30.3 DOH Programs & Environmental Sanitation: TB, Dengue, Rabies, Leprosy, Helminth and Other Disease Programs; the Sanitation Code (PD 856), Water Supply and Potability, Excreta and Solid Waste, Food Sanitation and Health Care Waste

Why this area matters

The TOS asks you to:

• summarize the basic health services and programs of the DOH;
• describe programs available in the community;
• use the diagnostic tools the DOH prescribes;
• coordinate with the local health department on vaccines, medicines and materials;
• apply environmental sanitation.

Most leading infectious causes of illness in the Philippines (diarrhea, typhoid, dengue, leptospirosis, helminths, TB) are controlled through these programs and through sanitation.

Priority DOH National Disease Control Programs

National Tuberculosis Control Program (NTP)

• Epidemiologic Burden: The Philippines remains among the top ten high-burden countries globally for both drug-susceptible tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB).
• Case Finding (Presumptive TB): Any individual presenting with persistent cough of $\ge 2\text{ weeks}$ duration, or unexplained constitutional symptoms (unintentional weight loss, night sweats, low-grade afternoon fevers, hemoptysis), or any high-risk contact of an active TB case regardless of respiratory symptoms.
• Primary Diagnostic Modality: Under updated DOH NTP guidelines, Rapid Molecular Diagnostic (mWRD) testing—specifically GeneXpert MTB/RIF or Truenat—is the mandatory initial diagnostic examination for all presumptive TB patients, superseding traditional Direct Sputum Smear Microscopy (DSSM). GeneXpert utilizes automated real-time PCR to simultaneously identify Mycobacterium tuberculosis complex DNA and detect mutations in the rpoB gene (conferring rifampicin resistance) within 2 hours. DSSM is preserved primarily for baseline bacillary burden quantification and monthly therapeutic monitoring.
• First-Line Treatment Regimen (Regimen 1): For drug-susceptible pulmonary and extrapulmonary tuberculosis:
  • Intensive Phase (2 months): Daily Fixed-Dose Combination (FDC) of Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), and Ethambutol (E) ($2\text{HRZE}$).
  • Continuation Phase (4 months): Daily Isoniazid and Rifampicin ($4\text{HR}$).
  • Directly Observed Therapy, Short-Course (TB-DOTS): Administration of medication under the direct visual observation of a trained treatment partner (health worker, BHW, or designated family supporter) to ensure strict adherence and prevent the development of multidrug resistance.
• Drug-Resistant TB (DR-TB): Evaluated and treated in Programmatic Management of Drug-Resistant TB (PMDT) centers utilizing all-oral, injection-free shorter regimens containing Bedaquiline, Pretomanid, Linezolid, and Moxifloxacin (BPaLM/BPaL).

National Dengue Prevention and Control Program

• Vector Biology: Transmitted primarily by Aedes aegypti (day-biting mosquito with peak biting activity 2 hours after sunrise and 2 hours before sunset; domestic container breeder in clean stagnant water) and peri-domestic Aedes albopictus.
• The Enhanced 4S Strategy:
  1. Search and destroy mosquito breeding sites (empty flower vases, clean roof gutters, discard discarded tires, cover water storage jars).
  2. Self-protection measures (wear light-colored long sleeves, apply DEET mosquito repellent, install window screens).
  3. Seek early consultation for persistent fever lasting $> 2\text{ days}$ or the emergence of warning signs.
  4. Support fogging or spraying only in hotspot areas where an increase in cases is recorded (fogging is not a routine control measure).
• Clinical Phases:
  • Febrile Phase (Days 1 to 3): High unremitting fever, facial flushing, retro-orbital pain, myalgia, arthralgia, positive tourniquet test (10 or more petechiae per square inch). Regular monitoring of CBC.
  • Critical Phase (Days 3 to 7, at Defervescence): Severe systemic plasma leakage due to endothelial dysfunction. Warning signs: persistent vomiting, severe abdominal pain, clinical fluid accumulation (ascites, pleural effusion), mucosal bleeding, lethargy, hepatomegaly $> 2\text{ cm}$, and hemoconcentration (hematocrit rise $\ge 20\%$) paired with rapid thrombocytopenia ($< 100,000/\mu\text{L}$). Can progress to Dengue Shock Syndrome (DSS).
  • Convalescent Phase (Days 7 to 10): Gradual fluid resorption; stabilization of vital signs; classic Herman's rash (confluent petechial erythema with white islands of normal skin) with intense pruritus. Avoid IV fluid overhydration during this phase.

National Rabies Prevention and Control Program

• Legal basis: the Anti-Rabies Act of 2007 (RA 9482) requires:
  • dog registration and annual vaccination of dogs;
  • responsible pet ownership, with penalties for owners who refuse to have their dogs vaccinated or to have biting dogs observed;
  • free PEP through animal bite treatment centers.
• Exposure management: the categories and PEP under DOH AO 2018-0013 are described in the rabies section of Microbiology (nervous system infections):
  • wash the wound, preferably for 10 minutes;
  • vaccine for Category II and III exposures;
  • RIG for Category III, including any Category II exposure on the head and neck;
  • intradermal vaccine on Days 0, 3 and 7.

