should always be indicated
because, for example an average risk of 10% of the population developing the disease over a 1-month period
implies a much higher risk than 10% of the population developing the disease over a 5-year period.

CI = (Number of new cases that developed during the period / Number of persons followed-up) x F

The term "attack rate" is often used instead of CI when the risk period for the occurrence of disease is very
short. For instance, if an outbreak of a diarrheal disease occurs within 6-24 hours among people who attended a
party, the outbreak investigation usually determines the attack rate (AR) for each type of food served during the
party through the following formula:

AR = (Number of people who ate the food item and developed diarrhea / Total number of people who ate the
food item (ill + well)) x 100

Especially when the follow-up period is relatively long, some cohort members are usually lost to follow-up due
to death from other causes, out-migration, or refusal to continue their participation in the study. In the event of
losses to follow-up (censoring), incidence density rate (ID) is computed by using the total person-time at risk
for the entire cohort as the denominator. For each individual in the cohort, the time at risk is the duration of
time during which the person under observation remains disease-free. For example, a person who develops the
disease after 2 years contributes 2 person-years to the denominator; one who is lost to follow-up after 6 months
contributes half a year. The denominator for the calculation of incidence rate is the sum of all the disease-free
time contributed by the cohort members during the defined time period of the study. As in CI, the specification
of ID must always include a unit of time (e.g. cases per 100,000 person-years). This morbidity indicator
measures the average instantaneous rate of disease occurrence. If the rate of disease occurrence is low, as with
many chronic diseases, it is also a good estimate of the CI or risk of developing the disease.

ID = (Number of new cases that develop during the period / Sum of person-time at risk) x F

Since it may not be possible to measure disease-free period precisely, the denominator for ID is often calculated
approximately by multiplying the average size of the study population by the length of the study period. This is
reasonably accurate if the size of the population is stable and the incidence rate is low.

ID = (Number of cases during the period / Average population x duration of follow-up) x F

When the Department of Health (DOH) publishes the leading causes of morbidity for a particular year, its basis
for the ranking is usually an approximation of the ID computed from the total number of cases detected by its
surveillance systems (which DOH considers as new cases that developed during the year) divided by the
midyear population or population as of the first day of July (which is considered the average population)
multiplied by one year. This approximation, of course, has limitations because of underreporting of cases and
because not all members of the population may be at risk of developing the disease.

Specific morbidity rates show disease rates in specific population groups such as by age, sex, occupation,
education, exposure to risk factors, place of residence, or combinations of these factors. In fact, disease rates
can also be computed specifically by seasons of the year. Therefore, epidemiologic questions such as, "Who is
affected? Where do they occur? When do they occur or increase?" can be answered by specific morbidity rates.
This description comes under the realm of descriptive epidemiology which is basically orienting a disease as to
time, place, and person characteristics through various study designs including ecologic studies.

As an example, when DOH calculates the age-specific rates of a disease for a given year, it first stratifies the
population into age groups, then the number of new cases of the disease that developed within the year in a
particular age group is divided by the midyear population of that same age group. Thus, the age-specific
morbidity rate for TB, say, is equal to:

(Number of TB cases among those aged 20-24 years / Midyear population aged 20-24 years) x 100,000

Mortality indicators

Because death is the most serious outcome of a morbid episode, mortality statistics provide important
information of the health status of the people in the community. The pattern of causes of death indicate the most
life-threatening diseases that are prevalent in the community, although it fails to detect the nonfatal conditions
which may not be fatal but are nonetheless widespread. The crude death rate (CDR) is defined as the rate with
which mortality occurs in a given population. It is computed as:

CDR = (Number of deaths in a calendar year / midyear population) x 1,000

Factors that affect the level of CDR include the age and sex composition of the population, the adverse
environmental and occupational conditions, and the peace and order conditions of a place. This rate is called
crude rate since the numerator and the denominator pertain to the total population and not to population
subgroups. The rate is thus expressed as the number of deaths per 1,000 population. The general availability of
the data needed for the computation of this rate in most countries allows for international comparisons.
However, caution should be taken for the interpretation of CDR when population structures are not comparable
with respect to factors such as age and sex that influence the risk of dying.

For example, in a particular year, the United States had a CDR of 10 per 1,000 population, whereas the
Philippines had 7 per 1,000. Does this mean that the latter had better health status and/or health care delivery
system since fewer people per 1,000 population were dying? The United States has a bigger proportion of
elderly individuals than the Philippines and therefore its CDR is higher than that of the Philippines. A better
measure for comparison is the age-standardized death rate, but this measure is not discussed in this chapter.

Specific mortality rates, just like the specific morbidity rates, show rates of dying in specific population groups.
A graph of age-specific mortality rates shows a J-shaped curve, which indicates that mortality rates are
relatively high during infancy, after which it declines among children and starts rising among the adults until it
peaks to a very high level among the elderly. Meanwhile, graphs of the sex-and-age-specific mortality rates
portray consistently higher rates among males. However, in some developing countries, the death rates of
females in the reproductive age group tend to be higher than the rates of males of the same age. The general
formula is given by:

Specific mortality rate = (Number of deaths in a specified group in a calendar year / Midyear population of the
same specified group) x F
The cause-of-death rate gives the rate of dying due to specific causes. This is also a crude rate since the
denominator includes the entire population. It can be made specific by relating the deaths from a specific cause
and group to the midyear population of that specified group, for example, one can compute for death rate of
diarrheas among children 1-4 years of age. Factors affecting the cause-of-death rates are the Completeness of
registration of deaths, the composition of the population, and more importantly, accuracy of ascertaining the
cause of death:

Cause-of-death rate = (Number of deaths from a certain cause in a calendar year / Midyear population)x F

Cause-of-death rate identifies the greatest threat to the survival of the people, thereby pointing to the need for
preventing such deaths. This becomes all the more important when effective measures are readily available for
the prevention and control of the leading causes of death. Many infectious diseases, common causes of infant
and maternal mortality, and accidents belong to this category. Furthermore, many countries, including
developing countries like the Philippines, are now contending with chronic noncommunicable diseases as major
causes of death. Such diseases can be reduced by simply adopting healthy lifestyles.

The infant mortality rate (IMR) is defined as the number of deaths of infants under one year of age in a
calendar year per one thousand live births in the same period. It is used as an approximation of the risk of dying
within the first year of life. It should be emphasized, however, that it is not a true measure of risk because not
all infants who the in a calendar year were also born in that year.

IMR = (Deaths under 1 year of age in a calendar year / Number o! live births in the same year) x 1000

The IMR is a good index of the level of health in a community because infants are very sensitive to adverse
environmental conditions. Thus, a high IMR means low levels of health standards that may be secondary to
poor maternal health and child health care, malnutrition, poor environmental sanitation, or deficient health
service delivery. IMR levels of 60 to 150 1,000 live births per thousand are commonly seen in poor
populations; greater than 200 per 1000 live births are indicative of very severe environmental conditions. It is
interesting to note, however, that the IMR can be artificially lowered just by improving the registration of
births.

The neonatal mortality rate and the post neonatal mortality rate add up to the IMR. The reason for such
subdivision is that the causes of neonatal deaths, that is, deaths among infants less than 28 days old, are due
mainly to prenatal or genetic factors, while those in the later months are influenced by environmental and
nutritional factors as well as infections. These indicators are computed as follows:

Neonatal mortality rate = (Number of deaths among those under 28 days of age in a calendar year / Number of
live births in the same year) x 1,000

Postneonatal mortality rate = (Number of deaths among those 28 days to less than 1 year of age in a calendar
year / Number of live births in the same year) x 1,000

A maternal death is defined as a "death of a female from any cause related to or aggravated by pregnancy or its
management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of
termination of pregnancy, irrespective of the duration and the site of the pregnancy". The ideal denominator for
the maternal mortality ratio (MMR) ought to be the number of pregnancies. However, because of the
unavailability of this data, the number of live births is used instead. MMR is a measure of obstetric risk and is
affected by maternal health practices, diagnostic ascertainment, and completeness of registration of births.

MMR = (Number of deaths due to pregnancy, delivery, puerperium in a calendar year / Number of live births
in the same year) x 100

The case fatality rate (CFR) is the proportion of cases that end up fatally. It gives us the risk of dying among
persons afflicted with a particular disease. Hence, it is similar to an incidence proportion because it is also a
measure of average risk. However, while the incidence proportion quantifies the risk of developing a disease
within a specified period of time, case fatality quantifies the risk of dying among those who have the disease.
The magnitude of the CFR depends on the nature of the disease itself, the diagnostic ascertainment, and the
level of reporting in the population. One would expect that the CFR from the hospital statistics will be higher
than that from the community since the hospitalized cases are usually the more severe cases of the disease.

CFR = (Number of deaths from a specified cause / Number of cases of the same disease) x 100

The millennium development goals (MDGs) and their corresponding indicators demonstrate applications of
some of the health indicators taken up earlier in this chapter. These MDGs were consensually agreed upon by
various countries that are under obligation to utilize their resources toward achieving these goals by the year
2015.

Population indicators

Population indicators include not only the population growth indicators (crude birth rate, general fertility rate,
total fertility rate, and annual growth rate) but also other population dynamics (migration) that can affect the
age-sex structure of the population and vice versa. The crude birth rate (CBR) measures how fast people are
added to the population through births. Thus, it is a useful measure of population growth. It is affected by the
fertility, marriage pattern and practices of the place, sex and age composition of a population, and birth
registration practice. The CBR is a crude rate since it is related to the total population including men, children,
and the elderly who are not capable of giving birth. Like the CDR, the CBR is widely used because of the
availability of data which go into its computation. A CBR greater than or equal to 45 out of 1,000 live births
implies high fertility, while a level less than or equal to 20 out of 1,000 live births implies low fertility.

CBR = (Number of registered live births in a year / Midyear population) x 1000

The general fertility rate (GFR) is a more specific rate than the CBR since births are related to the segment of
the population deemed to be capable of giving birth, that is, the women in the reproductive age groups. In some
countries, the reproductive age group for women is defined as 15-49 years of age; the Philippines uses 15-44
years. High and low fertility are indicated by GFR of 200 per 1,000 women and 60 per 1,000 women,
respectively.

GFR = (Number of registered live births in a year / Midyear population of women 15-44 years of age) x 1000

The population pyramid is a graphical representation of the age-sex composition of the population that should
also be examined during the assessment of the health status of the community. The shape of the pyramid
provides insights into the fertility and mortality patterns of the community as well as the most probable health
problems that would likely need health services. The former has a triangular shape which is characteristic of
less-developed countries where a large proportion of the population belongs to the younger age groups. Such a
population pyramid depicts high fertility and a relatively high mortality among the elderly. Socioeconomic
factors primarily poverty, poor environmental conditions, and inadequate health care services such as
immunization leads to the development of infectious diseases that usually occur during childhood. It follows
therefore that countries with triangular pyramids should allocate more resources for health problems of younger
segments of the population. Meanwhile, the pyramid of developed countries like Japan is almost rectangular
indicating that a substantial proportion of the population is elderly due to lower mortality from infectious
diseases and improved access to health care, Thus, the priority of such countries is the prevention and control of
chronic degenerative diseases and the provision of care for older persons.

Sources of data for calculation of health indicators

There are several sources of information for purposes of assessing the health status of the community. Many of
these are lodged primarily in government agencies such as the Department of Health; others are generated by
research institutions, private sector like insurance companies, and so on. Disease notification, disease registry,
surveillance, and downloadable data sets are briefly described subsequently.
Disease notification is an integral part of disease surveillance. In the Philippines, all individuals, health
facilities, both private and government, in all levels of governance (barangay/village, municipal, city,
provincial, regional, and national) are mandated by Act 3573 or the Law on Reporting of Communicable
Diseases to report notifiable diseases (e.g. dengue, rabies, leptospirosis, and human immunodeficiency
virus/acquired immunodeficiency syndrome (HIV/AIDS) to local and national health. Unfortunately, many
people who need services do not have access to health facilities. On the part of the health care providers,
particularly the private practitioners, there is usually minimal vigilance in reporting cases of the notifiable
diseases which leads to gross underreporting and, thence, to a distorted picture of health problems in the
community.

A disease registry is a compilation of information about a particular disease. The aim of disease registry is to
include all cases of the disease in the registry without duplication. Attainment of this aim is dependent on the
cooperation of agencies and health facilities that feed the registry and on a unique patient identifier that will
allow record linkage. In the Philippines, there is a cancer registry that covers Metro Manila and the province of
Rizal and an HIV/AIDS registry that is intended to include all newly detected cases of HIV infection and AIDS
in the Philippines.

Application of epidemiologic principles and methods is essential to ensure that a public health surveillance
system would achieve its primary goal of serving as an early warning system for impending epidemics of
diseases and other public health emergencies. The World Health Organization defines public health surveillance
as "the ongoing, systematic collection, analysis and interpretation of health-related data needed for the
planning, implementation, and evaluation of public health practice." Traditionally, surveillance systems were
developed for monitoring high burden diseases, detecting disease outbreaks that could escalate into epidemic
proportions, and monitoring progress toward attainment of targets for the control, elimination, or eradication of
a specific disease. The new public health paradigms for surveillance advocate inclusion of the detection of
toxins, hazardous chemicals, genetically modified products, and risky behaviors. The Philippine Integrated
Behavioral and Serologic Surveillance (PIBSS) monitors not only seropositivity among most at-risk groups for
HIV infection but also their behaviors that put them at risk for the infection.

Disease surveillance can either be passive or active. A passive surveillance is a system by which public health
staff receives reports from hospitals, clinics, public health units, or other sources. Hence, the count of cases is
expected to be grossly underestimated and the utility of the data may be greatly diminished as it may become
available only when it is no longer needed. In contrast, active surveillance is a system in which public health
staff members actively and regularly contact heath care providers or the population to obtain information about
the disease of interest. This strategy is much more expensive, but it yields more accurate and timely data. This
allows both an early detection of an impending epidemic and a more valid evaluation of the impact of public
health interventions. If the objective is to monitor eradication and elimination programs, it is imperative that
every case be detected. Therefore, a very active surveillance system should be used so that every case that
occurs can be detected.

'The Philippine Integrated Disease Surveillance and Response (PIDSR) integrates health statistics generated
through the major disease surveillance systems in the country, via.:

1. Notifiable Disease Reporting System (NDRS)

2. Field Health Service Information System (FHSIS)
3. National Epidemiology Sentinel Surveillance System (NESSS)
4. Expanded Program on Immunization Surveillance System (EPI Surveillance)
5. HIV-AIDS Registry

The priority diseases, syndromes, and conditions under surveillance because they are either epidemic prone,
targeted for eradication or elimination, or important to public health. Although rabies is still listed by PIDSR as
a disease of public health importance, the Bureau of Animal Industry of the Department of Agriculture is now
aiming for the elimination of rabies as mandated by RA 9482.
In developed countries like the United States, there are several data resources that can be downloaded from the
Internet. For instance, the US Census Bureau Internet site has a data extraction system that allows public access
to data from their census and surveys on income and other population characteristics. In the Philippines, one
may request for data from the National Statistics Office for a fee. However, due to manpower constraints, it
takes a relatively long period of time before one can avail of the data, if at all. Fortunately, the USAID-funded
Demographic and Health Survey that includes many low- and middle-income countries can be downloaded
from the Internet.

Considerations in the analysis and interpretation of health indicators

Because the various sources of data for the estimation of the health indicators that are used for the assessment
of the health status of the community have inherent strengths and limitations, the following points should be
considered when interpreting the health indicators:

1. Is the denominator of the rate the most appropriate one? Preferably, it should be the population in
which the events in the numerator are expected to or could have occurred.
2. Is the numerator an accurate count of the number of events? Inaccuracies can arise due to under
registration, underreporting, or duplication.
3. There should be correspondence in time and geographical location of the events in the numerator and
the population in the denominator.
4. Time specifications are usually on an annual basis. However, special indicators may have other period
specifications and these should be stated.
5. The factor used in the computation of the different rates may be any number of the base 10.

EXPLANATION OF THE NATURAL HISTORY OF DISEASE

The natural history of a disease is its course over time, starting from the
prepathogenesis stage to its termination. While clinical data of patients with various
stages of the disease are usually put together to determine the natural history of a
particular disease, a prospective cohort study could plot it better because of the benefit
of observing the cohort from the time that the members are disease-free to the time
they develop the disease through its termination. The applicable level of prevention that
is administered to the patient is dependent on the stage of the disease when the patient
was diagnosed.

The discovery of AIDS and its etiologic agent, HIV, happened during our lifetime, so it
serves as an excellent case study to demonstrate the role of epidemiology in the
elucidation of the natural history of disease. AIDS came to the fore after the publication
of a case scries describing the clinical features of five young homosexual men in their
30s who were hospitalized due to Pneumocystis carinii pneumonia (PCP).

Earlier, PCP was seen only in older immunocompromised persons. This led to the
generation of at least two hypotheses. First, that the patients were suffering from an
unknown disease that causes suppression of the immune system; and second, that
sexual behavior could increase the risk of the unknown disease.

To test these hypotheses, a prospective cohort study, the Multicenter AIDS Cohort Study
(MACS) was conducted among apparently healthy homosexual and bisexual men. The
study started in 1984 and is still ongoing. Because practically nothing was known yet
about the etiology of this disease, all types of specimens, for example, blood, stool,
urine, saliva, semen, were collected and stored. After the discover.' of laboratory
techniques for identifying HIV, the relevant specimens collected by MACS were tested
which indicated that some participants of the study, while clinically asymptomatic, were
actually infected with HIV. This gave the investigators an opportunity to observe such
patients through time. When anti-retroviral treatment drugs became available, these
patients were treated and it was evident that the treatment could improve the CD4
count of the patients. CD4 cells are white blood cells that fight infection and their count
indicates the stage of HIV infection. Hence, this study has contributed significantly not
only to the elucidation of the natural and treated histories of HIV-1 infection but also to
the understanding of the science of HIV, the AIDS epidemic, and the effects of therapy.
Additionally, the numerous publications generated by MACS served as evidence for the
crafting of public health policy

DETERMINATION OF DISEASE CAUSATION

Interventions that target the causes of a public health problem have greater chances of having positive
outcomes, hence the need to determine the etiology of the disease. This implies that answering the
epidemiologic questions, "What factors contribute to disease causation? Why does disease occur?" based on
valid evidence will contribute to the success of health interventions, A review of the theoretical and research
literature and an understanding of the natural history of the disease will contribute to the development of an
epidemiologic disease model representing the factors that influence disease causation. An epidemiologic
approach assumes a causal path and posits that changing or breaking a link in that causal path can either
prevent the occurrence of the disease or alter its course, so that the more serious sequelae can be avoided. As
demonstrated in the previous section, progression of HIV infection to AIDS can be deterred by interventions
that increase CD4 or by prophylaxis against PCP.

Further, after the London cholera outbreak investigation uncovered that cases were more likely to have used
water supplied by the Broad Street pump, this source of water was sealed and closed. The epidemic practically
halted after this intervention and affirmed that breaking the chain of the causal path prevents incidence of the
disease, despite the fact that the etiologic agent, Vibrio cholera, has not yet been discovered at that time. In
more modern times, epidemiologists sometimes conduct case-control studies to investigate outbreaks similar to
the cholera outbreak in London. Examination of the complex interrelationships of multiple (actors in disease
causation through case-control, cohort, quasi-experimental, and experimental studies is a function of analytic
epidemiology.

Models of disease causation

The multiple theory of disease causation has been depicted simply by the epidemiologic triad or triangle
model with the use of either one of two schematic presentations. Initially, the model was applied for infectious
diseases, so the agent referred to parasites, protozoans, bacteria, viruses, and other microbes. Later, as applied
to noncommunicable diseases, the agent was expanded to include nutritive factors, chemical agents, and
physical agents. The model suggests that the agent and the susceptible human host are interacting freely in a
common (physical, biologic, socioeconomic) environment. For as long as the balance is maintained or is tilted
in favor of the host (because of good nutritional status and high levels of immunity), disease does not occur.
However, when the balance is tilted in favor of the agent (through increased dosage, virulence, pathogenicity of
the agent), disease eventually occurs. Sometimes, environmental elements such as climate can also tilt the
balance in favor of the agent. For example, during the rainy season, healthy school children who get soaked in
the rain might become less resistant against pathogens that cause acute respiratory illnesses. In addition to
lower resistance, these children would also be exposed to a higher dosage of the pathogen since more people
serve as sources of infection during the rainy season. Thus, the initially healthy school children would tend to
have a higher risk of developing acute respiratory illnesses. Lilienfeld and Stoley provide an extensive listing
of the agent, host, and environmental factors that may influence disease occurrence in human populations.

Although the paradigm espoused by the wheel model of disease causation is basically the same as that of the
triad, the former gives emphasis on the role of the genetic makeup of the host that is presented as the inner core
of the wheel's hub. The outer core of the hub includes host characteristics like sex, age, socioeconomic status,
and behaviors. The rim or the outer edge represents the biologic, physical, and chemical environment. In
contrast to the triad, the infectious agent for communicable diseases is considered a part of the biologic
environment along with vectors, animal reservoir of infection, flora, and fauna.
When noncommunicable diseases became increasingly important as public health problems, the web model of
disease causation was deemed applicable to capture the complex interrelationships of numerous factors; some
of which increase the risk of disease, while others protect against the disease. The interconnections of these
multitude of factors is visualized as a spider's web. Under this model, disease can be prevented by breaking the
weakest strand of the causal web as identified previously through various types of epidemiologic studies.

The causal diagram proposed by the investigators of a study on leptospirosis in Metro Manila is web-like,
depicting the intricate interrelationships of the various sociodemographic characteristics and behaviors of the
host as well as the numerous environmental factors. Note that all connectors from one factor to the next are
directed paths (one-headed arrows) signifying the ancestors (the antecedent factors) at the tail of the arrow and
the descendants (intermediate factors) at the head of the arrow, further, if you trace the directed paths, they
would all lead to leptospirosis which is the outcome of interest

PREVENTION AND CONTROL OF DISEASES

As discussed in earlier sections, the field of epidemiology can be used to identify the important public health
problems of the community, to determine the magnitude and distribution of the health problem in terms of who
is affected and when and where the problem usually occurs, to elucidate the natural history of the disease, to
determine why the problem disease occurs, and to identify the factors that contribute to disease causation. All
of this information should be utilized by health workers who are tasked to plan preventive programs so that the
probability of attaining the program objectives is increased. Similarly, we also expounded earlier that
epidemiologic methods can be utilized for investigating a disease outbreak, so that appropriate control
measures may be implemented.

Outbreak investigation

The World Health Organization defines a disease outbreak as "the occurrence of cases of disease in excess of
what would normally be expected in a defined community, geographical area or season". However, even the
occurrence of one case of a communicable disease is considered an outbreak provided the disease is either a
previously unknown disease, has never occurred in the area where the lone case is observed, or has been absent
from the population for a long time. An impending outbreak is usually detected through the surveillance
system or through perceptive clinicians, infection control nurse, or laboratory worker who report an unusual
disease or the relatively large number of cases of a disease. It is imperative that an outbreak investigation be
conducted in order to identify then eliminate the source of infection and thus prevent the occurrence of more
cases. In many instances, the epidemic curve is already in its descending limb by the time the investigating
team arrives in the area. In such instances, even if the outbreak is already waning, it is still advisable to go
ahead with the investigation so that strategies for preventing similar outbreaks in the future can be formulated.
It can also provide the opportunity to assess the preventive strategies that are used. The basic steps in an
outbreak investigation are as follows:

 Operationally define what constitutes a case.

 Based on the operational definition, identify the cases.
 Based on the number of cases identified, verify the existence of an outbreak.
 Establish the descriptive epidemiologic features of the cases.
 Record the clinical manifestations of cases.
 Based on the clinical manifestations, incubation period, available laboratory findings,and other
information gathered, formulate a hypothesis regarding the probable etiologic agent, the sources of
infection, the mode of transmission, and the best approach for controlling the outbreak.
 Test the hypotheses by collecting relevant specimens from the patients and from the environment.
 Based on the results of the investigation, implement prevention and control measures to prevent
recurrence of a similar outbreak.
 Disseminate the findings of the investigation through media and other forms to inform the public
MONITORING AND EVALUATION OF HEALTH INTERVENTIONS

The plan for a health intervention should include the plan for its monitoring and evaluation. Although
monitoring is done while the intervention is still being implemented to provide feedback on its current status,
evaluation is done at the end of the project to assess whether or not its objectives were achieved.

Monitoring

Monitoring is an ongoing activity during program implementation to assess the current status of its
implementation in terms of compliance to the design of the program, timelines, and attainment of midterm
goals. Because successful attainment of the program objectives is dependent not only on the application of
technical know-how and skills but also on efficient utilization of resources (human resources, budget,
equipment, and supplies and materials), the latter should likewise be monitored. Thus, as a result of
monitoring, the project management team is able to:

 Assess the progress of program implementation.

 Identify problems.
 Take corrective action.
 Have a tool for quality assurance and management,
 Measure achievement of midterm program objectives.
 Lay the groundwork for program evaluation.

Evaluation

Evaluation is a process that systematically and objectively assesses compliance to the design of the program!
the performance, relevance and success of a project, that is, the extent to which a project accomplishes its
intended results (outcomes) and achieves measurable impacts. This process employs research techniques and
applies the methods of epidemiology and health statistics. The primary purpose of evaluation is to provide
feedback on the results (outcomes) and impact of the project in order to inform policymakers and planners
about the efficacy of the intervention. It answers such questions as:

 Did the program work as intended?

 What results (outcomes) did the program accomplish?
 What measurable impacts did the program achieve?
 Is the program cost effective?

Whether the evaluation is done by an external (independent experts) or an internal (persons responsible for the
project) group, the principles of impartiality, independence, partnership, communication and coordination,
credibility, and transparency should be maintained. The essence of impact evaluation is comparison. Typically,
comparisons are based on observations of different groups at the same time or of the same group at different
points over time. With the application of epidemiology and health statistics, impact evaluation is done to
measure and compare these observations and conclude whether or not observed differences may be attributed
to the project.

PROVISION OF EVIDENCE FOR HEALTH POLICY FORMULATION

Our previous discussions had implied that epidemiologic evidence is necessary for the formulation of health
policy. A recent example in the Philippine setting is the legislation of Republic Act 9288, also known as the
Newborn Screening (NBS) Act of 2004. This law was passed because of the compelling evidence from a
study done by a group of obstetricians and pediatricians from 24 hospitals in Metro Manila. The Philippine
Newborn Screening Project (PNBSP) showed that the incidence of six metabolic conditions is high enough to
be considered of public health importance. Although the sequelae of these conditions can compromise the
functionality of cases as they mature, the secondary level of prevention could be relatively simple in some
instances, for example, avoiding certain food items.

The NBS Act of 2004 institutionalized the "National NBS System" which ensures that:

 Every baby born in the Philippines is offered NBS

 A sustainable NBS System is established and integrated into the public health delivery system
 All health practitioners are aware of the benefits of NBS and of their responsibilities in offering it to
their patients; and All parents are aware of NBS and their responsibility in protecting their child
from any of the disorders

THE HEALTH CARE DELIVERY SYSTEMS

A nation's health care delivery system has a tremendous impact not only on the health
of its people but also on their total development, including their socioeconomic status. A
discussion of the health care delivery system often involves issues of cost and
challenges. Nations go through a struggle to overcome multiple forces in efforts to
advance the nation's health within the context of their financial and political situations.

Anderson and McFarlane emphasized the role of following factors in shaping 21st century
health that further influence health care delivery system:

1. Health care "reforms"

2. Demographics
3. Globalization
4. Poverty and growing disparities
5. Social disintegration

This chapter delineates the health care delivery systems in the Philippines, beginning
with the World Health Organization(WHO), as this specialized agency of the United
Nations (UN) provides global leadership on health matters. In the Philippines, health
services are provided by the government and the private sector—for profit as well as
nonprofit, with the latter frequently referred to as nongovernmental organizations or
NGOs. On the national level, direction is set by the Department of Health(DOH). By virtue
of the mandate of the Local Government Code (R.A. 7160), local government units
(LGUs) should have an operating mechanism to meet the priority needs and service
requirements of their communities. Basic health services are regarded as priority
services, for which LGUs are primarily responsible.

A health system consists of all organizations, people, and actions whose primary intent is
to promote, restore, or maintain health. A health system has six building blocks or
components:

1. Service delivery
2. Health workforce
3. Information
4. Medical products, vaccines, and technologies
5. Financing
6. Leadership and governance or stewardship.
This chapter focuses on service delivery, health workforce, financing, and leadership and
governance.

The nurse is an essential member of the health workforce in the country. For the nurse to
work efficiently within the health care delivery system, an understanding of the dynamic
relationships among its components is needed. For example, a nurse who understands
the referral system will be able to refer patients to the appropriate facility or health
personnel.

An appreciation of the value of the nurse's role in the system provides motivation to
work despite sometimes seemingly overwhelming odds. The study of this chapter affords
a realization of the nurse's position in the scheme of health care delivery in the
Philippines.

THE WORLD HEALTH ORGANIZATION

When diplomats formed the UN in 1945, they also discussed the creation of a global health organization. The
World Health Organization (WHO) was the outcome of these discussions. The WHO constitution came into
force on April 7, 1948. Since then, April 7 has been celebrated each year as World Health Day. With its
headquarters in Geneva, Switzerland, WHO has 147 country offices and 6 world regional offices for Africa, the
Americas, Eastern Mediterranean, Europe, Southeast Asia, and the Western Pacific. The Philippines is a
member of the Western Pacific Region, which holds office in Manila.

