Far Eastern University

Institute of Health Sciences and Nursing

Department of Nursing

COMMUNITY HEALTH NURSING 2 NUR1214

MODULE 2.2 ENVIRONMENTAL SANITATION, VECTOR AND VERMIN CONTROL

At the end of the Lecture the students will be able to:

1. Discuss the Different practices of Sanitation in the Philippines
2. Identify the different levels of Safe Water Sources and Excreta System
3. Enumerate the Food Safety rights in the Philippines
4. Identify the different segregation practices in the Philippines
5. Enumerate the different laws affecting Environmental Sanitation in the Philippines
6. Discuss Control Programs for Vector Borne and Vermin in the Philippines

Environmental Health is concerned with preventing illness through managing the environment and by
changing people’s behavior to reduce exposure to biological and non-biological agents of disease and injury
Environmental Sanitation is defined as the study of all factors in man’s physical environment which may have
a deleterious effect on man’s health, well being and survival.

Safe Sources of Water

THREE TYPES OF APPROVED WATER SUPPLY

DESCRIPTION LEVEL 1 LEVEL 2 LEVEL 3

POINT SOURCE / COMMUNAL FAUCET WATERWORKS SYSTEM
DEVELOPED SYSTEM / STAND POST
SPRINGS
SUITABLE AREA RURAL AREAS RURAL AREA WHERE DENSELY POPULATED
HOUSES ARE HOUSES ARE URBAN AREAS
THINLY CLUSTERED DENSELY
SCATTERED
NUMBER OF 15 – 25 HH AVERAGE OF 100 MORE THAN 100
HOUSEHOLDS HOUSEHOLD HOUSEHOLD
SERVED STAND POST: 4 – 6 HH
DISTANCE FROM NOT GREATER NOT MORE THAN 25 REACHES EVEN
FARTHEST THAN 250 MTERS METERS FROM THE OUTLYING
HOUSEHOLD FROM THE FARTHEST HOUSEHOLD COMMUNITIES
FARTHEST HOUSE
WATER YIELD OR 40 TO 140 LITERS 40 TO 80 LITERS OF AT LEAST INE FAUCET
DISCHARGE WATER PER CAPITAL PER HOUSEHOLD
PER DAY WITH ONE
FAUCET PER

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 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing

Proper Excreta and Sewerage System

LEVEL 1
• Non-water carriage toilet facility – no water is necessary to wash the waste into
the receiving space such as Pit Latrines, Reed odorless earth closet.
• Toilet Facilities requiring small amount of water to wash the waste into the
receiving space such as pour flush toilet and aqua prives

LEVEL 2
• On Site toilet facilities of the water carriage type with water-sealed and flush
type with septic vault/ tank disposal facility
• Commonly use in the Philippines

LEVEL 3
• Water carriage types of toilet facilities connected to septic tanks and or to
Sewerage System or Treatment Plant
• Commonly used in High End Villages and Condominiums where the toilet are
connected to a Sewerage System or Treatment Plant
• Rural areas use Blind Drainage or collection type of disposal facility.

Safe Food Practices

• Food Establishment must have sanitary permit
• No person shall be employed in food establisgment without any health certificate
• No person shall be allowed to work in food handling while affected by a communicable disease
such as boils, infected wounds, respiratory infection, diarrhea and GI upset
• After properly washing the Utensils, Immersion for at least half a minute in clean hot water
77C, or lukewarm water with 55-100ppm of chlorine solution for one minute, or steam for 15
minutes to 77C or 5 minutes to 200C

FOUR RIGHTS IN FOOD SAFETY

• Right Source
• Always Buy Fresh meat, fish, fruits and vegetables
• Always look at the Expiry Dates of processed foods and Avoid buying the expired
ones
• Avoid buying canned foods with dents, buldges, deformation, broken seals and
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 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing
improper seams
• Use water only from clean and safe sources
• When in doubt with water sources boil for at least 2 minutes (running boiling)

