CHN E-LEARNING MIDTERMS
As in family
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.
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 resuits 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 (ie., 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
to 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 focused on a particular
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,
o The following are the TCLs maintained
in RHUS and health centers:
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. Psychological
3. Physiological
4. Health-related behaviors
 The second level consist 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 client (individual,
family, or community) is 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 TABLE 1:
community health concern.
 In determining cost of reducing risk, the nurse Assigning criterion weight through nominal group technique. Problem:
Risk of maternal complications leading to maternal mortality in
has to consider economic, social, and ethical
Barangay Bagong Silang. Question: How important is the criterion in
requisites and consequences of planned
solving the problem?
action(s).
Criterion Nurs Midwif BHW Mrs. Mr. Averag
 Ability to identify the target population for the e J. e B. Dionisi Mirand Peralt e
intervention is a matter of availability of data Cruz Tan a a a weight
sources, such as FHSIS, census, survey reports, Significanc 8 10 7 10 6 8
and/or case-finding or screening tools. e of the
 Availability of resources to intervene in the problem
reduction of risk entails technological, financial, Communit 8 8 5 5 5 6
and other material resources of the community, y
the nurse, and the health agency. Accessibility of awareness
outside resources and the link to these resources Ability to 10 10 10 10 10 10
are taken into account. reduce
risk
For a realistic and useful outcome, the priority-setting Cost of 8 5 8 8 8 8
process requires the joint effort of the community, the reducing
nurse, and other stakeholders, such as other members of risk
the health team (referred to as "group" herein to simplify Ability to 4 5 6 5 6 5
the description of the process). The group defines identify
guidelines for discussion, particularly on the manner of target
reconciling differences of opinion. Shuster and Goeppinger population
Availabilit 8 8 6 5 8 7
suggested a flexible process using the nominal group
y of
technique wherein each group member has an equal voice
resources
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 TABLE 2:
ideas, and when consensus-building is desired over making
a choice based on the opinion of the majority. Criterion rating through nominal group technique. Problem: Risk of maternal com
to maternal mortality in Barangay Bagong Silang. Question: Can the group influen
The group makes a list of the identified community health relation to the criteria?
problems or conditions. Each of the identified problems is Criterion Nurse J. Midwife BHW Mrs. Mr. Average
treated separately according to a set of criteria agreed Cruz B. Tan Dionisia Miranda Peralta weight
upon by the group such as those suggested by the WHO. Significance 6 8 4 6 6 6
As suggested by Shuster and Goeppinger, the following of the
steps are carried out: problem
Community 10 10 10 5 5 8
1. From a scale of 1 to 10, 1 being the lowest, the awareness
members give each criterion a weight based on their Ability to 6 6 6 6 8 6
perception of its degree of importance in solving the reduce risk
problem. For example, each member assigns a weight to Cost of 6 6 6 4 4 5
the significance of the problem in response to the reducing
question, "How important is significance of the problem to risk
its solution?" Ability to 10 10 10 8 6 9
identify
2. From a scale of 1 to 10, 1 being the lowest, each target
member rates the criteria in terms of the likelihood of the population
group being able to influence or change the situation. For Availability 4 4 3 2 2 3
example, each member rates significance of the problem of
resources
in response to the question, "Can the group influence the
significance of this problem?"
4. Compute the total priority score of the problem by
3. Collate the weights (from step 1) and ratings (from step
multiplying collated weight and rating of each criterion.
2) made by the members of the group.
5. The priority score of the problem is calculated by adding
the products obtained in step 4.

