IN the final week of January in the eastern coastal province of Davao Oriental, hordes of residents from Caraga town were rushed to a district hospital in another town, or to the medical center in the capital town of Mati.
They were all complaining of gastrointestinal pains, and rectal swabs done at the government’s Southern Philippines Medical Center in Davao City confirmed the presence of the Vibrio cholerae bacteria, which causes cholera.
By the first week of February, some 491 residents of Caraga’s barangays Santiago, San Jose, T. Pichon, PM Sobrecarey, Poblacion and DL Bolante were all sent to hospitals for treatment. Unfortunately, six died.
Caraga later declared a state of calamity.
Cause unknown
THE municipal government of Caraga has constructed a makeshift hospital at its evacuation center to accommodate patients from the affected barangays. Severely dehydrated patients were sent to the Davao Oriental Provincial Hospital in the neighboring town of Manay.
Provincial health officer Dr. Reden Bersaldo and his team delivered IV fluids and other medical supplies to the town and were coordinating with local authorities to address the outbreak. Ambulances and additional health-care personnel were placed on standby.
While the cause remained unknown, the symptoms and complaints of patients have authorities suspecting contaminated food or water. The Provincial Disaster Risk Reduction and Management Office described it as a waterborne disease outbreak and the Provincial Health Office sent a team of 21 doctors, nurses, sanitary inspectors and support staff.
Bersaldo said the active surveillance, treatment and monitoring of the outbreak included a house-to-house survey of families to assess hydration status.
Aside from providing medical supplies and mobilization of additional manpower, Governor Nelson Dayanghirang also ordered concerned offices to provide assistance to families of those who died in the outbreak.
The World Health Organization said cholera “is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae.”
While authorities were yet to disclose the source of the outbreak, it has ruled out food contamination and has focused its investigation into the water sources, where initial test in Caraga found the water samples positive with the cholera bacteria.
The town’s health office has also asked residents to refrain from getting their drinking water direct from their faucets. Residents were also advised to boil their water before using it.
Incidentally, Caraga’s most affected Barangay Santiago was also the same area hit by a diarrheal outbreak in October last year, which downed 80 residents, with one turning out positive for cholera, the provincial government said.
Expected occurrences
WATER-BORNE diseases such as diarrhea and cholera are commonly expected or associated with occurrences of calamities and conflict.
For example, the Department of Health (DOH) reported more than 100 cases of acute gastroenteritis and diarrhea in Central Visayas and the Caraga Region (not referring to the town of Caraga, an area in Davao Oriental) in the weeks after Typhoon Odette (international code name: Rai) devastated the areas, including water facilities. DOH Undersecretary Maria Rosario Vergeire said 54 cases of diarrhea were recorded in Siargao. Cebu also reported 16 diarrhea cases.
On Dinagat Island, which was also hit by Odette, 80 people fell ill due to gastroenteritis.
“There were water interruptions in these areas. In some places, there’s water, but the pipes underground were damaged so it is possible there was contamination,” Vergeire said.
Many areas ravaged by Odette remained without enough food and water supply, and electricity needed to run water-refilling stations.
In the outburst of armed fighting in Marawi City in 2017, some 471,000 people have been displaced and hosted by families or evacuation centers in surrounding municipalities. Local and international relief and disaster-response agencies said the displacement “has put the IDPs [internally displaced persons, or evacuees] and host families into a precarious situation, with overwhelming threats of humanitarian nature, including the spread of epidemics.” They reported that between May 26 and June 28, nine confirmed cases of cholera were reported in the municipalities of Iligan, Saguiaran and Balo-i.
In addition, the WHO-supported Surveillance in Post Extreme Emergencies and Disasters (SPEED) suggests that a total of 584 cases of acute gastroenteritis were reported between May 31 and July 12.
Protect water source
THE incident has brought to the fore the importance of protecting water sources for potable use, especially in the countryside where the amenities and privilege of treated water and safe distribution process are practically absent.
Reports though have become few and far between of gastrointestinal outbreaks due to contaminated open water sources in the countryside, but occasional outbreaks like in Caraga town of Davao Oriental would come to the attention of previous finding and recommendation of the DOH 2019-2023 Food and Water-Borne Disease Prevention and Control Program (FWBD-PCP) Strategic Plan.
