A12 PREVMED MAIN HANDOUT APRIL 2024 PDF

TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE AND PUBLIC HEALTH MAIN HANDOUT BY DR. MANN For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for April 2024 PLE batch. This will be rendered obsolete for the next batch sin...

TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE AND PUBLIC HEALTH MAIN HANDOUT BY DR. MANN For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for April 2024 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. o Nucleic Acid Amplification Test- Loop Mediated Amplification Assay (NAAT-LAMP) o Plaque Reduction Neutralization Test (PRNT) B. DENGUE WITH WARNING SIGNS • A previously well person with acute febrile illness of 1-7 days plus any of the following: o Abdominal pain or tenderness o Persistent vomiting o Clinical signs of fluid accumulation (ascites) o Mucosal bleeding o lethargy or restlessness o Liver enlargement >2cm o Increase in hematocrit concurrent with rapid decrease in platelet count MNEMONIC DENGUE WARNING SIGNS Letter A to LetharGy A – Abdominal pain B – Bleeding C – Continuous vomiting D – Decrease in platelet (and increase in hematocrit) E – Enlargement of the Liver F – Fluid accumulation G - LetharGy C. SEVERE DENGUE • Severe plasma leakage leading to o shock (DSS) o fluid accumulation with respiratory distress • Severe bleeding: as evaluated by clinician • Severe organ impairment o Liver: AST or ALT ≥ 1000 o CNS: e.g., seizures, impaired consciousness o Heart and other organs (i.e., myocarditis, renal failure) PHASES OF DENGUE INFECTION FEBRILE PHASE • Usually last 2-7 days • Mild hemorrhagic manifestations like petechiae and mucosal membrane bleeding (e.g. nose and gums) may be seen. • Monitoring of warning signs is crucial to recognize its progression to critical phase. CRITICAL PHASE • Phase when patient can either improve or deteriorate. • Defervescence occurs between 3 to 7 days of illness. o Defervescence is known as the period in which the body temperature (fever) drops to almost normal (between 37.5 to 38°C). • Those who will improve after defervescence will be categorized as Dengue without Warning Signs, while those who will deteriorate will manifest warning signs and will be categorized as Dengue with Warning Signs or some may progress to Severe Dengue. • When warning signs occurs, severe dengue may follow near the time of defervescence which usually happens between 24 to 48 hours. RECOVERY PHASE • Happens in the next 48 to 72 hours in which the body fluids go back to normal. • Patients general well-being improves. • Some patients may have classical rash of “isles of white in the sea of red”. • The White Blood Cell (WBC) usually starts to rise soon after defervescence but the normalization of platelet counts typically happens later than that of WBC. o Without warning signs but with co-existing conditions (pregnancy, infancy, old age, obesity, diabetes mellitus, hypertension, heart failure, renal failure, chronic hemolytic diseases such as sickle-cell disease and autoimmune diseases, etc.) o Social circumstances such as living alone or living far from health facility or without a reliable means of transportation. o The referring facility has no capability to manage dengue with warning signs and/or severe dengue • Group C – patient with severe dengue requiring emergency treatment and urgent referral o Severe plasma leakage leading to dengue shock and/or fluid accumulation with respiratory distress. o Severe hemorrhage o Severe organ impairment (hepatic damage, renal impairment, cardiomyopathy, encephalopathy or encephalitis. Patients in Group C shall be immediately referred and admitted in the hospital within 24 hours Dr. Virata NATIONAL DENGUE PREVENTION AND CONTROL PROGRAM • Vision: A dengue free Philippines • Mission: Ensure healthy lives and promote well-being for all at all ages. • Goal: To reduce the burden of dengue disease • Objectives/Indicators: o To reduce dengue morbidity by at least 25% by 2022 o To reduce dengue mortality by at least 50% by 2022 o To maintain Case Fatality rate (CFR) to <1% every year • Program components o Surveillance § Case surveillance § Laboratory-based surveillance/virus surveillance § Vector surveillance o Case Management and Diagnosis o Integrated Vector Management § Training on Vector management, training on basic entomology for sanitary inspector and training on integrated vector management (IVM) for