• Right Preparation
• Avoid Contact between raw foods and cooked foods
• Always buy Pasteurized milk and fruit juices
• Wash vegetables well if to be eaten raw such as lettuce, cucumber , tomatoes
and carrots
• Always wash hand and kitchen utensils before and after preparing food
• Sweep kitchen floors to remove food droppings to prevent the harbor of rats and
insects

• Right Cooking
• Cooking food thoroughly and ensure that the temperature on all parts of the
food should reach 70 degrees centigrade
• Eat cooked food immediately
• Wash hands thoroughly before and after eating
• Right Storage
• All cooked food should be left at room temperature for NOT more than 2 hours
to prevent multiplication of Bacteria.
• Store cooked foods carefully. Be sure to use tightly sealed containers for storing
of foods.
• Be sure to store food under hot conditions (at least 60 degrees centigrade) or in
Cold conditions (below or equal to 10 degrees centigrade) This is vital if you plan
to store food for more than four to five hours. Microbrial organism easily multiply
within 10 – 60 degrees centigrade temperature
• Foods for infants should always be freshly prepared and not be stored at all
• Reheat strored food before eating. Food should be reheated to at least 70
degrees centigrade
• “WHEN IN DOUBT, THROW IT OUT”

Proper Disposal

Proper Solid Waste Management refers to satisfactory methods of storage, collection and final disposal of
solid waste
Refuse is a general term applied to solid and semi solid waste material other than human excreta. Waste in
refuse may be divided into:
a. Garbage – refers to leftover vegetable, animal and fish material from kitchen and food establishment.
These materials have the tendency to decay, thus giving off foul odors.
b. Rubbish – refers to waste materials such as bottles, broken glass, porcelain, tin cans, waste paper
discarded textile materials, pieces of metal and other wrapping materials.

PROHIBITED ACTS ON SOLID WASTE MANAGEMENT ACT

 Open Burning of Solid Wastes
 Open Dumping
 Burying on flood prone areas

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 Squatting in Landfills
 Operation of Landfills on any aquifer, groundwater reservoir or
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Institute of Health Sciences and Nursing
Department of Nursing
watershed
 Construction of any establishment within 200 meters from a dump
or landfill

CATEGORIES OF HEALTH CARE WASTE

Black – Non-infectious Dry Waste
Green – Non-infectious wet Waste
Yellow – Infectious / Pathological waste
Orange – Radioactive
Red – Sharps

MAJOR LAW REGULATIONG SANITATION IN THE PHILIPPINES

PD 856 SANITATION CODE OF THE PHILIPPINES
PD 825 ANTI LITTERING LAW
RA 9003 SOLID WASTE MANAGEMENT ACT
RA 8749 CLEAN AIR ACT
RA 9275 CLEAN WATER ACT
RA 9512 NALT ENVIRONMENTAL AWARENES ACT
EO 26 NATIONAL SMOKING BAN
RA 10611 FOOD SAFETY ACT
RA 6969 TOXIC SUBSTANCES AND HAZARDOUS AND NUCLEAR WASTE CONTROL ACT

VECTOR AND VERMIN CONTROL PROGRAMS

Leptospirosis (Weil’s disease)

 Leptospirosis is a bacterial disease that affects humans and animals. It is caused by bacteria of the
genus Leptospira. In humans, it can cause a wide range of symptoms, some of which may be mistaken
for other diseases. Some infected persons, however, may have no symptoms at all.
 Leptospirosis is a bacterial disease that occurs worldwide and can cause serious illnesses such as kidney
or liver failure, meningitis, difficulty breathing, and bleeding. Cases of leptospirosis can increase after
hurricanes or floods when people may be exposed to contaminated water or use it for drinking or bathing.

How do people get leptospirosis?

