Disclaimer: The Omnibus Health Guidelines (OHG) are based on best available local and international
literature at the time they are written. Evidence is dynamic and continuously evolving, hence, the contents
may not accurately reflect evidence which are newly-generated and/or published after the OHG release. The
provisions of the OHG are intended to assist target users for implementation and decision-making. When
used in patient encounters, they should be interpreted based on the patient’s individual circumstances and
applied with sound clinical judgment. Clinicians are expected to maintain discretion and exercise due
diligence while upholding the patient’s best interests in the utilization of the OHG.
Guidelines should not be interpreted as strict rules on which legal action may be based, nor should they be
the sole basis for evaluating insurance claims.
Suggested Citation:
Department of Health. (2023). The Omnibus Health Guidelines for Adults 20-59 years old ver 2023. Manila,
Philippines: Department of Health.
Feedback:
Contact the Disease Prevention and Control Bureau - Evidence Generation and Management Division at
egmd@doh.gov.ph.
Editorial Team
OHG Technical Team
Dr. Mel Anthony Acuavera
Dr. Diana Jean Vasquez
Dr. Marijuzca Nicolas
Dr. Timothy John Bautista
Dr. Joy Valerie Catameo
Dr. Neil Benjamin Kho
Mr. Gerald John Paz
Ms. Mita Lourdes Angela Santiago
Support Team
Dr. Jan Derek Junio
Mr. Dan Louie Renz Tating
Mr. Angelo Timothy Dawa
Mr. Miguel Gaston Agcaoili
Ms. Chelsea Danica Bercasio
Design and Lay-out Artist
Dr. Zashka Alexis Gomez
Editor
Dr. Ruth Divine Agustin
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OHG for Adults ver. 2023 | 2
Table of Contents
Table of Contents.........................................................................................................................................................................3
Abbreviations and Acronyms.......................................................................................................................................................5
Foreword...................................................................................................................................................................................... 7
Acknowledgements..................................................................................................................................................................... 8
About the Omnibus Health Guidelines (OHG)..............................................................................................................................10
Rationale.............................................................................................................................................................................10
Objectives........................................................................................................................................................................... 10
Development and Update Process...................................................................................................................................... 11
Target Users, Applications, and Uses................................................................................................................................. 11
Expansion Plans..................................................................................................................................................................12
Feedback Process...............................................................................................................................................................12
Section Guide......................................................................................................................................................................13
PART I:.........................................................................................................................................................................................19
The General Wellness and Preventive Measures Section:........................................................................................................ 20
General Principles..............................................................................................................................................................20
Self-care..............................................................................................................................................................................21
Household Care.................................................................................................................................................................. 25
The Supportive Care, First Aid Measures, and Basic Emergency Care Section:...................................................................... 32
General Principles.............................................................................................................................................................. 32
Self-monitoring and Self-testing.......................................................................................................................................32
Supportive Therapies and Symptomatic Relief.................................................................................................................33
First-aid and Basic Emergency Care................................................................................................................................. 34
The General History and Physical Examination Section:...........................................................................................................41
General Principles............................................................................................................................................................... 41
Screening for Red Flags.....................................................................................................................................................42
History Taking.................................................................................................................................................................... 42
Physical Examination.........................................................................................................................................................44
The Screening Services Section:.............................................................................................................................................. 50
General Principles of Screening........................................................................................................................................ 50
Screening Services............................................................................................................................................................. 51
The Immunization Services Section:........................................................................................................................................ 65
General Principles.............................................................................................................................................................. 65
Vaccines for Adults............................................................................................................................................................ 65
Monitoring and Management of Adverse Effects Following Immunization (AEFI)............................................................ 69
The Sexual and Reproductive Health Section:.......................................................................................................................... 72
General Principles.............................................................................................................................................................. 72
Family Planning Services................................................................................................................................................... 72
Assessment of Pregnancy..................................................................................................................................................76
Maternal Health Services................................................................................................................................................... 77
The Diagnosis of Common Conditions in Primary Care Summary Section.............................................................................. 85
General Principles of Diagnosis......................................................................................................................................... 85
Diagnostic Tests in Primary Care...................................................................................................................................... 85
The Treatment of Common Conditions in Primary Care Summary Section............................................................................ 101
General Principles............................................................................................................................................................. 101
Treatment Options in Primary Care.................................................................................................................................. 101
PART II:...................................................................................................................................................................................... 119
Non- Communicable Diseases................................................................................................................................................. 120
Acute Myeloid Leukemia....................................................................................................................................................121
Asthma.............................................................................................................................................................................. 124
Chronic Obstructive Pulmonary Disease......................................................................................................................... 130
Diabetes Mellitus...............................................................................................................................................................135
Dyslipidemia......................................................................................................................................................................142
Generalized Anxiety Disorder........................................................................................................................................... 146
Hepatocellular Carcinoma................................................................................................................................................ 150
Hypertension.....................................................................................................................................................................153
Major Depressive Disorder................................................................................................................................................160
Methamphetamine Use Disorder......................................................................................................................................165
Infectious Diseases.................................................................................................................................................................. 170
Community Acquired Pneumonia (CAP)............................................................................................................................ 171
Coronavirus Disease (COVID-19)....................................................................................................................................... 175
Dengue.............................................................................................................................................................................. 184
Human Immunodeficiency Virus - Acquired Immunodeficiency Syndrome (HIV AIDS).................................................. 188
Infectious Diarrhea........................................................................................................................................................... 194
Leptospirosis.................................................................................................................................................................... 198
Tinea Infection................................................................................................................................................................. 202
Tuberculosis, Pulmonary................................................................................................................................................. 205
National Practice Guidelines Program Products..................................................................................................................... 214
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Abbreviations and Acronyms
AAFP - American Academy of Family Physicians
AAO - American Academy of Ophthalmology
AAP - American Academy of Pediatrics
AAPD - American Academy of Pediatric Dentistry
ACOG - American College of Obstetricians and Gynecologists
ACC - American College of Cardiology
ACP - American College of Physicians
ACS - American Cancer Society
ADA - American Diabetes Association
ADAA - Anxiety and Depression Association of America
ADeA - Australian Dental Association
AEFI - Adverse Events Following Immunization
AGDHAC - Australian Government Department of Health and Aged Care
AHA - American Heart Association
AO - Administrative Order
APA - American Psychiatric Association
ARC - American Red Cross
ASCVD - Atherosclerotic Cardiovascular Disease
ASSIST - Alcohol, Smoking, and Substance Involvement Screening Test
ATS - American Thoracic Society
AUDIT - Alcohol Use Disorders Identification Test
COE - Council of Europe
COPD - Chronic Obstructive Pulmonary Disease
CSEP - Canadian Society for Exercise Physiology
DBM - Department of Budget and Management
DDB - Dangerous Drugs Board
DHHS - Department of Health and Human Services
DVA - Department of Veteran Affairs
DENR - Department of Environment and Natural Resources
DM - Department Memorandum
DO - Department Order
DOH - Department of Health
DOLE - Department of Labor and Employment
ESC - European Society of Cardiology
EREID - Emerging and Re-emerging Infectious Diseases
FNRI - Food and Nutrition Research Institute
FSRH - Faculty of Sexual and Reproductive Healthcare
GAD - Generalized Anxiety Disorder
GBD - Global Burden of Disease
GINA - Global Initiative for Asthma
GOLD - Global Initiative for Chronic Lung Disease
GSIS - Government Service Insurance System
IADT - International Association of Dental Traumatology
Omnibus Health Guidelines ver. 2023 | 5
Abbreviations and Acronyms
ICE - Institute of Clinical Epidemiology
ICRC - International Committee for the Red Cross
IDF - International Diabetes Federation
IDSA - Infectious Diseases Society of America
IDST - Infectious Disease Society of Taiwan
IHME - Institute of Health Metrics and Evaluation
ISH -International Society of Hypertension
JMC - Joint Memorandum Circular
JRRMMC - Jose R. Reyes Memorial Medical Center
LA - Labor Advisory
MOH - Ministry of Health
NCEP - National Cholesterol Education Program
NICE - National Institute for Health and Care Excellence
NIH - National Institutes of Health
NTP-MOP - National Tuberculosis Program-Manual of Procedures
ORS - Oral Rehydration Salts
PCCP - Philippine College of Chest Physicians
PCS - Philippine Cancer Society
PD - Presidential Decree
PHEX - Philippine Guidelines on Periodic Health Examination
PHILPEN - Philippine Package of Essential Noncommunicable Disease Interventions
PLAS - Philippine Lipid and Atherosclerosis Society
PNDF - Philippine National Drug Formulary
PPA - Philippine Psychiatric Association
PSH - Philippine Society of Hypertension
PSMID - Philippine Society for Microbiology and Infectious Diseases
RA - Republic Act
RACGP - Royal Australian College of General Practitioners
RANZCP - Royal Australian and New Zealand College of Psychiatrists
SSS - Social Security System
UN- United Nations
UP - University of the Philippines
UK NICE - United Kingdom National Institute for Health and Care Excellence
US CDC - United States Centers for Disease Prevention and Control
US DVA - United States Department of Veterans Affairs
US FDA - United States Food and Drug Administration
USPSTF - United States Preventive Services Task Force
WHO - World Health Organization
Omnibus Health Guidelines ver. 2023 | 6
Foreword
The passage of the Republic Act (RA) No. 11223 or the Universal Healthcare Act in 2018 ushered in multiple
innovations and reforms within the health sector, with the recognition that inherent to the achievement of
true universal health care (UHC) is the strengthening of primary care complemented by the development of
functional and integrated healthcare provider networks (HCPN).
The Department of Health, through the Disease Prevention and Control Bureau (DPCB), led the development
and updating of the Omnibus Health Guidelines (OHG), which is a major policy initiative to ensure the delivery
of safe, effective, and person-centered services to all Filipinos of various life stages, with main focus on
primary care strengthening (Administrative Order 2022-0018). By consolidating and defining evidence-based
service delivery standards using a lifestage approach, the OHG serves as a guide to ensure that every Filipino
is offered the best possible care at each opportunity.
The OHG embodies what we envision for primary care - “initial-contact, accessible, continuous,
comprehensive and coordinated care that is accessible at the time of need including a range of services for
all presenting conditions, and the ability to coordinate referrals to other health care providers in the health
care delivery system, when necessary”, as defined in the UHC Act. The principles of health promotion, set in
the Health Promotion Strategy Framework, along with services encompassing prevention, such as screening
and immunization, diagnosis, treatment, rehabilitation, and palliation, and referrals, are enumerated in the
OHG.
As a scientifically robust and comprehensive reference, the OHG contains links to relevant laws, policies,
local and international high-quality clinical practice guidelines (CPGs), manuals, clinician support tools, and
other materials, to facilitate well-informed decision-making for various users, such as primary care
providers, managers of various settings, and local governments . Because the contents of the OHG are
evidence-informed and updated with the standards of care also developed by our local medical societies, the
OHG promotes communication and collaboration between primary care providers and specialists - a critical
step in the realization of UHC. Further, new health technologies identified in the OHG serve as triggers for
initiating processes that enable health financing, including inclusion in the benefit packages of PhilHealth,
and health technology assessments by the Health Technology Assessment Council (HTAC).
It is my fervent hope that the OHG will be widely disseminated and utilized by clinicians and our partners in
health, to help us realize UHC and our DOH 8-point Agenda, in particular - Ligtas, dekalidad, at
mapagkalingang serbisyo para sa bawat Pilipino - dahil bawat buhay mahalaga.
TEODORO J. HERBOSA, MD
Secretary, Department of Health
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Acknowledgements
The development and updating of the Omnibus Health Guidelines were made possible through the concerted
efforts, commitment, and expertise of the personnel of various Divisions of the Disease Prevention and
Control Bureau, headed by the Division Chiefs Dr. Manuel Vallesteros, Dr. Raffy Deray, Dr. Jan Aurelle Llevado,
and Dr. Ruth Divine Agustin, overseen by Dir. Maria Elizabeth Caluag and Dir. Jose Gerard Belimac, and led by
Dir. Razel Nikka Hao, under the guidance of Assistant Secretary Beverly Lorraine Ho, and Public Health
Services Team Undersecretary Maria Rosario Singh-Vergeire.
We thank our stakeholders and target users who participated in our surveys and key informant interviews
and provided critical feedback for the improvement of the OHG. We also thank our various development
partners who dedicated their time and expertise to review the technical contents of the OHG.
We acknowledge the invaluable contributions of the members of the DOH Lifestage Technical Working Group
(LTWG), including Dr. Noel Espallardo and Dr. Cheridine Oro-Josef of the Philippine Academy of Family
Physicians, Dr. Ma. Encarnita Limpin, Dr. Diana Payawal, Dr. Imelda Mateo, Dr. Maaliddin Biruar, and Dr. Dax
Ronald Librado of the Philippine College of Physicians, Dr. Domingo S. Bongala, Jr., Dr. Rex Madrigal, Dr.
Jorge Concepcion, and Dr. Alejandro Dizon of the Philippine College of Surgeons, Dr. Gil Gonzalez, Dr. Mikaela
Erlinda Martinez-Bucu, and Dr. Suzette Munoz of the Philippine Obstetrical and Gynecological Society, Dr.
Jeremy Cordero and Dr. Dianne Marie De Jesus of the Philippine College of Emergency Medicine, and Dr.
Maria Ysabella Someros and Dr. Larimer Hugo of the Philippine Psychiatric Association.
We give our special thanks to the various representatives of the Centers for Health Development and the
Ministry of Health - Bangsamoro Autonomous Region in Muslim Mindanao for giving their constructive
comments and inputs in various consultation fora for the improvement of the OHG and the development of
the Roll-out Guide.
We are also grateful to the personnel of the various DOH Central Office Bureaus who gave crucial inputs to
improve the OHG.
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We acknowledge the following medical societies whose members dedicated their time and expertise to the
development and updating of the Omnibus Health Guidelines for Adults.
Philippine Academy of
Family Physicians (PAFP)
Philippine College of Physicians
(PCP)
Philippine College of Surgeons
(PCS)
Philippine Obstetrical and
Gynecological Society (POGS)
Philippine College of
Emergency Medicine (PCEM)
Philippine Psychiatric Association
(PPA)
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About the Omnibus Health Guidelines (OHG)
Rationale
In the past decades, the Department of Health (DOH) issued numerous policies on medical and public health
programs and health services that were usually disseminated and carried out using a fragmented, vertical
and programmatic manner. The roll-out of the Universal Health Care (UHC) Act called for a shift from this
towards a more integrative approach in terms of policy, planning, and health service delivery, with emphasis
on the central role of primary care in the achievement of UHC.
The UHC Act also paved the way to strengthening the health sector’s appreciation and use of evidence-based
standards of care by mandating the DOH to ensure the safety and quality of health services, to “set standards
for clinical care through the development, appraisal, and use of clinical practice guidelines in cooperation
with professional societies and the academe” (Section 27.c), and to ensure “evidence-informed sectoral
policy and planning for UHC” (Section 31). To achieve these, the DOH institutionalized the Expanded National
Practice Guidelines Program (NPGP) through Administrative Order (AO) No. 2023-0002, which elucidates a
comprehensive framework for the development, appraisal, and implementation of evidence-informed
guidelines. In conjunction, the Department issued Administrative Order No. 2022-0018, establishing the
Omnibus Health Guidelines as the overarching policy reference for the fulfillment of relevant mandates of the
UHC by 1) setting standards of care primarily through the utilization of quality-appraised Clinical Practice
Guidelines (CPGs), complemented by other evidence-informed references, 2) facilitating the achievement of
technical integration and guiding the functional and efficient linking of services across different levels of
care and settings, and 3) upholding primary care-oriented and people-centered care using a life course
approach to service delivery.
The achievement of UHC, as envisioned in the UHC Act, is the telos of the Omnibus Health Guidelines (OHG),
with primary care strengthening as the medium. By identifying what safe, effective, person-centered quality
care is for various life stages, the OHG is able to facilitate the achievement of UHC and contribute to the
fulfillment of the DOH 8-point agenda, in particular, Agenda 2: ”Ligtas, dekalidad, at mapagkalingang serbisyo”
para sa bawat Pilipino”.
Objectives
The OHG aims to provide comprehensive guidance for an integrated and consolidated approach to health
service delivery for various life stages (Child, Adolescent, Adults, Elderly), across the continuum of care–
from health promotion, prevention, screening, diagnosis, treatment, rehabilitation, to palliation– in various
settings and levels of care (AO No. 2022-0018).
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Development and Update Process
The development and updating of the Omnibus Health Guidelines consists of the following general
processes:
●
●
●
●
Rational priority setting and selection of topic updates based on the DOH 8-point agenda, burden of
disease, presence of emerging quality and new evidence, presence of practice variation, and
stakeholder feedback;
Scoping, review, and appraisal, when applicable, of various references containing standards of
care/service delivery standards, including DOH-approved CPGs, international CPGs and guidance
documents, DOH policies, and other relevant laws and policies;
Synthesis and translation of CPG recommendations and other standards from quality-appraised
sources to key provisions in the OHG to create comprehensive guidance across the entire spectrum
of care– encompassing health promotion, prevention, screening, diagnosis, treatment,
rehabilitation, palliation, and referrals; and
Vetting of the technical validity of the updated provisions by the Lifestage Technical Working Group
(LTWG), accompanied by multiple consultations with various stakeholders and target users.
Target Users, Applications, and Uses
The target users of the OHG are the following:
● Clinicians and primary care providers, including physicians, nurses, midwives, and Barangay Health
Workers (BHWs), can use the OHG as the main reference for service delivery including the clinical
consults, diagnosis, treatment, supportive care and palliation, and referral-enhancing patient care
and streamlining workflows;
● Primary care managers, especially those in national government institutions, local governments,
and settings-based managers for schools, workplaces, and establishments, can use the OHG as the
main reference for strategic planning, management, operations, and resource allocation– aiding in
identifying investment needs, gaps, priorities for quality assurance and systems strengthening;
● Health Program Managers can use the OHG as the main reference for designing interventions to
meet health outcome targets for more efficient and effective integration of program strategies and
provision of quality services;
● The Philippine Health Insurance Corporation (PhilHealth) can use the OHG as a policy basis for
development of benefit packages for quality and cost-effective service delivery;
● The Health Technology Assessment Council (HTAC) can use the OHG as a policy basis for identifying
priority health technologies for HTA; and
● Other partners of the health sector such as development and humanitarian partners, civil society
organizations, and the academe, may also refer to the OHG for the uses listed above, as relevant to
their respective roles and functions, in addition to developing and implementing activities related to
capacity-building and curriculum enhancement.
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Expansion Plans
To strengthen and enable our primary care providers to deliver safe, effective, high-quality, and
person-centered care, in accordance with the UHC Act, the OHG shall be regularly updated every 3 years, or
as frequently as necessary (AO No. 2022-0018). This is to ensure that the OHG contains standards of care
supported by the best available and most current evidence and is responsive to the need for guidance for the
multitude of conditions encountered in primary care.
Annually, the DOH, through Disease Prevention and Control Bureau - Evidence Generation and Management
Division (DPCB - EGMD), shall conduct surveys and stakeholder consultations to determine priority topics for
updating, obtain feedback for quality improvement, and assess the awareness and utilization of the OHG.
Further, to facilitate the implementation and utilization of target users, implementation tools (e.g., clinician
support tools) shall be developed and disseminated and implementation, monitoring, and evaluation
strategies shall be carried out, following the provisions of AO 2023-0018 and AO 2022-0002. A User Guide
shall be developed to facilitate ease of use for the different cadres and managers in primary care.
Feedback Process
Interested parties or individuals may provide feedback on the OHG in two ways:
● Submit comments and feedback on the contents of the OHG anytime by accomplishing this feedback
form; and/or
● Participate in annual surveys or stakeholder consultations. The call to participate in surveys and
consultations shall be released through Department Circulars.
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Section Guide
Figure 1. OHG Navigation Map
The 2023 update of the OHG seeks to facilitate a user-friendly and intuitive experience. The version 2023
OHG update is divided into two main parts with multiple sections. The navigation map of the updated OHG is
shown in Figure 1.
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Part I: General Primary Care is intended to consolidate the health service delivery standards regarding
general primary care and is not disease-specific. The Sections in Part I should be used to provide care for all
individuals consulting at primary care, whether they are healthy or symptomatic. Part I is comprised of the
following:
● General Wellness and Preventive Measures
○ This section contains provisions for Self-care and Household care. Multiple cadres of
primary care providers, including BHWs, midwives, nurses, and physicians, can use this as
reference in educating adults about general promotive and preventive actions to maintain
health and well-being.
● Supportive Care, First Aid Measures, and Basic Emergency Care
○ This section contains provisions on Self-monitoring and Self-testing, Supportive
Therapies and Symptomatic Relief, and First-aid and Basic Emergency Care. These
provisions can be used to educate individuals about health-seeking behaviors, self-care, and
home care for simple conditions.
● General History and Physical Examination
○ This section contains provisions and information that can be used during the actual clinical
encounter, including what to ask during the interview and what to look for during physical
examination. Red flags are enumerated to identify conditions necessitating immediate
attention and referral. Normal findings or values are provided to ensure clinicians are able to
distinguish between normal and pathological findings.
● Screening Services
○ This section contains provisions on the screening services that should be offered to eligible
groups of adults, based on the latest available evidence. This section is divided into
PE-based screening, questionnaire-based screening, and laboratory or imaging-based
screening.
● Immunization Services
○ This section contains provisions on the vaccines that should be offered to eligible adults,
based on the latest available evidence. Provisions on the monitoring and Management of
Adverse Effects Following immunization (AEFI) are also enumerated.
● Sexual and Reproductive Health Services
○ This section contains provisions on sexual and reproductive health services, including
family planning and pre-natal and post-natal services.
● Diagnostic Tests in Primary Care: Summary
○ This section consolidates the diagnostic tests for common or high-burden conditions that
should be made available or offered in primary care, in order to be able to deliver
comprehensive care at initial contact.
● Treatment Options in Primary Care: Summary
○ This section consolidates the medications that should be made available or offered in
primary care, in order to be able to deliver comprehensive care at initial contact.
Part II: Specific Guidance for Common and High-Burden Diseases in Adults is intended to provide the
relevant disease-specific, evidence-based standards of care, ranging from screening to basic emergency
care, for patients presenting with signs and symptoms of diseases commonly encountered in primary care.
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These standards mainly focus on what needs to be performed, offered, or administered in the primary care
context. The diseases are grouped into two sets: Non-communicable Diseases (NCDs) and Infectious
Diseases (IDs). Each set contains diseases/conditions arranged in alphabetical order for ease of use. As the
OHG is updated, this list will be continuously expanded in order to comprehensively cover the wide range of
acute and chronic conditions encountered in primary care.
● Non-Communicable Diseases
○ Acute Myeloid Leukemia
○ Asthma
○ Chronic Obstructive Pulmonary Disease
○ Diabetes Mellitus
○ Dyslipidemia
○ Generalized Anxiety Disorder
○ Hepatocellular Carcinoma
○ Hypertension
○ Major Depressive Disorder
○ Methamphetamine Use Disorder
● Infectious Diseases
○ Community Acquired Pneumonia
○ COVID-19
○ Dengue
○ Human Immunodeficiency Virus- Acquired Immunodeficiency Syndrome (HIV-AIDS)
○ Infectious Diarrhea
○ Leptospirosis
○ Tinea Infection
○ Tuberculosis, Pulmonary
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What is the OHG?
The OHG serves as the overarching policy reference containing consolidated best available evidence-based
standards of care across various life stages and various settings. (AO No. 2022-0018, AO No. 2023-0002). The
current focus of the OHG is strengthening primary care by consolidating primary care service delivery
standards.
When is the OHG used?
Users of the OHG may consult the document at any point in clinical or public health practice, when in need of
guidance on the continuum of care– from health promotion, prevention, screening, diagnosis, treatment,
rehabilitation, to palliation and referral.
What is the OHG used for?
Since the OHG details the “WHATs” of health care provision, the document can be used as a reference for:
health service delivery; resource mapping; strategic planning; project/program monitoring; technical and
organizational capacity building; and health curriculum enhancement.
Who is the OHG for?
The OHG can be used as a reference by primary care providers, public health managers, other national
government agencies, development and humanitarian partners, civil society organizations, research and
academia, students, and patients and their families and communities.
How is the OHG made?
The OHG development and update process begins with rational priority setting, followed by scoping, review,
and appraisal of evidence-based references. Recommendations or statements from these references are
plotted into a continuum-of-care matrix until the entire spectrum of care is completed. These are then
synthesized and translated into key provisions in the OHG. Finally, the OHG contents are vetted by the
Lifestage Technical Working Group alongside various stakeholders and target users. Only after undergoing
this sequential process does the DPCB release the OHG for public use.
Am I required to follow the guidelines listed in the OHG when treating my patients? What
if the test/treatment/intervention is not available where I am?
The OHG consolidates best available evidence on standards of care, so following guidelines detailed under
the OHG would be aligned with best practices. However, not all settings have the capacity to accommodate
specific cases nor are required resources available at all times. Further, because the OHG is updated
regularly, the newest safe and efficacious interventions (e.g., medications, tests) are already included but
may still be undergoing necessary processes for financing, procurement, and inclusion in the Philippine
National Formulary (PNF). There may also be unique characteristics of individuals that make the provisions
inapplicable. In these circumstances, healthcare professionals and other stakeholders can do any of these
suggested courses of actions, should the need arise:
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Omnibus Health Guidelines ver. 2023 | 16
For clinicians:
● Clinicians are advised to exercise due diligence when applying the provisions of the OHG to
their practice. The practice of medicine remains an art and a science. Hence, clinical
decision-making, taking into account the patient’s characteristics, values, and preferences,
should be paramount;
● Clinicians can be guided by the strength of recommendation for each statement made
apparent by the tags placed after each statement (ie. strong or weak/conditional
recommendation), and the differences in the strength of language used for each statement
(ie. stronger, more active language for strong recommendations vs. weaker, more passive
language for weak recommendations);
● Reference hyperlinks are also available for each guideline statement for instances that need
deeper investigation on the appropriateness of the provisions to particular cases; and
● Clinicians can be guided by the referral provisions of the OHG to refer patients to a
higher/lower level of care.
For public health managers and key decision makers:
● The OHG can be used as a reference for scoping/resource mapping, needs assessment,
strategic planning, and monitoring and evaluation on the roll-out of different health
programs.
For non-health professionals/general public:
● Consult with a licensed healthcare professional/team for any health concern.
I want to contribute further updates on guidelines stated in the OHG. Where can I submit
these?
The OHG is updated every three (3) years or as frequently as needed. To submit suggestions for updates/
amendments, accomplish and submit the feedback form.
I have other questions about the OHG. Where can I send my queries/concerns?
For other inquiries and concerns, you may contact the DPCB - Evidence Generation and Management Division
at egmd@doh.gov.ph.
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Category
Format
What changed?
The updated format now contains two major parts: General Primary Care and Specific Guidance.
Certain texts are clickable and hyperlinked to related sections or to reference documents or relevant
tools, forms, or materials.
Content
The content has been updated to reflect evidence-based standards of care for the key priority programs
of the Department of Health, including: Immunization, Reproductive Health, Tuberculosis (TB),
HIV-AIDS, Neglected Tropical Diseases and Emerging and Re-Emerging Infectious Disease (EREID),
Mental Health, and NCDs.
Specific guidance on certain common and high-burden conditions have also been provided, with a brief
description of the condition, an overview table, details on signs and symptoms, and enumeration of the
evidence-based standards in the spectrum of care, including screening, diagnosis, treatment,
palliation/rehabilitation (if applicable), and referral.
Recommendations from DOH-approved CPGs, other high-quality international CPGs, and other guidance
documents are integrated in various parts of this updated version. The strength of recommendation from
the source CPG is indicated (e.g., strong/recommended, weak/conditional) when available, and the actual
reference CPGs are indicated and hyperlinked for easier access. Users of CPGs may refer to Figure 1 when
interpreting and applying recommendations from CPGs.
References in-text are numbered in superscripts and hyperlinked to the source document. A reference
list is placed at the end of each section, with references numbered sequentially according to the order of
in-text citation, and with relevant hyperlinks.
Figure 1. Guide in Interpreting CPG Recommendations
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PART I:
General
Primary Care
This part provides a consolidation of
general primary care standards, including
preventive and self-care measures for
individuals and their households, screening
services, immunization services, sexual
and reproductive health services, and a
general overview of the diagnostic services
and therapeutic options that should be
offered and/or made available at the
primary care level.
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The General Wellness and Preventive Measures
Section:
aims to provide guidance to primary care providers on the advice that can be given to adults and their
households about general health and wellness and preventive measures, including healthy lifestyle and
self-care practices, household practices, home investments, and community activities.
Health is defined by the World Health Organization (WHO) as a “state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity”. 1 Further, the WHO defines a related term,
“well-being”, as “a positive state experienced by individuals and societies… [which] encompasses quality of
life and the ability of people and societies to contribute to the world with a sense of meaning and purpose” 1.
To achieve health and well-being and not merely the absence, cure, or control of diseases, a holistic approach
anchored on primary healthcare (PHC) is necessary. The OHG contributes to this goal by enumerating health
promotion and preventive interventions that can be delivered and taught in primary care, resulting in the
betterment of the health and empowerment of individuals, families, and communities.
The Republic of the Philippines, as a Member State of the United Nations (UN), is in adherence with the
stipulations of the Universal Declaration of Human Rights and the UN Statement of Common Understanding on
Human Rights-Based Approaches to Development Cooperation and Programming, which elaborated how
human rights standards and principles should be placed in practice and programming guidelines. 2,3
Stipulated in Article 25 of the Universal Declaration of Human Rights is “The Right to Adequate Standard of
Living/Basic Needs” which states:
“1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food,
clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment,
sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control; 2) Motherhood and
childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social
protection.” 2
In delivering any healthcare service, providers are reminded to place prime importance on the principles of
Article 25, alongside championing other human rights. Should patients require care and/or social services
outside of clinical care, providers are advised to attend to their health needs and refer them to the
appropriate government agencies to receive other social services/support needed.
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General Principles
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Preventive strategies are classified into the following:
○ Primordial prevention: preventing the development of risk factors for disease (e.g.,
strategies that modify the upstream determinants of chronic diseases such as eating
patterns, physical activity, environmental and social determinants of health, usually
through legislation or public policies);
○ Primary prevention: preventing the development of disease in individuals who already
have one or more risk factors (e.g., immunizations, pre-exposure and post-exposure
prophylaxis for certain infectious diseases, adequate treatment of hypertension and
dyslipidemia to prevent ischemic heart disease or stroke);
○ Secondary prevention: detecting disease in asymptomatic individuals to treat it early and
prevent its progression (e.g., screening for colorectal cancer or cervical cancer); and
○ Tertiary prevention: minimizing complications, improving quality of life, preventing
imminent death in the setting of an acute illness (e.g., thrombolysis in stroke or fluid
resuscitation and antibiotic administration in septic shock) or disability (e.g.,
rehabilitation for stroke or heart attack survivors).
Always seek to integrate education about general wellness and preventive measures in each
patient encounter.
Encourage adults to be aware of their rights, including their right to health, autonomy and
self-determination, confidentiality, and informed consent.
Encourage adults to be responsible for their health, actively seek medical advice, and be involved
in shared decision-making with their respective healthcare providers.
Self-care
Encourage adults to observe the following healthy practices:
● Dental Care.
○ Perform proper dental care by brushing twice a day using the right amount of fluoridated
toothpaste (1000-1500 ppm), which is recommended to be the entire brushing surface of
a toothbrush, flossing at least once a day, and avoiding rinsing with water after
toothbrushing to optimize the preventive effects of fluoride. 3,4
○ Visit the dentist regularly for oral prophylaxis and oral examination every 6 months or as
advised by the dentist (preferably 3 to 4 months based on caries risk assessment high-risk classification). 3,4
● Diet and Nutrition. Adhere to a healthy dietary pattern, visually guided by Pinggang Pinoy and
characterized by the following: 6, 7
○ Rich in fruits, vegetables, whole grains, fish, and low-fat dairy products;
○ Fortified with micronutrients;
○ Low in cholesterol and saturated fat, with avoidance of trans fat;
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Self-care
Reduced daily salt intake to less than 5 grams per day (equivalent to 2300 mg of sodium
and just under 1 teaspoon of table salt per day), with use of iodized table salt preferred;
○ Minimal to no intake of processed foods, canned goods, and “fast foods;” and
○ Minimal to no intake of sugar-sweetened foods and beverages, such as donuts, cookies,
sweets, fizzy drinks, and juice with added sugar.
Exercise.
○ Perform moderate to vigorous aerobic physical activities, consisting of at least 150
minutes per week of accumulated moderate-intensity physical activity or 75 minutes per
week of vigorous-intensity physical activity, unless contraindicated, or as prescribed by a
physician.8
○ Replace sedentary time with age-appropriate physical activity of any intensity (including
light intensity), to obtain benefits, such as but not limited to, decreasing the risk of
developing hypertension and diabetes, preventing obesity, reducing symptoms of anxiety
and depression, improving cognitive health, and decreasing the risk of mortality.8,9,10
Infectious Disease Prevention. Observe protective measures against infectious diseases, such as
the following, in line with the Water, Sanitation, and Hygiene (WASH) Strategy :
○ Observe proper personal hygiene:
■ Hand Hygiene. Perform proper handwashing with soap and water. Perform
disinfection with alcohol if soap and water are unavailable.
■ Body Hygiene. Bathe with soap and water daily. Use shampoo for hair and scalp
care. Avoid sharing personal items such as towels, uniforms, headsets/
earphones, slippers, and shoes, among others.
■ Proper respiratory hygiene and cough etiquette. When sneezing or coughing,
cover the mouth and nose or cough/sneeze into the elbow when tissue/covering
is not available.11,12
○ Prevention of communicable diseases based on transmission routes
■ Use the appropriate personal protective equipment (PPEs) (e.g. masks, gloves,
etc.) as necessary, according to the recommendations of health authorities.
○ Prevention of food- and water-borne diseases
■ Use safe drinking water.
■ Use a sanitary toilet and avoid open defecation practices.
○ Self-protection measures against mosquito-borne diseases
■ Wear light-colored clothes, long sleeves, and long pants if staying outdoors.
■ Apply insect repellent to prevent mosquito-borne diseases.
■ Use screen doors and windows or insecticide-treated screens/ curtains for doors
and windows.
■ Use long-lasting insecticide-treated nets (LLIN) at night in malaria-endemic and
high-risk areas.
○ Self-protection measures against soil-transmitted helminths/parasitic diseases/other
zoonotic diseases (e.g. leptospirosis)
■ Wear slippers/shoes.
○
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Self-care
Avoid wading in or swimming in and using infested freshwater, which may serve
as transmission sites for infectious diseases.
■ Wash legs/ feet with soap and water after wading in flood water.
■ Avoid intake of water from possible contaminated water sources.
Injury Prevention. Observe injury prevention measures such as the following:
○ Use sports-appropriate protective gear as necessary to prevent injury from
sports-related accidents.13
○ Observe driving practices that promote road safety and prevent road crash-related
injuries including the following:
■ Practice road courtesy at all times as a driver, as a passenger, and as a
pedestrian, by being aware of traffic signs and strictly following traffic rules and
regulations, in accordance with RA No. 4136: “Land Transportation and Traffic
Code”. This involves simple and practical measures such as following traffic light
rules, using the pedestrian crossing, overpass, underpass, and sidewalks, giving
the right of way to an overtaking vehicle, and driving within the set speed limit,
etc. 14,15
■ Use age-appropriate restraints and protective gear in both non-motor (e.g.
bicycles) and motor vehicles, including the use of helmets, seatbelts, goggles,
and child restraint systems (CRS), in accordance with RA No. 8750: “Seat Belts
Use Act of 1999”, RA No. 10054: “Motorcycle Helmet Act of 2009”, and RA No.
11229: “An Act Providing for the Special Protection of Child Passengers in Motor
Vehicles and Appropriating Funds Therefor”. 16, 17, 18
■ Avoid distracted driving and driving under the influence of alcohol, dangerous
drugs, and other similar substances, in accordance with RA No. 8750, RA No.
10054, and RA No. 11229.19, 20
○ Avoid or prevent fireworks-related injuries through the following, in accordance with RA
No. 7183: “An Act Regulating the Sale, Manufacture, Distribution and Use of Firecrackers
and Other Pyrotechnic Devices” and its revised 2012 Implementing Rules and Regulations
(IRR), and Executive Order (EO) No. 28 series of 2017: “Providing for the Regulation and
Control of the Use of Firecrackers and Other Pyrotechnic Devices” 21, 22:
■ Avoid using firecrackers outside the designated fireworks zones.
■ Properly supervise children and adolescents regarding the safe use of fireworks
○ Learn and practice water safety skills, including proper swimming techniques, avoiding
underwater hazards, and wearing life jackets whenever aboard boats, ships, and similar
water vessels.23
Sun protection. Avoid extreme exposure to the sun by wearing protective sunglasses, hats, and
umbrellas, and using sunscreen with Sun Protection Factor (SPF). 24
Weight Management. Maintain a healthy weight and a normal BMI of 18.5-22.9 kg/m2.25,26
Mental Health and Wellness. Engage in the following to promote and protect mental health:
○ Perform meditation, stress management, creative activities, and other relaxation
techniques.
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Self-care
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○ Maintain good relationships with family and peers.
○ Participate in health activities of the local community.
○ Keep regular routines.
○ Allocate time for working and time for resting.
○ Make time for recreational or leisure activities.
○ Observe self-care practices and approaches.
○ Develop personal skills and foster supportive environments.
○ Actively seek out mental health information and education.
Sleep. Attain good-quality sleep lasting 7-9 hours on a regular basis.9
Substance use avoidance or cessation. Avoid the initiation of or stop the following practices:
smoking tobacco or using e-cigarettes (vaping), drinking alcoholic beverages and using illicit
substances (e.g. marijuana, methamphetamine/shabu, etc.).
Safe and Responsible Sexual and Reproductive Health (SRH) Practices. Observe safe and
responsible SRH practices such as the following 27, 28:
○ Practice responsible sexual behavior and safer sex, including abstinence, avoidance of
having multiple sexual partners, and using contraceptives properly (e.g. proper use of
condoms and water-based lubricants, proper use of contraceptive pills, etc.) to prevent
unplanned pregnancy and sexually transmitted infections (STIs).
○ Observe other responsible practices such as but not limited to the following:
■ Assert one’s personal rights, practice healthy sexual development and sexuality,
and report any form of online and offline gender-based violence and any form of
sexual exploitation to appropriate authorities through proper channels.
