DESCRIPTION

FWBDs refer to the limited group of illnesses characterized by diarrhea, nausea, vomiting with or without fever, abdominal pain, headache and/or body malaise. These are spread or acquired through the ingestion of food or water contaminated by disease-causing microorganisms (bacterial or its toxins, parasitic, viral).

VISION

Zero Mortality from FWBDs

MISSION

To reduce morbidity and mortality due to FWBDs

OBJECTIVES

• To guarantee universal access to quality FWBD-PCP intervention and services at all stages of the life
• To guarantee financial risk protection of clients availing diagnosis, management and treatment for FWBDs
• To guarantee a responsive service delivery network for the prevention and control of FWBDs

PROGRAM COMPONENTS

1. Policy, Plans and Organizational Support. This component ensures that supportive policies, directional and annual plans are developed and updated to govern the design and implementation of the FWBD-PCP. It shall ensure that organizational support to the FWBD-PCP is in place at various levels of operations. This includes establishment of partnership between DOH and LGUs and with other partners in the other sectors.
2. Diagnosis, Management and Treatment. This component ascertains the proper diagnosis as well as prompt management and treatment of patients suffering from FWBDs. Focus will be given to the development of clinical practice guidelines (CPGs) on FWBD diagnosis, management and treatment. Diagnosis will encompass strengthening the laboratory services and the use of rapid diagnostic test (RDTs). In the management and treatment, support for the establishment and sustained operations of ORT corners in the hospitals and even in outpatient health facilities will be provided. Training of health providers will be undertaken on the CPGs and overall FWBD-PCP management. 
3. Quality Assurance System. This component ensures the quality of diagnostic services of FWBD cases. This requires regular test, validation and follow-up of laboratory capacities and competencies of medical technologists as well as provision of the necessary laboratory supplies and equipment.
4. Logistic Management. This component guarantees that essential drugs/medicines, supplies and equipment are in place and available at the point of service. While the LGUs are mainly responsible for placing-in these commodities and other logistics at their level, the DOH shall design a system for forecasting the needs nationwide and design a procurement, allocation and distribution system to ensure these reach the facilities with proper tracking and monitoring of their utilization.
5. Capability Building. This component secures the quality of services by training the service providers on the standards and protocols on the diagnosis, management and treatment of FWBDs. It shall also develop the managerial and supervisory capability of FWBD-PCP managers/coordinators at various levels of administration to ensure the efficient and effective implementation of the Program.
6. Health Promotion and Advocacy. This component ensures the prevention of FWBDs which hinges on the promotion of proper practices on water, sanitation and personal hygiene. It takes off from the development of an overall Health Promotion and Communication Plan aimed at effecting behavior change among community members and garnering support from key stakeholders through advocacy. It also encompasses collaboration with the Environmental Health and Sanitation Unit on the installation of safe water and sanitation facilities.
7. Monitoring and Evaluation, Research, Surveillance and Response.  Under this component, necessary system and tools will be developed to ensure that quality and timely data are generated as basis for decision-making, prioritization of resources and appropriate and immediate response to any outbreak. A FWBD Surveillance System that will provide a comprehensive epidemiologic information, on current situation on FWBD, in an area will be strengthened. Regular monitoring of the status of FWBD-PCP implementation will be carried out including special researches or studies as needed.
8. Outbreak Response/Disaster Management. This component ensures that any outbreak due to FWBD in any area is properly monitored and immediately responded to especially during disaster or emergency situations where the affected population became most prone to these infections as in evacuation centers or flooded areas.

TARGET POPULATION/ CLIENT

FWBD by Sex

Based on EB’s data in 2016, there were slightly more males generally experiencing FWBDs (cholera, typhoid, Hepa A, rotavirus and paralytic shellfish poisoning) than females. However, for acute bloody diarrhea, there were more females than males reported experiencing the disease in the same year.     

FWBDs by Age Group

Majority of the reported acute bloody diarrhea in 2016 were among the 1-4 year old children. Rotavirus as characterized occurs mainly among the same age group and those below 1 year old. As for Hepa A, mostly affected are the 15 to 39 year olds and also notable among the younger age group (5-14 years old). As for typhoid, cholera and paralytic shellfish poisoning, highest number of cases reported was among the 5-14 years old.