 Encountering water or soil containing urine or bodily fluids from infected animals
 Directly touching urine or bodily fluids from an infected animal
 Eating food or drinking water contaminated by urine

Clinical Manifestations:
 High fever
 Headache
 Chills
 Muscle aches
 Vomiting

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 Jaundice (yellow skin and eyes)
 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing
 Red eyes
 Abdominal pain
 Diarrhea
 Rash

Treatment:

Leptospirosis is treated with antibiotics, such as doxycycline or penicillin, which should be given early in the
course of the disease.
Intravenous antibiotics may be required for persons with more severe symptoms. Persons with symptoms
suggestive of leptospirosis should contact a health care provider.

DOH Program: Food and Waterborne Diseases Prevention and Control Program
Food and Waterborne Diseases (FWBDs) refer to the limited group of illnesses characterized by diarrhea, nausea,
vomiting with or without fever, abdominal pain, headache, and body malaise. These are spread or acquired
through the ingestion of food or water contaminated by disease-causing microorganisms which can be bacterial,
parasitic, or viral. Hence, this program aims to to reduce the morbidity and mortality due to FWBDs and outbreaks
through case management, lab diagnosis, health promotion, policy development, logistics management,
research and M&E, and surveillance and interagency collaboration. WATERBORNE, INFLUENZA, LEPTOSPIROSIS
AND DENGUE (WILD) DISEASES

Vision: A Food and waterborne disease free Philippines

Mission: To reduce the burden of FWDs and outbreaks through case management, lab diagnosis, health
promotion, policy development, logistics management, research and M&E, and surveillance and interagency
collaboration

Goal: Reduced morbidity and mortality due to FWBDs including outbreaks

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 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing

Malaria

 Malaria (from Medieval Italian: mala aria – “bad air”; formerly called ague or marsh fever) is an
infectious disease that is widespread in many tropical and subtropical regions.
Causative Agent: Plasmodium Falcifarum, P. Vivax, P. Ovale and P. Malariae

Signs & Symptoms:

 Chills to convulsion
 Hepatomegaly
 Anemia
 Sweats profusely
 Elevated temperature

DOH Program: Malaria Control and Elimination Program

Malaria is a life-threatening disease caused by plasmodium parasites transmitted by anopheles mosquito or
rarely through blood transfusion and sharing of contaminated needles. Untreated malaria may progress to severe
illness and even death. The Philippines carried a high burden of malaria disease in the past but with the
unrelenting efforts of the National Malaria Control and Elimination Program, cases and deaths have been reduced
significantly, and the country is now inching towards elimination. Hence, this program aims to eliminate malaria
by adopting a health system focused approach to achieve universal coverage with quality-assured malaria
diagnosis and treatment, strengthen governance and human resources, maintain the financial support needed,
and ensure timely and accurate information management.

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.

Malaria is a life-threatening disease caused by the Plasmodium parasite often transmitted to humans through
the bite of the Anopheles mosquito. People infected with malaria may experience kidney failure, seizure, coma,
and may die, if left untreated.

Modes of Transmission:
Malaria is caused by Plasmodium parasites, mainly: P. falciparum, P. vivax, P. ovale, and P.malariae. These
parasites are spread through the bites of the female Anopheles mosquito from an infected person to another.

Specifically, the Anopheles mosquito becomes a carrier of the parasite when it bites or takes a blood meal from
a person infected with plasmodium parasites in their bloodstream. The parasites then mix into the mosquito’s
saliva which then gets injected into the next person that gets bitten. Anopheles mosquitoes often bite between
dusk and dawn. Another Plasmodium parasite, P. knowlesi, can also cause malaria in humans but is transmitted
through macaques rather than mosquitoes. This is called “zoonotic malaria” and usually occurs in Southeast
Asia.

Malaria cannot be transmitted through close contact, but mothers who have the disease may pass on the parasite
before and during childbirth. People receiving blood transfusions and organ transplants, or sharing needles with
infected patients may also contract malaria.
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 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing

Symptoms of malaria”
Malaria is an acute febrile disease and symptoms often occurs within 10-15 days after the infective mosquito
bite. First symptoms usually appear mild like fever, chills, and headache, but as the disease progresses, patients
may experience anemia, jaundice, nausea, vomiting, and diarrhea. People infected with the P. Falciparum
parasite die within 24 hours, if left untreated.

