BSPH-3203 PUBLIC HEALTH WITH PHARMACOEPIDEMIOLOGY (FINALS)

CHAPTER 5: CONTROL AND PREVENTION OF COMMUNICABLE DISEASES

TUBERCULOSIS 1. It provides a definitive diagnosis of active TB;

Tuberculosis (TB) is caused by a bacterium called 2. The procedure is simple;
Mycobacterium tuberculosis. The bacteria usually attack 3. It is economical; and,
the lungs, but TB bacteria can attack any part of the 4. A microscopy center could be put up even in
body such as the kidney, spine, and brain. If not treated remote areas.
properly, TB diease can be fatal. TB is spread through
the air from one person to another. The TB bacteria are DSSM serves as one of the bases for categorizing TB
put into the air when a person with TB disease of the cases according to standard case definition. This is also
lungs or throat coughs, sneezes, speaks, or sings. used to : a) monitor progress of patients with TB while
People nearby may breathe in these bacteria and they are on anti-TB treatment; and b) confirm cure at
become infected. (2um) the end of treatment. Chest X-ray is used to
complement bacteriologic testing in making a diagnosis.
In healthy people, infection with Mycobacterium However, it has low specificity and does not
tuberculosis often causes no symptoms, since the differentiate drug-susceptible form drug-resistant
person’s immune system acts to “wall off” the bacteria. diseases. TB culture and drug susceptibility test (DST)
The symptoms of active TB of the lung are coughing, using solid (Ogawa or Lowenstein Jensen) or liquid
sometimes with sputum or blood, chest pains, media (MGIT) is a routine diagnostic test for drug-
weakness, weight loss, fever and night sweats. resistant TB cases under the NTP. It is also used for TB
prevalence surveys, drug resistance surveillance,
M. Tuberculosis has an unusual, waxy coating on its research and other special cases.
cell surface (primarily due to the presence of mycolic
acid), which makes the cells imperious to Gram staining. Tuberculin skin test (TST) is a basic screening tool
The Ziehl-Neelsen stain, or acid-fast stain is used for TB infection among children using purified protein
instead. This organism is highly aerobic. Humans are the derivative (PPD) tuberculin solution to trigger a delayed
only known reservoirs of M.tuberculosis. When in the hypersensitivity reaction among those previously
lungs, M. tuberculosis is taken up by alveolar infected. Also known as the PPD test or Mantoux test, it
macrophages, but they are unable to digest and is one of the criteria used in determining disease
eradicate the bacterium. Its cell wall prevents the activity among children. Rapid molecular diagnostic
fusion of the phagosome with the lysosome, which tests endorsed by the WHO will be utilized by the NTP.
contains a host of anti-mycobacterial factors. Currently, WHO- endorsed available diagnostic tests in
the country are Xpert MTB/RIF and Line-Probe Assay
In preventing and controlling the spread of (LPA) for first line drugs. Xpert MTB/RIF assay is a rapid
Tuberculosis, it is important to detect cases and reat test that detects Mycobacterium tuberculosis and
them accordingly. Case finding is the identification and Rifampicin resistance.
diagnosis of TB cases among individuals with signs and
symptoms presumptive of tuberculosis. The current Passive case finding is when symptomatic patients
approach to case finding includes passive and are screened for disease activity upon consultation at
intensified case finding. The available tests utilized by the health facility. Active case finding is a health
the program for diagnosing TB are direct sputum smear worker’s purposive effort to find TB cases in the
microscopy, TB culture and drug susceptibility test, community or among those who do not consult with
tuberculin skin test and rapid molecular diagnostic personnel in a DOTS facility. Intensified case finding is
tests. active case finding among individuals belonging to
special or defined populations: 9e.g., high-risk groups
Direct sputum smear microscopy (DSSM) is including those who consult or find themselves at the
fundamental to the detection of infectious cases and is facility for other purposes):
recommended for case finding among adults and
children who can expectorate. It is the primary 1. Close contact - a person who shared an enclosed
dianostic method adopted by the NTP among such space, such as the household, a social gathering
individuals because: place, workplace or facility, for extended periods
within the day with the index case during the 3
months before commencement of the current
treatment episode. I 4
 histology, and extra-pulmonary cases without
2.
High-risk clinical groups - individuals with clinical laboratory confirmation.
conditions that put them at risk of contracting TB
disease, particularly those with immune-
compromised states (e.g. HIV/AIDS, diabetes, end-
stage renal disease, cancer, connective tissue It can also be classified based on its anatomical location.
diseases, autoimmune disease silicosis, patients Remember that Tuberculosis can infect any part of the
who underwent gastrectomy or solid organ human body:
transplantation and patients on prolonged
IUATLD/ Conventional Fluorescence microcopy a. Pulmonary TB (PTB) - refers to a case of
WHO Light tuberculosis involving the lung parenchymya. A
Scale Microscopy patient with both pulmonary and extra-pulmonary
200x 400x TB should be classified as a case of pulmonary TB.
magnification magnification; b. Extra-pulmonary TB (EPTB) - refers to a case of
1 length = 30 1 length = 40 tuberculosis involving organs other than the lungs
fields fields (e.g., larynx, pleura, lymph nodes, abdomen,
0 No AFB seen No AFB No AFB genitourinary tract, skin, joints and bones,
in 300 oil observed/ 1 observed/ 1 meninges). histologically-diagnosed EPTB through
immersion length length biopsy of appropriate sites will be considered
field (OIF) clinically-diagnosed TB. Laryngeal TB, though likely
Confirmation Confirmation 1-2 AFB/ 1 sputum smear-positive, is considered an
required* required* length extrapulmonary case in the absence of lung
+n 1-9 AFB seen 5-49 AFB/ 1 3-24 AFB/ 1 infiltrates on Chest X-Ray.
in 100 OIF length length
1+ 10-99 AFB 3-24 AFB/ 1 1-6 AFB/ 1 A TB case can be classified according to history or
seen in 100 field field previous treatment or management. A New case is a
OIF patient who has never had treatment for TB or who has
2+ 1-10 25-250/ 1 7-60/ 1 field taken antiTB drugs for less than one month. Isoniazid
AFB/OIF in field preventive therapy or ther preventive regimens are not
at least 50 considered as previous TB treatment. A retreatment
fields case is a patient who has been previously treated with
3+ >10 AFB?OIF > 250/ 1 > 60/ 1 field anti-TB drugs for at least one month in the past.
in at least 20 field
fields DSSM Results and Interpretation
systemic steroids).