FWBDs by Geographical Areas

The Visayas Region particularly Regions 7 and 8 came out as hosts of the highest incidence of FWBDs in the country. Incidence of acute bloody diarrhea is highest in Region 7 and also the host of the highest number of reported Hepa A and Typhoid cases in 2016.  Region 8 on the other hand had the highest incidence of cholera and paralytic shellfish poisoning. Region 1 came out highest in the incidence of rotavirus in the same year.

AREA OF COVERAGE

FWBDs are usually manifested as diarrhea. Based on the 2015 Global Health Observatory (GHO) data, diarrhea accounts for 9% of the total deaths among children below 5 years old. In the Philippines, a total of 11,876 cases of acute bloody diarrhea (ABD) were reported from sentinel sites nationwide in the same year. In addition, 830 Hepatitis A cases and 74 cases of paralytic shellfish poisoning were also reported. The Philippine Health Statistics data showed that diarrhea placed 5^th as a leading cause of morbidity among general population in 2010 from being the top or second leading cause in the 1990s. Morbidity rate due to diarrhea has gone down from 1,520/100,000 population in 1990 to 347.3/100,000 population in 2010. Despite this decline however, several notable outbreaks continue to occur. It is believed that since the occurrence of FWBDs is essentially related to economic and socio-cultural factors.

PARTNER INSTITUTIONS

The management and implementation of the FWBD-PCP are shared responsibility among the following offices:

A. Department of Health – Central Office

1. Infectious Disease Office (IDO) - Disease Prevention and Control Bureau (DPCPB)

The overall management and coordination of the FWBD-PCP is lodged in the IDO-DPCB.  It takes the lead in setting the overall direction and focus of the Program.

• Formulate and disseminate national policies, standards and guidelines governing the management and implementation of the FWBD-PCP
• Develop strategic plans  and cascade this to the regional offices for adoption
• Ensure the provision/delivery of quality diagnosis, management and treatment services of FWBDs
• Design and undertake training program on various components of the program
• Manage the logistics requirements of the Program
• Secure financing for the FWBD-PCP
• Establish partnership with other national government agencies and other partners in the private sector
• Undertake monitoring and evaluation of the status and performance of the FWBD-PCP
• Coordinate with HPCS and other entities in promoting WASH practices and key messages on prevention and control of FWBDs
• Monitor together with EB any outbreak due to FWBD and coordinate with HEMB for the immediate response

2. Environmental Health and Sanitation

• Provide technical assistance to the regions and LGUs to comply with the provisions and requirements of the Sanitation Code in the Philippines;
• Formulate policies, guidelines and standards in promoting increased access to safe water and sanitation services
• Design strategic approaches to achieve zero open defecation areas nationwide
• Develop and promote guidelines on healthy wash, sanitation and hygiene practices among food handlers, and other concerned institutions
• Coordinate with the Department of Environment and Natural Resources (DENR) for interventions that will support the prevention and control of FWBDs

3. Epidemiology Bureau (EB)

• Establish, operate and sustain FWBD surveillance nationwide
• Support LGUs in case investigation of reported FWBD cases and in providing immediate and proper response
• Inform/communicate with the DOH-IDO and other offices concerned of any impending or notable FWBD outbreaks
• Generate timely FWBD surveillance reports and disseminate to concerned DOH offices
• Coordinate with RITM in taking the lead to develop a work and financial plan and/or proposal funding for the surveillance.
• Provide assistance to RESUs and LESUs if needed in the investigation of cases of food and waterborne illness.
• Notify the WHO through the National IRR (International Health Regulations) Focal Point when the assessment indicates a food or waterborne disease event is notifiable pursuant to paragraph 1 of Article 6 and Annex 2 and to inform WHO as required pursuant to Article 7 and paragraph 2 of Article 9 of IHR (Annex 3.8A).

4. Health Emergency Management Bureau (HEMB)

• Provide technical assistance in developing plans in times of emergencies and disasters.
• Mobilize WASH resources through Regional DRRM-H Manager to ensure adequate and safe water through water quality surveillance, disinfection / treatment in coordination with DPCB-EOH.
• Augment logistic support to FWBD during emergencies and disaster situations.