Most at risk of malaria:

In the Philippines, only Sultan Kudarat and two towns in the province of Palawan remain endemic with malaria.
Meanwhile, the following provinces have been declared malaria-free: Cebu, Bohol, Catanduanes, Iloilo, Aklan,
Capiz, Guimaras, Leyte, Biliran, Camiguin, Siquijor, Northern Samar, Southern Leyte, Benguet, Masbate, Cavite,
Surigao del Norte, Marinduque, Western Samar, Eastern Samar, Albay, Sorsogon, Batangas, Camarines Sur,
Batanes Islands, Dinagat Islands, Romblon, Abra, Quirino, Davao Oriental, Lanao del Norte, Misamis Occidental,
Mountain Province, Nueva Vizcaya, Misamis Oriental, South Cotabato , Bataan, La Union, Pangasinan, Ilocos
Norte, Surigao del Sur, Compostela Valley, Ilocos Sur, Kalinga, Bulacan, Pampanga, Bukidnon, Davao Occidental,
Ifugao, Agusan del Sur, Tarlac, Laguna, Quezon, Antique, Negros Oriental, Zamboanga del Norte, Zamboanga
Sibugay, Davao del Sur, Sarangani, Agusan del Norte.

Diagnosis and Treatment:

People suspected with malaria will have their blood diagnosed with a parasitological-based test to determine the
presence of Plasmodium parasites. Those found to have the fatal P. Falciparum needs to undergo artemisinin-
based combination therapy. Other malaria types can be cured through several prescription drugs and those in
the early stages can undergo chemoprophylaxis which can suppress the spread of malaria in the blood.

Prevention:
Insecticide-treated nets are recommended for those living in high-risk areas for malaria. Effective vector control
through indoor residual spraying of insecticide and eliminating mosquito breeding grounds can also help bring
down transmission rates. For added protection, the WHO prescribes sulfadoxine-pyrimethamine to pregnant
women and children below the age of 5 during high-transmission season.

Preventive Measures: (CLEAN)

 Chemically treated mosquito nets
 Larvae eating fish
 Environmental clean up
 Anti mosquito soap/lotion
 Neem trees/eucalyptus tree

Filariasis

 name for a group of tropical diseases caused by various thread-like parasitic round worms
(nematodes) and their larvae
 larvae transmit the disease to humans through a mosquito bite
 can progress to include gross enlargement of the limbs and genitalia in a condition called
elephantiasis
 The causative agents of lymphatic filariasis (LF) include the mosquito-borne filarial
nematodes Wuchereria bancrofti, Brugia malayi, B. timori An estimated 90% of LF cases are
caused by W. bancrofti (Bancroftian filariasis).

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 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing
Hosts and Vectors
 Wuchereria bancrofti, Brugia malayi, and B. timori are considered human parasites as animal reservoirs
are of minor epidemiologic importance or absent; felid species and some primates are the primary
reservoir hosts of zoonotic B. pahangi.
 The typical vector for Brugia spp. filariasis are mosquito species in the genera Mansonia and Aedes. W.
bancrofti is transmitted by many different mosquito genera/species, depending on geographical
distribution. Among them are Aedes spp., Anopheles spp., Culex spp., Mansonia spp., and Coquillettida
juxtamansonia.

Sign/Symptoms:

While severe manifestations do not develop in the majority of infections, LF is a potentially highly disfiguring
and disabling disease. The most prominent clinical feature is the development of severe lymphedema of the
limbs (“elephantiasis”) and occasionally genitalia (hydrocele) due to dysfunction of lymphatic vessels. Affected
limbs become grossly swollen; the skin may become thick and pitted, and secondary infection are frequent due
to lymphatic dysfunction. Scrotal hydrocele is also seen in some infected males. Lymphangitis, lymphadenopathy,
and eosinophilia may accompany infection in the early stages.