3. High-risk populations - persons with known high Case holding is the set of procedures which ensures
incidence of TB, particularly those in closed that patients complete their treatment. While effective
environments or living in congregate settings that anti-TB drugs are available in the country, there are still
promote easy disease transmission (e.g., inmates, many TB patients who are not cured because they stop
elderly, Indigenous People, urban/rural poor). taking anti-TB drugs or take them irregularly. This may
lead to chronic infectious illness, drug resistance, or
TB Disease Classification can be based on death. The best way to prevent the occurrence of these
bacteriological status: events is through the regular intake of appropriate
drugs for the prescribed duration. Case holding involves
a. Bacteriologically-confirmed - a TB patient from assignment of the appropriate treatment regimen
whom a biological specimen is positive by smear based on diagnosis and previous history of treatment,
microscopy, culture or rapid diagnostic tests (such supervised drug intake with support to patients, and
as Xpert MTB/RIF). monitoring responses to treatment through follow-up
b. Clinically-diagnosed - a PTB patient who does not sputum smear microscopy.
fulfill the criteria for bacteriological confirmation
but has been diagnosed with active TB by a Directly Observed Treatment (DOT) is a method
clinician or other medical practitioner who has developed to ensure treatment compliance by
decided to give the patient a full course of TB providing constant and motivational supervision to TB
treatment. This definition includes cases diagnosed patients. DOT works by having a responsible person,
on the basis of CXR abnormalities or suggestive referred to as treatment partner, watch the TB patient
take anti-TB drugs every day during the whole course or There are two types of drug treatments for TB:
treatment.
1) Fixed-dose combination (FDCs) - two or more first-
TB Disease Registration Groups line anti-TB drugs are combined in one tablet.
There are 2-, 3-, or 4-drug fixed-dose combinations,
Registration Group Definition of Terms namely: Isoniazid-Rifampicin (HR), Isoniazid-
New A patient who has never had Rifampicin-Ethambutol (HRE) and Isoniazid-
treatment for TB or who has Rifampicin-Pyrazinamide-Ethambutol (HRZE).
taken anti-TB drugs for less These are usually provided in kits with boxes of
than one (<1) month. blister packs corresponding to treatment phases of
R Relapse A patient previously treated an averag-weight patient.
E for TB, who has been declared
T cured or treatment completed 2) Single drug formulation (SDF) - each drug is
R in their most recent treatment prepared individually, either as tablet, capsule,
E episode, and is presently syrup or injectable (Streptomycin) form. Anti-TB
A diagnosed with treatment regimen shall be based on anatomical
T bacteriologically-confirmed or site, and bacteriologic status including drug
M clinically-diagnosed TB. resistance and history of prior treatment. Except in
E Treatment After A patient who has been cases of adverse drug reactions and special
N Failure previously treated for Tb and circumstances requiring treatment modifications,
T whose treatment failed at the TB treatment under the NTP shall conform to
end of their most recent standardized regimens.
course.
Recommended Treatment Regimen for Adults and
This includes: Children
 A patient whose sputum
smear or culture is Category of Classification and Treatment
positive at 5 months or Treatment Registration Group Regimen
later during treatment Category I Pulmonary TB, new
 A clinically-diagnosed (whether 2HRZE/4HR
patient (e.g., child or bacteriologically-
EPTB) for whom sputum confirmed or
examination cannot be clinically-diagnosed)
done and who does not
show clinical Extra-pulmonary TB,
improvement anytime new (whether
during treatment. bacteriologically-
Treatment After A patient who has previously confirmed or
Lost to Follow-up treated for TB but was lost to clinically-diagnosed)
(TALF) follow-up for two months or except CNS/ bones or
more in their most recent joints
course of treatment and is Category Ia Extra-pulmonary TB, 1HRZE/10HR
currently diagnosed with new (CNS/ bones or
either bacteriologically- joints)
confirmed or clinically-
diagnosed TB. Category Pulmonary or
Previous Patients who have been II extra-pulmonary, 2HRZES/1HRZE/5HRE
Treatment previously treated for TB but Previously treated
Outcome Unknown whose outcomes after their drug-susceptible
(PTOU) most recent course of TB (whether
treatment are unknown or bacteriologically-
undocumented. confirmed or
Other Patients who do not fit into clinically-
any of the categories listed diagnosed)
above.
 Relapse
  Treatment
After Failure Many TB patients would usually discontinue
 Treatment treatment either because they felt they have already
after Lost to been cured due to absence of symptoms or because of
Follow-up the adverse drug reactions that they experience.
(TALF) Treatment partners must know how to manage these
 Previous especially the latter.
Treatment
Outcome Adverse Reactions Drug(s) Management
Unknown probably
 Other responsible
Category Extra-pulmonary, Minor
IIa Previously treated 2HRZES/1HRZE/9HRE 1. Gastro-intestinal Rifampicin/ Give drugs at
drug-susceptible intolerance Isoniazid/ bedtime or
TB (whether Pyrazinamide with small
bacteriologically- meals.
confirmed or 2. Mild or localized Any kind of Give anti-
clinically-diagnosed skin reactions drugs histamines.
- CNS/bones or 3. Orange/red Rifampicin Reassure the
joints) coloured urine patient.
4. Pain at the injection Streptomycin Apply warm
Standard Rifampicin- site compress.
Regimen resistant TB or ZKmLfxPtoCs Rotate sites of
Drug- Multidrug-resistant  Individualized injection.
resistant TB once DST result 5. Burning sensation in Isoniazid Give
(SRDR) is available the feet due to Pyridoxine
 Treatment peripheral neuropathy (Vitamin B6):
duration for at 50-100 mg
least 18 months daily for
XDR-TB Extensively drug- Individualized bast treatment,
Regimen resistant TB on DST result and 10mg daily for
history of previous prevention.
treatment 6. Arthralgia due to Pyrazinamide Give aspirin or
hyperuricemia NSAID. If
symptoms
persist,
Drug Dose Per Kilogram Body Weight consider gout
Drug Adults Children and request
Isoniazid (H) 5 (4-6) mg/kg, 10 (10-15) for blood
not to exceed mg/kg, not to chemistry (uric
400mg daily exceed 300mg acid
daily determination)
Rifampicin ( R ) 10(8-12) mg/kg, 15 (10-20) and manage
not to exceed mg/kg, not to accordingly.
600mg daily exceed 600mg 7. Flu-like symptoms Rifampicin Give
daily (fever, muscle pains, antipyretics.
Pyrazinamide (Z) 25 (20-30) 30 (20-40t to inflammation of the
mg/kg, not to exceed 2g daily respiratory tract)
exceed 2g daily
Ethambutol ( E ) 15 (15-20) 20 (15-25) 1. Severe skin rash Any kind of Discontinue
mg/kg, not to mg/kg, not to due to drugs anti-TB drugs
exceed 1.2g exceed 1.2g hypersensitivity (especially and refer to
daily daily Streptomycin appropriate
Streptomycin (S) 15 (12-18) 30 (20-40) ) specialist.
mg/kg, not to mg/kg, not to 2. Jaundice due to Any kind of Discontinue
exceed 1g daily exceed 1g daily hepatitis drugs anti-TB drugsl
 (especially and refer to distribution of these social determinants, which
Isoniazid, appropriate influence the 4 stages of TB pathogenesis: exposure to
Rifampicin, specialist. If infection, progression to disease, late or inappropriate
and symptoms diagnosis and treatment, and poor treatment
Pyrazinamide subside, adherence and success. TB illness further exacerbates
) resume poverty, food insecurity, and malnutrition. Alleviating
treatment and the poverty and improving the food security of these
monitor impoverished populations may reduce their TB burden.
clinically.
3. Impairment of Ethambutol Discontinue
visual acuity and color Ethambutol
MALARIA
vision due to optic and refer to
neuritis appropriate The word malaria is based on the association
specialist. between the “bad air” of marshes where the Anopheles
4. Hearing Streptomycin Discontinue mosquitoes breed and human infection by Plasmodium
impairment, ringing of Streptomycin species. Malaria has afflicted the world’s human
the ear, and dizziness and refer to population for thousands of years and continues to do
due to damage of the appropriate so today. The earliest references to malaria in recorded
eighth cranial nerve specialist. history are descriptions of splenomegaly with fever
5. Oliguria or Streptomycin Discontinue from China in the Nei Ching Canon of Medicinein 1700
albuminuria due to / Rifampicin anti-TB drugs BC and from Egypt in the Ebers Papyrus in 1570 BC.
renal disorder and refer to Hippocrates clearly recognized the syndrome of malaria
appropriate and its relationship to marshes. Literary references to
specialist. malaria appear in Homer’s Iliad and in the works of
6. Psychosis and Isoniazid Discontinue Chaucer and Shakespeare. European travelers to India,
convulsion Isoniazid and sub-Saharan Africa and South America were decimated
refer to by malaria from the 16th to the 19th centuries.
appropriate
specialist. Malaria remains one of the main global health
problems of our time, causing an estimated 216 million
7. Thrombocytopenia, Rifampicin Discontinue
clinical cases and 655,000 deaths in 2020, with about
anemia, shock anti-TB drugs
90% of deaths and 8-% of cases occurring in Africa,
and refer to
south of the Sahara. Malaria transmission occurs in 90
appropriate
countries and territories between latitudes 45° N and
specialist.
40° S. these countries have tropical or subtropical zones
with optimal climatic conditions that favor the
Growing consensus indicates that progress in
development of anopheles mosquitoes and malaria
tuberculosis control in the low- and middle-income
parasites.
world will require not only investment in strengthening
tuberculosis control programs, diagnostics, and
treatment but also action on the social determinants
of tuberculosis. However, practical ideas for action are
scarcer than is notional support for this idea.
Interventions from outside the health sector -
specifically, in social protection and urban planning -
have the potential to strengthen tuberculosis control.

