Administrative Order No. 2009 - 0021

  

November 16, 2009

ADMINISTRATIVE ORDER

No. 2009 – 0021

DIAGNOSIS AND TREATMENT GUIDELINES FOR CAPILLARIASIS INFECTIONS

I.     BACKGROUND / RATIONALE

The Capillariasis outbreak of Zamboanga del Norte in the latter part of 2007 and early 2008 provided insights on the need for a standard treatment guidelines with regards to Capillariasis infections. During the outbreak, the lack of treatment guidelines resulted in medical practitioners using their own discretion as far as the frequency, dosing and duration of giving the anti–helminthic medications. There was also confusion as the duration of treatment in cases of relapse or re–infection.

Capilllariasis is often a fatal disease (Case Fatality Rate 10%) resulting from intractable diarrhea and the resultant protein losing enteropathy. It was discovered by a team from the UP–PGH and NAMRU–2 in 1962 when they investigated the mysterious death of a 29 year old male school teacher from Pudoc, Ilocos Norte who dies in PGH from intractable diarrhea initially diagnosed as Tropical Sprue (Cabrera & Cross, 1962). It also included among the neglected tropical disease found to be an obstacle to socio–economic development and is among the top ten leading causes of disease burden with Disability Adjusted Life Years (DALY) of 4.6 – 54.7 million years. Thus it is of clinical importance to treat and diagnose the disease early in its course by using the correct diagnostic tool and prescribing the appropriate drug of choice in the correct dosage and in the recommended duration.

II.    OBJECTIVE

To guide public and private healthcare providers in the diagnosis, treatment and management of Intestinal Capillariasis

III.  COVERAGE AND SCOPE

This guideline shall apply to all public health officers who directly treat patients. These physicians include, Provincial, City/Municipal Health Officers, training residents and other medical officers in the government. Likewise covered are private medical practitioners and health institutions.

IV.   DEFINITION OF TERMS

A. Capillariasis – a parasitic disease caused by the helminthic Capillaria philippinensis. It is acquired by eating raw fresh water or brackish water fish harboring the parasites. It is characterized by abdominal pain, borborygmus, and severe intractable diarrhea of more than 10 episodes a day. Protein–losing Enteropathy is also prominent feature of the disease. It is endemic in the Philippines, Taiwan and Indonesia as well in Egypt and Iran.

B. Formalin Ether Concentration Technique (FECT) – A laboratory technique in the detection of parasite ova in the stool specimen of 1 gram (approximately thumb – sized).

C. Oral Rehydration Salt (ORS) – oral solution of salt used for the management of dehydration due to diarrhea.

D. Protein Losing Enteropathy – any condition of the gastrointestinal tract that results I a net loss of protein in the body.

E. Re–infection – infection following recovery or superimposed on a previous infection of the same type.

F. Relapse – a recurrence of symptoms of a disease after a period of improvement.

G. Tropical Sprue / Malabsorption Syndrome – sprue occurring in the tropics, associated with enteric infection and nutritional deficiency and often complicated by anemia and folic acid deficiency.

V.     GUIDELINES AND PROCEDURES

A. Clinical Presentation

The history of intake of raw or inadequately cooked fresh water/brackish water fish (e.g. Bagsit fish of Ilocos Region) is usually a prominent feature when the patient’s personal history is taken. Unlike most parasitic/helminthic disease, there is no asymptomatic carrier in this disease, all patients infected with this parasites invariably develops the disease and if left untreated will lead to death due to heart failure or septicemia from secondary bacterial infection. Patients usually present with the following signs and symptoms:

Most Common Signs and Symptoms:

1.     Acute Stage

·  Abdominal Pain

·  Borborygmus or gurgling stomach

·  Intractable diarrhea of several weeks (8 – 10 voluminous stool daily)

2.     Chronic Stage

·       Muscle wasting and severe loss of body weight

·       Hypotension

·       Pulsus Alternans

·       Gallop rhythm

·       Hyporeflexia

·       Distant Heart Sound

·       Abdominal distention and Tenderness

·       Edema

B.     Diagnosis

1. Case Finding or screening of cases

Patients with history of diarrhea presenting with 8 – 10 voluminous stools per day plus history of eating raw or inadequately cooked fresh water fish shall be subjected to a stool exam using Formalin Ether Concentration Technique or Kato thick technique.