■ Assert the importance of consent, body autonomy, and setting and respecting
physical and mental boundaries at all times.
■ Respect partner’s rights at all times and maintain a good relationship with one’s
own partner.
■ Practice Digital Citizenship Education (DCE), in order to actively, positively, and
responsibly engage in both online and offline communities. 29
■ Avoid online and offline risky behaviors and always personally protect one’s own
and other’s online information and observe proper online behavior. 29
■ Use open communication to relay opinions, interests, preferences, and plans and
have a mutual decision and participative discussion.
○ Practice gender-responsive behavior, respect gender rights, and seek information on
topics including but not limited to the following:
■ Sexual and reproductive health (SRH)
■ Sexual Orientation and Gender Identity and Expression (SOGIE)
■ Gender-based violence (GBV)
■ Risky/abusive behaviors (towards self and others) to avoid violence and injuries
■ Recognition of abusive behaviors
■ Recognition of the cycle of abuse
■ Psychosocial couple-based prevention program
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Self-care
○
■ Psychoeducation
Be aware of the ban on all formal and informal unions of anyone below 18 years, in
accordance with RA No. 11596: “An Act Prohibiting the Practice of Child Marriage and
Imposing Penalties for Violations Thereof”. 30
Household Care
Encourage adults to observe the following practices in their households:
● Health awareness and health seeking behaviors. Maintain appropriate knowledge and
understanding of the specific health needs of each family member, including children,
adolescents, older persons, and persons with disabilities, and perform the necessary steps to take
care of each other’s physical and mental health, including the following:
○ Actively seek healthcare services from their primary care providers.
○ Ensure enrolment of household members in PhilHealth.
○ Facilitate regular wellness visits or follow-up visits of family members with their
healthcare providers.
○ Facilitate access to and observance of preventive measures, including vaccination, and
necessary medical tests, medications, or non-pharmacologic treatments.
● Hygiene and Sanitation. Observe sanitary and hygienic practices in the household such as the
following:
○ Observe safe and proper food preparation such as keeping food clean, separating raw and
cooked food, cooking thoroughly, keeping food at safe temperatures (e.g. refrigerating
food below 4℃, freezing food below -18℃), and using safe and clean water and raw
materials to avoid spoilage and food poisoning.31
○ Observe proper personal hygiene.
○ Use sanitary toilets. Abandon open defecation practices.
○ Observe proper waste handling and disposal practices, in compliance with RA No. 9003
“Ecological Solid Waste Management Act of 2000” 32, RA No. 6969 “Toxic Substances and
Hazardous and Nuclear Wastes Control Act of 1990” 33, and relevant LGU ordinances,
through:
■ Waste segregation according to the following solid waste classification (Table 1)
32,34
:
■ Waste management by:
● Composting of leftover foods, vegetables, peels, etc.
● Recycling or converting items into reusable materials
● Proper disposal of household chemicals, used bulbs, old appliances,
batteries and other products containing harmful substances guided by
the manufacturer’s instruction manual.
○ Regularly perform cleaning and pest control, including rodent and vermin control
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Household Care
Table 1. Solid Waste Classification
Classification:
Definition/ Examples:
Compostable (Nabubulok)
includes kitchen waste, vegetable and fruit peelings
Recyclable
(Nareresiklo/ nabebenta)
scrap metal, non-ferrous scrap metals, tin cans, aluminum, glass bottles, plastic
bottles, corrugated cardboard, newspaper, office paper
Non-recyclable/ Residual
(Hindi nabubulok)
waste materials that cannot be recycled or decomposed (e.g. used plastic or paper
cups, broken glass, food wrappers, plastic bags)
Special
Waste
Household
Household waste that requires treatment before disposal, including waste electrical
Hazardous waste or electronic equipment, paint cans, thinners, batteries, power banks, etc.
Household
Disposable masks, gloves, sharps, any other waste of an individual who has an
Healthcare waste infectious disease
Eliminate all open water reservoirs which may become breeding grounds for mosquitoes
in the home environment.
○ Avoid or minimize indoor and outdoor pollution, smoke, and vape emissions and maintain
adequate ventilation by:
■ Cessation of smoking and vaping, avoidance of burning garbage and dried leaves,
cessation of biomass fuel use, and avoidance of exposure to exhaust from
vehicles 35, 36, in accordance with RA No. 8749 “Philippine Clean Air Act”. 37
■ Ensuring that spaces adjacent to openable windows are free from toxic gases
and other pollutants.
■ Using ventilating fans/electric fans when the supply of fresh air is not enough or
cannot be supplied by natural ventilation.
■ Ensuring exhaust fans/air extractors are operated continuously in an occupied
room.
■ Ensuring that exhaust fans/ air extractors are regularly cleaned and maintained in
good condition.
■ Ensuring that household furniture equipment is not blocking the airflow across
the rooms and physical barriers that can impede airflow are removed.
Nurturing and Supportive Environment. Foster a safe, nurturing, supportive, and respectful
household13, in accordance with PD No. 603 through the following 38 :
○ Spend time talking about or processing each other's interests and experiences.
○ Use appropriate words and offer praise to show care to family members.
○ Ensure open communication lines where members feel safe to express their opinions and
emotions.
○ Show role model behavior to all household members, especially to children and
adolescents, including:
■ Avoiding consumption or use of tobacco, alcohol, or any other substance within
the household.
○
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Household Care
Prohibiting children and adolescents from using, purchasing, selling, trading and
distributing tobacco products, heated tobacco products and vapor products,
alcoholic beverages and illegal substances, among others, in accordance with RA
No. 9211 “Tobacco Regulation Act of 2003; RA No. 11467 “The National Internal
Revenue Code of 1997, as amended”. 39, 40
■ Avoiding violence at all times.
○ Encourage members to develop, determine, and express their gender identity, and
provide emotional support in a non-discriminatory, gender-affirming, developmentally
appropriate, safe, and inclusive household and environment.
○ Show pregnant members affection by offering encouragement to seek professional care,
take breaks and naps, and consume healthy food. In addition, offer help in caring for the
newborn and encourage and support them to breastfeed during the postnatal period.
○ Discuss crisis situations using honest language to ease anxiety and fear.
○ Seek help from family and peers, mental health service providers (e.g. allied health
professionals such as psychologists, psychometricians, or members of the trained to
provide mental health services), and other community support groups when negative life
events occur (i.e. violence, conflict, parental loss, abuse).
○ Support household members with any existing health conditions by encouraging them to:
■ Keep in touch with family, friends, or people who care for them.
■ Identify people whom they can contact for support anytime.
■ Ensure that they adhere to prescribed medications or non-pharmacologic
treatments, including counseling.
■ Follow up with a healthcare provider or support group regularly.
Positive Parenting. Use positive approaches when educating children and adolescents about
acceptable and unacceptable behavior (e.g. communicating calmly with the child in case of
conflict and not resorting to corporal or physical punishment) and perform the following activities,
as appropriate:
○ Spend quality ‘one-on-one time’ with children and adolescents to strengthen the
relationship, understand their feelings, and talk about their interests, experiences, and
plans, and make mutual decisions.
○ Reinforce Digital Citizenship Education (DCE) by developing, following, and routinely
revisiting a Family Media Use Plan to limit and monitor social media use.29
○ Seek advice from experts (e.g. licensed psychologists or psychiatrists) on parenting skills
that are appropriate for managing challenging behaviors or behavioral disorders in
children and adolescents.
Responsible Pet Ownership. Prevent rabies and other zoonotic diseases through responsible pet
ownership practices and handling of animals, in coordination with Local Government Units (LGUs),
such as the following:
○ Protect and promote the welfare of pets and animals and avoidance of their abuse,
maltreatment, cruelty and exploitation, in accordance with RA No. 8485 “Animal Welfare
Act of 1998, as amended, and its revised IRR”. 41
■
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Household Care
Provide pets and animals with food and water that are clean, adequate, and
appropriate, and provide shelter or living conditions that are safe and
comfortable. 41
■ Regularly vaccinate pets against rabies and maintain the registration card
containing all vaccination-related information for accurate record purposes in
accordance with RA No. 9482 “Anti-Rabies Act of 2007”. 42
■ Prevent pets from roaming the streets or any public place without a leash. 42
■ Immediately notify within twenty-four (24) hours to concerned officials for
investigation or appropriate action for any pet biting incident and for the pet to be
placed under the observation of a government or private veterinarian. 42
■ Bring a bite victim immediately to the nearest clinic or animal bite center.
■ Wash hands with soap and water after touching or handling pets and animals and
their surroundings.
Safe Use of Household Drugs, Chemicals and Products. Safely manage drugs, chemicals, and
other household products in the following manner:
○ Only use products registered and approved by the Department of Trade and Industry (DTI)
and the Food and Drug Administration (FDA) (e.g. FDA-notified cosmetic products;
FDA-registered household/urban hazardous products (HUHS) including dishwashing
soaps,
laundry
detergents,
cleaners
and
disinfectants;
FDA-approved
trichloroisocyanuric acid (TCCA) products) , in accordance with RA No. 9711 “Food and
Drug Administration Act of 2009". 43
○ Follow the manufacturer’s instructions and precautions printed on the product label
regarding the use, handling, storage, and disposal of household chemicals and products.
○ Use the original containers of potentially dangerous products with their original product
labels and avoid transferring them to another container.
○ Do not reuse containers of HUHS and HUPs for food and drinking water storage.
○ Ensure that HUHS not intended for children’s use and household/urban pesticides (HUPs)
are stored out of children’s reach and away from places where cross-contamination with
food may occur.
○ Keep flammable products well-insulated and out of reach of children and pets.
○ Use appropriate PPE (e.g. gloves) when handling or using chemicals.
○ Ensure that adverse events resulting from intentional or unintentional exposure to
cosmetic, TCCA, HUHS and HUP products are reported to the Marketing Authorization
Holder and/or FDA and any exposed household member is brought to a healthcare
provider for timely and appropriate management.
○ Avoid the use or purchase of mercury-containing devices such as mercury thermometers
and mercury sphygmomanometers.
Support for Community Programs and Activities. Participate in community programs, health
promotion, and disease prevention and control programs or activities, such as the following:
○ Community health clubs based on risk factors or known disease and community support
groups (e.g. parenting support groups, caregiver support groups).
■
●
●
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Household Care
○
Various health promotion and disease prevention and control activities such as but not
limited to:
■ Mass Drug Administration (MDA) activities for neglected tropical diseases
■ Selective Deworming activities for adults belonging to special populations (e.g.
farmers, military, paramilitary personnel, etc), particularly for adults living in
Schistosomiasis-endemic areas and adults living in filariasis-endemic provinces;
■ Community oral health programs and activities, including, but not limited to, oral
health education and toothbrushing drills, oral health screening, early detection,
caries risk assessment, and application of fluoride varnish or silver diamine
fluoride.
■ Community activities on emergency preparedness and response, in accordance
with RA No. 10121 “Philippine Disaster Risk Reduction and Management Act of
2010”44 and the Manual of Operations on Disaster Risk Reduction and
Management in Health in the Province-Wide and City-Wide Health System 45 such
as the following:
● Medical and Public Health Component Services and Sample Activities in
Response
○ Maternal and Child Health
■ Provide immediate and postpartum care services
■ Coordinate access to human milk banks
○ Prevention and control of Communicable Diseases
■ Practice of isolation
■ Continuously provide the following:
● Insecticide, treated bed nets, and facemask
● Medical prophylaxis
● Anti-tuberculosis drugs
○ Minimum Initial Service Package for Sexual and Reproductive
Health
■ Provide emergency birthing kits, hygiene kits, women’s
kits, family planning commodities, condoms,
anti-retroviral drugs
■ Establish conjugal rooms
■ Counseling services particularly for pregnant
adolescents, including their partners
○ Management of injuries
■ Provide trauma kits, first aid kits, other medical
supplies
■ Refer patient to higher level facility for the necessary
management
○ Control of non-communicable diseases
■ Provide medicine for hypertension, diabetes, etc.
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Household Care
Provide Tsekap kit (blood pressure apparatus,
stethoscope, etc.) to medical team
Community activities intended to prevent infectious diseases such as but not
limited to:
● “Enhanced 4S Strategy” according to DOH Administrative 2018-0021 for
the prevention of dengue and other infectious diseases transmitted by
Aedes mosquitoes. 46
● Rabies and animal bite prevention.
● Preventive chemotherapy for endemic infections including filariasis.
● Active case-finding activities including symptom screening and contact
investigation if household or close contact of a person with Tuberculosis
disease or any other infectious disease meriting case finding and
contact tracing.
● Government immunization initiatives against vaccine-preventable
diseases, including routine vaccination and vaccination during public
health emergencies (PHE) such as Coronavirus Disease 2019 (COVID-19).
Health promotion and advocacy initiatives and capacity development activities
from reputable health institutions, academe, and other partner or civil society
organizations:
Community parenting or caregiving activities and programs, including family
development sessions and caregiver well-being sessions.
■
■
■
■
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Devices
U.S. Centers for Disease Prevention and Control. Healthy and Safe Swimming Communications Toolkit. Published May 1, 2023. Accessed
December 12, 2023. https://www.cdc.gov/healthywater/swimming/safe-swimming-week/toolkit.html
American Academy of Pediatrics. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents (4th Edition).
American Academy of Pediatrics; 2017. https://doi.org/10.1542/9781610020237
Philippine Association for the Study of Overweight and Obesity. Know Your BMI Calculator. Published 2020. Accessed December 13,
2023. https://obesity.org.ph/know-your-bmi/
World Health Organization. Obesity: Preventing and Managing the Global Epidemic. World Health Organization; 2000.
https://books.google.com.ph/books?id=AvnqOsqv9doC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=fa
lse
Republic Act No. 10354 "The Responsible Parenthood and Reproductive Health Act of 2012″
WHO consolidated guideline on self-care interventions for health: sexual and reproductive health and rights. Geneva: World Health
Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. https://www.ncbi.nlm.nih.gov/books/NBK544164/pdf/Bookshelf_NBK544164.pdf
Council of Europe. Digital Citizenship Education Handbook. Council of Europe; January 2019. https://rm.coe.int/16809382f9
Republic Act No. 11596: “An Act Prohibiting the Practice of Child Marriage and Imposing Penalties for Violations Thereof”
U.S. Food and Drug Administration. Refrigerator Thermometers - Cold Facts about Food Safety. Published February 17, 2022. Accessed
December 12, 2023. https://www.fda.gov/food/buy-store-serve-safe-food/refrigerator-thermometers-cold-facts-about-food-safety
Republic Act No. 9003 “Ecological Solid Waste Management Act of 2000"
Republic Act No. 6969 “Toxic Substances and Hazardous and Nuclear Wastes Control Act of 1990"
Department of Environment and Natural Resources - Environmental Management Bureau. Waste Segregation Advisory. N.d. Accessed
December 16, 2023. https://emb.gov.ph/waste-segregation-advisory/
Global Initiative for Asthma. 2023 GINA Report. Published July 10, 2023. Accessed December 12, 2023.
https://ginasthma.org/2023-gina-main-report/
Global Initiative for Chronic Lung Disease. 2024 GOLD Report. Published December 1, 2023. Accessed December 13, 2023
https://goldcopd.org/2024-gold-report/
Republic Act No. 8749 “Philippine Clean Air Act”
Presidential Decree No. 603 “The Child and Youth Welfare Code
Republic Act No. 9211 “Tobacco Regulation Act of 2003”
Republic Act No. 11467 “The National Internal Revenue Code of 1997, as amended”
Republic Act No. 8485 “Animal Welfare Act of 1998, as amended, and its revised IRR”
Republic Act No. 9482 “Anti-Rabies Act of 2007”
Republic Act No. 9711 “Food and Drug Administration Act of 2009"
Republic Act No. 10121 “Philippine Disaster Risk Reduction and Management Act of 2010”
Department of Health. Manual of Operations on Disaster Risk Reduction and Management in Health in the Province-wide and
City-wideHealth System. Published June 2023. Accessed December 12, 2023.
https://drive.google.com/file/d/1hPW4YX0DCIC4zJdDt7GUYFh2TIgPG0Ds/view
Department of Health. Administrative Order 2018 - 0021. Guidelines for the Nationwide Implementation of the Enhanced 4S-Strategy
against Dengue, Chikungunva and Zika. Published July 25, 2018. Accessed December 12, 2023.
https://doh.gov.ph/sites/default/files/health_programs/ao2018-0021.pdf
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Omnibus Health Guidelines ver. 2023 | 31
The Supportive Care, First Aid Measures, and Basic
Emergency Care Section:
aims to provide guidance on the advice that can be taught to adults and their households about self-monitoring
and self-testing, supportive therapies, general first-aid measures, and basic emergency care for lay people.
General Principles
●
●
●
●
Encourage all asymptomatic adults to seek consultation with their primary care provider at least
annually.
Encourage all adults experiencing symptoms to consult at the nearest primary care facility or
healthcare provider for proper assessment and management.
Teach adults how to properly perform self-testing and self-monitoring and how to use appropriate
supportive therapies for applicable conditions.
Teach adults how to perform first-aid measures and seek basic emergency care as necessary.
Self-monitoring and Self-testing
Teach adults how to check and monitor their vital signs at home and do home tests or self-tests for certain
conditions.
●
●
Vital signs
○ Blood Pressure. Home blood pressure monitoring in patients with suspected or
confirmed hypertension or for monitoring response to BP-lowering drugs 1-3 or in pregnant
patients who are diagnosed with gestational hypertension or preeclampsia 2,3.
○ Pulse rate. Pulse rate determination, if clinically indicated, in patients who experience
palpitations, in patients who are suspected or diagnosed with rhythm abnormalities (e.g.
atrial fibrillation), or in patients who are maintained on heart-rate lowering drugs (e.g.
beta-blockers).1,2,3
○ Temperature. Temperature monitoring in patients who feel febrile or to monitor response
to treatment (e.g. fever lysis)
○ Oxygen saturation. Peripheral oxygen saturation monitoring (SpO2) in patients who are
considered suspect, probable, or confirmed COVID-19 cases who are on home isolation, or
in patients with cardiopulmonary diseases (such as COPD and pulmonary hypertension)
who are on oxygen home therapy.
Home tests/maneuvers for certain conditions.
○ Self-monitoring of blood glucose using home glucose meter/glucometer: for diabetic
patients, especially if they are on insulin as maintenance medication or are pregnant and
have chronic diabetes or gestational diabetes.4
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Omnibus Health Guidelines ver. 2023 | 32
Self-monitoring and Self-testing
○
○
○
○
Pregnancy testing using home pregnancy kits: for women of reproductive age who are
experiencing signs and symptoms such as late menstrual period, breast tenderness,
nausea or vomiting, weight change, fatigue, mood changes, changes in eating habits and
frequent urination.5
Breast self-awareness: for women to familiarize themselves with the normal appearance
and feel of one’s breasts. Immediately consult with a healthcare provider if any change
(e.g. pain, a mass, new onset of nipple discharge, or redness) is noticed 6,7.
Self-administered COVID-19 antigen testing using FDA-approved kits: for symptomatic
individuals, within 7 days from onset of symptoms, especially if the capacity for timely
RT-PCR results is limited or not available. 8
HIV Self-testing: for at risk individuals. 9,10
Supportive Therapies and Symptomatic Relief
Teach adults how to properly use supportive therapies and symptom-relieving medications, such as the
following, when applicable:
● Non-pharmacologic supportive therapies.
○ Adequate rest/sleep
○ Proper diet and nutrition
○ Increased water intake/oral hydration if ill and if without water intake restrictions due to a
medical condition (e.g. congestive heart failure, dialysis-requiring chronic kidney
disease);
○ Tepid sponge bath for fever
○ Cold compress for contusion
● Non-prescription or over-the counter (OTC) medications.
○ Provide guidance and teach necessary precautions to patients regarding the use of the
following common non-prescription/over-the-counter (OTC) medications for symptom
relief to avoid underdosing/overdosing, minimize adverse effects, and prevent drug
interactions:
■ Antipyretics for fever
● Paracetamol 325 to 650 mg orally or rectally every four to six hours (the
maximum total daily dose is 4 g per day).11,12
■ Analgesics for pain relief (observe caution when using non-steroidal
anti-inflammatory drugs (NSAIDs) in patients with kidney disease or
gastrointestinal bleeding; avoid in patients with allergies to NSAIDs)
● Paracetamol 325 to 650 mg orally or rectally every four to six hours (the
maximum total daily dose is 4 g per day).11,12
● Oral Ibuprofen 200 mg every 4 to 6 hours as needed; if no relief, may
increase to 400 mg every 4 to 6 hours as needed; maximum dose: 1.2
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Omnibus Health Guidelines ver. 2023 | 33
Supportive Therapies and Symptomatic Relief
■
■
g/day. Use for >10 days is not recommended unless directed by the
healthcare provider.12,13
● Mefenamic acid 500 mg orally once then 250 mg orally every 6 hours as
needed; usually not to exceed 1 week.11, 14
Cold medications for nasal congestion
● Phenylephrine 10 mg orally every 4 hours with a maximum dose of 60 mg
per 24 hours15, usually in combination with chlorpheniramine12 and/or
paracetamol.
Mucolytics or antitussives for cough
● Oral Ambroxol with daily dose of 30 mg to 120 mg taken in 2 to 3 divided
doses16 as mucolytic
● Carbocisteine orally with an initial 2,250 mg daily in divided doses, may
be decreased to 1,500 mg daily in divided doses when a satisfactory
response is obtained17 as mucolytic
● Oral Butamirate as 50 mg tablet, 2 or 3 tabs daily at intervals of 8 or 12
hours 12,18 as antitussive
First-aid and Basic Emergency Care
Teach adults about the recognition of signs and symptoms needing immediate consultation with a
healthcare provider, the proper way of providing first-aid care, and the administration of basic emergency
care by trained individuals.
● Signs and symptoms needing immediate consultation. Advice adults to consult at the nearest
health facility upon experiencing the following symptoms or conditions, which may be life- and/or
limb-threatening:
○ Any of the following signs and symptoms 19,20:
■ Acute neurologic symptoms such as loss of consciousness, altered mental
status, dizziness, facial asymmetry, slurring of speech, and new-onset weakness
or loss of sensation, seizure, or convulsions
■ Agitated and/or aggressive behavior or suicidal ideation/behavior
■ Acute vision loss
■ Eye injury/foreign body
■ Acute chest pain
■ Acute dental pain
■ Any other severe pain
■ Difficulty in breathing
■ Chest retractions
■ Contractions, pain, or bleeding in late pregnancy
○ Any of the following, accompanied by fever21,22,23:
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Omnibus Health Guidelines ver. 2023 | 34
First-aid and Basic Emergency Care
Living in an area where malaria is endemic;
History of travel to a malaria endemic area;
History of recent malaria infection in the previous months
Documented history of Plasmodium vivax infection;
History of blood transfusion in the previous month(s) or any dental or surgical
procedure
■ Headache
■ Body malaise
■ Myalgia (lower back, arms, and legs)
■ Arthralgia
■ Retro-orbital pain
■ Anorexia
■ Nausea
■ Vomiting
■ Diarrhea
■ Flushed skin
■ Rash (petechial, Hermann's sign)
■ Abdominal pain
■ Open wounds
Any of the three cardinal signs of leprosy24
■ Hypopigmentation of the skin;
■ Thickening of peripheral nerves with loss of sensation; or
■ Positive slit-skin smear upon screening.
Any of the following TB signs and symptoms 25,26:
■ At least 2 weeks of cough;
■ Unexplained fever;
■ Night sweats;
■ Unexplained weight loss.
Any of the following signs and symptoms of sexually transmitted diseases:
■ Vaginal/penile/anal discharge characterized by:
● presence of foul odor
● persistent pruritus
● burning sensation during urination
● greenish (pus-like) appearance
● painful intercourse (dyspareunia)
● post-coital bleeding
■ Painful or painless genital sores
■ Oral viral and fungal infection (leukoplakia, candidiasis, herpes zoster)
Inhalation, ingestion, and/or exposure to harmful substances19
Trauma and associated injuries or symptoms such as the following19,27:
■
■
■
■
■
○
○
○
○
○
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Omnibus Health Guidelines ver. 2023 | 35
First-aid and Basic Emergency Care
Loss of consciousness, altered mental status, or seizures
Difficulty of breathing
Bleeding, expanding hematoma, or signs of shock (e.g. pallor, cold extremities)
Traumatic dental injuries that result in subluxation, extrusion, lateral luxation,
intrusion, avulsion of permanent teeth, and root fracture caused by sporting
events, falls, motor vehicle accidents, or interpersonal violence
■ Abdominal pain and/or enlargement
■ Pain or limitation in motion of neck or extremities
■ Burns especially those involving the head and neck, hand, feet or groin area
First aid care kit. Encourage all adults and their respective households to prepare and maintain a
first-aid kit with the following contents28:
○ First aid manual
○ Plasters, sterile gauze dressings, sterile eye dressings, cotton balls and cotton-tipped
swabs, bandages, safety pins, disposable sterile gloves, tweezers, scissors, antiseptic
solution, antiseptic cleansing wipes, antiseptic cream, sticky tape, thermometer
(preferably digital), painkillers such as paracetamol (or infant paracetamol for children),
aspirin (not to be given to children under 16), or ibuprofen, antihistamine cream or tablets,
distilled water for cleaning wounds, eyewash, and eye bath;
○ Personal or maintenance medications
○ Epinephrine autoinjector or Epinephrine vial with appropriate syringe for individuals who
are at risk of anaphylaxis
First aid measures. Teach adults to administer first-aid measures for the following conditions:
○ Animal bites (e.g., dog bites)29
■ Immediately perform proper wound care, including washing with soap and water.
■ Seek consultation at the nearest DOH - Certified Animal Bite Treatment
Center/Animal Bite Center for safe and effective post-exposure anti-rabies
vaccination, anti-tetanus vaccination, antibiotics, and health education.
○ Dental Injuries.
■ Rinse avulsed permanent tooth gently in milk, saline, or saliva and take care not
to touch the root with fingers. If unable to replant the tooth, place in physiologic
storage medium like milk, saliva or saline and seek immediate dental treatment.27
■ Seek immediate medical attention for uncontrolled or profuse bleeding of a tooth
extraction site.
○ Minor closed wounds (e.g., bruise/contusion).30
■ Apply a cold compress or cold pack to the area for at least 10-20 minutes.
■ Elevate the injured area to a tolerable level to prevent swelling.
○ Minor open wounds (e.g., abrasion, superficial laceration/cuts).30
■ Apply direct pressure while wearing gloves if there is external bleeding from
wound.
■ Rinse with running water then wash with soap and water once the bleeding stops.
■ Apply antibiotic ointment, cream, or gel, as prescribed by a primary care provider.
■
■
■
■
●
●
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Omnibus Health Guidelines ver. 2023 | 36
First-aid and Basic Emergency Care
Cover with a sterile gauze pad or an adhesive bandage.
Consult at the nearest health facility if the wound is deep, extensive, persistently
bleeding, or at high risk of infection (e.g. puncture wound from a nail).
Minor, superficial or first-degree non-chemical burns.30
■ Stop the burning by removing the person from the source or removing the source
from the person.
■ Cool the burned area with cool or cold water (but not direct ice or ice water
application) for at least 10 minutes.
■ Avoid removing the cover of the blister to protect the burnt skin.
■ Cover with loose sterile dressing.
■ Apply silver sulfadiazine, as prescribed by a primary care provider, for
non-infected burns, if without allergy to sulfonamides and if the medications are
available.
■ Consult at the nearest health facility if the burn is deep, extensive, involves
critical areas (hands, feet, groin, head, face, circumferential burns), a dirty wound
is sustained, there are signs of infection (e.g. fever, purulent discharge) or there
is associated difficulty of breathing.
Muscle, bone, or joint injuries30:
■ Rest: Limit the use of the injured part.
■ Immobilize: Apply a splint or elastic bandage to limit motion.
■ Apply cold compress to the area for at least 10-20 mins every 6-8 hours in the
first 24 hours after injury.
■ Elevate the injured body part to a tolerable level to reduce swelling.
■ Consult at the nearest health facility if any of the following are present: difficulty
of breathing, an open fracture, deformity, abnormal movement or inability to
move, coldness or numbness, involvement of the head, neck or spine, or the
injury is suspected to be significant due to its cause (e.g. fall, vehicular accident).
Poisoning and Chemical burns31
■ Eye exposure.
● Immediately irrigate the affected eye with clear running tap water,
occasionally lifting and lowering the lids then seek medical attention.
● Avoid rubbing the eyes.
■ Inhalation.
● Remove the victim from the source of the hazardous substance and
bring him/her to an open space with fresh air.
● If the victim vomits, turn him/her to his/her side to avoid choking.
● Seek medical attention immediately.
■ Ingestion.
● Do not induce vomiting.
● Seek medical attention immediately.
■ Skin exposure.
■
■
○
○
○
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Omnibus Health Guidelines ver. 2023 | 37
First-aid and Basic Emergency Care
●
●
Inspect and note all areas of the body that came into contact or have
been contaminated by the substance, removing the clothes if necessary.
Wash or irrigate all contaminated areas with clear running tap water and
seek medical attention immediately.
Disasters.
■ If trained in Psychological First-Aid (PFA), facilitate and/or coordinate the
provision of PFA and other psychosocial services to disaster-affected
populations following the key principles of PFA (a sense of safety, calming, a
sense of self, and community efficacy, connectedness, and hope, etc.).
Safe provision of basic emergency care, cardiopulmonary resuscitation (CPR), and
psychosocial assistance. Teach adults to recognize the following emergencies and how to provide
help safely:
○ Common emergencies.30,32
■ Cardiac arrest: sudden loss of consciousness and unresponsiveness and absence
or abnormal breathing (e.g. gasping), and absence of pulse.
■ Possible acute stroke: unilateral weakness of face (e.g. drooping), arm, grip or
speech disturbance
■ Possible acute coronary syndrome: acute nontraumatic chest pain
■ Respiratory distress: shortness of breath, gasping, rapid shallow breathing,
painful or uncomfortable breathing
■ Life-threatening bleeding
■ Shock: drowsiness or altered mental status, excessive thirst, palpitations,
difficulty of breathing, weakness, cold extremities, pallor
■ Drowning
■ Vehicular accidents
○ Safe provision of help to emergency victims.32
■ Seek opportunities to learn or participate in first aid and basic emergency care
training, including lay Basic Life Support (BLS), cardiopulmonary resuscitation
(CPR), and basic disaster risk reduction and management from qualified experts
or trainers.
■ Always check for the safety of the scene to the self before extending help to
others.
■ Immediately call for help and activate emergency services upon witnessing any
emergency to facilitate the transport of the victim to the nearest healthcare
facility.
■ If trained, perform lay BLS on victims in cardiac arrest after ensuring that the
scene is safe and calling for help.
○ Help for violence/abuse victims. Advise adults to do the following when encountering or
witnessing interpersonal violence or abuse:
■ Immediately call 911 for help.
■ Talk to a friend, a family member, a trusted teacher, a doctor, or a counselor.
○
●
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Omnibus Health Guidelines ver. 2023 | 38
First-aid and Basic Emergency Care
■
■
Familiarize and access existing referral mechanisms in the locality
Collaborate with the Multidisciplinary Team (MDTs)
References
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COVID-19. Published 2022. Accessed December 14, 2023.. https://doh.gov.ph/sites/default/files/health-update/dm2022-0033.pdf
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recommendations for a public health approach. Published July 16, 2021. Accessed December 14, 2023.
https://www.who.int/publications/i/item/9789240031593
Department of Health. Administrative Order 2022-0035: Guidelines in the Implementation of Differentiated HIV Testing
Services.Published August 22, 2022. Accessed December 14, 2023. https://dmas.doh.gov.ph:8083/Rest/GetFile?id=724488
UpToDate. Acetaminophen (paracetamol): Drug information. N.d. Accessed December 14, 2023.
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e=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
Department of Health. Philippine National Drug Formulary: Essential Medicines List. Published 2008. Accessed December 14, 2023.
https://www.fda.gov.ph/wp-content/uploads/2021/03/PNDF-2008.pdf
UpToDate. Ibuprofen: Drug information. N.d. Accessed December 14, 2023.
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Drugs.Com. Mefenamic acid. N.d. Accessed December 14, 2023. https://www.drugs.com/mtm/mefenamic-acid.html#dosage
Drugs.Com. Phenylephrine. N.d. Accessed December 14, 2023. https://www.drugs.com/mtm/phenylephrine.html#dosage
Drugs.Com. Ambroxol Hydrochloride. N.d. Accessed December 14, 2023. https://www.drugs.com/ambroxol.html#dosage
MIMS. Carbocisteine. N.d. Accessed December 14, 2023. https://www.mims.com/philippines/drug/info/carbocisteine?mtype=generic
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Basic emergency care: approach to the acutely ill and injured. Geneva: World Health Organization and the International Committee of the
Red Cross 2018. Licence: CC BY-NC-SA 3.0 IGO. Accessed December 16, 2023.
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U.K. National Institute for Health and Care Excellence. Stroke and transient ischaemic attack in over 16s: diagnosis and initial
management. Published May 01, 2019. Updated April 13, 2022. Accessed December 14, 2023. https://www.nice.org.uk/guidance/ng128
U.S. Centers for Disease Prevention and Control. Definitions of Symptoms for Reportable Illnesses. Published 2017. Accessed
December 14, 2023. https://www.cdc.gov/quarantine/air/reporting-deaths-illness/definitions-symptoms-reportable-illnesses.html
Department of Health. Clinical Practice Guideline on the Diagnosis, Management and Prevention of Dengue for Adult and Pediatric
Filipinos. Published 2023. Accessed December 14, 2023.
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World Health Organization. Malaria. Published 2023. Accessed December 14, 2023.
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World Health Organization. Leprosy. Published 2023. Accessed December 14, 2023.
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University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (Phase 3): Screening for Infectious Diseases. Published October 13, 2023. Accessed December 14, 2023.
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Department of Health. NTP Manual of Procedures, 6th Ed. Published 2021. Accessed December 14, 2023.
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Omnibus Health Guidelines ver. 2023 | 39
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traumatic dental injuries: 1. Fractures and luxations. Dental Traumatology. 2020;36(4). doi:https://doi.org/10.1111/edt.12578
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https://doi.org/10.1161/CIR.0000000000000918
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Omnibus Health Guidelines ver. 2023 | 40
The General History and Physical Examination Section:
aims to provide guidance to the primary care providers on the conduct of a standard comprehensive
history-taking and physical examination. Properly conducted history-taking and physical examination
documented in a standard medical record are central to accurate diagnosis and management and guide
healthcare providers in creating a person-centered care plan that underpins safe, effective, and quality
service delivery.
Normal and abnormal findings are shown in this section to enhance the acuity of healthcare providers in
recognizing signs of diseases or disorders. Integrated into the history and physical examination are
important symptoms and signs of diseases and tools used by the priority programs of the Department of
Health.
General Principles
●
●
●
●
Patient autonomy. Respect the patient’s autonomy and act in his/her best interests.
Informed consent. Fundamental to each patient-physician encounter is informed consent. Always
seek to ensure that the patient thoroughly understands the risks and benefits of any diagnostic
maneuver or therapeutic intervention and secure informed consent.
Privacy and confidentiality. Always ensure that the patient’s privacy is protected, and
confidentiality of patient information is maintained. When laws or policies require reporting of
cases to protect the public’s health (e.g., mandatory reporting of notifiable diseases as mandated
by RA No. 11332 "Law on Reporting of Communicable Diseases" 1), ensure that measures are
followed to maintain data security and confidentiality.
Comprehensive health profile for holistic care. Primary care providers should seek to obtain a
complete health profile of individuals consulting at primary care through comprehensive
history-taking and physical examination. Due to time limitations, resource constraints, or
patient-specific factors, a single encounter may not be enough to obtain all the information or
perform all the maneuvers. Hence, certain parts of the history-taking and the PE may be done in
different encounters, as part of continuing care.
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Omnibus Health Guidelines ver. 2023 | 41
Screening for Red Flags
Before proceeding to comprehensive history taking and physical examination, screen the patient for
conditions that would necessitate immediate or emergent medical attention, assessment, management,
and/or referral to a higher level of care. Screening for red flags to guide the triaging of the patient may be
done by any trained member of the healthcare team. Examples of red flags are listed below.
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Chest pain/ discomfort/ heaviness, either in the center of the chest, radiating to left arm or chest,
when climbing up hill or in a hurry, not relieved by rest or medication, and/or lasts over an hour or
more;
Slurred speech;
Facial Asymmetry;
Weakness/ Numbness on arm on one side of the body;
Not oriented to time, person, place;
Seizure or convulsion;
Loss/ decreased level of consciousness;
Difficulty of breathing;
Act of self-harm/ Suicide;
Agitated and/or aggressive behavior;
Eye injury/ foreign body injury in the eye; or
Severe injuries/ signs of abuse
Severe or persistent abdominal pain
Severe allergic reaction
Loss of consciousness
Profuse bleeding
History Taking
Obtain the patient’s history in order in a systematic manner and document the patient’s story accurately in
the health record.
●
●
Obtain a comprehensive history at the first outpatient consultation to facilitate the completion of
an individual’s complete health profile and identify the various risk factors that need to be
addressed for preventive health and holistic care.
In certain instances, a focused approach instead of extended history-taking may be enough, such
as during consults that necessitate urgent or emergent care or during follow-up consults. Primary
care providers should adjust the history-taking approach according to the patient’s clinical status
and health needs.
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Omnibus Health Guidelines ver. 2023 | 42
History Taking
●
Ensure the completion of the health record with the following sections. The standardized Adult
Health Examination Form2 can be used to ensure the completeness and accuracy of the health
record.
○ Patient Identification. Obtain and record personal information accurately to ensure
patient safety and avoid fatal errors.
○ General Survey, Vital Signs, and Anthropometrics. The General Survey is a quick
assessment of the patient’s consciousness, coherence, and cardiorespiratory condition.
Obtain the vital signs and anthropometrics of the patient (e.g., height, weight, and BMI) to
aid in the overall assessment of the patient during the encounter.
○ Chief Complaint. Ask the patient about the main reason for the consult to guide the
differential diagnosis. The chief complaint should be the first problem in the problem list.
However, since individuals are also encouraged to regularly consult their primary care
providers, at least annually, even when they are asymptomatic – in these cases, the chief
complaint or reason for consultation can be recorded as a “well visit”, “annual health
exam”, or a “general check-up”.