Hargreaves et. Al. (2011) mention that “key

structural determinants of TB epidemiology include
global soicoeconomic inequalities, high levels of
population mobility, and rapid urbanization and
population growth. These conditions give rise to
unequal distributions of key social determinants of TB,
inluding food insecurity and malnutrition, poor
housing and environmental conditions, and financial,
geographic, and cultural barriers to health care access.
In turn, the population distribution of TB reflects the
 Malaria is a parasitic infectious disease caused by macrogametocytes mature to become male and female
protozoan parasites of the genus Plasmodium and is gametes. Fertilization of the female gametes produces
transmitted by mosquitoes. It is characterized by diploid zygotes which mature to become ookinetes.
recurrent symptoms of chills, fever and generalized Ookinetes then undergo a meiotic reduction division to
body pain. The four Plasmodium species of human produce haploid sporozoites, which migrate to the
malaria are: P.falciparum, P.vivax, P.ovale and salivary glands of the mosquito and subsequently
P.malariae. There are also increasing reports of human reinfect humans. In the P.vivax and P.ovale life cycles,
infections with the monkey malaria parasite P.knowlesi some sporozoites can lie dormant in the liver cells for
in forested regions of South-East Asia. months or years after the initial bloodstream infection
and do not cause symptoms during this time. The
Plasmodium falciparum is found worldwide, mainly dormant forms, called hypnozoites, eventually matire
in tropical and subtropical areas. It is the main species to become tissue schizonts which release infectious
that causes severe, potentially fatal malaria. merozoites, resulting in a clinical relapse.
Plasmodium vivax is found mainly is Asia, Latin America,
and in some parts of Arica. Recent evidence shows that The parasite incubation period in the vector
P.vivax can cause severe illness. P.vivax (also P.ovale) mosquito, known as extrinsic incubation, is
has dormant liver stages, the hypnozoites, which can temperature-dependent. P.falciparum takes 8-11 days
become activated and invade the blood to cause clinical to complete the mosquito phase at an optimal ambient
relapse several months or years after the infecting temperature of 28 ℃ and 22 days at 20 ℃ . the
mosquito bite. P.vivax does not infect individuals who temperature of the mosquito gut equals that of its
are negative for the Duffy blood group, as are many surroundings; a low environmental temperature
presidents of sub-Saharan Africa. Plasmodium ovale is therefore results in a longer development time for the
found mostly in the countries of west Africa and the parasite in the mosquito. P.falciparum is unable to
islands of the western Pacific. It is biologically and develop below 19 ℃ while P.vivax can develop in the
morphologically very similar to P.vivax. However, unlike mosquito at temperatures as low as 16℃; consequently
P.vivax, it is able to infect individuals who are negative P.vivax transmission is found in some areas where the
for the Duffy blood group. This explains the greater average temperature is too low for P.falciparum
prevalence of P.ovale (rather than P.vivax) in west transmission. Due to this difference in temperature
Africa. Plasmodium malariae is found worldwide. P. sensitivity, P.falciparum is common in tropical regions
malariae causes a persistant chronic infection which while P.vivax prevails in both tropical and temperature
may be lifelong. A small number of patients develop cold regions.
serious complications such as the nephrotic syndrome.
Endemicity of malaria describes the intensity of malaria
Humans acquire malaria from sporozoites transmission in a given community or region and can be
transmitted by the bite of an infected female classifed according to parasite rates. Based on intensity
anopheline mosquito. The sporozoites then travel of transmission, populations or regions may be
through the bloodstream to the liver within about 30 classified as follows:
minutes, where they invade hepatocytes and mature to
become tissue schizonts (pre-erythrocytic schizogony). Stable malaria areas - In these regions:
Tissue schizonts are a central feature of all plasmodium  Transmission occurs all year round, though there
species that infect humans. They amplify the infection may be seasonal variations;
by producing large numbers of merozoites (10,000 -  Older children and adults in the community have
30,000) from each sporozoite-infected hepatocyte. partial immunity which protects them from severe
Each merozoite released from the liver is capable of forms of malaria;
infectin g a human red blood cell (RBC) and establishing  Young children are susceptible to severe malaria.
the asexual cycle of replication in the red blood cells.
Unstable malaria areas - In areas with low transmission:
The asexual cycle starts with merozoite invasion  Intermittent transmission may be annual, biannual
and continues to schizont rupture (merozoite -> ring (twice a year) or variable;
stage -> mature trophozoite -> schizont -> merozoites),  Malaria epidemics tend to occur;
leading to invasion of more red blood cells. Some  Immunity to malaria is usually low or absent.
intraerythrocytic parasites develop into the sexual
forms, the gametocytes, which are necessary for the Uncomplicated malaria is symptomatic malaria with
sexual reproductive cycle that takes place in the vectors. parasitaemia without signs of severity or evidence of
vital organ dysfunction. Most cases of malaria in
When potent gametocytes are ingested by a female children in the tropics are of this type. The main
Anopheles mosquito during a blood meal, micro- and manifestations of uncomplicated malaria include fever,
chills, rigors, headaches, and body pains. Others are microscopist is able to detect asexual parasites at
malaise, nausea, vomiting, and joint weakness. Physical densities of fewer than 10 per microliter of blood but
examination may reveal pallor and under typical field conditions the limit of sensitivity is
hepatosplenomegaly. approximately 100 parasites per μl.

