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I. BACKGROUND/RATIONALE:

Globally, Lymphatic Filariasis (LF) is endemic in 83 countries and territories and over a billion people are at risk of developing it. An estimated 120 million people are affected worldwide among whom 40 million are debilitated and disfigured by the disease. Although LF is not a life threatening disease, it is one of the world’s leading causes of permanent and long-term disability.

The disease is still endemic in 42 provinces in the Philippines, although five provinces namely: Southern Leyte, Sorsogon, Biliran, Romblon and Agusan del Sur have achieved the criteria for elimination as a public health problem. More than half of the affected areas are in Mindanao. The regions with most LF disabilities are Bicol, Davao and Zamboanga Peninsula.

Lymphatic Filariasis causes a wide range of clinical acute and chronic signs and symptoms. The death of adult worms causes Acute Filarial Lymphangitis (AFL), inflammation of the lymphatic vessels while secondary bacterial infection provoke Acute Dermatolymphangioadenitis (ADLA), inflammation of the skin, lymphatic vessels and nodes. Acute attack caused by secondary bacterial infection is most common and plays an important role in the progression of lymphedema. The AFL caused by the death of adult worms is very rare. Major chronic manifestations include hydrocele and lymphedema of limbs while other chronic manifestations are chyluria, lymphedema of scrotum, adenopathy (swollen lymph nodes), hematuria and tropical pulmonary eosinophilia. The disease causes deformities of the limbs, breasts and genitals, and permanent long term disabilities which may lead to serious psychosocial consequences.

The World Health Assembly in 1997 resolved that LF should be eliminated as a public health problem. This was followed by the World Health Organization’s (WHO) launch of the Global Programme to Eliminate Lymphatic Filariasis (GPELF). In consultation with its major partners, the WHO proposed a comprehensive strategy for achieving the two-fold goal in elimination of LF to reduce disease burden: (1) interruption of transmission by drastically reducing microfilaria prevalence and (2) implementation of disability prevention activities for those individuals already suffering from LF-related disabilities. Guidelines have been issued by the DOH to achieve the goal of elimination of Filariasis as a public health threat: AO No. 25A 1998 which provides for the shifting of control strategies to elimination and AO No. 157, s. 2004 which provides the guidelines for Filariasis Mass treatment in all established endemic areas. This guideline is being issued to achieve effective implementation and management of filariasis in the area of disability prevention programmes at the field level.

II. OBJECTIVE

To guide public and private health providers in effectively implementing disability prevention due to filariasis in their areas of responsibility.

III. SCOPE

This order shall apply to all public and participating private health providers in filariasis endemic provinces especially in areas with high LF cases with deformities. The beneficiaries are patients suffering from lymphedema of one or more parts of the body and/or from hydrocele.

IV. DEFINITION OF TERMS

1. Acute Filarial Lymphangitis (AFL) – inflammation of the lymphatic vessels due to filariasis.

2. Acute Dermatolymphangioadenitis (ADLA) – inflammation of the skin, lymphatic vessels and nodes.

3. Adenopathy – swollen lymph nodes.

4. Chyluria – the presence of chyle in the urine giving it a milky appearance due to obstruction of lymph flow causing rupture of lymph vessels into the renal pelves, ureters, bladder or urethra.

5. Disability kits – a medical kit composed of antibiotic and antifungal ointments, soap, alcohol, cotton, cotton buds, hydrogen peroxide, gauze, small towel and paper tapes.

6. Hematuria – the presence of blood in the urine.

7. Hydrocele – enlargement of scrotum as a result of the collection of fluid in membrane surrounding the testes as detected by Trans-illumination Test.

8. Hydrocelectomy – a surgical procedure to remove accumulated fluid from the enlarged scrotum.

9. Informal Health Care Provider – community volunteers not limited to family members and BHWs trained on morbidity control, assisting patients and/or conducting family, home or community-based care.

10. Lymphedema – is a condition of localized fluid retention in the extremities and or in the breasts as a result of lymphatic obstruction.

11. Trans-illumination Test – is a part of physical examination where a flashlight is used to observe whether light passes through the enlarged scrotum confirming the collection of fluid thereat.