■ History of Present Illness (HPI). This is the most essential part of the diagnostic
examination. Ask the patient to describe, quantify, and identify the chronology of
their symptoms clearly and how it has affected their current activities of daily
living.
○ Past Medical and Surgical History. Ask about an individual’s past medical and surgical
history to gain better context and identify pre-existing conditions that may affect their
current and future health risks such as the following:
■ Chronic medical illnesses and allergies
■ Prior or current infectious diseases
■ Prior operations
■ Prior and current injuries
■ Prior hospitalizations
○ Obstetric and Gynecologic History (for females). Probe female patients regarding the
details of their obstetric and gynecologic history. This would include details on their
menstrual history, any previous or present pregnancies, contraceptive use, history of pap
smear and/ or cervical cancer screening. The information gathered can help identify
whether the patient will need to be referred for any pre- or post- natal care services, or
other sexual or reproductive health screening or interventions.
○ Personal and Social History (PSH). Probe details of the personal and social history of the
patient, particularly risk factors such as smoking, vaping, alcoholic intake, substance use,
dietary intake, physical activity, sexual practices, and mental health risk factors or
traumatic life events, and environmental exposures.
○ Family History (FH). Ask about the family history to identify hereditary/genetically linked
diseases or risk factors (e.g., certain cancers, cardiovascular diseases, etc.,) or diseases
that are transmitted among family members or close household contacts. An accurate
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Omnibus Health Guidelines ver. 2023 | 43
History Taking
○
○
family history helps assess risk and can help identify whether an individual will benefit
from screening or prophylactic interventions.
Preventive Care Services/Immunization. Ask about prior screening tests including dates
and results and vaccinations.
Review of Systems (ROS). Oftentimes, clinicians are tempted to skip the ROS due to lack
of time. However, it is essential to ask for salient symptoms by each system or anatomic
region to guide the differential diagnosis and identify any additional problem that might
not have been identified in the preceding parts of the history-taking. Record all pertinent
positives and pertinent negatives.
Physical Examination
Perform physical examination in a systematic manner and document the physical findings in the health
record (Table 2).
●
●
●
●
Be guided by the information gained from the individual’s history in identifying anatomic sites or
organ systems that need focused attention or a more thorough examination (e.g., a complaint or a
symptom of difficulty of breathing on exertion should prompt a more careful examination of the
cardiovascular and pulmonary systems; a complaint of a breast lump should prompt a clinical
breast examination).
Ensure a professional and empathic approach and respect a patient’s need for modesty.
Secure a patient’s informed consent for sensitive physical maneuvers.
The standardized Adult Health Examination Form2 can be used to ensure the completeness and
accuracy of the health record. Specific sections may be accomplished by the appropriate cadres
of healthcare providers in the healthcare care facility or in the primary care provider network.
Table 2. Physical Examination for Adults
Category
Component
General Survey
Vital signs
Blood pressure
Method/Device
Normal Values/Findings3-10
Inspection
Conscious, coherent, not in distress
Validated oscillometric
upper arm BP device
Systolic Blood Pressure: 90-120 mmHg 3-5
Diastolic Blood Pressure: 60-80 mmHg 3-5
Note: Elevated BP on screening physical confirmation that
prompts suspicion of Hypertension should be confirmed through
repeat office BP Measurement using a validated oscillometric BP
device with an appropriately-sized upper arm cuff, according to
the Standard BP Measurement Protocol or through Ambulatory
BP Monitoring (ABPM)4
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Omnibus Health Guidelines ver. 2023 | 44
Category
Anthropometrics
Component
Method/Device
Normal Values/Findings3-10
Respiratory Rate
Inspection
12-20 breaths per minute
Heart Rate
Auscultation
60-100 beats per minute
Temperature
Non-mercury
thermometer (e.g. digital
axillary thermometer,
tympanic, or infrared)
Oral: 35.8–37.3ºC
Axillary: 34.8–36.3ºC
Tympanic: 36.1–37.9ºC
Rectal: 36.8–38.2ºC
Infrared: 36.1-37.2 ºC6
Peripheral Oxygen
Saturation (if
clinically
warranted)
Pulse oximeter
95-99% at room air
Height
Beam Type Adult
Weighing Scale
(Physician’s Platform
Scale)
Weight
Beam Type Adult
Weighing Scale
(Physician’s Platform
Scale)
Waist
Circumference
Non-extensible/nonstretchable tape measure
Females: < 80 cm
Males: <90cm
Body Mass Index
(BMI)
Calculation:
(weight in kg)
(height in m)2
Asia-Pacific Cut-offs 7,8:
Underweight <18.5 kg/m2
Normal 18.5-22.9 kg/m2
Overweight 23-24.9 kg/m2
Obese ≥25 kg/m2
Note: In pregnant women, use pre-pregnancy BMI to determine
healthy weight gain 9
Skin
Head, Eyes, Ears,
Neck, and Throat
(HEENT)
Head
Eyes
Back to Table of Contents
Inspection, Palpation
Uniform skin color, no pallor, no jaundice, no rashes or
skin lesions, warm to touch, no loss/ decrease in
sensation
Inspection, Palpation,
Auscultation, Otoscopy,
Fundoscopy, Oral
Examination
Normocephalic, no deformities, no depression nor
tenderness
No lesion, bruises and scaling, no signs of hair loss
No masses, ptosis, lesions
No discharges, excessive lacrimation
No tenderness
Pink palpebral conjunctiva, anicteric sclera
Pupils are equally reactive to light and accommodation
Omnibus Health Guidelines ver. 2023 | 45
Category
Component
Method/Device
Normal Values/Findings3-10
Full extraocular muscle movement
Ears
No swelling or discharge
No tragal tenderness
No discoloration, thickening, perforations, lesions and
masses
Intact gross hearing
On otoscopy: No foreign bodies, non-hyperemic
external auditory canal, tympanic membrane intact
with a good cone of light
Nose
Symmetrical without deformities
Nasal septum at midline
Pink nasal mucosa without swelling, bleeding or
exudates
No tenderness over frontal and maxillary sinuses
Throat, including
mouth, oral
mucosa, and neck
Lips are light reddish and moist
Oral mucosa is pinkish with no ulcerations
Complete dentition, no cavities, no oral or mucosal
lesions or ulcerations
Gums are pinkish.
Tongue midline
Palatine tonsils are pinkish without lesions, exudates,
erythema, and enlargement
Uvula is midline
Supple Neck
Symmetrical, no limitations in range of motion
Trachea is at the midline.
No palpable lymph nodes or masses
Thyroid gland is barely palpable
Normal jugular venous pressure (JVP)
No bruit
Chest/Lungs
Inspection, Palpation,
Percussion, Auscultation,
Symmetrical chest expansion
No inspiratory contraction of the
accessory muscles,
supraclavicular retraction, or
intercostal retractions
Normal tactile and vocal fremitus
Bronchovesicular breath sounds heard all over the chest
Heart
Inspection, Palpation,
Percussion, Auscultation
Adynamic precordium, no precordial bulge
Normal/undisplaced Point of Maximal Impulse (PMI)
No thrills and heaves
Normal S1 and S2 with normal rate and regular rhythm, no
murmurs
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Omnibus Health Guidelines ver. 2023 | 46
Category
Component
Method/Device
Normal Values/Findings3-10
Abdomen
Inspection, Auscultation,
Percussion, Palpation
No discoloration, no visible peristalsis/ pulsation
Normoactive bowel sounds
Tympanic in all four quadrants
No shifting dullness or fluid wave
Abdomen is flat, soft and non-tender, no palpable masses
Liver edge and spleen non-palpable
No costovertebral angle tenderness
Extremities
Inspection, palpation,
auscultation
Nails are white with pinkish nail beds.
No clubbing
No cyanosis, no pallor
Extremities are warm, no edema
Full and equal pulses on all four extremities, no bruits
No joint swelling, no gross deformities, with full range of
motion
No numbing (intact and equal tactile senses)
Normal motor strength on all extremities
Inspection, Palpation
Mons Pubis and Pubic Hair: clear with normal hair
distribution; no nits or lice
Vulva:
● Labia majora and minora: symmetrical, smooth to
somewhat wrinkled, unbroken, slightly pigmented
skin surface; no ecchymosis, excoriation, nodules,
swelling, rash, lesions; no swelling, pain, induration
or purulent discharge upon palpation
● Multiparous women: majora are separated and
minora more prominent
Clitoris: approximately 2 cm in length and 0.5 cm in
diameter; no lesions
Urethral Meatus: slitlike in appearance, midline, no
discharge, swelling, and redness, about the size of a pea,
should not cause pain and/or result in any urethral
discharge upon palpation
Vaginal Introitus: pink and moist, patent without bulging
● Nulliparous with intact hymen, vaginal muscle tone
tight and strong
● Multiparous: with remaining hymen, vaginal muscle
tone diminished
● Normal Vaginal Discharge – white and free of foul
odor (some white clumps may be seen—mass
clamps of epithelial cells)
Perineum: Smooth. Slightly darkened
● Upon Palpation: smooth and firm (homogenous in
nulliparous, thinner in parous women)
● Well-healed episiotomy scar is also within normal
limits for parous women
Female External
Genitalia
Mons Pubis and
Pubic Hair
Vulva
Clitoris
Urethral Meatus
Vaginal Introitus
Perineum and Anus
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Omnibus Health Guidelines ver. 2023 | 47
Category
Male External
Genitalia
Component
Method/Device
General Pubic
Region
Penis
Urethra
Scrotum
Testes
Inguinal Region
Inspection, Palpation,
Back to Table of Contents
Normal Values/Findings3-10
Scrotum: thin loose skin over muscular layer, hairless or
with infrequent hair
● Size varies, may appear pendulous
● Skin color - often more deeply pigmented than
body skin; often reddened in red-haired individuals
● Sac is divided in half by septum, left scrotal sac
may be longer than the right
● Contracts in cold temperature; relaxes in warm
temperature
● Rugose surface
● Non-tender, no pitting
Testicle: Present in each scrotal sac,
● Equal in size, approximately 4x3x2 cm
● Left testis may normally be lower than the right
Mildly sensitive to gentle/moderate compression
●
but not tender
● Firm but not hard, smooth, rubbery, ovoid in shape,
● Free from nodules, swelling or bulges
Omnibus Health Guidelines ver. 2023 | 48
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Republic Act No. 113332 “Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act"
Department of Health. Health Examination Form for Adults 20 to 59 years old. Published 2023. Accessed December 7, 2023.
https://drive.google.com/file/d/1IzYtn7lnG5_pSWN7MO46N0TRu62Wy4Om/view
Unger et al. International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension, 75(6), 1334-1357. PMID:
32370572. 10.1161/HYPERTENSIONAHA.120.15026. 2020. https://www.ahajournals.org/doi/epub/10.1161/HYPERTENSIONAHA.120.15026
Philippine Society of Hypertension & Philippine Heart Association. Clinical Practice Guidelines for the Management of Hypertension in
the Philippines. Published 2020. Accessed December 14, 2023.
https://drive.google.com/file/d/1t3UFLQG6XxTUNkVniliIbKnvnUVmDuKD/view
Williams B, Mancia G, Spiering W. 2018 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal.
2018;39(33):3021-3104. doi:https://doi.org/10.1093/eurheartj/ehy339
Lapum JL, Verkuyl M, Garcia W, St-Amant O, Tan A. Vital Sign Measurement across the Lifespan - 1st Canadian Edition.; 2018.
https://pressbooks.library.torontomu.ca/vitalsign/
Philippine Association for the Study of Overweight and Obesity. Know Your BMI Calculator. Published 2020. Accessed December 13,
2023. https://obesity.org.ph/know-your-bmi/
World Health Organization. Obesity: Preventing and Managing the Global Epidemic. World Health Organization; 2000.
https://books.google.com.ph/books?id=AvnqOsqv9doC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=fa
lse
US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Behavioral Counseling Interventions for Healthy Weight and Weight
Gain in Pregnancy: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(20):2087-2093.
https://doi:10.1001/jama.2021.6949
Bickley, L. S., Szilagyi, P. G., & Hoffman, R. M. Bates' guide to physical examination and history taking. 12th ed. Wolters Kluwer; 2017
Back to Table of Contents
Omnibus Health Guidelines ver. 2023 | 49
The Screening Services Section:
aims to provide guidance to primary care providers on the appropriate screening services for adults.
Screening services are essential in the provision of preventive health services and are intended to “identify
people in an apparently healthy population who are at higher risk of a health problem or a condition, so that
an early treatment or intervention can be offered”1.
General Principles of Screening
●
●
●
Screening is a form of secondary prevention - it allows early detection of a disease to improve the
chances for positive health outcomes
Screening is different from early diagnosis: in screening, testing is offered to asymptomatic
individuals while in early diagnosis, testing is done to detect disease in symptomatic individuals.
Primary care managers and providers are encouraged to utilize the Wilson and Jungner’s
principles of screening1 when planning, developing, financing, or implementing screening
programs anchored on evidence-based screening interventions:
○ The condition should be an important health problem.
○ There should be an accepted treatment for patients with recognized disease.
○ Facilities for diagnosis and treatment should be available.
○ There should be a recognizable latent or early symptomatic phase.
○ There should be a suitable test or examination.
○ The test should be acceptable to the population.
○ The natural history of the condition, including development from latent to declared
disease, should be adequately understood.
○ There should be an agreed policy on whom to treat as patients.
○ The cost of case-finding (including a diagnosis and treatment of patients diagnosed)
should be economically balanced in relation to possible expenditure on medical care as a
whole.
○ Case-finding should be a continuous process and not a “once and for all” project.
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Omnibus Health Guidelines ver. 2023 | 50
Screening Services
●
●
●
●
●
●
Offer screening services to all eligible adults.
Select the appropriate screening tests individualized to a patient’s risk profile.
Screening questionnaires can be used to screen certain conditions during the actual patient
encounter in the primary care clinic (Table 3).
Some screening maneuvers are already integrated in the routine physical examination (e.g.,
screening for hypertension by BP measurement at every clinic visit, screening for obesity by
measurement of anthropometrics) but additional screening maneuvers may be performed
depending on the risk profile of the patient (Table 4).
Other screening tests or procedures may necessitate referral to an appropriate facility or
performance by a qualified/trained health personnel if the test/procedure is not available within
the primary care clinic (Table 5).
Ensure that a care cascade, including a functional referral system within the healthcare provider
network (HCPN) is in place for continuity of care after screening.
Table 3. Screening Tools/ Questionnaires
Conditions being
Screened
Alcohol use
(unhealthy
alcohol use)
Screening Tool/Questionnaire
Strength of Recommendation
(if available) and Reference
Guideline
Alcohol Use Disorders Identification Test (AUDIT) Tool
Alcohol, Smoking, and Substance Involvement Screening
Test (ASSIST) Tool2
Strong (PHEX 1 2021) 3
PhilPEN Risk Factor Assessment
PhilPEN 201219
Anxiety
Generalized Anxiety Disorder-7 (GAD-7) Scale4
Strong (PHEX 2021)5
Cardiovascular
Disease Risk
ASCVD Risk Calculator6
2020 ISH Global Hypertension
Practice Guidelines7
WHO Cardiovascular Disease (CVD) Risk Screening and
Assessment Tool
WHO 20208
Chronic
Obstructive
Pulmonary
Disease (COPD)
(among patients
with symptoms)
COPD Diagnostic Questionnaire
COPD Population Screener
Lung Function Questionnaire
CAPTURE Screening Tool
Weak (2023 Philippine Clinical
Practice Guidelines for the
Management of COPD)9
Dental Caries
Caries Risk Assessment
UK Department of Health and
Social Care 202110
Depression
Patient Health Questionnaire 9 (PHQ-9) for HCWs11
(CES-D) for Caregivers and Ill Adults
Strong (PHEX 2021)5
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Omnibus Health Guidelines ver. 2023 | 51
Conditions being
Screened
Screening Tool/Questionnaire
Strength of Recommendation
(if available) and Reference
Guideline
(GDS-15) for Older Adults12
High-risk Sexual
Behavior
Sexual Risk Survey
Safe Sex Behavior Questionnaire(SSBQ)
Sexual Health Practices Self-Efficacy Scale
Sexual Health Practices Self-Efficacy Scale
Condom use errors/ Problem survey (CUES)
Correct Condom Use Self Efficacy Scale (CCUSS)
UCLA Multidimensional Condom Attitudes Scale (MCAS)
Hypersexual Behavior Inventory (HBI)
Hypersexual Disorder Screening Inventory (HDSI)
Weak (PHEX 1 2021) 3
Mental,
Neurologic and
Behavioral
Disorders;
Psychiatric
Emergencies
Directed Assessment at Primary Care according to WHO
mhGAP Intervention Guide – Version 2.0
WHO 201613
Musculoskeletal
Disease
Gait, Arms, Legs, and Spine (GALS) locomotor screening
Weak (PHEX 2023)14
Nicotine
Dependencies in
Current Smokers
Fagerstrom Test
IA (evidence obtained from
systematic review of relevant
randomized controlled trials;
there is good evidence to
support the recommendation)
(2014 PCCP Philippine Clinical
Practice Guidelines on Diagnosis
and Treatment of Tobacco Use
and Dependence) 15
Obesity
Body Mass Index (BMI)
Waist Circumference (WC)
Waist-Hip Ratio (WHR)
Strong (for BMI)
Weak (for WC)
Weak (for WHR)
(PHEX 3 2023)16
Physical
Inactivity
Physical Activity Vital Sign (PAVS) Questionnaire
Strong (PHEX 2023)14
Substance Use
Alcohol, Smoking, and Substance Involvement Screening
Test (ASSIST) Tool
Strong (PHEX 2021)5
Suicide
Columbia-Suicide Severity Rating Scale (C-SSRS)
2017 PPA Consensus Treatment
Guidelines on Major Depressive
Disorder17
Tobacco Use
Screen during history-taking
Strong (for screening) (PHEX
2021)5
Grade A (USPSTF 2021) 18
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Omnibus Health Guidelines ver. 2023 | 52
Conditions being
Screened
Work-related
Musculoskeletal
Disorders
Screening Tool/Questionnaire
Strength of Recommendation
(if available) and Reference
Guideline
PhilPEN Risk Factor Assessment
PhilPEN 201219
Rapid Upper Limb Assessment (RULA)
Rapid Entire Body Assessment (REBA)
Weak
(PHEX 2023)14
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Omnibus Health Guidelines ver. 2023 | 53
Table 4. Screening Maneuvers in PE
Conditions being
Screened
Eligible Population
Screening Maneuver
Strength of
Recommendation (if
available) and
Reference Guideline
Normal Results
Abnormal Findings
Breast Cancer
All women 50 to 69 years old
Biennial Clinical Breast
Examination (CBE)
Strong (PHEX 2021)20
CBE: No nipple
discharge, no
retractions, symmetric,
no dimpling, no
palpable mass or
nodules (findings
should be correlated
with the physiologic
changes associated
with the menstrual
cycle)
CBE: Nipple discharge,
nipple retraction,
asymmetry, dimpling,
pain, palpable mass or
nodules (Note: findings
should be correlated
with the physiologic
changes associated
with the menstrual
cycle)
Cataract
Adults with risk factors (e.g.
hypertension, diabetes,
ocular trauma, obesity)
Visual acuity testing
Weak (AAO 2021)21
VA 20/20
Clear lens32
If VA is 20/40 -20/100
with or without
improvement in pinhole
or if
if VA is 20/200 or worse
For near vision, if <J4
using Jaeger chart
Lens opacity
Comprehensive Eye
Evaluation
Adults aged 40 who do not
have risk factors for eye
disease
External examination
Visual acuity testing using
far and near vision charts
(e.g. Snellen’s Chart, Sloan,
HOTV for literate LEA
symbols for illiterate;
Jaeger or similar near
vision chart)]
Visual fields by
confrontation
Weak (AAO 2020) 22
VA 20/20 or J1, no
visual cuts,pupils are
equally reactive to light
and accommodation,
full Extraocular muscle
(EOM) range of motion;
no masses, ptosis,
lesions; no discharges,
excessive lacrimation;
no tenderness; pink
palpebral conjunctiva,
anicteric sclera32
Decreased visual
acuity, visual field cuts,
asymmetric pupils,
limited EOM range of
motion, masses,
discharge, redness, or
tenderness
Pupillary function (e.g., size
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Omnibus Health Guidelines ver. 2023 | 54
Conditions being
Screened
Eligible Population
Screening Maneuver
Strength of
Recommendation (if
available) and
Reference Guideline
Normal Results
Abnormal Findings
and response to light,
relative afferent pupillary
defect)
Ocular alignment and
motility (e.g.,
cover/uncover test,
alternate cover test,
ductions and versions)
Fundoscopy
People Living with HIV with
symptoms of CMV retinitis
Dental Infection
Asymptomatic adults
Annual visual inspection
Strong (PHEX 2023) 23
Visual inspection:
normal
Visual Inspection:
swollen gums, apparent
bleeding, tooth decay
Diabetic retinopathy
Adults with type 1 or type 2
diabetes mellitus
Fundoscopy within 5 years
after the onset of diabetes
(for type 1) or at the time of
the diabetes diagnosis (for
type 2)
B (ADA 2022)24
No arterial narrowing 32
Cotton wool spots,
microaneurysm,
intraretinal
hemorrhages, macular
edema,
neovascularization, etc.
Familial
Hypercholesterolemia
Asymptomatic adults
Screening for family history
of premature
cardiovascular disease (e.g.
myocardial infarction,
ischemic stroke, peripheral
arterial disease or sudden
cardiac death before the
age of 55 years in males
and 65 in females) and
stigmata through physical
Strong (PHEX 2021)25
PE: Normal
PE: corneal arcus in
those aged 45 years or
younger, tendon
xanthoma, xanthelasma
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Omnibus Health Guidelines ver. 2023 | 55
Conditions being
Screened
Eligible Population
Screening Maneuver
Strength of
Recommendation (if
available) and
Reference Guideline
Normal Results
Abnormal Findings
examination
Hypertensive
retinopathy
Adults with grade 2 or 3
hypertension
Fundoscopy
Class I (ESC 2018) 26
No arterial narrowing,
hemorrhages or
exudates 32
Arteriolar constriction,
arteriovenous nicking,
flame-shaped
hemorrhages, cotton
wool spots, yellow hard
exudates, optic disk
edema
Glaucoma
Adults with family history of
glaucoma,type 2 diabetes
mellitus, myopia, elevated
intraocular pressure (IOP)
Visual acuity testing
Weak (AAO 2020)27,28,29
No visual field cuts
Visual field cuts
Clear optic disk
margins
Increased optic disk to
cup ratio
Normal intraocular
pressure (IOP): 12-21
mmHg
Elevated intraocular
pressure
Normal findings
Discoloration, masses,
persistent nodule or
ulcer, which may be red
or white patches,
swelling or persistent
sores, lump in the neck
area
Fundoscopy
IOP measurement
Oral Cancer
Adults aged 35 years and
older who are smokers
and/or alcohol drinkers
Back to Table of Contents
Visual and tactile
inspection once every 3
years by trained health
workers
Strong (PHEX 2021) 20
Closed angle
Omnibus Health Guidelines ver. 2023 | 56
Table 5. Screening Laboratory Tests and Procedures
Conditions being
Screened
Eligible Population
Screening Test to be
Offered at Primary
Care
Strength of
Recommendation (if
available) and
Reference Guideline
Normal Results
Abnormal Findings
Asymptomatic
Bacteriuria
Apparently healthy pregnant
women
Urine Culture
Weak (PHEX 2023)23
Urine Culture: negative
Urine Culture: positive
for specific organism/s
Breast Cancer
All women 50 to 69 years old
Mammography every 1
to 2 years
Strong (PHEX 2021)20
Mammography:
negative (BIRADS
Category I)
Mammography:
BI-RADS Category 2-6
(findings may be benign
or malignant)
Cervical Cancer
Women aged 30 to 65 years old
Every 3 years with
cervical cytology alone
or every 5 years with
high-risk HPV testing
alone
Strong (PHEX 2021)20
Cytology/Pap Smear:
negative (normal)
Cytology/Pap Smear:
positive (abnormal)
HPV testing: negative
HPV testing: positive
VIA: negative / no
acetowhite area
VIA: positive / with
acetowhite areas
OR
Every 5 years with
high-risk HPV testing in
combination
with cytology
(co-testing)
OR
Every 3 years using
visual inspection with
acetic acid, as an
alternative to Pap
smear, among
Back to Table of Contents
Omnibus Health Guidelines ver. 2023 | 57
Conditions being
Screened
Eligible Population
Screening Test to be
Offered at Primary
Care
Strength of
Recommendation (if
available) and
Reference Guideline
Normal Results
Abnormal Findings
asymptomatic women
Chlamydia and
Gonorrhea
Adults high risk for Chlamydia and
Gonorrhea (e.g. men with HIV
infection, non-monogamous
relationship without condom use,
age<25 years with 2 or more
sexual partners in the past year,
sex partner with active or
previous STI, with previous or
coexisting STI, douching within
the past year, commercial sex
workers, cervical ectopy)
Nucleic Acid
Amplification Test
(NAAT)
Strong (PHEX 2023)23
NAAT: negative
NAAT: positive
Colorectal Cancer
Adults 50 years old and above
Annual Fecal Occult
Blood Test (FOBT) or
Fecal
Immunohistochemical
Test (FIT), followed by
colonoscopy
Strong (PHEX 2021)20
FOBT or FIT: negative
FOBT or FIT: positive
Colonoscopy: normal
Colonoscopy: polyps,
masses, precancerous
growths, cancer
Adults aged 40 years and above,
or younger if with risk factors (e.g.
adults 20-39 years old with CVD
risk of 10% and above OR who are
overweight or obese OR who have
1 or more additional risk factors
for diabetes)
Fasting Blood Sugar
(FBS)
Strong (FBS) (PHEX
2023)16
Weak (HbA1c) (PHEX
2023)16
FBS: <100 mg/dL or
<5.6 mmol/L
Pre-diabetes
● FBS: 100-125 mg/dL
or 5.6-6.9 mmol/L
● HbA1c: 5.7-6.4%
Asymptomatic adults 40 to 75
Lipid Profile (must
Diabetes Mellitus
Dyslipidemia
Back to Table of Contents
HbA1c
HbA1c: ≤5.6%
Diabetes:
● FBS: ⋝126 mg/dl or ⋝7
mmol/L
● HbA1c: ⋝6.5%
Conditional (PHEX 1
Lipid Profile:
Lipid Profile:
Omnibus Health Guidelines ver. 2023 | 58
Conditions being
Screened
Gastric Cancer
Hepatitis B
Eligible Population
Screening Test to be
Offered at Primary
Care
Strength of
Recommendation (if
available) and
Reference Guideline
Normal Results
Abnormal Findings
years old with one or more CV risk
factors (e.g. DM, HTN, Smoking
Hx)
include Total
Cholesterol, LDL
Cholesterol, HDL
Cholesterol,
Triglycerides)
2021)3
● Optimal LDL
cholesterol:
<100mg/dL
● Near optimal LDL
cholesterol:100 to
129mg/dL
● HDL cholesterol:
>60mg/dL
● Total Cholesterol:
<200mg/dL
● Triglycerides:
<150mg/dL
● Total cholesterol ≥
200 mg/dL
● LDL cholesterol ≥130
mg/dL
● HDL Cholesterol <40
mg/dL in men or <50
mg/dL in women
● Triglycerides ≥150
mg/dL
Adults at risk for gastric cancer
(e.g. age >40y/o, FHx of Gastric
Ca, precancerous lesion, Hx of H.
pylori infection, Obesity, Hx of
smoking, Hx of high consumption
of salted food)
Upper Endoscopy
Weak (PHEX 2021)20
Upper Endoscopy:
normal
Upper Endoscopy:
masses,ulcerations,
precancerous growths,
cancer
All adults in highly endemic areas
Rapid or laboratory
based HBsAg
OR
Upper GI Series: normal
Upper Gastrointestinal
Series
Anti-HBs (will also help
determine who needs
to get Hepatitis B
vaccine boosters)
Hepatitis C
Adults high risk for Hepatitis C
(e.g. people who use injection
Back to Table of Contents
Serum anti-HCV
Upper GI Series:
masses, tumors, tissue
changes
2021 Clinical Practice
Guidelines for the
Management of
Hepatitis B in the
Philippines30
Rapid or laboratory
based HBsAg:
negative/non-reactive
Rapid HBsAg:
positive/reactive
Strong (PHEX 2023)23
Serum anti-HCV:
non-reactive
Serum anti-HCV:
reactive
Omnibus Health Guidelines ver. 2023 | 59
Conditions being
Screened
Eligible Population
Screening Test to be
Offered at Primary
Care
Strength of
Recommendation (if
available) and
Reference Guideline
Normal Results
Abnormal Findings
Patients at risk to develop HCC
may include patients with chronic
hepatitis B or C infection, heavy
and prolonged alcohol
consumption, cirrhosis, diabetes,
non-alcoholic fatty liver disease,
and inherited metabolic diseases
Liver Ultrasound with
alpha-fetoprotein test
every 6 months
Strong (PHEX 2021)20
Liver Ultrasound:
normal
Liver Ultrasound:
enlargement, masses,
fatty liver, cirrhosis
Human
Immunodeficiency
Virus
Adults high risk for HIV (e.g. key
populations including
adolescents, high-risk individuals
who have not been tested
recently, partners, infants and
children of people living with HIV,
patients showing signs and
symptoms consistent with AIDS
defining illness, patients with
sexually transmitted infections,
patients with Hepatitis B and C,
patients with undernutrition not
responsive to interventions, all
confirmed tuberculosis patients,
and all pregnant women
regardless of risk; key population:
MSM, people in prisons and other
closed settings, people who inject
drugs, sex workers, and
transgender men and women)
Rapid diagnostic test
Hypertension
All adults
Office BP
drugs or PWID)
Hepatocellular
Carcinoma
Back to Table of Contents
AFP: level between
10ng/mL to 20ng/mL
AFP: elevated AFP
Strong (PHEX 2023)23
RDT: non-reactive
RDT: reactive
Strong (for screening)
Normal BP:
BP: ⋝140/90mmHg 3,31
Omnibus Health Guidelines ver. 2023 | 60
Conditions being
Screened
Eligible Population
Screening Test to be
Offered at Primary
Care
Strength of
Recommendation (if
available) and
Reference Guideline
Normal Results
measurements using
standardized BP
measurement protocol
at every clinic visit
(PHEX 1 2021)3
<120/80mmHg
PSH 202031
Borderline BP:
120-139/80-89mmHg
Abnormal Findings
ISH 20207
Latent Tuberculosis
Adults high risk for TB infection
(e.g. close contacts)
Tuberculin Skin Test
(TST) or
Interferon-gamma
Release Assay (IGRA)
Weak (PHEX 2023)23
TST or IGRA: negative
TST or IGRA: positive
Lung Cancer
Adults high risk for lung cancer
(e.g. age of more than 50 years old
with history of smoking, family
history of lung cancer)
Annual low-dose CT
scan
Weak (PHEX 2021)20
Low-dose CT scan:
negative
Low dose CT: masses
(suspicious spots or
nodules)
Nutritional Anemia
Asymptomatic adults
Hemoglobin (Hgb) and
Red Blood Cell (RBC)
parameters
Strong (PHEX 3 2023)16
Hgb:
>13.5 g/dl (men)
>12.0 g/dl (women)
Hgb:
<13.5 g/dl (men)
<12.0 g/dl (women)
Hct:
42-52% (men)
37-47% (women)
Hct: above/below
normal
MCV: 80-100fL
MCH: 27-31 pg
Syphilis
Adults high risk for Syphilis (e.g.
HIV-positive men, men having sex
with men, unprotected sex,
Back to Table of Contents
Rapid Plasma Reagin
(RPR) or Venereal
Disease Research
Strong (PHEX 2023)23
RPR:
negative/non-reactive
VDRL: negative
MCV: above/below
normal
MCH: above/below
normal
RPR: positive/reactive
VDRL: positive
Omnibus Health Guidelines ver. 2023 | 61
Conditions being
Screened
Eligible Population
Screening Test to be
Offered at Primary
Care
persons living with HIV (PLHIV),
sexual contact with known case
of syphilis, commercial sex
workers, sexual contact with
persons from countries or
communities with high
prevalence of syphilis and
syphilis-related morbidity, prior
syphilis, born to a person
diagnosed with syphilis in
pregnancy, multiple sexual
partners, and history of sex in
conjunction with illicit drug use)
Laboratory (VDRL) tests
every 6 to 12 months
Back to Table of Contents
Strength of
Recommendation (if
available) and
Reference Guideline
Normal Results
Abnormal Findings
Omnibus Health Guidelines ver. 2023 | 62
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American College of Cardiology. ASCVD Risk Estimator Plus. n.d. Accessed December 14, 2023.
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World Health Organization. HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care: Risk-based
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Lung Center of the Philippines & University of the Philippines Manila - National Institutes of Health - Institute of Clinical
Epidemiology. Clinical Practice Guidelines for the Management of Chronic Obstructive Pulmonary Disease. Published 2023. Accessed
December 16, 2023. https://drive.google.com/drive/u/1/folders/1kAx4VZrlqH3AQkQ-E35TSQLg7Z6wQud1
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Caries. Updated November 09, 2021. Accessed December 14, 2023.
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ental-caries
U.S. National Institutes of Health. The Patient Health Questionnaire 9 - Overview. Published 2001. Accessed December 14, 2023.
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Agency for Healthcare Research and Quality.Geriatric Depression Scale (Short Form). N.d. Accessed December 14, 2023.
https://integrationacademy.ahrq.gov/sites/default/files/2020-07/Update_Geriatric_Depression_Scale-15.pdf
World Health Organization. mhGAP Intervention Guide Mental Health Gap Action Programme for mental, neurological and substance
use disorders in non-specialized health settings Version 2.0. World Health Organization. Published 2016. Accessed December 14,
2023. https://iris.who.int/bitstream/handle/10665/250239/9789241549790-eng.pdf?sequence=1
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX): Musculoskeletal Disorders. Published 2023. Accessed December 14, 2023.
https://drive.google.com/file/d/1p557JgrPgx9O9tI2NnSK-ha19KoECra1/view
Philippine College of Chest Physicians. Philippine Clinical Practice Guidelines: Diagnosis and Treatment of Tobacco Use and
Dependence.Published 2014. Accessed December 14, 2023, https://www.apsresp.org/pdf/esap/esap-201408-lectures/cs-5-3.pdf
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination Phase (PHEX) Phase 3: Task Force on Renal, Metabolic, Nutrition, and Endocrine Disorders. Published Published 2023.
Accessed December 14, 2023. https://drive.google.com/file/d/1jViG7Whi45tBVHADBKraV06mUnpKvnNS/view
Philippine Psychiatric Association. Consensus Treatment Guidelines on Major Depressive Disorder in Adults. Published 2017.
Accessed December 14, 2023. https://drive.google.com/drive/u/1/folders/1iykz29ZFbnkufon3eSCKndbQfTs1TCnw
U.S. Preventive Services Task Force. Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Interventions. Published
2021. Accessed December 14, 2023.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling
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Department of Health. Implementing Guidelines on the Institutionalization of Philippine Package of Essential NCD Interventions
(PHIL PEN) on the Integrated Management of Hypertension and Diabetes for Primary Health Care Facilities. Published December 4,
2012. Accessed December 14, 2023. https://dmas.doh.gov.ph:8083/Rest/GetFile?id=336917
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX): Screening for Neoplastic Diseases. Published 2021. Accessed December 14, 2023.
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American Academy of Ophthalmology. Cataract in the Adult Eye Preferred Practice Pattern. Published 2021. Accessed December 14,
2023. https://www.aaojournal.org/action/showPdf?pii=S0161-6420%2821%2900750-8
American Academy of Ophthalmology. Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern. Published 2020.
Accessed December 14, 2023. https://www.aaojournal.org/action/showPdf?pii=S0161-6420%2820%2931026-5
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX) Phase 3: Screening for Infectious Diseases. Published 2023.
https://drive.google.com/file/d/1up5YnRyy6S5YpTsGgRoZHo4XDCOSrjR7/view
American Diabetes Association. Retinopathy, Neuropathy, and Foot Care: Standards of Medical Care in Diabetes. Published 2022.
Accessed December 14, 2023.
https://diabetesjournals.org/care/article/45/Supplement_1/S185/138917/12-Retinopathy-Neuropathy-and-Foot-Care-Standards?sea
rchresult=1
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Examination (PHEX): Screening for Cardiovascular Disease. Published 2021.
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Omnibus Health Guidelines ver. 2023 | 63
26.
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2018;39(33):3021-3104. doi:https://doi.org/10.1093/eurheartj/ehy339
American Academy of Ophthalmology. Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern. Published 2020. Accessed
December 14, 2023. https://www.aaojournal.org/action/showPdf?pii=S0161-6420%2820%2931025-3
American Academy of Ophthalmology. Primary Open-Angle Glaucoma Preferred Practice Pattern. Published 2020. Accessed
December 14, 2023 https://www.aaojournal.org/action/showPdf?pii=S0161-6420%2820%2931024-1
American Academy of Ophthalmology. Primary Angle Closure Preferred Practice Pattern. Published 2020. Accessed December 14,
2023 https://www.aaojournal.org/action/showPdf?pii=S0161-6420%2820%2931023-X
Department of Health. Clinical Practice Guidelines for the Management of Hepatitis B in the Philippines.Published 2021. Accessed
December 14, 2023. https://drive.google.com/drive/folders/16PonztbznskCZhLpf1ro58ECYihNFOxP
Philippine Society of Hypertension & Philippine Heart Association. Clinical Practice Guidelines for the Management of Hypertension
in the Philippines. Published 2020. Accessed December 14, 2023.
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Bickley, L. S., Szilagyi, P. G., & Hoffman, R. M. Bates' guide to physical examination and history taking. 12th ed. Wolters Kluwer; 2017
Back to Table of Contents
Omnibus Health Guidelines ver. 2023 | 64
The Immunization Services Section:
aims to provide guidance to primary care providers on the appropriate immunization services for adults.
Routine immunization services not only protect individuals but the population at large. Vaccines are central
to the prevention of diseases of public health importance and age- and sex-appropriate vaccines should be
offered to eligible adults at every opportunity.
General Principles
●
●
●
●
●
Observe patient-centered care, with respect for the patient’s autonomy and right to
self-determination, privacy and confidentiality, and informed consent.
Engage in a shared decision-making process when selecting the vaccines appropriate to the
patient’s health profile and risks.
Acknowledge the concerns of individuals about vaccination and immediately address
misconceptions and vaccine hesitancy in a clear and respectful manner.