It warned that improvements in handling of potable water sources in many parts of the country would not ensure safe drinking water for all.
It said periodic occurrences of water-borne diseases due to contaminated water sources were caused by inappropriate messages and ineffective information dissemination to community residents, limited number of sanitary inspectors at the local level or other health personnel are multi-tasked, underreporting of cases due to various reasons (e.g., concern of tourism being affected), poor reporting system, with issues on reliability of data, lack of confirmation, no clear communication structure or late communication of local governments, where problems at the lower level would already be unmanageable.
Worse, the DOH strategic plan found out the low priority given by local leadership on the prevention and control of FWBDs. “There is lack of ownership of the program and poor appreciation of FWBDs’ consequences on the welfare and health of their constituents,” it said.
It said the promotion of personal hygiene and health sanitation practices “has not been palpable” and there were no surveys “carried out to establish the level of awareness, attitudes and practices of the population relative to personal hygiene and sanitary practices”.
While it said “there is a robust set of laws and policies that support food and water sanitation practices in the country; the extent of compliance and adherence, however, to these laws and policies cannot be fully ascertained given the absence of data relative to such practices.” Other laws related to water and food safety include RA 10611 on Food Safety Act (to strengthen the food safety regulatory system), RA Act 9003.200 (providing for an ecological solid waste management program), and Presidential Decree 856, the Code of Sanitation of the Philippines.
“Compliance and adherence to national laws and policies is low, while enforcement of sanctions and penalties by concerned authorities is weak. The increasing number of food and industrial establishments and growing population especially in urban areas against a stagnant number of sanitary inspectors available in the field prevent the conduct of regular inspections,” it said, citing such laws as the Philippine Clean Water Act of 2004. This law “aims to protect the country’s water bodies from pollution from land-based sources, industries and commercial establishments, agriculture and community household activities.”
In some cases, FWBD cases were underreported, even neither recorded nor reported.
Strain in health system, economy
THE DOH action plan said food and waterborne diseases are among the most common cause of diarrhea, which remains one of the 10 leading causes of morbidity and mortality in the country.
As outbreaks from FWBD can be very massive and catastrophic “since most of these diseases have no specific treatment modalities, the best approach to limit economic losses due to FWBD is prevention through health education and strict food and water sanitation.”
It said the occurrence of FWBDs “remains a significant health issue in both developed and developing countries with illnesses and deaths a constant threat to public health security and socio-economic development of any country.”
“FWBDs strain health-care systems, severely affect infants, young children, the elderly and the sick. They perpetuate a vicious cycle of diarrhea and malnutrition, hurting the national and local economy and international trade. In developing countries, about 80 percent of all the illnesses are caused by FWBDs, with diarrhea being the leading cause of childhood death. In the Philippines, FWBDs are among the most common causes of diarrhea, which remains as one of the 10 leading causes of morbidity and mortality in the country.”
FWBDs are usually manifested as diarrhea, the DOH said, and accounts for 9 percent of total deaths among children below five years old. Morbidity rate due to diarrhea has gone down, though, from 1,520/100,000 population in 1990 to 347.3/100,000 population in 2010. Despite the decline, however, several notable outbreaks continue to occur.
It is believed that since the occurrence of FWBDs is essentially related to economic and socio-cultural factors, these outbreaks will continue to persist unless underlying social ills are corrected, the DOH said.
The Philippines is considered one of the most vulnerable countries in the world to extreme weather events, being first in vulnerability to tropical cyclones, third for the number of people exposed to these seasonal events, and fourth most vulnerable to natural disasters. It experiences an average of 20 typhoons per year and faces increasing disaster risks.
The country is also challenged by intermittent political instability and episodic armed conflict in the South and localized areas of Luzon, which limit the delivery of social services and cause population displacement that may facilitate disease introduction or transmission.
The DOH strategic plan has recommended regulating and monitoring food and water sanitation practices at the local level through enforcement of national and local legislations, application of appropriate technical standards and participation of non-government agencies.
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