12. Tropical Pulmonary Eosinophilia – a hypersensitivity response of the lungs to filarial worms characterized by cough, breathlessness, wheezing, lymphadenopathy and sometimes splenomegaly, occasionally showing patchy infiltration of lungs in radiologic films.

V. GENERAL GUIDELINES AND PROCEDURES

1. The ultimate objective of this Order is to enable every LF patient to enjoy quality and more productive life, both socially and economically.

2. The LF transmission control and disability prevention activities shall be undertaken to:

a. Interrupt transmission of LF that is to prevent the development of new infections using Mass Drug Administration targeting the at-risk population.
b. Provide appropriate care for those who are already infected, with or without disability.

3. The following are the key activities that must be implemented for the LF disability prevention:

a. Conduct a Deformity Survey to masterlist and establish contact with lymphedema and/or hydrocele patients.
b. Provide sustainable care to all patients by establishing a functional two-way referral system and follow-up mechanism.
c. Intensify and sustain health promotion campaigns.
d. Empower patients to play an active role in the management of their lymphedema through self-care.
e. Improve access to safe and affordable hydrocelectomy.
f. Provide counseling to lymphedema and/or hydrocele patients.
g. Establish linkages to improve socioeconomic status of lymphedema and/or post hydrocelectomy patients.

VI. SPECIFIC GUIDELINES

A. Disability Prevention

1. The second objective of the LF elimination program is to alleviate the suffering of those people already affected. Filariasis causes suffering and disability from lymphedema, elephantiasis, hydrocele and other clinical manifestations. It facilitates the development of secondary bacterial/fungal infection of the skin resulting in severe febrile syndromes, progression and frequency of clinical symptoms. The following strategies have been proven to help in alleviating and preventing suffering and disability:

a. Early recognition of acute attacks and prompt treatment to prevent future clinical consequences and minimize progression of lymphedema.
b. Proper local hygiene prevents or removes some of the factors responsible for disease progression and acute attacks providing significant relief to patients;
c. Hydrocele can be successfully managed by surgery.

2. Determination of the number of lymphedema cases to help define the appropriate follow-up system:

a. The choice of follow-up system for lymphedema management is guided by the distribution of the patients within the social grouping, the awareness and support in the community and the number of patients to be followed-up. This number may vary according to the setting. (eg. Indigenous People community)
b. The type of follow-up system shall be crucial for an effective and efficient programme implementation and its sustainability. When deciding which type of follow-up system is applicable, the following criteria shall be observed taking into account the prevailing situation in the area:

b.1 Where the number of chronic lymphedema cases is more than 5 per community, it is advisable to adopt the community home-based care follow-up system involving informal healthcare providers.
b.2 Where the number of chronic lymphedema cases in the community is 5 or less, three different follow-up systems can be considered.

3. The types of follow-up system for prevention and basic management for lymphedema are the following:

a. Personal home-based care – is carried out by the patient at home.
b. Family home-based care – involves supportive family members with proper training on patient care.
c. Community home-based care – is carried out by informal healthcare providers. It can be integrated with other disability causing diseases (Leprosy, diabetes, neurological disorders) that require long-term care through the same activities.

4. Follow-up and monitoring of patients shall be carried out directly by health personnel at the most peripheral level of the health system assisted by the informal healthcare provider.

B. Systems Support

1. Capability building and technical assistance – The DOH shall provide capacity building to ensure the implementation of this Order.

2. Resource Mobilization – funding of disability kits and drugs shall be assured

3. Procurement of Logistics Managements

4. Rehabilitation

4.1 Counseling
4.2 Socioeconomic

5. Reporting and referral system

C. Monitoring and Evaluation

1. A Monitoring system shall be established that will regularly collect the following information:

i. Number of lymphedema cases
ii. Number of hydrocele cases

2. There should be regular assessment of the impact of disability prevention activities on LF patient population. The following are the indicators:

i. Frequency of acute attack in lymphedema patients
ii. Number of lymphedema cases provided interventions
iii. Number of hydrocele cases provided intervention

3. Each province through the Provincial Health Office is required to submit an annual report to the CHDs on the implementation of this Guideline.

