As far as the National Rabies Prevention and Control

1
Infectious Diseases in Local Context
MDG 6 Diseases for Elimination YOLANDA E.
OLIVEROS,MD,MPH MHSA Director IV National Center
for Disease Prevention Control Department of
Health
2
INFECTIOUS DISEASES OF LOCAL CONTEXT TARGETED FOR
ELIMINATION AS A PUBLIC HEALTH PROBLEM

• Lymphatic Filariasis
• Leprosy
• Schistosomiasis
• Rabies

3
STATUS TARGETS

4
National Filariasis Elimination Program BASIC
FACTS ON LYMPHATIC FILARIASIS

• Although mortality is low but is considered as
  the 2nd leading cause of permanent long term
  disability
• Affects 83 of the worlds poorest countries
• 120 million people infected 1.1 B at risk of
  infection
• Causes psychological, social economic problem
  in the afflicted individuals
• Regional rank Philippines has the highest
  burden among the Mekong Plus countries

5
GLOBAL PRIORITIZATION OF THE PROGRAM 1. World
Health Assembly Resolution 50.29 (May,
1997) Urges Member States......to strengthen
activities toward eliminating lymphatic
filariasis as a public health problem........ Req
uests the Director-General......to mobilize
support for global and national elimination
activities. 2. Millineum Dev. Goals Goal To
contribute to the attainment of the MDG
(MDG 6, Target 8) MDG 6 Combat HIV/AIDS,
malaria other diseases Target 8To have
halted the incidence of malaria other major
diseases
6
NATIONAL MAGNITUDE OF THE PROBLEM

• 40 prov. established
• Endemic
• Prev. of Microfilaremia /MF Rate Baseline (1998)
  9.7
• Endemic Reg 11
• Endemic Prov 40
• 76 of endemic areas belong to 4th-6th class
  municipalities
• 645,232 Fil infected with LF (based on the UP-NIH
  study)
• 23-30 M Filipinos are at risk of the disease

Luzon 25
Visayas 19
Mindanao 56
7
NATIONAL PRIORITIZATION OF THE PROGRAM 1.
Presidential Exec. Order for the campaign EO
369- signed by the President declaring Nov.
yearly as Mass treatment for filariasis in
established endemic areas 2. DOH management
Initiative FOURmula One includes Filariasis
among the diseases for elimination or the
Disease Free Zone Initiative 3. National
Objective For Health Document - to inform the
stakeholders on the thrust of the program from
2006-2010 4.AO157s2004 Declaring Month of Nov
of every yr as Mass treatment Month in
established endemic areas 5. AO 25-As 1998
Strategy shift of the Natl Filariasis Program
from control to elimination.
8
THE NATIONAL FILARIASIS ELIMINATION PROGRAM
(NFEP) GOAL Elimination of Filaria as a public
health problem in the Philippines by
2010. (Global target is 2020) PROGRAM TARGETS
1. Interruption of Transmission Elimination
Level- Prevalence of Microfilaremia of less
than 1 Mass Drug Administration (MDA)
Coverage of not less than 85 2. Control
reduce the morbidity by alleviating the
sufferings disability caused by its clinical
manifestations
9

• THE NATIONAL FILARIASIS
• ELIMINATION PROGRAM (NFEP)
• PROGRAM STRATEGIES
• Endemic Mapping (Deformity Survey Blood
  Survey)
• 2. Capability Building
• 3. Mass Treatment (Criteria for MDA Endemic
  areas with MFR of 1 up)
• 4. Support Control (Disability prevention
  vector control)
• 5. Monitoring and Supervision
• 6. Evaluation ( Conducting the Mid-Sentinel
  Surveys to measure the effectiveness of MDA)
• 7. National Certification (based on WHO
  Guidelines)

10
WHAT HAS BEEN DONE ?

• Elimination Plan was approved by the Global
  Technical Group
• Re-surveys conducted to stratify the endemic
  areas using the results of the 1960 National
  Prevalence Survey as baseline
• A Compilation of DOH data from 1960-1998 on
  Filariasis entitledFilariasis in the Phil was
  published
• MDA in 2001 started in selected areas and scaled
  up thru the years based on the budget allotted to
  the program
• Formulated CPGs, Reference Manual IEC materials