2. Laboratory findings:

a. The Diagnostic tool of choice is stool examination using Acid Ether Concentration Technique / Formalin Ether Concentration Technique (AECT/FECT). When done properly, the technique will yield eggs of Capillaria philippinensis which are characterized as peanut–shaped with bipolar plugs found on both ends. Striations can also be found on the eggshell. They usually measure 36 to 45 by 20 um seen in magnification, x 160.

b. If FECT is not yet available, the Kato Thick Technique can be used.

c. Other salient laboratory features seen are as follows:

o   Decrease total serum protein

o   Low levels of potassium, calcium, sodium & carotene

o   High levels of serum IgE

o   Diminished levels of IgG, IgM, IgA

o   Mal–absorption of fats and sugars

C. Therapeutic Management

1. Mebendazole – the drug of choice and this shall be given 400 mg/day in 2 divided doses for 20 days for all ages. Relapse and re–infection cases are treated for another 30 days independent from the initial treatment.

2. Albendazole – the alternative drug of choice, this shall be given 400 mg/day for 10 days. Re – infection and relapse cases shall be treated for another 20 days independent from the initial treatment regimen.

3. ORS – are to be used first as initial treatment for volume per volume replacement in accordance with established World Health Organization Control of Diarrheal Diseases (WHO CDD) protocols for adult and pediatric patients to prevent dehydration and electrolyte imbalance which lead to more severe complications.

4. Intravenous (IV) Fluids – are to be used in case patients cannot tolerate Oral Rehydration solution or are in critical condition. Likewise the criteria enumerated in the WHO CDD Protocol for shifting ORS to IVF should be strictly followed.

5. High Protein Diet – due to protein–losing enteropathy inherent in capillariasis, patients are to be placed on high protein diet to offset losses from diarrhea.

D.    Re–infection and Relapse Cases

·  Relapse of capillariasis occurs when the treatment is inadequate (e.g., treatment is underdosed or 20 day treatment was not completed).

·  Re–infection occurs when a previously treated patient who got well, continued eating raw freshwater fish

E. Disposition of Admitted Patients

Patients with no diarrheic episodes for 24 hours, with good hydration status and showing negative capillaria ova in succeeding stool exams by FECT shall be discharged and given home medications of anti–helminthics and advised follow– up after 5 days.

VI.   ROLES AND RESPONSIBILITIES

A.     Public Health Workers Duties and Responsibilities

1. National Center for Disease Prevention and Control (NCDPC):

·  Provide technical assistance to Center for Health Development (CHDs) and local units.

·  Leverage resources for effective implementation.

·  Assist the National Epidemiology Center (NEC) in capillaria outbreak investigations by providing technical support and assistance to the investigating team.

·  Assist the National Center for Health Promotion (NCHP) in the development of prototype Information Education Communication materials.

·  Compute drug requirement, provide allocation list.

2. Central Office Bids and Awards Committee (COBAC):

·  Procures required drugs in a timely manner

3.  Local Government Units are enjoined to:

·  Promote good hygiene particularly concerning the danger of eating raw or inadequately cooked fresh water fish.

·  Develop IEC materials on Capillariasis in the local vernacular based on the prototypes of DOH NCDPC and NCHP.

·  Ensure strengthening of skills of LGU medical technologist in identifying common intestinal parasites by allowing their participation in the refresher trainings once a year to be provided by the CHD concerned.

·  Protect fresh water sources especially rivers and lakes from fecal pollution.

·  Conduct FECT on all patients suspected with capillariasis. This is necessary to provide documentation of increased cases or outbreaks in a given area.

·  Thoroughly investigate the reports of a community outbreak of diarrhea through the Municipal Health Officer and immediately request for stool exam of suspected capillariasis cases.

4. Center for Health Development / DOH Provincial Health Teams in each province:

·  Conduct investigations of suspected Capillaria outbreaks through the Regional Epidemiology and Surveillance Units (RESU), especially in areas with no previous history of capillariasis. Reports of initial cases or suspected cases shall be reported at once to the National Epidemiology Center (NEC) and National Center for Disease Prevention and Control (NCDPC) for further investigations and verifications.

·  Conduct a yearly training for Medical Technologists and Medical Officers of both LGU and retained Hospitals to update their diagnostic skills.

·  Ensure adequate buffer stock or mebendazole or albendazole to address future outbreaks and distribute as soon as need arise.

VII. REPEALING CLAUSE

All rules and regulations which are inconsistent with the provision stated in this treatment guideline are hereby amended accordingly.

VIII. EFFECTIVITY

This order shall take effect fifteen (15) days after filing with the University of the Philippines Law Center, or upon posting/publication in the DOH Internet.

FRANCISCO T. DUQUE III, MD, MSc.

Secretary of Health