Provide accurate information about the benefits and risks of each vaccine, including adverse
events following immunization (AEFI) and clearly explain how the benefits outweigh the risks.
Share accurate scientific information about vaccines from verified sources.
Ensure that vaccine counseling and vaccination are part of regular clinical care and emphasize the
importance of keeping vaccinations up to date.
Vaccines for Adults
●
●
Offer vaccination services to all eligible adults (Table 6).
Encourage adults to maintain and safely keep updated immunization records.
Back to Table of Contents
Omnibus Health Guidelines ver. 2023 | 65
Table 6. Recommended Vaccines for Adults
Eligible Population
Vaccine
Strength of
Recommendation (if
available) and Reference
Guideline
Apparently Healthy Adults
All adults with complete primary
series of tetanus
Tetanus toxoid-containing vaccine
Strong (PHEX, 2023)1
All adults with unknown tetanus
vaccination status
Primary series: Tdap followed by any tetanus
toxoid-containing vaccine
Weak (PHEX, 2021)2
18 to 26 - year old females
Human papillomavirus vaccine
Strong (PHEX, 2021)2
(every 10 years)
(unvaccinated or incomplete primary
series)
18 to 26 - year old males
Weak (PHEX, 2021)2
(unvaccinated or incomplete primary
series)
18 to 64 years old
Hepatitis B vaccine
Strong (DOH, 2021)3
(as catch-up for those with no serological evidence of
immunity)
COVID-19 Vaccine
Strong (PSMID, 2023)4
Inactivated Influenza vaccine
Weak (PHEX, 2021)2
Pneumococcal Conjugate Vaccine - 13 valent
Weak (PHEX, 2021)2
Typhoid Vi polysaccharide intramuscular vaccine
Weak (PHEX, 2021)2
Hepatitis A vaccination
Weak (PHEX, 2023)1
(2-dose; 0,6 months)
Japanese encephalitis virus vaccine
Weak (PHEX, 2023; PSMID,
2018)1,5
Measles-containing vaccine
Weak (PHEX, 2023)1
(for non-pregnant or unvaccinated)
≥ 50 years old, for prevention of
herpes zoster infection
Adjuvanted recombinant zoster virus vaccine
Strong (PSMID, 2018)5
Adults with Medical/ Special Conditions or Special Circumstances
Asplenia
Haemophilus influenzae b vaccine
(anatomical or functional)
Bronchial asthma, COPD, and
cardiovascular disease
Weak (PHEX, 2023;
PSMID, 2018)1,5
Influenza vaccine
Strong (PSMID, 2018)5
Varicella vaccine
Strong (PSMID, 2018)5
Weak (PSMID, 2018)5
Strong (PSMID, 2018)5
(for the prevention influenza-related
respiratory infections and
hospitalizations)
Cancer
End-stage renal disease
Healthcare Workers
(for those without a history of varicella infection)
Back to Table of Contents
Omnibus Health Guidelines ver. 2023 | 66
Eligible Population
Vaccine
Strength of
Recommendation (if
available) and Reference
Guideline
Hepatitis B vaccine
Strong (PSMID, 2018)5
(including medical students)
Other high risk population for
Hepatitis B infection:
A. Persons deprived of
liberty (PDLs)
B. Drug users
C. Patients with chronic
renal failure
At risk for Meningococcal
disease:
A. Individuals living in close
quarters/proximity
B. Asplenic patients
C. Microbiologists
(increased exposure)
Persons living with HIV
Inactivated Influenza Vaccine
Rabies vaccines:
1. Direct carers of rabies patients
2. HCWs involved in rabies control
3. Personnel in rabies diagnostic laboratories
Hepatitis B vaccine
Weak (PHEX, 2021)2
Weak (PHEX, 2023)1
Meningococcal MenACWY vaccine
Weak (PHEX, 2023)1
*meningococcal MenB vaccine may be given to young adults
in crowded dormitories
Hepatitis B vaccine
Influenza Vaccine
(administer inactivated vaccines regardless of CD4 count)
Pregnant women
Strong (PSMID, 2018)5
Hepatitis B
Strong (PSMID, 2018)5
Strong (PSMID, 2018)5 ;(US
CDC, 2023)6
Strong (DOH, 2021)3
(for pregnant with no serological evidence of immunity)
Traveler to a Cholera-endemic
area
With stable medical
comorbidities and are at risk for
severe infection
With comorbidities or
Back to Table of Contents
COVID-19
Inactivated Influenza Vaccine
If complete with primary series containing tetanus
toxoid: Any tetanus toxoid-containing vaccines
If with unknown status or incomplete primary series:
adjuvanted tetanus toxoid, reduced diphtheria
toxoid, and acellular pertussis (Tdap) followed by any
tetanus toxoid-containing vaccines
If with high-risk exposure to cholera (e.g., outbreak
or travel to an endemic area): Oral cholera vaccine
If at risk for Hepatitis A during pregnancy, may offer
Hepatitis A
Oral cholera vaccine
Weak, (PSMID, 2023)4
Weak (PHEX, 2023)1
Weak (PHEX, 2021)2
COVID-19
Strong, (PSMID, 2023)4
Pneumococcal vaccine (None, unknown vaccination
Recommended (US CDC,
Weak (PHEX, 2021)2
Weak (PSMID, 2018)5
Recommended (PSMID,
2018)5; (US CDC, 2020)7
Strong (PHEX, 2023)1
Omnibus Health Guidelines ver. 2023 | 67
Eligible Population
Vaccine
immunocompromising
conditions:
status, received PCV7 at any age):
● Chronic renal failure congenital
or acquired asplenia
● Congenital or acquired
immunodeficiency (including
B-[humoral] or T-lymphocyte
deficiency, complement
deficiencies [particularly C1, C2,
C3, and C4 deficiencies], and
phagocytic disorders [excluding
chronic granulomatous disease])
● Generalized malignancy
● HIVinfection
● Hodgkin disease
● Iatrogenic immunosuppression
(including disease requiring
treatment with
immunosuppressive drugs such
as long-term systemic
corticosteroids and radiation
therapy)
● Leukemia
● Lymphoma
● Multiple myeloma
● Nephrotic syndrome
● Sickle cell disease and other
hemoglobinopathies
● Solid organ transplant (excludes
persons with a hematopoietic
stem cell transplant)
Option 1: Single-dose PCV20
Option 2: Single-dose PCV15 followed by a
single-dose of PPSV23 after ≥8 weeks
As pre-exposure prophylaxis for
other at-risk adult population
(PSMID, 2018)5:
1. Individuals directly involved
in rabies control
2. Pet owners and household
members
3. Animal handlers
4. Field workers such as dog
vaccinators/catchers
5. Veterinarians and veterinary
students
6. Spelunkers
Rabies Vaccine
Back to Table of Contents
Strength of
Recommendation (if
available) and Reference
Guideline
2023)8
Weak (PHEX, 2023)1
Omnibus Health Guidelines ver. 2023 | 68
Monitoring and Management of Adverse Effects Following Immunization
(AEFI)
Ensure systems are in place to monitor and address AEFI, such as the following:
●
●
●
●
●
●
Observe all adult vaccine clients for 15 minutes post vaccination to prevent secondary injury
associated with syncope.9
Inform clients for vaccination about the difference between a reaction related to the vaccine and
an adverse event which can have other causes (DOH Administrative Order 2023-0007)10.
Offer paracetamol to adults presenting with fever or headache after vaccination and/or localized
reactions such as pain, soreness, redness, itching, swelling, or burning at the injection site for 1 - 2
days.11,12
Ensure integrated health service approach for AEFI response that covers the clinical
management, navigation, referral, and communication, according to the updated AEFI
management pathways12 and clinical guidelines.
Report all adverse events following immunization (AEFI) of newly introduced vaccines regardless
of severity, that are suspected to be associated with the vaccine using the appropriate reporting
platform upon collection of the minimum required case details (DOH Administrative Order
2023-0007)10.
Report AEFIs for vaccines under the NIP or those with established vaccine safety profiles using
the appropriate reporting platform as long as no other clear cause has been identified and the
causal link to vaccine has not been established. Immediately notifiable AEFIs are the following
(DOH Administrative Order 2023-0007)10:
○ Acute flaccid paralysis (vaccine-associated paralytic poliomyelitis)
○ Anaphylactoid reaction (acute hypersensitivity reaction)
○ Anaphylaxis
○ Arthralgia
○ Brachial neuritis
○ Disseminated BCG infections
○ Encephalopathy
○ Hypotonic - hyporesponsive episode (HHE or shock-collapse)
○ Injection site abscess
○ Lymphadenitis (simple and/or suppurative)
○ Osteitis or osteomyelitis
○ Persistent inconsolable screaming
○ Seizures
○ Sepsis
○ Severe local reaction
○ Thrombocytopenia
○ Toxic shock syndrome (TSS)
Back to Table of Contents
Omnibus Health Guidelines ver. 2023 | 69
Monitoring and Management of Adverse Effects Following Immunization
(AEFI)
●
●
Refer all adults presenting with an anaphylactic reaction after receiving a vaccine dose to an
allergy specialist for clearance to determine if the vaccine client shall proceed with their next
scheduled vaccinations.
Advise vaccine recipients to report to the National Adverse Events Following Immunization
Committee in case of AEFI (Contact number: 8651-7800, local 2930).
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Omnibus Health Guidelines ver. 2023 | 70
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX): Adult Immunization. Published 2023. Accessed December 16, 2023.
https://drive.google.com/file/d/1q5m5uxA-zY_MHgBO2S9EW_AoK3x3qr0L/view
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX): Immunization for Adults. Published 2021. Accessed December 16, 2023.
https://drive.google.com/file/d/15bZXoiltUJxGMlp5wgOMxI70tY6PTplE/view
Department of Health. Clinical Practice Guidelines for the Management of Hepatitis B in the Philippines. Published 2021. Accessed
December 16, 2023. https://drive.google.com/drive/folders/16PonztbznskCZhLpf1ro58ECYihNFOxP
Philippine Society for Microbiology and Infectious Diseases. Philippine COVID-19 Living Recommendations. Published 2023. Accessed
December 14, 2023. https://www.psmid.org/philippine-covid-19-living-recommendations-3/
Philippine Society for Microbiology and Infectious Diseases. Philippine Clinical Practice Guidelines for Adult Immunization. Makati:
Zurbano Publishing and Printing Corp. Published 2018. Accessed December 14, 2023.
https://drive.google.com/file/d/1pdl986x5sLNzSCBwRGC9HNBAvgGHl06N/view
U.S. Centers for Disease Control and Prevention. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of
the Advisory Committee on Immunization Practices — United States, 2023–24 Influenza Season. Published 2023. Accessed December
14, 2023. https://www.cdc.gov/mmwr/volumes/72/rr/rr7202a1.htm
U.S. Centers for Disease Control and Prevention. Prevention of Hepatitis A Virus Infection in the United States: Recommendations of
the Advisory Committee on Immunization Practices.Published 2020. Accessed December 14, 2023.
https://www.cdc.gov/mmwr/volumes/69/rr/rr6905a1.htm
U.S. Centers for Disease Control and Prevention. Pneumococcal Vaccine for Adults Aged ≥19 Years: Recommendations of the Advisory
Committee on Immunization Practices, United States. Published 2023. Accessed December 14, 2023.
https://www.cdc.gov/mmwr/volumes/72/rr/pdfs/rr7203a1-H.pdf
U.S. Centers for Disease Control and Prevention. Vaccine Recommendations and Guidelines of the ACIP. Published 2022. Accessed
December 14, 2023. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/adverse-reactions.html
Australian Government Department of Health and Aged Care. Common side effects following immunisation for vaccines used in the
National Immunisation Program schedule. Australian Immunisation Handbook. Published 2023. Accessed December 14, 2023.
https://immunisationhandbook.health.gov.au/resources/tables/table-common-side-effects-following-immunisation-for-vaccines-u
sed-in-the-national-immunisation-program-schedule
Department of Health. Adverse Events Following Immunization (AEFI): A Manual of Procedure for Surveillance and Response to AEFI.
National Epidemiology Center. Published 2014. Accessed December 14, 2023.
https://drive.google.com/file/d/1aV_prtVB1xyuC8HwfY-EIdrOri9nfUQc/view
Department of Health. Interim AEFI Management Pathways for Healthcare Providers, Version 4. Published 2021. Accessed DEcember
14, 2023. https://drive.google.com/file/d/1xqsv-vP4zz2zsg-6y5NjuESzBlF7fhez/view
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Omnibus Health Guidelines ver. 2023 | 71
The Sexual and Reproductive Health Section:
aims to provide guidance on the services that should be offered at the primary care level in order to uphold
the right of individuals to sexual and reproductive health to achieve a state of complete physical, mental and
social well-being. This section encompasses standards of care in sexual and reproductive health, including
family planning and maternal health.
General Principles
●
●
●
Respect the right to autonomy and self-determination of all individuals.
Offer family planning to all eligible couples and individuals.
○ Family planning refers to a program which enables couples and individuals to decide
freely and responsibly the number and spacing of their children and to have the
information and means to do so, and to have access to a full range of safe, affordable,
effective, non-abortifacient modern natural and artificial methods of planning
pregnancy1.
■ The State shall promote and provide information and access, without bias, to all
methods of family planning, including effective natural and modern methods
which have been proven medically safe, legal, non-abortifacient, and effective in
accordance with scientific and evidence-based medical research standards1 .
■ Discuss the benefits and harms of different FP methods and select the best
method through participatory decision-making.
Offer maternal health services, including antenatal care, intrapartum care, and post-natal care to
all pregnant women and girls.
○ Antenatal care (ANC) is the care provided by skilled health-care professionals to
pregnant women and adolescent girls in order to ensure the best health conditions for
both mother and baby during pregnancy. The components of ANC include: risk
identification, prevention and management of pregnancy-related or concurrent diseases,
and health education and health promotion.
■ ANC reduces maternal and perinatal morbidity and mortality both directly,
through detection and treatment of pregnancy-related complications, and
indirectly, through the identification of women and girls at increased risk of
developing complications during labor and delivery, thus ensuring referral to an
appropriate level of care.2
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Family Planning
●
●
●
Offer contraception to women until they reach menopause.3
Determine the appropriate family planning methods through taking the family, menstrual,
contraceptive and sexual history. (Strong recommendation, UK-NICE)4
○ Women who meet the following criteria after a thorough menstrual and sexual history and
assessment of pregnancy risk can be reasonably excluded from a consideration of
pregnancy 5:
■ is ≤7 days after the start of normal menses
■ has not had sexual intercourse since the start of last normal menses.
■ has been correctly and consistently using a reliable method of contraception
■ is ≤7 days after spontaneous or induced abortion
■ is within 4 weeks postpartum
■ is fully or nearly fully breastfeeding of no interval of more than 4-6 hours between
breastfeeds (exclusively breastfeeding or the vast majority [≥85%] of feeds are
breastfeeds), amenorrheic, and <6 months postpartum
○ Offer a urine pregnancy testing to confirm pregnancy among women who do not fulfill
these criteria prior to initiating any form of contraception.
Select the appropriate family planning method after shared decision making between the patient
or the couple, and the primary care provider1,6. The different family planning methods include the
following6. The WHO Contraception Tool7 may be used a reference and teaching material for
recommending safe, and effective methods:
○ Medical Eligibility Criteria (MEC) refers to the medical conditions or characteristics
related to the safety and efficacy of the contraceptive. Categories range from 1 to 4,
weighing benefits and risks in using the contraceptive6.
○ Combined hormonal contraceptives6 (CHC) (e.g. combined oral contraceptive pills,
combined injectable contraceptive, combined contraceptive patches and rings)
■ Provide to women (Medical Eligibility Criteria Category 1):
● from age of menarche through 40 years of age
● > 42 days postpartum
● with varicose veins
● Women living with asymptomatic or mild HIV clinical disease (WHO stage
1 or 2)
● Women living with HIV taking any nucleoside reverse transcriptase
inhibitor (NRTI), newer non nucleoside reverse transcriptase inhibitors
(NNRTI) containing etravirine and rilpivirine, or raltegravir
■ Consider for (MEC Category 2):
● Breastfeeding women ≥ 6 months postpartum
● ≥ 21 days to 42 days postpartum without other risk factors for venous
thromboembolism
● with superficial venous thrombosis
● with known dyslipidemias without other known cardiovascular risk
factors
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Family Planning
Women with HIV using NNRTIs containing efavirenz
Women using protease inhibitors (e.g. ritonavir and antiretrovirals
boosted with ritonavir)
Progestogen-only containing contraceptives (POC)6 [e.g. progestogen-only pills,
implants [e.g levonorgestrel (LNG) (e.g. Sino-Implant (II) or etonogestrel (ETG)], and
injectables
■ Provide to breastfeeding women who are (MEC Category 1):
● ≥ 6 weeks to < 6 months months postpartum
● ≥ 6 months postpartum
● Women living with asymptomatic or mild HIV clinical disease (WHO stage
1 or 2)
● Women living with asymptomatic or mild HIV clinical disease (WHO stage
1 or 2)
● Women living with HIV taking any nucleoside reverse transcriptase
inhibitors
● Women living with HIV newer NNRTIs containing etravirine and rilpivirine
● Women living with HIV taking raltegravir
■ Consider for (MEC Category 2):
● breastfeeding women who are < 6 weeks postpartum
● Women living with HIV using NNRTIs containing efavirenz
● Women using protease inhibitors (e.g. ritonavir and ARVs boosted with
ritonavir)
Depot medroxyprogesterone acetate6 (intramuscular or subcutaneous). Provide for (MEC
Category 1):
● Women living with asymptomatic or mild HIV clinical disease (WHO stage
1 or 2)
● Women taking any nucleoside reverse transcriptase inhibitor
● Women living with HIV using protease inhibitors (e.g. ritonavir and ARVs
boosted with ritonavir)
● Women living with HIV using NNRTIs containing efavirenz or newer
NNRTIs containing etravirine and rilpivirine
● Women living with HIV taking raltegravir
Intrauterine device (IUD)6
■ Levonorgestrel-releasing intrauterine device (LNG-IUD):
● Provide to (MEC Category 1):
○ breastfeeding women who are ≥ 4 weeks postpartum
○ Women living with HIV taking newer NNRTIs containing
etravirine and rilpivirine
○ Women living with HIV taking raltegravir
● Consider for (MEC Category 2):
●
●
○
○
○
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Omnibus Health Guidelines ver. 2023 | 74
Family Planning
breastfeeding women who are < 48 hours postpartum
Women at increased risk of STIs
Women living with asymptomatic or mild HIV clinical disease
(WHO stage 1 or 2)
○ Women living with HIV taking the following antiretrovirals,
provided their HIV clinical disease is asymptomatic or mild (WHO
Stage 1 or 2)
■ protease inhibitors
■ NRTI
■ NNRTIs containing either efavirenz
■ Raltegravir
■ Copper-bearing IUD (Cu-IUD)
● Consider for women at increased risk of STIs (MEC Category 2)6
● Consider use until menopause when inserted at age 40 or over3
Progesterone-releasing vaginal ring6
■ Provide to (MEC Category 1):
● actively breastfeeding women and are ≥ 4 weeks postpartum
● women living with HIV taking newer NNRTIs containing etravirine and
rilpivirine
● women living with HIV taking raltegravir
Barrier method and other pericoital contraceptives 8
■ Offer condoms to all male and female adults, provided that they have no severe
allergic reaction to latex rubber.
■ Offer spermicides to all women, provided that they are not at high risk for HIV
infection or have HIV infection
■ Offer diaphragms to all women six weeks after giving birth or undergoing
second-trimester spontaneous abortion, not at high risk for HIV infection, or have
no allergic reaction to latex rubber
■ Offer cervical caps for women who are not undergoing treatment for cervical
precancer or cancer.
Sterilization methods
■ Offer counseling on the permanency of sterilization and the availability of highly
effective, long-acting, reversible methods of contraception. for adults
considering permanent sterilization methods (e.g. vasectomy, tubal ligation)5
Natural family planning methods for eligible women.8
■ Fertility awareness-based methods
● Consider the following methods among adults who are 1) able to comply
with FAB method requirements, and 2) abstain from sexual intercourse
or use barrier methods on fertile days9 :
○ Calendar-based method (e.g. Standards Days Method)
○
○
○
○
○
○
○
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Omnibus Health Guidelines ver. 2023 | 75
Family Planning
Symptoms-based methods (e.g Cervical mucus or ovulation
method, basal body temperature, Two-Day Method, and
symptothermal method)
■ Consider lactational amenorrhea method among postpartum women who meet all
of the following criteria:
● menstruation has not returned.
● the baby is fully or nearly fully breastfed and is fed often, day and night,
and
● the baby is less than 6 months old.
Monitoring for adverse effects.
○ Obtain blood pressure measurements taken before initiation of contraceptives (strong
recommendation)6
○ Offer the following examinations and tests prior to the initiation of hormonal
contraceptives, as appropriate:
■ BMI, Clinical breast examination, bimanual examination and cervical inspection
■ Hemoglobin, glucose, lipids, liver enzymes
■ Thrombogenic mutations
■ Cervical cancer screening
■ HIV screening
Referral for management of adverse effects
○ Refer women with current venous thromboembolism who are in need of hormonal
contraception while being treated to a specialist (Strong recommendation)4
○ Recognize signs and symptoms of venous thromboembolism (e.g., deep venous
thrombosis, pulmonary embolism) and refer to higher level of care.
○
●
●
Assessment of Pregnancy
●
●
Signs and symptoms of possible pregnancy. Suspect pregnancy in a women of reproductive age
presenting with signs and symptoms of possible pregnancy such as the following10:
○ Late, missed, or absent menstrual period;
○ Breast tenderness
○ Nausea or vomiting
○ Sudden or excessive weight change
○ Fatigue
○ Mood changes
○ Changes in eating habits
○ Frequent urination
History Taking. Perform comprehensive history taking, including the history of present illness,
past medical history, family history, personal, social and occupational history, in order to identify
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Omnibus Health Guidelines ver. 2023 | 76
Assessment of Pregnancy
●
●
●
risk factors such as the following: risk factors from personal, social, and occupational history,
ovulatory and menstrual irregularity, dysmenorrhea, gestational diabetes, hypertension in
pregnancy, preeclampsia, and other obstetric and/or gynecologic conditions.
Advise women who are sexually active and experiencing signs and symptoms of early pregnancy to
perform pregnancy testing using FDA approved urine home pregnancy kits and encourage them to
consult a healthcare professional for confirmation and appropriate medical advice.
Gold Standard for confirmation of pregnancy. Request for an early pregnancy ultrasound before
24 weeks of gestation to ensure an intrauterine pregnancy, and to establish gestational age with
certainty.
○ One ultrasound scan before 24 weeks of gestation (early ultrasound) is recommended for
pregnant women to estimate gestational age, improve detection of fetal anomalies and
multiple pregnancies, reduce induction of labor for post-term pregnancy, and improve a
woman’s pregnancy experience. (Recommended)10
Advise pregnant women on birth preparedness and complication readiness interventions (e.g.
schedule of appointments, what happens at different appointments, stages of pregnancy).11
(Strong recommendation)10
Maternal Health Services
●
Antenatal Care. Perform the following for each antenatal check-up:
○ Ensure quality antenatal care including the minimum of eight antenatal contacts (i.e.
active connection between a pregnant woman and a health-care provider) according to
the following schedule, and/or referral to a hospital for specialist care, if necessary
(Recommended)10:
■ First contact at 12 weeks;
■ Second and third contact at 20 and 26 weeks age of gestation (AOG),
respectively;
■ Subsequent third trimester contacts at 30, 34, 36, 38, and 40 weeks AOG; and
■ Return for delivery if still have not given birth at 41 weeks AOG;
○ Complete general and obstetrical examination, including 10,11,:
■ vital signs
■ weight gain based on pre-pregnant weight
■ oral health check-up and prophylaxis
■ screening for cigarette smoking, alcohol use, substance abuse, psychosocial risk
factors, depression and exposure to violence, HIV and syphilis
■ assessment of significant signs and symptoms
○ Classify women according to low-risk pregnancy and high-risk pregnancy11
○ Assist in developing a written Birth Plan and modify as necessary12
○ Provide information and instructions on the signs of labor12
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○
○
○
○
○
○
Provide information on how to modify or have a healthy lifestyle (diet, exercise).11,12 Teach
pregnant women about proper diet and nutrition during pregnancy using Pinggang Pinoy.
Manage according to identified risks and health concerns11
Discuss and give information on how to contact the health system for non-urgent advice
and/or urgent concerns, such as pain and bleeding11,10. Give information on what screening
programmes to do (such as blood tests, ultrasound) and explain the importance of such
screening tests.10,11,
Give advice regarding use of nutritional supplements such as:
■ Daily oral iron and folic acid supplementation with 30 mg to 60 mg of elemental
iron and 400 mcg (0.4 mg) of folic acid (Recommended).13
■ Offer calcium supplementation (1.5–2.0 g oral elemental calcium) for pregnant
women to reduce the risk of pre- eclampsia. (Context-specific
recommendation).2
■ Consider giving high dose of iron supplements to mothers in populations where
anemia is a public health concern to prevent maternal anemia (Recommended)13
■ Consider giving Multiple Micronutrient Supplementation (MMS) over Iron-Folic
Acid (IFA) supplements to mothers depending on the assessment and advice of
the physician (Context-specific recommendation). 13
Provide the following nutritional services for each antenatal checkup
■ Counseling on healthy eating and physical activity during pregnancy.
(Recommended).2
■ Women will be more likely to achieve and maintain a healthy weight before, during
and after pregnancy if they could14:
➢ eat fiber-rich foods such as oats, beans, peas, lentils, grains, seeds, fruit
and vegetables, as well as whole grain bread and brown rice and pasta
➢ eat at least five portions of a variety of fruit and vegetables each day, in
place of foods higher in fat and calories
➢ eat a low-fat diet and avoid increasing their fat and/or calorie intake
➢ eat as little as possible of fried food; drinks and confectionery high in
added sugars (such as cakes, pastries and fizzy drinks); and other food
high in fat and sugar (such as some take-away and fast foods)
➢ eat breakfast
➢ watch the portion size of meals and snacks, and how often they are
eating
➢ balanced, healthy diet
Provide advice on the following maternal exercises for each antenatal check up:
■ Aerobic physical activity and strength-conditioning exercise aimed at
maintaining a good level of fitness throughout pregnancy, without trying to reach
peak fitness level or train for athletic competition.10
■ Choose activities with minimal risk of loss of balance and fetal trauma such as10:
➢ Walking
➢ Cycling
➢ Swimming
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Omnibus Health Guidelines ver. 2023 | 78
●
●
●
●
●
➢ Aerobics
➢ Others: take the stairs instead of the lift or taking a walk at lunchtime,
minimize sedentary activities
○ Offer additional testing and services appropriate to the trimester of pregnancy (Table 7).
Intrapartum care. Deliver the appropriate intrapartum and neonatal care during labor and delivery
(Table 8).
Postpartum care. Deliver postpartum care as follows (Table 9):
○ Advise all postpartum women to consult the nearest health center and seek postnatal and
newborn care of at least four postnatal visits scheduled as follows15:
○ Within 24 hours of birth or before discharge (weak recommendation)15;
○ On postpartum day 3 (strong recommendation)15;
○ Between postpartum days 7-14 (strong recommendation)15; and
○ Six weeks after birth (strong recommendation, WHO 2013)15.
● Provide the following services during postpartum visits15:
■ Counseling and support for exclusive breastfeeding at each postnatal contact
(Strong recommendation)15
■ Offer basic mental health and psychosocial support from a primary care provider
and obtain a referral for evaluation and management by mental health
professionals if experiencing symptoms of postpartum depression (Weak
recommendation)15.
■ Offer advise on (Consensus statement)15:
➢ proper hygiene including perineal, hand and oral hygiene
➢ birth spacing and family planning including postpartum contraception,
safer sex including use of condoms.
➢ nutrition
Provide counseling regarding the benefits of birth spacing for the mother’s and the baby’s health.
It is recommended to wait until the youngest child is at least 2 years old before trying to become
pregnant again. Educate the postpartum mother about the following:
○ If not fully or nearly fully breastfeeding, mothers may become pregnant as soon as 4 to 6
weeks after childbirth
○ If fully or nearly fully breastfeeding, mothers may become pregnant as soon as 6 months
postpartum.
○ For maximum protection, a woman should not wait until the return of monthly bleeding to
start a contraceptive method.8
Provide information regarding family planning after delivery.8
○ Reproductive goals (desire and timing)
○ Contraceptives
○ Medical issues or comorbidities
Provide the following nutritional services and physical activity after delivery.15
○ In the settings where gestational anemia is of public health concern, consider giving oral
iron supplementation, either alone or in combination with folic acid supplementation, to
postpartum women for 6–12 weeks following childbirth to reduce the risk of anemia.
○ Offer regular physical activity throughout the postpartum period by doing at least 150
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Omnibus Health Guidelines ver. 2023 | 79
○
minutes of physical activity throughout the week.
Replace sedentary time with physical activity of any intensity (including light intensity) to
provide health benefits.
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Table 7. Summary of Antenatal Services in Primary Care
First Trimester
Provide Mother and Child Book and health
information 10,11
Assess for the following:
●
●
●
●
●
●
Nutritional
assessment
(Recommended11)
Syndromic assessment for HIV and
syphilis (Recommended)10
Diabetes mellitus risk factor evaluation
(Recommended)10
Tobacco
and
substance
use
(Recommended)10
Intimate
partner
violence
(Recommended)10
Compute for BMI11
Request the following tests:
● Blood typing11
● Ultrasound at 12 weeks AOG to determine
gestational
age,
detect
multiple
pregnancy (Recommended)11
Consider requesting for the following tests as
appropriate:
● Complete blood count/Hgb count
(Context-specific recommendation)10
screening
● Tuberculosis
(Context-specific recommendation)10
● Test for hepatitis B10,11
● Midstream urine culture (gold standard)
or midstream urine Gram staining (if
culture
is
not
available)
for
asymptomatic bacteriuria at 12 weeks
AOG
(Context-specific
recommendation)10
Second Trimester
Request and/or refer to an appropriate health facility to
undergo the following tests, as necessary:
●
●
●
●
●
●
Screen for gestational hypertension as early as
the 20th week AOG11
HIV screening (if the status is still unknown) 16
Urinalysis (Recommended)10
Ultrasound before 24 weeks AOG to confirm
normal anatomy, fetal growth and presentation
and sex of the baby10
75g-OGTT for gestational diabetes at 24-28
weeks AOG10
Routine retinal assessment for those with
pre-existing diabetes mellitus17
Third Trimester
Request HIV screening (for those with negative initial
HIV tests who are at increased risk of acquiring HIV)
(Evidence A)18
Consider requesting for the following tests as
appropriate (Context-specific recommendation)10:
●
●
●
Midstream urine culture or midstream urine
Gram staining for asymptomatic bacteriuria at
34 weeks AOG
Complete blood count/Hgb count and/or
Blood/RH group at 36 weeks
Viral load testing for pregnant women with HIV
on ART
Consider requesting for the following tests as appropriate:
(Context-specific recommendation)10
● Complete blood count/Hgb count at 26 weeks
● Midstream urine culture or midstream urine Gram
staining for asymptomatic bacteriuria at 26
weeks AOG
Provide information on benefits of birth spacing,
contraceptive options and initiation in the postpartum
period.8
Offer the following preventive measures (Context-specific
recommendation)10:
● Preventive antihelminthic treatment at 20 weeks
AOG for women living in endemic areas**
**Areas with greater than 20% prevalence of infection with
any soil-transmitted helminths
Refer to a CEmONC (comprehensive emergency
obstetric and newborn care) provider hospital as
necessary.
●
Offer IPTp from 36 weeks AOG in malaria-endemic
areas*
IPTp from 20 - 30 weeks AOG in malaria-endemic
areas*
Provide information on benefits of birth spacing,
contraceptive options and initiation in the postpartum
period.8
Offer the following preventive measures (Context-
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Omnibus Health Guidelines ver. 2023 | 81
specific recommendation)10
Pre-exposure prophylaxis for HIV
prevention at 12 weeks AOG
● Intermittent preventive treatment in
pregnancy (IPTp) starting at 13 weeks
AOG*
*Administer in areas with moderate to high
transmission of malaria
●
Provide information on benefits of birth spacing,
contraceptive options and initiation in the
postpartum period.8
Provide counseling on infant feeding options if
HIV infection is present.
Table 8. Summary of Intrapartum Services in Primary Care
Essential Newborn Care
Intrapartum Care
General
●
●
Provide effective
communication
(Recommended)19
○ use simple and
culturally
acceptable
methods
Provide respectful
maternal care
(Recommended)19
○ organize and
provide maternal
care to all women
in a manner that
maintains their
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Active phase of the first
stage of labor
●
Provide information
regarding the duration
of the first stage of
labor (latent and
active)19
○ active first stage
(from 5 cm until
full cervical
dilatation) usually
does not extend
beyond 12 hours in
first labors, and
usually does not
extend beyond 10
hours in
Second stage of labor
●
●
Encourage to do proper
method of pushing
(Recommended)19
○ support to follow
their own urge to
push.
Inform regarding
techniques for
preventing perineal
trauma to reduce
perineal trauma and
facilitate spontaneous
birth (based on women’s
preference and available
Third stage of labor
●
Give Prophylactic
uterotonics
(Recommended)19
○ The use of uterotonics
for the prevention of
postpartum hemorrhage
(PPH) during the third
stage of labor is
recommended for all
births.
○ Oxytocin (10 IU, IM/IV) is
the recommended
uterotonic drug for the
prevention of PPH)-.
Step by Step Intervention
Step 1. Immediate drying
additional stimulation20
and
For newly born babies who do not
breathe spontaneously after thorough
drying should be stimulated by rubbing
the back 2–3 times before clamping
the cord and initiating positive
pressure
ventilation.
(Weak
recommendation).
Step 2. Skin-to-skin contact in the
first
hour
of
life
(Strong
recommendation)20
Omnibus Health Guidelines ver. 2023 | 82
●
dignity, privacy
and
confidentiality,
ensures freedom
from harm and
mistreatment,
and enables
informed choice
and continuous
support during
labor and
childbirth
Allow companion
during labor and
childbirth
(Recommended)19
●
●
●
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subsequent labors
(Recommended)
Assess fetal well-being
on labor admission19
○ Auscultate using a
Doppler
ultrasound device
or Pinard fetal
stethoscope
(Recommended)
Do digital vaginal
examination
(Recommended)19
○ Digital vaginal
examination at
intervals of four
hours is
recommended for
routine
assessment of
active first stage
of labor in low-risk
women.
Provide relaxation
techniques, including
progressive muscle
relaxation, breathing,
music, mindfulness and
other techniques, are
recommended for
healthy pregnant
women requesting pain
relief during labor,
depending on a
woman’s preferences.
(WHO, 201819)
●
technique)
(Recommended)19
○ perineal massage
○ warm compresses
○ “hands on” guarding
of the perineum
For women with or
without epidural
analgesia, encourage
the adoption of a birth
position of the individual
woman’s choice,
including upright
positions
(Recommended)19
If oxytocin is
unavailable, the use of
other injectable
uterotonics (if
appropriate,
ergometrine/
methylergometrine, or
the fixed drug
combination of oxytocin
and ergometrine) or oral
misoprostol (600 μg) is
recommended.
May do controlled cord
traction (CCT) , if the care
provider and the parturient
woman regard a small
reduction in blood loss and a
small reduction in the
duration of the third stage of
labor (Recommended)19
○
●
Newborns
without complications
should be kept in skin-to-skin contact
with their mothers during the first hour
after birth to prevent hypothermia and
promote breastfeeding.
Step 3. Delayed Cord clamping (Strong
recommendation)20
Late cord clamping (performed after 1
to 3 minutes after birth) is
recommended for all births while
initiating
simultaneous
essential
newborn care.
Step 4. Non Separation from the
mother and initiation of breastfeeding
(Strong recommendation)20
All
newborns,
including
low-birth-weight babies who are able
to breastfeed, should be put to the
breast as soon as possible after birth
when they are clinically stable, and the
mother and baby are ready.
Give Vitamin K prophylaxis (Strong
recommendation)20
All newborns should be given 1 mg of
vitamin K intramuscularly (IM) after
birth
Omnibus Health Guidelines ver. 2023 | 83
Postnatal Care
Table 9. Summary of Postnatal Services in Primary Care
Immediate Postpartum Care (after 24 hours)15
●
●
●
●
●
●
Regular assessment for vaginal bleeding, uterine tone, fundal height
and vital signs: blood pressure, heart rate, body temperature,
respiratory rate (Consensus statement):
○ Every 15 minutes for the first 2 hours
○ Every hour for the next 2 hours
○ Every 6 hours thereafter until discharge.
Nutrition Counseling (Consensus statement)
Lactation management services to support breastfeeding initiation and
exclusive breastfeeding (Strong recommendation)
Recognition of danger signs among newborns (Strong
recommendation):
○ Stopped feeding well
○ History of convulsions
○ Fast breathing (breathing rate >60 per minute)
○ Severe chest in-drawing
○ No spontaneous movement
○ Fever (temperature >37.5 °C)
○ Low body temperature (temperature <35.5 °C)
○ Any jaundice in the first 24 hours of life, or yellow palms and
soles at any age.
ART and cotrimoxazole prophylaxis for HIV-exposed infants
early infant diagnosis for HIV-exposed infants
Back to Table of Contents
Day 3 and each subsequent check-ups between day 7 and 14, 6 weeks after
birth15
●
●
●
●
●
Assess general well-being (Consensus statement):
○ Micturition and urinary incontinence, bowel function, healing
of any perineal wound, headache, fatigue, back pain, perineal
pain, breast pain, uterine tenderness, and lochia.