5. Health Promotion and Communication Services (HPCS)

• Formulate and design a communication plan to address the poor health seeking behavior of the community and their unhealthy food and water practices including personal hygiene
• Develop key IEC messages for various groups of audiences relative to the prevention and control of FWBDs
• Design appropriate media channels and materials to communicate the key FWBD prevention and control messages
• Track improvement in the awareness, attitudes and practices of the targeted population on FWBD prevention and control

6. Research Institute for Tropical Medicine (RITM) and National Reference Laboratories (Parasitology, Bacterial Enterics and Viral Enterics)

• Perform laboratory testing for samples referred for the FWBD surveillance and outbreak investigation
• Provides technical support for specimen collection, transport and storage for the referring hospitals
• Provides laboratory technical support, training and quality assurance to the subnational, regional and other laboratories
• Provides linelist of laboratory results to EB and RESU, and individual laboratory results to the RESU, in the form of transmittals (for distribution to the DRUs)
• Refer a subset of samples to the designated Regional Reference Laboratory (RRL) for quality assurance purpose
• Performs further studies to determine other etiologies of FWBD
• Maintain continuous coordination/communication with stakeholders to promote information exchange
• Train laboratory personnel in the diagnosis of FWB pathogens
• Provide external quality assurance program for laboratory diagnosis for FWB pathogens
• Evaluate test kits and reagents in coordination with FDA
• Develop and offer confirmatory assays for other FWB pathogens
• Conduct research relevant to FWB program
• Provide recommendation to LRD office as to the need for activation of Outbreak Codes to mount multidepartment, division-level response as appropriate
• Conduct laboratory surveillance for the FWB pathogens

7. Food and Drug Administration (FDA)

• Perform microbiologic tests on food samples submitted to the laboratory
• Provide EB with a monthly report of etiologic agents of food and waterborne diseases on food samples tested
• Monitor the safety of pre-packaged food in the market and issue Public Advisory / Warning to prevent consumption of contaminated food
• Undertake surveillance of microbiologic agents of food and waterborne diseases which are transmissible to humans Alert the DOH offices in cases of unusual increases in the number of reported organisms known to cause food and waterborne disease in humans. (To be deleted) (Transfer to DA)

B. DOH – Regional Offices

1. Infectious Disease Prevention and Control Cluster

• Disseminate national policies, standards and guidelines governing the management and implementation of the FWBD-PCP
• Develop local plans and cascade to LGUs
• Undertake training related to FWBD-PCP to local government unit
• Provide logistic support on FWBD-PCP to LGU
• Monitor and evaluate the implementation of the program to LGU
• Coordinate with the regional environmental and Occupational Health on the implementation of the FWBD-PCP
• Assist RESU in monitoring incidence of FWBDs
• Coordinate with other partners in the region for the management of the FWBD-PCP

2. Regional Epidemiology and Surveillance Unit (RESU)

• Encode data on patients with laboratory confirmed Salmonella and other food and waterborne infections
• Analyze surveillance data and activate EICT outbreak investigation when deemed necessary
• Provide technical assistance during trainings on laboratory-based surveillance to be conducted among hospital staff or sentinel sites
• Fill up laboratory request forms and submit appropriately-labeled stool specimens from patients and samples of suspected food/water vehicles to the appropriate DOH or DA laboratory for microbiologic tests
• Encode and collate epidemiologic data from LGUs (Provincial/City Epidemiology Surveillance Unit, P/CESU), and hospital sentinel sites on the occurrence of Salmonella and other food and waterborne disease and submit to EB
• Submit monthly report to EB on notifiable diseases. (StratPlan – PIDSR Report)
• Notify EB through the National IRR (International Health Regulations) Focal Point when the assessment indicates a food or waterborne disease event is notifiable pursuant to paragraph 1 of Article 6 and Annex 2 and to inform WHO as required pursuant to Article 7 and paragraph 2 of Article 9 of IHR (Annex 3.8A)

3. Environmental and Occupational Health Unit

• Provide technical assistance to LGUs to increase HHs with access to safe water and with sanitary toilet, and achievement of zero defecation area
• Implement the preventive measures of FWBD
• Assist in the investigation of FWBD Outbreaks
• Support campaign of prevention and control of FWBD

4. Provincial DOH Office

• Advocate for LCEs’ support to FWBD-PCP
• Lobby to LGUs for funds/budget for FWBD-PCP through inclusion in the  annual budget
• Ensure adaption of DOH policy by LGU through ordinances
• Monitor implementation of FWBD
• Provide logistic / fund to EOH for FWBD prevention campaign.