The WHO constitution states that its objective is the attainment by all peoples of the highest possible level of
health. To attain its objective, WHO carries out the following core functions:

 Providing leadership on matters critical to health and engaging in partnerships where joint action is
needed. WHO has 193 member countries and 2 associate members. WHO and its members work with
UN agencies, NGOs, and the private sector . The WHO Country Focus is directed toward providing
technical collaboration with member states in accordance with each country's needs and capacities.
 Shaping the research agenda and stimulating the generation, translation, and disseminating valuable
knowledge. The WHO strategy on research for health has five goals:

 Capacity in reference to capacity-building to strengthen national health research systems;

 Priorities to focus research on priority health needs particularly in low- and middle-income
countries;
 Standards to promote good research practice and enable the greater sharing of research
evidence, tools, and materials;
 Translation to ensure that quality evidence is turned into products and policy; and
 Organization to strengthen the research culture within WHO and improve the management
and coordination of WHO research activities.

 Setting norms and standards and promoting and monitoring their implementation. WHO develops norms
and standards for various health and health-related issues, such as pharmaceutical products including
vaccines and other biological products used in immunization, practices in maternal and childcare, and
environmental conditions.
 Articulating ethical and evidence-based policy options. Through its Department of Ethics and Social
Determinants, WHO is involved in various issues on health ethics. In collaboration with other
governmental and nongovernmental organizations, WHO has worked on bioethical concerns such as
 those related to human organ and tissue transplantation, reproductive technology, and public health
response to threats of infectious diseases like AIDS, influenza, and tuberculosis.
 Providing technical support, catalyzing change, and building sustainable institutional capacity. WHO
offers technical support and training to its member countries in the fields of maternal and child health,
control of diseases, and environmental health services. WHO is involved in monitoring the health
situation and assessing health trends. WHO has developed guidance and tools on measurement,
monitoring, and evaluation.

The Philippines is a member of a global system of nations interacting with each other at different levels and in
different ways. Events that happen in other countries can affect the health status of Filipinos. Ease of travel
from one part of the globe to another makes transmission of communicable diseases likewise easy. This has
been proven by events as the emergence and spread of diseases like HIV/AIDS, SARS (severe acute respiratory
syndrome), and AH1N1 influenza (swine flu) to cite a few. In contrast, cooperation and sharing of resources
among nations serve as the key in the solution of many human problems—health and otherwise. WHO provides
the environment that facilitates cooperation and sharing of resources to promote and protect health and to
resolve health problems and alleviate their effects.

In the past decade, WHO has worked as a partner of the Philippine DOH in the development and provision of
services towards the attainment of health-related Millennium Development Goals (MDGs).

THE MILLENNIUM DEVELOPMENT GOALS

On September 6 to 8, 2000, world leaders in the UN General Assembly participated in the Millennium Summit.
The result of the Summit was a resolution entitled United Nations Millennium Declaration. In this declaration,
the world leaders recognized their collective responsibility to uphold the principles of human dignity, equality,
and equity at the global level. To uphold these principles is their duty to all the people of the world, especially
the most vulnerable and, in particular, the children.

The declaration expressed the commitment of the 191 member states, including the Philippines, to reduce
extreme poverty and achieve seven other targets—now called the Millennium Development Goals (MDGs)—
by the year 2015.

The following are the eight MDGs and the targets corresponding to health-related MDGs 4, 5, and 6:

1. Eradicate extreme poverty and hunger.

2. Achieve universal primary education.
3. Promote gender equality and empower women.
4. Reduce child mortality. Target: Reduce by two-thirds, between 1990 and 2015, the under-five
mortality rate.
5. Improve maternal health. Targets:

a. Reduce by three quarters the maternal mortality ratio.

b. Achieve universal access to reproductive health.

6. Combat HIV/AIDS, malaria, and other diseases. Targets:

a. Have halted by 2015 and begun to reverse the spread of HIV/AIDS.

 b. Achieve, by 2010, universal access to treatment for HIV/A IDS for all those who need it.
c. Have halted by 2015 and begun to reverse the incidence of malaria and other major
diseases.

7. Ensure environmental sustainability.

8. Develop a global partnership for development.

Of the eight MDGs, five are not considered as strictly health issues. However, these five MDGs are health-
related issues because they are goals toward upgrading socioeconomic conditions. These socioeconomic
conditions are, in themselves, health determinants.

THE PHILIPPINE HEALTH CARE DELIVERY SYSTEM

The DOH serves as the main governing body of health services in the country. The DOH provides guidance
and technical assistance to LGUs through the Center for Health Development in each of the 17 regions.
Provincial governments are responsible for administration of provincial and district hospitals. Municipal and
city governments are in charge of primary care through rural health units (RHUs) or health centers. Satellite
outposts known as barangay health stations (BHSs) provide health services in the periphery of the municipality
or city.

The Local Government Code mandated the devolution or decentralization of basic health services. This means
that LGUs have the autonomy and responsibility to plan and implement basic health services (primary care) on
behalf of their constituents. This is a mandate for LGUs. Depending on the capability and political will of the
municipal/city government, higher levels of services may be provided. Thus, it is possible for a city or a
municipality to administer a secondary or even a tertiary hospital. For example, Ospital ng Maynila Medical
Center, a tertiary hospital, is funded by the city government of Manila.

The private sector is composed of for-profit and nonprofit agencies. This sector provides all levels of services
and accounts for a large segment of health service providers in the country. About 30% of Filipinos utilize
private health facilities. An estimated 60% of the national health expenditure goes to the private sector. This
sector also employs more than 70% of the health professionals in the Philippines.

Financing of health services is provided by three major groups: the government (national and local), private
sources, and social health insurance. The leading payment scheme is out-of-pocket, accounting for 40-50% of
the total health expenditure. The National Health Insurance Act of 1995 (R.A. 7875) created the Philippine
Health Insurance Corporation (Philhealth). It is a tax-exempt government corporation attached to the DOH for
policy coordination and guidance, and aims for universal health coverage of all Filipino citizens.

The Department of Health

The Department of Health (DOH) is the national agency mandated to lead the health sector towards assuring
quality health care for all Filipinos. The DOH vision is to be a global leader for attaining better health
outcomes, competitive and responsive health care system, and equitable health financing. Its mission statement
is to guarantee equitable, sustainable, and quality health for all Filipinos, especially the poor, and to lead the
quest for excellence in health.

In the pursuit of its vision and execution of its mission, the DOH has the following major roles:

1. Leader in health
2. Enabler and capacity builder
3. Administrator of specific services
The leadership role of the DOH is specifically elucidated in Executive Order 102, series of 1999 in terms of the
following functions:

1. Planning and formulating policies of health programs and services.

2. Monitoring and evaluating the implementation of health programs, projects, research, training, and
services.
3. Advocating for health promotion and healthy lifestyles.
4. Serving as a technical authority in disease control and prevention.
5. Providing administrative and technical leadership in health care financing and implementing the
National Health Insurance Law.

As enabler and capacity builder, the DOH performs the following functions:

1. Providing logistical support to LGUs, the private sector, and other agencies in implementing health
programs and services.
2. Serving as the lead agency in health and medical research.
3. Protecting standards of excellence in the training and education of healthcare providers at all levels
of the health care system.

As administrator of specific services, the DOH is tasked to:

1. Serve as administrator of selected health facilities at subnational levels that act as referral centers for
local health systems, that is, tertiary and special hospitals, reference laboratories, training centers,
centers for health promotion, centers for disease control and prevention, and regulatory offices.
2. Provide specific program components for conditions that affect large segments of the population,
such as tuberculosis, malaria, schistosomiasis, HIV/AIDS, and micronutrient deficiencies.
3. Develop strategies for responding to emerging health needs.
4. Provide leadership in health emergency preparedness and response services, including referral and
networking systems for trauma, injuries, and catastrophic events.

The DOH core values reflect adherence to the highest standards of work, namely:

1. Integrity
2. Excellence
3. Compassion and respect for human dignity
4. Commitment
5. Professionalism
6. Teamwork
7. Stewardship of the health of the people

The DOH carries out its work through the various central bureaus and services in the Central Office, Centers
for Health Development (CHD) in every region, DOH-attached agencies, and DOH-retained hospitals.
Levels of health care delivery

Advances in health sciences and services have brought about the development of different types of health
facilities. In response, the DOH issued Administrative Order 2012-0012 (Rules and Regulations Governing the
New Classification of Hospitals and Other Health Facilities in the Philippines) that provides for a new
classification scheme of health facilities.

Although the levels of health care delivery have remained basically the same—primary, secondary, and tertiary
—the classification scheme of hospitals has changed. Hospitals are broadly classified as general or specialty
hospitals. A general hospital provides services for all kinds of illnesses, injuries, or deformities. The services
offered by a general hospital define it as level 1, level 2, or level 3. On the other hand, a specialty hospital
offers services for a specific disease or condition or type of patient, such as children, the elderly, or women.

DOH Administrative Order 2012-0012 classifies other health facilities as follows:

Category A. Primary care facility - a first-contact health care facility that offers basic services including
emergency services and provision for normal deliveries.


1. Without in-patient beds like health centers, out-patient clinics, and dental clinics,
2. With in-patient beds - a short-stay facility where the patient spends on the average of one to
two days before discharge. Examples are infirmaries and birthing (lying-in) facilities.

Category B. Custodial care facility - a health facility that provides long-term care, including basic services
like food and shelter, to patients with chronic conditions requiring ongoing health and nursing care due to
impairment and a reduced degree of independence in activities of daily living, and patients in need of
rehabilitation. Examples are custodial psychiatric facilities, substance/ drug abuse treatment and rehabilitation
centers, sanitaria/leprosaria, and nursing homes.

Category C. Diagnostic/therapeutic facility - a facility for the examination of the human body, specimens
from the human body for the diagnosis, sometimes treatment of disease, or water for drinking water analysis.
The test covers the preanalytical, analytical, and postanalytical phases of examination. This category is further
classified into:

1. Laboratory facility, such as, but not limited to the following:

a. Clinical laboratory
b. HIV testing laboratory
c. Blood service facility
d. Drug testing laboratory
 e. Newborn screening laboratory
f. Laboratory for drinking water analysis

2. Radiologic facility providing services such as X-ray, CP scan, mammography, MRI, and
ultrasonography.
3. Nuclear medicine facility - a facility regulated by the Philippine Nuclear Research Institute utilizing
applications of radioactive materials in diagnosis, treatment, or medical research, with the exception
of the use of scaled radiation sources in radiotherapy as in internal radiation therapy.

Category D. Specialized outpatient facility - a facility that performs highly specialized procedures on an
outpatient basis. Examples are dialysis clinic, ambulatory surgical clinic, cancer chemotherapeutic
center/clinic, cancer radiation facility, and physical medicine and rehabilitation center/clinic

The Rural Health Unit

The Rural Health Unit (RHU), commonly known as a health center, is a primary level health facility in the
municipality. The focus of the RHU is preventive and promotive health services and the supervision of BHSs
under its jurisdiction. The recommended ratio of RHU to catchment population is 1 RHU:20,000 population.

The BHS is the first-contact health care facility that offers basic services at the barangay level. It is a satellite
station of the RHU. It is manned by volunteer Barangay Health workers (BHWs) under the supervision of the
Rural Health Midwife (RHM).

The Rural Health Unit personnel

The Municipal Health Officer (MHO) or Rural Health Physician heads the health services at the municipal
level and carries out the following roles and functions:

1. Administrator of the RHU

a. Prepares the municipal health plan and budget

b. Monitors the implementation of basic health services
c. Management of the RHU staff

2. Community physician

a. Conducts epidemiological studies

b. Formulates health education campaigns on disease prevention
c. Prepares and implements control measures or rehabilitation plans

3. Medico-legal officer of the municipality

The revised implementing rules and regulations (IRRs) of R.A. 7305 or the Magna Carta of Public Health
Workers stipulate that there be one rural health physician to a population of 20,000.

The Public Health Nurse (PHN)

1. Supervises and guides all RHMs in the municipality;

2. Prepares the FHSIS quarterly and annual reports of the municipality for submission to the Provincial
Health Office;
3. Utilizes the nursing process in responding to health care needs, including needs for health education
and promotions, of individuals, families, and catchment community; and
4. Collaborates with the other members of the health team, government agencies, private businesses,
NCOs, and people's organizations to address the community's health problems.

R.A. 7305 IRRs provide for the same nurse-population ratio as that of the Rural Health Physician, that is,
120,000.

With a recommended ratio of 1 for every 5,000 population, the RHM:

1. Manages the BHS and supervises and trains the BHW.

2. Provides midwifery services and executes health care programs and activities for women of
reproductive age, including family planning counseling and services.
3. Conducts patient assessment and diagnosis for referral or further management.
4. Performs health information, education, and communication activities.
5. Organizes the community.
6. Facilitates barangay health planning and other community health services.

The functions of the Rural Sanitation Inspector are directed towards ensuring a healthy physical environment
in the municipality. This entails advocacy, monitoring, and regulatory activities, such as inspection of water
supply and unhygienic household conditions.

BHWs are considered as the interface between the community and the RHU. They are trained in preventive
health care, with a strong emphasis on maternal and child care, family planning and reproductive health,
nutrition, and sanitation. They are also equipped with basic skills for prevention and management of common
diseases. They assist in providing basic services at the BHS and the RHU. BHWs are accredited by the local
health board according to DOH guidelines. Although they carry the status of volunteers, R.A. 7883 or the
Barangay Health Workers' Benefit and Incentives Act entitles them to hazard and subsistence allowances and
other benefits. The recommended ratio of BHW to catchment population is BHW:20 households.

Local health boards

R.A. 7160 or Local Government Code was enacted to bring about genuine and meaningful local autonomy.
This will enable local governments to attain their fullest development as self-reliant communities and make
them more effective partners in the attainment of national goals. It mandates devolution of basic services from
the national government to LGUs. Devolution refers to the act by which the national government confers
power and authority upon the various LGUs to perform specific functions and responsibilities.

R.A. 7160 provided for the creation of the Provincial Health Board and the City/ Municipal Health Boards, or
Local Health Boards. The chairman of the board is the local executive—the Provincial Governor/Mayor. The
Provincial/City/Municipal Health Officer serves as vice chairman. Members of the board are composed of the
chairman of the committee on health of the Sanggunian, a representative from the private sector or NGO
involved in health services, and a representative of the DOH.

The functions of local health boards are as follows:

 1. Proposing to the Sanggunian annual budgetary allocations for the operation and maintenance of
health facilities and services within the province/city/ municipality;
2. Serving as an advisory committee to the Sanggunian on health matters; and
3. Creating committees that shall advise local health agencies on various matters related to health
service operations.

The health referral system

Implemented since 1992, devolution has brought decision making and accountability on basic government
services closer to the people. This has allowed local leaders to have a greater hand in the future of
communities. However, it has brought about fragmentation of the health care delivery system in the
Philippines. It resulted in a three-level system where local and national governments are responsible for
independent services. Also, municipalities/cities began operating separately from each other causing further
segregation of public health services.

Certain provisions of the Local Government Code deal with relations among local and national governments.
These provisions present a built-in mechanism for a referral system among different government agencies.

A referral is a set of activities undertaken by a health care provider or facility in response to its inability to
provide the necessary health intervention to satisfy a patient's need. A functional referral system is one that
ensures the continuity and complementation of health and medical services. It is comprehensive, encompassing
promotive, preventive, curative, and rehabilitative care. It engages all health facilities from the lowest to the
highest level. It usually involves movement of a patient from the health center of first contact and the hospital
at first referral level. When hospital intervention has been completed, the patient is referred back to the health
center. This accounts for the term two-way referral system.

Referrals may be internal or external. Internal referrals occur within the health facility, from one health
personnel to another. Examples of internal referral are RHM to PHN and PHN to MHO. An internal referral
may be made to request for an opinion or suggestion, co-management, or further management or specialty care.

An external referral is a movement of a patient from one health facility to another. It may be vertical, where the
patient referral may be from a lower to a higher level of health facility or the other way round. The referral
may also he horizontal, where the patient is referred between similar facilities in different catchment areas.

The levels of health care delivery provide the framework for an efficient referral system. The classification of
facilities can contribute to the overall efficiency of health care delivery if gate-keeping mechanisms within the
system are working properly. In this scenario, patients are given services in the facility providing the level of
care that they need. A patient who requires basic care need not be admitted into a hospital where services are
more expensive. A patient who consults at a primary facility but is diagnosed to have a serious condition is
referred to the appropriate secondary or tertiary facility. This process also affords optimal utilization of limited
resources of the family and the community.

The Inter-Local Health Zone

As stated earlier, devolution has resulted in a fragmented health care system and segregation of public health
services among different LGUs. The referral system functioning within the context of the Inter-Local Health
Zone (ILHZ) provides a means for consolidating health care efforts.

The ILHZ is based on the concept of the District Health System, a generic term used by WHO to describe an
integrated health management and delivery system based on a defined administrative and geographical area.
An ILHZ has a defined catchment population within a defined geographical area. It has a central or core
referral hospital and a number of primary level facilities such as RHUs and BHSs. The ILHZ does not only
cover government health services but includes all other sectors involved in the delivery of health services. It
may include community-based NCOs and the private sector—both local and foreign. Not synonymous with a
political congressional district, an ILHZ may be composed of one large municipality or several municipalities.

The ILHZ has the following components:

 People. Although WHO has described the ideal population size of a health district between 100,000
and 500,000, the number of people may vary from zone to zone, especially when taking into
consideration the number of LGUs that will decide to cooperate and cluster.
 Boundaries. Clear boundaries between ILHZs establish accountability and responsibility of health
service providers,
 Health facilities. RHUs, BHSs, and other health facilities that decide to work together as an integrated
health system and a district or provincial hospital, serving as the central referral hospital, make up the
health facilities of an ILHZ.
 Health workers. To deliver comprehensive services, the ILHZ health workers include personnel of the
DOH, district or provincial hospitals, RHUs, BHSs, private clinics, volunteer health workers from
NGOs, and community-based organizations.

The local governments of three adjacent municipalities and an NGO offering custodial care to elderly persons
have agreed to consolidate their health systems into a health cluster. The cluster provides primary services and
custodial care to a total population of about 165,000. The cluster has established a linkage with the district
hospital, which now serves as the central referral hospital of the ILHZ.

Health sector reform: Universal Health Care

Previous efforts at health sector reform have brought about substantial gains in health sector improvements,
Universal Health Care (UHC) (Kalusugan Pangkalahatan), also called the Aquino Health Agenda, is the latest
in a series of continuing efforts of the government to bring about health sector reforms. UHC was built upon
the strategies of two previous platforms of reform: the initial Health Sector Reform Agenda and FOURmula
One (F1) for Health. UHC is planned for implementation until 2016.

Rationale

Health sector reforms are intended to bring about equity in health service delivery. Survey data show that this
has not been achieved as of yet, despite health sector reforms since 1999. A DOH and Philhealth review
highlighted the need to improve health-related financial risk protection among Filipinos. More importantly,
Philhealth benefit delivery was found to be lowest among the target population—the poorest quintile. The
concern on inequitable access to health resources has not been resolved.

Population (quintiles are determined in this manner: During an NSO survey, a wealth index is constructed by
assigning a weight to each household asset. These scores are summed by household, individuals are ranked
according to the total score of the household in which they reside. The sample is then divided into five groups
(quintiles), with each group having the same number of individuals.

Neglect of public hospitals and health facilities due to inadequate health budgets has been observed. As of
October 2010, a total of 892 RHUs and 99 government hospitals had yet to qualify for accreditation by
Philhealth. Data show that the poorest of the population are the main users of government health facilities. This
means that the deterioration and poor quality of many government health facilities is particularly
disadvantageous to the poor who needs the services the most.

Finally, renewed efforts to achieve health-related MDGs are in order. The MDC 4 target is to reduce maternal
mortality rate from 209 maternal deaths/100,000 live births in 1990 to 52 deaths per 100,000 live births by
2015. The preliminary 2009 FHSIS report shows that the country had a maternal mortality rate of 64 per
100,000 live births in that year. Considering the short span of time to the year 2015, attainment of the MDC
target looks difficult. The decrease in infant and child mortality rates over the past two decades has been
remarkable. From a high under-five child mortality rate of 80 per 1,000 live births in 1990, the 2008 data
shows a decrease to 34 per 1,000 live births. There is a high probability of meeting MDG goal 5.
To address these challenges, UHC (Kalusugan Pangkalaliatan) was launched through Administrative Order
2010-0036.

Goals and objectives

UHC is directed towards ensuring the achievement of the health system goals of:

1. Better health outcomes.

2. Sustained health financing.
3. A responsive health system by ensuring that all Filipinos, especially the disadvantaged group, have
equitable access to affordable health care.

Strategic thrusts

The attainment of the goal of UHC is through the pursuit of three strategic thrusts:

a. Financial risk protection through expansion in NHIP enrollment and benefit delivery
b. Improved access to quality hospitals and health care facilities
c. Attainment of the health-related MDGs

To achieve the three strategic thrusts, six strategic instruments shall be optimized:

1. Health financing - instrument to increase resources for health that will be effectively allocated and
utilized to improve the financial protection of the poor and the vulnerable sectors.
2. Service delivery - instrument to transform the health service delivery structure to address variations
in health service utilization and health outcomes across socioeconomic variables.
3. Policy, standards, and regulation -instrument to ensure equitable access to health services, essential
medicines, and technologies of assured quality, availability, and safety.
4. Governance for health - instrument to establish the mechanisms for efficiency, transparency, and
accountability, and prevent opportunities for fraud.
5. Human resources for health - instrument to ensure that all Filipinos have access to professional health
care providers capable of meeting their health needs at the appropriate level of care.
6. Health information - instrument to establish a modern information system that shall:

a. Provide evidence for policy and program development;

b. Support for immediate and efficient provision of health care and management of province-
wide health systems.

Public health programs

Major public health programs that will be tackled in subsequent chapters of this book include the following:
 1. Reproductive and maternal health: prepregnancy services and care during pregnancy, delivery, and
postpartum period
2. Expanded Garantisadong Pambata (child health): advocacy for exclusive breastfeeding in the first 6
months of life, newborn screening program, immunization, nutrition services, and integrated
management of childhood illness
3. Control of communicable diseases such as tuberculosis, mosquito-borne diseases, rabies,
schistosomiasis, and sexually transmitted infections
4. Control of noncommunicable or lifestyle diseases
5. Environmental health

The health of Filipino mothers and children determines the health of the next generation of Filipinos. It
is a given that socioeconomic development can happen only when people are able to attain and maintain
a certain level of health. Understandably, to attain the first Millennium Development Goal (MDG) (to
eradicate extreme poverty and hunger), maternal and under-five mortality rates have to be drastically
reduced and diseases that take a heavy toll on human capital like malaria and human immunodeficiency
virus/acquired immune deficiency syndrome (HIV/AIDS) have to be controlled.

Access to adequate and good quality maternal, newborn, and child health and nutrition (MNCHN)
services is expected to impact on the national situation in general. Therefore, improving maternal and
child health condition is imperative and is being given top priority by health planners in the country.
Vigorous efforts toward this direction are evidenced by statements from the Department of Health
(DOH) leadership urging health workers to be committed to the attainment of MDGs 4 and 5 (reduction
of maternal and under-five mortality rates, respectively) and various documents containing evidence-
based directives on MNCHN.

This chapter deals mostly with DOH policies and guidelines on maternal and child services. If quality
maternal and child health goals are to be made accessible to the target populations, local government
units (LGUs) have to exert all efforts towards compliance with these directives.

THE CURRENT MATERNAL AND CHILD HEALTH AND NUTRITION SITUATION

Significant improvements in maternal and childcare have been realized in the past four decades. However,
pregnancy and childbirth still pose a great risk to Filipino women of reproductive age. Maternal mortality rate
is still high, reported by the National Statistics Office (NSO) at 162 per 100,000 live births in 2006 declining
slowly from 209 per 100,000 live births in 1990. These complications include hypertension, postpartum
hemorrhage, severe infections, and other medical problems arising from poor birth spacing, maternal
malnutrition, unsafe abortions, and presence of concurrent infections like tuberculosis (TB), malaria, and
sexually transmitted infections (STls) as well as lifestyle diseases like diabetes and hypertension.

The main causes of neonatal deaths within the first week of life are asphyxia, prematurity, severe infections,
congenital anomalies, newborn tetanus, and other causes.

These direct causes of maternal and neonatal deaths require care by skilled health professionals in well-
equipped facilities. However, more than 59% of births take place at home, with more than 25% of the births
attended by traditional birth attendants or Mots. This contributes to the three delays that lead to maternal and
neonatal deaths:

1. Delay in identification of complications.

2. Delay in referral.
3. Delay in the management of complications.

The likelihood of maternal and neonatal death increases with identified risk factors, namely:

1. Having mistimed, unplanned, unwanted, and unsupported pregnancy;

2. Not securing adequate care during the pregnancy;
3. Delivering without skilled birth attendance, that is, attendance by skilled midwives, nurses, or
physicians, and not having access to emergency obstetric and neonatal care; and
4. Not having proper postpartum and postnatal care for the mother and the newborn.

The country is on target in its efforts towards lowering child mortality rate, with infant mortality rate at 25.72
per 1,000 live births in 2008 and under-five mortality rate at 32.8 per 1,000 live births. The Food and Nutrition
Research Institute (FNRI), however, estimates the prevalence of underweight among children less than five
years of age at 20.6%. It is worth noting that many of the leading causes of infant mortality can be prevented by
quality and accessible maternal, newborn, and child services and improvement in maternal, infant, and child
nutrition.

Variations in data can be accounted for by differences in sources of information. Field Health Service
Information System (FHSIS) data are obtained mostly from administrative reports furnished by government
hospitals and local government health units, while the maternal and Child Health Survey is conducted by the
NSO annually, the Family Planning Survey every 5 years, and the Census of Population and Housing every 10
years

THE MATERNAL, NEWBORN, AND CHILD HEALTH AND NUTRITION STRATEGY

In its response to the maternal and child health situation, the DOH takes into consideration the interrelatedness
of:

1. Direct threats to the life of mothers and children that necessitate immediate health care and managing
risks that tend to increase maternal and child deaths
2. Underlying socioeconomic conditions that hinder the provision and utilization of MNCMN core
package of services.
The following are the four key strategies of MNCHN:

1. Ensuring universal access to and utilization of an MNCHN core package of services and
interventions directed not only to individual women of reproductive age and newborns at different
stages of the life cycle—referring to the prepregnancy, pregnancy, childbirth, postpartum, newborn,
and childhood periods—but also to the community;
2. Establishment of a service delivery network at all levels of care to provide the package of services
and interventions;
3. Organized use of instalments for health systems development to bring all localities to create and
sustain their service delivery networks, which are crucial for the provision of health services to all;
and
4. Rapid build-up of institutional capacities of DOH and Phil Health, being the lead national agencies
that provide support to local planning and development through appropriate standards, capacity
build-up of implemented, and financing mechanisms.

The MNCHN strategy aims to achieve the following intermediate results:

1. Every pregnancy is wanted, planned, and supported.

2. Every pregnancy is adequately managed throughout its course.
3. Every delivery is facility-based and managed by skilled birth attendants or skilled health
professionals.
4. Every mother-and-newborn pair secures proper postpartum and newborn care with smooth transitions
to the women's health care package for the mother and child survival package for the newborn.

The MNCHN core package of services

The maternal and newborn care package is characterized by a paradigm shift from the risk approach that
focuses on identifying pregnant women at risk of complications to one that considersall pregnant women at
risk of such complications. This is mainly in response to findings that reveal the inability of antenatal
protocols to accurately predict the onset of complications during childbirth.

The MNCHN core package of services consists of interventions for each life stage: prepregnancy (adolescence
and adulthood), pregnancy, delivery, and the postpartum, newborn, and childhood periods.

Prepregnancy package

1. Nutrition

 Nutritional counseling;
 Promotion of the use of iodized salt; and
 Provision of micronutrient supplements:

 Iron and folate: 60 mg elemental iron/400 μg folic acid 1 tablet daily for 3-6
months.
  Vitamin A at least 5,000 IU every week or a daily multivitamin supplement may
be taken as option when the required vitamin A is not available.

2. Promotion of healthy lifestyle including advice relative to smoking cessation, healthy diet, regular
exercise, and moderate alcohol intake.
3. Advice on family planning and provision of family planning services. This is based on the
observation that unwanted pregnancies are associated with poorer health outcomes for both the
mother and her newborn.
4. Prevention and management of lifestyle-related diseases like diabetes, and cardiovascular disease.
5. Prevention and management of infection, including deworming of women of reproductive age to
reduce other causes of iron deficiency anemia.
6. Counseling on STI/HIV/AIDS, nutrition, personal hygiene, and consequences of abortion.
7. Adolescent health services.
8. Provision of oral health services.

Prenatal package

The pregnant woman who avails of the prenatal package obtains adequate care. This consists of the following:

1. Prenatal visits:

 At least four visits throughout the course of pregnancy at least one visit in the first and
second trimesters and at least two visits in the third trimester.
 Prenatal assessment includes weight and blood pressure monitoring, measurement of fundic
height against the age of gestation, fetal heart beat and fetal movement count to assess the
adequacy of fetal growth and well-being, and performance of diagnostic examinations like
complete blood count, blood typing, urinalysis, screening for STIs, blood sugar screening,
pregnancy test, cervical cancer screening using acetic acid wash, and Papanicolaou smear.

2. Micronutrient supplementation:

 Iron and folate (60 mg/400 μg) once a day for 6 months or 180 tablets;
 Vitamin A 10,000 IU twice a week from the fourth month of pregnancy; and
 Elemental iodine 200 mg given once during the pregnancy.