Assess breastfeeding progress and maternal nutrition (Consensus
statement)
Check emotional well-being and resolution of postpartum depression at
10 - 14 days after birth (Consensus statement)
Observe risks, sign and symptoms of domestic abuse (Consensus
statement)
Offer iron and folic acid supplementation for at least three months
(Weak recommendation)
Omnibus Health Guidelines ver. 2023 | 84
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Republic Act No. 10354 “The Responsible Parenthood and Reproductive Health Act of 2012″
World Health Organization. WHO Recommendations on Maternal Health. Geneva: WHO. Published 2017. Accessed November 2023.
https://iris.who.int/bitstream/handle/10665/259268/WHO-MCA-17.10-eng.pdf?sequence=1
Faculty of Sexual and Reproductive Healthcare. FSRH Clinical Guideline: Contraception for Women Aged over 40 Years. Published
2023. Accessed December 14, 2023.
https://www.fsrh.org/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/
U.K. National Institute for Health and Care Excellence. Long-acting reversible contraception. Published 2019. Accessed December 14,
2023. https://www.nice.org.uk/guidance/cg30/chapter/Recommendations
U.S. Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use. Morbidity and
Mortality Weekly Report. Published 2016. Accessed December 14, 2023. https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6504.pdf
World Health Organization. Medical eligibility criteria for contraceptive use, 5th Edition. Published 2015. Accessed December 14, 2023.
https://www.who.int/publications/i/item/9789241549158
World Health Organization. New App for WHO’s Medical eligibility criteria for contraceptive use. Published 2019. Accessed December
14, 2023. https://www.who.int/news/item/29-08-2019-new-app-for-who-s-medical-eligibility-criteria-for-contraceptive-use
World Health Organization. Family Planning: A Global Handbook for Providers. Published 2022. Accessed December 14, 2023.
https://fphandbook.org/sites/default/files/WHO-JHU-FPHandbook-2022Ed-v221115a.pdf
UpToDate. Fertility awareness-based methods of pregnancy prevention. Published 2023. Accessed December 14, 2023.
https://www.uptodate.com/contents/fertility-awareness-based-methods-of-pregnancy-prevention?search=family%20planning%20
barrier%20method&source=search_result&selectedTitle=7~150&usage_type=default&display_rank=7#
World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Published 2016. Accessed
November 2023. https://iris.who.int/bitstream/handle/10665/250796/9789241549912-eng.pdf?sequence=1
U. K. National Institute for Health and Care Excellence. Antenatal Care. Published 2021. Accessed November 2023.
https://www.nice.org.uk/guidance/ng201/resources/antenatal-care-pdf-66143709695941
U. K. National Institute for Health and Care Excellence. Intrapartum Care. Published 2023. Accessed December 14, 2023.
https://www.nice.org.uk/guidance/ng235/chapter/Recommendations#antenatal-education-about-labour
World Health Organization. WHO antenatal care recommendations for a positive pregnancy experience - Nutritional interventions
update: Multiple micronutrient supplements during pregnancy. Published 2020 Accessed December 14, 2023.
https://iris.who.int/bitstream/handle/10665/333561/9789240007789-eng.pdf?sequence=1
U. K. National Institute for Health and Care Excellence. Weight management before, during and after pregnancy. Published 2010.
Accessed December 14, 2023.
https://www.nice.org.uk/guidance/ph27/resources/weight-management-before-during-and-after-pregnancy-pdf-1996242046405
World Health Organization. WHO recommendations on Postnatal care of the mother and newborn. Published 2013. Accessed
December 14, 2023. https://www.who.int/publications/i/item/9789241506649
World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring:
recommendations for a public health approach. www.who.int. Published July 16, 2021. Accessed December 16, 2023.
https://www.who.int/publications/i/item/9789240031593
U.K. National Institute for Health and Care Excellence. Diabetes in pregnancy: management from preconception to the postnatal
period. Published 2020. Accessed December 14, 2023.
https://www.nice.org.uk/guidance/ng3/chapter/Recommendations#gestational-diabetes
Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the Use of Antiretroviral
Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States. Department of Health and
Human Services. Published 2023. Accessed December 16, 2023.
https://clinicalinfo.hiv.gov/en/guidelines/perinatal/maternal-hiv-testing-identification-exposure
World Health Organization. WHO recommendations: Intrapartum care for a positive childbirth experience. Published 2018. Accessed
December 14, 2023. https://iris.who.int/bitstream/handle/10665/260178/9789241550215-eng.pdf?sequence=1
World Health Organization. WHO Recommendations on Newborn Health. Published 2018. Accessed December 14, 2023.
https://iris.who.int/bitstream/handle/10665/259269/WHO-MCA-17.07-eng.pdf?sequence=1
Back to Table of Contents
Omnibus Health Guidelines ver. 2023 | 85
The Diagnosis of Common Conditions in Primary Care
Summary Section:
aims to summarize the minimum diagnostic tests for various diseases that are commonly encountered in
primary care. The availability of these diagnostic tests in primary care facilities or within the HCPN is critical
in achieving UHC. Primary care managers and clinicians should aim to make these tests available and
accessible to their clients, through the use of various financing and contracting mechanisms, in line with the
UHC Act (e.g., Philhealth financing, LGU procurement, Special Health Fund, etc.)
General Principles of Diagnosis
●
●
●
●
●
Timely and accurate diagnosis facilitates the administration of early and appropriate management
of illnesses and leads to better health outcomes.
Always seek to obtain a good history and physical examination since they are central in developing
a working diagnosis and differentials and guiding the selection of appropriate diagnostic tests.
In the selection of diagnostic tests, always consider the evidence on the diagnostic accuracy (e.g.,
sensitivity, specificity, yield, discriminatory ability) of the test, together with factors such as
patient values and preferences, and the access to and availability of the tests within the system
(e.g., within the HCPN).
Exercise due diligence when requesting for diagnostic tests and seek to avoid overtesting and
overdiagnosis, including the performance of tests with unnecessary benefits or tests that lead to
diagnoses which do not otherwise cause problems or symptoms and do not need intervention.
Interpret diagnostic data in the context of the patient’s signs and symptoms and communicate the
results of tests clearly to the patient.
Diagnostic Tests in Primary Care
●
●
●
Table 10 is a consolidation of the various tests for conditions commonly encountered in primary
care.
The list of conditions is arranged alphabetically for ease of navigation.
The minimum tests that should be performed or requested for a given condition at the primary
care level, to be done within a primary care facility or within the primary care provider network
(PCPN) ,are itemized. Additional tests which can only be done at higher levels of care are identified
to guide referrals.
Back to Table of Contents
Omnibus Health Guidelines ver. 2023 | 86
Table 10. Diagnostic Tests for Conditions Encountered in Primary Care
Condition
Minimum Tests at
Primary Care
Acute Chest Pain
(Suspected Acute
Coronary
Syndrome)
Basic Emergency
Assessment (ABCDE)
Acute Neurologic
Symptoms
(Suspected
Stroke)
Basic Emergency
Assessment (Airway,
Breathing,
Circulation, Disability,
Exposure [ABCDE])
(WHO-ICRC, 2018)3
12 L- ECG within 10
minutes of
presentation if
available, provided it
does not delay
transfer to the
nearest ED
(UK-NICE, 2016)1
Strength of
Recommendation
(if available) and
Reference
Gold Standard
Additional Tests at Primary Care
Level
Invasive
coronary
angiography
Not Applicable
Cardiac biomarkers; Invasive coronary
angiography; non-invasive cardiac
imaging; functional cardiac testing; tests
for suspected or known comorbidities
(UK-NICE, 2016)1
(AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR
2021) 2
Computed
Tomography (CT)
of the brain
Not Applicable (N/A)
(Immediately transfer to the nearest
hospital)
At the Emergency Department
(ED)/referral hospital: CT of the brain,
Complete blood count (CBC), prothrombin
time (PT), partial thromboplastin time
(PTT), glucose, HbA1c, Creatinine, Lipid
profile, and other tests as necessary
(AHA/ASA 2021)5
Bacterial culture
followed by
confirmatory
tests–including
phage and
penicillin
sensitivity, and
PCR to detect
N/A
Gram stain and culture of blood, pleural
fluid, cerebrospinal fluid (CSF), discharge
from skin lesions; tissue biopsy
specimens; and Reverse TranscriptasePolymerase Chain Reaction (RT-PCR)
testing (if available)
FAST (Face Arm
Speech Test) for rapid
assessment
Capillary blood
glucose to check for
hypoglycemia
(UK-NICE, 2022)4
Anthrax
Back to Table of Contents
Clinical diagnosis,
Chest x-ray (US CDC,
2021)6
Additional tests at Higher Levels of Care
Omnibus Health Guidelines ver. 2023 | 87
Condition
Minimum Tests at
Primary Care
Strength of
Recommendation
(if available) and
Reference
Gold Standard
Additional Tests at Primary Care
Level
Additional tests at Higher Levels of Care
genes specific
to B. anthracis
Asthma
Clinical assessment
using GINA symptom
control tool
Spirometry preferred
If spirometry is not
available, peak
expiratory flow rate
(PEFR) using a peak
flow meter
(GINA, 2023)7
GINA, 20237
Breast Cancer
Clinical breast
examination,
diagnostic
mammography
Strong (DOH,
2022)8
Candidiasis,
Bacterial
Vaginosis,
Trichomoniasis
Wet mount, Gram
stain
Cervical Cancer
Cervical Cytology
(Pap smear), VIA, HPV
DNA Test
Back to Table of Contents
Spirometry
Spirometry
Peak expiratory flow (PEF) with
reversibility test
Chest X-ray (CXR) if the diagnosis is
in doubt or considering other
etiologies of cough and wheezing
(e.g. Pulmonary Tuberculosis [PTB])
(GINA, 2023)7
Core needle
Biopsy,
histopathologic
examination
Breast Ultrasound
For patients with confirmed breast
cancer: Chest x-ray (to check for
lung metastasis; Ultrasound of the
liver (to check for liver metastasis
Culture
Strong (PHEX,
2021)9
Biopsy,
histopathologic
examination
Spirometry
Bronchial provocation test
Allergy test
Sputum Eosinophil Count
Fractional Concentration of exhaled nitric
oxide (FeNO)
Other tests relevant to staging and
therapeutic goals:
CBC
Metabolic panel (liver function tests, BUN,
creatinine, calcium)
Bone scan
Biopsy
Tumor HR status (ER and PR
determinations
HER2-receptor status of the recurrence
Culture
N/A
Colposcopy, Biopsy, Tumor Markers (e.g.
Cancer Antigen - 125 [CA-125]),
Metastatic work-up (e.g. CT Scan, PET
Scan)
Omnibus Health Guidelines ver. 2023 | 88
Condition
Minimum Tests at
Primary Care
Strength of
Recommendation
(if available) and
Reference
Gold Standard
Additional Tests at Primary Care
Level
Additional tests at Higher Levels of Care
Other diagnostic tests relevant to staging
and therapeutic goals
Chronic Kidney
Disease (CKD)
Clinical risk
assessment,
urinalysis, FBS,CBC
creatinine, eGFR;
CKD Risk Assessment
Tool
Chronic
Obstructive
Pulmonary Disease
(COPD)
Clinical Scoring
system and handheld
spirometry
Colorectal Cancer
FOBT or FIT
Renal biopsy
Dipstick Urine test or urinary
albumin/creatinine ratio
Electrolytes, acid- base workup using
arterial blood gas (ABG), renal biopsy, renal
US, CT angiogram, urodynamic studies,
ureteroscopy; renal biopsy with electron
microscopy (EM) and immunofluorescence
microscopy (IF) assessment
Weak (LCP,
University of the
Philippines
National Institutes
of Health Institute of Clinical
Epidemiology,
2023)10
Facility-based
spirometry
CXR to detect causes of
exacerbation, rule out other
illnesses (GOLD, 2022)11
Facility-based spirometry
Strong (PHEX,
2021)9
Biopsy,
histopathologic
examination
N/A
Colonoscopy, Biopsy, Tumor markers (e.g.
Carcinoembryonic antigen [CEA],
Alpha-fetoprotein [AFP])
Whole Abdominal CT Scan, Metastatic
work-up
Depends on the
eye condition
N/A
Detailed ophthalmologic examination by a
specialist
Chest x-ray
Chest x-ray
Sputum gram stain and culture
Complete blood count
Urine testing for pneumococcal antigen
Serum procalcitonin or c-reactive protein
Other imaging tests: chest CT or
ultrasound
*for adults aged at
least 50 years
Common Eye
Problems
Basic eye
examination (DOH,
201912)
Community
Acquired
Pneumonia
Pneumonia Severity
Index (PSI)
Rapid influenza molecular assay
Confusion,
Respiratory rate,
Blood Pressure and
Back to Table of Contents
Strong (ATS &
IDSA, 2019)13
Conditional (ATS &
IDSA, 201913
Omnibus Health Guidelines ver. 2023 | 89
Condition
Minimum Tests at
Primary Care
Age (CRB65)
Strength of
Recommendation
(if available) and
Reference
Gold Standard
Additional Tests at Primary Care
Level
Additional tests at Higher Levels of Care
UK-NICE, 202314
Contact Dermatitis
Patch testing
Weak (JRRMMC,
University of the
Philippines
National Institutes
of Health Institute of Clinical
Epidemiology,
202315)
Patch Testing
Repeat open application test (ROAT)
Repeat open application test (ROAT)
Dengue
Dengue NS1 Rapid
Diagnostic Test (3
days from onset);
Strong (RITM,
University of the
Philippines
National Institutes
of Health Institute of Clinical
Epidemiology,
2023)16
Nucleic acid
amplification
tests (NAATs);
RT-PCR
Complete Blood Count with platelet
count
Nucleic acid amplification tests (NAATs);
RT-PCR
Dengue IgM/ IgG
Rapid Diagnostic Test
(5 days from the
onset)
Dengue NS1 Ag +
IgM/IgG
Liver function tests: Aspartate
Aminotransferase (AST), Alanine
Aminotransferase (ALT)
Coagulation Test: PT, PTT
Strong (RITM,
University of the
Philippines
National Institutes
of Health Institute of Clinical
Epidemiology,
2023)16
Strong (RITM,
University of the
Philippines
Back to Table of Contents
Omnibus Health Guidelines ver. 2023 | 90
Condition
Minimum Tests at
Primary Care
Strength of
Recommendation
(if available) and
Reference
Gold Standard
Additional Tests at Primary Care
Level
Additional tests at Higher Levels of Care
National Institutes
of Health Institute of Clinical
Epidemiology,
2023)16
Diabetes Mellitus
Asymptomatic:
Repeat FBS or HbA1c
75-gram oral glucose
tolerance test (75g
OGTT)
ADA, 202117; IDF,
201718; WHO,
202019
With classic
symptoms:
Random plasma
glucose (RPG)
determination
FBS OR 75 g
OGTT
(confirmatory)
OR Glycated
Hemoglobin A1c
Test (HbA1c or
A1c)
(ADA
Professional
Practice
Committee,
2022)20
Lipid profile
Liver function tests
Spot urinary albumin-to-creatinine
ratio
Serum creatinine
Estimated glomerular filtration rate
(eGFR)
Serum potassium (for patients with
ACE-inhibitors, ARBs, or Diuretics,
patients with Chronic Kidney
Disease)
Comprehensive eye examination and
diabetic retinopathy screening (ADA
Professional Practice Committee, 2022)20
Periodic psychosocial screening
Symptom screening for sleep disorders
and sleep disorders
Screening for liver fibrosis in
diagnosed T2DM patients with
elevated ALT or fatty liver on
ultrasound (Evidence C)
Age- and sex-appropriate cancer
screening tests
HbA1c at least two times a year to
check for glycemic control
(ADA Professional Practice
Committee, 202220)
Diarrhea
(Infectious)
Back to Table of Contents
Dehydration
assessment
Strong
(PSMID, 2019)21
Stool Culture,
PCR depending
on etiology
Fecalysis
RDT: Cholera or shigella
Complete Blood Count
Urinalysis
Serum Electrolytes
Stool Culture, PCR depending on etiology
Omnibus Health Guidelines ver. 2023 | 91
Condition
Minimum Tests at
Primary Care
Strength of
Recommendation
(if available) and
Reference
Gold Standard
Additional Tests at Primary Care
Level
Additional tests at Higher Levels of Care
Blood Urea Nitrogen
Creatinine
Serum bicarbonate
Dyslipidemia
Lipid Profile (should
include total
cholesterol, LDL,
HDL, and
triglycerides) (PLAS
2020)22
NCEP, 200123
Lipid Profile
(total
cholesterol,
LDL, HDL,
triglycerides)
(PLAS 2020)22
AST, ALT prior to initiation of statins
in individuals with cirrhosis or at risk
of developing liver injury (PLAS
2020)22
Creatine Kinase
Other tests for causes of Dyslipidemia (e.g.
metabolic disorders, genetic disorders)
Possible genetic testing for patients
suspected of having Familial
Hypercholesterolemia (FH)
Additional diagnostics to be
requested based on suspected or
known comorbidities
Ebola Hemorrhagic
Fever
Clinical diagnosis
RT-PCR
N/A
RT-PCR, Antibody-capture Enzyme-linked
Immunosorbent Assay (ELISA) or
Antigen-capture detection tests
Filariasis
Blood smear
microscopy
[Nocturnal Blood
Exam (NBE)];
Filaria Test Strip RDT (FTS-RDT)
NBE; RT-PCR
N/A
RT-PCR
Generalized
Anxiety Disorder
Diagnostic and
Statistical Manual of
Mental Disorders 5th
Edition (DSM-5)
Detailed
psychiatric
evaluation;
DSM-5
Assessment for self-harming
behaviors and suicidal ideations.
Thyroid function tests
Complete Blood Count
12 lead electrocardiogram
2-hour 75-g oral
glucose
tolerance test
Lipid profile, Serum Creatinine,
estimated Glomerular Filtration Rate
(eGFR), potassium, Dipstick Urine
Gestational
Diabetes Mellitus
(GDM) in Pregnant
Back to Table of Contents
2-hour 75-g oral
glucose tolerance
test (OGTT) at 24 to
AAFP, 202224
Thyroid function tests
Complete Blood Count
12 lead electrocardiogram
Lipid profile, Serum Creatinine, estimated
Glomerular Filtration Rate (eGFR),
potassium, Dipstick Urine test or urinary
Omnibus Health Guidelines ver. 2023 | 92
Condition
Minimum Tests at
Primary Care
Strength of
Recommendation
(if available) and
Reference
Gold Standard
Additional Tests at Primary Care
Level
Additional tests at Higher Levels of Care
Women
28 weeks Age of
Gestation (AOG)
(OGTT) at 24 to
28 weeks (AOG)
test or urinary albumin/creatinine
ratio, ECG (ADA Professional
Practice Committee, 202225)
albumin/creatinine ratio, ECG (ADA
Professional Practice Committee, 202225)
Gestational
Hypertension,
Preeclampsia, or
Chronic
Hypertension with
Superimposed in
Pregnant Women
Office BP
Measurement using a
a manual
sphygmomanometer
with
appropriately-sized
upper arm cuff,
according to the
Standard BP
Measurement
Protocol (PSH 2020)31
ABPM
12-lead Electrocardiogram (ECG);
FBS; lipid profile; serum creatinine,
eGFR, sodium, potassium; dipstick
urine test or urinary albumin/
creatinine ratio (PSH 2020)31
ABPM
Other tests if Pre-eclampsia and/or
Hypertension-Mediated Organ Damage
(HMOD) is suspected: Renal Ultrasound
(US), Echocardiography, Brain Imaging,
Ankle Brachial Index (ABI), Carotid Imaging,
Retinal Exam (ESC 2018)26
Fundoscopy to check for
hypertensive retinopathy
Home BP monitoring (HBPM) if
possible
An oscillometric BP
measurement device
may be used if it is
validated for
pregnancy. (PSH
2020)31
Hand, Foot and
Mouth Disease
Clinical diagnosis
DOH Department
Memorandum
2022-057228
Viral culture
N/A
For fetal status: Ultrasonography to
determine fetal growth every 3–4 weeks of
gestation; amniotic fluid volume
assessment at least once weekly
Reverse Transcription Polymerase Chain
Reaction (RT-PCR)
Viral Culture
Routine diagnostics plus ancillary tests
Samples for virological investigation:
Throat swab, Vesicle swab, Rectal
swab/stool and CSF
Hepatitis
B,
chronic disease
Back to Table of Contents
HBsAg
Conditional (DOH,
202128)
HBsAg
AST and CBC to determine AST to
Platelet Ratio Index (APRI) Score
HBV DNA and ALT to determine
treatment eligibility
Ultrasound, serum AFP, liver function
tests
Omnibus Health Guidelines ver. 2023 | 93
Condition
Hepatocellular
carcinoma
Human
Immunodeficiency
Virus
Minimum Tests at
Primary Care
Strength of
Recommendation
(if available) and
Reference
Clinical assessment
and referral to higher
level of care
Strong
2021)29
(DOH,
HIV Rapid diagnostic
test (RDT)
Strong (WHO,
2021)30
Gold Standard
N/A
HIV-1 Nucleic
Acid Test
Additional Tests at Primary Care
Level
Bilirubin
Liver aminotransferases
Alkaline phosphatase
Complete Blood Count with platelet
count
Prothrombin time
Albumin
Hepatitis B and C serology
Blood Urea Nitrogen
Creatinine
Liver ultrasound
Serum AFP
●
●
●
●
●
●
●
●
●
●
Hypertension
Back to Table of Contents
Ambulatory blood
pressure monitoring
Recommended
(PSH, 2020)31
Ambulatory BP
Monitoring
Plasma HIV RNA (viral load)
CD4 cell count for
identifying advanced HIV
disease or for management
of opportunistic infections
Complete blood count;
Chemistry profile: glucose,
blood urea nitrogen and
creatinine, liver enzymes
and bilirubin
Urinalysis
Serologies for hepatitis A,
B, and C viruses
Serum lipids
Age-appropriate TB
symptom screening
Pregnancy testing
Syphilis testing
Depression screening for
adults living with HIV
12-lead Electrocardiogram (ECG);
FBS; lipid profile; serum creatinine,
Additional tests at Higher Levels of Care
Multiphasic, contrast- enhanced CT Scan
of the Liver
Contrast-enhanced MRI
Core needle biopsy
Fine needle aspiration biopsy
Rapid HIV diagnostic algorithm (rHIVda),
CD4 count, Viral load testing
HLA-B*5701 test (if abacavir is being
considered)
Genotypic drug-resistance testing for
PLHIV on ART with unsuppressed viral load
For patients who have HIV RNA levels
<1,000 copies/mL, viral amplification for
drug resistance
ABPM
Other tests if Hypertension-Mediated
Omnibus Health Guidelines ver. 2023 | 94
Condition
Minimum Tests at
Primary Care
Strength of
Recommendation
(if available) and
Reference
(ABPM)
Gold Standard
(ABPM)
Home BP monitoring
Office BP
Measurement (OBPM)
Additional Tests at Primary Care
Level
eGFR, sodium, potassium; dipstick
urine test or urinary albumin/
creatinine ratio
Additional tests at Higher Levels of Care
Organ Damage (HMOD) is suspected: Renal
Ultrasound (US), Echocardiography, Brain
Imaging, Ankle Brachial Index (ABI), Carotid
Imaging, Retinal Exam (ESC 2018)26
Fundoscopy to check for
hypertensive retinopathy
Home BP monitoring (HBPM) if
possible
Influenza A(H5N1)
(Highly Pathogenic
Avian Influenza)
Clinical diagnosis
Rapid influenza
diagnostic test (if
indicated and
available)
Viral culture
N/A
Real-time RT PCR, Genome Sequencing,
Serological Methods
Influenza A H1N1
(Swine Flu)
Clinical diagnosis
Rapid influenza
diagnostic test (if
indicated and
available)
Viral culture
N/A
Real-time RT-PCR, viral culture and/ or
four-fold rise in Influenza H1N1 virus
specific neutralizing antibodies
Iron-deficiency
Anemia (IDA)
Clinical diagnosis
Hemoglobin
Hematocrit
CBC with RBC indices
Bone marrow
examination (if
indicated)
Peripheral blood smear,
RDW (red cell distribution width)
Reticulocyte count
Ferritin
Additional test if indicated: Serum iron
concentration, Total iron binding capacity,
transferrin saturation
Colonoscopy if GI bleeding is suspected as
the cause of IDA
Leprosy
Slit Skin Smear (SSS),
complete blood count
and chest x-ray
Strong (DOH,
2021)32
Slit Skin Smear,
Skin biopsy
AST, ALT and renal function tests,
and sputum smear microscopy
Chest x-ray
Fasting blood sugar
Glucose-6-phosphate dehydrogenase
deficiency (G6PD) deficiency screening
prior to treatment and pathological
examination of skin biopsies.
Electrocardiogram and lipid profile
Leptospirosis
Clinical diagnosis
Recommended
(DOH, 2019)33
Polymerase
Chain Reaction
(PCR) or Culture
Complete Blood Count with platelet
count
Urinalysis
Culture and isolation, RT-PCR,
microagglutination Test (MAT), specific IgM
Rapid Diagnostic Tests (RDT), nonspecific
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Omnibus Health Guidelines ver. 2023 | 95
Condition
Minimum Tests at
Primary Care
Strength of
Recommendation
(if available) and
Reference
Gold Standard
Additional Tests at Primary Care
Level
Additional tests at Higher Levels of Care
and isolation
Blood Urea Nitrogen
Creatinine
ALT, AST
Serologic testing for leptospirosis
RDT, rapid diagnostic tests
Lung Cancer
CXR
Conditional (PHEX,
2021)9
Biopsy,
histopathologic
examination
N/A
Chest CT Scan with contrast
Biopsy, Bronchoscopy, Video-assisted
thoracoscopy (VATS)
Metastatic work-up
Other diagnostic tests relevant to staging
and therapeutic goals
Major Depressive
Disorder
DSM-5
AAFP, 201834
Detailed
psychiatric
evaluation;
DSM-5
Thyroid Stimulating Hormone (TSH)
Complete Blood Count
Serum Electrolytes
Liver Function Tests
Thyroid Stimulating Hormone (TSH)
Complete Blood Count
Serum Electrolytes
Liver Function Tests
Assessment for depression,
intention for suicide or self harm.
Malaria
Malaria microscopy or
malaria RDT
Malaria
microscopy
CBC with platelet count
Additional tests depending on the
presence of severe disease (e.g. Liver
function tests, kidney function tests)
Meningococcemia
Clinical diagnosis
Culture of blood
and CSF
N/A
Gram stain and culture of blood and CSF,
CSF qualitative and quantitative analysis
and quantitative analysis, RT-PCR of CSF
Mental Disorders
Directed Assessment
at Primary Care
according to WHO
mental health gap
action program
(mhGAP) Intervention
Guide – Version 2.035
Detailed
psychiatric
evaluation;
DSM-5
N/A
Detailed psychiatric evaluation; DSM-5
Back to Table of Contents
Omnibus Health Guidelines ver. 2023 | 96
Condition
Minimum Tests at
Primary Care
MERS-CoV
Clinical diagnosis
Methamphetamine
Use Disorder
DSM-5
Strength of
Recommendation
(if available) and
Reference
AAFP, 201834
Gold Standard
Additional Tests at Primary Care
Level
Additional tests at Higher Levels of Care
RT-PCR
N/A
RT-PCR
Detailed
psychiatric
evaluation;
DSM-5
Consider requesting laboratory tests
as warranted to evaluate other
medical conditions (e.g.,
electrocardiogram)
Consider requesting laboratory tests as
warranted to evaluate other medical
conditions (e.g., electrocardiogram)
Confirmatory for
Methamphetami
ne: gas
chromatography
/mass
spectrometry
Assessment for other psychiatric
comorbidities, other substance use,
medical comorbidities, and
cardiovascular risk.
Assessment for other psychiatric
comorbidities, other substance use,
medical comorbidities, and cardiovascular
risk.
Obesity
Weight, height, BMI,
waist circumference
Weight, height,
BMI, waist
circumference
Additional diagnostics to be
requested based on suspected or
known comorbidities
Additional tests to work-up causes of
obesity if not responding to recommended
lifestyle modifications
Oro-dental
disorders
Oral Examination (OE)
Panoramic and
intraoral
radiographs
Hot and cold water test for pulp
vitality; percussion test using mouth
mirror handle, palpation
Temporomandibular joint (TMJ) series,
Cone Beam Computed Tomography (CBCT)
scan
Scabies
Clinical Diagnosis
Confirmatory:
Microscopic
examination of
skin scraping or
mite
examination
N/A
Dermoscopic examination or skin surface
microscopy
DOH, 202336
Consider additional tests for possible
complications like secondary bacterial
infection, sepsis, other systemic
complications (e.g. glomerulonephritis),
generalized urticaria.
Schistosomiasis
Fecalysis/Stool
Microscopy
Kato Katz
Technique
Ultrasound;
Kato Katz Technique
Hepatobiliary Ultrasound;
Histopathology-Biopsy; Kato Katz
Technique
Soil-transmitted
Fecalysis/Stool
Kato Katz
N/A
Kato Katz Technique
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Omnibus Health Guidelines ver. 2023 | 97
Condition
Minimum Tests at
Primary Care
Helminths (STH)
Microscopy
Stable Ischemic
Heart Disease/
Chronic Stable
Angina Pectoris
Clinical assessment
for angina ( features:
1) constricting
discomfort in the
front of the chest, or
in the neck,
shoulders, jaw or
arms, 2) precipitated
by physical exertion,
3) relieved by rest or
nitroglycerin within
about 5 minutes ; if
all are present typical angina; if 2
are present - atypical
angina; if 1 or none is
present - non-anginal
chest pain)
Resting 12-L ECG in
people whom clinical
assessment cannot
exclude stable angina
Syphilis
Rapid plasma reagin
(RPR)
and Treponema
Pallidum
Hemagglutination
Assay (TPHA)
Thyroid cancer,
welldifferentiated
Clinical diagnosis
Back to Table of Contents
Strength of
Recommendation
(if available) and
Reference
Gold Standard
Additional Tests at Primary Care
Level
Additional tests at Higher Levels of Care
Technique
UK-NICE, 20161,
UK-NICE, 201637
Invasive
coronary
angiography
Hypertension, Diabetes and
Dyslipidemia Screening (UK-NICE,
20161, UK-NICE, 201637)
Exercise Testing and Cardiac
Imaging may be requested if
clinically warranted (UK-NICE, 20161,
UK-NICE, 201637)
Strong (JRRMMC,
2021)38
Exercise testing (UK-NICE, 201637)
Non-invasive cardiac imaging
Functional cardiac testing
Invasive coronary angiography
Treponema
Pallidum
Hemagglutinat
ion Assay
(TPHA)
Rapid syphilis test using
immunochromatography (ICT)
RPR-quantitative, when
RPR-qualitative test is Reactive
Confirmatory treponema test (TPHA or
TPPA) is recommended whenever the
RPR-qualitative is reactive
Fine-needle
aspiration
biopsy
Serum TSH, T4 (free or total)
Diagnostic neck ultrasound
Radionuclide thyroid scan
FNAB
US-guided FNAB
Molecular testing
Omnibus Health Guidelines ver. 2023 | 98
Condition
Minimum Tests at
Primary Care
Strength of
Recommendation
(if available) and
Reference
Gold Standard
Additional Tests at Primary Care
Level
Additional tests at Higher Levels of Care
CT scan and/or MRI with intravenous
contrast
Tinea
Clinical Diagnosis
UpToDate, 202339;
RACGP, 201940
Fungal Culture
Potassium hydroxide (KOH)
preparation on skin scrapings
Fungal Culture
Tuberculosis,
pulmonary
Sputum Xpert
MTB/RIF or Xpert
Ultra
Strong
(WHO, 2022)41
TB culture with
phenotypic drug
susceptibility
test (DST)
Acid-fast Bacilli (AFB) Sputum
Smear Microscopy
Chest X-ray
Loop-mediated isothermal
amplification (LAMP)
Moderate Complexity NAAT
Xpert MTB/XDR
TB culture/phenotypic DST
Sputum Trunat MTB-Rif Dx
Low complexity Nucleic Acid Amplification
Test (NAAT)
Back to Table of Contents
High complexity reverse hybridization
based NAAT
First-line line-probe assay (LPAs)
Second-line LPAs
Sequence-based testing (ie. Whole
genome sequencing, pyrosequencing,
Sanger sequencing)
Omnibus Health Guidelines ver. 2023 | 99
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Peters, A. L., Prahalad, P., Reusch, J., Young-Hyman, D., Das, S., & Kosiborod, M. 2022. 15. Management of Diabetes in Pregnancy:
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Well-Differentiated Thyroid Cancer. 2021. https://drive.google.com/file/d/1RIcCFw2LWt30jufz7v3Y3jRocPsOEWFJ/view
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adolescents. www.who.int. Published March 18, 2022. Accessed December 16, 2023.
https://www.who.int/publications/i/item/9789240046764
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Omnibus Health Guidelines ver. 2023 | 101
The Treatment of Common Conditions in Primary Care
Summary Section:
aims to summarize the first-line treatments for various diseases, including acute, chronic, and
urgent/emergent conditions that are commonly encountered in primary care. The availability of these
first-line treatments, including medications, procedures, and basic emergency interventions in primary care
facilities or access within the HCPN is critical in achieving UHC and in ensuring quality care is provided at
initial contact to all primary care clients. Primary care managers and clinicians should aim to make these
available and accessible to their clients, through the use of various financing and contracting mechanisms,
in line with the UHC Act (e.g., Philhealth financing, LGU procurement, Special Health Fund, etc.)
General Principles
●
●
●
●
●
●
●
An accurate diagnostic process, inclusive of well-performed history-taking, physical examination,
and diagnostic testing, is a prerequisite for proper treatment.
In the selection of treatment for a certain condition, always consider the evidence on safety,
efficacy, and cost of the test, together with factors such as patient values and preferences, and
the access to and availability of the treatment within the system (e.g., within the HCPN).
Clearly communicate with the patient the benefits and harms of various treatment options and
encourage participatory decision-making.
Respect the patient’s autonomy and act in his/her best interests.
Seek the patient’s informed consent for therapeutic interventions.
Use clear language when providing instructions about treatment.
Encourage and monitor treatment adherence.
Treatment Options in Primary Care
●
●
●
●
Table 11 is a consolidation of the first-line medications for conditions commonly encountered in
primary care.
Table 12 is a consolidation of the first-line procedures in primary care.
Table 13 is a consolidation of basic emergency services that may be provided in primary care while
awaiting or facilitating transfer to the nearest higher level facility.
The list of conditions is arranged alphabetically for ease of navigation.
Back to Table of Contents
Omnibus Health Guidelines ver. 2023 |
102
Table 11. Summary of First-line medications for Conditions Encountered in Primary Care
Disease/Condition
First-line Medications
Alzheimer’s
Newly-diagnosed, mild, or moderate severity:
Disease and
Cholinesterase inhibitors - Donepezil 5mg orally once daily as starting dose, then 10mg daily as
Vascular Dementia maintenance dose (increase after 4-6 weeks)
Anthrax
Strength of Recommendation (if
available) and Guideline/Reference
Grade 2A
UpToDate, 20231
Moderate to advanced severity - Memantine 10mg twice daily (as add-on or as monotherapy)
Grade 2B
UpToDate, 20231
Severe Dementia - continue Memantine 10mg twice daily
Grade 2C
UpToDate, 20231
For post-exposure prophylaxis: Doxycycline 100mg every 12 hours,or Ciprofloxacin 500mg every 12
hours
US CDC, 20142
For treatment of systemic anthrax: refer for admission and intravenous antibiotic administration (e.g.
Ciprofloxacin 400mg every 8 hours PLUS Meropenem 2g every 8 hours PLUS Linezolid 600mg every 12
hours)
Anxiety Disorders
(Panic Disorder,
Generalized
Anxiety Disorder
(GAD), Social
Anxiety Disorder)
Selective Serotonin Reuptake Inhibitors (SSRIs):
Sertraline initial dose of 25-50mg daily then 50-200mg daily
Fluoxetine initial dose of 10-20mg daily then 20-60mg daily
Escitalopram initial dose of 5-10mg daily then 10-20mg daily
Grade 2C Recommendation
UpToDate, 20233
Asthma
Inhaled corticosteroid (ICS)-formoterol:
Budesonide-formoterol combination metered dose inhaler (MDI) 160mcg-4.5mcg/inhalation or dry
powder inhaler (DPI) 200 mcg-6 mcg/inhalation
Evidence B
GINA, 20234
Step 1: 1 inhalation as needed
Back to Table of Contents
Evidence B
GINA, 20234
Step 2: 1 inhalation as needed
Evidence A
GINA, 20234
Step 3: 1 inhalation once or twice daily, PLUS 1 inhalation whenever needed
Evidence A
GINA, 20234
Omnibus Health Guidelines ver. 2023 |
103
Disease/Condition
First-line Medications
Step 4: 2 inhalations twice daily, PLUS 1 inhalation whenever needed
Strength of Recommendation (if
available) and Guideline/Reference
Evidence D
GINA, 20234
Bacterial vaginosis Metronidazole 500 mg orally twice a day for 7 days, or
(not a
Metronidazole gel 0.75% 5g one full applicator intravaginally once a day for 5 days
sexually-transmitt Clindamycin cream 2% 5g once full applicator intravaginally at bedtime for 7 days
ed disease)
US CDC, 20215
Bipolar Disorder
Grade2B
UpToDate, 20236
First line maintenance treatment is the same regimen that successfully treated the acute bipolar
mood episode.