Severe malaria refers to acute P.falciparum malaria Types of stains

with signs of severity or evidence of vital oral Many differential stains have been developed for
dysfunction. A patient is regarded as having severe the detection of malaria parasites but the Romanowsky
falciparum malaria if there are asexual forms of stains that stain the nucleus red and cytoplasm blue
P.falciparum in a blood film and any of the following have proved the most adaptable and reliable for
clinical or laboratory features. routine work. Giemsa stain, an alcohol-based
Romanowsky stain, is the "gold standard". It is the
The signs and symptoms of malaria are non-specific. most commonly used stain and the best for routine
This means that many other infections can cause signs diagnosis due to its applicability to both thick and thin
and symptoms identical to those caused by malaria. blood films, its stability during storage and its constant
Malaria is suspected clinically mainly on the basis of and reproducible staining quality over a temperatures.
fever or history of fever in settings where exposure to Field stain, most widely used aqueous-based stain, is a
infection may have occurred. Clinical diagnosis of good method to stain thick smears but not suitable for
uncomplicated malaria is only justifiable when a thin smears. Field stain has the advantage that the film
diagnostic testing is not available. Current WHO is stained extremely quick. It is useful in laboratories
recommendations for such situations are: where the workload is high but variable results may
occur during routine use, thereby reducing its
1. In settings where the risk of malaria is low, widespread application. Other stains include
clinical diagnosis of uncomplicated malaria Leishman's stain solution which uses methanol as
should be based on the degree of exposure to solvent and therefore, useful to stain thin smears;
malaria and a history of fever in the previous Wright's stain can be used if rapid results are needed
three days, in the absence of features of other but it is not optimal for blood parasites. Thick smears
severe diseases; are more sensitive for detecting the presence of
2. In settings where the risk of malaria is high, parasites, and thin smears can provide more details for
clinical diagnosis should be based on a history species determination. This requires a skilled
of fever in the previous 24 hours and/or the microscopist. If an experienced microscopist is not
presence of anemia, for which pallor of the available, RDTs should be used.
palms appears to be the most reliable sign in
young children, in the absence of features of Giemsa stained thick and thin blood smears are the
other severe diseases. basis for mi- croscopic diagnosis of malaria. Before
starting parasite count, 100 fields of the thick smear at
Parasitological diagnosis is required for confirmation a magnification of 700 (equivalent to 0.25μl of blood)
of the diagnosis of malaria. It is recommended for all are examined to establish presence of parasites and
suspected malaria cases in all transmission settings. The their species. If diagnosis of species is uncertain, a
advantages of parasitological diagnosis are: further 100 fields should examined to identify a
a. improved care of parasite-positive patients owing potential mixed infection. Thin smears are not routinely
to greater certainty that the cause of the present examined to diagnose malaria in a patient except when
illness is malaria; there is technical problems with the thick smears (e.g
b. identification of parasite-negative patients for lost during the staining, auto-fixed, unreadable for
whom another diagnosis must be sought; other reason), when confirmation of the species is
c. prevention of unnecessary use of anti-malarials, difficult or uncertain in the thick smear or when the
thereby reducing the risk of ad- verse side effects parasite density is very high. Examine the thin smear
and drug interactions; until the presence and species of malaria parasites have
d. confirmation of treatment failures; and been identified, or up to at least 800 fields before
e. improved malaria case detection and reporting. declaring the slide negative. The limit of detection by
experienced microscopists is usually 10-20 parasites per
Microscopy has a high degree of sensitivity and μl of blood. Therefore a negative slide does not exclude
specificity when performed well. In addition, it allows the possibility that the patient may have malaria
quantification of malaria parasites and identification of parasites in the blood. Following a negative result,
the infecting species. It is inexpensive and considered to examination of the blood should be repeated after a
be the "gold standard" against which the sensitivity and few hours.
specificity of other methods must be assessed. A skilled
Malaria rapid diagnostic tests (RDTS) detect malaria- 50mg of artesunate and 153mg base of amodiaquine
specific antigens derived from the blood stages of are also available.
malaria parasites. The presence of antigen is indicated Therapeutic dose: A target dose of 4mg/kg/day
by a result line across a nitrocellulose strip. RDTs artesunate and 10mg/kg day amodiaquine once
provide a useful support to clinical diagnosis of malaria a day for 3 days, with a therapeutic dose range
and a valid alternative to microscopy for the clinical between 2- 10mg/kg/day artesunate and 7.5-
diagnosis of uncomplicated malaria, particularly where 15mg/kg/day amodiaquine.
good quality microscopy services are not readily
available. The sensitivity and specificity of RDTs in Artesunate plus mefloquine
detecting falciparum and vivax malaria are comparable Blister packs with separate scored tablets
to field microscopy. containing 50mg. of artesunate and 250mg of
mefloquine base are available.
Some RDTs detect only one species, P. falciparum, Therapeutic dose: A target dose of 4mg/kg/day
some detect this species in combination with one or artesunate given once a day for 3 days and
more of the other three species of human malaria 25mg base/kg of mefloquine either split over 2
parasites (P. vivax, P. ovale and P. malariae), and some days as 15mg/kg and 10mg/kg, or
RDTS detect all of these species. The commercially 8.3mg/kg/day mefloquine once a day for 3 days.
available RDTs target the Plasmodium falciparum The therapeutic dose range is be- tween 2-
Histidine-Rich Protein 2 (HRP2), the plasmodium lactate 10mg/kg/day of artesunate and 7-11
dehydrogenase (pLDH) and/or aldolase (common to all mg/kg/day of mefloquine.
malaria species). Different variants of pLDH are present
in the commercially available RDTs: pLDH-Pan (common Artesunate plus sulfadoxine-pyrimethamine
to all human malaria species), pLDH-Pf (present only in This is currently available as separate scored tablets
P. falciparum), pLDH-Pv (present only in P. vivax) and containing 50mg of artesunate and 500mg of
pLDH-Pvom (present in all species except P. falciparum). sulfadoxine and 25mg of pyrimethamine.
Therapeutic dose: A target dose of 4mg/kg/day
Treatment of Uncomplicated Falciparum Malaria artesunate given once a day for 3 days and a
single administration of 25/1.25mg/kg
Any infection with P. falciparum can become severe sulfadoxine-pyrimethamine on day 1, with a
if treatment is delayed or inadequate. However. people therapeutic dose range between 2-
who have been repeatedly exposed to falciparum 10mg/kg/day artesunate and 25-70/1.25-
malaria develop partial immunity and are less likely to 3.5mg/kg sulfadoxine-pyrimethamine.
experience severe falciparum malaria.
Dihydroartemisinin plus piperaquine
Artemether plus lumefantrine This is currently available as a fixed-dose
This is currently available as a fixed-dose combination with tablets containing 40mg of
formulation with dispersible or standard tablets Dihydroartemisinin and 320mg of piperaquine.
containing 20mg of artemether and 120mg of Therapeutic dose: A target dose of 4mg/kg/day
lumefantrine. dihydroartemisinin and 18mg/kg/day
Therapeutic dose: The recommended treatment piperaquine once a day for 3 days, with a
is a 6-dose regimen over 3 days. The dosing is therapeutic dose range between 2-
based on the number of tablets per dose 10mg/kg/day dihydroartemisinin and 16-
according to predefined weight bands (5-14kg. I 26mg/kg/day piperaquine.
tablet; 15-24kg. 2 tablets; 25-34kg: 3 tablets;
and > 34kg. 4 tablets), given twice a day for 3 Use of antipyretics: Fever is a cardinal feature
days. This corresponds to a target dose of of malaria. It may be associated with vomiting
1.7/12mg/kg body weight per dose of and seizures, and causes great discomfort. For
artemether-lumefantrine, respectively, given fever management, paracetamol should be
twice a day for 3 days,with a therapeutic dose used and, if necessary, tepid sponging of the
range of 1.44mg/kg of artemether and 10- body. Paracetamol at a dose of 15mg/kg given
16mg/kg of lumefantrine. at 4-hour intervals has been effective in fever
management. Ibuprofen (5mg/kg) may also be
Artesunate plus amodiaquine used. A systematic review of several
This combination is currently available as a fixed- randomized control trials did not show any
dose formulation with tablets containing 25/67.5, deleterious effect from the use of antipyretics,
50/135 or 100/270mg of artesunate and amodiaquine. and consequently their use is encouraged
Blister packs of separate scored tablets containing especially in children prone to seizures.
 Use of anti-emetics: Vomiting is common in Chloroquine+proguanil can be recommened for areas
malaria and anti-emetics are frequently where both P. vivax and P. falciparum malaria
prescribed. However their efficacy has not been transmission co-exist and where chloroquine resistance
studied and documented. is emerging For these areas, atovaquone+proguanil can
be used as an alternative that can be started the day
Management of convulsions: Generalized before travel.
seizures are common in children with
falciparum malaria compared to other forms of Atovaquone-proguanil, doxycycline or mefloquine
malaria. When seizures occur the airways (selected according to re ported resistance pattern) are
should be maintained and an anticonvulsant recommended for areas with (i) high risk of P.
given (intramuscular paraldehyde, rectal or falciparum malaria, in combination with reported
parenteral benzodiazepine). Multiple antimalarial drug resistance; (ii) moderate/low risk of P.
convulsions are a sign of severe malaria. falciparum malaria, in combination with reported high
levels of drug resistance.

