The following discussion is a summary of the following notes, based on the 2nd Philippine edition of Nies and McEwen’s Community and Public Health Nursing (Famorca) textbook.
This discussion is continued at CHN D2. As discussed by Ma’am Aida V. Garcia, RN, MAN
Traditional and Complementary Medicines
Republic Act 8423, titled the Traditional and Alternative Medicine Act (TAMA) authored by Senator Juan Flavier institutes the Philippine Institute of Traditional and Alternative Health Care (PITAHC) under the DOH to improve the quality and delivery of health care services to the Filipino people through the development of traditional and alternative health care and its integration into the national health care. Today, these methods are called T&CM, Traditional and Complementary Medicine.
Herbal Medicines
Colloquially known as “Botika sa Paso” (literally “Pot Pharmacy”), it is defined as the use of plants or derivatives from plants for the treatment of specific conditions. In the Philippines, it is one of the most popular modalities of complementary medicine. Currently, the DOH recommends ten such medicines:
- Lagundi:
- Use: Cold, cough, fever, asthma, dysentery, pain, skin diseases, wounds
- Preparation: Decoction, Wash affected site with decoction
- Yerba Buena: analgesic
- Use: Headache, stomachache, cough and colds, rheumatism and arthritis
- Preparation: Decoction, Infusion, Massage Sap
- Sambong:
- Use: Antiedema, antiurolithiasis
- Preparation: Decoction
- Tsaang Gubat:
- Use: Diarrhea, Stomachache
- Preparation: Decoction
- Niyog-niyogan:
- Use: Anthelminthic; not for children less than 4 years old
- Preparation: Seeds are used
- Bayabas: antiseptic, antiinflammatory
- Use: Washing wounds, diarrhea, gargle, toothache
- Preparation: Decoction
- Akapulko:
- Use: Antifungal
- Preparation: Poultice
- Ulasimang Bato A.K.A. Pansit-pansitan:
- Use: Lowers blood uric acid (rheumatism and gout)
- Preparation: Decoction, eaten raw
- Bawang:
- Use: Hypertension, lowers blood cholesterol, toothache
- Preparation: Eaten raw or fried, applied on part (for toothache)
- Ampalaya:
- Use: Mild Diabetes Mellitus Type 2, increases insulin sensitivity
- Preparation: Decoction or Steamed Baby Leaves
| Preparation | Procedure |
|---|---|
| Decoction | The recommended part of the plant material is boiled in water. The recommended boiling time is 20 minutes at a maximum of 100°C, in a clay pot. |
| Infusion | The plant material is soaked in hot water, much like making tea. The recommended soaking time is 10 to 15 minutes. |
| Poultice | Directly apply (pahid) the recommended plant material or its essence on the part affected, usually used on bruises, wounds, or rashes. |
| Tincture | Mix the plant material in alcohol. |
Other Traditional Alternative Healthcare
| Terminology | Definition |
|---|---|
| Acupressure | A method of healing and health promotion that uses the application of pressure on acupunture points. |
| Acupuncture | A method of healing using special needles to puncture and stimulate specific anatomical points on the body. |
| Aromatherapy | The art and science of the sense of smell whereby essential aromatic oils are combined and then applied to the body in some form of treatment. |
| Chiropracty | A discipline of the healing arts concerned with the pathogenesis, diagnosis, therapy, and prophylaxis of functional disturbances, pathomechanical states, pain syndromes, and neurophysiological effects related to the static and dynamics of the locomotor system, especially of the spine and pelvis. |
| Phytomedicine/Herbal Medicine | Finished, labeled, medicinal products that contain as active ingredients aerial or underground parts of the plant or other materials or combination thereof, either in the crude state or as plant preparations. |
| Massage | A method wherein the superficial soft parts of the body are rubbed, stroked, kneaded, or tapped for remedial, aesthetic, hygienic, or limited therapeutic purposes. Massaging modalities include effleurage, petrissage, tapotement, and friction. |
| Nutritional Therpay | The use of food as medicine and to improve healthy by enhancing the nutritional value of food components that reduces the risk of a disease. It is synonymous with nutritional healing. |
| Pranic Healing | A holistic approach of healing that follows the principle of balancing energy. |
| Reflexology | The application of therapeutic pressure on the body’s reflex points to enhance the body’s natural healing mechanisms and balance body functions. It is based on the principle that internal glands and organs can be influenced by properly applying pressure to the corresponding reflex area on the body. |
Expanded Program on Immunization
Immunization is an essential public health service and is commonly defined as the process of conferring artificial immunity to population groups. Immunity is described as resistance and protection from disease attributed to the presence of antibodies in the blood. The National Immunization Program (NIP) is committed to guaranteeing free immunization services and ensures that Filipinos, especially the poor, have access to routinely recommended vaccines. It further guarantees the immunization of neonates, infants, children, adolescents, mothers, and elderly populations as part of the comprehensive strategy for disease prevention and control following the life stage approach. Its goal is to reduce morbidity and mortality among infants and children caused by common childhood immunizable diseases. Specifically, the NIP has the following goals.