Valproate Initial dose 500-750 mg/day in 1-4 divided doses, increase by 250-500mg every 1-3 days to
reach usual therapeutic dose 1.5-2.5g, or
Quetiapine Initial dose of 100-200 mg once daily at bedtime then increase by 100 mg/day to reach
400mg/day by day 4
Cancer
Candidiasis
Back to Table of Contents
General Palliative care:
Pain: Morphine 5-15mg every 4 hours as needed or scheduled around the clock
UpToDate, 20237
Nausea and vomiting: metoclopramide 10mg every 4-6 hours, haloperidol 0.5-2mg every 6-8 hours, OR
olanzapine 5mg once daily for 7 days
Constipation: 8.6 sennosides/tablet 2 tablets once daily
Xerostomia: oral hygiene
Dysphagia: modify food and fluid consistency
Insomnia: modify environment, encourage healthy sleep-wake cycle, minimize disruptions
Depression: treat uncontrolled symptoms like pain, supportive psychotherapy
Airway secretions: proper positioning, suctioning if available,
Glycopyrronium 0.2 subcutaneous every 4-6 hours or IV infusion 0.6-1.2mg/day, or 0.1mg SL every 6
hours as needed
UptoDate, 20238
Uncomplicated vulvovaginitis in non-pregnant:
Single dose of oral fluconazole 150mg
Grade 2C
UpToDate, 20239
Vulvovaginitis in pregnancy:
Clotrimazole 1% cream 1 applicatorful (5g) vaginally at bedtime for 7 days, or
Miconazole 2% cream 1 applicatorful (5g) vaginally at bedtime for 7 days, or
Grade 2C
UpToDate, 20239
Omnibus Health Guidelines ver. 2023 |
104
Disease/Condition
First-line Medications
Strength of Recommendation (if
available) and Guideline/Reference
Nystatin suppository (100,000 units) 1 suppository vaginally at bedtime for 14 nights
Cervicitis caused
by chlamydial
infection
Doxycycline 100 mg orally twice a day for 7 days
US CDC, 202110
Chronic
Obstructive
Pulmonary Disease
(COPD)
FEV≥80% or mmRC <2, not in exacerbation:
Long acting Muscarinic Antagonist (LAMA) monotherapy
E.g. Tiotropium dry powder inhaler (DPI) 18 mcg/capsule 1 inhalation daily or soft mist inhaler (SMI)
2.5mcg/actuation 2 inhalation once daily
Weak recommendation
LCP, University of the Philippines
National Institutes of Health - Institute
of Clinical Epidemiology 202311
FEV<80% or mmRC≥2, not in exacerbation:
Long Acting β2-Agonists (LABA)-LAMA combination therapy
E.g. Tiotropium 2.5 mcg/olodaterol 2.5 mcg per actuation SMI 2 inhalations once daily
Glycopyrrolate 50 mcg/indacaterol 110 mcg DPI 1 inhalation once daily
Strong recommendation
LCP, University of the Philippines
National Institutes of Health - Institute
of Clinical Epidemiology 202311
FEV1<80% or mmRC≥2, with increased risk for exacerbations and absence of concurrent respiratory
infection:
Inhaled corticosteroids-LABA
E.g. Budesonide-formoterol 160/4.5 mcg/actuation MDI 2 inhalations twice daily
Strong recommendation
LCP, University of the Philippines
National Institutes of Health - Institute
of Clinical Epidemiology 202311
Pregnant Women: Azithromycin 1g orally in a single dose
Community
Acquired
Pneumonia (Low
Risk)
For Low Risk CAP without comorbidities:
Amoxicillin 500mg-1g thrice a day for 5-7
Low Risk CAP with stable comorbidities:
β-lactam with β-lactamase inhibitor combinations (BLIC e.g. Co-amoxiclav 500/125mg thrice a day for
5-7 days) or second generation cephalosporins (e.g. Cefuroxime 500mg twice a day for 5-7 days) with or
without extended macrolides (Azithromycin 500mg once a day OR clarithromycin 500mg twice a day
for 3-5days)
Dengue
Oral rehydration solution for dengue without warning signs
RITM, University of the Philippines
National Institutes of Health - Institute
of Clinical Epidemiology, 202315
Diabetes Mellitus
Metformin
Alternatives: sulfonylureas, DPP4- inhibitors, SGLT-2 inhibitors, Insulin
ADA, 202316
Dyslipidemia
Statins
Recommended
Back to Table of Contents
Strong Recommendation
ATS & IDSA, 201912
UK-NICE, 201913
IDST, 201914
Omnibus Health Guidelines ver. 2023 |
105
Disease/Condition
First-line Medications
Strength of Recommendation (if
available) and Guideline/Reference
PLAS, 202017
Ebola
Supportive care
Hydrate orally or through IV infusion
Give usual medication to support blood pressure, reduce vomiting and diarrhea, and to manage fever
and pain.
Treat other infections, if they occur.
US CDC, 202118
Epilepsy, Juvenile
Myoclonic
Broad spectrum antiseizure drugs
E.g. Valproate 10-15mg/kg/day in 1-4 divided doses
Levetiracetam 500mg twice daily
Grade 1A
UpToDate, 202319
Extrapyramidal
Symptoms (EPS)
Diphenhydramine 25-50mg IV then continue orally for 2-3 days
UpToDate, 202320
Hand, Foot and
Mouth Disease
(HFMD)
Symptomatic treatment
Give usual medications for fever and pain such as paracetamol or ibuprofen.
Hydrate orally.
US CDC, 202321
Hepatitis B
infection, chronic,
non-cirrhotic or
cirrhotic
Tenofovir Disoproxil Fumarate (TDF) or (Tenofovir Alafenamide) TAF or (Entecavir) ETV
Strong
DOH, 202151
Highly Pathogenic
Avian Influenza
A(H5N1)
Oseltamivir 75mg orally twice daily for five days
Grade 2C
UpToDate, 202322
Hypertension
Monotherapy or combination therapy using the following first-line drug classes:
Recommended
Angiotensin-converting enzyme inhibitors (ACEI) (e.g. Enalapril, captopril, lisinopril), PSH, 202023
Angiotensin-receptor blockers (ARB) (e.g., Telmisartan, Losartan, Valsartan), Calcium channel blockers
(CCBs) (e.g. Amlodipine, Felodipine), Thiazide/Thiazide-like diuretics (e.g., Hydrochlorothiazide,
Chlorthalidone
Human
Immunodeficiency
Virus (HIV)
Tenofovir (TDF) + Lamivudine (3TC) + Dolutegravir (DTG)
300mg once daily, 150mg twice daily or 300mg once daily, 50mg once daily (with additional dose of
DTG 50mg if with Rifampicin-based regimen for TB treatment), or
Back to Table of Contents
Strong Recommendation
WHO, 202124
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Disease/Condition
First-line Medications
Strength of Recommendation (if
available) and Guideline/Reference
TDF + Emtricitabine (FTC) + DTG 300 mg once daily, 200 mg once daily, 50 mg once daily, or
TDF + 3TC (or FTC) + EFV 400 mg 300 mg once daily, 150 mg twice daily or 300 mg once daily, 400 mg
once daily
Ischemic Heart
Disease
For secondary prevention of cardiovascular event:
Aspirin 75-100mg/day (If contraindicated, Clopidogrel 75 mg/day)
Atorvastatin 40-80mg/day or Rosuvastatin 20-40mg/day
UpToDate, 202325
UpToDate, 202325
Grade 2B
UpToDate, 202325
Colchicine 0.5-0.6mg/day
Rivaroxaban 2.5mg orally twice per day added with aspirin for high risk patients
UpToDate, 202325
Others: beta-blockers, ACE inhibitors, ARBs, aldosterone blockers
UpToDate, 202325
Leprosy
Multi-drug
treatment (MDT)
Paucibacillary (PB)
Leprosy
Multibacillary (MB)
Leprosy
PB - 6 blister packs of Rifampicin, Dapsone and Clofazimine taken within 6-9 months
MB - 12 blister packs of Rifampicin, Dapsone and Clofazimine taken within 12-18 months
Weak recommendation
DOH, 202126
For Leprae reaction: Corticosteroid
Prednisolone 0.5mg/kg to 1mg/kg daily tapered by 5mg every 2 weeks until completion of 20 weeks
Strong recommendation
DOH, 202126
Leptospirosis
For Mild leptospirosis: Doxycycline100 mg tab twice daily orally for 7-10 days
For severe leptospirosis: intravenous antibiotics e.g. Penicillin G 1.5 million units IV q6 hours for 7 days,
or
Ceftriaxone 1g q24 hours for 7 days
DOH, 201927
UpToDate, 202328
Filariasis
(microfilaremia)
Diethylcarbamazine(DEC) 6mg/kg for 12 days
UpToDate, 202329
Major Depressive
Disorder
Escitalopram initial dose 10mg daily then 10-20mg daily, or fluoxetine initial dose 20mg daily then
20-60mg daily, sertraline initial dose 50mg daily then 50-200 daily
Recommendation for Use
APA, 201930
Strong Recommendation
ACP, 202331
UK-NICE, 202232
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107
Disease/Condition
First-line Medications
Strength of Recommendation (if
available) and Guideline/Reference
UpToDate, 202333
Malaria
Uncomplicated
Malaria
For all species (P. falciparum, P. vivax, P. malariae, P. ovale, P. knowlesi), regardless if it is single species Strong Recommendation
infection or a mixed type: Artemether Lumefantrine (AL) Target dose: Artemether 5-24mg/kg and WHO, 202334
lumefantrine 29-144mg/kg, to be given twice a day for 3 days (total of 6 doses), the first 2 doses should
be given 8 hours apart.
For uncomplicated P. falciparum with treatment failure or hypersensitivity with AL, or with limited Strong Recommendation
access to AL: Pyronaridine-artesunate (PA) 60 mg + 180 tablet55
WHO, 202334
DM 2023-012856
Meningococcemia
Ceftriaxone 2g IV every 12 hours
US CDC, 202235
Grade 1B
UpToDate, 202336
Methamphetamine Psychosocial therapy using contingency management with or without other behavioral interventions
Use Disorder
Weak Recommendation
US DVA, 202137
UpToDate, 202338
Middle Eastern
Respiratory
Syndrome Coronavirus
(MERS-CoV)
Supportive Care
Treat with antibiotics if with secondary bacterial infection
US CDC, 201939
Rabies
Post exposure prophylaxis:
DOH AO 2018-001340
Category I
● No vaccine or Rabies Immunoglobulin (RIG) needed
Category II
● Rabies Vaccination regimen until Day 7 for WHO Prequalified (PQ) vaccines and until day 28 for
Non PQ vaccines
● RIG not indicated
Category III
● Give both vaccine and RIG
● Complete rabies vaccination regimen until Day 7 for WHO PQ vaccines and until day 28 for Non
PQ vaccines
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108
Disease/Condition
First-line Medications
Strength of Recommendation (if
available) and Guideline/Reference
Purified Verocell rabies Vaccine (PVRV) 0.5ml/ vial
● ID 0.1ml given at Day 0, 3, 7, 28
● IM 0.5ml given at Day 0, 7, 21 or Day 0, 3, 7, 14
Purified Chick Embryo Cell Vaccine (PCECV) 1ml/vial
● ID 0.1ml given at Day 0, 3, 7, 28
● IM 1.0ml given at Day 0, 7, 21 or Day 0, 3, 7, 14
Human Rabies Immune Globulin (HRIG) 150 IUml at 2ml/vial dose: 20 IU/kg
Equine Rabies Immune Globulin (ERIG) 200IU/ml at 5ml/vial dose: 40 IU/kg
*Procurement of non-WHO Prequalified Cell Culture & Embryonated Egg-based Vaccine (CCEEV) shall
cease when WHO-prequalified vaccines become available and have a stable supply in the market.
Schistosomiasis
Praziquantel 60mg’kg per day orally in 3 divided doses for one day
US CDC, 202041
Seizure, Focal
Onset
Gabapentin 300-600mg thrice a day
Oxcarbazepine 300-600mg/day in 2 divided doses
Carbamazepine Initial 2-3mg/kg/day in 2-4 divided doses, may gradually increase every ≥5 days in
increments of ≤200 mg/day to a usual maintenance dose of ~10 mg/kg/day in 2 to 4 divided doses
UpToDate, 202342
Seizure,
Generalized Onset
Valproate 10-15mg/kg/day in 1-4 divided doses
Levetiracetam 500mg twice daily
Topiramate 50mg/day
UpToDate, 202342
Seizure, Unknown
Onset
Valproate 10-15mg/kg/day in 1-4 divided doses
Levetiracetam 500mg twice daily
Topiramate 50mg/day
UpToDate, 202342
Soil-transmitted
Helminthiasis
Albendazole (400 mg)
Mebendazole (500 mg)
Strong Recommendation
WHO, 202343
Syphilis
Parenteral Benzathine Penicillin G administered parenterally, is the preferred drug for treating patients Strong Recommendation
in all stages of syphilis.
USPSTF, 201844
Trichomoniasis
Metronidazole
For Women: Metronidazole 500 mg 2 times/day for 7 days
For Men: Metronidazole 2 g orally in a single dose
Back to Table of Contents
Strong Recommendation
US CDC, 202145
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109
Disease/Condition
Tuberculosis
First-line Medications
Strength of Recommendation (if
available) and Guideline/Reference
For drug-susceptible TB:
● Regimen 1: 2HRZE (Isoniazid-RifampicinPyrazinamide-Ethambutol)/4HR
● Regimen 2: 2HRZE/10HR (for EPTB of CNS,
bones, joints)
Wherein:
Isoniazid (H): 4 - 6 mg/kg, 300 mg formulation
Rifampicin (R): 8 - 12 mg/kg, 300 mg formulation
Ethambutol (E): 15 - 25 mg/kg, 400 mg formulation
Pyrazinamide (Z): 20 - 30 mg/kg, 500 mg formulation
Strong recommendation
WHO, 202246
For TB Preventive Treatment:
● Weekly: Isoniazid/Rifapentine for 12 weeks
● Daily Isoniazid for 6 months
● Daily Isoniazid/Rifampicin for 3 months
● Daily Rifampicin for 4 months
Uncomplicated
Gonococcal
infections of the
cervix, urethra,
and rectum;
Ceftriaxone 500 mg* IM in a single dose for persons weighing <150 kg
Strong recommendation
US CDC, 202147
* For persons weighing ≥150 kg, 1 g ceftriaxone should be administered.
Table 12. Summary of First-line Procedures for Conditions Encountered in Primary Care
Condition
Primary Care Procedures
Animal Bite
Aseptic Wound Care
Referral to Animal Bite Center
Dengue
Supportive care-rehydration with oral or intravenous fluids
Dental caries
Atraumatic Restorative Treatment (ART) using fluoride releasing restorative material (Glass Ionomers)
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110
Dental root caries
Topical application of Silver Diamine Fluoride
Food
and water-borne
diarrhea/gastroenteritis)
Diseases
(infectious
Supportive care-rehydration with oral or intravenous fluids
Foreign Body
Foreign body removal
Gingivitis
Oral Prophylaxis
Known Rheumatic Heart Disease
Monthly intramuscular injections of Penicillin G prophylaxis
Musculoskeletal Injuries
Immobilization with bandage or splint
Non-bite Traumatic Wound (minor wound)
Wound Care; Rest, immobilize, apply cold compress, and elevate injured part (RICE)
Application of topical antiseptic
Debridement and/or suturing, as needed
Tetanus vaccination (according to immunization status)
Oral Urgent Treatment (OUT)
Relief of pain, removal of unsavable tooth, referral of complicated cases to higher levels of care
Periodontitis
Deep scaling, root planing and debridement, referral to higher levels of care (if necessary)
Various Vaccine-Preventable Conditions
Immunization
White spot lesion (White opacities seen on tooth/teeth)
Topical application of Fluoride Varnish
Table 13. Summary of Basic Emergency Services at Primary Care
Condition
First Line Medication
First Line Procedure or Procedures that can be done at primary
care
Active gastrointestinal
bleeding (hematochezia/
hematemesis)
Intravenous proton pump inhibitor (e.g. Omeprazole)
IV Fluid resuscitation
Nasogastric tube (NGT) insertion (for decompression)
Acute infectious diarrhea/
gastroenteritis with severe
dehydration
Oral rehydration solution
NGT insertion if unable to tolerate oral intake
Acute Neurologic Symptoms
due to hypoglycemia
Intravenous glucose (Dextrose 50% solution)48
IV Access
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Condition
First Line Medication
First Line Procedure or Procedures that can be done at primary
care
Aggressive or agitated
behavior
Evaluate for possible underlying causes and rule out
other possible causes:
● Check blood glucose. If low, give glucose
● Check vital signs. If with desaturation, give oxygen.
● Rule out delirium, medical causes including
poisoning, drug and alcohol use, and agitation due
to psychosis or manic episodes in bipolar disorder.
● Sedate as appropriate to prevent injury (WHO,
2016b):
○ Agitation due to mania or psychosis:
Haloperidol 2 mg PO/IM hourly up to 5 doses
(maximum 10 mg). Cautiously check for
dystonic reactions from high doses of
Haloperidol. Biperiden may be used to treat
acute reactions.
○ Agitation due to ingestion of substances, such
as alcohol/ sedative withdrawal or stimulant
intoxication, use Diazepam 10-20 mg PO and
repeat as needed.
○ Extreme violence: Haloperidol 5 mg IM, repeat
in 15-30 mins if needed (maximum 15 mg)
In case of extreme violence, seek help from police or staff, consult a
specialist, and facilitate transfer to a capable facility.
Altered Mental Status
Oxygen support
IV fluids
IV glucose for hypoglycemia (CBG <70 mg/dL)
Other medications depending on the cause of altered
mental status (e.g. naloxone for opioid overdose,
benzodiazepine for active seizure/convulsion, magnesium
sulfate for suspected eclampsia, glucose and
benzodiazepine for alcohol withdrawal)48
Rapid assessment (ABCDE), AVPU assessment to check level of
consciousness, GCS to check trauma patients, quick focused
history taking and PE, capillary blood glucose measurement, basic
emergency care48
Anaphylaxis
Epinephrine48
IV Access, Basic Emergency Care for shock, airway obstruction/
respiratory distress, cardiac arrest48
Asthma Exacerbation
See Asthma Disease-specific Guidance
Transfer to Acute Care Facility if not responding to medications.
Cardiac Arrest
Epinephrine, intravenous (IV) fluids
BLS/CPR, including bag-valve ventilation48, 50
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112
Condition
First Line Medication
First Line Procedure or Procedures that can be done at primary
care
Closed Fracture
Pain reliever
Splint/Immobilization
COPD Exacerbation
See COPD Disease-specific Guidance
Refer immediately to at least a Level 2 health facility, preferably with
an ICU.
Dental extraction with
uncontrolled or profuse
bleeding
Tranexamic acid
Suturing of the extraction site
Dental injury, traumatic
Pain reliever (e.g. Non-steroidal anti-inflammatory drugs
like Mefenamic acid, Ibuprofen) and antibiotics
For avulsed teeth (permanent) at the place of accident:
Find the tooth; avoid touching the root portion; transfer it
in a suitable & convenient storage medium with milk,
HBSS or saliva; and urgently bring the medium with the
patient to the clinic the soonest for higher chance of
reimplantation.
Tooth splint and referral to dentist, dental professional or to higher
levels of care (orthodontist, oral and maxillofacial surgeon)
Difficulty of breathing (DOB)
Oxygen Support
Other medications depending on suspected cause of
difficulty of breathing (e.g. Epinephrine for anaphylaxis,
short-acting beta-agonist (SABA) for asthma
exacerbation, aspirin for suspected ACS, naloxone for
opioid overdose)48
Rapid assessment (ABCDE), quick focused history taking and PE,
basic emergency care (including bag-valve-mask ventilation if
unconscious)48
Disorders due to Substance
Use: Alcohol intoxication,
Opioid Overdose, Alcohol or
Sedative Withdrawal,
Stimulant Intoxication,
Delirium Associated with
Substance Use
Naloxone if with suspected opioid overdose
If with sedative intoxication (e.g. alcohol, opioids, other sedatives),
drug overdose, or withdrawal - Check Airway, Breathing, Circulation
(ABC), provide initial respiratory support (e.g. bag-valve -mask
ventilation), give oxygen, provide basic emergency care as needed48
Benzodiazepine (e.g Diazepam) if with suspected alcohol,
Benzodiazepine or other sedative withdrawal.
Thiamine 100 mg daily for five days if with suspected
alcohol withdrawal
Diazepam for acute stimulant intoxication; Haloperidol if
not responding to Diazepam
Haloperidol if with suspected alcohol or sedative
withdrawal and delirium
Back to Table of Contents
Additional interventions:
1. Psychoeducation
2. Motivational Interviewing
3. Strategies for Reducing and Stopping Use:
a. Identify triggers for use and ways to avoid them
b. Identify emotional cues for use and ways to cope with
them
c. Encourage the person not to keep substances at home
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113
Condition
First Line Medication
First Line Procedure or Procedures that can be done at primary
care
Methadone or Buprenorphine for opioid withdrawal; if
either is not available - use another opioid e.g. Morphine
Sulphate or an alpha agonist e.g. Clonidine or Lofexidine
Eclamptic Seizure
Magnesium sulfate Solution (for intravenous and
intramuscular administration)48
Supplemental oxygen
IV access
Place patient in lateral position, if possible
Immediately transfer to CEmONC facility
Emergency labor
Administer a loading dose of life saving drugs, as
applicable, prior to transport to a Referral Hospital such
as52:
● Oxytocin,
● Magnesium sulfate,
● Antibiotics,
● Maternal steroids
IV Access
Immediately transfer to CEmONC facility
Hypertensive Emergency/
Hypertensive Crisis (severe BP
Intravenous Nicardipine or Labetalol if available53
IV Access
Adjust/intensify maintenance medications, ensure
adherence to therapy, and arrange follow-up within a
short period53
Not applicable
Close follow-up on an outpatient basis
elevation accompanied by new or
worsening target organ damage or
dysfunction)
Hypertensive Urgency (severe
BP elevation in a stable patient
WITHOUT acute organ damage or
change in baseline target organ
damage or dysfunction)
Medically Serious Act of Self
Harm/ Imminent Risk of
Self-Harm / Suicide
See Table 7 for the management of concurrent Mental
Health conditions
Musculoskeletal injury with
profuse bleeding
Tranexamic acid
Back to Table of Contents
1.
2.
3.
4.
5.
Place the person in a secure and supportive environment (do
not leave them alone)
Remove access to means of self-harm
Refer to mental health specialist/higher level of care
Ensure continuity of care
Include the carers if the person wants their support during
assessment and treatment49
IV fluid resuscitation
If with profuse or life-threatening bleeding - Direct manual pressure
application if a manufactured tourniquet is not immediately
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114
Condition
First Line Medication
First Line Procedure or Procedures that can be done at primary
care
available or fails to stop bleeding; tourniquet application with a
manufactured tourniquet is available50
Non-eclamptic Seizure
Benzodiazepine (e.g. Midazolam, Diazepam)48
IV access
Airway protection48
Poisoning (includes
chemicals, snakebites and
toxins)
Antidote/antivenom54 if available
IV fluids and oxygen support as needed
Emergency stabilization, Basic Emergency Care, Decontamination,
Immediate transport to nearest hospital
Possible Acute Coronary
Syndrome
Aspirin loading dose
Statin
Sublingual nitroglycerin or nitrate (e.g. isosorbide
dinitrate [ISDN]) for pain relief.
Note: the absence or presence of response to
nitroglycerin or nitrate administration should not be used
to diagnose the absence or presence of acute coronary
syndrome (UK-NICE, 2016)
Basic emergency care48, 50
Possible Stroke
Not applicable at primary care (imaging needed to rule out
hemorrhagic stroke)
Basic emergency care48
Shock
IV fluids appropriate for the patient’s age and condition
(Ringer’s lactate if with normal nutritional status)48
Hydration via nasogastric tube if no IV fluid available
Oxygen support
Other medications depending on the cause of shock (e.g.
oxytocin for postpartum hemorrhage, aspirin for
suspected heart attack, epinephrine for anaphylaxis)
Rapid assessment (ABCDE), quick focused history taking and PE,
basic emergency care including IV access and fluid resuscitation48
Trauma
IV fluids if bleeding or in shock48, 50
Rapid assessment (ABCDE) and basic emergency care, proper
immobilization (e.g. cervical spine immobilization)
If with profuse or life-threatening bleeding - Direct manual pressure
application if a manufactured tourniquet is not immediately
available or fails to stop bleeding; tourniquet application with a
manufactured tourniquet is available48, 50
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115
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Department
of
Health.
Leprosy
Clinical
Practice
Guidelines.
Published
2021.
Accessed
December
16,
2023.
https://drive.google.com/file/d/1OmRtxsx4_02L-FDZjEcGZ28i7I7an0k4/view
Department of Health. DOH Guidelines for Leptospirosis for Hospitals. 2019 edition. DOH: 2017.
https://drive.google.com/drive/folders/1pxQDWu3H1rmtGlXhJB2G1ZA1x09DREgk
UpToDate. Leptospirosis: Treatment and prevention. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/leptospirosis-treatment-and-prevention/print
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29.
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UpToDate. Lymphatic filariasis: Treatment and prevention. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/lymphatic-filariasis-treatment-and-prevention?search=lymphatic%20filariasis&source=search_result&selectedTitl
e=2~33&usage_type=default&display_rank=2#
Mcquaid J, Lin E, Washington K, et al. Clinical Practice Guideline for the Treatment of Depression across Three Age Cohorts American Psychological
Association Guideline Development Panel for the Treatment of Depressive Disorders. APA; 2019. Accessed December 16, 2023.
https://www.apa.org/depression-guideline/guideline.pdf
Qaseem A, Owens DK, Etxeandia-Ikobaltzeta I, Tufte J, Cross JT, Wilt TJ. Nonpharmacologic and Pharmacologic Treatments of Adults in the Acute Phase of
Major Depressive Disorder: A Living Clinical Guideline From the American College of Physicians. Annals of Internal Medicine. 2023;176(2):239-252.
doi:https://doi.org/10.7326/m22-2056
U.K. National Institute for Health and Care Excellence. Recommendations | Depression in adults: treatment and management | Guidance | NICE.
www.nice.org.uk. Published June 29, 2022. Accessed December 16, 2023.
https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#further-line-treatment
UpToDate. Unipolar major depression in adults: Choosing initial treatment. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/unipolar-major-depression-in-adults-choosing-initial-treatment?search=major%20depressive%20disorder%20trea
tment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#
World Health Organization. WHO Guidelines for Malaria. Published October 16, 2023. Accessed December 16, 2023.
https://iris.who.int/bitstream/handle/10665/373339/WHO-UCN-GMP-2023.01-Rev.1-eng.pdf?sequence=1
United States Centers for Disease Control and Prevention. Meningococcal Disease. Published 2022. Accessed December 16, 2023.
https://www.cdc.gov/meningococcal/clinical-info.html
UpToDate. Treatment and prevention of meningococcal infection. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/treatment-and-prevention-of-meningococcal-infection?search=meningococcemia&source=search_result&selected
Title=2~40&usage_type=default&display_rank=2#
United States Department of Veteran Affairs. Clinical Practice Guideline for the Management of Substance Use Disorders. Published 2021. Accessed
December 16, 2023. https://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPG.pdf
UpToDate. Stimulant Use Disorder: Treatment Overview.Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/stimulant-use-disorder-treatment-overview
United States Centers for Disease Control and Prevention. Middle East Respiratory Syndrome (MERS): Prevention & Treatment. Published 2019. Accessed
December 16, 2023. https://www.cdc.gov/coronavirus/mers/about/prevention.html
Department of Health. DOH AO 2018-0013: Revised Guidelines on the Management of Rabies Exposures. Published 2018. Accessed December 16, 2023.
https://www.psmid.org/wp-content/uploads/2020/03/CPG-rabies-AO-2018-0013.pdf
United States Centers for Disease Control and Prevention. Parasites - Schistosomiasis: Resources for Health Professionals. Published 2020. Accessed
December 16, 2023. https://www.cdc.gov/parasites/schistosomiasis/health_professionals/index.html#tx
UpToDate. Initial treatment of epilepsy in adults. Published 2023. Accessed December 16, 2023.
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e=1~150&usage_type=default&display_rank=1#
World Health Organization. Soil-transmitted helminth infections. Published 2023. Accessed December 16, 2023.
https://www.who.int/news-room/fact-sheets/detail/soil-transmitted-helminth-infections#:~:text=and%20heavy%20intensity.-,Treatment,few%20and%
20minor%20side%2Deffects
United States Preventive Services Task Force. Syphilis Infection in Pregnant Women: Screening. Published September 4, 2018. Accessed December 16,
2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/syphilis-infection-in-pregnancy-screening
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Accessed December 16, 2023. https://www.cdc.gov/std/treatment-guidelines/trichomoniasis.htm
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Accessed December 14, 2023. https://www.who.int/publications/i/item/9789240006997
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Adolescents and Adults. Published 2021. Accessed December 16, 2023. https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm
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Accessed December 16, 2023. https://iris.who.int/bitstream/handle/10665/208895/9789241549578_eng.pdf?sequence=1
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by Nurses and Midwives in Birthing Centers. Published 2015. Accessed December 16, 2023.
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%20training%20courses
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Combination Therapy (ACT) for the Treatment of Malaria. 2023. https://drive.google.com/file/d/1qsBkQeZj2av8U-cTzp5kOT25cegy9ce3/view
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PART II:
Specific
Guidance
for
Common and
High Burden
Diseases
in Adults
This part provides more detailed
evidence-based standards on
common and/or high-burden
conditions presenting at primary care
and encompasses the signs,
symptoms, and the disease-specific
spectrum of care from screening (if
applicable) to referral.
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NonCommunicable
Diseases
(NCDs)
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Acute Myeloid Leukemia
is a type of leukemia which is characterized as a “heterogeneous malignancy defined by clonal proliferation
and improper differentiation of myeloid precursors”1. In AML, chromosomal translocations result in the
production of chimeric proteins that are disruptive to the normal myeloid precursor cell maturation process1.
From 1990 to 2017, worldwide disease burden of AML has risen steadily from 63,840 to 119,570 cases1 with the
highest prevalence found in Western Europe and South Asia geographical zones1. In the Philippines, cancer
remains to be among the top three leading causes of mortality1. Among cancer-related mortalities, leukemia
ranks 5th among all cases, with up to 4,370 deaths1. The five-year survival rate of AML for those under 20
years of age is 68% which sharply decreases to 26% for those over 20 years old1. Early recognition and
management are key to improving the survival of patients.
Table 14. Acute Myeloid Leukemia Continuum of Care Overview
Acute Myeloid Leukemia (AML) Overview
Risk Factors
Screening
Diagnosis
Pharmacologic Treatment
Supportive and Palliative Care
History of Myelodysplastic syndrome
History of Myelofibrosis
Aplastic anemia
Down's syndrome
Bloom syndrome
Exposure to radiation therapy and/or cytotoxic agents like, tobacco, and/or benzene
Not Applicable
Minimum at primary care: Complete blood count (CBC) with platelet count, Peripheral
Blood Smear (PBS), Reticulocyte Count
Gold Standard. Confirmatory Multiparameter flow cytometry for patients with low RBC and
low WBC counts, if available.
Refer to higher level of care for appropriate treatment
Psychosocial Care
Palliative Care
Pain Management
End-of-life Care Concerns
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Signs and Symptoms
●
Suspect the presence of a hematologic malignancy such as Acute Myeloid Leukemia in an adult
who presents with any of the following symptoms, appearing over a few weeks and becoming more
severe over time1:
○ Fatigue/exhaustion
○ Weight loss
○ Fever
○ Night sweats/ excessive sweating
○ Loss of appetite
○ Headache
○ Pale or "washed-out" skin
○ Breathlessness
○ Frequent infections
○ Unusual and frequent bleeding
○ Easily bruised skin
○ Flat red or purple spots on the skin
○ Bone and joint pain
○ A feeling of fullness or discomfort in the tummy
○ Swollen glands in the neck
Diagnostic Tests
●
●
●
Minimum at primary care. Obtain a complete history and perform a complete physical
examination on patients exhibiting signs and symptoms. Request the following tests in patients
with suspected AML1
○ Complete blood count (CBC) with platelet count
○ Peripheral Blood Smear (PBS)
○ Reticulocyte Count
Gold Standard. To confirm AML, refer the patient to a higher level of care for multiparameter flow
cytometry of the bone marrow core biopsy and aspirate smears among patients presenting with
low RBC and WBC counts. (Strong Recommendation)1
Other tests. Refer the patient for the following additional tests:
○ Test for HBsAg, anti-HBc total, anti-HBs, anti-HCV, and/or HIV especially among high-risk
populations (Good Practice Statement)1:
○ Immunohistochemistry (Strong Recommendation)1
○ Cytogenetic study using conventional karyotyping for risk stratification of patients and to
guide individualized therapy. (Strong Recommendation)1
○ Baseline molecular analysis of c-KIT, FLT3-ITD, FLT3-TKD, NPM1, CEBPA, IDH1, IDH2,
RUNX1, ASXL1, and TP53 for gene mutations may be recommended (Weak
Recommendation)1.
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Diagnostic Tests
○
In cases with inadequate karyotype analysis, addition of fluorescence in situ hybridization
(FISH) can be recommended. (Strong Recommendation)1
Treatment and Referral
●
●
●
●
●
●
Refer to higher levels of care for the confirmation of the diagnosis and specialized treatment of
patients with AML.
For Supportive and Palliative Care: Advise referral of patients and their families to provision of
health systems support interventions at any point in the course of illness to address (RA 11215)2
Financial support: Cancer patients, persons living with cancer and cancer survivors are
considered persons with disabilities (PWDs) and are accorded the same rights, privileges, social
welfare and benefits as other PWDs.2,3,4,5,6,7
Palliative care: Cancer patients and families of patients that need palliative support may consult
with/ may be referred to accredited associations and institutions handling hospice and palliative
care.8
Psychosocial needs: Cancer patients and families of patients that need psychosocial support may
consult with/ may be referred to support groups, associations and institutions handling
psychosocial care. 8,9,10
Pain and symptom management: Medical professionals caring for cancer patients may consult the
WHO Analgesic Ladder and the DOH Cancer Pain Relief Program for guidance on pain management
and referral11
■ End-of-life care concerns: Cancer patients who are contributors and their
families are eligible to apply for illness, disability, and funeral benefit claims from
SSS and GSIS 2,6,7
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Department of Health. Acute Myeloid Leukemia National Clinical Practice Guidelines. National Integrated Cancer Control Program.
2022. https://drive.google.com/file/d/1PtOyZbMV1krEGQAcQvnli7Pp4LvYKa2u/view
Republic Act No. 11215 "National Integrated Cancer Control Act"
Republic Act No. 7277 “Magna Carta for Disabled Persons, and for Other Purposes”
Department of Health and Department - Department of Budget and Management. DOH-DBM Joint Memorandum Circular 2022-0002:
Implementing Guidelines for the Use of Cancer Assistance Fund (CAF). 2022.
https://www.dbm.gov.ph/wp-content/uploads/Issuances/2022/Joint-Memorandum-Circular/DOH-DBM-Joint-Memorandum-CircularNo-2022-0002.pdf
Department of Labor and Employment. DOLE Labor Advisory No. 20 series of 20223: Guidelines on the Implementation of the
Workplace Policy and Program on Cancer Prevention and Control in the Private Sector. 2023.
https://oshc.dole.gov.ph/wp-content/uploads/2023/10/LA-20-series-of-2023.pdf
Social Security System. SSS Benefits Overview. N.d. https://www.sss.gov.ph/sss/appmanager/pages.jsp?page=ssbenefits
Government Service Insurance System. GSIS Policy and Procedural Guidelines No. 274-14. 2016.
https://www.gsis.gov.ph/downloads/ppg-br/20160304-PPG-274-14.pdf
Philippine Cancer Society. Hospice Groups. N.d. https://www.philcancer.org.ph/index.php/support/hospice-groups
Silakbo PH. Mental Health Resources. N.d. http://www.silakbo.ph/help/
MentalHealthPH. Directory. N.d. https://mentalhealthph.org/directory/
Department of Health. The Philippine Cancer Control Program. N.d.
https://doh.gov.ph/sites/default/files/health_programs/The-Philippine-Cancer-Control-Program.pdf
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Asthma
is described in the Global Initiative for Asthma (GINA) 20231 as a heterogenous disease, usually characterized
by chronic airway inflammation. It is common and affects 1-29% of the population in different countries.
According to the World Health Organization, it is also in these countries that asthma is under-diagnosed and
under-treated2. In the Global Asthma Report 20223, the Philippines ranked second in the age-standardized
deaths per million population covering the years 2011-2015. The symptoms and airflow limitation from asthma
is described as varying over time and intensity. Its features can resolve spontaneously, respond to
medications or be absent for weeks or months. However, asthma exacerbations can also occur which can
lead to death. In addition, the majority of deaths due to asthma happen in low- and middle-income countries1.
Asthma poses a threat to the productivity of individuals and to the economics of families and the community,
hence, it is important that asthma recognition and management is strengthened at the primary care level.
Table 15. Asthma Continuum of Care Overview
Asthma Overview
Risk Factors
Prevention
Screening
Diagnosis
Pharmacologic
Treatment
Non-pharmacologic
management
●
Tobacco smoke exposure
●
Occupational exposure to noxious aerosols
●
Allergic rhinitis
●
Obesity
The development of asthma cannot be prevented but exacerbations can be prevented and
symptoms can be controlled by the identification and avoidance of asthma “triggers” and respiratory
irritants e.g. allergens, fumes, cigarette exposure (secondary and tertiary prevention) (See General
Wellness and Preventive Measures for general guidance).
Not applicable
Minimum at primary care. Consider probable asthma by clinical history among patients with typical
symptoms.
Gold Standard. Confirm the diagnosis of asthma through spirometry pre-and post-bronchodilator.
Additional laboratory tests depending on the clinical indication. PEF with reversibility test,
bronchial provocation test, allergy tests, Chest X-ray, sputum eosinophil count, FeNO.
Reliever.
First-line reliever is inhaled corticosteroid (ICS)-formoterol.
Second-line reliever is ICS-short acting beta-agonist (SABA). SABA alone treatment is not
recommended.
Maintenance.
Stepwise approach depending on clinical presentation and asthma control is followed for
maintenance therapy.
●
Patient education, written asthma plan
●
Smoking and vape use cessation
●
Weight reduction among overweight and obese patients
●
Mental health assessment for anxiety/panic attacks
●
Food allergen avoidance
●
Avoidance of occupational/domestic triggers
●
Influenza vaccination every year
●
Breathing exercises
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Signs and Symptoms
●
Consider asthma among adults presenting with the following1.
○ Wheezing, shortness of breath, chest tightness, and cough that vary over time, including
in their frequency and intensity
○ Symptoms that are often worse at night or in the early morning
○ Symptoms that are triggered by viral infections (colds), exercise, allergen exposure,
changes in weather, laughter, or irritants such as car exhaust fumes, strong smells,
cigarette or vape smoke
Screening
●
Not applicable
Diagnostic Tests
●
●
●
Minimum at primary care. Consider the diagnosis of probable asthma by clinical history among
patients presenting with typical symptoms that respond promptly and completely to therapy4.