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 Criterion Criterion Problem score
weight (1- rating (1-10) (weight x rating)
10)
Significan 8 6 48
ce of the
problem Deciding on community interventions
Communi 6 6 38
ty Because of their inherent differences, what may work for
awarenes one community may not be effective in another. The group
s analyzes the reasons for people's health behavior and
Ability to 10 6 60 directs strategies to respond to the underlying causes. For
reduce
example, reasons for preference of home delivery over
risk
facility-based delivery should be identified. If the majority
Cost of 8 5 40
of the women would choose to have a home delivery
reducing
risk because of cost or lack of access of birthing facilities,
Ability to 5 9 45 strategies should then be focused on improving facility-
identify based services. But if the primary reason is sociocultural,
target the planning team may opt to concentrate on providing
populatio opportunities for skills development of traditional birth
n attendants and/or exerting effort to gain the trust and
Availabilit 7 3 21 confidence of the women and their families. In the process
y of of developing the plan, the group takes into consideration
resources the demographic, psychological, social, cultural, and
Total 262 economic characteristics of the target population on one
priority hand and the available health resources on the other
score of hand.
problem
After repeating the process on all identified health IMPLEMENTING THE COMMUNITY HEALTH
problems, compare the total priority scores of the INTERVENTIONS
problems. The problem with the highest total priority
score is assigned top priority, the next highest is assigned Often referred to as the action phase, implementation is
second priority, and so on. the most exciting phase for most health workers. Aside
from being able to deal with the recognized priority health
Formulating goals and objectives concern, the entire process is intended to enhance the
community's capability in dealing with common health
As in family health nursing, goals are the desired outcomes
conditions/problems. The nurse's role therefore may be to
at the end of interventions, whereas objectives are the
facilitate the process rather than directly implement the
short-term changes in the community that are observed as
planned interventions. Implementation also entalls
the health team and the community work towards the
coordination of the plan with the community and the
attainment of goals. Objectives serve as instructions,
other members of the health team. This requires a
defining what should be detected in the community as
common understanding of the goals, objectives, and
interventions are being implemented. Just like any other
planned interventions among the members of the
community endeavor, attaining goals and objectives is
implementing group. Collaboration with other sectors such
more likely if the community has participated in the
as the local government and other agencies may also be
process and these have been mutually agreed upon.
necessary
Specific, measurable, attainable, relevant, and time-bound
(SMART) objectives provide a solid basis for monitoring EVALUATION OF COMMUNITY HEALTH INTERVENTIONS
and evaluation.
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 evaluation is 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 Besides serving as tools for assessing the health status of
the population or making a situational analysis of a
Each of these practical applications is discussed in greater community), health indicators are also used for:
detail in the subsequent sections, Hopefully, these would
make us understand that epidemiology is an important 1. Determining factors that may contribute to causation
tool that is applied by the members of the community and control of diseases.
health management team, which includes the public
2. Identifying public health problems and needs.
health nurse for performing their roles and functions. For
instance, the discussions show how the use of basic 3. Indicating priorities for resource allocation.
epidemiologic techniques by public health practitioners
can aid them rank health problems, identify risk factors for 4. Monitoring implementation of health programs.
such problems, design targeted health interventions, and
5. Evaluating outcomes of health programs.
monitor and evaluate such interventions.
Morbidity indicators
ASSESSMENT OF THE HEALTH STATUS OF THE
COMMUNITY (COMMUNITY DIAGNOSIS) Morbidity indicators are generally based on the disease-
specific incidence or prevalence for the common and
Epidemiology is often used to describe the health status of
severe diseases, such as malaria, diarrhea, leprosy,
the population through estimation of health indicators.
dengue, diabetes, and cardiovascular diseases. With the
These are quantitative measures, usually expressed as
use of these indicators, we can partly answer two
rates, ratios, or proportions, that describe and summarize
epidemiologic questions, viz., "What are the health
various aspects of the health status of the population.
problems in our area?" and "Flow many cases occur in the
Thus, there are various types of health indicators
area?" Prevalence proportion (P) measures the total
depending on the aspect of health that is of interest. Some
number of existing cases of a disease at a particular point
of these indicators are discussed in greater detail in the
in time divided by the number of people at that point in
subsequent sections
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.
Cl = (Number of new cases that developed during the
period/Number of persons followed-up) xF
The term "attack rate" is often used instead of Cl 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 fo 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 Cl, 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 Cl 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) xF
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.
LESSON 5
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. 4• 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/AIDS 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, 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
£. 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
Maternal, Newborn and Child Health and Nutrition
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 (STIs) 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 considers all 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:
Exclusive breastfeeding up to 6 months
• Sustained breastfeeding up to 24 months with
complementary feeding
• Micronutrient supplementation