11
WHAT HAS BEEN DONE ?

• Integrated with other programs such as GP, STH,
  Schistosomiasis Leprosy.
• Public-Private Partnership
• - Business Sectors Changing Lives , Best
• Business Social Practices that Makes
  remarkable
• changes in Filipino that was conducted in
  March ,07
• - Shell Foundation- provided DEC for Palawan
  Sulu
• - Culion Foundation adopted CARAGA
• - Peace and Equity Foundation (PEF)
• grantmaker/funding agency (3-yr funding
  assistance to Neglected Tropical Parasitic
  Diseases
• Insular Life, PhilamLife, Maple Tree Found.
• Philippine Health Information System ( Filariasis
  Elimination Prog)

12
WHAT HAS BEEN DONE ?

• Conducted Mid-sentinel Surveys to determine the
  effectiveness of the program strategy thru the MF
  rates Antigen tests
• 2005 survey results

13
WHAT HAS BEEN DONE ?
2006 survey results

• All survey sites (41) recorded decrease in MF
  Rates except for 2 areas.
• There were MFR reduction on all derived
  provincial MFRs
• There was association between coverage
  classification (i.e., low, medium, high) on the
  degree of reduction on the MFR.

14
WHAT HAS BEEN DONE ?

• On Disability Prevention
• -Philippines was chosen by WHO to pilot the
  drafted
• Disability Manual (Sorsogon Davao City)
• On MDA Coverage in endemic areas

NOTE No reports from Reg. 8, 10, Partial
reports from reg , 5 (Albay, camarines Norte),
12 ( South Cotabato North Cotabato)
15
MDA COVERAGES 2006

• CATEGORIZATION OF PROVINCES BY MDA COVERAGE
  2006
• 80 ABOVE (red) 65-79(blue) 64
  BELOW(yellow)
• REGION 4B    
• MINDORO ORIENTAL MARINDUQUE
• MINDORO OCCIDENTAL  
• ROMBLON    
• PALAWAN    
•      
• REGION 5    
• ALBAY    
• CATANDUANES CAMARINES
  NORTE CAMARINES SUR
• SORSOGON  
• MASBATE  
•    
•      
• REGION 8    
• SOUTH LEYTE NORTH LEYTE
• BILIRAN   WEST SAMAR
• EAST SAMAR   NORTH SAMAR

16
MDA COVERAGES 2006
17
WHAT ARE THE CHALLENGES

• Governance
• - Sustaining partnership thru international,
  inter-agency intra-agency coordination
• - M E Implementation of the "End Stage" in
  relation
• with our Diseases-Free Zone Initiative by
  conducting the
• Lot Quality Assurance Survey
• Monitor and evaluate the implementation of the
  program
• at the provincial municipal levels
• LGU ownership commitment in the
  implementation of
• the program is lacking in some areas.
• - Empowerment of the community to participate in
  the MDA

18
WHAT ARE THE CHALLENGES

• FINANCING
• Ensure timely sufficient MDA drugs for the
  whole duration of elimination program
• Prepare package for Disability Management for
  hydrocele patients elephantiasis patients
• Assist chronic cases with Livelihood projects
• STANDARDS REGULATIONS
• Disseminate the Standard Guidelines in conducting
  the End Stage Evaluation of endemic areas
• Ensure good quality of MDA drugs

19
PRIORITY AREAS FOR ACTION

• Ensure timely good quality of MDA drugs for the
  whole duration of elimination program by securing
  from GOP.
• Look at the Filariasis Elimination Program as
  medium-term concern, and not as a long term
  problem adopt a sense of urgency in eliminating
  the disease ( by ensuring high MDA Coverages)
• Package the program on filariasis elimination
  with the tenure of the local chief executives in
  order to be politically palpable.
• Package the Filariasis Elimination Program with
  other Neglected Tropical Diseases

20
National Leprosy Control Program CURRENT FACTS
STATUS OF LEPROSY

• Discovered to be endemic in majority of areas in
  the Philippines during the Spanish era
• Enormous disability disfigurement cause
  economic social consequences
• Dismal prospect in the control using the Dapsone
  monotherapy
• NLCP started as a pilot project in 1985 with the
  introduction of MDT (in Cebu Ilocos Norte)
• Nationwide MDT implementation improved the
  management of the disease in 1988