A chronic syndrome called “tropical pulmonary eosinophilia” has been associated with W. bancrofti and B.
malayi infections, involving eosinophilic pulmonary infiltrate, peripheral hypereosinophilia, wheezing, chest pain,
splenomegaly, and bloody sputum. This has most frequently been documented in South and Southeast Asia.

Management:
 Diethylcarbamazine citrate or Hetrazan
 Ivermectin,
 Albendazolethe
 No treatment can reverse elephantiasis
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 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing

Prevention and Control

The best way to prevent lymphatic filariasis is to avoid mosquito bites. The mosquitoes that carry the
microscopic worms usually bite between the hours of dusk and dawn . If you live in an area with lymphatic
filariasis:

 At night
o Sleep in an air-conditioned room or
o Sleep under a mosquito net
 Between dusk and dawn
o Wear long sleeves and trousers and
o Use mosquito repellent on exposed skin.
Another approach to prevention includes giving entire communities medicine that kills the microscopic
worms — and controlling mosquitoes. Annual mass treatment reduces the level of microfilariae in the
blood and thus, diminishes transmission of infection. This is the basis of the Global Programme to
Eliminate Lymphatic Filariasis.

Experts consider that lymphatic filariasis, a neglected tropical disease (NTD), can be eliminated
globally and a global campaign to eliminate lymphatic filariasis as a public health problem is under way.
The elimination strategy is based on annual treatment of whole communities with combinations of
drugs that kill the microfilariae. As a result of the generous contributions of these drugs by the
companies that make them, hundreds of millions of people are being treated each year . Since these
drugs also reduce levels of infection with intestinal worms, benefits of treatment extend beyond
lymphatic filariasis. Successful campaigns to eliminate lymphatic filariasis have taken place in China and
other countries.

DOH Program: Filariasis Elimination Program

Various provinces and areas in the country still experience an outbreak of Filariasis, which is a disease caused
by parasitic roundworms usually transmitted through mosquito bites. Consequently, this program aims to
eliminate Filariasis as a public health problem through a comprehensive approach and universal access to quality
health services that combat the disease such as mass treatment programs integrated with parasitic control
programs and elimination campaigns

Vision: Healthy and productive individuals and families for filariasis-free Philippines

Mission: Elimination of Filariasis as public health problem thru a comprehensive approach and universal access
to quality health services

Schistosomiasis

Schistosomiasis (Bilharziasis) is caused by some species of blood trematodes (flukes) in the

genus Schistosoma. The three main species infecting humans are S chistosoma haematobium, S. japonicum,
and S. mansoni. Three other species, more localized geographically, are S. mekongi, S. intercalatum, and S.

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guineensis (previously considered synonymous with S. intercalatum). There have also been a few reports of
 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing
hybrid schistosomes of cattle origin (S. haematobium, x S. bovis, x S. curassoni, x S. mattheei) infecting
humans. Unlike other trematodes, which are hermaphroditic, Schistosoma spp. are dioecous (individuals of
separate sexes).

Clinical Presentation
Symptoms of schistosomiasis are not caused by the worms themselves but by the body’s reaction to the eggs.
Many infections are asymptomatic. A local cutaneous hypersensitivity reaction following skin penetration by
cercariae may occur and appears as small, itchy maculopapular lesions. Acute schistosomiasis (Katayama
fever) is a systemic hypersensitivity reaction that may occur weeks after the initial infection, especially by S.
mansoni and S. japonicum. Manifestations include systemic symptoms/signs including fever, cough, abdominal
pain, diarrhea, hepatosplenomegaly, and eosinophilia.