C. Other Government Agencies

1. Department of Interior and Local Government (DILG)

• Support the DOH and DA in the collection and documentation of food-borne illness data, monitoring and research
• Participate in training programs, standards development and other food safety activities to be undertaken by the DA, DOH and other concerned national agencies

2. Department of Education

• Integrate messages on proper water, food and sanitary practices including personal hygiene in the school curriculum
• Support and expand the implementation of WINS in public schools
• Integrate hand-washing practices during school feeding programs

3. Department of Agriculture

• Develop and transfer technologies that will improve and sustain the development of the livestock industry which ensure food security and competitiveness of the local produce in the global market
• Plan, coordinate and implement research and development programs on swine, beef cattle, poultry, small ruminants and equine on areas of genetics and breeding system, animal nutrition and feed resources utilization, herd management, animal health and disease control, containment and eradication of diseases, post-production, value-added meat products and by-products technology and animal waste management
• Submit report of all investigations involving foodborne disease
• Alert the Department of Health agencies in cases of unusual increase in the number of reported organisms known to cause foodborne disease in humans (DA, BAI)

4. Department of Social Welfare and Development

• Proper water, food and sanitary practices including personal hygiene of DSWD residential centers, canteen, caterers
• Support and expand implementation of hand-washing practices during feeding programs
• Ensure that DSWD residential centers, canteen, caterers, and DSWD-food for work and feeding programs use and serve fortified foods with Sangkap Pinoy Seal, if available
• Use and serve fortified foods such as rice, wheat, flour, oil and refined sugar in DSWD relief operations and encourage LGUs and NGOs to follow the same
• Authorize food manufacturers to use the DOH seal of acceptance as guide for consumers in selecting nutritious foods (DSWD)

5. Department of Environment and Natural Resources

• Control the construction and maintenance of waterworks, sewerage, and sanitation systems and other public utilities
• Prohibiting dumping of waste products detrimental to the plants and animals or inhabitants therein
• Prohibiting of leaving an exposed or unsanitary conditions refuse or debris or depositing in ground or in bodies of water
• Raise awareness on the importance of maintaining reliable and effective treatment of wastewater
• Endeavor to achieve social justice by ensuring the integrity of our ecosystems on which local communities depend for food and livelihood
• Strive to recycle wastewater to benefit communities and not to allow untreated wastewater that will harm people (DENR)

D. Local Government Units (LGUs)

The LGUs are primarily responsible in the delivery of quality FWBD diagnosis, management and treatment and conduct of preventive and control interventions at the local level. Specifically, the LGUs are expected to:

• Enforce the implementation of the “Code of Sanitation of the Philippines” (PD No. 856, December 23, 1975): (i) sanitation particularly in public markets, slaughterhouses, micro and small food processing establishments and public eating places, (ii) codes of practice for production, post-harvest handling, processing and hygiene, (iii) safe use of food additives, processing aids and sanitation chemicals and (iv) proper labeling of prepackaged foods
• Ensure access of households to safe drinking water, safe water and sanitation facilities
• Inspect food establishments on adherence to standards sanitation practices
• Provide training to food handlers and regulate
• Ensure proper waste disposal
• Establish, operate and sustain local epidemiology and surveillance units with the following tasks:
  • Register cases of laboratory confirmed Salmonella and other food and waterborne infections identified from the local government unit (LGU) in the surveillance.
  • Fill up laboratory request forms and submits appropriately labeled specimens from patients and samples of suspected food/water vehicles to the appropriate DOH or DA laboratory for microbiological tests
  • Provide technical support for training on laboratory-based surveillance to hospital staff of sentinel sites
  • Encode and collate epidemiologic data on the occurrence of Salmonella and other food and waterborne infections to the EB
  • Submit monthly reports of food and waterborne diseases to RESU
  • Notify RESU when the assessment indicates a food and waterborne disease event is notifiable pursuant to paragraph 1 of Article 6 and Annex 2 of IHR and to inform WHO as required pursuant to Article 7 and paragraph 2 of Article 9 of IHR (Annex 3.8A)

E. Hospitals

• Attend to cases of diarrhea (no signs, some signs, severe signs of dehydration)
• Request for basic laboratory workups  in case of complications
• Carry out further investigation as deemed necessary
• Refer cases appropriately to specialties/sub-specialties when needed
• Observe proper hydration and monitoring of hemodynamic status Encourage oral rehydrating solution as soon as patient can tolerate
• Give appropriate anti-microbial if indicated
• Provide health education including handwashing, sanitation, hygiene will be provided
• Give IEC materials to patient/s prior to discharge