- To immunize all (previously <100%) infants against vaccine preventable diseases
- To sustain polio-free status of the Philippines
- To eliminate measles infections
- To eliminate maternal and neonatal tetanus
- To control Diphtheria, Pertussis, Hepatitis B infection and German Measles (Rubella)
- To prevent extrapulmonary tuberculosis among children
Related laws:
- PD No. 996 of 1976: providing compulsory basic immunization for infants and children below 8 years old (covers DPT, poliomyelitis, and measles)
- RA 7846 of 1994: inclusion of Hepatitis B immunization for infants and children below 8 years old
- RA 10152 of 2011: Mandatory Infants and Children Health Immunization Act of 2011 for children up to 5 years of age and inclusion of new vaccines: Hepatitis B, Mumps, Rubella, and Haemophilus Infuenza type B (Hib). This repealed PD 996 and is considered the current legal basis of the NIP.
- Presidential Proclamation No. 6 of 1996: Implementing a United Nations Goal on Universal Immunity by 1990; and designating Wednesdays as Immunization day.
Vaccine Types
Immunization may be active (with the immune system) or passive (gained from someone else), and natural or artificial, depending on how it is obtained.
| Type | Natural | Artificial |
|---|---|---|
| Active | Exposure Carrier Sick of the disease | Antigens Attenuated (BCG, OPV, AMV, Rotavirus) Killed (Pertussis, HBV) Weakened Toxins (TT, Diphtheria) |
| Passive | Breastmilk (IgA) Placenta (IgG) | Gamma globulin (6 months - 1 year) Antitoxin/antiserum/serum |
- Live Attenuated Vaccines have weakened forms of a pathogen to stimulate the body to produce antibodies for the disease. This type of vaccine only requires one or two doses to provide life-long protection. Examples include BCG, OPV, AMV, and Rotavirus.
- Because of its nature, it is contraindicated in immunocompromised children, as even a weakened pathogen may cause adverse effects.
- Inactivated (Killed) Vaccines are dead pathogens that also stimulate the body to produce antibodies for the disease. A trade-off of its safety is less effectivity, typically requiring three doses for protection, and requiring booster doses over time. Examples include IPV and wP (Whole-cell Pertussis Vaccine).
- Toxoid Vaccines are vaccines that contain an inactivated form of a pathogen’s toxins. It is also safe, but also requires several doses with periodic boosters. Examples include TT and DT.
- Conjugate/Subunit Vaccine include parts of the capsule of the pathogen. It operates similar to live attenuated vaccines, but are not as effective. Examples include Hib, PCV, HBV, and aP (Acellular Pertussis Vaccine).
General Considerations for Implementation
- Remind caregivers of children to comply with the prescribed schedule of routine immunization.
- Previous doses do not have to be repeated regardless of interval.
- The eligible age for Pentavalent vaccines is up to 5 years old.
- Booster doses are not really necessary.
- Vaccines may be given on the same day, but in different sites:
- If through the same leg, space the site at least 2.5 to 5 centimeters (1 to 2 inches; at least two fingerbreadths).
- Start with OPV, then Rotavirus, then the other vaccines.
- Observe the “First Expiry, First Out” (FEFO) or “First In, First Out” (FIFO) principle in utilizing vaccine stocks.
- Use cotton in cleaning the injection site. If with alcohol, thoroughly dry before administrating the vaccine.
- BCG, AMV, and MMR have special diluents. After reconstitution, these vaccines are only valid for 6 hours. This used to be 4 hours
- Protect BCG from sunlight, and Rotavirus from light. This principle may be used in questions that ask which location is appropriate for vaccination
- Information caregivers of children for immunization about common side effects, and how to deal with it.
- Reusable vaccines such as OPV, Pentavalent, Hepatitis B, and Tetanus Toxoid may last for a maximum of 4 weeks as long as the vaccine has (a) not expired, (b) been maintained in appropriate cold chain conditions, (c) remained uncontaminated during aspiration, (d) a VVM that does not indicate discarding, and (e) the vaccine septum has not been submerged in water.