• 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 the community
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. ACHT 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.
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 stages 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 accordance 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 that
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.
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:
o Menstruation.
o 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.
o 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.
o 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.
o 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:
o 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.
o 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.
o Avoid intercourse during days of changing
pattern of fertility until the fourth day after the
peak.
o 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:
o 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.
o 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.
o 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:
o Does not interfere with intercourse:
o Since it does not contain estrogen, it
can be used while breastfeeding a baby
6 months or older:
o May help protect against endometrial
cancer, pelvic inflammatory disease
(PID), and iron-deficiency anemia.
• Its disadvantages include:
o Delayed return to fertility for about 1-4
months after use:
o Irregular vaginal bleeding is common;
and
o Gradual weight gain
o 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:
o Local action;
o Has no effect on amount or quality of
breast milk;
o Low cost;
o Docs not interfere with sexual
intercourse; One-time application;
o Immediate return to fertility upon
removal;
o Can be inserted immediately after
childbirth or after abortion and can be
removed by a trained provider; and
o Long-lasting-the copper-bearing IUD
lasts for 10 years or more.
• Disadvantages include:
o Has common side effects such as pain and
cramping, longer and heavier menstrual
bleeding and menstrual irregularities:
o Device may be expelled, possibly without
the woman knowing it (especially for
postpartum insertions):
o Requires a pelvic exam before insertion and
requires a trained health service provider to
insert/remove the IUD;
o Does not protect against STIs and may
increase the incidence of PID;
o Although rare (1 in 1,000 cases, according
to WHO), possible uterine perforation,
which usually occurs at the time of
insertion; and
o 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.
o 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.
o 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 EPI 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 X2.7%
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.
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.
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
lodization 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. 10025 - 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 Expanded
Garantisadong 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 first 6 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;
• Putting the 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.
 Micronutrient supplementation for children
Micronutrien Target Schedule
t population
Vitamin A Infants 6-11 100,000 IU once only
capsule months old
Children 12- 200,000 IU every 6 months
71 months
old
Iron Infants 2-6 0.3 ml once a day to start at 2
months with months until 6 months when
low birth complementary foods are given.
(<2,500 g) Preparation is 15 mg elemental
iron/0.6 ml
Anemic 1 tsp once a day for 3 months or
children 2-59 30 mg once a week tor 6 months
months old with supervised administration
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.
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:
• Grade+ (mild) - both feet/ankles.
• Grade++ (moderate) - both feet, lower legs,
hands, or lower arms.
• Grade+++ (severe) - generalized edema including
both feet, legs, hands, arms, and face.
"Baggy pants" is a term used to describe loose skin on the
buttocks because of loss of subcutaneous and muscle
tissues. In public health practice, "baggy pants" helps in
detecting visible severe wasting. For infants less than 6
months old, SAM is detected by the presence of clinical
signs of visible severe wasting and edema, together with
difficulties in breastfeeding.
Protein energy malnutrition is prevented and managed by
complying with the recommended feeding practices for
infants and young children. However, children with SAM
should be assessed for associated conditions, such as
infections. The Integrated Management of Childhood
Illness protocol advises urgent referral to the hospital for
children with severe malnutrition.
Micronutrient malnutrition
Micronutrients are so-called because they are needed only
in very small amounts, that is, they are present in the
human body in amounts less than 0.005% of body weight.
All vitamins are micronutrients. Some minerals, like
calcium, sodium, potassium, and chlorine, are abundantly
present in the body and are, therefore, not micronutrients.
Micronutrients enable the body to produce enzymes,
hormones, and other substances essential for proper
growth and development. As tiny as the amounts are,
however, the consequences of their absence are severe.
Iodine, vitamin A, and iron are most important in global
public health terms; their lack represents a major threat to
the health and development of populations the world
over, particularly children and pregnant women.
Aside from good breastfeeding practices, prevention and
management of micronutrient deficiencies are done
through the three-pronged strategy of supplementation,
food fortification, and diet diversification.
Vitamin A deficiency
Aside from the ill effects of VAD on the eyes, it also
diminishes the ability to fight infections. Even a mild,
subclinical deficiency can be a problem, as it may increase
children's risk for respiratory and diarrheal infections,
decrease growth rates, slow bone development, and
decrease the likelihood of survival from serious illness.
VAD also contributes to maternal mortality and other poor
outcomes of pregnancy and lactation. Subclinical VAD is
detected through serum retinol determination, though this
examination is not routinely performed because of the
cost entailed. If it is done, a plasma or serum retinol
concentration <20 μg or 0.70 mmol/liter indicates
subclinical VAD in children and adults, and <10 μg or 0.35
mmol/liter indicates severe VAD.