3. Tetanus toxoid (TT) immunization:

 0.5 ml of TT is injected intramuscularly on the deltoid muscle.

 Adequate immunization of women with TT prevents tetanus in both the mother and the
newborn. The newborn develops protection through passive immunity as maternal
 antibodies pass through the placenta into the fetal circulation.

4. Promotion of exclusive breastfeeding, newborn screening (NHS), and infant immunization.

5. Counseling on healthy lifestyle with focus on smoking cessation, healthy diet and nutrition, regular
exercise, STI and HIV prevention, and oral health.
6. Early detection and management of complications of pregnancy.
7. Prevention and management of other conditions where indicated: hypertension, anemia, diabetes, TB,
malaria, schistosomiasis, and STI/HIV/ AIDS.
8. Birth planning and promotion of facility-based delivery.

In addition to her facility-based record, the Home-Based Mother's Record (HBMR) is used when rendering
care to the pregnant woman. The HBMR is a simplified record of the history of present and past pregnancies,
when applicable, and the findings and measures of the TBA, BHW, or health professionals. In the evaluation of
the HBMR in eight countries, including the Philippines, Shah concluded that the HBMR:

1. Provides a means of promoting continuity of care through a woman's reproductive life;

2. Promotes early recognition of women who are at risk of developing conditions like severe anemia,
hypertension, bleeding, and moderate-lo-severe edema;
3. Encourages self-care where appropriate and referral suited to the needs of the woman;
4. Supports initiation of appropriate care according to the woman's identified needs;
5. Serves as a useful record of care and health information and source of health statistics; and
6. Guides the health workers in providing for the health educational needs of the client about risk and
care during pregnancy and the periods in between pregnancies, and care of the newborn and the
postpartum.

Childbirth package

1. Skilled birth attendance/skilled health professional-assisted delivery and facility-based deliveries

including the use of partograph. Most maternal deaths occur during labor or the first 24 hours
postpartum, and most complications cannot be predicted or prevented . It is logical that the best
strategy to prevent maternal deaths is to promote facility-based childbirth with a skilled health
professional attendance.
2. Proper management of pregnancy and delivery complications and newborn complications. The DOH,
Philhealth, and WHO recommend essential intrapartum and newborn care (EINC) practices in
hospitals and other birthing facilities in the country. EINC is called Unang Yakap. EINC practices
during the intrapartum period consist of measures that, based on scientific evidence, are necessary for
safe and quality care of the woman during childbirth. The recommended evidence-based practices
include:

 Continuous maternal support by having a companion of choice during labor and delivery;
 Freedom of movement during labor;
 Monitoring progress of labor using the partograph; the partograph is a graphic recording of
the progress of labor and significant conditions of the mother and the fetus. It is useful in
detecting deviations from normal and in early decision-making on referral;
  Nondrug pain relief before offering labor anesthesia;
 Position of choice during labor and delivery;
 Spontaneous pushing in a semi-upright position;
 Hand hygiene;
 Nonroutine episiotomy; and
 Active management of the third stage of labor (AMTSL).

3. Access to basic emergency obstetric and newborn care (BEmONC) or comprehensive emergency
obstetric and newborn care (CEmONC) services.

Postpartum package

1. Postpartum visits: within 72 hours and on the 7th day postpartum check for conditions such as
bleeding or infections.
2. Micronutrient supplementation

 Iron and folate (60 mg/400 μg) once a day for 3 months or 90 tablets;
 Vitamin A 200,000 IU within 4 weeks after delivery.

3. Counseling on nutrition, child care, family planning, and other available services.

Newborn (first week of life) care package

Recommended EINC practices in the care of the newborn are evidence-based measures that are vital for the
survival and the quality care of the newborn.

1. Interventions within the first 90 minutes include the following:

 Immediate and thorough drying, which does not only protect the newborn from cold stress
and hypothermia, but also stimulates breathing. This is recommended as the immediate first
action for all newborns, regardless of gestational age or birth weight.
 Skin-to-skin contact between mother and newborn does not only provide warmth and an
opportunity for bonding. It plays a part in protection of the newborn against infection and
hypoglycemia. Studies have shown that skin-to-skin contact at birth helps in stabilizing the
baby and promotes successful breastfeeding by facilitating colostrum feeding.
 Cord clamping 1-3 minutes after birth is recommended. The customary cord clamping
immediately after birth is not a recommended practice in EINC because evidence shows
that delaying cord clamping by 1-3 minutes allows placental transfusion at birth. This
 increases the newborn's blood volume and iron reserves, and eventually reduces the
likelihood of iron deficiency anemia in infancy. Studies have also shown that delayed cord
clamping provides significant benefits to preterm infants by reducing the need for blood
transfusions and lowering the incidence of brain hemorrhages.
 Early initiation of breastfeeding means breastfeeding within an hour after birth as
recommended by WHO. This practice brings about gains for both the mother and the
newborn. In developing countries, early initiation of breastfeeding has been shown to
reduce infant deaths attributed to diarrhea and lower respiratory tract infections. Benefits to
the mother include stimulation of oxytocin secretion resulting in uterine contraction.
 Nonseparation of baby from the mother, also known as rooming-in if the childbirth is in a
hospital or a similar health facility, promotes bonding and allows the mother to breastfeed
her baby on demand.

2. Essential newborn care after 90 minutes to 6 hours:

 Vitamin K prophylaxis;
 Hepatitis B and KCG vaccination;
 Examination of the baby for birth injuries, malformations, or defects; and
 Additional care for a small baby (a baby with a birth weight <2,500 grams) or twin.

3. Care prior to discharge: after the first 90 minutes:

 Support unrestricted, per demand breastfeeding, day and night;

 Ensure warmth of the baby. The care of a preterm infant carried skin-to-skin with the
mother, also known as kangaroo mother care (KMC), is an effective way to meet the baby's
needs for warmth, breastfeeding, protection from infection, stimulation, safety, and love.
 Washing and bathing (hygiene);
 Look for danger signs and start resuscitation, if necessary, keep warm, give first 2 doses of
IM antibiotics, give oxygen;
 Look for signs of jaundice and local infection;
 Perform newborn screening (blood spot) and newborn hearing screening (if available); and
 Provide instructions on discharge.

Child care package

1. Immunization
2. Nutrition:

o Exclusive breastfeeding up to 6 months

o Sustained breastfeeding up to 24 months with complementary feeding
o Micronutrient supplementation
o Integrated management of childhood illnesses
 3. Injury prevention
4. Oral health
5. Insecticide-treated nets for mothers and children in malaria-endemic areas

MNCHN service delivery network

No single facility or unit can provide the entire MNCHN core package of services. It is important that different
health care providers within the locality are organized into a well-coordinated MNCHN service delivery
network to meet the varying needs of populations and ensure the continuum of care. The MNCHN network can
be a province-or city-wide network of public and private health care facilities and providers capable of giving
MNCHN services, including basic and comprehensive emergency obstetric, and essential newborn care. It also
includes the communication and transportation system supporting this network.

There are three levels of care in the MNCHN service delivery network:

1. Community level service providers or thecommunity health team (CHT) gives primary health
care services. These may include out-patient clinics such as RHUs, BHSs, and private clinics as well
as their professional health staff and volunteer health workers, such as barangay health workers and
traditional birth attendants. A CHT plays two basic functions:

 Navigation functions: informing families of health risks and assisting families in health
risks and needs assessment; assisting families to develop and use health plans like birthing
plans; and facilitating access by families to critical health services (e.g. emergency
transport, communication, outreach services) and financing sources (e.g. PhilHealth).
 Basic service delivery functions: advocating for birth spacing and counseling on family
planning services; tracking and master listing of pregnant women, women of reproductive
age, and children below 1 year of age; early detection and referral of high-risk pregnancies;
and reporting maternal and neonatal deaths. CHTs should be present in each priority
population area to improve utilization of services and ensure provision of services as well
as follow-up care for postpartum mothers and their newborn.

2. A BEmONC-capable facility or provider can perform the following six signal obstetric functions:

 Parenteral administration of oxytocin in the third stage of labor;

 Parenteral administration of loading dose of anticonvulsants;
 Parenteral administration of initial dose of antibiotics;
 Performance of assisted deliveries (imminent breech delivery);
 Removal of retained products of conception; and
 Manual removal of retained placenta.

A BEmONC-capable facility is also able to provide emergency newborn interventions, which, at the
least, include the following:
  Newborn resuscitation;
 Treatment of neonatal sepsis/infection; and
 Oxygen support.

A BEmONC-capable facility is also capable of providing blood transfusion services on top of its
standard functions, depending on the presence of qualified personnel and required equipment and
supplies.

A BEmONC can be based in an RHU, MHS, lying-in clinic, or birthing home and can either be a
stand-alone facility or composed of a network of facilities and skilled health professionals capable of
delivering the six signal functions. A typical stand-alone BEmONC-capable facility is an RHU that
has the complement of skilled health professionals such as doctors, nurses, midwives, and medical
technologists. At the minimum, this can be operated by a midwife who is either under supervision by
the rural health physician or has referral arrangements with a hospital or doctor trained in the
management of maternal and newborn emergencies. Under this arrangement, a midwife can provide
lifesaving interventions within the intent of DOH A.O. (Administrative Order) 2010-0014 on the
subject Administration of Life-Saving Drugs and Medicines by Midwives to Rapidly Reduce
Maternal and Neonatal Morbidity and Mortality.

A BEmONC-capable RHU or BHS or lying-in clinic/birthing home should at least have one midwife
or nurse with a physician on call. WHO recommends a ratio of BEmOC facility per 125,000
population.

3. A CEmONC-capable facility or provider can perform the six signal obstetric functions as in
BEmONC, as well as provide caesarean delivery services, blood banking and transfusion services,
and other highly specialized obstetric interventions. It is also capable of providing neonatal
emergency' interventions for BEmONC plus management of low birth weight or preterm newborn
and other specialized newborn services.

In an area with a population of at least 500,000, WHO recommends 1 CEmONC-capable facility

4.

THE REPRODUCTIVE HEALTH PROGRAM

Reproductive health (RH) is a state of complete physical, mental, and social well-being, and not merely the
absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and
processes. Reproductive health is based on the right of access to appropriate health care services that will
enable women to go safely through pregnancy and childbirth and provide couples with the best chance of
having a healthy infant.

Reproductive health care refers to the constellation of methods, techniques, and services that contribute to
reproductive health and well-being by preventing and solving reproductive health problems.

The Magna Carta of Women, which was enacted in 2009, provides that the "State shall, at all times, provide
for a comprehensive, culture-sensitive, and gender-responsive health services and programs covering all stage
of a woman's life cycle and which addresses the major causes of women's mortality and morbidity". This law
also states that in the provision for comprehensive health services, due respect shall be accorded to women's
religious convictions, the rights of the spouses to found a family in accordance with their religious conviction,
and the demands of responsible parenthood, and the right of women to protection from hazardous drugs,
devices, interventions, and substances. It also stated that the full range of RH services shall be ensured by the
government.

R.A. 10354, also known as the Responsible Parenthood and Reproductive Health Act of 2012, begins with a
declaration of policy that the State recognizes and guarantees the human rights to sustainable human
 development, health, education and information, and the right to choose and make decisions and in accordanc
with one's religious convictions, ethics, cultural beliefs, and demands of responsible parenthood. Among other
provisions, this law states that LGUs shall endeavor to provide adequate services for maternal care and skilled
birth attendance by hiring additional personnel to achieve an ideal skilled health professional-to-patient ratio
and by upgrading facilities to provide emergency obstetric and newborn care. It also directs the DOH to
procure, distribute to LGUs, and monitor the usage of family planning supplies for the whole country.

The Reproductive Health Program of the Philippines adopts the life-span approach. It recognizes the fact that
RH is a concern that affects different age brackets. It is client-centered, not program focused, which means tha
clients will be provided with the RH services they need. LGUs are being encouraged to integrate the provision
of the needed RH services the required facilities whenever they are able to make available and their personnel
have the appropriate competence.

The following are the 10 elements of reproductive health care:

1. Family planning;
2. Maternal and child health and nutrition (MCHN);
3. Prevention and control of reproductive tract infections, STIs, and HIV/AIDS;
4. Adolescent reproductive health;
5. Prevention and management of abortions and its complications;
6. Prevention and management of breast and reproductive tract cancers and other gynecological
conditions;
7. Education and counseling on sexuality and sexual health;
8. Men's reproductive health and involvement;
9. Prevention and management of violence against women and children; and
10. Prevention and treatment of infertility and sexual dysfunction

5.
THE PHILIPPINE FAMILY PLANNING PROGRAM (PFPP)

The Family Planning Program started in the 1970s as a family planning service delivery
component to achieve fertility reduction. It has evolved to its present-day health
orientation of improving the health of women and children and has been integrated with
other RH programs giving importance to recognizing choice and rights of FP users. This
shift was in line with the country's commitments made in the International Conference
on Population and Development, held in Cairo in 1994 and the Fourth World Conference
on Women, held in Beijing in 1995.

The National Family Planning Policy, articulated through A.O. 50-A, s. 2001, asserts that
family planning as a health intervention shall be made available to all men and women
of reproductive age (15-44 years old). FP is a means to prevent high-risk pregnancies
brought about by the following conditions:

1. Being too young (less than 18 years old) or too old (over 34 years old);
2. Having had too many (4 or more) pregnancies;
3. Having closely spaced (too close) pregnancies (less than 36 months); and
4. Being too ill or unhealthy/too sick or having an existing disease or disorder like
iron deficiency anemia.
A.O. 132, s. 2004 created the DOH Natural Family Planning (NFP) Program in recognition
of modern NFP methods acknowledged by international authorities and NFP service
providers and that have been subjected to extensive testing to ascertain their efficacy
and scientific validity. These include fertility awareness-based (FAB) methods and
lactational amenorrhea method.

A.O. 2012-0009 on the national strategy' towards reducing unmet need for modern
family planning as a means to achieving MDGs on maternal health emphasized the
implementation of the FP program integrated and synchronized with other public health
programs such as the MNCII and Garantisadong Pambata in the broader context of
the Kalusugan Pangkalahatan Execution Plan. It also pushed for the enrolment of poor
families into the National Health Insurance Program and education on the use of
Philhealth benefits for FP.

Four pillars of the PFPP

The guiding principles of the FP program, also called the four pillars of the (PFPP), are as
follows:

1. Responsible parenthood. This refers to the will and ability to respond to the
needs and aspirations of the family. It promotes the freedom of responsible
parents to decide on the timing and size of their families in pursuit of a better
life.
2. Respect for life. The 1987 Constitution protects the life of the unborn from the
moment of conception. FP aims to prevent abortions, thereby saving lives of both
women and children.
3. Birth spacing. Proper spacing of 3-5 years from a recent pregnancy enables a
woman to recover from pregnancy and to improve her well-being, the health of
the child, and the relationship between husband and wife and between parents
and children.
4. Informed choice. Couples and individuals are fully informed on the different
modern FP methods. Couples and individuals decide and may choose the
methods that they will use based on informed choice and to exercise responsible
parenthood in accordance with their religious and ethical values and cultural
background, subject to conformity with universally recognized international
human rights.

Client counseling and assessment

Family planning counseling is a client-centered, face-to-face, interactive communication

process between the health service provider and the client that helps the latter to make
free and informed choices regarding one's fertility intention or plan. It helps clients make
voluntary, fully-informed, well-considered decisions about their reproductive health
needs. It also enables clients to know more about the benefits, advantages, and
disadvantages of different family planning methods and what to do if problems develop.

The family planning counselor must:

1. Possess knowledge about the client, client needs, and the different family
planning methods;
2. Have a positive attitude towards work;
 3. Be sensitive, understanding, and helpful. Being a family planning counselor is an
important role that the nurse assumes as a provider of community health
services.

Although counseling must be based on client needs, the following are the essential
content of the nurse-client interaction regarding the chosen method:

1. Effectiveness;
2. Advantages and disadvantages;
3. Possible side effects, complications, and signs that require an immediate visit to
the health facility;
4. How to use the chosen method;
5. Prevention of STIs; and
6. When to return to the health facility.

When the client has decided on a method, the first stage in the provision of FP services is
undertaken—client assessment. Client assessment refers to the procedures done by the
health worker to determine the client's health status, particularly the client's eligibility
for contraceptive use. It aims to gather pertinent information about a client's health
status through medical history, physical examination, and, if applicable, laboratory
examinations to determine if the client may safely utilize a particular method. Ideally, all
clients who wish to utilize a method should undergo a thorough assessment prior to
provision of the chosen FP method.

Benefits of family planning

 Benefits to mothers

1. Enables her to regain her health after delivery

2. Gives enough time and opportunity to love and provide attention to her
husband and children
3. Gives more time for her family and own personal advancement
4. When suffering from an illness, gives enough time for treatment and
recovery

 Benefits to children

1. Healthy mothers produce healthy children

2. Will get all the attention, security, love, and care they deserve

 Benefits to fathers
 1. Lightens the burden and responsibility in supporting his family
2. Enables him to give his children their basic needs (food, shelter,
education, and better future)
3. Gives him time for his family and own personal advancement
4. When suffering from an illness, gives enough time for treatment and
recovery

Family planning methods

Different methods of family planning exist in every country, and policies define which are
made available to the public. In this text, family planning methods in the Philippines are
classified into natural and artificial. The methods presented are scientifically proven to
be effective and are included in the "The Philippine Clinical Standards Manual on Family
Planning".

Natural family planning

Natural family planning (NFP), as defined by the World Health Organization, refers to
methods for planning or avoiding pregnancies by observation of the natural signs and
symptoms of the fertile and infertile phase of the menstrual cycle. When NFP is practiced
to avoid pregnancy, drugs, devices, surgical procedures are not used and there is
abstinence from intercourse during the fertile phase. Modern NFP methods include
lactational amenorrhea method and fertility awareness-based (FAB) methods. The
traditional methods of withdrawal and calendar/rhythm method are no longer
recommended as these practices have been found to be ineffective and are not evidence
based.

NFP offers the following advantages:

1. It is effective when used correctly.

2. There are no physical side effects.
3. It is inexpensive since it does not involve surgery or the use of medications or
supplies.
4. There is no need for follow-up medical appointments.
5. The couple develops better understanding about their sexual physiology and
reproductive function.
6. It promotes shared responsibility for family planning.
7. It fosters better communication between spouses, thereby strengthening the
marriage and the family.
8. The couple may utilize the signs and symptoms of the woman's fertility to either
avoid or achieve pregnancy based on the couple's decision.

Lactational amenorrhea method (LAM) is based on the natural effect of

breastfeeding on the mother's fertility, that is, there is delay in the return of fertility after
childbirth. The act of breastfeeding suppresses the secretion of gonadotropin-releasing
hormone by the hypothalamus, thereby inhibiting pituitary secretion of gonadotropin
and, eventually, the development of the ovarian follicle. The end effect is a low estrogen
level in blood and transient infertility. In addition to its natural birth spacing effect, LAM
encourages the best breastfeeding practice benefiting both the mother and the baby.

Breastfeeding is 98 to 99.5% effective for birth spacing if all the following criteria are
met:

1. The mother's menstrual period has not returned.

2. Full (100%) or nearly full (85%) feeding of the baby with breast milk, day and
night.
3. The baby is less than 6 months.

If a client expresses the desire to use LAM, a simple algorithm may be used to determine
the suitability of the method to the client's circumstances.

FAB methods are based on scientific analysis of the fertile time in the woman's
menstrual cycle. These methods involve recognition of physiologic markers indicating a
woman's fertility.

FAB methods include:

1. The Billings' ovulation method (BOM), also known as cervical mucus method,
is fertility management based on cervical mucus, the body's natural sign of
fertility. Developed by Drs. John and Evelyn Billings, it has undergone successful
trials by WHO. In addition to the other advantages of NFP, the Billings method is
applicable to women in all stages of reproductive life. It may be used by women
with irregular menstrual cycles, by peri menopausal women, and by nursing
mothers. With consistent and correct use, BOM is 95-97% effective in preventing
pregnancies. However, a 12-month study in China involving 992 couples showed
99.5% efficacy.

 BOM requires that the woman observe and record the following phases in
her menstrual cycle:

 Menstruation.
 Basic infertile pattern (BIP) - observed after menstruation; the
woman feels dry around the genital area and does not have
vaginal discharge, or she may have an unchanging pattern of
vaginal discharge; this phase has no fixed number of days.
 Changing pattern of fertility - vaginal discharge becomes thinner
and clearer and there is a sensation of being wet and slippery; a
feeling of fullness or swelling of the tissues of the vulva may
accompany the slippery sensation; the last day is the peak of
fertility.
 Peak of fertility - the last of the slippery sensation; the day after
the peak of fertility, confirmed by the loss of the slippery
sensation on the next.
 Postovulatory infertile phase - lasts for about 14 days; the woman
may feel dry again or may have some discharge, but there is no
 slippery sensation; this is the phase before the start of
menstruation.

 To avoid pregnancy, the couple has to follow the four rules of BOM:

 Avoid intercourse on menstrual days. If the woman is going

through a short cycle, she may become fertile while having
menstrual bleeding. In this event, she will not notice the passage
of fertile mucus.
 During the BIP period, the couple may have intercourse every
other evening at the most to allow for observation of passage of
fertile mucus. If the couple has intercourse during the day, the
discharge of seminal fluid may mask the passage of fertile
mucus, which occurs when the woman is up and about.
 Avoid intercourse during days of changing pattern of fertility until
the fourth day after the peak.
 The couple may have intercourse at any time from the fourth day
after the peak until the next menstruation.

2. Basal body temperature (BBT) refers to one's body temperature when one is
fully at rest, that is, upon rising from sleep and before eating. BBT changes
related to hormonal changes are observed around the time of ovulation, and
these changes may be used for predicting fertility. At the time of ovulation, BBT
goes down slightly (around 0.3°C). This is followed by a rise in temperature no
higher than normal maintained over a period of several days until the next
menstruation. The decrease in BBT at the time of ovulation is due to the surge in
the secretion of luteinizing hormone, while the BBT rise occurs with the secretion
of progesterone by the corpus luteum.

 The couple who chooses BBT method for fertility regulation should be
given the following instructions:

 The woman should take her BBT every morning before arising,
using the same digital oral thermometer. For accuracy, the
woman must have at least 3 hours of continuous sleep.
 The couple/woman should record the daily BBT and look for a
pattern. A slight increase (typically less than 0.5°C) sustained for
3 days or more indicates ovulation has taken place and that the
woman may be fertile.
 The woman is most fertile 2-3 days before BBT rises, to avoid
pregnancy, the couple should abstain from the start of
menstruation up to 3-4 days after BBT rises.
  BBT may be influenced by many factors like illness, stress, changes in
sleep patterns, and intake of alcohol, and is also the least effective NFP
method. For these reasons, BBT is better used in combination with other
signs of fertility (symptothermal method). Another disadvantage of this
method is the strict adherence to a daily routine of taking the BBT.

3. In the symptothermal method, all the signs of fertility are taken note of. In
addition to tracking cervical mucus and BBT, other signs of ovulation are
observed such as:

 Mittelschmerz - one-sided, lower abdominal pain that occurs at around

the time of ovulation .
 Spinnbarkeit - the capacity of cervical mucus to stretch a distance before
breaking.
 Breast tenderness.
 Increased libido.
 Mood changes, such as depression and mood swings.

4. Standard Days method (SDM) is appropriate for the couple where the woman's
menstrual cycle lasts from 26 to 32 days. This method requires tracking of
menstrual cycles. The first day of menstruation is counted as day 1. Days 8
through 19 are noted as fertile days when the couple abstains from intercourse if
they want to avoid a pregnancy. A necklace, called SDM beads, is used as a
memory aid by the woman. SDM beads are color-coded beads with a movable
rubber marker to facilitate tracking the menstrual cycle. With correct use, SDM is
95% effective for women with cycles between 26 and 32 days long; with typical
use, it is 88% effective.

5. The Two-Day Method is a simple, fertility awareness technique that uses

cervical secretions as an indicator of fertility. It requires the woman to check the
presence of secretions every day. If a woman notices any secretions that day or
the day before, she should consider herself fertile and avoid intercourse on those
days. This method has been found to be about 96% effective with correct use,
and 86% effective with typical use.

FAB methods offer all the advantages of NFP. However, they may present the following
disadvantages:

1. Except for SDM, the couple needs training and time to use the method
effectively. It takes about two to three cycles to accurately identify the fertile
period.
 2. Except for SDM, these methods require consistent and accurate record keeping.
3. These methods require a high level of diligence and motivation by the couple.
4. These methods require periods of abstinence from intercourse, which may be
difficult for some couples.
5. These methods offer no protection against STIs/HIV/AIDS.

Artificial family planning methods

Methods provided through MNCHN include the following:

1. Combined oral contraceptives (COCs), simply called pills, are preparations

that contain hormones similar to the woman's natural hormones—estrogen and
progestogen—taken daily to prevent conception. They prevent conception mainly
by suppressing ovulation. They also cause changes in the endometrium and
thicken cervical mucus making sperm transport inside the uterus difficult or
unfavorable. It is 99.7% effective with perfect use, 92% with typical use.

 COCs come in either 21- or 28-day packs. All pills in a 21-day pack
contain the hormones estrogen and progesterone. If the woman is using
a 21-pi 11 pack, she takes one pill a day regularly, with a 7-day rest
period before starting a new pack. In the 28-day pack, 21 pills contain
hormones. The remaining seven, which are of a different color, are
placebo or nonhormone pills. A woman using a 28-day pack takes a pill
every day and starts a new pack immediately when she finishes the
pack. It is best for the woman who is beginning to use pills to start taking
them within the first 5 days of the menstrual cycle. Below are
instructions to follow when a woman misses her pills:

Advantages of using COCs include:

 Convenient and easy to use;

 Makes menstrual cycles more regular and predictable;
 Reduces symptoms of gynecologic conditions such as
dysmenorrhea and endometriosis;
 Reduces the risk of ovarian and endometrial cancer;
 Reversible, rapid return to fertility;
 Does not interfere with intercourse; and
 Safe as proven through extensive studies, although proper
precautions have to be observed by both health worker and
client.

Disadvantages of using COCs include;

  Effectiveness is lowered with incorrect use and intake of some
drugs such as rifampicin and most anticonvulsants;
 Can suppress lactation;
 Requires regular resupply;
 Offers no protection against STIs, including HIV;
 Has side effects such as nausea, dizziness, or breast tenderness,
which are not generally harmful but which some women may find
difficult to tolerate; and
 May pose health risks for some women. The most serious side
effect of COG use is an increased risk of cardiovascular disease-
specifically blood clots, heart attacks, and strokes.

Safety in the use of COCs depends on actions of both the health

worker and the client. Women who take oral contraceptives have
an increased risk of benign liver tumors. A number of studies also
show that current or recent users of birth control pills had a slightly
higher risk of developing breast cancer than women who had never
used the pill. Long-term use of oral contraceptives (5 or more
years) is associated with an increased risk of cervical cancer.
However, this increased risk may be because sexually active
women have a higher risk of becoming infected with the human
papillomavirus, which causes virtually all cervical cancers. The
health worker has to determine the eligibility of COCs for a client
by diligently using the medical eligibility checklist for COCs. The
client needs to learn and observe herself for side effects and
adverse effects of COCs.

Definite contraindications to the use of COCs include breastfeeding and less than
6 weeks postpartum, history of and current ischemic heart disease or stroke,
smoking 15 or more cigarettes per day in a woman aged 35 years or more,
raised blood pressure (systolic >160 or diastolic >100 mm Hg), diabetes mellitus
with vascular complications of >20 years duration, deep vein thrombosis, breast
cancer within the past 5 years, and liver conditions like active viral hepatitis,
benign or malignant liver tumor, and decompensated cirrhosis.

2. Depot medroxyprogesterone acetate, known by its brand name Depo

Provera, is a progestin-only preparation injected intramuscularly every 3 months.
The hormone is then released slowly into the bloodstream. Its main action is the
suppression of ovulation, but it also changes the cervical mucus and endometrial
lining. It is about 99% effective with perfect use, 97% with typical use.

 The main advantages of using depot medroxyprogesterone acetate

include:

 Does not interfere with intercourse;

  Since it does not contain estrogen, it can be used while
breastfeeding a baby 6 months or older;
 May help protect against endometrial cancer, pelvic inflammatory
disease (PID), and iron-deficiency anemia.

 Its disadvantages include:

 Delayed return to fertility for about 1-4 months after use ;

 Irregular vaginal bleeding is common ; and
 Gradual weight gain
 Does not protect against STIs.

 Contraindications include liver conditions like cirrhosis, hepatitis, or

tumor; hypertension where systolic is 160 mm Hg or higher or diastolic
pressure is 100 or higher; diabetes mellitus with vascular complications
of >20 years duration; serious cardiovascular problems like stroke,
myocardial infarction, and deep vein thrombosis; and history of breast
cancer.

3. An intrauterine device (IUD) is usually a small plastic or metal device inserted

inside a woman's uterus to prevent pregnancy. It releases copper or a hormone.
Almost all IUDs have one or two strings that hang through the cervical opening
into the vagina. There are two types of IUD: hormone-releasing and copper-
bearing IUD. The latter is being used in the PFPP. It is about 99% effective.