○ Consider classifying asthma severity into mild, moderate, and severe based on difficulty
to treat or the level of treatment required to control the patient’s symptoms and
exacerbations after at least several months of treatment1
○ Consider classifying asthma as well-controlled, partly controlled, or uncontrolled using
the GINA symptom control tool1,5
Gold standard. Confirm the diagnosis of asthma among adults with clinical history of asthma
symptoms through spirometry pre- and post-bronchodilator to demonstrate variable expiratory
airflow limitation. 1,4
○ Excessive variability in lung function: increase in FEV1 of >12% and >200 ml compared
with pre-bronchodilator values, AND
○ Expiratory airflow limitation: FEV1/FVC reduced compared with lower limit of normal
(usually >0.75-0.80 in adults)
Other laboratory tests. Additional laboratory tests may be requested depending on the clinical
indication and the availability of the test:
○ May use peak expiratory flow (PEF) with reversibility test to confirm variable expiratory
flow in diagnosing asthma. Consider PEF also for short and long-term monitoring of
asthma.1
○ May use bronchial provocation test to assess airway hyperresponsiveness.1
○ Consider performing allergy tests to determine presence of atopy which increases the
probability that a patient with respiratory symptoms has allergic asthma.1
○ Consider performing imaging studies such as Chest X-ray to investigate the possibility of
comorbid conditions or alternative diagnoses in those with difficult-to-treat asthma.1
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Diagnostic Tests
○
○
Consider requesting for sputum eosinophil count among adult patients with moderate or
severe asthma for adjusting ICS-containing maintenance. (Evidence A)1
Consider requesting for fractional concentration of exhaled nitric oxide (FeNO) among
young adults with asthma for adjusting ICS-containing maintenance. (Evidence A)1
Treatment
●
Pharmacologic Therapy. Follow a step-wise approach to pharmacologic therapy treatment to
achieve control of asthma. Do not give short-acting beta-agonist (SABA)-only treatment in adults
with asthma since those treated with SABA alone compared with inhaled corticosteroid (ICS) are
at increased risk of asthma-related death (Evidence A) and urgent asthma-related healthcare
(Evidence A).1
○ Step 1. I If patient has infrequent symptoms, e.g. less than twice a month and no risk
factors for exacerbations, including no exacerbations in the last 12 months:
therapy.
As-needed
low-dose
ICS--formoterol
[e.g.
■ First-line
budesonide-formoterol
combination
metered
dose
inhaler
(MDI)
160mcg-4.5mcg/inhalation or dry powder inhaler (DPI) 200 mcg-6 mcg/inhalation,
1 inhalation]. (Evidence B)1
■ Alternative therapy. Low dose ICS taken whenever SABA is taken, in combination
or separate inhaler. (Evidence B)1
○ Step 2. If patient has symptoms or need for reliever twice a month or more:
■ First-line therapy. As-needed low-dose ICS formoterol (Evidence A)1
■ Alternative. May give any of the following1:
● Daily low-dose ICS plus as-needed SABA (Evidence A)
● As-needed low-dose ICS-SABA
● Daily leukotriene receptor antagonist (LTRA) plus as-needed SABA,
although LTRA were found to be less effective than ICS, particularly for
exacerbations1
○ Step 3. If patient has troublesome symptoms on most days e.g. 4-5 days a week, or
waking due to asthma once a week or more, especially if with risk factors for
exacerbations (smoking, allergen exposure if sensitized, previous intubation or intensive
care unit stay for asthma, low FEV1 esp. <60% predicted, obesity, food allergy, chronic
rhinosinusitis, and poor adherence/inhaler technique):
■ First Line. Low-dose ICS-formoterol maintenance-and-reliever therapy (MART).
(Evidence A)1
■ Alternative. May give any of the following1:
● Daily low-dose ICS-long acting beta-agonist (LABA) plus as-needed
SABA (Evidence A) or plus as-needed ICS-SABA (Evidence B)
● Daily medium-dose ICS plus as-needed SABA (Evidence A) or plus
as-needed ICS-SABA. (Evidence B)
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Treatment
Daily low dose ICS and LTRA daily plus as needed- SABA (Evidence A)
Daily low dose ICS and low-dose, sustained release theophylline daily
plus as needed SABA (Evidence B)
Step 4. If patient initially presented with severely uncontrolled asthma, or with an acute
exacerbation, daily symptoms, waking with asthma once a week or more, and low lung
function:
■ First Line. May give medium-dose ICS-formoterol maintenance and reliever
therapy (MART) and a short course of oral corticosteroids. (Evidence D)1
■ Alternative. May give any of the following1:
● Daily medium-high-dose ICS-LABA plus as-needed SABA or plus
as-needed ICS-SABA (Evidence D)
● High-dose ICS plus as-needed SABA (Evidence A)
● Add-on long-acting muscarinic antagonist (LAMA) to ICS-LABA or switch
to ICS-LAMA-LABA (Evidence A) plus as-needed SABA
● Add-on LTRA to medium or high-dose ICS as controller (Evidence A)
● Add-on theophylline to medium or high-dose ICS as controller (Evidence
B)
●
●
○
Consider stepping down gradually to find the patient’s lowest treatment when good
asthma control is achieved and maintained for 2-3 months.1
○ Consider stepping up when symptoms are confirmed to be due to asthma and not from
common problems such as inhaler technique, adherence, allergen exposure, and
multimorbidity1
Non-pharmacologic therapy. Consider providing or teaching the following non-pharmacologic
interventions to improve asthma control:
○ Patient education to address the mentioned common problems.1
○ Written asthma action plan for patient use, including short-term changes to their
treatment in response to changes in their symptoms and/or PEF and when to access
medical care. (Evidence A)1
○ Smoking cessation, including cessation of vape use through providing access to
counseling and smoking cessation programs. (Evidence A)1
○ Strategies for weight reduction among overweight and obese patients with asthma.
(Evidence B)1
○ Mental health assessment for patients with symptoms of asthma and anxiety. May also
provide advice about management of panic attacks. (Evidence D)1
○ Food allergen avoidance to reduce risk of asthma exacerbation. (Evidence D)1
○ Exposure avoidance among those with occupational/domestic asthma triggers.
(Evidence A)1
○ Utilization of non-polluting heating and cooking sources of pollutants to be vented
outdoors where possible. (Evidence B)1
○ Influenza vaccination every year. (Evidence C)1,6
○
●
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Treatment
○
Breathing exercises to supplement pharmacotherapy for symptom relief and
improvement of quality of life. (Evidence A)1
Referral
●
Refer patients with any of the following to higher level facility or specialized care when patient has
any of the following1:
○ Difficulty confirming the diagnosis of asthma
○ Persistent or severely uncontrolled asthma or frequent exacerbations, described as the
following:
■ Symptoms remain uncontrolled or the patient has ongoing exacerbations or low
lung function despite correct inhaler technique and good adherence with Step 4
treatment.
■ The patient frequently uses asthma-related health care (e.g. multiple emergency
department visits or urgent primary care visits).
○ Severe or life-threatening exacerbations described as with symptoms of drowsiness,
confusion, or silent chest
○ Low FEV1, especially if <60% predicted
○ Suspected occupational asthma
○ Any risk factors for asthma-related death (near-fatal asthma attack at any time in the
past, suspected or confirmed anaphylaxis or food allergy)
○ Evidence of, or risk of, significant treatment side-effects
○ Symptoms suggesting complication (e.g. allergic bronchopulmonary aspergillosis) or
subtypes of asthma (e.g. aspirin-exacerbated respiratory disease/aspirin-induced
asthma, perimenstrual/catamenial asthma)
First Aid Measures and Basic Emergency Care
●
●
Assess patients for asthma exacerbations in patients presenting with progressive increase in
symptoms of shortness of breath, cough, wheezing, or chest tightness and progressive decrease
in lung function.
Consider administering the following main initial therapies in patients suspected of having asthma
exacerbation: repetitive administration of rapid-acting inhaled bronchodilators, early introduction
of systemic corticosteroids, and controlled flow oxygen supplementation1.
○ Mild to moderate exacerbation:
■ Inhaled SABA 4-10 puffs by pMDI + spacer or nebulizer, repeat every 20 minutes
for 1 hour. (Evidence A)1
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First Aid Measures and Basic Emergency Care
Consider immediate transfer to higher facility if with worsening of symptoms or
no relief despite 3 doses of SABA. After the first hour, consider giving additional
SABA (can range from 4-10 puffs every 3-4 hours up to 6-10 puffs every 1-2 hours),
ipratropium bromide, oxygen therapy, and systemic corticosteroid while waiting
transfer to a higher facility1
■ May give oral corticosteroids such as prednisolone 40-50mg (maximum of
50mg/day) and continue for 5-7 days. (Evidence B) (GINA, 20231)
■ May give controlled oxygen therapy to maintain oxygen saturation of 93-95%1
■ Assess response to treatment after 1 hour or earlier then assess for discharge.
May discharge the patient if with the following1:
■ Symptoms improved, not needing SABA
■ PEF improving, and >60-80% of personal best or predicted
■ Oxygen saturation >94% room air
■ Resources at home adequate
Severe or life-threatening exacerbation: Facilitate immediate transfer to a higher level
facility. Give SABA, ipratropium bromide, oxygen therapy, and systemic corticosteroid
while waiting transfer to a higher facility1
■
○
○
References
1.
2.
3.
4.
5.
6.
Global Initiative for Asthma. 2023 GINA Report. Published July 10, 2023. Accessed December 12, 2023.
https://ginasthma.org/2023-gina-main-report/
World Health Organization. Asthma. 2023. https://www.who.int/news-room/fact-sheets/detail/asthma
Global Asthma Network. The Global Asthma Report 2022. The International Journal of Tuberculosis and Lung Disease. 2022;26(1):1-104.
doi:https://doi.org/10.5588/ijtld.22.1010
UpToDate. Asthma in adolescents and adults: Evaluation and diagnosis. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/asthma-in-adolescents-and-adults-evaluation-and-diagnosis?search=asthma&source=search_
result&selectedTitle=3~150&usage_type=default&display_rank=3#
Global Initiative for Asthma. GINA Implementation Toolbox: GINA symptom control tool. Published 2018. Accessed December 12, 2023.
https://ginasthma.org/wp-content/uploads/2019/01/GINA-Implementation-Toolbox-2019.pdf#page=20
Philippine Society for Microbiology and Infectious Diseases. Philippine Clinical Practice Guidelines for Adult Immunization. Makati:
Zurbano
Publishing
and
Printing
Corp.
Published
2018.
Accessed
December
14,
2023.
https://drive.google.com/file/d/1pdl986x5sLNzSCBwRGC9HNBAvgGHl06N/view
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Omnibus Health Guidelines ver. 2023 | 128
Chronic Obstructive Pulmonary Disease
is a disease characterized by chronic respiratory symptoms and airflow obstruction. Chronic respiratory
diseases like Chronic Obstructive Pulmonary Disease (COPD) are among the top 10 causes of mortality and
morbidity in the Philippines1. It also affects quality of life, due to exacerbations and hospitalizations. The
most common and most important risk factor remains smoking, hence interventions for smoking cessation
are critical in COPD management. The long-term goals of management include the improvement of health
outcomes and quality of life, reduction of symptoms, exacerbations, hospitalizations, and mortality, and
improvement of lung function2.
Table 16. Chronic Obstructive Pulmonary Disease Continuum of Care Overview
COPD Overview
Risk Factors
●
Cigarette smoking or vaping - most important
●
Asthma and airway hyperresponsiveness
●
Childhood pneumonia
●
Respiratory infections - risk factor for COPD exacerbations
●
Occupational exposures to dust and fumes (e.g. coal mining, gold mining, cotton textile dust)
●
Biomass/biofuel combustion - particularly among women
●
Genetic risk factors (e.g., α1 antitrypsin deficiency)
Avoidance/cessation of smoking, avoidance of second-hand exposure - most important preventive
measure for primary, secondary, and tertiary prevention
Avoidance of environmental exposure to biomass smoke, pollution, etc.
Adequate treatment of respiratory infections including pneumonia (particularly in
infancy/childhood) and TB
Prevention
Screening
Diagnosis
Pharmacologic
Treatment
Non-pharmacologic
management
(See General Wellness and Preventive Measures for general guidance)
In asymptomatic patients. Not recommended.
In symptomatic patients. Use clinical scoring systems to assess the probability of COPD.
Minimum at Primary Care. Clinical scoring system + handheld spirometer
Classify confirmed COPD patients using the Modified Medical Research Council (mmRC) Dyspnea
Scale
Gold standard. Facility-based spirometer
Stable COPD, not in exacerbation:
●
FEV1≥80% or mmRC <2: LAMA Monotherapy
●
FEV1<80% or mmRC ≥2: LABA + LAMA Combination; if unavailable, LAMA monotherapy
○
If with increased risk of exacerbation and without infection: add ICS
COPD in exacerbation: SABA + SAMA; if unavailable, SABA monotherapy
COPD + bacterial infection: Oral antibiotics
●
COPD Action Plan
●
Smoking or vaping Cessation
○
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Signs and Symptoms
●
Consider COPD in adults with a history of smoking and presenting with persistent and progressive
respiratory symptoms such as difficulty of breathing, cough, and phlegm production2
Screening
●
●
Screening for COPD is not recommended in asymptomatic adults3
Assess patients with symptoms of probable COPD using a clinical scoring system to identify
patients for confirmatory testing (Strong Recommendation)2
Diagnostic Tests
●
●
●
●
Minimum at Primary Care.
○ Confirm the diagnosis among probable COPD patients by using the combination of a
clinical scoring system and handheld spirometry, as alternative to facility-based
spirometry (Weak recommendation)2. Examples of a clinical scoring system are:
■ COPD Diagnostic Questionnaire (CDQ)
■ COPD Population Screener (COPD-PS)
■ Lung Function Questionnaire (LFQ)
■ COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease
and Exacerbation Risk (CAPTURE) Screening Tool
○ Do not use clinical scoring system, handheld spirometer, or peak flow meter alone to
confirm the diagnosis (Strong recommendation against use)2
○ COPD is confirmed if there is non-fully reversible airflow limitation: FEV1/FVC 0.7
post-bronchodilation.
Gold Standard. If available and accessible, request for the gold standard - facility-based
spirometry, to confirm the diagnosis2. Refer to a higher level facility for this test, if necessary.
Initial assessment of confirmed COPD. Consider determining the following four fundamental
aspects in COPD assessment among those confirmed with COPD by spirometry:4
○ Severity of airflow limitation
○ Nature and magnitude of current symptoms
○ Previous history of moderate and severe exacerbations
○ Presence and type of other disease (multimorbidity)
Classification of confirmed COPD. Classify the patient’s symptoms according to the Modified
Medical Research Council (mmRC) Dyspnea Scale to identify the appropriate treatment.
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Diagnostic Tests
Table 17. Modified Medical Research Council (mmRC) Dyspnea Scale2
mmRC Classification
Symptoms
mmRC 0
Dyspnea only with strenuous exercise
mmRC 1
Dyspnea when hurrying or walking up a slight hill
mmRC 2
Walks slower than people of the same age because of dyspnea or has to stop for breath
when walking at own pace
mmRC 3
Stops for breath after walking 100 yards (91 meters) or after a few minutes
mmRC 4
Too dyspneic to leave house or breathless when dressing
Treatment
●
●
●
Start treatment in all adults who have COPD.
Pharmacologic Management of Stable COPD.
○ First-line therapy. Choose the appropriate therapy according to the FEV1 and mmRC
classification of the patient.
■ FEV1≥80% or mmRC <2 and not in exacerbation:
● LAMA monotherapy (Weak recommendation)2
■ FEV1<80% or mmRC ≥2 and not in exacerbation:
● Long-acting B2-agonist (LABA)/Long-acting antimuscarinic antagonist
(LAMA) combination therapy (Strong recommendation)2
● If LABA/LAMA combination therapy is not available, use LAMA instead of
LABA (Weak recommendation)2
■ FEV1<80% or mmRC ≥2 with increased risk of exacerbation and absence of
concurrent respiratory infection:
● Add an inhaled corticosteroid (ICS) on top of long-acting bronchodilator
(LABD) (e.g. LABA/LAMA/ICS or LABA/ICS + LAMA/LABA) (Strong
recommendation)2
○ Second-line therapy. If inhaled long-acting bronchodilators (e.g. LAMA, LABA) are not
available or accessible , offer oral methylxanthines However, long-acting bronchodilators
remain preferred over oral methylxanthines. (Strong recommendation)2.
■ Methylxanthines include Theophylline and Doxofylline.
Pharmacologic Management of COPD in Exacerbation.
○ First-line. Administer short-acting B2-agonist (SABA) + short-acting antimuscarinic
antagonist (SAMA) combination. If SABA + SAMA is not available, administer SABA alone
(Strong recommendation)2.
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Omnibus Health Guidelines ver. 2023 | 131
Treatment
Add-on therapy. If the patient in exacerbation has worsening symptoms and does not
respond to bronchodilators (SABA + SAMA or SABA alone), give a short course of oral
steroids (5-10 days) (Strong recommendation)2.
○ Refer patients with COPD in exacerbation to higher levels of care as necessary.
Management of Bacterial Coinfection in Outpatients with COPD Exacerbation.
○ Initiate oral antibiotics in patients with COPD who present with at least 2 of the following
symptoms: increased dyspnea, increased frequency of cough, increased sputum volume
or purulence (Anthonsen’s criteria) (Strong recommendation)2.
■ Antibiotic options, to complete course in 5-10 days (2018 National Antibiotics
Guideline):
● Amoxicillin 500 mg 3 times a day
● Doxycycline 100 mg tab 2 times a day
● Cefuroxime 500 mg tab 2 times a day
Nonpharmacologic Management.
○ Smoking or vaping cessation in current smokers or vapers
○ Develop a COPD Action Plan (sample5) with the patient to be used for self-guided
management (Strong recommendation)2.
○
●
●
Referral
●
●
Refer patients with COPD who have any of the following conditions which are associated with
higher risk of moderate to severe exacerbation to higher level of care (Strong recommendation)2:
○ Prior history of exacerbations
○ Presence of comorbidities
○ Severe or very severe airflow limitation
Refer patients with COPD who have any of the following conditions which are associated with
higher risk mortality to higher level of care (Strong recommendation)2:
○ Presence of uncontrolled diabetes or cardiovascular disease
○ Previous hospitalization for acute exacerbation within the past year
○ Hospital readmission within 30 days
○ Use of long-term oxygen therapy.
Palliative Care
●
Consider giving low flow oxygen therapy to relieve dyspnea in symptomatic COPD patients with
moderate to severe breathlessness (mmRC 3-4) who are not hypoxemic and who do not fulfill the
criteria for long-term oxygen therapy (LTOT), provided it is used with caution and the patient is
closely supervised (Weak recommendation)2:
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Palliative Care
●
○ Prior history of exacerbations
○ Presence of comorbidities
○ Severe or very severe airflow limitation
Consider giving opioids (e.g., Morphine) to relieve dyspnea despite maximized medical
managements in patients with advanced-stage or end-stage COPD and/or refractory dyspnea
(Strong recommendation)2:
○ Presence of uncontrolled diabetes or cardiovascular disease
○ Previous hospitalization for acute exacerbation within the past year
○ Hospital readmission within 30 days
○ Use of long-term oxygen therapy
First-aid Measures and Basic Emergency Care
●
●
Manage exacerbations as indicated in the Treatment Section
Facilitate the immediate transfer of patients in severe respiratory distress to higher levels of care.
○ Ensure IV access prior to transfer.
○ Administer oxygen therapy.
References
1.
2.
3.
4.
5.
GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a
systematic analysis for the Global Burden of Disease Study 2019 [published correction appears in Lancet. 2020 Nov
14;396(10262):1562]. Lancet. 2020;396(10258):1204-1222. doi:https://10.1016/S0140-6736(20)30925-9
Lung Center of the Philippines & University of the Philippines Manila - National Institutes of Health - Institute of Clinical Epidemiology.
Clinical Practice Guidelines for the Management of Chronic Obstructive Pulmonary Disease. Published 2023. Accessed December 16,
2023. https://drive.google.com/drive/u/1/folders/1kAx4VZrlqH3AQkQ-E35TSQLg7Z6wQud1
Webber EM, Lin JS, Thomas RG. Screening for Chronic Obstructive Pulmonary Disease. JAMA. 2022;327(18):1812.
doi:https://doi.org/10.1001/jama.2022.4708
Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Prevention, Diagnosis and Management of COPD: 2023
Report. Published 2023. Accessed December 16, 2023. https://goldcopd.org/2023-gold-report-2/
Living Well with COPD. Plan of Action. Published 2022. Accessed December 16, 2023.
https://www.livingwellwithcopd.com/DATA/DOCUMENT/64_en~v~plan-of-action.pdf
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Omnibus Health Guidelines ver. 2023 | 133
Diabetes Mellitus
is a disorder of glucose metabolism, leading to chronic elevation of blood sugar, which leads to various
complications. Between 2009 and 2019, diabetes mellitus (DM) was the seventh leading cause of combined
death and disability in our country1. DM is initially a silent disease, with people having asymptomatic
subclinical disease for 5-7 years before its actual diagnosis2. This period between the asymptomatic phase of
the disease and the development of its various clinical manifestations and complications (e.g. blindness from
diabetic retinopathy, chronic kidney disease from diabetic nephropathy, ischemic heart disease and
peripheral arterial disease from accelerated atherosclerosis) is a window of opportunity for aggressive
screening, risk management, and blood sugar control in the primary care setting.
The scope of this section is limited to Type 2 Diabetes Mellitus.
Table 18. Type 2 Diabetes Mellitus Continuum of Care Overview
Type 2 Diabetes Mellitus Overview
Screening
Overweight or obese
Smoking
Maternal history of diabetes or having Gestational Diabetes Mellitus (GDM) during pregnancy
Family history of type 2 Diabetes in first- or second-degree relative
Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans,
hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight)
Healthy diet, exercise and physical activity, weight management (See General Wellness and Preventive
Measures for general guidance)
FBS (strong recommendation) OR HbA1c (Weak)3
Diagnosis
Minimum at Primary Care. Repeat FBS, HbA1c or 75-g OGTT to confirm. DM is confirmed if:
Risk Factors 3 ,11
Prevention
●
●
●
●
●
FBS ≥126 mg/dL (7.0 mmol/L) after at least 8 hours of no caloric intake or
HbA1c ≥6.5% (48 mmol/mol) or
2–hour postprandial plasma glucose after ingestion of 75 gram anhydrous glucose load ≥ 200
mg/dL (11.1mmol/L) or
●
RBS ≥ 200 mg/dL (11.1mmol/L) + classic symptoms of hyperglycemia (polydipsia, polyuria,
weight loss)
Additional tests for comorbidities/complications:
●
Lipid profile (including LDL, HDL, triglycerides), liver function tests, spot urinary
albumin-to-creatinine ratio, serum creatinine and estimated glomerular filtration rate (eGFR),
serum potassium
●
TB Screening by symptomatic screening or by chest X-ray
●
Age and sex-appropriate cancer screening tests
First-line: Metformin
Alternatives as monotherapy or in combination depending on glycemic status and targets: Sulfonylureas,
thiazolidinedione, DPP-4 inhibitor, SGLT2 inhibitor, GLP-1 receptor agonist, insulin
For primary prevention of CVD: Moderate-intensity statin for all patients with diabetes, Aspirin for DM
with high CVD risk
●
Medical nutrition therapy, (MNT), weight loss/management, exercise, psychosocial care, smoking
cessation/avoidance
●
●
●
Pharmacologic
Treatment
Non-pharmacologic
management
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Signs and Symptoms
●
●
●
At the early stages or subclinical phase of DM, individuals are often asymptomatic.
Consider the presence of overt DM in patients presenting with classic symptoms of hyperglycemia
(polyuria, polydipsia, and weight loss) or symptoms of hyperglycemic crisis (nausea, vomiting,
abdominal pain, altered mental status or decreased sensorium)2, 4,5
Uncontrolled diabetes can lead to the following complications:
○ Diabetic retinopathy, presenting with visual symptoms of curtain falling, floaters, or
decreased visual acuity that cannot be corrected with refraction6
○ Diabetic neuropathy, presenting with numbness, loss of balance, and tingling and pain of
the toes and feet usually worse at night, foot ulcers, and foot deformity7
○ Diabetic nephropathy is asymptomatic at an early stage but microscopic albuminuria is a
sign. It is the leading cause of chronic kidney disease, which manifests as poorly
controlled blood pressure or resistant hypertension, fatigue, edema, and congestion.
Screening
●
●
Fasting blood sugar (FBS). Screen all apparently healthy adults who are 40 years old and above, or
those younger if with risk factors, using FBS. (Strong recommendation)3. Risk factors that should
prompt screening in younger patients include:
○ Overweight or obese
○ Maternal history of diabetes or having Gestational Diabetes Mellitus (GDM) during
pregnancy
○ Family history of type 2 diabetes in first- or second-degree relative
○ Signs of insulin resistance or conditions associated with insulin resistance (acanthosis
nigricans,
hypertension,
dyslipidemia,
polycystic
ovary
syndrome,
or
small-for-gestational-age birth weight)
Hemoglobin A1c (HbA1c). Consider using HbA1c as an alternative to FBS for screening. (Weak
recommendation)3.
Diagnostic Tests
●
Minimum at Primary Care.
○ In asymptomatic adults with initial positive screening test, confirm the diagnosis of DM
using any of the following tests: repeat FBS, repeat HbA1c, or 75-gram oral glucose
tolerance test (75 g OGTT). The diagnosis is confirmed if any of the following diagnostic
criteria are met2, 4,5:
■ FBS ≥126 mg/dL (7.0 mmol/L) after at least 8 hours of no caloric intake or
■ HbA1c ≥6.5% (48 mmol/mol) or
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Diagnostic Tests
2–hour postprandial plasma glucose after ingestion of 75 gram anhydrous
glucose load ≥ 200 mg/dL (11.1mmol/L)
○ In adults with classic symptoms of hyperglycemia or hyperglycemic crisis, confirm the
diagnosis of DM using a random plasma glucose (RPG) determination.
■ RPG ≥200 mg/dL (11.1 mmol/L) confirms the diagnosis in symptomatic patients 2,
4,5
.
○ If HbA1c is requested to confirm the diagnosis of DM, ensure the accuracy of the test by
having it performed in a laboratory that uses a method that is NGSP-certified and
standardized according to the Diabetes Control and Complications Trial (DCCT) assay
(Evidence B)4 or certified by the National Reference Laboratory (NRL).
○ Evaluate for diabetes complications and comorbid conditions by performing a
comprehensive diabetes medical evaluation, including comprehensive history taking,
physical examination (including visual acuity determination and foot examination), and
laboratory evaluation (Evidence A)4.
○ Perform cardiovascular risk assessment to identify and appropriately manage risk
factors.
Additional tests at Primary Care. Request for the following laboratory tests to assess for
comorbidities and complications:
○ Lipid profile (including LDL, HDL, triglycerides)
○ Liver function tests
○ Spot urinary albumin-to-creatinine ratio
○ Serum creatinine and estimated glomerular filtration rate (eGFR)
○ Serum potassium in patients who are being treated with ACE-inhibitors, ARBs, or
Diuretics, especially in patients with Chronic Kidney Disease
○ Screening for liver fibrosis in diagnosed T2DM patients with elevated ALT or fatty liver on
ultrasound (Evidence C)8
Other tests. Consider additional tests at higher level care facilities to assess for comorbidities and
complications:
○ Refer to an ophthalmologist for a comprehensive eye examination and diabetic
retinopathy screening.
○ Age- and sex-appropriate cancer screening tests
○ Consider periodic psychosocial screening and when there is a change in the disease,
treatment, or life circumstances of the patient (Evidence C)8
○ Consider screening for symptoms of sleep disorders and sleep disruptions in people with
diabetes (Evidence B)8.
■
●
●
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Treatment
●
●
●
Start treatment in all adults who are confirmed to have diabetes.
Glycemic Targets.
○ HbA1c Targets.
■ Target HbA1c of <7% (53 mmol/mol) in nonpregnant adults who have no
significant hypoglycemia (Evidence A)8
■ Consider targeting HbA1c of <8% (64 mmol/mol) in adults who have limited life
expectancy or when harms of treatment are greater than the benefits (e.g., if with
hypoglycemic episodes with more stringent sugar control) (Evidence B)8.
○ HbA1c Monitoring.
■ Monitor A1c according to the achievement of glycemic targets:
● If glycemic targets are met, do HbA1c at least 2 times a year (Evidence E)8
● If glycemic targets are not met or if the therapeutic regimen was
recently changed, assess HbA1c quarterly (Evidence E)8.
○ Capillary plasma glucose monitoring may be used as an alternative to HbA1c monitoring.
The following glycemic targets appear to correlate with a HbA1c of <7%8.
■ Preprandial capillary plasma glucose: 80–130 mg/dL (4.4–7.2 mmol/L)
■ Peak postprandial (taken 1-2 hours after the beginning of the meal) capillary
plasma glucose: <180 mg/dL (10.0 mmol/L)
Pharmacologic Therapy.
○ First line medications. Offer metformin, a biguanide, as the first-line oral medication for
T2DM8. Discontinue or avoid metformin in patients with eGFR <30 mL/min/1.73 m2.
○ Alternatives.
■ Consider initiating a dual-combination therapy or more potent glucose-lowering
drugs in patients who have A1C is ≥1.5-2% (>12.5 mmol/mol) above the glycemic
target. Options include:
■ Sulfonylureas (e.g., glimepiride, glipizide, glyburide)
■ Thiazolidinedione (e.g. Pioglitazone)
■ Dipeptidyl peptidase 4 (DPP-4) inhibitors (e.g. Linagliptin, Saxagliptin, Sitagliptin)
■ Sodium–glucose cotransporter 2 (SGLT2) inhibitors (e.g. Canaglifozin,
Empaglifozin, Dapaglifozin)
■ Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) (injectables) (e.g.
Exenatide, Semaglutide, Liraglutide)
■ Insulin
○ Additional considerations.
■ Offer SGLT-inhibitors or GLP-1 RAs to patients with T2DM and established
atherosclerotic cardiovascular disease, high cardiovascular risk, heart failure, or
established kidney disease, for their demonstrated cardiovascular and renal
benefits on top of glucose-lowering effects (Evidence A)9.
■ Metformin should be continued upon initiation of insulin therapy (unless
contraindicated or not tolerated) for ongoing glycemic and metabolic benefits
(Evidence A)9.
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Treatment
Combine insulin with GLP-1 RAs for greater efficacy, durability of treatment
effect, and weight and hypoglycemia benefit (Evidence A)9.
■ Consider factors such as the presence or cardiovascular and renal comorbidities,
efficacy of the medications, risk of hypoglycemia and other side effects, effect
on weight, cost and access, and patient preferences, when choosing among the
various pharmacologic therapies (Evidence E)9
○ Cardiovascular Risk Management
■ Primary Prevention. Offer the following primary prevention measures to patients
with diabetes to prevent the occurrence of atherosclerotic cardiovascular
disease (e.g., acute coronary syndrome/heart attack, stroke, etc.)
● Give a moderate-intensity statin to all patients with diabetes aged 40–75
years without atherosclerotic cardiovascular disease for primary
prevention (Evidence A)10
● Consider initiating statin therapy in people with diabetes aged 20-39
years old, with additional atherosclerotic disease risk factors (Evidence
C)10
● Consider giving Aspirin (75-162 mg/day) in those with diabetes who have
an increased cardiovascular risk based on CV risk assessment, after a
comprehensive discussion with the patient about the CVD prevention
benefit versus the comparable increased bleeding risk (Evidence A)10.
■ Secondary Prevention. Offer the following secondary prevention measures to all
patients who have diabetes and a history of atherosclerotic cardiovascular
disease.
● Give a high-intensity statin. (Evidence A)10
● Monitor and target LDL goal of less than 55 mg/dL. (Evidence B)
● Give Aspirin (75-162 mg/day) (Evidence A)10.
○ Diabetic retinopathy is not a contraindication to Aspirin use for
cardioprotection (Evidence A)8
● If patient has a documented Aspirin Allergy, give Clopidogrel 75 mg/day
(Evidence B)10
Nonpharmacologic Therapy
○ Medical nutrition therapy (MNT). Offer medical nutrition therapy among individuals with
diabetes to improve health, achieve and maintain body weight goals, attain glycemic,
blood pressure and lipid goals, and delay or prevent diabetes complications or refer to a
qualified dietician nutritionist.
○ Exercise. Teach individuals with diabetes to engage in at least 150 minutes or more of
moderate-vigorous intensity aerobic activity per week, over at least 3 days/week and with
no more than 2 consecutive days without activity (Evidence B)8.
■ Instruct patients to decrease sedentary behavior (Evidence B)8, interrupt
prolonged sitting every 30 minutes (Evidence C)8, and increase non sedentary
■
●
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Treatment
○
○
○
activities above baseline (e.g. walking, housework, gardening, swimming,
dancing, yoga) (Evidence B)8.
Weight loss. Advise patients with type 2 DM who are overweight or obese to target weight
loss of at least 5% using nutrition, physical activity, and behavioral therapy (Evidence B)8
Psychosocial Care. Provide psychosocial care using a collaborative, person-centered,
culturally-informed approach (Evidence A)8 or refer to a qualified mental health HCP for
targeted mental health interventions as indicated (Evidence B)8
Smoking and e-cigarette use/vape avoidance or cessation. (Evidence A)8, 11
Monitoring and follow-up
●
Consider scheduling follow-up at least every 3-6 months to monitor the effects of the therapeutic
regimen and medication-taking behavior (Evidence E)9.
○ Also review for occurrence and risk for hypoglycemia during each follow-up or clinical
encounter.
Referral
●
●
To specialists or higher levels of care. Refer the following patients to specialists or higher levels
of care:
○ Refer newly-diagnosed patients with DM to an ophthalmologist for an initial dilated and
comprehensive eye examination (Evidence B)8. Subsequent follow-up schedule with eye
specialists depends on the presence and severity of diabetic retinopathy.
○ Refer patients with DM for individualized MNT provided by a registered dietitian
nutritionist who is knowledgeable and skilled in providing diabetes-specific MNT.8
○ Patients with a history of prior lower-extremity complications, loss of protective
sensation, structural abnormalities (e.g . foot ulcers, Charcot foot), or peripheral arterial
disease (PAD) to foot care/vascular specialists (Evidence B)8
○ Patients needing more specialized assessment or treatment for symptoms of distress,
depression, suicidality, anxiety, treatment-related fear of hypoglycemia, disordered
eating and/or cognitive issues (Evidence B)8
○ Patients with sleep disturbance or suspected sleep disorders (Evidence B)8
○ Patients with uncontrolled neuropathic pain despite initial pharmacologic treatment
Immediate transfer to a higher level of care. Refer and immediately facilitate the transfer of
patients presenting with symptoms of hyperglycemic crisis or severe hypoglycemia to a hospital.
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First Aid Measures and Basic Emergency Care
●
●
Hypoglycemia. Recognize and immediately treat a patient presenting with signs and symptoms of
hypoglycemia (blood glucose <70 mg/dL).
○ Immediately check blood glucose in a diabetic patient presenting with symptoms of
hypoglycemia such as shakiness, irritability, confusion, hunger, and tachycardia. Severe
hypoglycemia can present as loss of consciousness, seizure or coma.
○ Immediately administer Glucose 15-20 mg orally if able to ingest food or drinks (e.g.
glucose tablets, soda, table sugar, candies) (Evidence B)8
○ Immediately check blood glucose in a diabetic patient presenting with symptoms of
hypoglycemia such as shakiness, irritability, confusion, hunger, and tachycardia. Severe
hypoglycemia can present as loss of consciousness, seizure or coma.
○ Immediately administer Glucose 15-20 mg orally if able to ingest food or drinks (e.g.
glucose tablets, soda, table sugar, candies) (Evidence B)8
Hyperglycemic crisis. Secure IV access, delivery of basic emergency care, and facilitate
immediate transfer of patients presenting with symptoms of hyperglycemic crisis (e.g., air hunger,
nausea, vomiting, abdominal pain, altered sensorium, polyuria, polydipsia, weakness).
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a
systematic analysis for the Global Burden of Disease Study 2019 [published correction appears in Lancet. 2020 Nov
14;396(10262):1562]. Lancet. 2020;396(10258):1204-1222. doi:https://doi.org/10.1016/S0140-6736(20)30925-9
World Health Organization. HEARTS D: diagnosis and management of type 2 diabetes. Published 2020. Accessed December 16, 2023.
https://www.who.int/publications/i/item/who-ucn-ncd-20.1
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX) Phase 3: Task Force on Renal, Metabolic, Nutrition, and Endocrine Disorders. Published 2023. Accessed December
16, 2023. https://drive.google.com/file/d/1jViG7Whi45tBVHADBKraV06mUnpKvnNS/view
American Diabetes Association. Classification and diagnosis of diabetes: Standards of medical care in diabetes—2021. Diabetes Care.
2021;44(Supplement 1):S15-S33. doi:https://doi.org/10.2337/dc21-s002
International Diabetes Federation. Type 2 diabetes. No date. Accessed December 16, 2023.
https://idf.org/about-diabetes/type-2-diabetes/
UpToDate. Diabetic retinopathy: Classification and clinical features. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/diabetic-retinopathy-classification-and-clinical-features?search=diabetic%20retinopathy&sou
rce=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#
UpToDate. Screening for diabetic polyneuropathy. 2023.
https://www.uptodate.com/contents/screening-for-diabetic-polyneuropathy?search=diabetic%20neuropathy%20symptoms&sectio
nRank=1&usage_type=default&anchor=H2&source=machineLearning&selectedTitle=1~150&display_rank=1#
American Diabetes Association. Standards of Care in Diabetes—2023 Abridged for Primary Care Providers. Clinical Diabetes. 2022;41(1).
doi:https://doi.org/10.2337/cd23-as01
ElSayed NA, Aleppo G, Aroda VR, et al. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2023.
Diabetes Care. 2022;46(Supplement_1):S140-S157. doi:https://doi.org/10.2337/dc23-s009
ElSayed NA, Aleppo G, Aroda VR, et al. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2023. Diabetes
Care. 2022;46(Supplement_1):S158-S190. doi:https://doi.org/10.2337/dc23-s01
UpToDate. Type 2 diabetes mellitus: Prevalence and risk factors. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/type-2-diabetes-mellitus-prevalence-and-risk-factors?search=diabetes%20mellitus%20type%
202&source=search_result&selectedTitle=13~150&usage_type=default&display_rank=12#H10
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Dyslipidemia
is a known risk factor for cardiovascular disease. It can also co-exist with other risk factors for CVD, including
diabetes mellitus, overweight/obesity, metabolic syndrome, and hypertension 1, 2, 3. Dyslipidemia ranks second
among the top risk factors among Filipinos for cardiovascular related diseases [1,194 disability-adjusted life
years (DALYs) per 100,000]4. The primary and secondary prevention of CVD involves adequate recognition of
risk factors, diagnosis of dyslipidemia, and management of cholesterol levels through a combination of
pharmacologic and nonpharmacologic measures.
Table 19. Dyslipidemia Continuum of Care Overview
Dyslipidemia Overview
Risk Factors
Overweight or obesity
Diabetes mellitus
Metabolic syndrome
Alcoholism
Hypothyroidism
Kidney disease (e.g. nephrotic syndrome)
Liver Disease
Prevention
Healthy diet, exercise and physical activity, weight management (See General
Wellness and Preventive Measures for general guidance)
Screening
Fasting lipid profile in adults 40 years and above with at least one cardiovascular
risk factor
Diagnosis
Dyslipidemia is present if lipid profile shows:
● LDL-C ≥ 130 mg/dl;
● HDL-C <40 mg/dL in males and <50 mg/dL in females;
● TG ≥ 150 mg/dL
Source:NCEP, 20015
Pharmacologic Treatment
First-line therapy. Statins
Second-line therapies. Fibrates, ezetimibe, pure eicosapentaenoic acid (EPA)
Treatment intensity should be adjusted according to LDL-C goals. See Statin
Initiation and Titration Guide .