Xerophthalmia refers to all signs and symptoms affecting

the eye that can be attributed to VAD. The following are
the eye symptoms of VAD progressing from the mildest,
that is, night blindness, to the potentially blinding
condition keratomalacia:

Night blindness - difficulty in seeing in the dark with the

child refusing to play after dusk, stumbling on furniture,
groping for food, and asking questions at dusk indicating
difficulty in seeing. Night blindness responds rapidly,
usually within 24-48 hours, to treatment with a high-dose
vitamin A.
• Conjunctival xerosis - marked dryness of the
affected area in the conjunctiva. The area
appears roughened, with fine droplets or
bubbles on the surface. Conjunctival xerosis
usually appears with Bitot's spots. These
symptoms respond within 2-5 days to treatment
with a high dose of vitamin A.
• Bitot's spots - foamy, soapy, whitish patches
seen in the white part of eye (scleral
conjunctiva). This can be removed but may
reaccumulate later if VAD is not corrected.
• Corneal xerosis - cloudy dry cornea with an
orange-peel appearance. Some people call this
fish scale. The child's vision is diminished even at
daytime. Corneal xerosis responds within 2-5
days to treatment with a high dose of vitamin A.
The cornea regains its normal appearance in 1-2
weeks.
• Corneal ulceration/keratomalacia - soft, bulging
cornea with large perforation or holes in the
surface. Children with prolonged diarrhea and
measles frequently progress to this stage. This
may result in perforation, collapse of the eyeball,
and blindness. Emergency treatment with a high
dose of vitamin A may still save the other eye.
VAD prevention and management includes feeding the
child with a variety of vitamin A-rich sources, both animal
(e.g. milk, egg yolk, and liver) and plant (dark green leaves
and orange- or yellow-colored fruits and vegetables). In
addition, this condition is associated with infections like
measles and diarrheal diseases. for this reason, prevention
of infectious diseases through immunization also
contributes to VAD prevention.
Iron deficiency anemia
WHO defines anemia in children under 5 years of age and
pregnant women as a hemoglobin value < 110 g/liter. The
finger-prick blood sample test may be done to detect
anemia.
A simple method of detection of anemia is to assess the
child for palmar pallor. To detect this sign, hold the child's
palm open by grasping it gently from the side. Do not
stretch the fingers backward as this may cause pallor by
blocking the blood supply. Comparing the child's palm with
your own or the palm of other children helps in detecting
palmar pallor. If the skin of the child's palm is pale, the
child has some palmar pallor. If the skin of the palm is very
pale or so pale that it looks white, the child has severe
palmar pallor. In the Integrated Management of Childhood
Illness protocol, severe palmar pallor requires urgent
referral to a hospital.
Iron deficiency is probably the most common cause of
anemia. Other causes include acute and chronic infections
that result in inflammation and hemorrhages, such as
Dengue, deficiencies of other vitamins and minerals,
especially folate, vitamin B12, and vitamin A, and
genetically inherited traits, such as G6PD deficiency.
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS: AN
OVERVIEW
In the Philippines, through the years 2004-2006,
pneumonia was the third leading cause of infant deaths,
while diarrhea and gastroenteritis of presumed infectious
origin ranked tenth.
The top three leading causes of mortality among children
aged 1-4 years were:
1. Pneumonia
2. Accidents
3. Diarrheas and gastroenteritis of presumed infectious
origin
On a global perspective, in 1998, more than 50 countries
still had childhood mortality rates of more than 100 per
1000 live births. More than 10 million children each year in
developing countries before they reach their fifth birthday.
Seven in ten of these deaths are due to acute respiratory
infections (mostly pneumonia), diarrhea, measles, malaria,
or malnutrition-and often to a combination of these