 For a woman with menstrual cycles, the optimum time of IUD insertion is
while she is having menstrual bleeding. However, it may be done at any
time within the cycle as long as the woman is certain she is not pregnant.
The amenorrhoeic woman may have an IUD inserted as long as she is
determined not to become pregnant. After childbirth, optimum time is
within 48 hours after a normal delivery, and 5 weeks after a Caesarean
delivery.
 Advantages of using IUD are :

 Local action;
 Has no effect on amount or quality of breast milk;
 Low cost;
 Docs not interfere with sexual intercourse; ° One-time
application;
 Immediate return to fertility upon removal;
 Can be inserted immediately after childbirth or after abortion and
can be removed by a trained provider; and
 Long-lasting - the copper-bearing IUD lasts for 10 years or more.
  Disadvantages include:

 Has common side effects such as pain and cramping, longer and
heavier menstrual bleeding and menstrual irregularities;
 Device may be expelled, possibly without the woman knowing it
(especially for postpartum insertions);
 Requires a pelvic exam before insertion and requires a trained
health service provider to insert/remove the IUD;
 Does not protect against STIs and may increase the incidence of
PID;
 Although rare (1 in 1,000 cases, according to WHO), possible
uterine perforation, which usually occurs at the time of insertion;
and
 Requires self-checking of IUD strings from time to time, which
some women may not want to do.

Definite contraindications include known or suspected pregnancy; infections of

the reproductive tract like current or recent STIs, PID, pelvic TB and infection
following childbirth or incomplete abortion; unexplained vaginal bleeding before
evaluation; known or suspected cervical, endometrial cancer; and conditions with
distortion of the uterine cavity.

4. Barrier methods involve the use of devices that mechanically or chemically

prevent fertilization. Barrier devices include male condoms, diaphragms, cervical
caps, and spermicides. Female condoms are not readily available in the
Philippines. Effectiveness ranges from around 70% (for cervical caps and
spermicides) to around 85% (for male condoms).

 They are generally easy to use, except for the diaphragm and cervical
cap, which require pelvic manipulation. However, they cannot be used by
couples where one or both are allergic to latex rubber (for condoms,
diaphragms, cervical caps) or to the spermicide ingredients.
 The diaphragm and the cervical cap are left in place for 6 hours after
ejaculation. Not removing the diaphragm for more than 24 hours and the
cervical cap for more than 48 hours may result in toxic shock syndrome.

5. Permanent methods are vasectomy for the male and bilateral tubal ligation
(BTL) for the female.
  Vasectomy is a surgical procedure where the vas deferens is tied and
cut or blocked through a small opening on the scrotal skin. This may be
done either through a traditional/incisional vasectomy where a small
incision is done in the scrotal skin using a scalpel or through no-scalpel
vasectomy (NSV), where a puncture wound using a vas dissecting
forceps is made at the midline of the scrotal skin to reach both vas on
either side. This offers advantages such as lesser pain and tissue trauma,
and shorter operating and recovery time. NSV is now the procedure of
choice in the Philippines.

 Vasectomy works by blocking the vas deferens, resulting in

absence of sperm in the seminal fluid. This method is almost
100% effective 3 months after the procedure, when the seminal
fluid no longer contains sperms. This is a permanent method and
therefore should be used only by couples who have the desired
number of children and after appropriate counseling. Like other
surgical procedures, a written consent is required.
 Possible complications include scrotal hematoma, wound
infection, epididymitis, and sperm granuloma, which is caused by
leakage of sperm from the cut ends of the vas causing
inflammation.

 Bilateral tubal ligation (BTL) involves cutting or blocking the two

fallopian tubes. The acceptable standard procedure is mini-laparotomy
under local anesthesia and light sedation. It prevents conception by
blocking the passage of the ovum through the fallopian tube thereby
preventing fertilization.

 This method is almost 100% effective and can be performed

immediately after a woman gives birth or immediately after an
abortion. For other women, certainty that they are not pregnant
is a requirement for the procedure. Before the procedure, a
written consent is obtained.

 As in other minor surgeries, BTL involves risks like infection,

bleeding at the incision she, injury to internal organs, and
anesthesia risk. Rarely, ectopic pregnancy may result alter a BTL.
Like vasectomy, this is a permanent procedure and should be
undertaken only after counseling and the woman is sure she does
not want to become pregnant in the future. Reversal surgery is
difficult, expensive, and not available in most areas. Also, success
is not guaranteed.

NEWBORN SCREENING
Newborn screening (NBS) is a simple procedure to find out if a baby has a congenital
metabolic disorder that may lead to mental retardation or even death if left untreated.
Having the baby undergo NBS is important because most babies with metabolic
disorders look "normal" at birth. By doing NBS, metabolic disorders may be detected
even before clinical signs and symptoms are present. Treatment can then be given early
to prevent serious consequences of untreated metabolic conditions.

Newborn screening in the Philippines

Recognition of the importance of NBS is evidenced by the passage of R.A. 9288 also
known as the Newborn Screening Act of 2004. This law states that, prior to delivery, any
health practitioner who delivers, or assists in the delivery, of a newborn in the Philippines
has the obligation to inform the parents or legal guardian of the newborn of the
availability, nature, and benefits of NBS. The health practitioner shall maintain
documentation in (he patient's records that NBS information has been provided). If a
parent or legal guardian refuses testing, he or she shall acknowledge in writing
understanding that refusal for testing places the newborn at risk for mental retardation
or death of undiagnosed heritable conditions. Likewise, a copy of this refusal document
shall be made part of the newborn's medical record. Refusal shall also be indicated in the
national NBS database .

The law provided for the establishment of the Newborn Screening Reference Center
(NSRC), which shall be responsible for the national testing database and case registries,
training, technical assistance, and continuing education for laboratory staff in all
Newborn Screening Centers (NSCs).

Although ideally done on the 48th to the 72nd hours of life, NBS may also be done after
24 hours from birth. The law provides that NBS be done after 24 hours of life, but not
later than three (3) days from complete delivery of the newborn. However, newborns
who need 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.

In the Philippines, the disorders tested for NBS are:

1. Congenital hypothyroidism - a condition in which the baby is born with the

inability to produce enough thyroid hormone.
2. Congenital adrenal hyperplasia - a group of inherited disorders characterized by
the inability of the adrenal gland to secrete Cortisol or aldosterone, or both.
3. Galactosemia - an inherited disorder in which the body is unable to metabolize
galactose and the person is unable to tolerate any form of milk—human or
animal.
4. Phenylketonuria - an inherited condition in which a baby is born without the
ability to properly break down an amino acid called phenylalanine.
5. Glucose-6-phosphate-dehydrogenase (G6PD) deficiency - a hereditary condition
in which red blood cells break down when the body is exposed to certain drugs,
foods, severe stress, or severe infection.
6. Maple syrup urine disease - a genetic defect in which a person is unable to break
down the amino acids leucine, isoleucine, and valine; urine of affected persons
smells like maple syrup.
Newborn screening procedure

The specimen for NBS is obtained through a heel prick. A few drops of blood are taken
from the baby's heel, blotted on a special absorbent filter card and then sent to an NSC.
The blood sample for NBS may be obtained by a physician, nurse, medical technologist,
or trained midwife. NBS is available in hospitals, lying-in clinics, RHUs, health centers,
and some private clinics. If babies are delivered at home, babies may be brought to the
nearest institution offering NBS.

Normal (negative) NBS results are available by 7-14 working days from the lime samples
are received at the NSC. Positive NBS results should be relayed to the parents
immediately by the health facility. Babies with positive results must be referred at once
to a specialist for confirmatory testing and further management. Should there be no
specialist in the area, the NBS secretariat office will assist the baby's attending
physician.

An NSC is a facility equipped with according to the standards established by the NIHP
(National Institutes of Health, Philippines) and provides all required laboratory tests and
recall/follow-up programs for newborns with heritable conditions. NSCs are located at the
following sites:

1. NSC-NIH for the National Capital Region and Luzon: National Institutes of Health,
University of the Philippines Manila, Pedro Gil St., Ermita, Manila
2. NSC-Central Luzon for Regions I, II, III, and CAR: Angeles University Foundation
Medical Center, Angeles City
3. NSC-Visayas: West Visayas State University Medical Center, Iloilo City
4. NSC-Mindanao: Southern Philippines Medical Center, Davao City

Newborn hearing screening

R.A. 9709, also known as the Universal Newborn Hearing Screening and Intervention Act
of 2009, established a Universal Newborn Hearing Screening Program (UNHSP) for the
early detection of congenital hearing loss among newborns and referral for early
intervention services to infants with hearing loss. It also established the Newborn
Hearing Screening Reference Center at the National Institutes of Health.

The law places on any health care practitioner who delivers or assists in the delivery of a
baby in the Philippines the obligation to inform the parents or legal guardian of the
newborn of the availability, nature, and benefits of hearing loss screening among
newborns or infants 3 months old and below. As in NBS, parents or legal guardians of
newborns who refuse the test shall sign a waiver indicating their understanding of the
risks of undiagnosed congenital hearing loss. The document shall become part of the
newborn's medical record.

Early detection and intervention facilitate speech development and prevent future
learning and psychosocial difficulties of the child with hearing impairment

EXPANDED PROGRAM ON IMMUNIZATION

The Expanded Program on Immunization (EPI) was established in 1976 to ensure that infants/children and
mothers have access to routinely recommended infant/childhood vaccines. Six vaccine-preventable diseases
were initially included in the EPI: TB, poliomyelitis, diphtheria, tetanus, pertussis, and measles.

The immunization coverage of children has improved. The 2008 National Demographic and Health Survey
showed that 3 out of 4 births were protected against neonatal tetanus, that is, women whose last birth was
protected against neonatal tetanus was 76%. The differentials in protection against neonatal tetanus among
subgroups of women vary. Across regions, tetanus toxoid (TT) coverage ranged from 39% in ARMM to 88% in
Central Visayas and Cagayan Valley. By level of education, IT coverage was lowest for women with no
education at 34% and highest for women with high school education at 80%.

Goals of the expanded program on immunization and supporting legislation

To achieve the over-all EPI goal of reducing the morbidity and mortality among children against the most
common vaccine-preventable diseases, the following laws have given the mandate of protecting children
through immunization to the DOH and LGUs:

 R.A. 10152, also known as Mandatory Infants and Children Health Immunization Act of 2011,
mandates basic immunization covering the vaccine-preventable diseases. Added to the six
immunizable diseases previously mentioned are hepatitis B, mumps, rubella, diseases caused
by Haemophilus influenzae type B (Hib), and other diseases as determined by the Secretary of Health
in a department circular. It gives the directive to government hospitals and health centers to provide
for free mandatory basic immunization to infants and children up to 5 years of age. This law has
repealed PD 996.
 R.A. 7846 provided for compulsory immunization against hepatitis B for infants and children below 8
years old. It also provided for hepatitis B immunization within 24 hours after birth of babies of
women with hepatitis B.

The following are the specific goals of the program:

1. To immunize all infants/children against the most common vaccine-preventable diseases.

2. To sustain the polio-free status of the Philippines.
3. To eliminate measles infection. Presidential Proclamation No. 4, s. 1998 launched the Philippine
Measles Elimination Campaign.
4. To eliminate maternal and neonatal tetanus. Presidential Proclamation No. 1066, s. 1997 declared a
national neonatal tetanus elimination campaign starting 1997.
5. To control diphtheria, pertussis, hepatitis B, and German measles.
6. To prevent extrapulmonary TB among children.

Immunization schedule for infants and young children

Immunization is an essential health intervention for eligible children and women, and this service is available in
all health facilities and institutions providing health services for women and children nationwide. Wednesday is
the designated immunization day in government health facilities unless otherwise revised by local traditions,
customs, and other exceptions.

Infants are given this service according to the schedule and manner prescribed by the DOH.

Receiving the antigens at the earliest possible age reduces the chance of the child getting infected or sick of the
immunizable diseases. Administration of the hepatitis B vaccine at birth reduces the chance of the child
becoming a carrier. Studies also show that measles vaccine is 85% effective.

In 2012, two new vaccines were introduced as part of EPI; Rotavirus vaccine and Hib vaccine. Rotavirus
infects the large intestine. It is the most common cause of severe diarrhea in infants and children. Children
between the ages of 6 and 24 months are at greatest risk for developing severe Rotavirus infection. In the
Philippines, at least 30% of diarrhea-related hospitalizations are caused by Rotavirus.
Hib is a bacterium responsible for serious illnesses, such as meningitis and pneumonia, with almost all cases
younger than 5 years, with those between 4 and 18 months of age especially vulnerable.

The following are important considerations related to the schedule and manner of administering infant
immunizations:

 Use only one sterile syringe and needle per client.

 There is no need to restart a vaccination series regardless of the time that has elapsed between doses.
 All the FPI antigens are safe and effective when administered simultaneously, that is, during the same
immunization session but at different sites. It is not recommended, however, to mix different vaccines
in one syringe before injection, or to use a fluid vaccine for reconstitution of a freeze-dried vaccine.
When a vaccine is administered to an infant at the same time with another injectable vaccine, the
vaccines should be administered on different sites. However, if more than one injection has to be
given on the same limb, the injection sites should be 2.5-5 cm apart to prevent overlapping of local
reactions.
 The recommended sequence of the coadministration of vaccines is OPV first followed by Rotavirus
vaccine, then other appropriate vaccines.
 OPV is administered by putting drops of the vaccine straight from the dropper onto the child's tongue.
Do not let the dropper touch the tongue.
 Only monovalent hepatitis B vaccine must be used for the birth dose. Pentavalent vaccine must not be
used for the birth dose because DPT and Hib vaccine should not be given at birth. A monovalent
vaccine is one that contains an antigen against a single disease. Pentavalent vaccine contains antigens
against five diseases: diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus influenzae B.
 Children who have not received AMV1 as scheduled and children whose parents or caregivers do not
know whether they have received AMV1 shall be given AMV1 as soon as possible, then AMV2 one
month after the AMV1 dose.
 All children entering day care centers/preschool and Grade 1 shall be screened for measles
immunization. Those without the immunization shall be referred to the nearest health facility for
immunization.
 The first dose of Rotavirus vaccine is administered only to infants aged 6 weeks to 15 weeks. The
second dose is given only to infants aged 10 weeks up to a maximum of 32 weeks.
 Administer the entire dose of the Rotavirus vaccine slowly down one side of the mouth (between the
cheek and gum) with the tip of the applicator directed toward the back of the infant's mouth. To
prevent spitting or failed swallowing, stimulate the rooting and sucking reflex of the young infant. For
infants aged 5 months or older, lightly stroke the throat in a downward motion to stimulate
swallowing.

EPI vaccines

Preparations used in EPI are either inactivated (killed) microorganisms, attenuated microorganisms, fragments
horn microorganisms like hepatitis B vaccine, or toxoids. Attenuated vaccines are live microorganisms that
have been altered so that they are no longer pathogenic, but are still antigenic. Toxoids are inactivated or altered
bacterial exotoxins.

Target setting and vaccine requirements

The first specific goal of EPI in the Philippines indicates a target of 100% immunization of infants/children
against the most common vaccine-preventable diseases. At the RHU/health center level, the public health nurse
is responsible for preparing vaccine requirements and overseeing vaccine allocation. Vaccine requirement is
calculated based on eligible population. The nurse uses the following formulas to estimate eligible population:
Estimated number of infants = total population X 2.7%

Estimated number of 12- to 59-month-old children = total population X 10.8%

Estimated number of pregnant women = total population X 3.5%)

Maintaining the potency of EPI vaccines

Vaccines confer immunity only when they are potent, and to retain their potency, vaccines must be properly
stored, handled, and transported. The following points are important considerations to maintain the potency of
EPI vaccines.

Maintain the cold chain

The cold chain is a system for ensuring the potency of a vaccine from the time of manufacture to the time it is
given to an eligible client.

The person directly responsible for cold chain management at each level is called the Cold Chain Officer. At
the RHU/health center, the public health nurse acts as the Cold Chain Officer. This means that the nurse is in
charge of maintaining the cold chain equipment and supplies, such as the freezer/refrigerator, transport box,
vaccine bags/carriers, cold chain monitors, thermometers, and cold packs. The nurse implements an emergency
plan in the event of an electrical breakdown or power failure.

EPI vaccines and the special diluents have the following cold chain requirements:

 OPV: -15 to -250C. OPV has to be stored in the freezer. In the vaccine bag, OPV is placed in contact
with cold packs.
 All other vaccines, including measles vaccine, MMR, and Rotavirus vaccine, have to be stored in the
refrigerator at a temperature of +2 to +8°C. These vaccines should be stocked neatly on the shelves of
the refrigerator. Do not stock vaccines at the refrigerator door shelves.
 Hepatitis R vaccine, Pentavalent vaccine, Rotavirus vaccine, and TT are damaged by freezing, so they
should not be stored in the freezer. Wrap the containers of these vaccines with paper before putting
them in the vaccine bag with cold packs.
 Keep diluents cold by storing them in the refrigerator in the lower or door shelves.

Other Considerations to Maintain Potency

 Observe the first expiry-first out (FEFO) policy.

 Comply with recommended duration of storage and transport. At the health center/RHU with a
refrigerator, the duration of storage should not exceed one month. Using transport boxes, vaccines can
be kept only up to a maximum of 5 days.
 Take note if the vaccine container has a vaccine vial monitor (VVM) and act accordingly. The VVM is
a round disc of heat-sensitive material placed on a vaccine vial to register cumulative heat exposure.
A direct relationship exists between rate of color change and temperature: the lower the temperature,
the slower the color change; the higher the temperature, the faster the color change.

 Abide by the open-vial policy of the DOH. A multidose vial may be opened for one or two clients if the
 health worker feels that a client cannot come back for the scheduled immunization session. Multidose
liquid vaccines, such as OPV, Pentavalent vaccine, hepatitis B vaccine, and TT from which one or
more doses have been taken following standard sterile procedures, may be used in the next
immunization sessions for up to a maximum of 4 weeks, provided that all the following conditions
are met:

 the expiry date has not passed.

 the vaccine has not been contaminated.
 the vials have been stored under appropriate cold chain conditions,
 The vaccine vial septum has not been submerged in water
 The VVM on the vial, if attached, has not reached the discard point.

 Reconstitute freeze-dried vaccines such as BCG, AMV, and MMR only with the diluents supplied with
them.
 Discard reconstituted freeze-dried vaccines 6 hours after reconstitution or at the end of the
immunization session, whichever comes sooner.
 Protect BCG from sunlight and Rotavirus vaccine from light.

Side effects and adverse reactions of immunization

Vaccine recipients or their parents/guardians should be informed of side effects or adverse reactions of the
vaccine(s) to be given. Adverse events should be monitored closely.

BCG injection results in the formation of a wheal that disappears within 30 minutes. After about 2 weeks, a
small red tender swelling appears at the injection site, which may develop into a small abscess which ulcerates.
The ulcer heals by itself and leaves a scar. The whole course from vaccination to the formation of a scar takes
about 12 weeks. This is an expected response and does not require any management.

Side effects of vaccination and their management

(Expanded Program on Immunization, Philippines)

BCG Koch's No
phenomenon: an management is
acute needed
inflammatory
reaction within 2-
4 days after
vaccination;
usually indicates
previous
exposure to
tuberculosis

Deep abscess at Refer to the

vaccination site; physician for
almost invariably incision and
due to drainage
subcutaneous or
deeper injection

Indolent Treat with

ulceration: an INH powder
 ulcer which
persists after 12
weeks from
vaccination date

Glandular If suppuration
enlargement: occurs, treat as
enlargement of deep abscess
lymph glands
draining the
injection site

Hepatitis B Local soreness at No treatment

vaccine the injection site is necessary

DPT-HepB- Fever that usually Advise parents

Hib(Pentavalent lasts for only 1 to give
vaccine) day. Fever antipyretic
beyond 24 hours
is not due to the
vaccine but to
other causes

Local soreness at Reassure

the injection site parents that
soreness will
disappear after
3-4 days

Abscess after a Incision and

week or more drainage may
usually indicates be necessary
that the injection
was not deep
enough or the
needle was not
sterile

Convulsions: Proper
although very management
rare, may occur of
in children older convulsions;
than 3 months; pertussis
caused by vaccine should
pertussis vaccine not be given
anymore

OPV None

Anti-measles Fever 5-7 days Reassure

vaccine after vaccination parents and
in some children; instruct them
sometimes, there to give
is a mild rash antipyretic to
the child

MMR Local soreness, Reassure

fever, irritability, parents and
and malaise in instruct them
some children to qive
antipyretic to
the child
 Rotavirus Some children Reassure
vaccine develop mild parents and
vomiting and instruct them
diarrhea, fever, to give
and irritability antipyretic and
Oresol to the
child

Tetanus toxoid Local soreness at Apply cold

the injection site compress at
the site. No
other treatment
is needed
Contraindications to immunization

In general, there are no contraindications to immunization of a sick child if the child is well enough to go home.
Sending children away and telling mothers to bring them back for immunization when they are well enough is a
bad practice because it delays immunization. Bringing the child back to the RHU/health center for
immunization at another time may not be easy for the mother, leaving the child at risk of getting sick of an
immunizable disease.

There are few absolute contraindications to the EPI vaccines. Do not give:

 Pentavalent vaccine/DPT to children over 5 years of age;

 Pentavalent vaccine/DPT to a child with recurrent convulsions or another active neurological disease of
the central nervous system;
 Pentavalent vaccine 2 or 3/DPT 2 or 3 to a child who has had convulsions or shock within 3 days of the
most recent dose;
 Rotavirus vaccine when the child has a history of hypersensitivity to a previous dose of the vaccine,
intussusceptions or intestinal malformation, or acute gastroenteritis; and
 BCG to a child who has signs and symptoms of AIDS or other immune deficiency conditions or who
are immunosuppressed.

Some conditions are considered false contraindications. If they are seen in children, the health worker may
continue with the appropriate immunizations. These are:

 Malnutrition, which should be considered as an indication that the child especially needs the protection
conferred by immunization;
 Low-grade fever;
 Mild respiratory infection; and
 Diarrhea. Children with diarrhea who are due for OPV should receive a dose of OPV during the visit.
However, the dose is not counted. The child should return when the next dose of OPV is due.

EPI recording and reporting

EPI recording and reporting are accomplished using the FHSIS.

Fully immunized children (FIC) are those who were given BCG, three doses of OPV, three doses of DPT and
hepatitis B vaccine or three doses of Pentavalent vaccine, and one dose of anti-measles vaccine before reaching
one year of age.

Completely immunized children refer to children who completed their immunization schedule at the age of
12-23 months.

A child protected at birth (CPAB) is a term used to describe a child whose mother has received:
 a. Two doses of IT during this pregnancy, provided that the second dose was given at least a month
prior to delivery;
b. At least three doses of TT any time prior to pregnancy with this child.
c.

INFANT AND YOUNG CHILD FEEDING

Optimal infant and young child feeding practices rank among the most effective interventions to improve child
health. In 2006, an estimated 9.5 million children worldwide died before their fifth birthday, and two-thirds of
these deaths occurred in the first year of life. Undernutrition is associated with at least 35% of child deaths. It is
also a major disabler preventing children who survive from reaching their full developmental potential.

In 2002, WHO and UNICEF jointly issued the Global Strategy for Infant and Young Child Feeding (IYCF) to
renew world attention to the impact that feeding practices have on the nutritional status, growth and
development, health, and thus the very survival of infants and young children. The commitment of the
Philippine DOH to the global strategy is shown in various administrative issuances, particularly Administrative
Order 2005-0014 that states the national policies on infant and young child feeding.

Mothers and families should have access to objective, consistent, and complete Information about appropriate
feeding practices, free from commercial influence. In particular, they need to know about the recommended
period of exclusive and continued breastfeeding; the timing of the introduction of complementary foods; what
types of food to give, how much, and how often; and how to feed these foods safely.

Health care professionals can play a critical role in providing support, through influencing decisions about
feeding practices among mothers and families. Therefore, it is critical for health professionals to have basic
knowledge and skills to give appropriate advice, counsel and help solve feeding difficulties, and know when
and where to refer a mother who experiences more complex feeding problems.

In addition to good feeding practices, other measures such as micronutrient supplementation, food fortification,
diet diversification, and deworming are applied to improve the nutritional status of infants and young children.
Aside from the actual implementation of micronutrient supplementation and deworming, the public health
professional contributes to the program through health education on diet diversification and food fortification.

Infant and young child feeding: The Philippine situation

Legislative efforts to improve the nutritional status of infants and young children in the country include:

Executive Order No. 51 - also known as the Milk Code; among other provisions, prohibits advertising,
promotion, or other marketing materials that shall imply or create a belief that bottle-feeding is equivalent or
superior to breastfeeding.Executive Order No. 382 - provided for the observance of the National Food
Fortification Day every November 7.R.A. 7600 - also known as the Rooming-In and Breast-heeding Act;
among other provisions, states that newborn infants be put to the breast of the mother immediately after birth
and roomed-in within 30 minutes after normal spontaneous deliveries and within 3-4 hours after birth by
caesarian delivery.R.A. 8172 - also known as ASIN (Act for Salt Iodization Nationwide) Law; requires all
producers of food-grade salt to iodize the salt that they produce, import, trade, or distribute.R.A. 8976 - also
known as the Philippine Food Fortification Act; mandates the fortification of rice with iron, wheat flour with
vitamin A and iron, refined sugar with vitamin A, and cooking oil with vitamin A; and promotes fortification of
food products through the Sangkap Pinoy Seal Program.R.A. 1002S - also known as the Expanded
Breastfeeding Promotion Act; among other provisions, mandates the setting up of lactation stations in all health
and nonhealth facilities, establishments, or institutions; and also grants break intervals for nursing employees to
breastfeed or express milk.A.O. 36, s2010 - also known as ExpandedGarantisadong Pambata (CP); a
comprehensive and integrated package of services on health, nutrition, and environment for children available
every day at various settings such as homes, schools, health facilities, and communities by government and
nongovernment organizations, private sectors, and civic groups.Despite efforts, however, National and
Demographic Health Survey (NDHS) results indicate that the prevalence of breastfeeding in the Philippines has
not changed over the past two decades. (Note that the National Statistics Office conducts the NDHS every 5
years.) The 2008 NDHS results show that, among children born in the 5-year period preceding the survey,
about 88% were ever breastfed. Among the last-born children who were ever breastfed, only around 54%
started breastfeeding within 1 hour of birth and 82% within 1 day.

The 2008 survey also showed that the median duration of exclusive breastfeeding is less than 1 month, which is
much shorter than the recommended duration of 6 months of exclusive breastfeeding. The median duration of
breastfeeding was 14 months, which is again, shorter than the recommended 2-year duration. Overall, 55% of
children age 6-23 months are fed according to the recommended YVCV practices, that is, they are given breast
milk or milk products, foods from the recommended number of food groups, and are fed at least the
recommended minimum number of times per day.

The Seventh National Nutrition Survey in 2008 likewise showed the need to improve feeding practices of
infants, young children, and pregnant women, with particular focus on iodine intake for the last group. Based
on survey findings, an estimated 26.2% of ttnder-5-year-old children were underweight for their age and about
27.9% had stunting or were short or below height for their age. The prevalence rate of vitamin A deficiency
(VAD) among 6-month- to 5-year-old children was estimated at 15.2%, whereas the prevalence rate of anemia
was estimated at 55.7% among infants aged 6-11 months and 20.9% among children aged 1-5 years. Among
pregnant women, 10.5% were estimated to have severe iodine deficiency, whereas 15.3% had moderate
deficiency.

Nutritional assessment of the infant and young child

Nutritional assessment begins with history taking. The child's dietary and health history, such as a recent
episode of infection like measles, may point to key factors that may have influenced the child's current
nutritional status.

In the documentation of a child's dietary history, the nurse uses the following terms to describe different
feeding practices:

 Exclusive breastfeeding - this means that the infant receives breast milk (including expressed breast
milk or breast milk from a wet nurse) and allows the infant to receive oral rehydration salt (ORS),
drops, syrups (vitamins, minerals, medicines), but nothing else.
 Predominant breastfeeding - this means that the infant's predominant source of nourishment has been
breast milk, including milk expressed or from a wet nurse as the predominant source of nourishment.
However, the infant may also have received liquids—water and water-based drinks, fruit juice, ritual
fluids, and Oresol drops or syrups, such as vitamins, minerals, and medicines,
 Complementary feeding - the process of giving the infant foods and liquids, along with breast milk,
when breast milk is no longer sufficient to meet the infant's nutritional requirements.
 Bottle feeding - this means that the child is given food or drink (including breast milk) from a bottle
with a nipple/teat. Information on bottle feeding is useful because of the potential interference of
bottle feeding with optimal breastfeeding practices and the association between bottle feeding and
increased diarrheal disease morbidity and mortality.
 Early initiation of breastfeeding - initiating breastfeeding of the newborn after birth within 90 minutes
of life in accordance to the essential newborn care protocol.

Nutritional assessment may also include any or several of the following:

 Anthropometry is the measurement of physical dimensions and gross composition of the body.
Anthropometric assessment of a child to determine nutritional status include:

 Weight-for-age reflects body weight relative to the child's age. This measurement is used
to determine underweight. Because it is easy to measure, weight-for-age is frequently used.
 Length/height-for-age reflects attained growth in length or height in relation to child's age
 at a given time. This can help identify children who are short or stunted due to prolonged
undernutrition or repeated illness. However, one must consider the effect of heredity when
using this measurement.
 Mid-upper arm circumference (MUAC) can be used for rapid screening for malnutrition
to identify children who need referral for further assessment or treatment. MUAC below
115 mm is an accurate indicator of severe malnutrition in children aged 6-59 months.

The MUAC is always taken on the left arm. To measure MUAC, find the midpoint between
the top of the shoulder and the tip of the elbow while the child's left arm is bent. Wrap a
measuring tape around the upper arm at the level of the midpoint. Read the MUAC while
the arm is hanging down the side of the body and relaxed.