VII. ROLES and RESPONSIBILITIES

A. Department of Health

A.1 National Center of Disease Prevention and Control

1.1 Formulate the Policy Guidelines in the Prevention of disabilities due to Lymphatic Filariasis

1.2 Coordinate the design, implementation and appropriate advocacy relevant to the setting-up of necessary management systems to include logistics, surveillance and reporting systems to ensure an effective and efficient implementation of this policy.

1.3 Coordinate with PD/MMD to ensure provision of logistics to all implementing units.

1.4 Coordinate with NEC on the surveillance system and reporting system

1.5 Conduct orientation and/or training of CHD technical staff on the Guidelines in the Prevention of disabilities due to Lymphatic Filariasis when necessary

1.6 Coordinate and ensure the timely procurement and distribution of disability kits to established filariasis endemic regions based on the validated reports of patients with disabilities

1.7 Advocate and lobby for funds for the implementation of this policy.

1.8 Promote and strengthen partnership with other stakeholders.

1.9 Initiate resource mobilization for the implementation of this policy.

A.2 National Center for Health Promotion (NCHP)

2.1 Develop Health promotion package for the implementation of this policy.

2.2 Develop IEC prototypes on disabilities caused by Lymphatic Filariasis

2.3 Assist NCDPC in the conduct of Partner’s meeting

2.4 Assist NCDPC in resource mobilization

2.5 Assist NCDPC in the conduct of KAP survey

A.3 Health Policy Development and Planning Bureau (HPDPB)

3.1 Secure adequate funding for National Filariasis Elimination Program in accordance with the Health Sector Expenditure Framework

3.2 Facilitate and support program evaluation studies

A.4 Procurement Division/Material Management Division 

4.1 Ensure timely procurement of disability kits
4.2 Ensure the proper storage, timely distribution and delivery of logistic to the target clients.

A.5 Centers for Health Development

5.1 Disseminate this policy to the concerned LGUs
5.2 Conduct orientation and training of DOH retained, LGU and private hospitals on this policy guideline on prevention of disabilities due to Lymphatic Filariasis
5.3 Ensure the availability and distribution of initial supply of disability kits in coordination with NCDPC.
5.4 Collect, consolidate, analyze and submit report to National Epidemiology Center (NEC) copy furnished NCDPC
5.5 Reproduction and distribution of IEC materials in coordination with NCHP.

B. Local Government Units

B.1 Provincial Health Office

1.1 Disseminate and implement this policy to the concerned cities/municipalities

1.2 Conduct orientation/training of health workers on this policy

1.3 Allocate counterpart funding for the implementation of disability prevention (Timely replenishment of disability kits, enrolment of PWDs associated with LF to PHIC).

1.5. Monitor implementation of this policy in their areas of responsibility.

1.6 Collect, consolidate, analyze and submit report to CHDs.

1.7 Establish linkages with other agencies for socio-economic programs

1.8 Develop and submit proposals for funding with other agencies

B.2 City/Municipal Health Office

2.1 Conduct orientation/training to staff and community on this policy
2.2 Implement this policy
2.3 Allocate counterpart funding for the implementation of disability prevention activities such as timely replenishment of disability kits and enrolment of PWDs associated with LF to PHIC.
2.4 Monitor implementation of this policy in their areas of responsibility including quality care given by frontline health workers to filariasis cases.
2.5 Collect, consolidate, analyze and submit report to PHOs.
2.6 Establish linkages with other agencies for socio-economic programs.
2.7 Develop and submit proposals for funding in partnership with other agencies.

C. Regional/Provincial/District Hospitals

1. Provide services for disability management including surgery for hydroceles.
2. Provide logistic support in the management of LF patients with disabilities.

D. Private Health Providers

1. Referral of LF patients with disabilities to government facilities.
2. Provide services to patients with LF.

VIII. REPEALING CLAUSE

All policies inconsistent or contrary to the provisions of this Order are hereby repealed/rescinded.

IX. EFFECTIVITY

This Order takes effect immediately upon approval.

(SGD.) ESPERANZA I. CABRAL, MD
  Secretary of Health