Treatment for Uncomplicated Non-Falciparum

Malaria
In a study done in Tanzania, researchers have found
For chloroquine-sensitive vivax malaria (as in most out that "education, gender, availability of health care
places where P. vivax is prevalent), oral chloroquine at facility and livelihood practices were the major social
a dose of 25mg/kg is well tolerated and effective. It is determi nants that influence malaria acquisition and
given at an initial dose of 10mg/kg followed by either care seeking pattern (Shayoa et. al., 2015)". This study
5mg/kg at 6h, 24h and 48h or, more commonly has also clearly shown that rural community livelihood
10mg/kg on the second day and 5mg/kg on the third activities are important factors in malaria transmission
day. This should be combined with primaquine, anti- and control. The findings suggest that malaria control
relapse medicine, at a dose of 0.25mg base/kg bw, programs must therefore, account for the livelihoods
taken with food once daily for 14 days in patients and ecosystems contexts in which they are
without G6PD deficiency. In Oceania and South-East implemented. Efforts should be made to improve
Asia however, the dose of primaquine should be communication strategies on malaria prevention and
0.5mg/kg body weight. control to strengthen the local knowledge on malaria
and its prevention.
There is evidence that amodiaquine, mefloquine
and quinine are effective in the treatment of
chloroquine-resistant vivax malaria. P. ovale and P. At all levels, from the hospital to the community,
malariae infections are considered to be generally education is vital to optimizing antimalarial treatment.
sensitive to chloroquine. Treatment for P. ovale, Clear guidelines in the language understood by the local
relapsing malaria, is the same as for P. vivax, i.e. with users, posters, wall charts, educational videos and other
chloroquine and primaquine. P. malariae forms no teaching materials, public awareness campaigns,
hypnozoites and, therefore, treatment with only education of and provision of information materials to
chloroquine is sufficient. shopkeepers and other dispensers can all improve the
understanding of malaria and the likelihood of im-
Prophylaxis against Malaria proved prescribing and adherence, appropriate referral,
No prophylactic regimen gives complete protection but and minimizing the unnecessary use of anti-malarials.
good chemoprophylaxis (adherence to the
recommended medicine regimen) does reduce the risk
of fatal disease. Depending on the malaria risk in the
area to be visited and the local patterns of resistance to Insecticide-treated bed nets (ITNs) are a form of
antimalarial medicine, the recommended medicine may personal protection that has been shown to reduce
be chloroquine, chloroquine plus proguanil, mefloquine, malaria illness, severe disease, and death due to
or doxycycline: malaria in endemic regions. In community- wide trials in
several African settings, ITNs have been shown to
Chloroquine alone can only be recommended for areas reduce the death of children under 5 years from all
where malaria is due exclusively to P. vivax or fully causes by about 20%. Only pyrethroid insecticides are
chloroquine-sensitive P. falciparum. approved for use on ITNs. These insecticides have been
shown to pose very low health risks to humans and
other mammals, but are toxic to insects and kill them,
even at very low doses. Pyrethroids do not rapidly
break down unless washed or exposed to sunlight. blood. The person can either have symptoms of dengue
Previously, nets had to be treated every 6 to 12 months, fever or DHF, or they may have no symptoms. After
or even more frequently if the nets were washed. Nets about one week, the mosquito can then transmit the
were retreated by simply dipping them in a mixture of virus while biting a healthy person. Dengue cannot be
water and insecticide and washed allowing them to dry spread directly from person to person.
in a shady place. The need for frequent retreatment
was a major barrier to widespread use of ITNs in When a mosquito carrying dengue virus bites a
endemic countries. In addition, the additional cost of person, the virus enters the skin together with the
the insecticide and the lack of understanding its mosquito's saliva. It binds to and enters white blood
importance resulted in very low retreatment rates in cells, and reproduces inside the cells while they move
most African countries. throughout the body. The white blood cells respond by
producing a number of signaling proteins, such as
Recent studies have suggested that the rise of cytokines and interferons, which are responsible for
pyrethroid resistance may under. mine the many of the symptoms, such as the fever, the flu-like
effectiveness of nets. To help manage resistance, some symptoms and the severe pain. In severe infection, the
net products incorporate piperonyl butoxide (PBO) virus production inside the body is greatly increased,
along with a pyrethroid insecticide, but there is not yet and many more organs (such as the liver and the bone
evidence that this significantly improves ITN marrow) can be affected. Fluid from the bloodstream
effectiveness in areas with high levels of pyrethroid leaks through the wall of small blood vessels into body
resistance, and WHO currently does not consider nets cavities due to capillary permeability. As a result, less
that incor- porate PBO to be tools for managing blood circulates in the blood vessels, and the blood
pyrethroid resistance. Several companies have pressure becomes so low that it cannot supply
developed long-lasting insecticide-treated nets (LLINS) sufficient blood to vital organs. Furthermore,
that maintain effective levels of insecticide for at least 3 dysfunction of the bone marrow due to infection of the
years, even after repeated washing. LLINS have been stromal cells leads to reduced numbers of platelets,
associated with sharp decreases in malaria in countries which are necessary for effective blood clotting; this
where malaria programs have achieved high LLIN increases the risk of bleeding, the other major
coverage. WHO now recommends that LLINS be complication of dengue fever.
distributed to and used by all people ("universal
coverage") in malaria-endemic areas, not just by the
most vulner- able groups: pregnant women and
children under 5 years. LLINS are most commonly
distributed through mass campaigns approximately
every 3 years. Mobilizing resources to procure these
nets remains a major challenge. After much debate,
WHO is currently recommending that LLINS be provided
free.