 Clinical examination involves recognition of signs of malnutrition. Data may come from physical
examination, such as eye examination for lesions in VAD, or history taking, such as the mother's
description of her child's night blindness. Clinical examination is useful in detecting micronutrient
deficiencies and severe forms of malnutrition like kwashiorkor and marasmus.
 Biochemical examination is the assessment of specific components of blood or urine samples of an
individual in order to measure specific aspects of one's metabolism. These are not routinely done in
RHUs/ health centers because of the cost the tests entail. Biochemical examinations were done during
the National Nutrition Survey in 2008: a blood test—serum retinol determination—to detect and
determine severity of VAD; hemoglobin determination for iron deficiency anemia (IDA) detection;
and urine examination for iodine levels to detect and determine severity of iodine deficiency.

Recommended infant and young child feeding practices

The national policies on infant and young child feeding advocate for the following practices:

 Early initiation of breastfeeding;

 Exclusive breastfeeding for the first6 months, which is possible, except for a few medical conditions,
such as galactosemia. Infants suffering from phenylketonuria or maple syrup urine disease may still
be breastfed with monitoring of the infant's blood levels of the nontolerated amino acids;
 Extended breastfeeding up to 2 years and beyond, which is recommended even if the infant's
consumption of breast milk declines as complementary foods are given;
 Appropriate complementary feeding with the use of locally available and culturally acceptable foods;
 Micronutrient supplementation;
 Universal salt iodization since ordinary salt contains very little iodine that cannot provide for the needs
of the human body; and
 Food fortification.

Diet diversification has been added to the strategy of micronutrient supplementation and food fortification to
combat micronutrient deficiencies in the country. Diet diversification refers to changing dietary practices that
affect young children, pregnant and lactating mothers, toward consumption of foods adequate in energy and
rich in micronutrients, especially those in short supply in the current diet. Diet diversification is promoted
through nutrition information and education.

These interventions will yield maximum results with other integrated services like deworming, environmental
sanitation, healthy lifestyle promotion, and immunization.

Promoting breastfeeding

Preparation for breastfeeding begins during pregnancy. To promote the practice of breastfeeding, providing
mothers and families with adequate, accurate, and timely information and opportunities for developing
necessary skills for good breastfeeding practices is essential. An empathetic nurse can help create a supportive
health care environment that allows mothers and other family members to express their ideas and concerns
about breastfeeding. Responding to the mother's educational needs related to breastfeeding practices requires
assessing the mother's knowledge, skills, and attitudes about breastfeeding. The nurse then makes a health
education plan based on the mother's needs.

Benefits of breastfeeding

Promoting good breastfeeding practices begins with information on the benefits of breastfeeding. Breastfeeding
cannot be equaled in terms of providing ideal food for the healthy growth and development of infants. Because
of its effect on the mother's reproductive process, it also has important implications for her health. Early
initiation of breastfeeding will stimulate early onset of full milk production and promote bonding of the mother
and child.

To the child, benefits of breastfeeding include:

 Breast milk provides all of the nutrients an infant needs for growth in the first 6 months. From the age of
6 months, breast milk is no longer sufficient, but it continues to be an important source of energy and
high-quality nutrients.
 Breast milk carries antibodies from the mother that help combat disease. This is particularly true of
colostrum, the yellowish fluid secreted by the mammary glands in the first few days after birth, and it
is rich with antibodies and white cells to protect against infection.
 Breast milk prevents diarrhea because of reduced risk from contaminated formula as well as of the
antibodies in breast milk. All types of antibodies have been found in human milk. However, the most
abundant type is secretory IgA that protects the mucosal membrane in the baby's gut against
pathogens.
 Compared to artificially fed infants, breastfed infants have a lower risk of developing later in life
chronic conditions like allergies, asthma, obesity, diabetes, and heart disease.
 Breastfeeding provides benefits for intellectual and motor development of the infant. Many studies
confirm that breastfed children do better on tests of cognitive and motor development.

The health benefits of breastfeeding for the mother include:

 Early initiation of breastfeeding helps to contract the uterus and therefore reduce bleeding.
 Breastfeeding may help in the return to prepregnancy weight.
 Exclusive breastfeeding delays the return of fertility.
 A long-term benefit is a lower risk of premenopausal breast cancer and ovarian cancer.

Finally, breastfeeding presents economic benefits to the family because it is the least expensive feeding method
and, because the infant has reduced risk of infection and other diseases, the cost of health care is likewise
reduced.

Technique of breastfeeding

While teaching a woman about the breastfeeding technique, she may express concern about certain breast and
nipple conditions. If a woman lacks confidence in her capacity to breastfeed because of small breasts, the nurse
must explain to her that the size of her breasts does not affect her capacity to produce milk. Exclusive
breastfeeding on demand results in ample milk production.

If a woman has flat or inverted nipples, the nurse builds the woman's confidence and explains that the shape of
the nipples is not important. When the infant has latched properly to the breast during feeding, he or she suckles
the breast and not the nipple. Management of flat or inverted nipples is not helpful; for example, stretching
nipples or wearing nipple shields does not help.

The nurse teaches the mother to position herself comfortably for breastfeeding, holding the infant close to her
body, tummy to tummy. She may choose from the following positions:
  Cradle hold - the mother sits with her arms supported and, using her arm on the same side as the nursing
breast, cradles the infant in front of her body.
 Cross-cradle hold - similar to the cradle hold, except that the mother cradles her infant with the arm on
the opposite side of the nursing breast.
 Football, clutch, or underarm hold - the mother sits, holds the infant between her flexed arm and body,
positions the infant facing her, and supports the infant's head with her open hand. Twins may be fed at
the same time using the double-football hold.
 Side-lying hold - the mother lies on her side with one arm supporting her head. The infant lies beside
the mother, facing the breast. The mother grasps and offers her breast to the infant with the other
hand. Once the infant has latched on, she supports the infant's body.

For successful breastfeeding, the infant must properly latch on to the mother’s breast. To achieve this, the
mother:

 Provides support by positioning her fingers against her chest wall below and her thumb above the
breast;
 Stimulates the rooting reflex by touching her infant's lips with her nipple;
 Waits for the infant's mouth to open wide;
 Quickly moves her infant to the breast (she brings her infant to the breast; she does not move herself or
her breast to the infant);
 Aims her infant's lower lip below her nipple so that the infant's chin will touch her breast.

The mother is informed of signs that the baby has latched on to the breast properly:

 The baby's mouth is wide open.

 The lower lip is turned out.
 The chin is touching the breast (or nearly so).
 More areola is visible above the baby's mouth than below.

The mother is also told of signs that the baby is suckling effectively. Signs that the baby is getting enough milk
include:

 The baby's swallowing can be seen or heard.

 You can see or hear the baby swallowing.
 The baby's cheeks are full and not drawn inward during a feed.
 The baby finishes the feed and releases the breast by himself/herself and looks contented.

Other points included in the breastfeeding education sessions are the following;

 Puttingthe infant to breast stimulates oxytocin release, making the mother's uterus contract after
delivery, which helps to reduce bleeding. However, the contractions can cause uterine pain when a
baby suckles during the first few days.
 During lactation, a mother's intake should be increased to cover the energy cost of breastfeeding: by
about 10% if the woman is not physically active, but 20% or more if she is moderately or very active.
In practice, a lactating mother uses about 500 kilocalories (roughly equivalent to one extra meal) each
 day to make 750 ml of breast milk for an infant. Studies show evidence of the efficacy of malunggay
(Moringa oleifera) as a galactagogue—an agent that promotes the flow of milk. Because the dark
green leaves of malunggay are also rich in iron, this is a highly recommended vegetable in the diet of
lactating mothers.
 Breasts do not need to be washed before or after feeds—normal washing as for the rest of the body is all
that is necessary. Washing removes natural oils from the skin, and makes soreness more likely.
 For breast engorgement and for the times when the mother has to leave her infant, manual milk
expression may be done, or if she chooses, she may use a breast pump. The mother must be made to
understand that regular emptying of the breasts is important to maintain lactation.

 If a woman expresses concern about sagging of the breasts due to breastfeeding, the nurse explains that
studies have shown that this is not true. Breast changes occur during pregnancy because of hormonal
influences, not because of breastfeeding.

Complementary feeding practices

From the age of 6 months, an infant's need for energy and nutrients starts to exceed what is provided by breast
milk, and complementary feeding becomes necessary to fill the energy and nutrient gap.

Infants are particularly vulnerable during the transition period when complementary feeding begins. Ensuring
that their nutritional needs are met requires that complementary foods be:

 Timely - complementary foods are introduced when the need for energy and nutrients exceeds what can
be provided through exclusive and frequent breastfeeding;
 Adequate - they should provide sufficient energy, protein, and micronutrients to meet a growing child's
nutritional needs;
 Safe - foods are hygienically stored and prepared, and fed with clean hands using clean utensils and not
bottles and artificial nipples; and
 Properly fed - foods are given consistent with a child's signals of appetite and satiety, and that meal
frequency and feeding method—actively encouraging the child, even during illness, to consume
sufficient food using fingers, spoon, or self-feeding—are suitable for age.

Micronutrient supplementation

The value of micronutrient supplementation in the attainment of MIX', targets is emphasized in Administrative
Order 2010-0010.

Micronutrient (vitamin and mineral) supplements are sources in concentrated forms of those nutrients alone or
in combinations, marketed in forms such as capsules, tablets, powders, and solutions, that are designed to be
taken in measured small-unit quantities. The purpose of micronutrient supplementation is to add to the vitamins
and minerals provided by a normal diet.

Micronutrient supplementation is a short-term intervention for correcting high levels of micronutrient

deficiencies until more sustainable food-based approaches can be used effectively.

The 2008 National Nutrition Survey results show that micronutrient deficiencies, particularly VAD, iron
deficiency anemia, and iodine deficiency disorders still persist in the Philippines. For this reason, micronutrient
supplementation is recommended for 0- to 59-month-old children, in addition to pregnant and lactating women
and other women of reproductive age, or those within the ages of 15-49 years old.

Micronutrient supplementation for children

 Micronutrient Target Schedule
population

Vitamin A Infants 6-11 100,000 IU once only

capsule months old

Children 12- 200,000 IU every 6

71 months months
old

Iron Infants 2-6 0.3 ml once a day to

months with start at 2 months until
low birth 6 months when
(<2,500 g) complementary foods
are given. Preparation
is 15 mg elemental
iron/0.6 ml

Anemic 1 tsp once a day for 3

children 2- months or 30 mg once
59 months a week tor 6 months
old with supervised
administration

Zinc supplement is also given to children aged 0-59 months and who are having diarrhea. For infants less than
6 months, the dose is 10 mg elemental zinc per day; for children 6-59 months, 20 mg elemental zinc per day for
10-14 days. Given to children with diarrhea, zinc reduces the duration and severity of the episode. Giving zinc
supplements for 10-14 days lowers the incidence of diarrhea in the following 2-3 months.

Food fortification

Fortification is defined as the addition of micronutrients to staple food such as rice, sugar, cooking oil, flour,
and salt. This also means the addition of micronutrients to processed foods at levels above the natural state.

The Sangkap Pinoy seal is conferred by the DOH and affixed to the packaging of food products that have been
certified as fortified either singly or in combination of the micronutrients vitamin A, iron, and iodine. The seal
guarantees that the food was processed in compliance with the fortification standards of the government.

Deworming

Deworming of children aged 1-12 years is done every 6 months. Children aged 12-24 months are given
Albendazole 200 mg or half tablet or Mebendazole 500 mg tablet. Children older than 2 years are given
Albendazole 400 mg or Mebendazole 500 mg tablet. Both of these drugs require intake on a full stomach.

The following are possible adverse effects of the anthelminthic drugs and their respective management:

 Local sensitivity or allergy - give an antihistamine.

 Mild abdominal pain - give an antispasmodic.
 Diarrhea - Give oral rehydrating solution.
 Erratic worm migration - Pull out worms from mouth/nose or from other body orifices.

Deworming is not advised if the child is known to have any of the following conditions:

 Serious illness, such as an illness that requires referral to a hospital,

 Abdominal pain,
  Diarrhea,
 History of hypersensitivity to the drug, or
 Severe malnutrition.

Malnutrition in children

Protein energy malnutrition

Protein energy malnutrition consists of underweight, stunting, wasting, and overweight. Measurement of
weight, height, and/or MUAC is important in the detection of these conditions. Severe cases also present signs
such as edema and the so-called "baggy pants.“

The following are some points to remember about these conditions:

 Underweight - defined as weight for age < -2 standard deviations (SD) of the WHO Child Growth
Standards median; mortality risk of children who are even mildly underweight is increased, and
severely underweight children are at even greater risk.
 Stunting - defined as height for age < -2 SD of the WHO Child Growth Standards median; stunting is
growth retardation as a result of poor diets or recurrent infections; associated with delayed mental
development, poor school performance, and reduced intellectual capacity.
 Wasting - defined as weight for height < -2 SD of the WHO Child Growth Standards median; a
symptom of acute undernutrition, usually as a consequence of insufficient food intake or a high
incidence of infectious diseases, especially diarrhea.
 Overweight - defined as weight for height > +2 SD Of the WHO Child Growth Standards median;
associated with a higher probability of obesity in adulthood, which can lead to a variety of disabilities
and diseases such as diabetes and cardiovascular diseases.

Severe acute malnutrition (SAM) in children 6-59 months of age is defined as weight-for-height less than -3 SD
of the WHO Child Growth Standards median, or the presence of edema of both feet, or a MUAC of less than
115 mm. Children with a MUAC <115 mm should be treated for severe malnutrition regardless of their weight-
for-height.

Pitting edema of both feet is an indication of SAM. It is verified by applying thumb pressure for 3 seconds on
top of both feet. The pit will remain in both feet for several seconds. Both feet have to be examined. If the
edema is not bilateral, it is not an indication of malnutrition. There are three grades of edema, indicated by plus
(+) signs:
NONCOMMUNICABLE DISEASES

The World Health Organization (WHO) reports noncommunicable diseases (NCDs) to be

the leading cause of mortality. Statistics revealed that almost 63% of the total deaths
worldwide were due to NCDs and the remaining 37% were due to communicable
diseases. It is estimated that deaths due to NCDs are expected to increase worldwide by
2030. In the Philippines, 75% of the total deaths can be attributed to NCDs which is
similar to the estimates in most developing countries, and 30-50% occurred at the age
below 60 years of age. Reports of the National Statistics Office showed that the top 10
leading causes of mortality are NCDs like diseases of the heart, cerebrovascular
diseases, cancer, chronic obstructive pulmonary disease (COPD), diabetes, road
accidents and injuries, and kidney problems.
NCD is a medical condition that is noninfectious and nontransmissible. A communicable
disease, on the other hand, is caused by an infectious agent and is transmitted from one
person to another. Most often, NCDs are referred as "chronic diseases" due to their long
duration. It is termed chronic because the condition interferes with the individual's way
of living a normal life brought about by different signs and symptoms lasting for more
than 6 months. Moreover, NCDs are also referred as "lifestyle-related diseases" due to
common risk factors such as lifestyle of the individual that increases the likelihood of
NCDs. Therefore, NCDs are diseases that are usually brought about by having an
unhealthy lifestyle. The effects of NCDs may alter the normal functioning of the
individual for a long duration.

NCDs are a public health problem of great proportions. It is estimated that 75% of the
total deaths can be attributed to NCDs. In 2005, 49.9% of mortality causes in the country
were caused by chronic lifestyle-related noncommunicable diseases (LRNCDs) such as
cardiovascular, cerebrovascular disease, cancers, COPD, and diabetes. It is expected
that the onset of chronic LRNCDs will continue over the next few years.

Cardiovascular and cerebrovascular disease

Cardiovascular disease (also called heart disease) is the general term used to refer to
diseases that involve the heart or blood vessels (arteries, capillaries, and veins).
Cerebrovascular disease or stroke, on the other hand, is a group of brain dysfunction
related to disease of the blood vessels supplying the brain. The most common causes of
these two diseases are atherosclerosis and hypertension.

Hypertension or high blood pressure is defined as a systolic blood pressure equal to or

above 140 mm Hg or a diastolic blood pressure equal to or above 90 mm Hg.
Atherosclerosis, on the other hand, is a disease of the blood vessels characterized by the
deposition of fats and cholesterol within the walls of the artery. Uncontrolled
hypertension and atherosclerosis lead to heart attack, stroke, kidney damage, and a host
of complications.

The National Statistics Office revealed that 33.8% of the leading causes of death are
heart disease and stroke. Although age and family history are immutable, they share
common risk factors such as unhealthy diet, smoking, sedentary lifestyle, and alcohol
consumption. It is estimated that 5% of the population are now considered obese, 10%
are diagnosed with hypercholesterolemia, and 24% are considered hypertensive.
Moreover, studies reveal that there has been an observable increase in the consumption
of NCD-implicated food items.
One of the strategies involved in the prevention of cardiovascular and cerebrovascular
disease is screening. Screening is the identification of an unrecognized disease by the
application of test, examination, or other procedures that can be applied rapidly to help
identify an individual's chances of becoming ill. Screening for hypertension involves the
monitoring of blood pressure. WHO recommends the use of reliable aneroid devices such
as sphygmomanometers that are calibrated every 6 months. Blood pressure should be
recorded twice daily in the morning and evening, and for several days before a diagnosis
of hypertension can be made. Measurements taken on the first day are discarded. Two
consecutive measurements are taken, at least a minute apart and with the person
seated. The average value of all the remaining measurements is taken to confirm a
diagnosis of hypertension.

Screening for elevated cholesterol in the blood involves taking a blood sample to
determine the total serum cholesterol, low-density lipoprotein (LDL), and high-density
lipoprotein (HDL). Prior to testing, the individual should withhold food or drinks for at
least 8 hours to ensure accuracy of results. In all adults aged 20 years or older, a fasting
lipoprotein profile should be obtained once every 5 years. If the test is done in a non-
fasting individual, the values for total cholesterol and HDL cholesterol will be used.
Research indicates that elevated LDL cholesterol is a major cause of cardiovascular
diseases. LDL cholesterol is known as the bad cholesterol because it increases the
likelihood of the formation of plaque that can block blood flow in the arteries. HDL, on
the other hand, is known as the good cholesterol because it clears the excess LDL in the
arteries. Total cholesterol is the sum total of all the cholesterol (LDL, HDL, and other
cholesterol) at a given time. Therefore, high total cholesterol or high LDL increases the
risk of the individual to develop cardiovascular disease. Moreover, the higher the HDL,
the better is the health of the individual.
Cancer

Cancer is one of the most common causes of death worldwide. According to the WHO,
over 12 million people are diagnosed with cancer every year. In the Philippines, 50,000
cancer cases have been recorded, and this number is estimated to increase by 5% every
year. Meanwhile, 16% of these recorded deaths are due to breast cancer. Breast cancer
was the leading cancer killer in both men and women (15%) in 2010 and ranked first
among women (28%). Lung cancer was the second leading cause of cancer deaths for
both sexes combined (14%) in 2010. It is the leading site in males (22%) and the third
leading site among females (6%).

Estimated cancer cases by site and

gender in 2010

Cancer site Male Femal Both

e sexes

Oral cavity 833 594 1,427

Nasopharynx 638 2S1 919

Other pharynx 1,145 705 1,850

Esophagus 567 301 868

Stomach 1,920 1,209 3,129

Colon/rectum 3,20S 2,579 5,787

Liver 5,522 1,809 7,331

Pancreas 716 613 1,334

Larynx 577 209 786

Lung 8,772 2,686 11,458

 Estimated cancer cases by site and
gender in 2010

Skin melanoma 181 242 423

Breast - 12,26 12,262

2

Cervix/uteri - 4,812 4,812

Corpus uteri - 1,760 1,760

Ovary - 2,165 2,165

Prostate 2,712 - 2,712

Testis 224 - 224

ladder 570 239 S09

Kidney 848 458 1,306

Brain/nervous 1,236 1,000 2,236

system

Thyroid 406 1,474 1,880

Non-Hodgkin 982 682 1,664

lymphoma

Hodgkins disease 369 147 516

Multiple 76 56 132
myeloma

Leukemia 1,669 1,484 3,153

All sites but skin 39,01 43,45 82,468

2 6
Cancer or malignant neoplasm is a group of various diseases involving unregulated cell
growth. In cancer, the cells divide, grow uncontrollably forming malignant tumors, and
invade parts of the body. Substances that cause some cells to undergo genetic
mutations are called carcinogens. Although the body is capable of repairing these
mutations, there are still lifestyle-related factors involved in the causation of cancer,
which include cigarette smoking, unhealthy diet, alcohol drinking, physical inactivity, and
overweight/obesity.

Screening for cancer involves the early detection of the warning signals of cancer
developed by the American Cancer Society. The warning signals of cancer can be
remembered through the use of the following mnemonic device: CAUTION US

 Change in bowel or bladder habits

 A sore throat that does not heal
 Unusual bleeding or discharge
 Thickening or lump in breast
 Indigestion or difficulty of swallowing
 Obvious change in a wart or mole
 Nagging cough or hoarseness
  Unexplained anemia
 Sudden weight loss

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a disease of the lungs in which the
airways narrow over time. It includes chronic bronchitis, chronic asthma, and
emphysema. It is estimated that 7% of deaths worldwide are due to chronic respiratory
diseases. Smoking is a strong risk factor for COPD, and statistics shows that 15% of
cigarette smokers develop COPD. Second-hand smoke and pollution also aggravate the
problem.

Diabetes

Diabetes is a group of metabolic disease in which an individual has high blood sugar
because the pancreas does not produce enough insulin or the cells do not respond to the
insulin produced. Insulin is a hormone that regulates blood sugar. Hyperglycemia or high
blood sugar is a common effect of diabetes. Current guidelines of the WHO for the
diagnosis of diabetes is a fasting blood sugar (FBS) of > 7.0 mmol per liter (126mg/ dl) or
2-hour blood sugar test of >11.1 mmol per liter (200mg/dl). These tests predict the risk
for premature mortality.

Prevalence of high fasting blood sugar (FBS) among adults in 2008 was 4.8%, and
mortality rate from diabetes has increased significantly to 18.1 deaths per 100,000
population. Experts predict the number to increase by 2025. Symptoms of diabetes
include increased frequency and amount of urination (polyuria), increased thirst
(polydipsia), constant hunger (polyphagia), weight loss, vision changes, and fatigue. The
many complications associated with diabetes include heart disease, neuropathies,
amputations, and dental disease. Lifestyle-related factors to diabetes include unhealthy
diet, overweight, and obesity

RISK FACTORS FOR NONCOMMUNICABLE DISEASES

Many factors play a major part in the development of NCD. The public health nurse
should assess lifestyle factors of individuals, families, and vulnerable groups that
predispose them to NCD, Factors that epidemiologists call "risk factors" are the
following:
1. Physical inactivity

 Physical inactivity is defined as less than 5 times of 30 minutes of

moderate activity per week, or less than 3 times of 20 minutes of
vigorous activity per week, or equivalent. It is considered to be one of
the most important public health problems of the 21st century. Many
studies have examined the association between physical inactivity and
chronic diseases. Physical activity is a key determinant of energy
expenditure and is thus fundamental to energy balance and weight
control. It improves endothelial function that enhances vasodilation and
vasomotor function in the blood vessels. Moreover, physical activity
contributes to weight loss, glycemic control, improved blood pressure
and lipid profile, and insulin sensitivity. The WHO estimates that 2 million
deaths per year can be attributed to physical inactivity, making it a
global health crisis. According to the WHO, 60% of the world's population
do not get enough physical activity. The risk of getting a cardiovascular
disease increases by 1.5 times for noncompliance of the minimum
recommendations for physical activity.

2. Cigarette smoking

 Cigarette smoking is a primary risk factor for development of NCDs. The

Tobacco and Poverty Study in the Philippines reported that 6-8% or an
average of 87,600 of mortality in the Philippines is attributed to smoking-
related diseases such as cerebrovascular disease, COPD, and lung
cancer. Studies revealed that smoking cigarettes damages the lining of
blood vessels and reduces HDL cholesterol and oxygen in the blood.
Moreover, chemicals found in cigarettes are known to cause cancer.
Evidence suggests that cigarette smoking causes lung cancer, cancer of
the mouth, pharynx, larynx, and esophagus.

3. Unhealthy eating

 "Obesogenic" or unhealthy eating is one of the major risk factors

responsible for the global increase of cardiovascular disease, cancer,
diabetes, and obesity worldwide. High dietary intakes of saturated fat,
trans-fat cholesterol, and salt, and low intakes of fruits and vegetables
and fish are linked to overweight and obesity. Evidence suggests that
unhealthy eating has adverse metabolic effects on blood pressure,
cholesterol, triglycerides, and insulin resistance.
 Food and nutrition environments are believed to be major contributors to
obesity.
4. Excessive alcohol drinking

 Ingestion of excessive alcohol may lead to metabolic and physiological

effects on all organ systems such as gastrointestinal and cardiovascular
disturbances. Alcohol may cause malabsorption, inflammation of the
gastrointestinal tract, liver problems, and cancer. Evidence suggests that
excessive alcohol intake is associated with colon and rectal cancer. It has
also been linked to the development of cancers of the breast, liver,
esophagus, mouth, and larynx. Cardiovascular disturbances include
cardiac dysrhythmias, cardiomyopathy, hypertension, and
atherosclerosis. Alcohol consumption has also been shown in several
large cohort studies to predict diabetes incidence by increasing glucose
levels in the blood. Most recent statistics showed that an average of 4.8
liters of alcohol is consumed by every Filipino. The 2010 Midline Survey
for the National Objectives of Health showed that the highest prevalence
of alcohol intake was among adults and adolescents with 42.8% and
31.3%, respectively. Data revealed that one-third of all household
members are alcoholic beverage drinkers. As of 2007, WHO reports that
17% of Filipino adolescents have been drunk at least once. Therefore,
the risk factors of acquiring NCD is a growing concern to all age groups.

5. Viruses

 Viruses play a role in the development of certain cancers. Viruses cause

mutation by breaking the normal cell's DNA chain during infection. Some
viruses that causes cancer are the Human Papilloma Virus that is linked
with cervical and vulvar cancer, Epstein-Barr virus that is associated with
nasopharyngeal and anal cancer, human T-lymphotropic virus (HTLV-1)
that is linked with non-Hodgkin lymphoma, and hepatitis B virus and
hepatitis C virus (HCV), which are the most common causes of liver
cancer in the Philippines. Viruses capable of causing cancer are known as
"oncoviruses".

6. Radiation

 Radiation is energy emitted and transferred through matter and space.

The two most common forms are ultraviolet radiation (UV) and ionizing
radiation. UV radiation adversely affects the genes, and the cell enzymes
causing DNA mutation, whereas ionizing radiation causes tissue and cell
damage by breaking the DNA molecule. Solar radiation is the primary
source of UV radiation and the major cause of skin cancer worldwide. On
the other hand, ionizing radiation includes X-rays, gamma rays, and
particulate radiation from nuclear accidents, occupational exposure, and
 treatments. Studies have shown that the risk for development of
radiation-associated cancer depends on the type, amount, and length of
exposure, but evidence suggests that the risks tend to be cumulative.

PREVENTION OF NONCOMMUNICABLE DISEASES

The best hope for protecting the public against these diseases is for them to learn how
to prevent them, or at least how to delay their onset. Prevention requires understanding
of the causes of diseases and the factors that influence how they progress. The following
are recommended as part of the healthy lifestyle practices.

Promote physical activity and exercise

Physical activity is defined as any bodily movement produced by skeletal muscles that
results in expenditure of energy and includes occupational, leisure-time, and routine
daily activities. Exercise is a subcategory of physical activity that is planned, structured,
repetitive, and aimed at improving or maintaining physical fitness or health. Physical
fitness is a measure of a person's ability to perform physical activities with vigor and
alertness, without undue fatigue, and with ample energy to enjoy leisure-time pursuits
and respond to emergencies. It requires endurance, strength, flexibility, balance, speed,
reaction time, and body composition.

The Physical Activity Guidelines describes four levels of physical activity: inactive, low,
medium, and high. It is recommended that medium and high levels of regular physical
activity are essential to achieve health benefits. Because the public is not aware of
metabolic equivalents (METs), activity recommendation is discussed in number of
minutes needed per week. A MET is the ratio of the rate of energy expenditure during an
activity to the rate of energy expenditure at rest. A range of 500 to 1,000 METs of
moderate intensity 5 days a week for 30 minutes or high-intensity activity 3 days a week
for 20 minutes has been shown to provide substantial benefits. However, recent
research indicated that moderate intensity activity for 30 minutes for 5 days each week
levels of regular physical activity is recommended at least 30 minutes daily.

Regular physical activity contributes to physiologic stability and high-level functioning in

all ages and ethnic groups. It improves cardiovascular fitness, increases bone mass,
enhances mental well-being, and prevents development of cardiovascular disease,
diabetes, and other chronic diseases in children and adolescents. Although gender
differences and age appropriateness determine the nature of physical activity, it is
recommended that a minimum of 60 minutes of moderate or vigorous physical activity
every day is recommended for adolescents and children.

Physical activity in adults has been shown to reduce the risk for cardiovascular and
cerebrovascular diseases, cancer, and diabetes. Furthermore, it increases functional
independence in adults through improved muscle mass, increased bone density, and
better cardiovascular fitness. It is recommended that adults below 65 years of age have
at least 150 minutes each week of structured moderate-intensity activity, 75 minutes of
structured vigorous intensity each week, or a combination of the two. However,
supervision may be needed to learn to exercise at a moderate level to prevent untoward
effects in adults with an existing illness. Aggressive physical activity may create
arrhythmias or precipitate a cardiac arrest or myocardial infarction. Moreover, it is
suggested that adults aged 50 years of age should be evaluated medically before
starting regular physical activity.