conditions.
The WHO/UNICEF-initiated Integrated Management of
Childhood Illness (IMCI) strategy offers simple and
effective methods for child survival, healthy growth, and
development and is based on the combined delivery of
essential interventions at community, health facility, and
health systems levels. The IMCI process includes
preventive as well as curative measures to address the
most common conditions that affect young children.
The IMCI strategy includes three main components:
• Improvements in case management skills of
health care staff
• Improvements in the health system needed for
effective management of childhood illness
• Improvements in family and community
practices
IMCI case management
IMCI clinical guidelines are meant to be used by the health
worker in the management of sick children from age 1
week up to 5 years. They are based on expert clinical
opinion and research results. Using an integrated
approach, the IMCI protocol guides the health worker in:
• Assessing signs that indicate severe disease;
• Assessing a child's nutrition, immunization, and
feeding;
• Teaching parents how to care for a child at
home;
• Counseling parents to solve feeding problems;
and
• Advising parents about when to return to a
health facility.
The entire IMCI case management process involves the
following elements:
1. Assess a child by checking first for danger signs
(or possible bacterial infection in a young infant),
asking questions about common conditions,
examining the child, and checking nutrition and
immunization status. Assessment includes
checking the child for other health problems.
2. Classify a child's illnesses using a color-coded
triage system. Many children have more than
one condition. Each illness is classified according
to whether it requires:
• Urgent prereferral treatment and
referral (pink),
• Specific medical treatment and advice
(yellow), or
• Simple advice on home management
(green).
3. After classifying all conditions, identify specific
treatments for the child. If a child requires
urgent referral, give essential treatment before
the patient is transferred. If a child needs
treatment at home, develop an integrated
treatment plan for the child and give the first
dose of drugs in the clinic. If a child should be
immunized, give immunizations,
4. Provide practical treatment instructions,
including teaching the mother or caretaker on
how to give oral drugs, how to feed and give
fluids during illness, and how to treat local
infections at home. Ask the mother or caretaker
to return for follow-up on a specific date, and
teach her how to recognize signs that indicate
that the child should return immediately to the
health facility.
5. Assess feeding, including assessment of
breastfeeding practices, and counsel to solve any
feeding problems found. Then counsel the
mother about her own health.
6. When a child is brought back to the clinic as
requested, give follow-up care and, if necessary,
reassess the child for new problems.
The case management process is presented on two
different sets of charts: one for children aged 2 months up
to 5 years, and one for children aged 1 week up to 2
months. This means that the health worker's initial step is
ask the child's age to select the appropriate case
management chart. "Up to 5 years" means the child has
not yet reached his fifth birthday, for IMCI management of
this child, the health worker uses the chart for the sick
child. The child who is younger than 2 months is
considered a young infant. Case management of the young
infant is different, so the health worker uses the chart for
the sick young infant,
The next step is to ask about the child's or young infant's
problem, then ask if this is an initial visit for the problem. If
this is an initial visit, the health worker follows the
guidelines for an initial visit. A child or young infant on a
follow-up visit is given follow-up care according to the
guidelines.
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.
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.