In cases of a measles outbreak, a supplemental measles vaccine is administered.
- For children under 9 months old, give MR (no vaccine for mumps) reconstituted with two vials of special diluent (6 mL total), giving 0.5 mL subcutaneously to the child.
- For children 9 months to 5 years old, give MMR.
These are NOT CONTRAINDICATIONS:
- Fever up to 38.5°C “up to” means a fever of 38.5°C still permits vaccination.
- Mild acute respiratory infection
- Simple diarrhea
- Malnutrition conversely, this is an indication; malnutrition poses greater risk for disease
Vaccines and Administration
| Vaccine | Diseases | Age | Dose | Route | Site |
|---|---|---|---|---|---|
| Bacillus Calmette-Guerin (BCG) | Tuberculosis Meningitis Leprosy | At birth | 0.05 mL | ID | Right upper arm/deltoid |
| Hepatitis B Vaccine (HBV) | Hepatitis B Liver Cancer | At birth | 0.5 mL | IM | Vastus Lateralis |
| Pentavalent (DPT-HepB-Hib) | Diphtheria Pertussis Tetanus Hepatitis B Pneumonia Meningitis | 6, 10, 14 weeks; not given if >5 years | 0.5 mL | IM | Vastus Lateralis |
| Oral Polio Vaccine (OPV) | Poliomyelitis | 6, 10, 14 weeks | 0.5 mL; 2-3 drops | PO | Mouth |
| Inactivated Polio Vaccine (IPV) | Poliomyelitis | 14 weeks, 9 months | 0.5 mL | IM | Vastus Lateralis |
| Pneumococcal Conjugate Vaccine (PCV) | Pneumonia Meningitis | 6, 10, 14 weeks | 0.5 mL | IM | Vastus Lateralis |
| Mumps Measles Rubella (MMR) | Mumps Measles Rubella | 9, 12-15 months | 0.5 mL | SC | Outer arm |
| Appearances: |
- Freeze-dried: AMV, MMR, BCG freeze-dried vaccines have special diluents for reconstitution
- Liquid and Clear: Pentavalent, OPV (pinkish), Rotavirus, TT (sometimes slightly turbid)
- Liquid and Cloudy: HBV
Common Vaccination Side Effects and Management
| Vaccine | Side Effect | Management |
|---|---|---|
| BCG | Wheal for 30 minutes followed by ulceration for 2 weeks then scar formation within 12 weeks | Normal Reaction |
| BCG | Koch’s Phenomenon: an acute inflammatory reaction within 2 to 4 days after vaccination usually due to previous exposure to tuberculosis. | No management is needed. |
| BCG | Deep (subcutaneous) abscess at vaccination site; almost invariable due to subcutaneous or deeper injection | Refer to the physician for incision and drainage (I&D). |
| BCG | Indolent ulcer: an ulcer which persists after 12 weeks from vaccination date | Treat with Isoniazid (INH) powder. |
| BCG | Glandular enlargement: enlargement of the lymph glands draining the injection site | Treat as deep abscess (I&D) if suppuration occurs. |
| HBV | Local soreness at injection site | No treatment necessary. Cold compress may be used. |
| DPT-HepB-Hib | Fever that usually last for only 1 day. A fever beyond 24 hours is not due to the vaccine. | Advise parents to give an antipyretic. |
| DPT-HepB-Hib | Local soreness at the injection site | Reassure parents that soreness will disappear after 3 to 4 days. Paracetamol may be given for pain. |
| DPT-HepB-Hib | Abscess after a week or more usually indicates that the injection was not deep enough or the needle was not sterile. | I&D may be necessary. |
| DPT-HepB-Hib | Convulsions, although very rare, may occur in children older than 3 months caused by the pertussis component. | Proper management of convulsion; may give DT next vaccination. |
| OPV | None | - Nothing per orem for 30 minutes to prevent vomiting and to enhance absorption - If the child vomits, administer another dose. - If the child has simple diarrhea, the dose may be given, but it is not counted and another dose will be given the next visit. |
| IPV | Local tenderness | Cold compress |
| MMR | Local soreness, fever, irritability, and malaise in some children | - Reassure parents and instruct parents to give an antipyretic to the child. - Give 200,000 IU of Vitamin A to promote epithelialization and increase immunity. |
Cold Chain
The DOH provide recommendations for the cold chain principle of proper vaccine storage, handling, and transport of vaccines in the prescribed temperature. Methods for ensuring biological potency include the following:
- First Expiry, First Out (FEFO) Principle: use the vaccines nearest to their expiration date.