DENGUE FEVER/ DENGUE HEMORRHAGIC

FEVER

Dengue Fever is a disease caused by any one of five

closely related dengue viruses (DENV I, DENV 2, DENV 3,
DENV 4 or DENV5). The viruses are transmitted to hu-
mans by the bite of an infected mosquito. In the Pathogenesis of the Dengue Virus
Western Hemisphere, the Aedes aegypti mosquito is
the most important transmitter or vector of dengue The principal symptoms of dengue fever are high
viruses, although a 2001 outbreak in Hawaii was fever, severe headaches, severe pain behind the eyes,
transmitted by Aedes albopictus. It is estimated that joint pain, muscle and bone pain, rash, and mind
there are over 100 million cases of dengue worldwide bleeding (e.g., nose or gums bleed, easy bruising).
each year. generally, younger children and those with their dengue
infection have a milder illness than older children and
Dengue is transmitted to people by the bite of an adults.
Aedes mosquito that is infected with a dengue virus.
The mosquito becomes infected with dengue virus Dengue hemorrhagic fever is characterized by a
when it bites a person who has dengue virus in their fever that lasts from 2 to 7 days, with general signs and
symptoms consistent with dengue fever. When the Dengue With Warning Signs
fever declines, symptoms includig persistent vomiting, Lives in or travels to dengue-endemic area, with fever
severe abdominal pain, and difficulty breathing, may lasting for 2-7 days, plus any of the following:
develop. This marks the beginning of a 24- to 48-hour abdominal pain or tenderness, persistent vomiting,
period when the smallest blood vessels (capillaries) clinical signs of fluid accumulation, mucosal bleeding,
become excessively permeable allowing the fluid lethargy, restlessness, liver enlargement, Laboratory:
component to escape from the blood vessels into the increase in Hematocrit and/or decreasing platelet count
peritoneum (causing ascites) and pleural cavity (leading
to pleural effusions). This may lead to failure of the Severe Dengue
circulatory system and shock, followed by death, if Lives in or travels to dengue-endemic area with fever
circulatory failure is not corrected. In addition, the lasting for 2-7 days and any of the above clinical
patient with DHF has a low platelet count and manifestations for dengue with or without warning
hemorrhagic manifestations, tendency to bruise easily signs plus any of the following: severe plasma leakage
or other types of skin hemorrhages, bleeding nose or leading to shock or fluid accumulation with respiratory
hums, and possibly internal bleeding. distress; severe bleeding; severe organ impairment:
Liver - AST or ALT ≥ 1000, CNS - seizures, impaired
Dengue is an all-year round diseases in the consciousness, Heart - myocarditis, Kidneys - renal
Philippines. In March of 2012, the DOH released failure.
Administrative Order No. 2012-0006 or the Revised
Dengue Clinical Case Management Guidelines 2011. the
revised guidelines introduced new ways of classifying There is no vaccine for preventing dengue. The
levels of severity of the diseases and appropriate best preventive measure for residents living in areas
clinical management. infested with Ae. aegypti is to eliminate the places
where the mosquito lays her eggs, primarily artificial
Under the new guidelines, patients with dengue are containers that hold water.
classified according to levels of severity as having
Dengue without Warning Signs, Dengue with Warning Items that collect rainwater or to store water (for
SIgns and Severe Dengue based on clinical example, plastic containers, 55- gallon drums, buckets,
manifestations with or without laboratory parameters. or used automobile tires) should be covered or properly
dis- carded. Pet and animal watering containers and
Dengue Without Warning Signs vases with fresh flowers should be emptied and cleaned
Probable Dengue: Confirmed Dengue: (to remove eggs) at least once a week. This will
Lives in or travels to Viral culture isolation eliminate the mosquito eggs and larvae and reduce the
dengue-endemic area, Polymerase Chain number of mosquitoes present in these areas.
with fever, plus any two of Reaction
the following: Using air conditioning or window and door screens
a. Headache reduces the risk of mosquitoes coming indoors. Proper
b. Body malaise application of mosquito repellents containing 20% to
c. Myalgia 30% DEET as the active ingredient on exposed skin and
d. Arthralgia clothing decreases the risk of being bitten by
e. Retro-orbital pain mosquitoes. The risk of dengue infection for
f. Anorexia international travelers appears to be small. There is
g. Nausea increased risk if an epidemic is in progress or visitors
h. Vomiting are in housing without air conditioning or screened
i. Diarrhea windows and doors.
j. Flushed skin
k. Rash