National Leprosy Control Program (NLCP)

• Etiology: Mycobacterium leprae; targets cutaneous tissue and peripheral nerves (Schwann cells).
• WHO Multidrug Therapy (MDT) Regimens:
  • Since 2018, WHO recommends the same three drugs for both groups: rifampicin, dapsone and clofazimine.
  • Paucibacillary (PB) Leprosy (1 to 5 skin lesions, negative slit-skin smear):
    • Rifampicin + Clofazimine + Dapsone (doses as below) for 6 months.
  • Multibacillary (MB) Leprosy ($> 5$ skin lesions, multiple nerve trunk involvement, or positive slit-skin smear):
    • Rifampicin ($600\text{ mg}$ once monthly supervised) + Clofazimine ($300\text{ mg}$ once monthly supervised and $50\text{ mg}$ daily unsupervised) + Dapsone ($100\text{ mg}$ daily unsupervised) for 12 months (completed within 18 months).

Soil-Transmitted Helminthiasis (STH) Control

• Target Nematodes: Ascaris lumbricoides, Trichuris trichiura, and hookworms (Ancylostoma duodenale, Necator americanus).
• National Mass Drug Administration (MDA): Preventive chemotherapy given twice a year to preschool and school-age children, through health centers and schools.
• Medications: Single-dose oral Albendazole ($400\text{ mg}$) or single-dose oral Mebendazole ($500\text{ mg}$).

Maternal and Child Health: Kangaroo Mother Care (KMC)

• Target Population: Low birth weight ($< 2,500\text{ g}$) and preterm infants who are clinically stable.
• Core Components: Continuous, prolonged skin-to-skin contact between mother (or surrogate) and infant in an upright vertical position against the bare chest; exclusive and frequent breastfeeding; early discharge from hospital with systematic outpatient follow-up.
• Clinical Benefits: Prevents neonatal hypothermia, reduces hospital-acquired neonatal sepsis, accelerates weight gain, enhances maternal-infant bonding, and shortens duration of hospital stay.

Other DOH programs

• National Immunization Program and school-based immunization.
• Maternal, newborn and child health:
  • eight antenatal contacts;
  • facility-based delivery;
  • Essential Intrapartum and Newborn Care;
  • newborn screening and hearing screening;
  • IMCI.
• Family planning under the RH Law.
• Nutrition, with the National Nutrition Council: Operation Timbang Plus, micronutrient supplementation and management of acute malnutrition.
• Malaria, filariasis and schistosomiasis elimination programs: mass drug administration (DEC plus albendazole for filariasis, praziquantel for schistosomiasis), long-lasting insecticidal nets and case management.
• HIV/AIDS and STI program:
  • social hygiene clinics and treatment hubs;
  • rHIVda confirmation;
  • PrEP and ART.
• Non-communicable disease program:
  • PhilPEN (Philippine Package of Essential NCD Interventions) for risk screening and management in primary care;
  • tobacco control;
  • cancer control under RA 11215.
• Oral health, mental health, eye health and health emergency management.

Environmental Health: PD 856 Sanitation Code

Environmental sanitation standards in the Philippines are established by Presidential Decree No. 856 (The Code on Sanitation of the Philippines).

Drinking Water Supply Classification

These service levels are used in DOH water and sanitation programs together with the Sanitation Code (PD 856) and its implementing rules.

Microbiological Potability Standards

Regulated under the Philippine National Standards for Drinking Water (PNSDW):

• Standard bacteriological surveillance utilizes the Most Probable Number (MPN) or Membrane Filtration (MF) method to detect coliform organisms.
• Potability Standard: Potable drinking water must contain zero Total Coliforms, zero Fecal Coliforms, and zero Escherichia coli per 100 mL sample ($< 1.1\text{ MPN}/100\text{ mL}$). The presence of E. coli serves as a definitive indicator of recent fecal contamination.

Healthcare Waste Management: DOH Color-Coding System

The DOH Health Care Waste Management Manual, 4th edition (2020) sets the following color codes for bins and liners. They replace the older scheme of the 3rd edition, which used red sharps containers and yellow bags with a black band.

Presidential Decree 856 (the Code on Sanitation of the Philippines, 1975), with its implementing rules, covers water supply, food establishments, markets, schools, industrial hygiene, excreta and sewage, refuse, vermin control, burial and many other places and activities.

Excreta disposal, solid waste, food sanitation and vector control

• Excreta disposal:
  • a sanitary toilet isolates excreta from people, flies, animals and water sources, for example a pour-flush or water-sealed toilet, or a properly sited pit latrine;
  • septic tanks need periodic desludging;
  • toilets are sited at a safe distance and downhill from wells;
  • the DOH Zero Open Defecation Program promotes community-led total sanitation and certification of barangays as zero open defecation.
• Solid waste: RA 9003 (Ecological Solid Waste Management Act of 2000):
  • segregation at source into biodegradable, recyclable, residual and special (hazardous) waste;
  • barangay materials recovery facilities;
  • the 3Rs (reduce, reuse, recycle);
  • closure of open dumpsites in favor of sanitary landfills.
• Food sanitation:
  • food establishments need a sanitary permit;
  • food handlers need a health certificate from the local health office after examination;
  • safe food practices are the WHO "Five Keys": keep clean, separate raw and cooked, cook thoroughly, keep food at safe temperatures, use safe water and raw materials.
• Vector and vermin control:
  • eliminate breeding sites (dengue, malaria, filariasis);
  • environmental management;
  • use larvicides and insecticides judiciously;
  • rodent control to prevent leptospirosis.
• Health care waste: it must be segregated at the point of generation using the DOH color codes, then collected, stored, treated (autoclave, microwave) and disposed of safely, because infected sharps transmit HBV, HCV and HIV.