5.2 Control of Communicable and Non-Communicable Diseases

National Tuberculosis Control Program and DOTS

Tuberculosis (TB), caused by Mycobacterium tuberculosis, remains a leading cause of morbidity in the Philippines. The Department of Health (DOH) administers the National TB Control Program (NTP) utilizing the DOTS (Directly Observed Treatment, Short-course) strategy to ensure treatment compliance and prevent Multi-Drug Resistant TB (MDR-TB).

Diagnostics:

Historically, Sputum Smear Microscopy (DSSM) was the primary test. Current NTP guidelines mandate GeneXpert MTB/RIF (a rapid molecular test) as the primary diagnostic tool. GeneXpert is superior because it detects Mycobacterium tuberculosis DNA and identifies resistance to Rifampicin (a marker for MDR-TB) within two hours.

DOTS Strategy Components:

1. Sustained political and financial commitment.
2. Case detection through quality-assured bacteriology (GeneXpert).
3. Standardized short-course chemotherapy with direct observation by a trained treatment partner (a BHW, midwife, nurse, or family member under strict supervision).
4. Uninterrupted supply of quality-assured anti-TB drugs.
5. Standardized recording and reporting system.

Treatment Categories and Regimens:

Anti-TB treatment is divided into two phases: the Intensive Phase (to rapidly kill active bacilli, rendering the client non-infectious, lasting 2 months) and the Continuation Phase (to eradicate remaining dormant bacilli, preventing relapse, lasting 4-6 months).

• Category I (New Cases): Used for new pulmonary or extra-pulmonary TB patients.
  • Regimen: 2 HRZE / 4 HR (2 months of Isoniazid, Rifampicin, Pyrazinamide, Ethambutol daily; followed by 4 months of Isoniazid and Rifampicin daily).
• Category II (Retreatment Cases): Used for previously treated patients (relapses, treatment failures, or loss to follow-up).
  • Regimen: 2 HRZES / 1 HRZE / 5 HRE (Includes Streptomycin injection during the first 2 months, followed by 1 month of oral HRZE, and 5 months of oral HRE).

Management of Adverse Drug Reactions (ADRs):

Dengue Prevention and Control

Dengue is a viral illness transmitted by the Aedes aegypti (and Aedes albopictus) mosquito, characterized by diurnal (day-biting) habits.

The Enhanced 4S Strategy:

1. Search and destroy: Eliminate all potential mosquito breeding sites (stagnant clean water in flower vases, discarded tires, roof gutters, bamboo poles).
2. Self-protection measures: Wear long-sleeved clothing, light colors (which do not attract mosquitoes), and use insect repellents. Use mosquito nets at home.
3. Seek early consultation: Visit a healthcare facility immediately if a fever persists for more than two days or if warning signs appear.
4. Say yes to fogging: Fogging is recommended only during impending outbreaks or hotspots to kill infected adult mosquitoes. Indiscriminate fogging is discouraged.

Tourniquet Test Procedure (Capillary Fragility Test):

The tourniquet test is a simple diagnostic aid used to assess capillary fragility:

1. Place the blood pressure cuff on the patient's arm and measure the systolic and diastolic blood pressure.
2. Calculate the Mean Arterial Pressure (MAP): $ ext{MAP} = rac{ ext{Systolic BP} + ext{Diastolic BP}}{2}$ (or add one-third of pulse pressure to diastolic BP).
3. Inflate the cuff to the calculated MAP and keep it inflated for 5 minutes in children (or 10 minutes in adults).
4. Deflate the cuff, wait for 2 minutes for normal circulation to return, and inspect the skin distal to the cuff (usually the antecubital fossa).
5. Count the number of petechiae within a 1-square-inch (2.5 cm x 2.5 cm) area. A count of 20 or more petechiae is considered a positive tourniquet test, indicating increased capillary fragility.

Warning Signs of Severe Dengue:

Nurses must monitor dengue patients closely for transition to severe dengue, marked by plasma leakage:

• Severe abdominal pain or tenderness.
• Persistent vomiting (more than 3 times in 24 hours).
• Clinical fluid accumulation (pleural effusion, ascites).
• Mucosal bleeding (epistaxis, bleeding gums, hematemesis, melena).
• Lethargy or restlessness.
• Hepatomegaly (liver enlargement >2 cm).
• Laboratory: Progressive increase in hematocrit (indicating hemoconcentration) concurrent with a rapid decrease in platelet count (below 100,000/mm³).