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.
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%).

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
Cancer or malignant neoplasm is a group of various
likelihood of the formation of plaque that can block blood
diseases involving unregulated cell growth. In cancer, the
flow in the arteries. HDL, on the other hand, is known as
cells divide, grow uncontrollably forming malignant
the good cholesterol because it clears the excess LDL in the
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 cause 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.
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 cause 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.
1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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:
1. Defined or direct burden - burden affecting
persons with mental disorders such as cost of
treatment, quality of life, and disability.
2. 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.
3. Hidden burden-stigma and violations of human
rights to persons affected with mental health
problems.
4. 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:
1. Inadequate policies and standards for people with
disability
2. Negative attitudes of people
3. Lack of provision of services for PWDs
4. Poor service delivery
5. Inadequate funding
6. Lack of accessibility
7. Lack of involvement
8. Lack 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
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, ChristoffelBlindenmission, 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 (ICD11): 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 LAWS AFFECTING CONTROL OF NONCOMMUNICABLE
prevented and treated. However, people living in poor DISEASES
communities remain at risk due to lack of access to eye
care services. To address the problem of global blindness, 1. Executive Order No. 958
the WHO launched in 1999 the "Vision 2020: The Right to
Sight", which is the Global Initiative for the Elimination of  National Healthy Lifestyle Advocacy
Avoidable Blindness. The aim of Vision 2020 is to develop a Campaign. Declaring the years 2005-2015 as
sustainable comprehensive health care system that will the decade of healthy lifestyle
ensure the best possible vision for all, thus improving their
2. Republic Act No. 1054
quality of life. The program is a partnership between the
WHO, and a large umbrella organization for eye-care  Free emergency medical and dental
professional groups and nongovernmental organizations treatment for employees.
involved in eye care known as the International Agency for
Prevention of Blindness. The program has three essential 3. Republic Act No. 9211
components of the action plans: cost-effective disease
 Tobacco Regulation Act of 2003. Regulates
control interventions, human resource development, and
the packaging, use, sale, distribution, and
infrastructure development.
advertisements of tobacco products.
In the Philippines, the program that addresses visual
4. Republic Act No. 6425
impairment is the National Prevention of Blindness
Program developed by the DOH. The guidelines in the  Penalties for Violations of the Dangerous
implementation of the National Prevention of Blindness Drug Act of 1972.
Program are described in Administrative Order No. 179
series of 2004. Strategies employed by in the 5. Republic Act No. 9165
implementation include advocacy and health education on
 Comprehensive Dangerous Drug Act of
the nature, risk factors, extent of visual impairments,
2002.
complications, early diagnosis and treatment, and
prevention of visual impairment. To ensure that quality 6. Republic Act No.8423
eye care services are locally available, accessible, and
affordable, training of personnel and partnership between  Traditional and Alternative Medicine Act of
public and private facilities will be developed. 1997.
Organizations involved in the implementation of program
7. Administrative Order No. 179 Series of
includes the National Committee for Sight Preservation,
Philippine Academy of the Ophthalmology, Philippine  Guidelines for the Implementation of the
Information Agency, Optometric Association of the National Prevention of Blindness Program.
Philippines, Rotary International, Integrated Philippine
Association of Optometrists, foundation for Sight, Helen 8. Department Personnel Order No. 2005-0547
Keller International, Lions Club International, Tanggal
Katarata Foundation, UP Institute of Ophthalmology,  Creation of a Program Management
Christian Blind Mission, Resources for the Blind, and Committee for the National Prevention of
Sentro Ofthalmologico Jose Rizal. 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 intermediary
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,
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. 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. 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
• 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. 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 Disease
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 l-inch (2.5
cm) square. A positive result would mean the
presence of 20 or more petechiae per 1-inch
square
2. Capillary refill testor 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
thumbnail 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 softbristled
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
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
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)
4 Cs 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.
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. 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