health workers § Insecticide treated screens (ITS) as dengue control strategy in schools. o Outbreak response § Continuous DOH augmentation of insecticides such as adulticides and larvicides to LGU during outbreak o Health promotion and Advocacy § Celebration of ASEAN Dengue Day every June 15 o Research DENG-GET OUT 5S STRATEGY • Search and destroy mosquito breeding places tulad ng mga lumang gulong, paso, balde at drum • Secure self-protection tulad ng pantalon, long sleeved na damit, at mosquito repellant • Seek early consultation lalo na kung may sintomas ng dengue tulad ng mataas na lagnat at sakit ng kasu-kasuan, at pananakit ng likod ng mata • Support fogging and spraying only in hotspot areas • Sustain hydration lalo na kapag nilalagnat dahil sa dengue Previously 4S, ngayon, mas pinatibay na! Ginawa na nilang 5S para uminom ng tubig ang mga tao since supportive management talaga ang backbone ng Dengue therapy Please Note that 4S strategy also covers for other water related insect vector diseases – Zika and Chikungunya Dr. Mann and Dr. de la Rosa MALARIA • Malaria is a life-threatening disease caused by plasmodium parasites transmitted by Anopheles mosquito or rarely through blood transfusion and sharing of contaminated needles causing acute febrile illness and symptoms in the form of fever, headache MANAGEMENT (BASED ON PATIENT TYPE) and chills. • Group A – patient may be sent home if: • The principal vector throughout the Philippines is Anopheles o Tolerate adequate volume of oral fluids flavirostris, found from coastal plains near sea level up to 600mo Pass urine every 6 hours 1500m elevation. o Do not have any warning signs particularly when the fever o It has a strong preference for clear, slow-moving freshwater subsides habitats that are typically shaded by vegetation and with o Have stable hematocrit stream margins. • Group B – referred for in-hospital management o It is an opportunistic feeder and has a short flight range of just o With warning signs 1-2km. TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE AND PUBLIC HEALTH MAIN HANDOUT BY DR. MANN Page 51 of 77 For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the April 2024 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE AND PUBLIC HEALTH MAIN HANDOUT BY DR. MANN For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for April 2024 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. REVISED POLICY AND GUIDELINES ON THE DIAGNOSIS AND TREATMENT OF MALARIA • Microscopy will continue to be the “gold standard” for diagnosing malaria • The Artemether-Lumefantrine (AL) combination will be the first line medicine in the treatment of confirmed uncomplicated and severe Plasmodium falciparum malaria, replacing CQ+SP combination • If AL is not available, whether the patient is conscious or unconscious, and in case of treatment failure, quinine (QN) in combination with either tetracycline or doxycycline or clindamycin (QN+T/D/C x 7 days), will be the second-line treatment. • In severe malaria cases wherein the patient is unconscious, and the facility has no capacity to adequately manage the patient (e.g., naso-gastric tube or intravenous therapy), Artesunate (AS) suppository can be introduced pending transfer of patient to the next level of care.” • ACT can be used for all Plasmodium species and mixed infections • Direct Observed Treatment (DOT) will be adopted as the mode of treatment of all patients, with the first 3-day doses of AL treatment supervised by a trained health worker, BHW or treatment partner. • Immediate referral are recommended for severe malaria, patients who are pregnant and children below 5 years old. • Chloroquine (CQ) • Sulphadoxine/pyrimethamine (SP) • Artemisinin (ACT) Dr. Mann PREVENTION AND CONTROL • Strategies to disrupt malaria transmission include effective deployment of antimalarial drugs, personal mosquito protection, mosquito vector control, and research (including vaccine development) • Personal protection from infection — Potential tools for personal protection from infection include use of mosquito repellants and insecticide treated nets, intermittent preventive treatment for selected patient groups o Insecticide-treated nets § Pyrethroids are the major insecticides used routinely for bed net treatment § Long-Lasting Insecticidal Net (LLIN) § insecticide treated nets (ITNs) RECOMMENDED PROPHYLAXIS • Atovaquone-proguanil o take 1 tablet daily (atovaquone 