21
National Leprosy Control Program CURRENT FACTS
STATUS OF LEPROSY

• Leprosy control integrated into the basic health
  services of Rural Health Units BHS, 8 sanitaria
  21 skin clinics in 1990
• Adopted the global call to eliminate the disease
  in 1991 (WHA resolution 44.9)
• Achieved elimination level in 1998 at the natl.
  level -
• -Availability of MDT drugs (WHO)
• -Several activities conducted (SAPEL,CAPEL,
  LEC,
• LPESS)
• Technical Financial assistance from partners
  esp. ALM PLM with strong political will natl
  local levels

22
AREAS WITH HIGH PREVALENCE AS OF 2006
As of 2006 Prev Rate 0.42 cases/10,000
Ilocos Sur Ilocos Norte Metro Manila
Tawi-tawi Basilan Sulu Candon City Vigan
City San Jose City Munoz Science City Cagayan de
Oro City Gen. Santos City Isabela City
23
THE NATIONAL LEPROSY CONTROL PROGRAM PROGRAM
GOAL 1. Sustain elimination of leprosy as a
public health problem at the national level.2.
Eliminate the disease at the sub-national levels
by reducing the no. of cases by 50 by 2010. 3.
Prevent reduce disabilities thru Rehabilitation
Prevention of Impairments Disabilities. 4.
Strengthen collaboration with partners and other
stakeholders.
24
THE NATIONAL LEPROSY CONTROL PROGRAM PROGRAM
OBJECTIVES GENERAL To decrease the
Prevalence Rate of leprosy at the sub-national
level to lt1/10,000 pop by year 2010. SPECIFIC
1. Ensure provision of MDT 2. Increase the
capability of HWs in quality diagnosis case
management including impairments
disabilities 3. Intensify social mobilization
advocacy activities on leprosy 4. Strengthen
collaboration with partners in service other
stakeholders 5. Develop the Leprosy
Post-elimination Surveillance System (LPESS)
upgrade the Leprosy Information System
25
WHAT HAS BEEN DONE ?

• Leprosy Elimination Campaigns conducted in
  hyperendemic prov/cities/municipalities
  (awareness campaign, intensified casefinding
  activities supported by LCEs)
• A Global Appeal to end stigma discrimination
  to persons affected by leprosy, was disseminated
  with several partners, health workers former
  patients with leprosy
• Monitoring Evaluation was also conducted
  especially in hyper-endemic areas
• Capability building was done in priority areas.

26
WHAT HAS BEEN DONE ?

• Reviewed the existing status of the program
  Global Operational Guidelines strategies
• Reviewed the current status of the existing
  sanitaria
• Reviewed the existing CPGs, AOs directives

27
WHAT ARE THE CHALLENGES

• GOVERNANCE
• Need the commitment of LGUs counterpart budget
  for supportive drugs
• Involvement of private practitioners to adhere to
  the DOH guidelines/protocols
• M E - Post-elimination Surveillance system in
  areas where elimination has been achieved should
  be maintained
• Strengthen collaboration with partners and
  other
• stakeholders in the provision of quality
  leprosy services

28
WHAT ARE THE CHALLENGES

• SERVICE DELIVERY
• Regular monitoring of areas that have high number
  of cases.
• Sustaining awareness of the community
• Capacity building of untrained new program
  coordinators in recognizing, diagnosis
  management of leprosy
• Strengthen integration with other existing
  programs especially on disability prevention like
  filariasis
• Monitor evaluate the program implementation at
  the LGU levels

29
WHAT ARE THE CHALLENGES

• FINANCING
• Ensure the availability of resources (diagnostics
  MDT)
• STANDARD REGULATION
• Ensure delivery of good leprosy services in
  health facilities
• Ensure good quality of drugs

30
PRIORITY AREAS FOR ACTION

• Paradigm shift from program-oriented to
  patient-centered
• services
• Post-elimination Surveillance should be
  strengthened
• Budget needed to conduct activities in highly
  burden provinces cities should be ensured

31
Schistosomiasis Control Program CURRENT FACTS
STATUS OF SCHISTOSOMIASIS

• Schistosomiasis is prevalent in 12 out of 16
  geographic Regions ( involving 28 Provinces, 15
  Cities , 190 municipalities and 2230 barangays
  ) as of 2006
• Total exposed population of 2.5 M
• Total population at risk is 12 M
• National average prevalence of 2.5