- Vaccine Vial Monitor (VVM): a round disc of heat-sensitive material to register cumulative heat exposure. The lower the temperature, the slower the color change and vice versa.
- If the square is lighter than the circle, use the vaccine if not expired.
- If the square matches or is darker than the circle, do not use the vaccine and inform the supervisor.
- Shake Test: an approach to determine if a freeze-sensitive biological has been frozen then thawed, to determine it for use or for disposal.
- If the vial is smooth and cloudy immediately after shaking, the biological can be used. If it appears granular and not smooth, it should be discarded.
- If, after 30 minutes, the vial starts to clear but no sediment has formed, it is viable. Otherwise, an almost clear vial with thick sediment should be discarded.
Vaccines are often temperature sensitive, and therefore should be maintained in their respective temperatures during transport and storage. The cold chain is a system for ensuring vaccine potency. This system is managed by the cold chain manager, a role held by the public health nurse.
- Transport Boxes: for transporting vaccines, with a viable duration of five days.
- Vaccine Carriers: a smaller transport box used within the community, with a viable of two days (48 hours).
- Refrigerator: a refrigerator used for vaccines is divided between the body (kept at 2°C to 8°C) and the freezer (-15°C to -25°C). The door of the refrigerator is never used due to it being subject to fluctuations in temperature. Vaccines may be stored in these for 30 days; 1 month.
- In a health unit, the temperature is checked routinely at least twice a day by the cold chain officer, usually upon opening and before closing.
- Only OPV is kept in the freezer; freeze-dried vaccines do not require freezing. Their special diluents are kept on the refrigerator door or the lower compartment.
| Sensitivity | Vaccines | Temperature | Stability |
|---|---|---|---|
| Most sensitive | OPV | -15°C to -25°C | - |
| Least sensitive to heat/most sensitive to cold | Pentavalent, HBV, DT Toxoid | 2°C to 8°C | 8 hours if in room temperature |
| Most sensitive to light | - | - | 4 to 6 hours |
Recommended Duration of Storage for Biologicals (only the 1 month limit was really mentioned during the discussion)
| Institution | Duration |
|---|---|
| Regional Health Office | 6 months |
| Provincial/District Health Office | 3 month |
| Rural Health Unit | 1 month |
| Maximum Transport Period (with cold packs) | 5 days |
Documentation
- Fully Immunized Child (FIC): the child has received all immunizations that should be given before reaching the first year of life (a dose of BCG, HBV, MMR, IPV; 3 doses of Pentavalent and OPV)
- Completely Immunized Child (CIC): the child has received all immunizations scheduled at the age of 12 to 23 months.
- Child Protected At Birth (CPAB): a child whose mother has received 2 doses of Diphtheria Tetanus (DT) toxoid during pregnancy provided that the 2nd dose was given at least a month prior to delivery or 3 doses of DT given any time prior to pregnancy with this child.
- Fully Immunized Mother (FIM): a mother who has received the complete five (5) doses of diphtheria tetanus.
| Dose | Schedule | Protection | Duration |
|---|---|---|---|
| 1 | ASAP during first pregnancy or nonpregnant childbearing age woman | N/A | N/A |
| 2 | 1 month after DT1 | 80% | 3 years |
| 3 | 6 months after DT2 | 95% | 5 years |
| 4 | 1 year after DT3 | 99% | 10 years |
| 5 | 1 year after DT4 | 99% | Lifetime |
Summary of Laws
- RA 8423: the Traditional and Alternative Medicine Act (TAMA) institutes the Philippine Institute of Traditional and Alternative Health Care (PITAHC) under the DOH
- PD No. 996 of 1976: providing compulsory basic immunization for infants and children below 8 years old
- RA 7846 of 1994: inclusion of Hepatitis B immunization for infants and children below 8 years old
- RA 10152 of 2011: Mandatory Infants and Children Health Immunization Act of 2011 for children up to 5 years of age and inclusion of new vaccines: Hepatitis B, Mumps, Rubella, and Haemophilus Infuenza type B (Hib). This repealed PD 996 and is considered the current legal basis of the NIP.
- Presidential Proclamation No. 6 of 1996: Implementing a United Nations Goal on Universal Immunity by 1990; and designating Wednesdays as Immunization day.