To prevent potential risks for adverse events, a program of gradually increasing the
physical activity is recommended by proper warm-up and cooldown. Warm-up is
important before any physical activity to increase blood flow to the heart and skeletal
muscles, enhance oxygenation of tissues, and increase flexibility of muscles. It usually
takes about 7-10 minutes of slow walking, arm circles, leg exercises, or wall push-ups,
and followed immediately by moderate to vigorous physical activity. Cooldown, on the
other hand, is done after physical activity to eliminate lactic acid in the muscles and
maintain blood flow to and from the muscle. It usually lakes about 5-10 minutes of slow
walking, jogging, or cycling.

There are several factors that should be considered by the nurse in promoting and
designing physical activity programs in the community. Programs should be based on
the interests, preferences, and readiness of the individual. The activity must be
enjoyable and should include a variety of activities to encourage participation. Research
has shown that parents can influence their children's behavior with regard to physical
activities. Therefore, the nurse must encourage direct involvement of family members in
physical activities like sports and other recreational programs. The physical environment
such as school, neighborhood, and workplace may also influence physical activity
behaviors. It is considered the most place-dependent health behavior. Nurses should
conduct programs in the community conducive for physical activities to promote
participation.

Promote healthy diet and nutrition

Good nutrition is a primary determinant of good health. Therefore, healthy diet is a

cornerstone of good health in preventing NCDs. To achieve healthy diet and nutrition, it
is recommended to follow the ABCs of good nutrition. These include Aim for physical
fitness, Build a healthy base of nutrition practices, and Choose foods sensibly.

Achieving fitness involves having an ideal body weight. Methods used to assess healthy
weight are the body mass index (BMI) and waist circumference (WC). Although these
tools do not necessarily reflect body fat distribution, these tools are useful for assessing
overweight or obesity that reflects the risk for diabetes, cardiovascular diseases, and
some forms of cancer. BMI is calculated as weight in kilograms divided by body height in
meters squared. On the other hand, WC is used to assess central fat distribution and the
degree of abdominal obesity. A high WC is associated with an increased risk for
diabetes, dyslipidemia, hypertension, and CVD. Measurement is taken using a standard
tape measure. Accurate measurement is achieved by measuring halfway between the
lowest rib and top of the hipbone, in line with the belly button. Measurement should be
done in a standing position with relaxed abdominal muscles, taken at the end of normal
expiration. It is also important to note that waist circumference is not the same as belt
size.

According to the WHO, the BMI and WC cutoff point at risk of chronic diseases maybe
lower for Asians, which includes Filipinos due to differences in body composition among
ethnic groups. Individuals within the higher end of the normal BMI and below the risk
range of WC may still be at risk for developing chronic disease. However, for purposes of
reporting and comparison with other countries, this reference is used. Also, there are
multiple factors to consider when assessing one's health to determine the relative risk of
developing NCD.

Maintaining a desirable body weight should be a lifelong goal of every individual to

reduce the risk of developing NCDs. To achieve this, individuals must balance food
consumption and physical activity. Strategies to promote healthy eating and physical
activity include the following:

1. Choose sensible portions of foods lower in fat. Watch portion sizes.

2. Learn healthier ways to make favorite foods.
 3. Learn to recognize and control environmental cues that make you want to eat.
4. Have a healthy snack an hour before a social gathering.
5. Engage in moderate-intensity physical activity for 30 minutes every day.
6. Do not eat meals in front of the television.
7. Keep records of your food intake and physical activity. Weigh yourself weekly.
8. Pay attention to why you are eating.

The benefits of healthy diet and nutrition come across all age groups. Infants' and
children's caloric and nutrient intake are critical for supporting growth and development.
A healthy start for infants is to encourage mothers to practice exclusive breastfeeding.
The use of breast milk prevents nutritional deficiencies during the early years of life.
During the first year of life, infants consume 40% of calories from fat. However, at the
age of 2, it is recommended to consume a diet lower in total fat, saturated fat, and
cholesterol to lessen the risk of chronic diseases in later years. Like physical activity, the
dietary habits and eating behaviors of young children are profoundly affected by family
beliefs and practices. Therefore, it is important that the public health nurse is aware of
the family's nutrition practices to make necessary changes in food consumption
patterns.

Adolescents' dietary requirement are based on the pubertal development and growth.
Body size, composition, functions, and physical abilities are rapidly changing; thus
adolescents should consume diets providing more nutrients that they consumed as
young children. The onset of menstruation among girls and the increased physical
activity among boys increase the need for adequate intake of iron, calcium, and vitamin
D. However, moderation is necessary to prevent overweight and obesity. It is
recommended that adolescent fat intake should be less than 30% of calories per day
with less animal fat and cholesterol to less than 300 mg daily to reduce the risk for
cardiovascular disease and diabetes as early as adolescence and later carried into
adulthood. The consumption of a Fast-food meal such as burger with shake and fries is
an example of a high fat meal exceeding the recommended less than 30% calories from
fat. The effect of peer influence, social media, and fast-food establishments pose a
challenge to an adolescent to maintain healthy diet and nutrition. Heightening
awareness of the importance of good nutrition and its long-term effects, as well as
creating an environment that fosters healthy diet, should be the focus of the public
health nurse.

Adults' and elderly’s recommended diet is low in saturated fatty acids, total fat and
saturated fats, and cholesterol to maintain desired body weight and lower the risk of
cardiovascular disease. Changes in body size, body mass, basal metabolism rate, and
physical activity alter the nutritional requirements. Essential components of the diet are
complex carbohydrates and fiber for proper bowel elimination, reduce serum cholesterol
and risk of colon cancer, and improved glucose response. Supplementation may also be
necessary due to reduced appetite, and difficulty in chewing and swallowing among
elderly, but it should be initiated after consultation. Moreover, medications may also
affect absorption of food; therefore, there is a need for further exploration of food-drug
interactions among elderly. Benefits of a healthy diet along with physical activity can
prevent premature mortality from cardiovascular disease in middle-aged adults and can
maintain vigor in the elderly.

Overweight and obesity is a result of an imbalance in energy due to excessive intake of

calories with the number of calories burned. While physical activity is essential in
maintaining healthy weight, so is controlling food intake. Overweight and obese
individuals who desire to lose weight should consult a health care provider before
starting a weight loss program. An individual with a BMI of 30 or above or between 25
and 30 with two or more weight-related health problems or with a waist circumference
of over 35 inches for women or 40 inches for men even if the BMI is less than 25, is
qualified for a weight loss program. An assessment of the dietary habits, family and
health history, physical examination, BMI, waist circumference, blood glucose, and
cholesterol analysis is needed to develop an effective weight management program.
Learning to control food intake and maintaining physical activity is crucial in any weight
management program. Radical changes in food consumption are not recommended
because of their harmful effects like dehydration, nutritional deprivation, fainting, and
heart attack. The time of the day does not also affect how the body uses calories, but it
is the overall caloric balance over the 24 hours that affects weight gain. Therefore,
withholding food intake at night is also ineffective.

Reducing calorie intake with attention to portion size, while maintaining the adequate
intake of vitamins, minerals, and fiber combined with regular physical activity can help
lose weight. A 5-15% reduction in body weight over 6 months significantly reduces
obesity-related risk. Losing 0.5-2 lbs. weight per week is cited as a safe rate. Diet should
include low-carbohydrate, low-fat, high-protein, and high-fibers. Replacement of high
caloric foods with fiber, fruits, and vegetables can decrease the individual's caloric
intake without eating less and feeling hungry. It is also important for obese and
overweight individuals to understand that some fat-free and low-fat foods sold in the
market have extra sugars that contain a high number of calories. It is advised to read
the nutrition facts on food labels to find out the calorie content based on serving size.
The public health nurse may assist the individual in planning a weight management
program that is safe, effective, and sustainable for a lifetime. Strategies would involve
health education on the benefits of healthy diet and nutrition, and behavioral
modification techniques that are proven to be effective. In addition, the nurse must
assist families with limited economic means in selecting low-cost foods that meet
recommended nutritional requirements.

Promote a smoke-free environment

Smoking is a major risk factor for developing cardiovascular and cerebrovascular

disease (CVC), lung cancer, and chronic lung disease.

Stress management

Stress is an inevitable human experience in a rapidly changing society. Selye defined

stress as "the nonspecific response of the body to any demand on it". It is estimated
that more than a quarter of visits to health facilities have been attributed to or made
worse by stress.

Managing stress involves understanding of a person's reaction to stress. Numerous

studies have been conducted to identify ways on managing stress. However, the overall
effectiveness and safety of interventions have not been sufficiently studied. In general,
the overall aim of managing stress should focus on minimizing the frequency of stress-
inducing situations, increasing resistance, and avoiding physiologic arousal resulting
from stress.

The advent of alternative medicine gives way to its use in managing and preventing
stress-related NCDs. Methods involved the use of biofeedback, meditation, breathing
relaxation exercise, and massage.

Ten Facts about the Global Burden of Disease

The global burden of disease is a comprehensive global assessment of mortality and

disability from major diseases, injuries. and risk factors.
1. Around 10 million children under the age of 5 die each year.

 The WHO estimates that nearly all of these deaths are preventable with
low-cost interventions such as primary care to treat diarrhea and
respiratory infections, and with integrated health systems.

2. Cardiovascular disease are the leading causes of death in the world.

 The WHO estimates that 80% of premature deaths from cardiovascular

disease and strokes could be prevented from appropriate diets, physical
exercise, and avoiding the use of tobacco.

3. HIV/AIDS is the leading cause of adult death in Africa.

 Inadequate health systems and limited access to care are major barriers
in reducing deaths due to HIV/AIDS.

4. Population aging is contributing to the rise in cancer and heart disease.

 There is a need to prepare health systems and caregivers to cope with

the elderly and their associated chronic illnesses and other health
problems.

5. Lung cancer is the most common cause of death from cancer in the world.

 The WHO estimates that smoking is responsible for 80% of lung cancer;
thus efforts to reduce smoking would have significant effect on lung
cancer deaths.

6. Complications of pregnancy account for almost 15% of death in women of

 reproductive age worldwide.

 The WHO estimates that each year more than 500,000 women die from
preventable complications during pregnancy or childbirth.

7. Mental disorders such as depression are among the 20 leading causes of

disability worldwide.

 Lack of mental health services is a major problem worldwide. The WHO

estimates that less than 25% of persons with depression have access to
adequate treatment and health care.

8. Hearing loss, vision problems, and mental disorders are the most common
causes of disability.

 There are many international organizations that are excellent resources

for promoting appropriate services and protecting the rights of persons
with disabilities, including the World Federation of the Deaf, the Disabled
Persons International, the International Disability Alliance, and the World
Blind Union.

9. Road traffic injuries are projected to rise from the ninth leading cause of death
globally in 2004, to the fifth in 2030.

 This problem could be reduced by the use of seat belts and helmet (for
motorcycle riders and bikers), and reduction of driving under the
influence of drugs or alcohol.

10. Undernutrition is the underlying cause of death for at least 30% of all
children under the age of 5.

 The WHO estimates that nearly 20 million children worldwide are

severely malnourished, increasing their risk of acquiring infections and
 reducing their ability to resist such infections


MENTAL HEALTH

Mental health is an integral part of every individual. The WHO defined mental health as
a state of social well-being in which every individual realizes his or her own potential
(self-image), can cope with the normal stresses of life (resiliency), can work productively
and fruitfully (productivity and creativity), and is able to make a contribution to her or
his community (sense of purpose).

Mental health is determined by the interplay of different factors that affect the mental
state and well-being of an individual. It may be determined by socioeconomic factors;
however, there is evidence that genetics may affect the mental state of an individual.
Poverty, low levels of education, poor living conditions, and hopelessness may increase
vulnerability to mental illness. For example, street children are more likely to be
exposed to physical illness, accidents, family problems, inadequate social support, and
mental health problems or even depression in the family. Chemical imbalance in the
brain due to trauma, infectious diseases, and toxic substances has also been shown to
be associated with mental illness. Behavioral problems like substance abuse, violence,
and abuse of women and children and health problems such as HIV/AIDS are also linked
with mental illnesses.

Mental illness or mental disorder is any illness experienced by a person that interferes
with his or her thinking, feeling, or social activities and even daily functioning. It
produces a negative effect on one's life or the lives of the family. A mental health
problem, on the other hand, does not hamper functioning and is temporarily
experienced as a reaction to life stressors. It is less severe and shorter in duration, but it
may develop into mental disorders.

Mental health problems have four facets as a public health burden. These are defined
burden, undefined burden, hidden burden, and future burden:

Defined or direct burden - burden affecting persons with mental disorders such as cost
of treatment, quality of life, and disability.Undefined or indirect burden - burden relating
to the impact of mental health problems to others such as family members or the
community who care for the patient.Hidden burden - stigma and violations of human
rights to persons affected with mental health problems.Future or health burden - burden
resulting from the aging population or increasing social problems such as the
development of complications or other medical illnesses or death.
There is no single cause of mental illness. The interplay among biological, social,
cultural, and psychological factors determines the development of mental illness. In
many cultures, both medical (biological) and traditional (social and cultural)
explanations are used to understand the causes of mental illness. The following were
identified as conditions that can lead to mental illness:

1. Stressful life events like death of a loved one, financial problems, marital
conflict, and violence.
2. Difficult family background; for example, a history of neglect and violence may
result in an unhappy childhood.
3. Brain diseases like mental retardation and brain infections, AIDS, head injuries,
epilepsy, and stroke.
4. Heredity may be a factor; however, this is also influenced by environmental
factors,
 5. Medical problems like kidney and liver failure, or medicines taken can alter
processes.

According to the WHO, approximately one out of four families has at least one member
currently suffering from mental illness. It is estimated that one in five of all adults will
experience a mental health problem. Studies across countries showed that as much as
40% of adults consulting at the general health care service is suffering from some kind
of mental illness. Statistics showed that 4 out of 10 most disabling conditions in the
world were mental illnesses. The rapid change and increasing demand of our society
increase the likelihood of developing mental health problems. Although mental illness
can be treated with simple, relatively inexpensive methods, mental health services are
not adequate. There is a shortage of mental health professionals who can provide
quality mental health services. Moreover, individuals with mental illness are often
discriminated by their family and the community.

In the Philippines, home care management for mentally ill patients is advocated. This is
also referred to as deinstitutionalization of mental health care, so as to apply the
promotive and preventive levels in this aspect of health rather than pursue the curative
and rehabilitative care. This gives the community health nurse the opportunity to
identify high-risk individuals and families, provide health care before mental ill-health
happens and for persons with mental illness to be accorded the respect needed as
members of a community. Acute cases are managed by the National Center for Mental
Health or hospitals with psychiatric facilities.
MENTAL HEALTH

Mental health is an integral part of every individual. The WHO defined mental health as a
state of social well-being in which every individual realizes his or her own potential (self-
image), can cope with the normal stresses of life (resiliency), can work productively and
fruitfully (productivity and creativity), and is able to make a contribution to her or his
community (sense of purpose).

Mental health is determined by the interplay of different factors that affect the mental
state and well-being of an individual. It may be determined by socioeconomic factors;
however, there is evidence that genetics may affect the mental state of an individual.
Poverty, low levels of education, poor living conditions, and hopelessness may increase
vulnerability to mental illness. For example, street children are more likely to be
exposed to physical illness, accidents, family problems, inadequate social support, and
mental health problems or even depression in the family. Chemical imbalance in the
brain due to trauma, infectious diseases, and toxic substances has also been shown to
be associated with mental illness. Behavioral problems like substance abuse, violence,
and abuse of women and children and health problems such as HIV/AIDS are also linked
with mental illnesses.

Mental illness or mental disorder is any illness experienced by a person that interferes
with his or her thinking, feeling, or social activities and even daily functioning. It
produces a negative effect on one's life or the lives of the family. A mental health
problem, on the other hand, does not hamper functioning and is temporarily
experienced as a reaction to life stressors. It is less severe and shorter in duration, but it
may develop into mental disorders.

Mental health problems have four facets as a public health burden. These are defined
burden, undefined burden, hidden burden, and future burden:

Defined or direct burden - burden affecting persons with mental disorders such as cost
of treatment, quality of life, and disability.Undefined or indirect burden - burden relating
to the impact of mental health problems to others such as family members or the
community who care for the patient.Hidden burden - stigma and violations of human
rights to persons affected with mental health problems.Future or health burden - burden
resulting from the aging population or increasing social problems such as the
development of complications or other medical illnesses or death.
There is no single cause of mental illness. The interplay among biological, social,
cultural, and psychological factors determines the development of mental illness. In
many cultures, both medical (biological) and traditional (social and cultural) explanations
are used to understand the causes of mental illness. The following were identified as
conditions that can lead to mental illness:

1. Stressful life events like death of a loved one, financial problems, marital
conflict, and violence.
2. Difficult family background; for example, a history of neglect and violence may
result in an unhappy childhood.
3. Brain diseases like mental retardation and brain infections, AIDS, head injuries,
epilepsy, and stroke.
4. Heredity may be a factor; however, this is also influenced by environmental
factors,
5. Medical problems like kidney and liver failure, or medicines taken can alter
processes.

According to the WHO, approximately one out of four families has at least one member
currently suffering from mental illness. It is estimated that one in five of all adults will
experience a mental health problem. Studies across countries showed that as much as
40% of adults consulting at the general health care service is suffering from some kind
of mental illness. Statistics showed that 4 out of 10 most disabling conditions in the
world were mental illnesses. The rapid change and increasing demand of our society
increase the likelihood of developing mental health problems. Although mental illness
can be treated with simple, relatively inexpensive methods, mental health services are
not adequate. There is a shortage of mental health professionals who can provide quality
mental health services. Moreover, individuals with mental illness are often discriminated
by their family and the community.

In the Philippines, home care management for mentally ill patients is advocated. This is
also referred to as deinstitutionalization of mental health care, so as to apply the
promotive and preventive levels in this aspect of health rather than pursue the curative
and rehabilitative care. This gives the community health nurse the opportunity to
identify high-risk individuals and families, provide health care before mental ill-health
happens and for persons with mental illness to be accorded the respect needed as
members of a community. Acute cases are managed by the National Center for Mental
Health or hospitals with psychiatric facilities.

PREVENTION OF NONCOMMUNICABLE DISEASES

The best hope for protecting the public against these diseases is for them to learn how
to prevent them, or at least how to delay their onset. Prevention requires
understanding of the causes of diseases and the factors that influence how they
progress. The following are recommended as part of the healthy lifestyle practices.

Promote physical activity and exercise

Physical activity is defined as any bodily movement produced by skeletal muscles that
results in expenditure of energy and includes occupational, leisure-time, and routine
daily activities. Exercise is a subcategory of physical activity that is planned,
structured, repetitive, and aimed at improving or maintaining physical fitness or health.
Physical fitness is a measure of a person's ability to perform physical activities with
vigor and alertness, without undue fatigue, and with ample energy to enjoy leisure-
time pursuits and respond to emergencies. It requires endurance, strength, flexibility,
balance, speed, reaction time, and body composition.

The Physical Activity Guidelines describes four levels of physical activity: inactive, low,
medium, and high. It is recommended that medium and high levels of regular physical
activity are essential to achieve health benefits. Because the public is not aware of
metabolic equivalents (METs), activity recommendation is discussed in number of
minutes needed per week. A MET is the ratio of the rate of energy expenditure during
an activity to the rate of energy expenditure at rest. A range of 500 to 1,000 METs of
moderate intensity 5 days a week for 30 minutes or high-intensity activity 3 days a
week for 20 minutes has been shown to provide substantial benefits. However, recent
research indicated that moderate intensity activity for 30 minutes for 5 days each
week levels of regular physical activity is recommended at least 30 minutes daily.

Regular physical activity contributes to physiologic stability and high-level functioning

in all ages and ethnic groups. It improves cardiovascular fitness, increases bone mass,
enhances mental well-being, and prevents development of cardiovascular disease,
diabetes, and other chronic diseases in children and adolescents. Although gender
differences and age appropriateness determine the nature of physical activity, it is
recommended that a minimum of 60 minutes of moderate or vigorous physical activity
every day is recommended for adolescents and children.

Physical activity in adults has been shown to reduce the risk for cardiovascular and
cerebrovascular diseases, cancer, and diabetes. Furthermore, it increases functional
independence in adults through improved muscle mass, increased bone density, and
better cardiovascular fitness. It is recommended that adults below 65 years of age
have at least 150 minutes each week of structured moderate-intensity activity, 75
minutes of structured vigorous intensity each week, or a combination of the two.
However, supervision may be needed to learn to exercise at a moderate level to
prevent untoward effects in adults with an existing illness. Aggressive physical activity
may create arrhythmias or precipitate a cardiac arrest or myocardial infarction.
Moreover, it is suggested that adults aged 50 years of age should be evaluated
medically before starting regular physical activity.

To prevent potential risks for adverse events, a program of gradually increasing the
physical activity is recommended by proper warm-up and cooldown. Warm-up is
important before any physical activity to increase blood flow to the heart and skeletal
muscles, enhance oxygenation of tissues, and increase flexibility of muscles. It usually
takes about 7-10 minutes of slow walking, arm circles, leg exercises, or wall push-ups,
and followed immediately by moderate to vigorous physical activity. Cooldown, on the
other hand, is done after physical activity to eliminate lactic acid in the muscles and
maintain blood flow to and from the muscle. It usually lakes about 5-10 minutes of slow
walking, jogging, or cycling.

There are several factors that should be considered by the nurse in promoting and
designing physical activity programs in the community. Programs should be based on
the interests, preferences, and readiness of the individual. The activity must be
enjoyable and should include a variety of activities to encourage participation.
Research has shown that parents can influence their children's behavior with regard to
physical activities. Therefore, the nurse must encourage direct involvement of family
members in physical activities like sports and other recreational programs. The
physical environment such as school, neighborhood, and workplace may also influence
physical activity behaviors. It is considered the most place-dependent health behavior.
Nurses should conduct programs in the community conducive for physical activities to
promote participation.

Promote healthy diet and nutrition

Good nutrition is a primary determinant of good health. Therefore, healthy diet is a
cornerstone of good health in preventing NCDs. To achieve healthy diet and nutrition, it
is recommended to follow the ABCs of good nutrition. These include Aim for physical
fitness, Build a healthy base of nutrition practices, and Choose foods sensibly.

Achieving fitness involves having an ideal body weight. Methods used to assess healthy
weight are the body mass index (BMI) and waist circumference (WC). Although these
tools do not necessarily reflect body fat distribution, these tools are useful for
assessing overweight or obesity that reflects the risk for diabetes, cardiovascular
diseases, and some forms of cancer. BMI is calculated as weight in kilograms divided
by body height in meters squared. On the other hand, WC is used to assess central fat
distribution and the degree of abdominal obesity. A high WC is associated with an
increased risk for diabetes, dyslipidemia, hypertension, and CVD. Measurement is
taken using a standard tape measure. Accurate measurement is achieved by
measuring halfway between the lowest rib and top of the hipbone, in line with the belly
button. Measurement should be done in a standing position with relaxed abdominal
muscles, taken at the end of normal expiration. It is also important to note that waist
circumference is not the same as belt size.

According to the WHO, the BMI and WC cutoff point at risk of chronic diseases maybe
lower for Asians, which includes Filipinos due to differences in body composition among
ethnic groups. Individuals within the higher end of the normal BMI and below the risk
range of WC may still be at risk for developing chronic disease. However, for purposes
of reporting and comparison with other countries, this reference is used. Also, there are
multiple factors to consider when assessing one's health to determine the relative risk
of developing NCD.

Maintaining a desirable body weight should be a lifelong goal of every individual to

reduce the risk of developing NCDs. To achieve this, individuals must balance food
consumption and physical activity. Strategies to promote healthy eating and physical
activity include the following:

1. Choose sensible portions of foods lower in fat. Watch portion sizes.

2. Learn healthier ways to make favorite foods.
3. Learn to recognize and control environmental cues that make you want to eat.
4. Have a healthy snack an hour before a social gathering.
5. Engage in moderate-intensity physical activity for 30 minutes every day.
6. Do not eat meals in front of the television.
7. Keep records of your food intake and physical activity. Weigh yourself weekly.
8. Pay attention to why you are eating.

The benefits of healthy diet and nutrition come across all age groups. Infants' and
children's caloric and nutrient intake are critical for supporting growth and
development. A healthy start for infants is to encourage mothers to practice exclusive
breastfeeding. The use of breast milk prevents nutritional deficiencies during the early
years of life. During the first year of life, infants consume 40% of calories from fat.
However, at the age of 2, it is recommended to consume a diet lower in total fat,
saturated fat, and cholesterol to lessen the risk of chronic diseases in later years. Like
physical activity, the dietary habits and eating behaviors of young children are
profoundly affected by family beliefs and practices. Therefore, it is important that the
public health nurse is aware of the family's nutrition practices to make necessary
changes in food consumption patterns.

Adolescents' dietary requirement are based on the pubertal development and growth.
Body size, composition, functions, and physical abilities are rapidly changing; thus
adolescents should consume diets providing more nutrients that they consumed as
young children. The onset of menstruation among girls and the increased physical
activity among boys increase the need for adequate intake of iron, calcium, and
vitamin D. However, moderation is necessary to prevent overweight and obesity. It is
recommended that adolescent fat intake should be less than 30% of calories per day
with less animal fat and cholesterol to less than 300 mg daily to reduce the risk for
cardiovascular disease and diabetes as early as adolescence and later carried into
adulthood. The consumption of a Fast-food meal such as burger with shake and fries is
an example of a high fat meal exceeding the recommended less than 30% calories
from fat. The effect of peer influence, social media, and fast-food establishments pose
a challenge to an adolescent to maintain healthy diet and nutrition. Heightening
awareness of the importance of good nutrition and its long-term effects, as well as
creating an environment that fosters healthy diet, should be the focus of the public
health nurse.

Adults' and elderly’s recommended diet is low in saturated fatty acids, total fat and
saturated fats, and cholesterol to maintain desired body weight and lower the risk of
cardiovascular disease. Changes in body size, body mass, basal metabolism rate, and
physical activity alter the nutritional requirements. Essential components of the diet
are complex carbohydrates and fiber for proper bowel elimination, reduce serum
cholesterol and risk of colon cancer, and improved glucose response. Supplementation
may also be necessary due to reduced appetite, and difficulty in chewing and
swallowing among elderly, but it should be initiated after consultation. Moreover,
medications may also affect absorption of food; therefore, there is a need for further
exploration of food-drug interactions among elderly. Benefits of a healthy diet along
with physical activity can prevent premature mortality from cardiovascular disease in
middle-aged adults and can maintain vigor in the elderly.

Overweight and obesity is a result of an imbalance in energy due to excessive intake of

calories with the number of calories burned. While physical activity is essential in
maintaining healthy weight, so is controlling food intake. Overweight and obese
individuals who desire to lose weight should consult a health care provider before
starting a weight loss program. An individual with a BMI of 30 or above or between 25
and 30 with two or more weight-related health problems or with a waist circumference
of over 35 inches for women or 40 inches for men even if the BMI is less than 25, is
qualified for a weight loss program. An assessment of the dietary habits, family and
health history, physical examination, BMI, waist circumference, blood glucose, and
cholesterol analysis is needed to develop an effective weight management program.
Learning to control food intake and maintaining physical activity is crucial in any
weight management program. Radical changes in food consumption are not
recommended because of their harmful effects like dehydration, nutritional
deprivation, fainting, and heart attack. The time of the day does not also affect how the
body uses calories, but it is the overall caloric balance over the 24 hours that affects
weight gain. Therefore, withholding food intake at night is also ineffective.

Reducing calorie intake with attention to portion size, while maintaining the adequate
intake of vitamins, minerals, and fiber combined with regular physical activity can help
lose weight. A 5-15% reduction in body weight over 6 months significantly reduces
obesity-related risk. Losing 0.5-2 lbs. weight per week is cited as a safe rate. Diet
should include low-carbohydrate, low-fat, high-protein, and high-fibers. Replacement of
high caloric foods with fiber, fruits, and vegetables can decrease the individual's caloric
intake without eating less and feeling hungry. It is also important for obese and
overweight individuals to understand that some fat-free and low-fat foods sold in the
market have extra sugars that contain a high number of calories. It is advised to read
the nutrition facts on food labels to find out the calorie content based on serving size.
The public health nurse may assist the individual in planning a weight management
program that is safe, effective, and sustainable for a lifetime. Strategies would involve
health education on the benefits of healthy diet and nutrition, and behavioral
modification techniques that are proven to be effective. In addition, the nurse must
assist families with limited economic means in selecting low-cost foods that meet
recommended nutritional requirements.

Promote a smoke-free environment

Smoking is a major risk factor for developing cardiovascular and cerebrovascular

disease (CVC), lung cancer, and chronic lung disease.

Stress management

Stress is an inevitable human experience in a rapidly changing society. Selye defined

stress as "the nonspecific response of the body to any demand on it". It is estimated
that more than a quarter of visits to health facilities have been attributed to or made
worse by stress.

Managing stress involves understanding of a person's reaction to stress. Numerous

studies have been conducted to identify ways on managing stress. However, the
overall effectiveness and safety of interventions have not been sufficiently studied. In
general, the overall aim of managing stress should focus on minimizing the frequency
of stress-inducing situations, increasing resistance, and avoiding physiologic arousal
resulting from stress.

The advent of alternative medicine gives way to its use in managing and preventing
stress-related NCDs. Methods involved the use of biofeedback, meditation, breathing
relaxation exercise, and massage.

Ten Facts about the Global Burden of Disease

The global burden of disease is a comprehensive global assessment of mortality and

disability from major diseases, injuries. and risk factors.

1. Around 10 million children under the age of 5 die each year.

 The WHO estimates that nearly all of these deaths are preventable with
low-cost interventions such as primary care to treat diarrhea and
respiratory infections, and with integrated health systems.