32
Map of Endemic Areas
Geographic distribution of Schistosoma japonicum
in the Philippines showing endemic and
non-endemic areas
33

• THE SCHISTOSOMIASIS CONTROL PROGRAM
• PROGRAM GOAL Schistosomiasis is eliminated as
  a public health problem in all endemic areas
• Objectives
• 1. Reduce the Prev. Rate by 50 in endemic
  provinces
• 2. Increase the coverage of mass treatment of
  popuation
• in endemic provinces
• Standard Schistosomiasis is eliminated as a
  public health problem if the Prev. Rate is
  maintained at lt1 for at least 5 years

34
THE SCHISTOSOMIASIS CONTROL PROGRAM PROGRAM
STRATEGIES 1. Active Casefinding
Surveillance 2. Treatment 3. Environmental
Sanitation 4. Environmental Modification 5.
Snail control 6. Health education
35
WHAT HAS BEEN DONE ?

• Prevalence Survey thru the WHO Biennium
  budget commisioned to UP-CPH in collaboration
  with CO, RHO LGUs

36
WHAT HAS BEEN DONE ?

• A five-year review of the program status at the
  provincial level conducted
• Formulated disseminated the Revised
  Guidelines in the Management Prevention of
  Schistosomiasis
• Formulation and development of snail
  sentinel surveillance guideline
• Conceptualized of web based Schisto
  Information System thru GIS
• Designed a schistosomiasis-free framework thru
  consultations with Prog coordinators, academe,
  WHO partners

37
WHAT HAS BEEN DONE ?

• Health Promo Plan drafted
• Conducted Proficiency, Quality Control/Quality
  Assurance Trngs for Med. Techs in dse-free zone
• Snail Surveillance Trainings for
  Malacologists
• Designed the Schistosomiasis Information System
  in coordination with IMS started
• Conducted in collaboration with UPNIH the
  Efficacy and Safety of Praziquantel,600 mgs and
  40 mgs single dose

38
WHAT HAS BEEN DONE ?

• Provided technical assistance in Schistosomiasis
• Component Projects development attached to
• Irrigation Agricultural Projects HCAAP
  with LGU
• North Samar SPISP with NIA for CARAGA
• Conducted Rapid Epidemiological Surveys in
  response to suspected areas with NEC,CHD and
  LGUs concerned Gonzaga , Cagayan ,Region 2
  Calatrava, Negros Occidental ,Region 6

39
WHAT ARE THE CHALLENGES ?

• GOVERNANCE
• Technical leadership of LGUs in the
  implementation of the program
• LGU commitment on counterpart budget allocation
  to conduct the program strategies
• Strengthen partnership with other stakeholders
• SERVICE DELIVERY
• Sensitivity of the Kato Katz and stool
  microscopy as diagnostic tool

40
WHAT ARE THE CHALLENGES ?

• SERVICE DELIVERY
• Strengthening integration with other neglected
  tropical diseases
• Strengthening monitoring of the program at all
  levels
• FINANCING
• - Assurance of budget required to carry out
  F1 Reforms (at least P40M/year)

41
WHAT ARE THE CHALLENGES ?

• STANDARD REGULATION
• Quality assurance for microscopy
• Ensure good quality of drugs

42
PRIORITY AREAS FOR ACTION

• QA/AC of all lab facilities
• Budget augmentation required to carry out F1
  Reforms
• Transfer of technology to LGUs for them to
  effectively implement and own the program

43
National Rabies Control Program CURRENT FACTS
STATUS OF RABIES

• Human Rabies
• - Among the top ten countries in human rabies
  death.
• - National Incidence Rate 2.46
• - 60 are children 15 years old and below

44
Incidence of Rabies Animal Bites1992 2006,
Philippines
Mam me graph dito
45
REGIONS WITH MOST NUMBER OF HUMAN RABIES CASES
Region 2
Mam me map dito
Region 3
Region 5
Region 8
Region 6
Region 7
Region 12
46
PROVINCES WITH MOST NUMBER OF HUMAN RABIES
CASES, 2006
La Union
Cagayan Isabela
Mam me map dito
Tarlac
Iloilo
Bohol
47