F. Laboratories

1. Subnational Laboratories

• Perform laboratory testing of samples from FWBD cases referred by the disease reporting units, as well as from cluster/outbreak investigations. (we should refer this to our 'algorithm')
• Participate in monitoring and evaluation visits by the DOH FWBD Monitoring team
• Participate in the laboratory quality assurance program
• Provide laboratory results to the National Reference Laboratories and RESU
• Coordinate with the National Reference Laboratories for technical concerns (specimen collection, transport, storage, testing and troubleshooting)

2. Regional Laboratories

• Perform direct fecal smear, modified acid fast staining, formalin ether concentration technique, kato-katz and RDT for detection of FWB parasites

3. Tertiary Hospitals

• Perform direct fecal smear, modified acid fast staining, formalin ether concentration technique, kato-katz and RDT for detection of FWB parasites

4. Level 3 Laboratories

• Perform direct fecal smear, modified acid fast staining, formalin ether concentration technique, kato-katz and RDT for detection of FWB parasites

5. Level 2 Laboratories

• Perform direct fecal smear, kato-katz and modified acid fast staining for detection of FWB parasites

6. Level 1 Laboratories

• Perform direct fecal smear and kato-katz for detection of FWB parasites

7. Rural Health Units

• Perform direct fecal smear and kato-katz for detection of FWB parasites

POLICIES AND LAWS

CALENDAR OF ACTIVITIES

Cholera and Typhoid

Morbidity. Though the number of confirmed typhoid and cholera cases decreased over the past 6 years, substantial number of cases continue to be reported. Cholera cases slightly increased from 2013 to 2016 while typhoid cases decreased from 2013 to 2014. However, this rose again in 2015.

Mortality. There have been no deaths reported due to cholera from 2015 to 2016. No death was also reported due to typhoid in 2015. Two deaths were reported though from the National Capital Region (NCR) in 2016

Other Food and Water-Borne Diseases

Morbidity. Surveillance data from 2015 to 2016 showed the occurrence of Hepa A, Rotavirus and Paralytic Shellfish Poisoning cases and deaths. The number of Hepa A cases went down from 2015 to 2016. Cases of rotavirus and paralytic shellfish poisoning increased over the same period. These increases could be a result though of increasing sentinel sites reporting during this period.

Mortality. There were a number of deaths reported due to Hepa A, rotavirus and paralytic shellfish poisoning (PSP) from 2015 to 2016. The number of PSP deaths doubled from 3 in 2015 to 6 in 2016 and so with deaths due to Hepa A from 1 in 2015 to 2 in 2016. Only 5 deaths were reported due to rotavirus over the same period.

FWBDs by Sex Based on EB’s data in 2016, there were slightly more males generally experiencing FWBDs (cholera, typhoid, Hepa A, rotavirus and paralytic shellfish poisoning) than females. However, for acute bloody diarrhea, there were more females than males reported experiencing the disease in the same year.

FWBDs by Age Group Majority of the reported acute bloody diarrhea in 2016 were among the 1-4 year old children. Rotavirus as characterized occurs mainly among the same age group and those below 1 year old. As for Hepa A, mostly affected are the 15 to 39 year olds and also notable among the younger age group (5-14 years old). As fortyphoid, cholera and paralytic shellfish poisoning, highest number of cases reported was among the 5-14 years old.

WBDs by Geographical Areas The Visayas Region particularly Regions 7 and 8 came out as hosts of the highest incidence of FWBDs in the country. Incidence of acute bloody diarrhea is highest in Region 7 and also the host of the highest number of reported Hepa A and Typhoid cases in 2016.  Region 8 on the other hand had the highest incidence of cholera and paralytic shellfish poisoning. Region 1 came out highest in the incidence of rotavirus in the same year.

B. Outbreaks Due to FWBDs

The objective of the FWBD-PCP to eliminate FWBD outbreaks was not realized given the several reported FWBD-related events experienced in the various parts of the country from 2012 to 2016. A total of 115 food and waterborne Illness health events were verified by the Event-Based Surveillance and Response (ESR) Unit from 2012 – 2016. In these events, a total of 17, 246 cases and 143 deaths were reported during the period.

Summary of Food and Water-Borne Illness Health Events, 2012 - 2016

PROGRAM MANAGER CONTACT INFORMATION

Theodora Cecile G. Magturo, MD

cecilemagturo9172@gmail.com

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Last updated: September 14, 2017