250 mg + proguanil 100 mg). o start 1-2 days before entering the malarious area, continue daily during your stay and continue for 7 days after leaving. • Doxycycline o take 1 tablet daily of 100 mg. o start 1 day before entering malarious area, continue daily during your stay and continue for 4 weeks after leaving. • Mefloquine o take 1 tablet of 250 mg (228 mg base) once a week. o tart 1-2 weeks before entering the malarious area, continue weekly during your stay and continue for 4 weeks after leaving. https://www.cdc.gov/malaria/travelers/country_table/p.html Chloroquine phosphate or hydroxychloroquine sulfate can be used for prevention of malaria only in destinations where chloroquine resistance is not present, here in the Philippines we have chloroquine resistant malaria Dr. Mann PREGNANT PATIENTS • The major tools for preventing malaria in pregnant women are mosquito avoidance and preventive drug therapy • Pregnant travelers should be advised to defer travel to areas where risk of acquiring malaria is high until after delivery, if feasible • Nonimmune pregnant women (i.e., those not living in an endemic area) who cannot defer travel to an endemic area should take chemoprophylaxis. o The agents of choice are chloroquine (for travel to areas with chloroquine-sensitive malaria o Mefloquine (for travel to areas with chloroquine-resistant malaria) MALARIA CONTROL AND ELIMINATION PROGRAM • Vision: A malaria-free Philippines by 2030 • Mission: By 2022, malaria transmission will have been interrupted in all provinces except Palawan, 75 provinces will have been declared malaria-free, and the number of indigenous malaria cases will be reduced to less than 1200, i.e. by at least 75% relative to 2018. FOOD AND WATERBORNE DISEASES PREVENTION AND CONTROL PROGRAM • FWBDs refer to the limited group of illnesses characterized by diarrhea, nausea, vomiting with or without fever, abdominal pain, headache and/or body malaise. • These are spread or acquired through the ingestion of food or water contaminated by disease-causing microorganisms (bacterial or its toxins, parasitic, viral). BASIC CONCEPTS • There are five (5) infectious FWBDs that are under surveillance in the Philippines. o Acute bloody diarrhea, o Cholera, o Rotavirus, o Hepatitis A o Typhoid • The most common symptom of food and water-borne diseases is diarrhea. • And the most threatening consequence of diarrhea is dehydration. ASSESSMENT OF DEHYDRATION CLINICAL MANIFESTATION OF DIARRHEA IN CHILDREN ACCORDING TO THE LEVEL OF DEHYDRATION NO SIGNS OF DEHYDRATION <5% 3% Well; alert Drinks normally; not thirsty PARAMETERS Infant Child 2. General condition* 1. Fluid deficit 3. Thirst MILD TO MODERATE DEHYDRATION 5-10% 6% Restless; irritable SEVERE DEHYDRATION >10% 9% Lethargic; unconscious Thirsty; drinks eagerly Drinks poorly; not able to drink Present Slightly depressed / slightly sunken Present or decreased No tears <2 sec ~2 sec <3 sec 7. Respiration Normal Deep, may be rapid 8. Skin pinch* Goes back quickly 9. History of urine output Normal Goes back slowly Decreased (<0.5 mL/kg/hr in 8 hr) The presence of two or more of the above signs 4. Fontanel/eyes* Normal 5. Tears 6. Cutaneous perfusion/capillary time Interpretation Sunken Deep and rapid 2 months – 12 months: ≥ 50 breaths per min >1 year – 5 years: > 40 breaths per min Goes back very slowly Minimal (<0.3 mL/kg/hr in 16 hr) OR None(no urine output in 12 hr) The presence of two or more of the above signs Manual of Procedures Food and Water-borne Diseases Prevention and Control Program DEPARTMENT OF HEALTH TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE AND PUBLIC HEALTH MAIN HANDOUT BY DR. MANN For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the April 2024 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. Page 52 of 77 TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE AND PUBLIC HEALTH MAIN HANDOUT BY DR. MANN For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for April 2024 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. CLINICAL MANIFESTATION OF DIARRHEA IN ADULTS ACCORDING TO THE LEVEL OF DEHYDRATION PARAMETERS Fatigue Thirst Sunken eyes Blood pressure Respiratory rate (breaths per minute) Heart rate (beats per minute) Peripheral circulation Level of consciousness Oral mucosa Muscle weakness Skin turgor Capillary refill time Urine output (mL/kg/hr) MILD DEHYDRATION +/+/Normal MODERATE DEHYDRATION + + + Orthostatic