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(NAR) VOL. 23 NO. 1, JANUARY - MARCH 2012)
[ DOH ADMINISTRATIVE ORDER NO. 2011-0019, October 24, 2011 ]
GUIDELINES IN EVALUATION OF LOW ENDEMIC PROVINCES FOR DECLARATION AS MALARIA-FREE
I. INTRODUCTION
Through the decades, the trend of malaria incidence has been influenced by the strategies adopted (shift from control to eradication to control), the organizational set-up of program implementation (centralized to decentralized), available funding, program policies and directions, industrialization, environmental and climatic conditions.
Malaria remains a public health concern in the Philippines being ranked as the 9th major cause of diseases nationwide. Malaria threatens the lives of about 12 million Filipinos with a rough estimate of 110 people getting sick of malaria daily. In 1990, when the population was about 62,049,229, the confirmed malaria cases numbered 76, 270 with 913 deaths. In 2006 cases were reduced from the 2005 data by 24%, that is from 46,352 cases to 35,405 cases and deaths reduced by 19% s from 150 to 122. In 2007, deaths were reduced by 42% ( 122 to 73) while the number of cases slightly increased from 35,402 to 36,235. In 2008, a total of 23,655 confirmed malaria cases were reported giving an overall incidence of 26 per 100,000 population and deaths were reduced by 23% from 73 to 56 or a mortality rate of 0.06/100,000 population.
Of the 81 provinces, 58 (71%) are malaria endemic. In 2001, twenty-six (26) provinces were classified as Category A ( with a three-year average of > 1000 cases) which accounted for 90% of the cases nationwide. In 2008, the number of Category A provinces was reduced to 5, while the number of low endemic provinces increased to 26 from 18 in 2006. In 2010, the number of malaria-free provinces (Category d) almost doubled from 13 in 2001 to 23. Given the aforementioned improvements in the reduction of morbidity and mortality of malaria , the DOH is moving its program direction from prevention to control to elimination. Challenges still remain in sustaining the malaria-free status of those provinces declared malaria-free and support concerned provinces to increase the number of malaria-free provinces and realize our vision of malaria-free Philippines .
Given the inputs poured into the malaria endemic provinces towards elimination of the disease, periodic assessment to determine their status needs to be undertaken. This Order is hereby issued as a guide in the assessment of low endemic provinces to be declared as malaria-free.
II. OBJECTIVE:
This Order shall set the guidelines in the assessment of the malaria situation in low endemic/candidate provinces to become malaria-free.
III. SCOPE and COVERAGE:
This Guidelines shall apply to all health workers in the national, regional, local, public and private health facilities whose functions and activities contributes to the assessment of malaria situation in low endemic provinces to become malaria-free.
IV. DEFINITION OF TERMS:
1. Category C or Low endemic provinces are provinces with < 100 average malaria cases per year
2. Category B provinces are provinces with 100 - <1000 average malaria cases per year
3. Category A provinces are provinces with >1000 average malaria cases per year.
4. Endemic – applied to malaria is a situation where there is a constant measurable incidence of malaria cases and mosquito-borne transmission in an area over a succession of years.
5. Indigenous malaria case is a malaria case the origin from local transmission of which cannot be disproved.
6. Malaria incidence is the number of malaria cases during a specified time period in a specified population
7. Malaria-free province refers to a province where there is no continuing local mosquito-borne malaria transmission and the risk of acquiring the disease is limited to introduced cases only.
8. Introduced case is a case where it can be proven that the infection is a first step (first generation) of local transmission subsequent to proven imported case.
9. Imported case – a case, the origin of which can be traced to a known malarious area outside the area in which the case was diagnosed.
V. IMPLEMENTING GUIDELINES IN DECLARING MALARIA-FREE PROVINCES
A. General Guidelines
1. Malaria is a disease which remains a public health concern, and therefore Local Government Units have the responsibility to implement malaria control program in their localities which include reporting of malaria cases.
2. The Malaria Control Program goal is to support provinces to attain malaria-free status and this requires an evaluation of the malaria situation by province to prove that no indigenous case have been confirmed in the province in the last five years.
3. A malaria surveillance system shall be set up and implemented in the province and this shall require the presence of a diagnostic laboratory including a medical technologist trained in malaria microscopy.
4. Epidemic Investigation shall be conducted and Response Teams shall be organized to undertake epidemic response and management which shall be aligned with the guidelines contained in the Philippine Integrated disease Surveillance and response (PIDSR).
5. The Local Government Units shall make available vector control logistic support for any occurrence of outbreak and anti-malaria drugs for imported cases.