• THE NATIONAL RABIES CONTROL PROGRAM
• PROGRAM GOAL Rabies is eliminated as a public
  health problem by year 2020
• OBJECTIVES
• Reduce the incidence of human rabies cases to no
  more than 2.5 cases per million population
• Increase the voluntary pre-exposure coverage
• Increase the coverage of dog immunization
• Elimination level achieved in 7 provinces

48
Program Strategies

• Strengthen IEC campaign on anti-rabies program
• Creation/Strengthen of Rabies Control Committees
  in all levels
• Strict enforcement of Rabies Control Ordinances
• Establishment of functional Animal Bite Treatment
  centers
• Mass Dog Vaccination
• Functional Regional Rabies Diagnostic lab
• Disease Surveillance

49
National Rabies Control and Prevention Program

• National Rabies Committee multi-agency,
  multi-sector
• RA 9482 Anti-Rabies Act of 2007
• Mass vaccination of Dogs
• Establishment of central database system for
  registered and vaccinated dog
• Impounding, field control, and disposition of
  unregistered, stray and unvaccinated dogs
• Conduct of information and education campaign on
  the prevention and control of rabies
• Provision of pre- exposure prophylaxis to high
  risk individuals and to school children aged five
  to fourteen in areas where there is high
  incidence of rabies
• Provision of post- exposure treatment to animal
  bite victims and
• Encouragement of the practice of responsible pet
  ownership.

50
WHAT HAS BEEN DONE ?

• Health Policy Program development
• IRR of the RA 9482 (Anti-Rabies Act of 2007)
  signed by Sec. Duque
• Developed IRR with NRC
• Public Hearing has been conducted
• Revised Management Guidelines of Animal Bite
• AO has been approved and for dissemination and
  orientation
• Training manual for Tandoks

51
WHAT HAS BEEN DONE?

• Capability Building for LGUs other
  Stakeholders
• - Augmentation of vaccines and immuno-globulins
  for PET
• - Augmentation of vaccines and immuno-globulins
  to ABTCs thru CHDs
• Technical Assistance to LGUs, CHDs and other
  stakeholders
• Advocacy/activities for LGUs and all
  stakeholders

52
WHAT ARE THE CHALLENGES

• GOVERNANCE
• High cost of complete post-exposure rabies
  vaccination regimen
• Mass Animal vaccination as the cost-effective
  intervention from a public health perspective
  (but is not the mandate of DOH)
• Weak enforcement of local ordinances
• Weak enforcement of Responsible Pet Ownership
• Needs to strengthen local ABTC and support from
  Local executives

53
WHAT ARE THE CHALLENGES

• GOVERNANCE
• Interagency collaboration
• Needs to strengthen local ABTC and support from
  Local executives
• M E Strengthen disease surveillance
• Strengthen partnership with other stakeholders

54
WHAT ARE THE CHALLENGES?

• SERVICE DELIVERY
• Advocate for the full implementation of the RA
  9482
• Assist the CHDs in the intensification of
  advocacy health educatioN
• Recording and reporting of rabies needs
  improvement.
• - Continuos capability building among LGU
  health workers in the implementation of the
  program
• FINANCING
• Ensure budget allocation for the procurement of
  anti-rabies vaccine by the LGUs
• PhilHealth package for Rabies Program

55
WHAT ARE THE CHALLENGES?

• STANDARD REGULATION
• Ensure good quality of vaccines
• Private practitioners/bite clinics adhering to
  DOH Standards/Protocols
• Standard Recording and reporting of rabies

56
PRIORITY AREAS FOR ACTIONS

• Strict enforcement of Rabies Control Ordinances
  RA 9482
• Strengthen of Rabies Control Committees in all
  levels
• DOH to lobby extensively for the DA to increase
  its efforts in dog immunization
• Ensure the allotment of budget to augment the
  needed vaccines for the LGUs and to conduct other
  program strategies

57
For Successful Elimination..

• Strong and sustained surveillance system
• Sustained resources (financial, logistics,
  manpower)
• Advocacy and partnership
• Community participation
• Leadership
• Strengthened health system

58

• LETS ADOPT A SENSE OF URGENCY TO ELIMINATE
  THESE DISEASES.

59
THANK YOU FOR LISTENING !!!!