hypertension SEVERE DEHYDRATION + + + Shock Normal 21-25 >25 ≥80 Warm Alert Moist None ≤2 sec ≤2 sec ≥0.5 >100 Cold, clammy Lethargic Dry Mild to moderate ≥2 sec ≥2 sec ≤0.5 Faint or thready pulse Cold, clammy Coma or stupor Dry Severe ≥2 sec ≥2 sec ≤0.5 MANAGEMENT OF DIARRHEA CASE • Fluid Replacement Therapy o Fluids and electrolyte replacement are the basic treatment of diarrhea to prevent death. o For breastfeed infants, breastfeeding should be continued in addition to hydration therapy. CONDITIONS FOR ADMISSION OF CHILDREN WITH ACUTE INFECTIOUS DIARRHEA: • Children who are not able to tolerate oral fluids • Children suspected of electrolyte imbalance • Children with the following physical findings on examination: o altered consciousness o abdominal distention o respiratory distress o hypothermia (body temperature of < 36 degrees Celsius) • Children with co-existing medical conditions such as pneumonia, meningitis / encephalitis, sepsis, moderate to severe malnutrition, and suspected surgical condition CONDITIONS FOR ADMISSION OF ADULT WITH ACUTE INFECTIOUS DIARRHEA: • Inability to tolerate oral rehydration • Moderate to severe dehydration • Acute Kidney injury • Presence of electrolyte abnormalities • Co-morbid conditions such as uncontrolled diabetes, congestive heart failure, coronary artery disease, chronic kidney disease, chronic liver disease, immunocompromised conditions; • Weak or elderly patients (>60 years old) • Poor nutritional status Please note that sport, carbonated, caffeinated, and sweetened drinks are not recommended to replace fluid losses. In pediatrics, primary management in acute infectious diarrhea is still rehydration therapy, routine empiric antibiotic therapy is NOT recommended. Antimicrobials may be recommended for the following conditions: suspected case of cholera, cases of bloody diarrhea and diarrhea associated with other acute infections (eg, pneumonia, meningitis) Zinc supplementation (20mg/day for 10-14 days) should be given routinely as adjunctive therapy for acute infectious diarrhea in children more than 6 months old. Probiotics are recommended as an adjunct therapy in children throughout the duration of the diarrhea. It has shown to reduce symptom severity and duration of diarrhea and may be extended 7 more days after completion of antibiotics Dr. VIrata REHYDRATION GUIDE FOR CHILDREN ACCORDING TO THE LEVEL OF DEHYDRATION NO MILD TO SEVERE DEHYDRATION MODERATE DEHYDRATION DEHYDRATION Reduced Reduced Rapid IV osmolarity oral osmolarity ORS is rehydration is rehydration recommended to recommended solution (ORS) is replace ongoing with plain lactated recommended to losses Ringer’s (pLR) replace ongoing solution or 0.9% losses If oral rehydration sodium chloride is not feasible, (with or without If commercial ORS administration of 5% glucose) is not available, ORS via NGT is homemade ORS preferred over IV may be given hydration (4-5 tsp of sugar and 1 tsp of salt in 1L of clean drinking water) RHU level Hospital level Hospital level Manual of Procedures Food and Water-borne Diseases Prevention and Control Program DEPARTMENT OF HEALTH RECOMMENDED REHYDRATION GUIDE FOR ADULTS ACCORDING TO THE LEVEL OF DEHYDRATION Mild dehydration Moderate dehydration Severe dehydration Oral rehydration solution is For Admitted Patients: For Admitted Patients: recommended at 1.5 – 2 times the 500 to 1,000 ml of plain Lactated 1,000 to 2,000 ml of PLRS within the first hour is estimated amount of volume deficit Ringer’s solution (PLRS) in the first 2 recommended. plus concurrent gastrointestinal hours is recommended. Once Once hemodynamically stable, give: losses. hemodynamically stable, give: • 2-3 ml/kg/hour PLRS for patients with actual or • 2-3 ml/kg/hour PLRS for patients estimated body weight of <50 kg with actual or estimated body weight • 1.5-2 ml/kg/hour PLRS for patients with actual or of <50 kg; estimated body weight of> 50 kg. • 1.5-2 ml/kg/hour PLRS for patients • Use ideal body weight for overweight or obese with actual or estimated body weight patients. of >50 kg; • Replace ongoing losses volume per volume with • Use ideal body weight for overweight PLRS boluses. ORS is not recommended since or obese patients; Replace ongoing patients with severe dehydration may have losses volume per volume with PLRS compromised mental status and therefore have boluses or ORS (if tolerated). high risk for aspiration. Manual of Procedures Food