6. Continued intensive health education and advocacy on malaria prevention and control shall be implemented at all levels.
B. Specific Guidelines
1. The membership of the evaluation team who shall undertake the assessment of the malaria situation in low endemic/candidate provinces as malaria-free shall be reviewed and updated. The team shall be comprised of the following: the national malaria program manager, a medical specialist on hospital and clinical malaria management, medical technologist, national/regional entomologist with entomological aide, regional malaria coordinator, provincial malaria coordinator and activity coordinator.
2. Annual reports of provinces shall be reviewed to identify the provinces without indigenous case in the last five years or Regional Malaria Coordinators shall be required to submit their request for evaluation of candidate provinces under their jurisdiction.
3. Records of malaria control program activities implemented in the last five years before the last reported indigenous case up to the time of evaluation shall be requested from the provincial malaria control program office/provincial health team office.
4. The different health facilities ( Rural Health Units, public/private hospitals) within the province shall be visited and assessed for the following: a) diagnostic laboratory set-up, b) training of medical technologists on malaria microscopy, case register and case reporting; and c) available medical technologist, trained or untrained on malaria microscopy, case register and case reporting; d) assess the medical officers on clinical, hospital and treatment management.. .
5. Key informants ( i.e. old/former malaria personnel, other health facility staff, barangay health workers) shall be interviewed using a structured questionnaire. Questions shall include knowledge on malaria, and the current and previous malaria situation and attitudes and practices on malaria control treatment and management.
6. Mosquito collection shall be conducted through carabao bait trap collection and or larval dippings on breeding streams in the municipality/barangay where the last indigenous case was reported . All anopheline species trapped shall be collected and the number of every species particularly the vectors shall be recorded. In the absence of vector species caught in the carabao bait trap, larval surveys in breeding streams shall be conducted.
7. Results of the assessment shall be reported to the Malaria Technical Working Group (TWG) together with the concerned Center for Health Development Director and Regional Malaria Coordinator.
8. The Malaria TWG approves/disapproves the recommendation of the assessment team to declare or not the Province as malaria-free
VI. REPEALING CLAUSE:
Provisions from previous and related issuances inconsistent or contrary with the provision of this Administrative Order are hereby revised, modified and rescinded accordingly. All other provisions of existing issuances which are not affected by this Administrative Order shall remain valid and in effect.
VII. EFFECTIVITY:
This Order shall take effect immediately.
Adopted: 24 October 2011
(SGD.) ENRIQUE T. ONA, MD, FPCS, FACS
Secretary of Health
Through the decades, the trend of malaria incidence has been influenced by the strategies adopted (shift from control to eradication to control), the organizational set-up of program implementation (centralized to decentralized), available funding, program policies and directions, industrialization, environmental and climatic conditions.
Malaria remains a public health concern in the Philippines being ranked as the 9th major cause of diseases nationwide. Malaria threatens the lives of about 12 million Filipinos with a rough estimate of 110 people getting sick of malaria daily. In 1990, when the population was about 62,049,229, the confirmed malaria cases numbered 76, 270 with 913 deaths. In 2006 cases were reduced from the 2005 data by 24%, that is from 46,352 cases to 35,405 cases and deaths reduced by 19% s from 150 to 122. In 2007, deaths were reduced by 42% ( 122 to 73) while the number of cases slightly increased from 35,402 to 36,235. In 2008, a total of 23,655 confirmed malaria cases were reported giving an overall incidence of 26 per 100,000 population and deaths were reduced by 23% from 73 to 56 or a mortality rate of 0.06/100,000 population.
Of the 81 provinces, 58 (71%) are malaria endemic. In 2001, twenty-six (26) provinces were classified as Category A ( with a three-year average of > 1000 cases) which accounted for 90% of the cases nationwide. In 2008, the number of Category A provinces was reduced to 5, while the number of low endemic provinces increased to 26 from 18 in 2006. In 2010, the number of malaria-free provinces (Category d) almost doubled from 13 in 2001 to 23. Given the aforementioned improvements in the reduction of morbidity and mortality of malaria , the DOH is moving its program direction from prevention to control to elimination. Challenges still remain in sustaining the malaria-free status of those provinces declared malaria-free and support concerned provinces to increase the number of malaria-free provinces and realize our vision of malaria-free Philippines .
Given the inputs poured into the malaria endemic provinces towards elimination of the disease, periodic assessment to determine their status needs to be undertaken. This Order is hereby issued as a guide in the assessment of low endemic provinces to be declared as malaria-free.
II. OBJECTIVE:
This Order shall set the guidelines in the assessment of the malaria situation in low endemic/candidate provinces to become malaria-free.