Hydration Therapy:

Hydration is the cornerstone of dengue management. For patients without warning signs, oral hydration using ORS or fruit juices is sufficient. For patients with warning signs or severe dengue, intravenous fluid resuscitation using isotonic crystalloids (Lactated Ringer's or 0.9% Normal Saline) is critical to maintain hemodynamic stability and prevent hypovolemic shock. Hematocrit must be monitored frequently to guide fluid titration.

HIV/AIDS Prevention and Control

The legal landscape of HIV/AIDS in the Philippines is governed by Republic Act No. 11166 (Philippine HIV and AIDS Policy Act of 2018), which replaced the old RA 8504.

Key Legal Provisions under RA 11166:

• Consent for HIV Testing: Any person aged 15 years and older can voluntarily consent to undergo HIV testing without requiring parental consent. For children under 15 who are pregnant, married, engaged in high-risk behaviors, or orphans, testing can be conducted with the consent of a social worker or guardian.
• Confidentiality: Testing results and records are strictly confidential. Unauthorized disclosure of a person's HIV status is a criminal offense with severe penalties.
• Voluntary Counseling and Testing (VCT): HIV testing must be voluntary and accompanied by pre-test and post-test counseling. Pre-test counseling prepares the client, while post-test counseling delivers results, provides risk-reduction education, and links positive cases to care.

Clinical Staging & CD4 Monitoring:

• Normal CD4 Count: 500 to 1,500 cells/mm³.
• Clinical AIDS Diagnosis: Defined by a CD4 count below 200 cells/mm³ or the presentation of an AIDS-defining opportunistic infection (OI).
• Common Opportunistic Infections (OIs):
  • Pneumocystis jirovecii Pneumonia (PCP): Fungal lung infection presenting with dry cough, fever, and progressive dyspnea. Diagnosed via sputum induction or bronchoscopy. Managed with high-dose Co-trimoxazole (trimethoprim-sulfamethoxazole).
  • Tuberculosis (TB): The leading cause of death among people living with HIV (PLHIV). All PLHIV must be screened for TB.
  • Kaposi's Sarcoma (KS): A vascular tumor caused by Human Herpesvirus 8, presenting as painless purple/red papules or nodules on the skin and mucous membranes.
  • Candidiasis: Oropharyngeal or esophageal thrush, presenting as white plaques that can be scraped off, causing dysphagia.

Non-Communicable Diseases (NCDs) and PhilPEN

Non-communicable diseases (hypertension, diabetes mellitus, cardiovascular diseases, cancer, and COPD) represent a major burden of disease. The DOH implements the PhilPEN (Philippine Package of Essential Non-Communicable Disease Interventions) protocol to identify and manage risks at the primary care level.

PhilPEN Risk Assessment:

Nurses conduct risk assessments for all adults aged 20 years and older. The process involves:

• Screening: Measuring blood pressure (hypertension screening), fasting blood sugar (diabetes screening), total cholesterol, and calculating BMI (obesity screening).
• Risk Prediction: Using WHO/ISH risk prediction charts to estimate a patient's 10-year risk of developing a major cardiovascular event (stroke or myocardial infarction).

Lifestyle Modifications (The Primary Preventive Strategy):

• Dietary Adjustments: Promoting the DOH "Pinggang Pinoy" concept. Advise a low-sodium diet (less than 2g of sodium per day, or 1 teaspoon of salt), low-fat, high-fiber, and reduction of processed foods.
• Physical Activity: Recommending at least 150 minutes of moderate-intensity aerobic physical activity per week (e.g., 30 minutes of brisk walking 5 days a week).
• Tobacco Cessation: Utilizing the 5A's framework (Ask about tobacco use, Advise to quit, Assess willingness to make a quit attempt, Assist in quitting, Arrange follow-up).
• Alcohol Reduction: Limiting alcohol intake to prevent hypertension and liver damage.