and Water-borne Diseases Prevention and Control Program DEPARTMENT OF HEALTH PREVENTIVE MEASURES • Personal Hygiene • Safe, clean water • Proper Food Handling : Some of the regulations from Chapter III of PD 856 are as follows: o No food establishment operates for public patronage without a Sanitary Permit. The permit is renewable yearly and should be posted in a conspicuous area. o No person shall be employed in any food establishment without a health certificate issued by the city/municipal health officer. This certificate shall be issued only after the required physical and mental examinations and immunizations. TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE AND PUBLIC HEALTH MAIN HANDOUT BY DR. MANN For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the April 2024 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. Page 53 of 77 TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE AND PUBLIC HEALTH MAIN HANDOUT BY DR. MANN For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for April 2024 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. o Requirements for food handlers: § Wearing of hair nets (restrain) and clean working garments; § Proper hand washing before handling any food (raw ingredients and cooked), after visiting the toilet, coughing or sneezing and after smoking; § No person shall be allowed to work as food handlers and be engaged in food preparation while afflicted with a communicable disease. • Proper excreta disposal oPer DOH recommendation, approved excreta disposal facilities include flush toilet connected to community sewer, Imhoff tank, septic tank, digester tank, chemical tank. Pit privy: VIP latrine, pit type, and antipolo toilet. o Separate utensils are used for each kind of food. o Left-over foods are never used o All contaminated foods of those of doubtful quality are condemned. • Vaccination o Killed oral cholera vaccine may be given to children and adults living in endemic areas to prevent outbreaks caused by cholera o Rotavirus is an important cause of diarrheal disease particularly in children under 5 years. o Rotavirus vaccines are effective in preventing rotavirus diarrhea and immunization of infants with rotavirus vaccine is recommended. Cholera vaccine is not meant to replace the provision for clean water and sanitation and hygiene (WASH), which are the core strategy for prevention of cholera. THE FOLLOWING HEALTHY PRACTICES SHOULD BE Dr. Mann OBSERVED AND FOLLOWED AT HOME OR IN ANY FOOD BUSINESS: FOOD SAFETY • Food preparation: • Food Safety is the assurance/guarantee that food will not cause o Only safe and wholesome food materials are used. harm to the consumers when it is prepared and/or eaten o Food materials are cleaned with safe water. according to its intended use o Enough equipment and utensils are provided, properly • Food-borne infection: Produced by living organisms entering cleaned and sanitized. the body with the food. o Food and food materials are prepared, processed and cooked in a sanitary manner. • Food poisoning/ food intoxication: produced by toxins or • Food storage: poisonous agents present in the food before consumption o Wet and dry foods are stored separately. o Proper temperature is maintained. COMMON CAUSES OF FOOD AND WATER BORNE DISEASES o Food and food materials are protected from contamination by • unsafe sources of drinking water insects and rodents, chemical substances and others. • improper disposal of human waste • Food serving: • unhygienic practices like spitting anywhere, blowing or picking o Food and food materials are properly displayed and protected the nose from all possible contamination. • unsafe food handling and preparation practices i.e. street o Food are served with clean and sanitized utensils. vended foods Maintenance of proper temperature ETIOLOGICAL PROBLEM FOOD INVOLVED PREVENTIVE MEASURES AGENT Cook food thoroughly Salmonellosis Salmonella species Poultry, salads, warmed over foods Strict personal cleanliness Moist food, dairy product, water, shell fish, Dysentery Species of Shigella salad contaminated with excreta of a carrier Strict personal cleanliness, cook food direct or indirect Pasteurization of milk and other dairy Typhoid fever S. typhi Same as above products, chlorination of water; vaccination T. saginata (beef) Insufficiently cooked beef, pork, fresh water Tapeworm T. solium (pork) Adequate cooking fish. D latum Toxins A,B, or C of