Occasionally, Schistosoma infections may lead to central nervous system lesions. Cerebral granulomatous
disease may be caused by ectopic S. japonicum eggs in the brain, and granulomatous lesions around ectopic
eggs in the spinal cord may occur in S. mansoni and S. haematobium infections. Continuing infection may
cause granulomatous reactions and fibrosis in the affected organs (e.g., liver and spleen) with associated
signs/symptoms.

Pathology associated with S. mansoni and S. japonicum schistosomiasis includes various hepatic complications
from inflammation and granulomatous reactions, and occasional embolic egg granulomas in brain or spinal
cord. Pathology of S. haematobium schistosomiasis includes hematuria, scarring, calcification, squamous cell
carcinoma, and occasional embolic egg granulomas in brain or spinal cord.

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 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing

Preventive measures
 health education regarding mode of transmission and methods of protection; proper disposal of
feces and urine; improvement of irrigation and agriculture practices
 Control of patient, contacts and the immediate environment

Treatment:
Safe and effective medication is available for treatment of both urinary and intestinal schistosomiasis.
Praziquantel, a prescription medication, is taken for 1-2 days to treat infections caused by all schistosome
species.

Dengue

 DENGUE is a mosquito-borne infection which in recent years has become a major international
public health concern..
 It is found in tropical and sub-tropical regions around the world, predominantly in urban and semi-
urban areas.
Sign/Symptoms: (VLINOSPARD)
 Vomiting
 Low platelet
 Nausea
 Onset of fever
 Severe headache
 Pain of the muscle and joint
 Abdominal pain
 Rashes
 Diarrhea
Treatment:
 The mainstay of treatment is supportive therapy.
 Intravenous fluids
 A platelet transfusion

DOH Program: Schistosomiasis Control and Elimination Program

Schistosomiasis japonicum is an acute and chronic disease caused by parasitic worms called trematodes or blood
flukes. It is endemic in the Philippines and is transmitted through contact with fresh water infested with the
parasite that penetrates human and animal skin. In the Philippines, the total population at risk is approximately
12.4 million with 2.7 million individuals directly exposed to the disease. Hence, this program aims to eradicate
the transmission and incidence of Schistosomiasis Infection in all endemic barangays by 2025.

Vision: Schistosomiasis Free Philippines

Mission: Synchronized and harmonized public and private stakeholders’ efforts in the elimination of
schistosomiasis in the Philippines

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Dengue is an infection caused by the virus carried by female mosquitoes Aedes aegypti and Aedes altropicus.
 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing

Mode of Transmission: Vector Borne through a Mosquito Bite. A. aegypti can be identified by the white and black
stripes on their body. These mosquitoes are usually bites between 6:00 to 8:00 a.m. and 4:00 to 8:00 p.m.
night. A. aegypti mosquitoes usually live and nest in clear water. Exposed containers outside your homes can
be filled with water when it rains it makes a breeding site or nest of mosquitoes.

Causative Agent: DENV I, DENV2, DENV3 and DENV4

Symptoms of dengue include the following:

sudden high fever that can last from two (2) to seven (7) days , joint and muscle pain, weakness, skin rashes,
stomach ache, nosebleeds when the fever begins to subside, vomiting, dark colored poop, difficulty breathing,
pain behind the eye