AND Laboratory test, at

RABIES
least CBC (leukopenia with Rabies is a zoonotic disease and human infection
or without caused by Lyssavirus, usually occurring after a
thrombocytopenia) and/or transdermal bite or scratch by an infected animal.
dengue NSI antigen test or Transmission may also occur when infectious material,
denge IgM antibody test usually the saliva, comes into direct contact with the
(optional) victim's mucosa or fresh skin lesions. Very rarely, rabies
may occur through inhalation of virus-containing
aerosol or via infected organ transplants. It is a highly  The amount of the virus inoculated into the wound
fatal disease characterized by fluctuations in or mucosa.
consciousness, phobic or inspiratory spasms and  Severity of exposure - Patients with multiple
autonomic instability. and/or deep penetrating bite wounds may have
shorter incubation period.
Rabies is estimated to cause 55,000 deaths every  Location of exposure Patients with bite wounds in
year worldwide, with about 56% of the cases occurring highly innervated areas and/or close to the central
in Asia and 43.6% in Africa, mostly in rural areas. Rabies nervous system may have shorter incubation
is present on all continents with the exception of period.
Antartica. Once symptoms of the disease develop,
rabies is nearly always fatal. Rabies is a neglected After inoculation, the rabies virus multiplies in the
disease of poor and vulnera- ble populations whose muscle cells (myocytes) or may invade the nerve
deaths are rarely reported. It occurs mainly in remote directly without prior multiplication in the myocytes. It
rural communities where measures to prevent dog to is possible that the rabies virus may persist locally at
human transmission have not been implemented. the site of inoculation for an unspecified period of time.
Under-reporting of rabies also prevents mobilization of This could explain the long incubation period for some
resources from the international community for the rabies infections. The virus then penetrates the
elimination of human dog-mediated rabies. peripheral nerve cells via viral uptake at neuronal
endings. The virus is transported through both the
Rabies remains to be a public health problem in the sensory and motor nerve fibers to the central nervous
Philippines. It is the most acutely fatal infectious system (CNS).
disease responsible for the death of 200-250 Filipinos
every year. At least one-third of human rabies deaths In vitro studies show that velocity of axonal transport of
are among children less than 15 years of age. Two the virus ranges from 25 to 50 mm per day. The spread
thirds of human rabies cases are males. Dogs are the of the rabies virus in the coulometer and optic nerves
source of the vast majority of human rabies deaths. The could be as fast as 12 mm/day. Once the virus reaches
high cost of anti-rabies vaccine and immunoglobulins, the CNS, rabies replication occurs primarily in the
expenditure for medical consultations and the loss of neurons or brain cells through viral budding and the
income are an additional burden to a regular Filipino virus spreads and infects the nearby brain cells.
family confronted with a potential rabies exposure. Dissemination through the cerebrospinal fluid (CSF)
occurs in the late stages of infection. While viral
Bites from infected animals are the most common dissemination occurs in the central nervous system, the
mode of transmission of rabies to humans. Exposure to rabies virus spreads into the peripheral tissues such as
rabies may come from bites of infected dogs, cats, muscle fibers, salivary glands, corneas, adrenal
other domestic and wild animals including bats. medullae, lacrimal glands, myocardium, kidneys, lungs,
However, bites from rats, rabbits, other rodents, pancreas and epidermis. Infection of salivary glands
reptiles and birds do not pose a risk for rabies infection. allows further transmission of the disease to other
Non-bite exposures are less important and are mammals.
infrequent modes of transmission. However, scratches,
open wounds or mucous membranes that are licked by The prodromal stage occurs when there is initial
an infected animal, can be points of entry of the rabies viral replication at the striated muscle cells at the site of
virus and these may be in the form of the following: inoculation just before it enters the brain. The virus
 Contamination of intact mucosa (eyes, nose, then spreads centripetally up the nerve to the central
mouth, genitalia) with saliva of infected animal; nervous system through the peripheral nerve axoplasm.
 Licks on broken skin; and This stage lasts for 0-10 days with non-specific
 Inhalation of aerosolized virus in closed areas (e.g. manifestations, which include fever, sore throat,
caves with rabid bats, laborato- ries for rabies anorexia, nausea, vomiting, generalized body malaise,
diagnosis). headache and abdominal pain. Paresthesia or pain at
the site of bite is due to viral multiplication at the spinal
Incubation period is the period from the time of ganglion just before it enters the brain.
exposure up to the appearance of first clinical signs and
symptoms of rabies. The average incubation period of The acute neurologic stage is the stage when the
human rabies is between one to three (1-3) months. In virus reaches the CNS and replicates most exclusively
90-95 % of cases, incubation period less than one year within the gray matter. This stage has two types of
but may be longer in 5-10 % cases. The duration of the presentation: encephalitic or furious type, which is
incubation period depends on certain factors: present in 80% of rabies cases, and paralytic or dumb
type, which is seen in 20%. Autonomic manifestations
such as hypersalivation appear during this stage. The suspected rabies
virus passes centrifugally among autonomic nerves to cases) and routine
reach other tissues- the salivary gland, adrenal medulla, delivery of health
kidney, lung, liver, skeletal muscle, skin and heart. care to patient with
Passage into the salivary gland facilitates further signs and symptoms
transmission of the disease through infected saliva. This of rabies
stage lasts for 2-7 days, characterized by hyperactivity, Nibbling of 1. Wash wound
hypersalivation, disorientation, hallucination, bizarre uncovered skin with with soap and
behavior interspersed with lucid intervals, seizures, or without water.
nuchal rigidity or paralysis. bruising/hematoma 2. Start vaccine
Often the diagnosis of rabies is based on the clinical immediately:
manifestations and a history of exposure to a rabid Minor/superficial
animal. In cases where the pathognomonic scratches/abrasions A. Complete
hydrophobia and/or aerophobia are present, the without bleeding, vaccination regimen
diagnosis is straight forward. However, clinical diagnosis including those until Day 28 (see
may be difficult in cases of paralytic rabies and atypical induced to bleed table 1a) if:
presentations. Thus, rabies laboratory confirmation is CATEGORY (i) . Biting animal is
necessary. Rabies diagnosis can be performed on fresh II All Category II laboratory proven
tissue specimens stored at appropriate temperatures, exposures on the to be rabid OR
preferably refrigerated. The specimens to be collected head and neck area (ii) Biting animal is
depend on the test to be performed. In transporting are considered killed/died without
specimen glycerine preservative (temperature: +40C or Category III and laboratory testing
-200C) or dried smears of brain tissue on filter paper should be managed OR
(temperature: +300C) enables safe transport. as such (iii) Biting animal
has signs and
When directly exposed to a suspected rabid animal, symptoms of rabies
it is important that the person must be able to receive OR
post-exposure prophylaxis (PEP) as soon as possible. (iv) Biting animalis
Initi- ation of post-exposure prophylaxis should not be not available for
delayed for any reason regardless of interval between observation for 14
exposure and consultation as it increases the risk of days
rabies and it is associated with treatment failure. The
National Rabies Control and Prevention Program B. May omit Day 28
defines the categories of treatment: dose if:
i) Biting animal is
Category Type of Exposure Management alive AND remains
of healthy after the
Exposure 14-day observation
Feeding/touching 1. Wash exposed period. OR
an animal skin immediately ii) Biting animal
with soap and died within the 14
Licking of intact skin water. days observation
(with reliable 2. No vaccine or RIG period, confirmed
history and needed by veterinarian to
thorough physical have no signs and
examination) Pre-exposure symptoms of rabies
prophylaxis may be and was FAt-
CATEGORY Exposure to considered for high negative
1 patients with signs risk persons. RIG is not indicated
and symptoms of Transdermal bites 1. Wash wound
rabies by sharing of (puncture wounds, with soap and
eating or drinking lacerations, water.
utensils avulsions) or 2. Start vaccine and
CATEGORY scratches/abrasions RIG immediately:
Casual contact III with spontaneous
(talking to, visiting bleeding A. Complete
and feeding vaccination regimen
 Licks on broken skin until Day 28 (see are also required to administer only vaccines approved
or mucous Table 1a) if: by WHO for ID use.
membrane i) Biting animal is One dose for ID administration is equivalent to 0.1
laboratory proven ml both for PVRV and PCECV. One dose should be
Exposure to a rabies to be rabid OR given on each deltoid (or at the anterolateral aspect of
patient through ii) Biting animal is both thighs in infants) on Days 0, 3, 7 and 28.
bites, killed/died without
contamination of laboratory testing Intradermal Regimen
mucous membranes OR
(eyes, oral/nasal iii) Biting animal has Day of PVRV Site of injection
mucous, signs and symptoms immunization /PCECV
genital/anal mucous of rabies OR Day 0 0.1 mL Left and right deltoids
membrane) or open iv) Biting animal is or anterolateral thighs
skin lesions with not available for in infants
body fluids through observation for 14 Day 3 0.1 mL Left and right deltoids
splattering and days or anterolateral thighs
mouth-to-mouth in infants
resuscitation B. May omit Day 28 Day 7 0.1 mL Left and right deltoids
dose if: or anterolateral thighs
Unprotected i) Biting animal is in infants
handling of infected alive AND remains Day 28 0.1 mL Left and right deltoids
carcass healthy after the or anterolateral thighs
14-day observation in infants
Ingestion of raw period. OR biting
infected meat animal died within *PVRV = Purified Vero Rabies vaccine; PCECV = Purified
14 days observation Chick Embryo Cell Vaccine
Exposure to bats period, confirmed
by veterinarian to Immunocompromised patients such as those with
All Category II have no signs and HIV infection, cancer/etc and patients with chronic liver
exposures on head symptoms of rabies disease and those taking chloroquine and systemic
and neck areas. and was FAT- steroids should be given standard IM regimen as the
negative. response to ID regimen is not optimum for these
conditions. Vaccination should not be delayed in these
circumstances as it increases the risk of rabies. Vaccine
Pregnancy and infancy are not contraindications to PEP should never be injected in the gluteal area as
with modern culture cell vaccine and RIG. Babies who absorption is unpredictable
are born to rabid mothers should be given rabies
vaccination as well as RIG as early as possible upon Intramuscular Regimen
birth. Exposed persons who are present for evaluation
or treatment weeks or months after the bite should be Day of PVRV PCECV Site of injection
managed as if the exposure has occurred recently. Immunization
However, if the biting animal has remained healthy and Day 0 0.5 ml 1.0 ml One deltoid or
alive with no signs of rabies until 14 days after the bite, anterolateral thigh
PEP is no longer recommended. in infants
Day 3 0.5 ml 1.0 ml One deltoid or
Rabies is a vaccine-preventable disease. A person anterolateral thigh
exposed to a rabid animal can be given active and in infants
passive immunization. In the Philippines, Animal Bite
Day 7 0.5 ml 1.0 ml One deltoid or
Treatment Centers (ABTC) are established in strategic
anterolateral thigh
areas in order to provide immunization as a post-
in infants
exposure prophylaxis to victims of animal bites. For
Day 14 0.5 ml 1.0 ml One deltoid or
active immunization, due to limited resources in the
anterolateral thigh
Philippines, all Animal ABTCs are required to use only
in infants
the recommended Intradermal (ID) regimen in
Day 28 0.5 ml 1.0 ml One deltoid or
managing rabies exposures/animal bites. According to
anterolateral thigh
WHO, the ID use of Tissue Culture Vaccines can
in infants
decrease the cost of PEP by as much as 60-80%. ABTCs
 For passive immunization, Rabies Immunoglobulin
(RIG) is given in combination with rabies vaccine to Removing the rabies virus at the site of the infection
provide the immediate availability of neutralizing by chemical or physical means is an effective means of
antibodies at the site of the exposure before it is protection. Therefore, prompt local treatment of all
physiologically possible for the patient to begin bite wounds and scratches that may be contaminated
producing his or her own antibodies after vaccination. with rabies virus is important. Recommended first-aid
This is given to patients with Category III exposures. procedures include immediate and thorough flushing
However, immune-compromised individuals such those and washing of the wound for a minimum of 15
with HIV Infection, cancer/transplant patients, patients minutes with soap and water, detergent, povidone
on immunosuppressive therapy should be given RIG for iodine or other substances that kill the rabies virus.
both CAT II and III exposures. Human RIG (HRIG) has a
half-life of approximately 21 days while Equine RIG The most cost-effective strategy for preventing
(ERIG) is 14 days. rabies in people is by eliminating rabies in dogs through
vaccination. Vaccination of animals (mostly dogs) has
Generic Name Preparation Dose reduced the number of human (and animal) rabies
Human Rabies 150 IU/, 2ml/vial 20 IU/kg cases in several countries around the world. Preventing
Immunoglobulin human rabies through control of domestic dog rabies is
(HRIG) a realistic goal for large parts of Africa and Asia, and is
Equine Rabies 200 IU/, 5ml/vial 40 IU/kg justified financially by the future savings of
Immunoglobulins discontinuing post-exposure prophylaxis for people.
(ERIG)
F(ab’)2 products 200 IU/, 5ml/vial 40 IU/kg Safe, effective vaccines can be used for pre-
exposure immunization. This is recommended for
travelers spending a lot of time outdoors, especially in
The total computed dose should be infiltrated rural areas, involved in activities such as bicycling,
around and into the wound as much as anatomically camping, or hiking as well as for long-term travelers and
feasible, even if the lesion has healed. In case some expatriates living in areas with a significant risk of
amount of the total computed dose of the RIG is left exposure.
after all wounds have been infiltrated, it should be
administered deep IM at a site distant from the Pre-exposure immunization is also recommended
infiltration site, preferably anterolateral thigh using for people in certain high-risk occupations such as
another needle. The total computed dose should be laboratory workers dealing with live rabies virus and
administered as a single dose. other rabies-related viruses and people involved in any
activities that might bring them professionally or
RIG should always be given in combination with otherwise into direct contact with bats, carnivores, and
rabies vaccine. RIG should be ad- ministered at the other mammals in rabies-affected areas. As children are
same time with the first dose of rabies vaccine (Day 0). considered at higher risk because they tend to play with
In case RIG is unavailable on Day 0, it may still be given animals, may receive more severe bites, or may not
until 7 days after the first dose of the vac- cine (Day 0). report bites, their immunization could be considered if
Beyond Day 7, regardless of whether day 3 and day 7 living in or visiting high risk areas.
doses were received, RIG is not indicated.