C. Home processed CHON food; inadequately Pressure cooking in processed food; Botulism botulinum canned foods with pH over 3.5 adequate cooking Staph food Enterotoxin Cooked ham, salads of CHON-food Adequate cooking Poisoning producing staph • Recent board question: What are the different etiologic agents of acute infectious bloody diarrhea? Balikan ang Micro/Para, mga bhie! • Shigella, E. coli (EHEC), Entamoeba, Campylobacter, Salmonella, Yersinia enterocolitica • Memory aid: Having bloody diarrhea does not seem SEECSY (sexy) to me Dr. Tan TETANUS • Acute, often fatal, disease caused by an exotoxin produced by the bacterium Clostridium tetani. • Characterized by generalized rigidity and convulsive spasms of skeletal muscles. o muscle stiffness usually begins in the jaw (lockjaw) and neck and then becomes generalized PATHOGENESIS • Enters body through wound. Neonatal tetanus usually occurs because of umbilical stump infections. • Spores germinate in anaerobic conditions • Toxin binds in central nervous system • Interferes with neurotransmitter (GABA and glycine) release to block inhibitor impulses CLINICAL FEATURES • Incubation period average of 8 days (range, 3 to 21 days) • Three forms: o Generalized (most common -80% of cases) § Trismus (lockjaw), stiffness of the neck, difficulty swallowing, rigidity of abdominal muscles. o local (uncommon) § Muscle spasms in a confined area close to the site of the injury o cephalic (rare) § Incubation is short, usually 1-2 days. Sx include flaccid cranial nerve palsies and spasm of the jaw muscles. GUIDE TO TETANUS PROPHYLAXIS IN ROUTINE WOUND MANAGEMENT Indication for TT Immunization All Animal Bites VACCINATION HISTORY Unknown or < 3 3 or more doses doses Td* TIG/ATS Td* TIG/ATS YES YES NO** NO *TdaP may be substituted for Td if the person has not received TdaP and is 10 years or older; DPT may be given for patients < 7 years old; TT may be given if Td not available **Yes, if more than 5 years since last dose Table 16. National Rabies Prevention and Control Program Manual of Procedures 2019: 84 TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE AND PUBLIC HEALTH MAIN HANDOUT BY DR. MANN For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the April 2024 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. Page 54 of 77 TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE AND PUBLIC HEALTH MAIN HANDOUT BY DR. MANN For inquiries visit www.topnotchboardprep.com.ph or https://www.facebook.com/topnotchmedicalboardprep/ This handout is only valid for April 2024 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. NATIONAL RABIES PREVENTION AND CONTROL PROGRAM • Rabies is a human infection that occurs after a transdermal bite or scratch by an infected animal, like dogs and cats. • can be transmitted when infectious material, usually saliva, comes into direct contact with a victim’s fresh skin lesions. RABIES IN THE PHILIPPINES • Rabies is endemic in the Philippines, and remains to be a public health concern. • 100% fatality rate but 100% preventable • One of the measures by which rabies could be prevented is through the implementation of the RA 9482, Anti-Rabies Act of 2007, which mandated the creation of a National Rabies Prevention and Control Program (NRPCP) • Agencies / Organizations involved in attaining the goals of the National Rabies Prevention and Control Program: o Department of Health (DOH) o Department of Agriculture (DA) – chair (Bureau of Animal Industry) o Department of Education (DepEd) o Department of Interior and Local Government (DILG) o Department of Environment and Natural Resources (DENR) o World Health Organization (WHO) o Animal Welfare Coalition (AWC) COMPONENTS • Mass Dog Vaccination o most effective measure to control canine rabies. o Headed by the Department of Agriculture in mass dog vaccination campaigns and provision of animal rabies vaccine. • Post-Exposure Prophylaxis (PEP) and Pre-Exposure (PrEP) o Post Exposure Prophylaxis (PEP) – antirabies prophylaxis should be administered after an exposure (such as bite, scratch, lick, etc.) o Pre-Exposure Prophylaxis (PrEP) – vaccination should be given to individuals who are at high risk of getting rabies • Health Education and advocacy campaign o Celebration of Rabies Awareness Month under Executive Order No. 84, March is Rabies Awareness Month o September 28 is World Rabies Day o Development of IEC materials o Integration of Rabies Program