B. 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
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
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.
 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.
LEPTOSPIROSIS (Canicola, Weils disease) Causative agent:
Leptospira interrogans FILARIASIS (elephantiasis, filarioidea infection) Causative
agent: Wuchereria bancrofti, Burgia malayi
Mode of transmission: Inoculation into broken skin,
ingestion Source of infection: Urine and excreta of rodents Mode of transmission: Bite of mosquito
and infected Vector: Aedes poecilus, Culex quinquefasciatus
Incubation period: 7-13 days Signs and symptoms: Chills, fever, myalgia, lymphangitis
Laboratory/diagnostic test: with gradual thickening of the shin (commonly affecting
limbs, scrotum), resulting in elephantiasis and hydrocele
1. Blood culture
Laboratory/diagnostic test: Circulating filarial antigen
2. Leptospira agglutination test (LAT) (CFA) - finger prick Treatment: Diethylcarbamazine citrate
(Hetrazan)
Signs and symptoms:
Prevention: Eradication of vectors
1. Septicemic - High remittent fever 4-7 days,
myalgia/myosites, particularly calf pain SEXUALLY TRANSMITTED INFECTIONS GONORRHEA (clap,
drip, tulo)
2. Immune/toxic stage-jaundice
Causative agent: Neisseria gonorrhoeae
3. Convalescence
Mode of transmission: Sexual contact
Treatment:
Incubation period: 2-7 days
1. Medical management; Penicillin or tetracycline
Signs and symptoms: Thick purulent urethral discharge,
2. Nursing management: Symptomatic frequency of urination among females, burning urination
Prevention: Eradication of source SCHISTOSOMIASIS (Snail among males/females
fever, Bilharziasis) Diagnostic examination:
Causative agent: Schistosoma japonicum, S.mansoni, S. 1. Culture of specimen in cervix-female
haematobium
2. Gram stain - male
Treatment: Penicillin, ceftriaxone, doxycycline speculum examination - thick whitish plugs attached to
vaginal wall, vaginal epithelium bleeds when the plug is
Nursing care: Symptomatic removed, but the cervix is normal.
Prevention: Diagnosis: Microscopic demonstration of pseudohyphae or
• Crede's prophylaxis - silver nitrate/tetracycline • Avoid yeast cells in infected tissue or body fluids (vaginal
contact with secretions discharge)

• Practice monogamous sexual contact Treatment:

SYPHILIS • Nystatin vaginal pessary,

Causative agent: Treponema pallidum • Miconazole or clotrimazole creams,

Mode of transmission: Sexual contact • Ketoconazole

Incubation period: 10-90 days • Fluconazole in recurrent cases

Signs and symptoms: Prevention and control:

1. Primary - chancre 1. Case treatment

2. Secondary - condylomata, alopecia, sore throat, mucous 2. Treatment of underlying medical conditions or
patches of the mouth predisposing factors

3. Tertiary-gumma formation, cardiovascular and nervous LAWS FOR THE CONTROL OF COMMUNICABLE DISEASES
system involvement 1. Republic Act 3573 - Reporting of Communicable
Laboratory diagnostic test: Diseases

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,
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.
2. 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.
3. 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.

4. 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.

5. 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.

6. Memorandum Circular No. 98-155

Pronounced the National Tuberculosis Control Programs as

the highest priority public health program of the LGUs.

7. 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
poliofree by 1995.

8. 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.

9. Administrative Order No. 24 series of 199

The National Tuberculosis Control Program adopted

Directly Observed Treatment, Short Course (DOTS) in the
management of TB