A skin test must be performed prior to ERIG NEGLECTED TROPICAL DISEASES

administration using a gauge 26 needle. For skin testing,
0.02 ml of 1:10 dilution solution is infiltrated to raise a In the Philippine setting, there are at least two
bleb 3 mm and read after 15 minutes. A positive skin major Neglected Tropical Diseases (NTDs). These are
test is an induration of >6 mm surrounded by a Filariasis and Schistosomiasis. These parasitic diseases
flare/erythema. If initial skin test is positive, repeat skin cause chronic disabilities and deformities that hamper
test on same arm; use distilled water as control on the the growth and development of children, as well as the
other arm. The skin test is considered positive if the working ability or productivity of adults. For Lymphatic
ERIG skin is positive but the control is negative. Patients Filariasis alone, the country's annual economic loss due
with positive skin test to purified ERIG should be given to decreased productivity and increased costs of care is
HRIG. Patient must be observed for at least one hour estimated at US$4.4M a year.
after injection for any adverse reactions.
Schistosomiasis between vigorous upward movement and sinking to
Also known as Katayama Fever, Schistosomiasis is a maintain their position in the water. Cercarial activity is
disease caused by parasitic worms of the Schistosoma particularly stimulated by water turbulence, by
type. It may infect the urinary tract or the intestines. shadows and by chemicals found on human skin.
Signs and symptoms may include abdominal pain,
diarrhea, bloody stool, or blood in the urine. In those The most common way of getting schistosomiasis is
who have been infected for a long time, liver damage, by wading or swimming in lakes, ponds and other
kidney failure, infertility, or bladder cancer may occur. bodies of water that are infested with the snails (usually
In children it may cause poor growth and learning of the genera Biomphalaria, Bulinus, or Oncomelania)
difficulty. that are the natural reservoirs of the Schistosoma
pathogen.
The disease is spread by contact with water
contaminated with the parasites. These parasites have
been released from their freshwater snail hosts. The
disease is especially common among children in
developing countries as they are more likely to play in
contaminated water. Other high risk groups include
farmers, fishermen, and people using unclean water for
their daily chores. Diagnosis is by finding the eggs of the
parasite In a person's urine or stool. It can also be
confirmed by finding antibodies against the disease in
the blood.

Schistosomiasis remains endemic in 12 regions of

the Philippines, covering 28 provinces, 190
municipalities, 15 cities and approximately 2,222
barangays (local communities). The total population at
risk is approximately 12 million people, with 2.5 million
individuals directly exposed to the disease. Recent
surveys conducted through active surveillance by field
schistosomiasis teams revealed a national average
prevalence of 2.5% (0.04% to 6%) according to the DOH
as of 2008.

Schistosomes have a typical trematode vertebrate-

invertebrate lifecycle, with humans being the definitive
host. Infections by this parasitic worm is in a family of
diseases known as helminthiases. The life cycles of all
five human schistosomes are broadly similar. parasite
eggs are released into the environment from infected
individuals, hatching on contact with fresh water to
release the free-swimming miracidium. Miracidia infect
freshwater snails by penetrating the snail's foot. After
infection, close to the site of penetration, the
miracidium transforms into a primary (mother)
sporocyst. Germ cells within the primary sporocyst will
then begin dividing to produce secondary (daughter)
sporocysts, which migrate to the snail's hepato-
pancreas. Once at the hepatopancreas, germ cells
within the secondary sporocyst begin to divide again,
this time producing thousands of new parasites, known
as cercariae, which are the larvae capable of infecting
mammals.

Cercariae emerge daily from the snail host in a

circadian rhythm, dependent on ambient temperature
and light. Young cercariae are highly mobile, alternating