into the School Curriculum Bakit March and Rabies Awareness Month? Kasi higher yung chances na maging aggressive ang mga hayop ng summer dahil sa init. Integration in school curriculum, specifically sa Elementary since sila kasi yung madalas nakakagat dahil sila yung mas adventurous at mas malaro sa mga hayop • • • • Dr. de la Rosa Training/Capability Building Training on National Rabies Information System (NaRIS) Establishment of ABTCs by Inter-Local Health Zone DOH-DA joint evaluation and declaration of Rabies-free areas/provinces 4 R’S IN ANIMAL RABIES RISK ASSESSMENT: • Recognizing • Recording • Reporting • Referral RECOGNIZE THE CLINICAL SIGNS OF RABIES IN DOMESTIC ANIMALS • Withdrawal from and resistance to contact; seeking seclusion • Wide-eyed; reduced frequency or absence of blinking; dilated pupils; photophobia • Exaggerated, often aggressive, response to tactile, visual, or auditory stimuli • Snapping/biting at imaginary objects • Pica (eating or mouthing sticks, stones, soil, clothing, feces, etc.) • Aggressively attacking inanimate objects • Sexual excitement with attempts to mount inanimate objects • Compulsive running or circling, often to the point of exhaustion • Obsessive licking, biting, or scratching at the site of viral inoculation • Dropped jaw, inability to swallow, excessive salivation • Change in tone, timbre, frequency, or volume of vocalizations • Flaccid or deviated tail/penis • Tenesmus (due to paralysis of the anal sphincter) • Muscular tremors • Acute onset of mono-para-,or quadri-paresis; lameness • Abnormal, exaggerated gait; ataxia and incoordination • Convulsive seizures • Paralysis, prostration, recumbency • Death Reminder lang doc, signs po ito ng rabid animal hindi ng human patient! J Aso yern? Aw aw! The Burial Requirement under the Philippine Sanitation Code (PD 856) Section 91 states that “When the cause of death is a dangerous communicable disease, the remains shall be buried within 12 hours after death. They shall not be taken to any place of public assembly. Only the adult members of the family of the deceased may be permitted to attend the funeral.” It is highly recommended that early disposal of the body by cremation or burial should be done depending on their religious practice. Dr. Mann MEDICAL MANAGEMENT OF ANIMAL BITES • There are three main tenets on the management of animal bite cases based on the categorization of the bite o Cleaning of the wound o Active Immunization o Passive Immunization • If signs of infection are present: o Swab for culture o Antibiotic therapy • Empirical therapy should be directed against those microorganisms most likely to be present for dogs and cats pathogen such as Pasteurella, Streptococcus, Staphylococcus and Anaerobes. Category II Category I CATEGORIES OF RABIES EXPOSURE WITH CORRESPONDING MANAGEMENT EXPOSURE • Feeding/touching an animal • Licking of intact skin (with reliable history and thorough physical examination) • Exposure to patient with signs and symptoms of rabies by sharing of eating or drinking utensils • Casual contact (talking to, visiting and feeding suspected rabies cases) and routine delivery of health care to patient with signs and symptoms of rabies • Nibbling of uncovered skin with or without bruising/hematoma • Minor/superficial scratches/abrasions without bleeding, including those induced to bleed All Category II exposures on the head and neck area are considered Category III and shall be managed as such. MANAGEMENT • Wash exposed skin immediately with soap and water. • No vaccine or RIG needed • Pre-exposure prophylaxis may be considered for high-risk persons • Wash wound immediately with soap and water for at least 10 minutes. • Start vaccine immediately o No human rabies vaccine shall be provided, provided that ALL of the following conditions are satisfied: § Dog/cat is healthy and available for observation for 14 days § Dog/cat was vaccinated against rabies for the past 2 years • Complete vaccination regimen until day 7 • No RIG needed o If the biting animal starts to show signs of rabies, immediately give vaccine and RIG TOPNOTCH MEDICAL BOARD PREP PREVENTIVE MEDICINE AND PUBLIC HEALTH MAIN HANDOUT BY DR. MANN For inquiries visit www.topnotchboardprep.com.ph or email us at [email protected] This handout is only valid for the April 2024 PLE batch. This will be rendered obsolete for the next batch since we update our handouts regularly. Page 55 of 77