DENGUE CASE CLASSIFICATION AND LEVEL OF SEVERITY

 Dengue illness is categorized according to level of severity as dengue without warning signs,
dengue with warning signs and severe dengue.
 Dengue without warning warnings can be further classified according to signs and symptoms
and laboratory tests as suspect dengue, probable dengue and confirmed dengue.
a. dengue without warning signs
a.1 suspect dengue
- a previously well individual with acute febrile illness of 1-7 days duration plus two of the following: headache,
body malaise, retro-orbital pain, myalgia, arthralgia, anorexia, nausea, vomiting, diarrhea, flushed skin, rash
(petechial, Hermann’s sign)
a.2 probable dengue
- a suspect dengue case plus laboratory test: Dengue NS1 antigen test and atleast CBC (leukopenia with or
without thrombocytopenia) or dengue IgM antibody test (optional)
a.3 confirmed dengue
- a suspect or probable dengue case with positive result of viral culture and/or Polymerase Chain Reaction
(PCR) and/or Nucleic Acid Amplification Test- Loop Mediated Amplification Assay (NAAT-LAMP) and/ or 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: abdominial pain or
tenderness, persistent vomiting, clinical signs of fluid accumulation (ascites), mucosal bleeding, lethargy or
restlessness, liver enlargement, increase in haematocrit and/or decreasing platelet count
c. severe dengue
severe plasma leakage leading to
 shock (DSS)
 fluid accumulation with respiratory distress
severe bleeding
 as evaluated by clinician
severe organ impairment
 Liver: AST or ALT ≥ 1000
 CNS: e.g. seizures, impaired consciousness
 Heart:and other organs (i.e. myocarditis, renal failure)
PHASES OF DENGUE INFECTION
a. Febrile Phase
 Usually last 2-7 days

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 Mild haemorrhagic manifestations like petechiae and mucosal membrane bleeding (e.g
nose and gums) may be seen.
 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing
 Monitoring of warning signs is crucial to recognize its progression to critical phase.
b. Critical Phase
 Phase when patient can either improve or deteriorate.
 Defervescence occurs between 3 to 7 days of illness. 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.
c. 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.
MANAGEMENT (based on patient type)
1. Group A- patients who may be sent home
These are patients who are able to:
 Tolerate adequate volumes of oral fluids
 Pass urine every 6 hours
 Do not have any of the warning signs particularly when the fever subsides
 Have stable haematocrit
2. Group B- patient who should be referred for in-hospital management
Patients shall be referred immediately to in-hospital management if they have the following conditions:
 Warning signs\
 Without warning signs but with co-existing conditions that may make dengue or its
management more complicated ( such as pregnancy, infancy, old age, obesity, diabetes
mellitus, hypertension, heart failure, renal failure, chronic haemolytic diseases such as
sickle- cell disease and autoimmune diseases, etc.)
 Social circumstances such as living alone or living far from health facility or without a
reliable means of transportation.
 The referring facility has no capability to manage dengue with warning signs and/or
severe dengue.
3. Group C- patient with severe dengue.requiring emergency treatment and urgent referral
These are patients with severe dengue who require emergency treatment and urgent referral because they are
in the critical phase of the disease and have the following:
 Severe plasma leakage leading to dengue shock and/or fluid accumulation with
respiratory distress;
 Severe haemorrhages;
 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.

DOH Program: Aedes Borne Viral Disease Prevention and Control Program

Vision Aedes-borne Viral Disease-free Philippines

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 Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing
Mission Reduced disease burden of Dengue, containment and prevention of transmission of Chikungunya and
Zika
Goal: To reduce the disease burden of dengue, and to contain and prevent transmission of chikungunya and
zika

Notable DOH Program:

Remember the 4 o’clock habit where the community is encouraged to look for water containers where
mosquitoes can infest and destroy or overturn.
Always remember 4S:
1. Search and destroy mosquito breeding places. Sweep and destroy the infested with mosquitoes.
2. Self protection. Self protect against mosquitoes.
3. Seek early consultation. Go to the nearest hospital immediately to avoid it ○ the pain worsened
4. Support fogging/spraying only in hotspot areas where increase in cases is registered for two consecutive
weeks to prevent an impending outbreak.

REFERENCES:
Cuevas, F.L., Reyala, J.P (2007) Public Health Nursing in the Philippines
David, E.S. (2007) Community Health Nursing. An Approach to Families and Population Groups
Maglaya, A.S. (2009) Nursing Practice in the Community
Navales, D.M. (2020) Common Communicable and Infectious Diseases
www.cdc.com
www.doh.gov.ph

Prepared by:
John Vincent A. Gasmin, CHN 2 Team Leader
August 2023

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