2. Cardiovascular disease are the leading causes of death in the world.

 The WHO estimates that 80% of premature deaths from cardiovascular

disease and strokes could be prevented from appropriate diets,
physical exercise, and avoiding the use of tobacco.
3. HIV/AIDS is the leading cause of adult death in Africa.

 Inadequate health systems and limited access to care are major

barriers in reducing deaths due to HIV/AIDS.

4. Population aging is contributing to the rise in cancer and heart disease.

 There is a need to prepare health systems and caregivers to cope with

the elderly and their associated chronic illnesses and other health
problems.

5. Lung cancer is the most common cause of death from cancer in the world.

 The WHO estimates that smoking is responsible for 80% of lung cancer;
thus efforts to reduce smoking would have significant effect on lung
cancer deaths.

6. Complications of pregnancy account for almost 15% of death in women of

reproductive age worldwide.

 The WHO estimates that each year more than 500,000 women die from
preventable complications during pregnancy or childbirth.

7. Mental disorders such as depression are among the 20 leading causes of

disability worldwide.

 Lack of mental health services is a major problem worldwide. The WHO

estimates that less than 25% of persons with depression have access to
adequate treatment and health care.
 8. Hearing loss, vision problems, and mental disorders are the most common
causes of disability.

 There are many international organizations that are excellent resources

for promoting appropriate services and protecting the rights of persons
with disabilities, including the World Federation of the Deaf, the
Disabled Persons International, the International Disability Alliance, and
the World Blind Union.

9. Road traffic injuries are projected to rise from the ninth leading cause of death
globally in 2004, to the fifth in 2030.

 This problem could be reduced by the use of seat belts and helmet (for
motorcycle riders and bikers), and reduction of driving under the
influence of drugs or alcohol.

10. Undernutrition is the underlying cause of death for at least 30% of all
children under the age of 5.

 The WHO estimates that nearly 20 million children worldwide are

severely malnourished, increasing their risk of acquiring infections and
reducing their ability to resist such infections


MENTAL HEALTH 

Mental health is an integral part of every individual. The WHO defined mental health as
a state of social well-being in which every individual realizes his or her own potential
(self-image), can cope with the normal stresses of life (resiliency), can work
productively and fruitfully (productivity and creativity), and is able to make a
contribution to her or his community (sense of purpose).

Mental health is determined by the interplay of different factors that affect the mental
state and well-being of an individual. It may be determined by socioeconomic factors;
however, there is evidence that genetics may affect the mental state of an individual.
Poverty, low levels of education, poor living conditions, and hopelessness may increase
vulnerability to mental illness. For example, street children are more likely to be
exposed to physical illness, accidents, family problems, inadequate social support, and
mental health problems or even depression in the family. Chemical imbalance in the
brain due to trauma, infectious diseases, and toxic substances has also been shown to
be associated with mental illness. Behavioral problems like substance abuse, violence,
and abuse of women and children and health problems such as HIV/AIDS are also
linked with mental illnesses.

Mental illness or mental disorder is any illness experienced by a person that interferes
with his or her thinking, feeling, or social activities and even daily functioning. It
produces a negative effect on one's life or the lives of the family. A mental health
problem, on the other hand, does not hamper functioning and is temporarily
experienced as a reaction to life stressors. It is less severe and shorter in duration, but
it may develop into mental disorders.

Mental health problems have four facets as a public health burden. These are defined
burden, undefined burden, hidden burden, and future burden:

Defined or direct burden - burden affecting persons with mental disorders such as cost
of treatment, quality of life, and disability.Undefined or indirect burden - burden
relating to the impact of mental health problems to others such as family members or
the community who care for the patient.Hidden burden - stigma and violations of
human rights to persons affected with mental health problems.Future or health burden
- burden resulting from the aging population or increasing social problems such as the
development of complications or other medical illnesses or death.
There is no single cause of mental illness. The interplay among biological, social,
cultural, and psychological factors determines the development of mental illness. In
many cultures, both medical (biological) and traditional (social and cultural)
explanations are used to understand the causes of mental illness. The following were
identified as conditions that can lead to mental illness:

1. Stressful life events like death of a loved one, financial problems, marital
conflict, and violence.
2. Difficult family background; for example, a history of neglect and violence may
result in an unhappy childhood.
3. Brain diseases like mental retardation and brain infections, AIDS, head injuries,
epilepsy, and stroke.
4. Heredity may be a factor; however, this is also influenced by environmental
factors,
5. Medical problems like kidney and liver failure, or medicines taken can alter
processes.

According to the WHO, approximately one out of four families has at least one member
currently suffering from mental illness. It is estimated that one in five of all adults will
experience a mental health problem. Studies across countries showed that as much as
40% of adults consulting at the general health care service is suffering from some kind
of mental illness. Statistics showed that 4 out of 10 most disabling conditions in the
world were mental illnesses. The rapid change and increasing demand of our society
increase the likelihood of developing mental health problems. Although mental illness
can be treated with simple, relatively inexpensive methods, mental health services are
not adequate. There is a shortage of mental health professionals who can provide
quality mental health services. Moreover, individuals with mental illness are often
discriminated by their family and the community.

In the Philippines, home care management for mentally ill patients is advocated. This is
also referred to as deinstitutionalization of mental health care, so as to apply the
promotive and preventive levels in this aspect of health rather than pursue the curative
and rehabilitative care. This gives the community health nurse the opportunity to
identify high-risk individuals and families, provide health care before mental ill-health
happens and for persons with mental illness to be accorded the respect needed as
members of a community. Acute cases are managed by the National Center for Mental
Health or hospitals with psychiatric facilities.

DISABILITY

The WHO reported that more than one billion of the world's population had some form
of disability. However, local statistics registered 1.23% persons with disabilities (PWDs),
a rate which is below the prevalence rate estimated by the WHO. The International
Classification of Functioning, Disability and Health defined disability as a general term
for impairments, activity limitations, and participation restrictions. Impairment is a
problem in body function or structure. Activity limitation is a difficulty encountered by
an individual in executing a task or action. Participation restriction is a problem
experienced by an individual with regard to the involvement in life situations.
Moreover, disability refers to the negative aspects of the interaction between
individuals with a health condition, personal, and environmental factors.

According to the WHO Report 2010, nearly 200 million people experience difficulties in
functioning due to aging and onset of chronic health conditions such as diabetes,
cardiovascular diseases, and mental illness. Studies indicated that people with
disabilities experience poorer health outcomes, lower educational achievements, less
economic participation, higher rates of poverty, increased dependency, and restricted
participation than people without disabilities. Barriers identified includes:

Inadequate policies and standards for people with disabilityNegative attitudes of

peopleLack of provision of services for PWDsPoor service deliveryInadequate
fundingLack of accessibilityLack of involvementLack of data and evidence on disability
As a result, the United Nations on December 13, 2006 adopted the Convention on the
Rights of Persons with Disabilities (CRPD). The CRPD supersedes the United Nations
Standard Rules on the Equalization of Opportunities for Persons with Disabilities in
1993, it aims to "promote, protect and ensure the full and equal enjoyment of all
human rights and fundamental freedoms by all persons with disabilities, and to
promote respect for their inherent dignity". The CRPD became the foundation for the
paradigm shift toward understanding disability.

In the Philippines, the program that addresses the needs of individuals with physical
disability is the National Health Program for Persons with Disabilities. Republic Act No.
7277 or the Magna Carta for Disabled Persons particularly requires:

1. a national health program for PWDs,

2. establishment of medical rehabilitation centers in provincial hospitals, and
3. an integrated and comprehensive program for the health development of PWDs
that shall make essential health services available to them at an affordable
cost

Rule 4, Section 4 of the implementing rules and regulations of RA 7277 address the
health concerns of seven different categories of disability that include:

1. psychosocial and behavioral disabilities

2. chronic illness with disabilities
3. learning disabilities
 4. mental disabilities
5. visual/seeing disabilities
6. orthopedic/moving, and
7. communication deficits.

Strategies employed in the implementation include advocacy and health education on

the nature, risk factors, extent of impairments, complications, early diagnosis and
treatment, and prevention of disability. An information system known as the Philippine
Registry for Persons with Disability will be used to monitor and develop the registration
of PWDs. To ensure that quality services are locally available, accessible, and
affordable, training of personnel and partnership between facilities will be developed.
International organizations involved in the implementation of the program includes
American Leprosy Missions, Australian Agency for International Development,
Christoffel-Blindenmission, JICA, and UNICEF.
VISUAL IMPAIRMENT

Visual impairment is a worldwide health problem. The WHO reported that approximately 314
million people are visually impaired. Of these, 45 million are blind and 269 million have low
vision. Globally, the major causes of blindness include cataract (39%), uncorrected refractive
errors (18%), glaucoma (10%), age-related macular degeneration (7%), corneal opacities (4%),
diabetic retinopathy (4%), eye diseases in children (3%), trachoma (3%), and onchocerciasis
(0.7%).

In the Philippines, the DOH 2002 reported that 592,000 people are blind, and 2 million people
have moderate or severe visual impairment. The number of individuals blind due to cataract is
around 367,000 (62%), and 59,000 (10%) are due to uncorrected refractive errors. Among
persons aged 0-19 years old, prevalence of blindness is 0.06% (26,690), and low vision is 0.09%
(40,035). Causes of visual impairment to this age group are error of refraction (53%), cataract
(40.8%), and all other blinding causes (6.1%). However, compared to adults, the leading cause is
still cataract.

The International Statistical Classification of Diseases, Injuries and Causes of Death, 11th
revision (ICD-11): 1154 classified visual impairment as low vision and blindness. Low vision is
defined as visual acuity of less than 6/18, but equal to or better than 3/60, or a corresponding
visual field loss to less than 20 degrees in the better eye with best possible correction (ICD-11
visual impairment categories 1 and 2). On the other hand, blindness is defined as visual acuity of
less than 3/60, or a corresponding visual field loss to less than 10 degrees in the better eye with
best possible correction (ICD-11 visual impairment categories 3, 4, and 5).

According to the WHO, visual impairment can be prevented and treated. However, people living
in poor communities remain at risk due to lack of access to eye care services. To address the
problem of global blindness, the WHO launched in 1999 the "Vision 2020: The Right to Sight",
which is the Global Initiative for the Elimination of Avoidable Blindness. The aim of Vision 2020 is
to develop a sustainable comprehensive health care system that will ensure the best possible
vision for all, thus improving their quality of life. The program is a partnership between the WHO,
and a large umbrella organization for eye-care professional groups and nongovernmental
organizations involved in eye care known as the International Agency for Prevention of
Blindness. The program has three essential components of the action plans: cost-effective
disease control interventions, human resource development, and infrastructure development.

In the Philippines, the program that addresses visual impairment is the National Prevention of
Blindness Program developed by the DOH. The guidelines in the implementation of the National
Prevention of Blindness Program are described in Administrative Order No. 179 series of 2004.
Strategies employed by in the implementation include advocacy and health education on the
nature, risk factors, extent of visual impairments, complications, early diagnosis and treatment,
and prevention of visual impairment. To ensure that quality eye care services are locally
available, accessible, and affordable, training of personnel and partnership between public and
private facilities will be developed. Organizations involved in the implementation of program
includes the National Committee for Sight Preservation, Philippine Academy of the
Ophthalmology, Philippine Information Agency, Optometric Association of the Philippines, Rotary
International, Integrated Philippine Association of Optometrists, foundation for Sight, Helen Keller
International, Lions Club International, Tanggal Katarata Foundation, UP Institute of
Ophthalmology, Christian Blind Mission, Resources for the Blind, and Sentro Ofthalmologico Jose
Rizal

 LAWS AFFECTING CONTROL OF NONCOMMUNICABLE DISEASES

1. Executive Order No. 958

 National Healthy Lifestyle Advocacy Campaign. Declaring the years 2005-

2015 as the decade of healthy lifestyle.

2. Republic Act No. 1054

 Free emergency medical and dental treatment for employees.

3. Republic Act No. 9211

 Tobacco Regulation Act of 2003. Regulates the packaging, use, sale,

distribution, and advertisements of tobacco products.

4. Republic Act No. 6425

 Penalties for Violations of the Dangerous Drug Act of 1972.

5. Republic Act No. 9165

 Comprehensive Dangerous Drug Act of 2002.

6. Republic Act No. 8423

  Traditional and Alternative Medicine Act of 1997.

7. Administrative Order No. 179 Series of 2004

 Guidelines for the Implementation of the National Prevention of Blindness

Program.

8. Department Personnel Order No. 2005-0547

 Creation of a Program Management Committee for the National Prevention

of Blindness Program

9. Proclamation No. 40

 Declaring the month of August every year as "Sight Saving Month".

10. Republic Act 7277

 Magna Carta for Disabled Persons. An act providing tor the rehabilitation,
and self-reliance of disabled persons and their integration into the
mainstream of society and for other purposes.

COMMUNICABLE DISEASES

Communicable disease is one of the major public health problems in the Philippines,
Most of the leading causes of morbidity in the Philippines are attributed to communicable
diseases. Pneumonia and tuberculosis (TB) were the 4th and 5th leading causes of
mortality despite the aggressive campaign initiated by the DOH. Although the
prevalence is low, the number of HIV cases in the country is increasing due to sexually
transmitted infections (STI), (HIV/AIDS Surveillance Technical Report, 2010). Malaria,
schistosomiasis, filariasis, and other endemic diseases are still prevalent in several
regions of the country. Moreover, new and reemerging communicable diseases due to
demographic and environmental factors also contributed to the existing public health
problems.
The Philippines' commitment to control communicable diseases in response to the sixth
Millenium Development Goal (MDG) has intensified its efforts to reduce morbidity and
mortality in 2015. Campaign initiated by the DOH in collaboration with various
organizations focused on enhancing public awareness of the different communicable
diseases. The public health nurse, as an important member of the health team, must be
knowledgeable of the different communicable diseases common in the community, as
well as the different DOH programs in the prevention and control of communicable
diseases.

Communicable diseases are illnesses caused by an infectious agent or its toxic products
that is transmitted directly or indirectly to a person, animal, or intemediary host or
inanimate environment. Communicable diseases could either be a contagious or an
infectious disease. The term "contagion," a derivative of "contact", is transmitted by
direct physical contact. On the other hand, an infectious disease is transmitted indirectly
through contaminated food, body fluids, objects, airborne inhalation, or through vector
organisms that would require a break or inoculation in the skin or mucous membranes of
individuals. An infectious disease is sometimes called contagious. However, other
infectious diseases are usually not regarded as contagious. For this reason, the term
contagious disease is not popularly used.

EPIDEMIOLOGIC TRIANGLE MODEL

The fundamental public health concept on explaining the development of communicable disease is the
epidemiologic triangle model. Although multiple factors are involved in disease causation, the model has been
used for decades by epidemiologists to explain the etiology of communicable disease. It recognizes three major
components, namely, agent, host, and environment.

The agent is an organism involved in the development of a disease. In relation to infectious diseases, an agent
must be present for an infection to occur. Agents include bacteria (e.g. TB, pneumonia, typhoid fever), viruses
and rickettsia (e.g. viral hepatitis* herpes simplex, influenza, and viral meningitis), rickettsial agents (e.g.
Rocky Mountain spotted fever, and rickettsial pox), fungi (e.g. ringworm or tinea capitis, athlete's foot or tinea
pedis), protozoa (e.g. malaria, amebiasis, and giardiasis), helminths (e.g. ascariasis, enterobiasis,
ancylostomiasis, and schistosomiasis), and arthropods (e.g. scabies) that act as vectors to agents from their
reservoirs to humans.

Although the agent must be present for an infection to occur, it must be capable of infecting a host. The host is
any organism that harbors and provides nutrition for the agent. Most often, humans are the host of infectious
organisms. However, other organisms like animals can be considered as hosts as they relate to human health.
The ability of the host to fight the agent causing the infection is influenced by many factors such as age, gender,
socioeconomic status, ethnicity, nutritional and immune status, genetic makeup, hygiene, and behavior.

The environment refers to the condition in which the agent may exist, survive, or originate. It comprises
physical, biological, and socioeconomic components. The physical environment includes temperature, weather,
soil, water, and food sources. The biological environment includes animals, insects, flora, and other human
beings that act as reservoir or foster the survival of organisms. The socioeconomic environment includes the
behavior, personality, attitudes, cultural characteristics of people, occupation, and urbanization.

CHAIN OF INFECTION

In the prevention and control of communicable diseases, it is important that the public health nurse understands
the chain of infection. It is a logical sequence of factors that are essential to the development of a
communicable disease. Thus, removing any one of the elements prevents the onset of a communicable disease.
The elements in the chain of infection include the following:

1. Causative agent is any organism capable of producing a disease. It includes bacteria, viruses,
rickettsial fungi, protozoa, and helminths.
2. Reservoir is the environment or object in or on which an organism survives and multiplies. Inanimate
objects, human beings, and other animals can serve as reservoir.
3. Portal of exit is the path by which an agent leaves its reservoir. Common portals of exit include the
respiratory, genitourinary, skin and mucous membranes, and gastrointestinal tract.
4. Mode of transmission is the means by which the agent passes from the portal of exit in the reservoir
to the susceptible host. It can be transmitted through contact, airborne, droplet, vehicle, and vector-
borne.
5. Portal of entry is the path by which an agent invades a susceptible host. Usually, this path is the same
as the portal of exit.
6. Susceptible host is the various factors of the individual that present barriers to the invasion and
multiplication of agents.

DISEASES TARGETED FOR ERADICATION

The ultimate goal in the control of communicable disease is its elimination and eradication so that it is no
longer considered a public health problem. Most often, eradication and elimination are synonymously used;
however, these two terms are different. Eradication refers to the permanent reduction to zero of the worldwide
prevalence of a disease caused by a specific agent. Eradication, in its true sense, involves completely removing
or eliminating the microorganism from nature, like in the case of the smallpox virus. However, it is also
possible to eliminate a disease even if the microorganism is still present in the environment, like the neonatal
tetanus that was declared globally eliminated by 1995. Elimination, on the other hand, is reduction to zero
prevalence of a disease in a single country, continent, or other limited geographical area. Elimination may also
be defined as the control of the manifestations of a disease so that it is no longer a public health problem by
reducing its incidence to a level below one case per 10,000 population. Contrary to eradication, intervention
measures are still needed in elimination since the disease is still present elsewhere.

During the past years, a number of infectious diseases have been targeted for eradication or elimination. In
1988, the International Task Force for Disease Eradication (ITFDE) was established to systematically review
potential candidate diseases for eradication and to provide leadership and advocacy for the concept of
eradication where appropriate and useful. The ITFDF identified smallpox, poliomyelitis, measles, rubella,
lymphatic filariasis, dracunculiasis (guinea worm disease), and taeniasis (tapeworm) as diseases for global
eradication, whereas diseases for global elimination are hepatitis B, malaria, neonatal tetanus, rabies, Chagas
disease, trachomatis, onchocerciasis, iodine deficiency disorders, and yaws. The World Health Organization
initiative to eradicate yaws started in 1954, followed by malaria in 1955, smallpox in 1980, dracunculiasis and
paralytic poliomyelitis in 2000, and measles in 2015. So far, smallpox is the only disease that has been
successfully eradicated worldwide in 1977. However, substantial progress has been made to eliminate malaria
and poliomyelitis in endemic, countries. In the Philippines, the National Objectives for Health 2011-2016
identified rabies, leprosy, filariasis, and schistosomiasis as diseases targeted for elimination.

Rabies is one of the most acute fatal infections, and the country has consistently ranked among the top 10
countries regarding human rabies death. The goal of the National Rabies Prevention and Control Program is to
eliminate rabies as a public health problem at less than 0.5 cases per million population and to declare the
Philippines rabies-free by the year 2020. As of 2010, the DOH reported that there are five areas declared rabies
free: Siquijor, Batanes, Camotes Island, Apo Island, and Malapascua Island.

Leprosy in the country has a consistently low prevalence rate of less than one per 10,000 population since
1998. However, the Philippines has the highest prevalence of leprosy among the countries in the Western
Pacific region. The prevalence rate computed from Field Health Services Information System and World
Health Organization Weekly Epidemiological Record of leprosy in 2010 is higher (0.46%) compared to that in
2008. The Leprosy Program target is to eliminate leprosy as a public health problem at a level of one case per
10,000 population in DOH identified endemic areas like Eastern Visayas, Ilocos, Zamboanga peninsula,
Central Visayas, and Northern Mindanao.
Filariasis is endemic in the Philippines. The WHO classification for endemicity is based on the elimination
level of a microfilaria rate of less than 1%, and an antigen rate of less than 1% per implementing unit. Out of
80 endemic provinces, 43 provinces have not reached the target level due to the lack of awareness and
understanding about the disease and its elimination. The goal of the National Filariasis Elimination Program
(NFEP) is to eliminate filariasis as a public health problem by 2015 with a prevalence rate of microfilaremia of
less than 1%.

Schistosomiasis is endemic in 12 regions in the country. It has a national prevalence rate of 2.5% and peaking
at 15-49 years of age. Despite the continuous efforts of the DOH through mass chemotherapy in endemic areas,
morbidity rate has risen to 10% in 2008 compared to 6.6% in 2007. The goal of the Schistosomiasis Control
Program is to eliminate schistosomiasis as a public health problem with the prevalence rate of less than 1% for
the last five consecutive years.

The eradication and elimination of the disease is crucial to sustainable improvement in public health. The focus
of communicable disease control is directed toward eradicating the disease, because it can reduce or eliminate
the burden of disease and its associated mortality. Moreover, eradication is permanent, and its benefits address
public health and socioeconomic issues in health care.

FUNCTIONS OF THE PUBLIC HEALTH NURSE IN THE CONTROL OF COMMUNICABLE

DISEASES

1. Report immediately to the Municipal Health Office any known case of notifiable disease.
2. Refer immediately to the nearest hospital.
3. Conduct a strong health education program directed toward prevention of an outbreak.
4. Assist in the diagnosis of the suspect based on the signs and symptoms.
5. Conduct epidemiologic investigations as a means of contacting families' case finding and individual
as well as community health education

SPECIFIC COMMUNICABLE DISEASES

Tuberculosis (Phthisis, Consumption disease, Koch's disease)

Incidence

Tuberculosis (TB) is one of the oldest and deadly diseases worldwide. The Global Tuberculosis
Report of 2012 by WHO revealed that, there are 9 million new cases of TB in 2011 and 1.4
million TB deaths. The WHO has predicted that by 2020, nearly one billion people would be infected
with TB, and of that number, 70 million would die. The Center for Disease Control accounted that
75% of the cases worldwide occur in Asia. In 2009, the WHO repotted that the Philippines ranked
ninth among the 22 countries worldwide with a high TB burden. In the Western Pacific region, the
country ranked second in terms of new smear-positive TB notification rate and third in case density.

In the Philippines, TB ranked fifth in the leading causes of mortality among Filipinos with an average
of 75 deaths every day. Despite the decrease in mortality rate in the past 20 years, TB remained to
be a major public health problem in the Philippines.

The burden of disease from TB in the Philippines is high among the poor sectors of the society. It is
known to be a perennial disease of poor Filipinos due to unsanitary living conditions, overcrowding,
poor ventilation, and malnutrition. Demographic profile of TB in the Philippines showed that majority
are males, and 70% of the TB population is within the economically productive age group. Hence, it is
estimated that 20-30% of household annual income is lost for morbidity, and 15 years of income is
lost for mortality.

Etiology
Causative agent: Usually by Mycobacterium tuberculosis and M. africanum from humans, but
occasionally by M. bovis from cattle, or M. canettii

Mode of transmission: Airborne droplet through inhalation of coughing, singing, or sneezing.

Incubation period: 4-6 weeks.

Signs and symptoms: Fever: low grade late afternoon, loss of appetite, easy fatigability, night
sweats, dry cough, later productive with hemoptysis, chest pain.

Laboratory/diagnostic test:

1. Direct sputum smear microscopy is the principal diagnostic method adopted by the National
Tuberculosis Program (NTP) as it provides a definitive diagnosis of active TB. It is simple and
economical, and a microscopy center could be put up even in remote areas of the country
owing to its feasibility, A definitive diagnosis of TB is made with the demonstration of
Mycobacterium tuberculosis using fluorescence acid-fast microscopy staining because of its
specificity and efficiency in detecting acid-fast bacilli (AFB) count in the sputum.

Guidelines for the interpretation of the results of the three specimens state that a smear
positive (+) would mean at least two positive (+) sputum smear results, whereas smear
negative (-) would mean all three sputum smear results as negative (-). The specimen out of
the smear positive (+) results with the highest number is the final AFB quantification. Doubtful
is the interpretation if there is only one positive (+) out of the three specimens examined. In
case of doubtful results, another set of three sputum specimens is requested from the patient if
at least one specimen from the second set of specimens is positive (+), laboratory diagnosis is
positive (+). If all three specimens from the second set of specimens are negative (-), the
diagnosis is negative (-).

2. Chest X-ray is another method used in the diagnosis of TB. However, it has assumed a
secondary role in the diagnosis of TB based on the NTP. Alonzo et al. (1990) cited that the
infectivity of a person is difficult to determine by chest radiography alone. Second, there is no
radiographic picture that is absolutely typical of TB; many other diseases can imitate the
pattern of pulmonary TB (PTB). Moreover, the level of disagreement on the interpretation of
chest radiography is high. Nevertheless, it is helpful in localizing the site of TB lesion, and may
be useful in diagnosing TB patients who are asymptomatic, and those who cannot submit
sputum specimen but are suspected to have TB.

Management:

TB is curable. In the Philippines, the National Tuberculosis Control Program was created with a vision
of a country where TB is no longer a public health problem. Its mission is to ensure that TB services
are available, accessible, and affordable to the communities in collaboration with the local
government units (LGLIs) and other partners. The goal is to reduce prevalence and mortality from TB
by half by the year 2015 through its targets:

1. cure at least 85% of the new sputum smear-positive cases discovered

 2. detection at least 70% of the estimated new sputum smear positive cases.

The NFP became one of the DOH flagship programs. More recently, the Philippines adopted the
Comprehensive Unified Policy on TB control. The Comprehensive Unified Policy put all TB control
protocols under one umbrella and enjoined other key government agencies and private organizations
involved in TB control to carry out their respective TB control efforts in the context of the NTP. The
NTP adopted DOTS, which is believed to be the most effective strategy for controlling TB. However,
political commitment, quality microscopy services, regular supply of anti-TB drugs, supervised
medication by a treatment partner, and standardized reporting are essential elements to ensure
success in its implementation .

The directly observed treatment (DOT) or locally known as Tutok Camutan is a method developed to
ensure treatment adherence by providing constant supervision to TB patients. DOT works by having
a responsible person, referred to as treatment partner such as a nurse, midwife, or trained
community member, watch the TB patient take medicines every day during the whole course of
treatment.

TB can be cured but requires adherence to drug intake for the prescribed duration. This comprises a
combination of antibiotics, which need to be taken together to prevent the development of drug
resistance. Antibiotics taken involved five major drugs, namely, isoniazid (H), rifampicin (R),
pyrazinamide (Z), ethambutol (E), and streptomycin (S). The first four are given orally, and the latter
is given parenteral. Local studies have shown that these antibiotics are the most potent antibiotics
against all forms of TB. These drugs are used for short-course chemotherapy because of their
sterilizing effect on TB bacilli.

The initial phase of treatment should consist of 2 months of HRZE, and continuation phase consists
of RI for 4 months. The fixed-dose combination (FDC), in which two or more anti-TB drugs are
combined in one tablet, is highly recommended, especially when medication ingestion is not
observed. Single-drug formulation (SDF), in which each drug is prepared individually, is also
available. FDC has several advantages over SDK:

1. FDC is administered more easily than SDF;

2. monotherapy is avoided, therefore there is less chances of drug resistance;
3. there is a decrease in medication errors;
4. it is useful when DOT is not possible;
5. it improves health workers and patients adherence.

These drugs are usually available in blister packs good for one week. The number of tablets of FDCs
per patient depends on the body weight. Hence, all patients must be weighed (using kilograms)
before treatment is started.

Prevention:

1. Bacillus Calmette-Guerin (BCG) vaccination of newborn infants provides 50% protection

against any TB disease
2. Health education
3. Environmental sanitation
4. Early diagnosis and treatment
5. Respiratory isolation
Roles and responsibilities of the nurse in the NTP and DOTS strategy:

 Nurse as administrator. As a public health nurse, the Comprehensive and Unified Policy for
TB Control of the Philippines (DOH) enumerated specific functions such as:

1.

1. Manage the procedures for case-finding activities with other NTP staff workers;
2. Assign and supervise a treatment partner for patients who will undergo DOTS;
3. Supervise rural health midwives to ensure proper implementation of DOTS.
4. Maintain and update the NTP Register;
5. Facilitate requisition and distribution of drugs and other NTP supplies;
6. Provide continuous health education to all TB patients placed under treatment and
encourage family and community participation in TB control;
7. Conduct training of the health workers in coordination with MHO/CHO; and
8. Prepare and submit the Quarterly Reports to PHO/CHO.
9. Analyze the data together with the MHO/CHO for future planning activity.

 Nurse as health educator. Patient education is very important in the intensive phase of
treatment. However, it is vital to a successful treatment outcome that patient education will be
an on-going process throughout the duration of treatment period.

 Nurse as case manager and coordinator. The roles of the TB nurse manager can be
summed up into two major functions:

1.