III. SCOPE and COVERAGE:
This Guidelines shall apply to all health workers in the national, regional, local, public and private health facilities whose functions and activities contributes to the assessment of malaria situation in low endemic provinces to become malaria-free.
IV. DEFINITION OF TERMS:
1. Category C or Low endemic provinces are provinces with < 100 average malaria cases per year
2. Category B provinces are provinces with 100 - <1000 average malaria cases per year
3. Category A provinces are provinces with >1000 average malaria cases per year.
4. Endemic – applied to malaria is a situation where there is a constant measurable incidence of malaria cases and mosquito-borne transmission in an area over a succession of years.
5. Indigenous malaria case is a malaria case the origin from local transmission of which cannot be disproved.
6. Malaria incidence is the number of malaria cases during a specified time period in a specified population
7. Malaria-free province refers to a province where there is no continuing local mosquito-borne malaria transmission and the risk of acquiring the disease is limited to introduced cases only.
8. Introduced case is a case where it can be proven that the infection is a first step (first generation) of local transmission subsequent to proven imported case.
9. Imported case – a case, the origin of which can be traced to a known malarious area outside the area in which the case was diagnosed.
V. IMPLEMENTING GUIDELINES IN DECLARING MALARIA-FREE PROVINCES
A. General Guidelines
1. Malaria is a disease which remains a public health concern, and therefore Local Government Units have the responsibility to implement malaria control program in their localities which include reporting of malaria cases.
2. The Malaria Control Program goal is to support provinces to attain malaria-free status and this requires an evaluation of the malaria situation by province to prove that no indigenous case have been confirmed in the province in the last five years.
3. A malaria surveillance system shall be set up and implemented in the province and this shall require the presence of a diagnostic laboratory including a medical technologist trained in malaria microscopy.
4. Epidemic Investigation shall be conducted and Response Teams shall be organized to undertake epidemic response and management which shall be aligned with the guidelines contained in the Philippine Integrated disease Surveillance and response (PIDSR).
5. The Local Government Units shall make available vector control logistic support for any occurrence of outbreak and anti-malaria drugs for imported cases.
6. Continued intensive health education and advocacy on malaria prevention and control shall be implemented at all levels.
B. Specific Guidelines
1. The membership of the evaluation team who shall undertake the assessment of the malaria situation in low endemic/candidate provinces as malaria-free shall be reviewed and updated. The team shall be comprised of the following: the national malaria program manager, a medical specialist on hospital and clinical malaria management, medical technologist, national/regional entomologist with entomological aide, regional malaria coordinator, provincial malaria coordinator and activity coordinator.
2. Annual reports of provinces shall be reviewed to identify the provinces without indigenous case in the last five years or Regional Malaria Coordinators shall be required to submit their request for evaluation of candidate provinces under their jurisdiction.
3. Records of malaria control program activities implemented in the last five years before the last reported indigenous case up to the time of evaluation shall be requested from the provincial malaria control program office/provincial health team office.
4. The different health facilities ( Rural Health Units, public/private hospitals) within the province shall be visited and assessed for the following: a) diagnostic laboratory set-up, b) training of medical technologists on malaria microscopy, case register and case reporting; and c) available medical technologist, trained or untrained on malaria microscopy, case register and case reporting; d) assess the medical officers on clinical, hospital and treatment management.. .
5. Key informants ( i.e. old/former malaria personnel, other health facility staff, barangay health workers) shall be interviewed using a structured questionnaire. Questions shall include knowledge on malaria, and the current and previous malaria situation and attitudes and practices on malaria control treatment and management.
6. Mosquito collection shall be conducted through carabao bait trap collection and or larval dippings on breeding streams in the municipality/barangay where the last indigenous case was reported . All anopheline species trapped shall be collected and the number of every species particularly the vectors shall be recorded. In the absence of vector species caught in the carabao bait trap, larval surveys in breeding streams shall be conducted.
7. Results of the assessment shall be reported to the Malaria Technical Working Group (TWG) together with the concerned Center for Health Development Director and Regional Malaria Coordinator.
8. The Malaria TWG approves/disapproves the recommendation of the assessment team to declare or not the Province as malaria-free
VI. REPEALING CLAUSE:
Provisions from previous and related issuances inconsistent or contrary with the provision of this Administrative Order are hereby revised, modified and rescinded accordingly. All other provisions of existing issuances which are not affected by this Administrative Order shall remain valid and in effect.
VII. EFFECTIVITY:
This Order shall take effect immediately.
Adopted: 24 October 2011
Secretary of Health