1. Managing services for the individually diagnosed or suspected of having TB from

initiation to completion of treatment and a change in the diagnosis or death.
2. Immediately schedule another date if patient is unable to keep appointments to avoid
the patient being labeled as delinquent. TB case management is directed toward
accomplishing the following goals:

a. All hospitalized patients diagnosed or suspected of TB disease received

continuity of care during transition from hospital to the outpatient setting without
interruption in treatment or essential service.
b. Disease progressions without drug resistance are preventive.
c. Each patient received TB care and treatment according to prescribed standards
of care.
d. An integrated, coordinated system of health care allows patients to experience
TB care along a continuum rather than in fragments.
e. Patients complete TB treatment with appropriate time frames and with minimal
interruption in their lifestyle or work.
f. Transmission of TB within the community is prevented through effective contact
investigation and delinquency control activities.
g. The patient/family/community is educated about TB infections, disease, and
treatment.
h. Individuals diagnosed with clinically active or suspected TB are reported
according to regulations, and TB control activities are complemented according
to standards of the country, regional, or municipal TB control program.
i. Case managers participate in policy development within the health care system
that positively affects clinical and TB control outcomes.
 j. Case managers participate in studies to improve case management services and
documentation, enhancement of adherence, and TB nursing.

2.

 Nurse as community organizer (CO), TB is a public health priority and of concern to the
community as a whole, not just to the TB patient and but also to immediate contacts. The
workplace is a part of the community. Activities can be carried out in collaboration with local
authorities, community associations, nongovernment organizations (NGOs), and donor
agencies. With this, the nurse can assume the role as CO, and ensures that all activities
related to the TB control program are done in such a way that the patients and the people in
general will benefit. There should be a collective effort among all concerned individuals or
groups to achieve its goals. One activity that has been initiated and functional is the
establishment of the TB Network.


 Community organization activities:



1. Generate data on the incidence of TB in the locality.
2. Conduct home visitation to patients and treatment partners.
3. Meet health workers and other key leaders.
4. Determine resources for the treatment regimen.
5. Build the team.
6. Conduct networking and linkaging with the LGUs, and NGOs.

 Nurse as treatment partner. The nurse may continue to use the nursing process as a
systematic approach in providing individualized care to the patient.

 Nurse as TB advocate. Following are some of the roles of the TB-DOTS advocate:

1.
1. Shares experiences and accomplishments in terms of cure and referral to TB network.
2. Disseminates correct information on TB through available information, education, and
communication campaign materials.
3. Serves as moral support to TB patients and fellow advocates.
4. Refers individuals with cough for 2 weeks or more to the nearest DOTS center for
proper management.
5. Conducts health education activities on how TB is acquired and developed.
6. Promotes the DOTS services of TB partners including the private sector.
7. Advocates DOTS as a strategy for curing TB.
8. Participates during NTP activities including National Health Events, if possible.
9. Encourages other people from different sectors to be TB-DOTS advocates.
10. Assists the treatment partner or may serve as the treatment partner, if necessary

SPECIFIC COMMUNICABLE DISEASES

Mosquito-borne diseases

Dengue (hemorrhagic fever, break bone or dandy fever, dengue shock syndrome)
Incidence

Dengue is a public health problem in the Philippines. The disease once associated with the rainy
season has begun to change its pattern in the country. Although the case fatality rate decreased in
2005, recent statistics shows that dengue cases in the Philippines increased in 2009 to its peak with
57,819 cases. The sudden change of pattern may be attributed to climate change and urbanization,
since the vector of the disease proliferates in congested urban areas.

Causative agent: Dengue virus (DEN), a single stranded RNA virus of four types (DEN-1, 2, 3, 4)
that belong to the genus Flavivirus, family Flaviviridae. All of the four types have been isolated in the
country. Therefore, a person can get the infection four times since there is no cross-immunity
between types. However, lifetime immunity is possible for a specific type of virus.

Vector: Infected female Aedes mosquitoes. Aedes aegypti, also known as yellow fever mosquito or
tiger mosquito, is the principal vector predominant in urban areas seen in tropical and subtropical
countries. These mosquitoes proliferate in clean, clear and unpolluted stagnant bodies of water used
for domestic water storage or rain-filled habitats like flower vases, earthen jars, concrete water tanks,
discarded vehicle tires, ant traps, metal drums, water barrels, tin cans, and any other containers that
can accumulate water up to 7 days. Typically, these mosquitos fly within a 100-meter radius from the
breeding place with a flight range of 50 meters. They feed almost entirely on humans at dusk, just
before sunset, at dawn, and just after sunrise when indoors. As domestic mosquitoes, Aedes
aegypti prefer to rest in cool, dark corners of the house. Commonly, they are found in closets and
under beds, tables, and chairs.

Aedes albopictus, also known as the Asian tiger mosquito, is the secondary vector predominant in
rural areas that proliferates in leaf axils, tree holes, bamboo stumps, coconut shells or husks, and
ground or deep holes. These mosquitoes feed on other mammals aside from humans during daylight
in the outdoors. Unlike A. aegypti, A. albopictus usually rest in clearings and vegetation, and they
can survive even in cold temperatures. They can fly within a 200-meter radius from the point of origin
with a flight range of 180 meters. Moreover, they are the only mosquitoes that can transmit the
chikungunya virus.

Dengue outbreaks in other countries have also been attributed to Aedes polynesiensis and several
species of Aedes sculellahs. Each of these species has a particular ecology, behavior, and
geographical distribution. Therefore, it is important to note their characteristics as vectors to control
dengue. However, one common characteristic of these three species is that their eggs are found in
water-filled habitats closely associated with human dwellings.

Mode of transmission: The dengue virus is transmitted to humans through the bile of an infected
Aedes mosquito. The dengue virus circulating in the blood of infected individuals is ingested by
female mosquitos during feeding. The virus then infects the mosquito's mid-gut and subsequently
spreads systemically over a period of 8-12 days. After this, the virus can be transmitted to other
humans during subsequent probing or feeding.

Susceptible: All individuals regardless of age, gender, or geographic location are at risk. However,
children between 0-9 years are commonly affected based on age distribution. Moreover, the
epidemic is frequent in populated areas with poor environmental conditions conducive for vector
breeding.

Incubation period: 3-14 days, commonly 5-7 days

Laboratory diagnostic test:

1. Tourniquet test or Rumpel-Leads test. This test measures the coagulability of the blood. This
is done by applying a tourniquet on a client's extremity and observing the amount of petechiae
produced. It is the presumptive test for dengue, which is used to assess bleeding tendencies
of a patient suspected to have the disease. Before doing the test, the public health nurse must
explain the procedure and purpose, and he or she must assess the individual's arm for any
petechiae, ecchymoses, or infections that may affect the result. The tourniquet test is also
contraindicated for individuals with fistula, those with arteriovenous shunt, and those who
 have undergone a mastectomy. The public health nurse must inform the individual that the
patient may be uncomfortable for a while but not in pain. In performing this test, the nurse
places the sphygmomanometer on the upper arm of the individual and inflates the blood
pressure cuff to a point midway between the systolic and diastolic pressure for 5 minutes.
Then, the cuff is released and the nurse makes an imaginary 1-inch (2.5 cm) square just
below the cuff, at the antecubital fossa, finally, the nurse inspects and counts the number of
petechiae in a I-inch (2.5 cm) square. A positive result would mean the presence of 20 or
more petechiae per 1-inch square.
2. Capillary refill test or nail blanch test. Capillary refill is the rate at which blood refills empty
capillaries. It measures dehydration and decreased peripheral perfusion for patients with
dengue. It can be measured by holding a hand higher than heart-level, then the soft pad of the
thumb nail or toe nail is pressed until it turns white or until blanching occurs. Pressure is then
released and the time needed for the color to return once pressure is released is measured.
Normal refill time is less than 3 seconds. Hence, a refill time of more than 3 seconds is a
warning sign.
3. Platelet count and hematocrit (HCT)count. To confirm the diagnosis of dengue, a laboratory
test such as platelet and hematocrit count should be performed. A rapid decrease in platelet
count (150,000 to 400,000 cu.mm) in parallel with a rising hematocrit (F-36-46%, M-41-53%)
is suggestive of progress to the critical phase of dengue. If no proper laboratory services are
available, the minimum standard is the point-of-care testing of hematocrit by capillary (finger
prick) blood sample with the use of a microcentrifuge.
4. Hemagglutination-inhibition (HI) test. This test is frequently used for patients admitted in the
hospital, as this test would require paired sera. The HI test is based on the ability of dengue
virus antibodies to inhibit agglutination.

Dengue case classification

Due to the differing clinical presentations and unpredictable clinical evolution and outcomes, a new
model for classifying dengue has been developed by a WHO expert consensus group. This model is
for the practical use in the clinician's decision as to where and how intensively the patient should be
observed and treated.

Phases of Illness

1. Febrile phase lasts from 2 to 7 days -high-grade fever, facial flushing, skin erythema,
generalized body ache, myalgia, arthralgia, and headache. Some may have sore throat,
infected pharynx, and conjunctival infection. Anorexia, nausea, and vomiting are common. A
positive tourniquet test result increases the probability of dengue. Therefore, monitoring for
warning signs and other parameters is needed to recognize progress to critical phase. Mild
hemorrhagic manifestations like petechiae and mucosal membrane (nose and gums) bleeding
may be seen. A progressive decrease in total white cell count in the blood would alert the
nurse to a high probability of dengue.
2. Critical phase lasts from 24 to 48 hours -when the temperature drops and remains below 37.5-
38°C or less usually on days 3 to 7 of illness, an increase in capillary permeability in parallel
with increasing hematocrit levels may occur. Rapid decrease in platelet count usually
precedes plasma leakage. Pleural effusion and ascites may be detectable. Shock may occur
when a large amount of plasma is lost through leakage that is preceded by warning signs.
Prolonged shock results in organ impairment (severe hepatitis, encephalitis, myocarditis),
metabolic acidosis, and disseminated intravascular coagulation.
3. Recovery phase usually takes place in the following 48-72 hours - 'The general well-being
improves, appetite returns, gastrointestinal symptoms subsides, and hemodynamic status
become stable.
Management: Treatment for dengue is symptomatic and supportive. Follow-up is also important for
proper observation and monitoring of patients. All suspected cases of dengue should be referred
immediately for proper management and to prevent complications.

1. Give paracetamol every 6 hours. If the patient still has high fever, do tepid sponge bath. Do
not give acetylsalicylic acid (aspirin), ibuprofen, or other nonsteroidal anti-inflammatory agents
(NSAIDs), as these drugs may aggravate bleeding. Acetylsalicylic acid (aspirin) may be
associated with Reye's syndrome.
2. Encourage oral intake of oral rehydration solution (ORS), fruit juice, and other fluids containing
electrolytes and sugar to replace losses from fever and vomiting. ORS like ORESOL can be
given at 75 ml/KBW in 4 hours to children or at 2-5 liters in adults. If not tolerated, start
intravenous fluid therapy of 0.9% saline or Ringer's lactate with or without dextrose at
maintenance rate.
3. Advise the patient to avoid dark-colored foods that can mask bleeding. Diet should be low fat,
low fiber, nonirritating, and noncarbonated.
4. Ensure strict bed rest and protect patient from trauma to reduce the risk of bleeding.
5. Do not give intramuscular injections to avoid hematoma.
6. Instruct the caregivers that the patient should be brought to the hospital immediately if any of
the following occur: no clinical improvement, deterioration around the time of defervescence,
severe abdominal pain, persistent vomiting, cold and clammy extremities, lethargy or
irritability/restlessness, bleeding (e.g. black stools or coffee-ground vomiting), and not passing
urine for more than 4-6 hours.
7. For nose bleeding (epistaxis), maintain an elevated position and apply ice compress to
promote vasoconstriction. If there is bleeding of gums, give ice chips, and advise the patient to
use a soft-bristled toothbrush. For gastrointestinal bleeding, place the patient on NPO.
8. Blood transfusion should be given as soon as severe bleeding is suspected or recognized.
However, blood transfusion must be given with care because of the risk of fluid overload.
9. In cases of shock, place patient in a dorsal recumbent position to promote circulation.
10. Monitor laboratory results such as platelet and hematocrit count accordingly. Those with
stable laboratory results, without fever, or with no danger signs for 72 hours can be sent home
after being advised to return to the hospital immediately if they develop any of the warning
signs such as abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation,
mucosal bleeding, lethargy, and restlessness.

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

SPECIFIC COMMUNICABLE DISEASES

Malaria (marsh fever, periodic fever, king of tropical diseases)

Causative agent: Protozoa genus Plasmodium:

 P. falciparum
 P. vivax
 P. ovale
 P. malariae
  P. knowlesi

Symptoms: Recurrent fever preceded by chills and profuse sweating (triad signs), malaise, anemia

Mode of transmission: Vector (female Anopheles)

Laboratory diagnostic test:

1. History of having been in a malaria-endemic area: Palawan and Mindoro.

2. Blood smear
3. Rapid diagnostic test (RDT)

Treatment Oral:

1. Chloroquine phosphate 250 mg - all species except P. malariae

2. Sulfadoxine 50 mg - For resistant P. falciparum
3. Primaquine - For relapse P. vivax and P. ovale.
4. Pyrimethamine 25 mg/tab
5. Quinine sulfate 300 mg/tab
6. Tetracycline HQ 250 mg/cap
7. Quinidine sulfate 200 mg/durules

Parenteral:

Quinine hydrochloride 300 mg/ml, 2ml, quinidine glucolate 80 mg (50 mg) 1 vial

Malaria prevention and control:

1. Mosquito control
2. Chemical methods - use of insecticides
3. Biological methods - stream seeding
4. Zooprophylaxis - larvae-eating fish, farm animals should be kept near the house
5. Environmental methods - cleaning and irrigating canals
6. Screening of houses
7. Educational methods
8. Mechanical methods - use of fly swats or traps
9. Universal precaution
10. Screening of blood donors

SPECIFIC COMMUNICABLE DISEASES

Human immunodeficiency virus infection/acquired immune deficiency syndrome (HIV/AIDS)

Causative agent: HIV 1 and 2

Mode of transmission: Sexual contact, blood transfusion, contaminated syringes, needles, nipper,
blades, direct contact of open wounds/mucous membranes with contaminated blood, body fluids,
semen, and vaginal discharges

Incubation period: varies (3-6 months) to many years (8-10)

Signs and symptoms: Major signs include weight loss, chronic diarrhea, prolonged fever for 1
month. Minor Signs involves cough for 1-month, pruritic dermatitis, recurrent herpes zoster,
candidiasis, and lymphadenopathy

Prevention of HIV/AIDS:

1. Blood and blood products

a. Screen blood donors.
b. Observe universal precaution.
c. Refrain from using contaminated needles and syringes.

2. Sexual transmission
a. Abstain from promiscuous sexual contact.
b. Be faithful to your partner and practice monogamous sexual contact.
c. Follow correct and consistent use of condoms.

3. Mother-to-child transmission. For HIV+ mothers, consult with health workers to have access
to care, treatment, and support to services during pregnancy, labor and delivery, and
postpartum.

List of treatment facilities for HIV in the Philippines

In the Philippines, public health facilities in different regions are identified as treatment hubs or
hospital facilities with an established HIV/AIDS Core Team (HACT), providing prevention, treatment,
care, and support services to people living with HIV including but not limited to HIV counseling and
testing, clinical management, patient monitoring, and other care and support services. Antiretroviral
(ARV) treatment can only be accessed through these facilities:

1. San Lazaro Hospital (SLH) located at Quiricada St., Santa Cruz, Manila
2. Philippine General Hospital at Taft Avenue, Ermita, Manila
3. Research Institute for Tropical Medicine (RITM) at Filinvest Corporate City, Alabang,
Muntinlupa City
4. Jose B. Lingad Memorial Medical Center at San Fernando City, Pampanga
5. Ilocos training and Regional Medical Center (ITRMC) at San Fernando, La Union
6. Baguio General Hospital and Medical Center (BGHMC) at BGHMC Compound, Baguio City
7. Cagayan Valley Medical Center at Tuguegarao City, Cagayan Valley
8. Bicol Regional Training and Teaching Hospital (BRTTH) at Legazpi City, Albay
9. Western Visayas Medical Center (WVMC) at Q. Abeto St., Mandurriao, Iloilo City
10. Corazon Locsin Montelibano Memorial Regional Hospital (CLMMRH) at Lacson St., Bacolod
City, Negros Occidental
11. Vicente Sotto, Sr. Memorial Medical Center (VSSMC) at B. Rodriguez St., Cebu City
12. Davao Medical Center (DMC) at I.P. Laurel St., Bajada, Davao City
13. Zamboanga City Medical Center (ZCMC) at Evangelista St., Zamboanga City

Community support organizations for HIV/AIDS

There are several NGOs, people’s organizations, and medical service providers in the Philippines
that provide direct care and support services for people living with HIV/AIDS (PLWHA), their affected
families, and significant others:
 1. Pinoy Plus Association (PPA) is a sole organization composed of PLWHA. It is a support
group dedicated to the welfare of PLWHA in the Philippines.
2. Positive Action Foundation Philippines Inc. (PAFPI) is an organization founded in 1998
composed of HIV-positive and non-positive staff members and volunteers whose mission is to
contribute to the national response to HIV and AIDS prevention, treatment, and care services
for PLWHA and their families.
3. Remedios AIDS Foundation (RAF) is a nonstock, nonprofit organization that works with
communities, individuals, and families working in the prevention and control of STIs, HIV, and
AIDS.
4. Babae Plus is a support group of women living with HIV and AIDS in the Philippines. It was
founded to create an enabling environment that addresses the psychological, economic,
health, and gender-related concerns of women living with HIV/AIDS and their affected
families.
5. AIDS Society of the Philippines (ASP)
6. Health Action Information Network (HAIN)
7. Lunduyan para sa Pagpapalaganap, Pagtataguyod at Pagtatanggol ng Karapatang Pambata
Foundation, Inc. (LUNDUYAN)
8. The Library Foundation Sexuality Health and Rights Educators Collective, Inc. (TLF SHARE)
9. Action for Health Initiatives, Incorporated (ACHIEVE)
10. Alliance Against AIDS in Mindanao, Inc. (ALAGAD)
11. Foundation for Adolescent Development, Inc. (FAD)

4Cs in syndromic case management for STI:

1. Compliance of clients in the treatment, prevention and successful recommendation for

preventing recurrence of disease.
2. Counseling and education on the nature of the disease, signs and symptoms, management,
and prevention.
3. Contact tracing facilitates the process of partner treatment to prevent the spread of the
disease.
4. Condom use and promoting them to risk individuals to reduce the risk of acquiring the
disease

SPECIFIC COMMUNICABLE DISEASES

Rabies (Hydrophobia, Lyssa)

Causative agent: Rhabdovirus

Mode of transmission: Bite of rabid animal

Source: Saliva of infected animal or human

High risk: Nonbite, handling of animals

Incubation period: 20-90 days for humans, 1 week to 7.5 months for dogs

Laboratory/diagnostic test: Postmortem direct fluorescent antibody staining test

Signs and symptoms:

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

Nursing management:

1. Isolate patient.
2. Encourage family to provide care and company.
3. Darken room and observe silence.
4. Give food if patient is hungry.
5. Keep water out of sight.
6. Observe universal precaution, which are essentially wearing gloves.
7. Wash hands frequently.
8. Remove oral and nasal secretions.
9. Dispose contaminated materials.
10. Perform terminal disinfection.

Postexposure treatment for rabies: For dog bite:

 Wash wound with soap and water and seek consultation

 Anti-tetanus scrum/tetanus anti-toxin suture if severe wounds
 Observe dog for 10 days, if possible, for signs of rabies

A.
A. Recommended vaccines that provide active immunity that is infiltrated in and around
the wound for the first dose of the vaccine.

1. PVCV (purified vero cell vaccine) = 0.1 ml

2. PDEV (purified duck embryo vaccine) = 0.2 ml
 a. Reduce multisite intramuscular (IM) (2-1-1) schedule

Reduce Multi-Site
Intramuscular Regimen

Schedule Site Dose

and
route

Day 0 Deltoid 2
IM doses
 Day 7, Deltoid 1
21 IM dose

 b. 2 site intradermal regimen cost-effective

Site Intradermal Regimen -

most cost effective treatment

Schedule Site Dose

and
route

Day 0, 3, Deltoid 2
7 ID doses

Day 30 Deltoid 1
ID dose

Day 90 Deltoid 1
ID dose

B.

C. Recommended immunoglobulins that provides passive immunity administered IM route

distant from the site of vaccine inoculation

 Equine rabies » KBW x 0.2 ml

 Human rabies « KBW x 0.133 ml

Immunoglobulins

Schedul Site Dose

e

Day 0 Deltoid (adult), Anterolateral 1

(infants) dose

Day 7 Deltoid (adult), Anterolateral 1

(infants) dose

Prevention of rabies
 1. Pre-exposure prophylactic treatment for high-risk individuals
 Treatment: High-risk EVERY year (lab), 2x/year (vet)
 PDEV - 1.0 ml
 PVCV - 0.5 ml

Prevention of Rabies

Schedule Dose

Day 0, 7 1 dose IM

Day 21 1 dose ID

SPECIFIC COMMUNICABLE DISEASES

Leprosy (Hansenosis, Hansen's disease, Leontiasis)

Causative agent: Mycobacterium leprae/Hansen's bacillus

Mode of transmission: Prolonged skin contact, droplet infection

Incubation period: 5 months-5 years

Laboratory/diagnostic test: Skin slit test

Signs, and symptoms:

1. Early signs - reddish or white change in skin color, loss of sensation on the skin lesion,
decrease/loss of sweating and hair growth over the lesion, thickened and/or painful nerves,
muscle weakness, pain or redness of the eye, nasal obstruction/bleeding, ulcers that do not
heal.
2. Late signs - loss of eyebrow (madarosis), inability to close eyelids (lagophthalmos), clawing of
fingers and toes, contractures, sinking of the nose bridge, enlargement of the breast in males
(gynecomastia), chronic ulcers.

Prevention:

 BCG vaccination
 avoidance of prolonged skin to skin contact with active untreated case
 good personal hygiene
 adequate nutrition
 health education

Patient classification of leprosy:

 1. Paucibacillary (PB): (-) Skin slit test or five or less lesions
2. Multibacillary (MB): (+) Skin slit test and more than five lesions

Multidrug treatment therapy for leprosy

Multidrug therapy (MDT) involves the use of two or more drugs such as rifampicin, clofazimine, and
dapsone in the treatment of leprosy. The main purpose of MDT is to kill all viable organisms in a
relatively short period of time rendering the patient noninfectious. It is highly cost-effective in the
treatment of leprosy and in preventing drug resistance. WHO information shows that relapse rate is
very low (e.g. 0.1% per year for PB and 0.06% per year for MB on the average). Among these,
rifampicin is the most important drug included in the treatment of both types of leprosy. It is a potent
bactericidal agent against M. leprae. The high bactericidal activity of rifampicin makes it feasible and
cost-effective for leprosy control. However, rifampicin causes slightly reddish discoloration of the
urine for a few hours after its intake. Clofazimine causes brownish black discoloration and dryness of
skin, but it disappears within a few months after treatment. Dapsone causes allergic reaction such as
itchy skin rashes and exfoliative dermatitis. Patients known to be allergic to sulfa drugs are not given
this drug. Therefore, it is important to explain the side effects of the drug to patients starting MDT
regimen.

SPECIFIC COMMUNICABLE DISEASES

Leptospirosis (Canicola, Weils disease)

Causative agent: Leptospira interrogans

Mode of transmission: Inoculation into broken skin, ingestion

Source of infection: Urine and excreta of rodents and infected

Incubation period: 7-13 days

Laboratory/diagnostic test:

1. Blood culture
2. Leptospira agglutination test (LAT)

Signs and symptoms:

1. Septicemic - High remittent fever 4-7 days, myalgia/myosites, particularly calf pain
2. Immune/toxic stage - jaundice
3. Convalescence

Treatment:

1. Medical management; Penicillin or tetracycline

2. Nursing management: Symptomatic

Prevention: Eradication of source

Schistosomiasis (Snail fever, Bilharziasis)

Causative agent: Schistosoma japonicum, S. mansoni, S. haematobium

Vector: Oncomclania quadrasi (snail)

Incubation: period: 2 months

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

Laboratory/diagnostic test: Direct stool examination

1. COPT (Cercum Ova Precipetin Test)

2. Kato Katz Technique

Signs and symptoms: Rash at site of inoculation, enlargement of the abdomen, diarrhea, body
weakness

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

Prevention:

1. Proper disposal of feces and urine

2. Proper irrigation of all stagnant bodies of water
3. Prevent exposure to contaminated water (wearing of rubber boots)
4. Eradication of breeding places of snails.
5. Use of molluscicides.

Filariasis (elephantiasis, filarioidea infection)

Causative agent: Wuchereria bancrofti, Burgia malayi

Mode of transmission: Bite of mosquito

Vector: Aedes poecilus, Culex quinquefasciatus

Signs and symptoms: Chills, fever, myalgia, lymphangitis with gradual thickening of the shin
(commonly affecting limbs, scrotum), resulting in elephantiasis and hydrocele

Laboratory/diagnostic test: Circulating filarial antigen (CFA) - finger prick

Treatment: Diethylcarbamazine citrate (Hetrazan)

Prevention: Eradication of vectors

Sexually transmitted infections

Gonorrhea (clap, drip, tulo)

Causative agent: Neisseria gonorrhoeae

Mode of transmission: Sexual contact

Incubation period: 2-7 days

Signs and symptoms: Thick purulent urethral discharge, frequency of urination among females,
burning urination among males/ females

Diagnostic examination:

1. Culture of specimen in cervix - female

2. Gram stain – male

Treatment: Penicillin, ceftriaxone, doxycycline

Nursing care: Symptomatic

Prevention:

 Crede's prophylaxis - silver nitrate/ tetracycline

 Avoid contact with secretions
 Practice monogamous sexual contact

Syphilis

Causative agent: Treponema pallidum

Mode of transmission: Sexual contact

Incubation period: 10-90 days

Signs and symptoms:

1. Primary - chancre
2. Secondary - condylomata, alopecia, sore throat, mucous patches of the mouth
3. Tertiary - gumma formation, cardiovascular and nervous system involvement

Laboratory diagnostic test:

1. Darkfield illumination test

2. Venereal disease research laboratory (VD RE) test
3. Fluorescent treponemal antibody test

Treatment: Penicillin, tetracycline, erythromycin

Nursing care: Symptomatic

Prevention:

 Practice monogamy
 Sex education

Candidiasis
Causative agent: Candida albicans (most common cause), Candida tropicalis (rare cause)

Mode of transmission: Contact with secretions or excretions of mouth, skin, vagina, and feces,
from patients or carriers.

Incubation period: Variable

Period of communicability: Presumably while lesions are present

Signs and symptoms: Severe vulvar pruritus (prominent feature); vaginal discharge (scanty,
whitish, yellow, thick to form curds, nonoffensive); sore vulva due to itching, speculum examination -
thick whitish plugs attached to vaginal wall, vaginal epithelium bleeds when the plug is removed, but
the cervix is normal.

Diagnosis: Microscopic demonstration of pseudohyphae or yeast cells in infected tissue or body

fluids (vaginal discharge)

Treatment:

 Nystatin vaginal pessary,

 Miconazole or clotrimazole creams,
 Ketoconazole
 Fluconazole in recurrent cases

Prevention and control:

1. Case treatment
2. Treatment of underlying medical conditions or predisposing factors

LAWS FOR THE CONTROL OF COMMUNICABLE DISEASES

Republic Act 3573 - Reporting of Communicable Diseases

Requires all individuals and health facilities to report notifiable diseases to local and national public
health authorities. Pursuant to Section 3 of Act 3573, the lists of notifiable disease are epidemic-
prone diseases, which are targeted for eradication or elimination, and subject to international health
regulation. Category 1 (Immediately notifiable) includes acute flaccid paralysis, adverse event
following immunization, anthrax, human avian influenza, measles, meningococcal disease, neonatal
tetanus, paralytic shellfish poisoning, rabies, and Severe Acute Respiratory Syndrome (SARS).
Category II (Weekly Notifiable) includes acute bloody diarrhea, acute encephalitis syndrome, acute
hemorrhagic fever syndrome, acute viral hepatitis, bacterial meningitis, cholera, dengue, diphtheria,
influenza-like illness, leptospirosis, malaria, non-neonatal tetanus, pertussis, typhoid and
paratyphoid fever.

Republic Act 4073- An Act Liberalizing the Treatment of Leprosy

No persons afflicted with leprosy shall be confined in a leprosarium provided that such person shall
be treated in any government skin clinic, rural health unit or by a duly licensed physician.

Republic Act 8504- Philippines AIDS Prevention and Control Act of 1998

An act 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 9482- The Rabies Act of 2007

Rabies control ordinances shall be strict implemented and the public shall be informed on the proper
management of animal bites and/or rabies exposures.

Republic Act 1136- Tuberculosis Law of 1954

Creation of the Division of Tuberculosis under an appointed Director of the National Tuberculosis
Center of the Philippines (NTCP) established at the DOH compound.

Memorandum Circular No. 98-155

Pronounced the National Tuberculosis Control Programs as the highest priority public health
program of the LGUs.

Presidential Proclamation No. 46 of 1992

Reaffirming the commitment to the Universal Child and Mother Immunization goal by launching the
Polio Eradication Project, which aims to make the Philippines polio-free by 1995.

Presidential Proclamation No. 1204 of 1998

Declaring the month of June of every year as National Dengue Awareness Month, and formulation of
the National Dengue Prevention and Control Program to reduce morbidity and mortality due to
dengue so that it will no longer be a public health problem.

Administrative Order No. 24 series of 1996

The National Tuberculosis Control Program adopted Directly Observed Treatment, Short-Course
(DOTS) in the management of TB