Non-pharmacologic
management
Low fat, low cholesterol diet, rich in fruits and vegetables
Adequate exercise
Weight management
Smoking/vaping avoidance/cessation
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Signs and Symptoms
●
Consider dyslipidemia among adult patients with the following:
alcoholism,
○ Overweight or obesity, diabetes mellitus, metabolic syndrome,
1,6
hypothyroidism, kidney disease such as nephrotic syndrome, or liver disease.
○ Presence of arcus cornealis (before 45 years of age), tendon xanthoma and xanthelasma.
(Recommended1); (Strong recommendation2)
Screening
●
Screen for dyslipidemia in asymptomatic adults 40 years and above with at least one
cardiovascular risk factor (e.g., Diabetes mellitus, hypertension, history of smoking) using a lipid
profile test (Conditional recommendation3).
Diagnostic Tests
●
●
Minimum at primary care.
○ Confirm the diagnosis of dyslipidemia if the lipid profile tests shows any of the following
NCEP 5:
■ LDL-C ≥ 130 mg/dl;
■ HDL-C <40 mg/dL in males and <50 mg/dL in females;
■ TG ≥ 150 mg/dL
○ Perform thorough history and physical examination in all individuals diagnosed with
dyslipidemia to assess primary and/or secondary causes of dyslipidemia. Primary causes
include Familial Hypercholesterolemia (FH) while secondary causes include diabetes
mellitus, hypothyroidism, Cushing syndrome, alcoholism, etc. Request for additional
tests if clinically indicated.
Additional tests.
○ Consider requesting for liver transaminases in patients at risk of liver injury prior to
initiating statin therapy and 1 to 3 months after (MOH).6
○ Consider requesting for creatine kinase if myositis is suspected after initiating statin
therapy (MOH).6
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Omnibus Health Guidelines ver. 2023 | 142
Treatment
●
●
●
First line pharmacologic therapy. Initiate statin therapy (see Statin Initiation and Titration Guide2)
among adults with dyslipidemia as follows:
○ Elevated LDL with risk factors but without atherosclerotic cardiovascular disease.
Prescribe low to medium intensity statin among adults without diabetes mellitus age ≥ 45
years with LDL-C ≥ 130 mg/dL and ≥ 2 risk factors (male sex, postmenopausal women,
smoker, hypertension, BMI > 25 kg/m2, with family history of premature cardiovascular
disease, proteinuria, and left ventricular hypertrophy) without atherosclerotic
cardiovascular disease (ASCVD) to reach LDL-C goal of <130 mg/dL. (Recommended)1
○ Diabetes mellitus. Prescribe moderate to high intensity statin among adults with
diabetes mellitus and optimize therapy to reach the following LDL-C goals:
(Recommended) 1
■ <100 mg/dL among most adults with diabetes and without evidence of ASCVD
■ <70 mg/dL among adults with diabetes and with >1 risk factor or target organ
damage
■ <55 mg/dL among adults with diabetes and at high risk of recurrent
cardiovascular events
○ Suspected or confirmed familial hypercholesterolemia (FH). Give statin therapy to all
adults suspected or confirmed to have familial hypercholesterolemia (FH) to reach the
following LDL-C goals: (Strongly Recommended)1
■ FH without ASCVD: <70 mg/dL
■ FH with ASCVD and risk factors: LDL <55 mg/dL
○ Chronic Kidney Disease. Give statin therapy to adults with Chronic Kidney Disease not on
dialysis. (Recommended)1
○ Acute coronary syndrome. Immediately initiate early high intensity statin therapy and
continue among adults with acute coronary syndrome to reach the goal of LDL-C <55
mg/dL. (Recommended)1
Other therapies. The following patient groups may benefit from additional therapies:
○ Hypertriglyceridemia. Consider prescribing fibrates to adults with persistently high
triglycerides (>200 mg/dL) with low HDL-C (<35 mg/dL) and to men with controlled
diabetes1
○ Persistently high triglycerides but at goal LDL-C. May consider prescribing omega fatty
acids (pure eicosapentaenoic acid [EPA]) to adults with ASCVD on statin therapy at goal
LDL-C, but with persistently high triglyceride levels of 135-499 mg/dL1
○ Persistently elevated LDL-C despite maximally-tolerated statin therapy. Prescribe
ezetimibe in addition to maximally tolerated statin therapy to adults with ASCVD and have
not reached LDL-C goal as secondary prevention of cardiovascular disease.
(Recommended)1
Non-pharmacologic therapies. Advice adults at any level of cardiovascular risk on the following:
○ Low fat, low cholesterol diet, rich in fruits and vegetables. (Recommended)1,
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Treatment
○
○
Cigarette smoking and vaping cessation (Cigarette Smoking Cessation: Strongly
Recommended, Vaping Cessation: Recommended)1,
Advice adequate exercise of approximately 150 minutes of moderate- to high-intensity
exercise per week to adults capable of exercise after assessing functional capacity.
(Recommended)1,
Referral
●
●
Refer to a specialist/higher level of care if lipid goals are not met despite uptitration of statin to
maximally tolerated dose and good patient adherence to therapy, or if the patient has other
comorbidities needing specialty care (e.g., atherosclerotic cardiovascular disease).
Consider referring adults who are incapable of safely performing moderate to high intensity
exercise to the next level of care.1,
References
1.
2.
3.
4.
5.
6.
Philippine Lipid and Atherosclerosis Society. Clinical Practice Guidelines for the Management of Dyslipidemia in the Philippines.
Published 2020. Accessed December 13, 2023. https://drive.google.com/file/d/1-_k8Uk9Lct56jT5T8xUcFQZoBAv_z8VL/view
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX): Screening for Cardiovascular Disease. Published 2021. Accessed December 13, 2023. .
https://drive.google.com/file/d/1LyjMZhD0hAh2DJI6ta-IUPEDZacI8yow/view
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX): Phase 1. Published 2021. Accessed December 13, 2023.
https://drive.google.com/drive/u/1/folders/1UXFurxj0dLH1J-Ua1KmrYaTuky7pON8Z
GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a
systematic analysis for the Global Burden of Disease Study 2019 [published correction appears in Lancet. 2020 Nov
14;396(10262):1562]. Lancet. 2020;396(10258):1204-1222. doi:https://doi.org/10.1016/S0140-6736(20)30925-9
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of
the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in
Adults (Adult Treatment Panel III). JAMA: The Journal of the American Medical Association. 2001;285(19):2486-2497.
doi:https://doi.org/10.1001/jama.285.19.2486
Ministry of Health - Malaysia. 5th Edition of Clinical Practice Guidelines: Management of Dyslipidaemia. Putrajaya, Malaysia. Published
2017. Accessed December 13, 2023. https://www.moh.gov.my/moh/resources/Penerbitan/CPG/CARDIOVASCULAR/4.pdf
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Generalized Anxiety Disorder
is characterized by persistent and excessive worry about a number of different things that are difficult to
control. It occurs more days than not for at least 6 months. It can cause significant impairments in daily
functioning, and diminished quality of life.1 It is considered as one of the world’s most common mental health
disorders, affecting 301 million people in 2019, which is mostly women rather than men. In 2019, Anxiety
Disorder contributed to 1.45% of DALYs among Filipinos.2 With the increase in the global anxiety prevalence,
this represents a significant threat to the population's well-being and quality of life. Symptoms often have
early onset during childhood or adolescence. But with early detection, there are available highly effective
treatments.3
Table 20. Generalized Anxiety Disorder Continuum of Care Overview
Generalized Anxiety Disorder Overview
Risk Factors
Screening
Diagnosis
Pharmacologic Treatment
Non-pharmacologic
management
Age
Gender
Socioeconomic Status
Substance Abuse
Genetic factor
Environmental Change
Standardized instrument: GAD-7, GAD-2, or Hospital Anxiety and Depression
Scale-Anxiety (HADS-A) once a year
Diagnose according to the Diagnostic and Statistical Manual of Mental Disorders
5th Edition (DSM-5) Criteria
First-line:
1. Cognitive behavior therapy (CBT)
2. Selective serotonin reuptake inhibitor
or selective norepinephrine reuptake inhibitor
Lifestyle modification such as healthy eating habits, having good sleep, regular
exercise and reduced intake of caffeine, tobacco, nicotine, and alcohol
Community-based drug rehabilitation programs (e.g. Katatagan, Kalusugan, at
Damayan ng Komunidad)
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Signs and Symptoms
●
Consider the presence of an anxiety disorder among adult patients with the following4,5:
○ Excessive anxiety, fear or worry about events or activities that are out of proportion to the
situation or difficult to control occurring more days than not in the past six months and
causes impairment of functioning.
○ Symptoms are often associated with three or more physical symptoms such as
restlessness or feeling keyed up or on edge, easily fatigued, difficulty concentrating or
mind going blank, irritability, muscle tension, or sleep disturbance.
Screening
●
●
Screen adults for Generalized Anxiety Disorder using standardized instruments such as GAD-7,
GAD-2, or Hospital Anxiety and Depression Scale-Anxiety (HADS-A) once a year (Strong
recommendation)6. This screening may be incorporated in annual health visits.
Screen for anxiety among pregnant adults and during postpartum period. (Recommended)7
Diagnostic Tests
●
Minimum at primary care. Diagnose general anxiety disorder among adults using the following
criteria from the Diagnostic and Statistical Manual of Mental Disorders 5th Edition 4,5:
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at
least six months, about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with
at least some symptoms having been present for more days than not for the past six months):
1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (eg, a drug of
abuse, a medication) or another medical condition (eg, hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (eg, anxiety or worry about
having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social
phobia], contamination or other obsessions in OCD, separation from attachment figures in
separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder,
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Diagnostic Tests
●
●
gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived
appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder,
or the content of delusional beliefs in schizophrenia or delusional disorder). Because the majority
of the anxiety symptoms are not specific to GAD, it is important to exclude the other anxiety
disorders before making the diagnosis.
Consider assessing adults with anxiety disorders for self-harming behaviors and suicidal
ideations.8
Additional laboratory tests at primary care.
○ Consider requesting laboratory tests as warranted, such as thyroid function tests,
complete blood count, 12 lead electrocardiogram, to rule out other medical conditions.4,5
Treatment
●
●
●
First-line Management. Offer the following first-line interventions for 4-6 weeks after shared
decision-making with the patient and his/her family4, 5;8,9:
○ Monotherapy using either:
■ Cognitive behavior therapy (CBT);
■ Pharmacotherapy with selective serotonin reuptake inhibitor (such as Citalopram
10mg tablet, Escitalopram 5 to 10mg tablet, Sertraline 25 to 50mg tablet,
Paroxetine 10 to 20 mg tablet, Fluoxetine 10 to 20 mg capsule, or Fluvoxamine 50
mg tablet) or selective norepinephrine reuptake inhibitor (such as Venlafaxine 75
mg capsule, or Duloxetine 30 mg capsule) starting at low dose;
○ Combination therapy using CBT and pharmacotherapy
○ Consider CBT for pregnant and nursing adult women with anxiety (Consensus-based
Recommendation)8
Alternative Pharmacotherapy.
○ Consider the following medications as alternative to first line medications: Mirtazapine 15
mg tablet or Quetiapine 25 to 50 mg tablet.5
○ Consider the following medications as augmentation of treatment: Buspirone 10 mg
tablet, Gabapentin 300 mg tablet, Pregabalin 50 mg tablet in divided doses, or
Hydroxyzine 50 mg tablet.5
Other Non-pharmacologic Therapy. Consider offering the following advice to improve symptoms:
○ Lifestyle modification such as healthy eating habits, having good sleep, regular exercise
and reduced intake of caffeine, tobacco, and alcohol (Consensus-based recommendation)
8
○
○
Yoga, tai chi, meditation, spiritual activities, music therapy, aromatherapy, acupuncture
or massage as additional management to adults with anxiety.4,10
Cessation of cigarette smoking and vaping (Cigarette Smoking Cessation: Strongly
Recommended, Vaping Cessation: Recommended)1.
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Treatment
○
Development of a safety plan among adults with anxiety who have self-harmed or at risk
of suicide.12
Referral
●
Refer the following adults to mental health specialists or higher level of care4,8,13:
○ With significant physical or mental health comorbidities such as personality disorder,
substance use or misuse disorder
○ With learning disability or cognitive impairment
○ With marked functional impairment or self-neglect
○ With history of self-harm or with suicidal or self-harm intentions
○ With poor response to treatment.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Anxiety & Depression Association of America. Generalized Anxiety Disorder (GAD) . Adaa.org. Published 2019. Accessed December 16,
2023. https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad
GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a
systematic analysis for the Global Burden of Disease Study 2019 [published correction appears in Lancet. 2020 Nov
14;396(10262):1562]. Lancet. 2020;396(10258):1204-1222. doi:https://doi.org/10.1016/S0140-6736(20)30925-9
World Health Organization. Anxiety disorders. www.who.int. Published September 27, 2023. Accessed December 16, 2023.
https://www.who.int/news-room/fact-sheets/detail/anxiety-disorders
DeGeorge KC, Grover M, Streeter GS. Generalized Anxiety Disorder and Panic Disorder in Adults. American Family Physician.
2022;106(2):157-164. Accessed December 16, 2023.
https://www.aafp.org/pubs/afp/issues/2022/0800/generalized-anxiety-disorder-panic-disorder.html
UpToDate. Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and
diagnosis. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/generalized-anxiety-disorder-in-adults-epidemiology-pathogenesis-clinical-manifestations-cou
rse-assessment-and-diagnosis?search=generalized%20anxiety%20disorder&source=search_result&selectedTitle=1~150&usage_type
=default&display_rank=1#
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX): Screening for Mental Health and Addiction. Published 2021. Accessed December 16, 2023. .
https://drive.google.com/file/d/1Nq-QO0UYMh0MiLWeKmO8CSdcuZyFdlbg/view
U.S. Preventive Services Task Force. Recommendation: Anxiety Disorders in Adults: Screening | United States Preventive Services
Taskforce. www.uspreventiveservicestaskforce.org. Published June 20, 2023. Accessed December 16, 2023.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/anxiety-adults-screening#bootstrap-panel--12
Andrews G, Bell C, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the
treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Australian & New Zealand Journal of Psychiatry.
2018;52(12):1109-1172. doi:https://doi.org/10.1177/0004867418799453
Mazza, D., Brijnath, B., Chakraborty, S.P. and the Guideline Development Group. Clinical guideline for the diagnosis and management of
work-related mental health conditions in general practice. Melbourne: Monash University; 2019.
https://www.racgp.org.au/FSDEDEV/media/documents/Clinical%20Resources/Guidelines/Mental%20health/Work-related-mental-he
alth-conditions-in-general-practice.pdf
UpToDate. Complementary and alternative treatments for anxiety symptoms and disorders: Physical, cognitive, and spiritual
interventions. 2023.
https://www.uptodate.com/contents/complementary-and-alternative-treatments-for-anxiety-symptoms-and-disorders-physical-cog
nitive-and-spiritual-interventions?search=generalized%20anxiety%20disorder&topicRef=101879&source=see_link#H5472412
Philippine Lipid and Atherosclerosis Society. Clinical Practice Guidelines for the Management of Dyslipidemia in the Philippines.
Published 2020. Accessed December 13, 2023. https://drive.google.com/file/d/1-_k8Uk9Lct56jT5T8xUcFQZoBAv_z8VL/v
U.K. National Institute for Health and Care Excellence. Overview | Self-harm: Assessment, management and preventing recurrence |
Guidance | NICE. www.nice.org.uk. Published September 7, 2022. Accessed December 16, 2023.
https://www.nice.org.uk/guidance/NG225
U.K. National Institute for Health and Care Excellence. Recommendations | Generalised anxiety disorder and panic disorder in adults:
management | Guidance | NICE. www.nice.org.uk. Published June 15, 2020. Accessed December 16, 2023.
https://www.nice.org.uk/guidance/cg113/chapter/Recommendations
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Hepatocellular Carcinoma
is a primary tumor of the liver and constitutes more than 90% of the primary tumors of the liver. It occurs in
approximately 85% of patients diagnosed with cirrhosis. HCC is now the fifth most common cause of cancer
worldwide1 and is the fourth leading cause of cancer-related deaths in the world, according to the World
Health Organization GLOBOCAN database2. According to recent data from the Philippine Statistics Authority,
liver diseases accounted for 27.3 cases per 1000 deaths in the country in 2020. Liver cancer is the fourth
most common cancer type after breast, lung and colon cancer and the second most common cause of
cancer deaths. The calculated incidence rate for liver cancer in the country is 11.4 and the mortality rate of
10.8 per 100,000. The most common cause of HCC in the country is still chronic hepatitis B infection.3
The prognosis of patients with HCCA remains poor, with a five-year survival rate of 18 percent. Because it is
frequently diagnosed late due to the absence of symptoms in patients with early disease, and the lack of
surveillance for high-risk patients, screening is essential. The goal is to detect the tumors early when they
are ≤2 cm in size to improve survival since the five-year survival rate of patients whose tumors are detected
at an early stage and who receive proper treatment exceeds 70 percent.2,4
Table 21. Hepatocellular Carcinoma Continuum of Care Overview
Hepatocellular Carcinoma Overview
Risk Factors
Prevention
Screening
Diagnosis
Treatment and Referral
Gender
Race/ Ethnicity
Chronic infection with HBV, or HCV
Liver Cirrhosis
Non alcoholic fatty liver disease
Excessive alcohol consumption
Smoking
Inherited Metabolic Diseases
Screening and treatment of hepatitis B/C infection
Avoidance of excessive alcohol consumption
Liver Ultrasound with alpha fetoprotein every 6 months among adults at risk
Multiphasic, contrast- enhanced CT Scan of the Liver
Refer adults with hepatocellular carcinoma to the higher level of care for
appropriate management
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Signs and Symptoms
●
Signs and Symptoms. Suspect hepatocellular carcinoma (HCCA) among adults with liver cirrhosis
with or without signs and symptoms of liver decompensation such as variceal bleeding or ascites,
adults with palpable mass in the upper abdomen, weight loss, or early satiety.4
Screening
●
Screen the following adults at risk of HCCA using liver ultrasound with alpha-fetoprotein every 6
months. (Strong recommendation5):
○ hepatitis B and/or C infection
○ family history of hepatocellular carcinoma
○ metabolic diseases
○ non-alcohol/ alcohol liver disease
○ prolonged heavy alcohol consumption
○ Smokers x
○ males aged 40 years and above
Diagnostic Tests
●
●
Minimum at Primary Care. Refer to higher level of care or a capable facility for confirmation of
diagnosis using multiphasic, contrast-enhanced CT scan to diagnose hepatocellular carcinoma
among adults. (Strong recommendation)6
Other Laboratory Tests.
○ Consider requesting for bilirubin, liver aminotransferases, alkaline phosphatase,
complete blood count with platelet count, prothrombin time, albumin, hepatitis B and C
serology, blood urea nitrogen and creatinine.4
○ Refer to higher levels of care for further diagnostic work-up, including:
■ Contrast-enhanced MRI, should be available, to diagnose hepatocellular
carcinoma among adults. (Strong Recommendation)6
■ Core needle biopsy to adults who do not fulfill the imaging criteria such as small
size of the lesion or cirrhotic liver. (Strong Recommendation)6
■ Fine needle aspiration biopsy to adults wherein core needle biopsy cannot be
done and adults who do not fulfill the imaging criteria such as small size of the
lesion or cirrhotic liver. (Conditional Recommendation6)
Treatment and Referral
●
Refer adults with hepatocellular carcinoma to the higher level of care for appropriate treatment7
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Treatment and Referral
●
●
●
●
●
For Supportive and Palliative Care: Advise referral of patients and their families to provision of
health systems support interventions at any point in the course of illness to address8
Financial support: Cancer patients, persons living with cancer and cancer survivors are
considered persons with disabilities (PWDs) and are accorded the same rights, privileges, social
welfare and benefits as other PWDs.8,9,10,11,12,13
Palliative care: Cancer patients and families of patients that need palliative support may consult
with/ may be referred to accredited associations and institutions handling hospice and palliative
care14
Psychosocial needs: Cancer patients and families of patients that need psychosocial support may
consult with/ may be referred to support groups, associations and institutions handling
psychosocial care.14,15,16
Pain and symptom management: Medical professionals caring for cancer patients may consult the
WHO Analgesic Ladder and the DOH Cancer Pain Relief Program for guidance on pain management
and referral.17
○ End-of-life care concerns: Cancer patients who are contributors and their families are
eligible to apply for illness, disability, and funeral benefit claims from SSS and GSIS8,12,13
References
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2.
3.
4.
5.
6.
7.
8.
9.
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11.
12.
13.
14.
15.
16.
17.
18.
Asafo-Agyei KO, Samant H. Hepatocellular Carcinoma. [Updated 2023 Jun 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559177/
World Health Organization. Global Cancer Observatory. Iarc.fr. Published 2020. Accessed December 17, 2023. https://gco.iarc.fr/
Ornos ED, Murillo KJ, Ong JP. Liver diseases: Perspective from the Philippines. Ann Hepatol. 2023;28(3):101085.
doi:https://doi.org/10.1016/j.aohep.2023.101085
UpToDate. Clinical features and diagnosis of hepatocellular carcinoma. Published 2023. Accessed December 17, 2023.
https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-hepatocellular-carcinoma
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX): Screening for Neoplastic Diseases. Published 2021.
https://drive.google.com/file/d/1oMATzGvpulZZrarfVktgVJzNt_7eavH4/view
UpToDate. Epidemiology and risk factors for hepatocellular carcinoma. Published 2023. Accessed December 17, 2023.
https://www.uptodate.com/contents/epidemiology-and-risk-factors-for-hepatocellular-carcinoma?search=hepatocellular%20carcin
oma&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=6#H2020279294
Department of Health. Philippine Clinical Practice Guideline for the Diagnosis and Management of Hepatocellular Carcinoma. Published
2021. Accessed December 16, 2023. https://drive.google.com/file/d/1jsxkDiqNgDw4353N2Ivl81waBHmmCsaY/view
UpToDate. Overview of treatment approaches for hepatocellular carcinoma. Published 2023. Accessed December 17, 2023.
https://www.uptodate.com/contents/overview-of-treatment-approaches-for-hepatocellular-carcinoma?search=hepatocellular%20ca
rcinoma&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#
Republic Act No. 11215 "National Integrated Cancer Control Act"
Republic Act No. 7277 “Magna Carta for Disabled Persons, and for Other Purposes”
Department of Health & Department of Budget and Management. DOH-DBM Joint Memorandum Circular 2022-002: Implementing
Guidelines for the Use of Cancer Assistance Fund (CAF). Published 2022. Accessed December 17, 2023.
https://www.dbm.gov.ph/wp-content/uploads/Issuances/2022/Joint-Memorandum-Circular/DOH-DBM-Joint-Memorandum-CircularNo-2022-0002.pdf
Department of Labor and Employment. DOLE Labor Advisory No. 20: Guidelines on the Implementation of the Workplace Policy and
Program on Cancer Prevention and Control in the Private Sector. Published 2023. Accessed December 17, 2023.
https://oshc.dole.gov.ph/wp-content/uploads/2023/10/LA-20-series-of-2023.pdf
Social Security System. SSS Benefits Overview. N.d. Accessed December 17, 2023.
https://www.sss.gov.ph/sss/appmanager/pages.jsp?page=ssbenefits
Government Service Insurance System. Policy and Procedural Guidelines No. 274-14. Published 2016. Accessed December 17, 2023.
https://www.gsis.gov.ph/downloads/ppg-br/20160304-PPG-274-14.pdf
Philippine Cancer Society. Hospice Groups. N.d. Accessed December 17, 2023.
https://www.philcancer.org.ph/index.php/support/hospice-groups
Silakbo PH. Mental Health Resources. N.d. Accessed December 17, 2023. http://www.silakbo.ph/help/
MentalHealthPH. Directory. N.d. Accessed December 17, 2023. https://mentalhealthph.org/directory/
Department of Health. The Philippine Cancer Control Program. N.d. Accessed December 17, 2023.
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https://doh.gov.ph/sites/default/files/health_programs/The-Philippine-Cancer-Control-Program.pdf
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Hypertension
is defined as the presence of an office blood pressure (BP) of 140/90 mm Hg or above, typically at least
twice taken on 2 separate days 1. It is a common disorder affecting Filipinos with an estimated prevalence of
19.2% among adults in 2018. Hypertension is an important risk factor for other cardiovascular diseases
including ischemic heart disease (IHD), heart failure (HF), stroke, chronic kidney disease (CKD), and peripheral
arterial disease. IHD, stroke, and CKD are among the top 10 causes of mortality and morbidity in our country.
Hence, the early detection and appropriate management of hypertension are public health priorities.
Because individuals tend to have multiple risk factors for cardiovascular diseases, it is important that
primary providers perform an overall assessment of cardiovascular disease risk in hypertensive patients and
patients at risk of developing hypertension and create an individualized plan to address all CV risk factors.
Table 22. Hypertension Continuum of Care Overview
Hypertension Overview
Risk Factors
●
●
●
●
Prevention
Healthy diet, limitation of sodium intake, exercise and physical activity, weight
management (See General Wellness and Preventive Measures for general guidance)
Screening
Office BP measurements. Use standardized BP measurement protocol at every clinic
visit.
History and PE. Screen for other cardiovascular risk factors, secondary causes of
hypertension.
A single BP measurement is not enough to confirm the diagnosis of hypertension.
Confirm diagnosis using any of the following confirmatory methods:
● Ambulatory BP monitoring (preferred)
● Home BP monitoring (HBPM)
● Repeat Office BP measurement (OBPM) using standardized BP measurement
protocol
Request for basic laboratory tests: 12 -L ECG, FBS, Lipid Profile, Serum Creatine,
Sodium, Potassium, GFR
BP reduction to <130/80 mmHg in most hypertensive patients
First-line. Angiotensin-converting enzyme inhibitors (ACEI), Angiotensin-receptor
blockers (ARB), Calcium channel blockers (CCBs), Thiazide/Thiazide-like diuretics
(TZD/TZDL) (as monotherapy or in combination)
Dosing should be titrated according to BP response and BP targets
● Sodium intake <1500 mg/day
● Healthy diet
● Regular exercise
● Weight loss >5% in those who are overweight or obese
● Avoid or moderate alcohol intake
● Stop/avoid smoking
Diagnosis
Therapeutic Goal
Pharmacologic
Treatment
Non-pharmacologic
management
Age
Obesity and weight gain
High dietary sodium intake
Low dietary calcium and potassium
intake
●
●
●
●
●
Smoking/vaping
Alcohol consumption
Low levels of physical activity
Psychosocial stress
Genetics
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Signs and Symptoms
●
Most hypertensive individuals are asymptomatic, leading to complacency and poor adherence to
medical management. Therefore, primary care providers should:
○ Ensure that all adults are well-informed about the consequences of untreated
hypertension.
○ Observe due diligence in eliciting signs and symptoms of hypertensive complications or
hypertension-mediated organ damage (HMOD) such as the following2:
■ Brain and eyes: headache, vertigo, syncope, impaired vision, transient ischemic
attack, sensory or motor deficit, stroke, carotid revascularization, cognitive
impairment, dementia (in the elderly)
■ Heart: chest pain, shortness of breath, oedema, myocardial infarction, coronary
revascularization, syncope, history of palpitations, arrhythmias (especially AF),
heart failure
■ Kidney: thirst, polyuria, nocturia, haematuria, urinary tract infections
■ Peripheral arteries: cold extremities, intermittent claudication, pain-free walking
distance, pain at rest, peripheral revascularization
Screening
●
●
Office BP measurement
○ Screen all adult Filipinos for hypertension through office BP measurement using a
properly validated automated/digital/electronic oscillometric device with an
appropriately-sized cuff during each clinic visit.1,2,3 If no automated oscillometric device
is available, consider using a manual sphygmomanometer in office BP measurement
Office BP Measurement with an appropriately-sized upper arm cuff, according to the
Standard BP Measurement Protocol.1
○ Perform office BP measurement using the Standard Office BP Measurement Protocol 4
Cardiovascular disease (CVD) risk assessment
○ Obtain comprehensive history and cardiovascular disease risk assessment using the WHO
CVD Risk Charts 5 or other validated CV risk assessment tools/calculators (e.g. ASCVD risk
calculator).
Diagnostic Tests
●
Minimum at Primary Care. Confirm the diagnosis of hypertension through any of the following
methods, depending on the availability and patient values/preferences:
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Diagnostic Tests
Out of office BP Measurement: Ambulatory blood pressure monitoring (ABPM) (preferred
method if available, gold standard) (Recommended)1
○ Out of office BP Measurement: Home BP monitoring (HBPM) (Recommended)1
○ Office BP Measurement (OBPM): Repeat office BP measurements on succeeding visit1
Note that a single measurement of blood pressure is not enough to confirm the diagnosis of
hypertension due to the phenomena of white coat hypertension and masked hypertension.
■ Use the following BP classification for adult Filipinos (Recommended)1
● Normal: BP <120/80 mmHg
● Borderline: BP 120-139/80-89 mmHg
● Hypertension: BP more than or equal to 140/90 mmHg
Additional tests at primary care. Perform basic laboratory testing in hypertensive patients to
search for HMOD and important comorbidities, ideally within 1 month from the confirmation of the
diagnosis of hypertension in an adult patient 2,3,6 :
■ 12-lead ECG - to screen for LVH and other cardiac abnormalities and, document
baseline heart rate and rhythm
■ Fasting blood glucose - to screen for Diabetes Mellitus
■ Lipid profile - to determine baseline lipid levels and guide cardiovascular risk
reduction (primary or secondary prevention) strategy
■ Serum Creatinine, estimated Glomerular Filtration Rate (eGFR), sodium,
potassium - to detect possible renal disease and electrolyte abnormalities that
can affect choice of anti-hypertensive drugs
■ Dipstick Urine test or urinary albumin/creatinine ratio - to detect possible renal
disease and guide choice of anti-hypertensive treatment
Additional tests at a higher level of care.
○ Perform additional tests, such as the following if Hypertension-Mediated Organ Damage
(HMOD) is strongly suspected 2,3. Alternatively, facilitate referral to a higher level of care as
necessary.
■ Renal Ultrasound (US)
■ Echocardiography
■ Brain Imaging
■ Ankle Brachial Index (ABI)
■ Carotid Imaging
■ Retinal Exam
○
●
●
Treatment
●
Start treatment in all adults who are confirmed to have hypertension through any of the previously
mentioned confirmatory methods (ABPM, HBPM, OBPM).
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Treatment
●
●
BP Target.
○ Target to control the BP of hypertensive adults, including individuals with diabetes or
chronic kidney disease or history of stroke, to a goal BP of <130/80 mmHg
(Recommended)1.
○ Avoid lowering systolic BP to less than 120 mmHg and diastolic BP to less than 70 mmHg in
patients with hypertension and concomitant coronary artery disease.
Non-pharmacologic therapy. Advise all patients who have hypertension or pre-hypertension to
observe the following (Recommended)1:
○ Limit sodium intake to less than 1500 mg/day (approximately equivalent to less than ¾
teaspoon of salt)
○ Adhere to a healthy dietary pattern, guided by the Dietary Approaches to Stop
Hypertension (DASH) meal plan7 and PInggang Pinoy8.
○ Perform moderate to vigorous aerobic physical activities, consisting of at least 150
minutes per week of accumulated moderate-intensity physical activity or 75 minutes per
week of vigorous-intensity physical activity, unless medically contraindicated, and
dynamic resistance exercises 1, 9.
○ Maintain body weight between recommended limits10
■ For obese or overweight adults, target weight loss of least 3% of baseline weight
1.1
●
○ Avoid alcohol intake or drink in moderation.
○ Stop/avoid smoking/vaping.
First line pharmacologic therapy.
○ Offer pharmacologic treatment in all patients with hypertension. The following are the
first-line antihypertensive drugs and can be used as monotherapy (one drug in one pill) or
in combination (at least two drugs) (Recommended)1.
■ Angiotensin-converting enzyme inhibitors (ACEI) (e.g., Enalapril, Captopril,
Lisinopril, etc., )
■ Angiotensin-receptor blockers (ARB) (e.g., Telmisartan, Valsartan, Losartan., etc.)
■ Calcium channel blockers (CCBs) (e.g., Amlodipine, Felodipine, etc.,)
■ Thiazide/Thiazide-like diuretics (TZD/TZDL) (e.g., Hydrochlorothiazide,
Chlorthalidone, etc.)
■ If using combination-therapy, the following may be combined (2 drugs in one pill
or free combinations) (Recommended, PSH 2020):
■ ACEI + CCB
■ ACEI + TZD/TZDL
■ ARB + CCB
■ ACEI + TZD/TZDL
○ Other combination therapies may be used if with compelling indications.
■ Use an ACEI or ARB as first-line medication for CKD patients with urinary
albumin-to-creatinine ratio more than or equal to 30 mg/g (or equivalent)
(Recommended)1. Administer the antihypertensive medication at bedtime.
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Treatment
Prioritize the use of the following BP-lowering drug classes for specific types of
hypertensive patients with coronary artery disease 2,3:
● For patients with a history of heart attack/myocardial infarction:
beta-blockers and RAS blockers (ACEI or ARB):
● For patients with angina but no prior history of heart attack/myocardial
infarction: beta blockers and/or CCBs
● Prioritize the use of an ACE inhibitor or ARB, and a beta-blocker and
diuretic and/or mineralocorticoid receptor antagonist in the treatment
of Hypertension in a patient diagnosed with Heart Failure with reduced
Ejection Fraction (HFrEF) 2,3
○ Titrate the dosing of medications and add additional first-line drugs as needed to lower
BP and achieve BP targets (see sample Titration Guide).
Special considerations in administering anti-hypertensive medications
○ Do not combine ACEIs with ARBs or ACEIs and ARBs with direct renin inhibitors.1
○ In hypertensive women who are of reproductive age and without consistent
contraception, perform a pregnancy test to rule out pregnancy prior to the initiation of
ACE inhibitors, ARBs, or thiazide diuretics.
○ Discontinue ACEI or ARB and shift to a non-dihydropyridine CCB (Diltiazem or Verapamil) if
a hypertensive patient with CKD develops any of the following:
■ Serum creatinine level increases by 30 % over baseline during the first two
months of treatment.
■ Hyperkalemia (K+ more than or equal to 5.6 mmol/L).
■ Adverse effects are experienced by the patient.
■
●
Monitoring and Follow-up
●
Schedule regular follow-up to monitor achievement of BP target, check for adverse effects, and
titrate dose of antihypertensive medications.
○ Consider scheduling monthly follow-up after initiation of treatment or modifying a
patient’s antihypertensive therapy until the BP target is reached. (Conditional)6
Consider scheduling longer follow-up periods (e.g., every 3-6 months) in patients who
○
have reached their BP targets/whose BP are under control. (Conditional)6
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Referral
●
●
Refer the following hypertensive patients to a specialist for outpatient evaluation and
individualized management (Recommended)1:
○ Patients with Diabetic Kidney Disease
○ Patients with Grade 4 and 5 CKD
○ Patients with proteinuria of more than 1g/day
○ Patients with Coronary Artery Disease and very low diastolic BP < 50 mmHg
○ Patients with White Coat Hypertension
○ Patients with symptomatic postural hypotension
○ Patients with resistant hypertension (BP remains uncontrolled despite receiving
maximally-tolerated doses of 3 drug classes, including a diuretic)
○ Suspicion of pheochromocytoma (repetitive episodes of sweating, headache, anxiety, or
palpitations) and other causes of secondary hypertension
○ Patients with suspected coronary artery disease
○ Patients with suspected heart failure
○ Patients above 90 years of age, very frail or with limited life expectancy
Refer patients presenting with hypertensive emergencies immediately for inpatient emergent
specialty care 2,3.
○ Severely elevated blood pressure (SBP≥180 mmHg or DBP ≥110 mmHg) PLUS any of the
following:
○ New-onset blurring or loss of vision, retinal hemorrhage or papilledema on fundoscopy
○ Lethargy, seizures, cortical blindness, and coma in the absence of other explanations
○ New onset neurologic deficit - consider acute stroke
○ New onset chest pain or difficulty of breathing - consider acute coronary syndrome or
acute heart failure
First-aid Measures and Basic Emergency Care
●
Administer the following measures to patients presenting with hypertensive urgency or
emergency.
○ For Hypertensive Urgency (severe BP elevation in a stable patient WITHOUT acute organ
damage or change in baseline target):
■ Adjust/intensify maintenance medications, ensure adherence to therapy, and
arrange follow-up within a short period12
■ BP reduction is best achieved with oral medication according to the drug
treatment algorithm and initiation of long-acting BP medications 2 (ESC, 20182)
○ Hypertensive Emergency/ Hypertensive Crisis (severe BP elevation accompanied by new
or worsening target organ damage or dysfunction):
■ Create intravenous access and administer intravenous Nicardipine or Labetalol
(if available) 12 while awaiting/facilitating transfer to a higher level of care. Do not
delay immediate transfer.
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First-aid Measures and Basic Emergency Care
●
●
Nicardipine continuous IV infusion: Initial: 5 mg/hour; titrate by 2.5
mg/hour at 5- to 15-minute intervals to achieve target blood pressure;
maximum dose: 15 mg/hour 13
Labetalol
○
Intermittent IV: Initial: 10 to 20 mg over 1 to 2 minutes followed
by 20 to 80 mg every 10 minutes until target blood pressure is
reached; consider a continuous infusion if unable to obtain
target blood pressure 14
○ Continuous IV infusion: Initial loading dose: 10 to 20 mg over 2
minutes (optional if intermittent dosing is used), followed by 0.5
to 2 mg/minute; some patients may require titration up to 10
mg/minute 14
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Philippine Society of Hypertension & Philippine Heart Association. Clinical Practice Guidelines for the Management of Hypertension in
the Philippines. Published 2020. Accessed December 14, 2023.
https://drive.google.com/file/d/1t3UFLQG6XxTUNkVniliIbKnvnUVmDuKD/view
Williams B, Mancia G, Spiering W. 2018 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal.
2018;39(33):3021-3104. doi:https://doi.org/10.1093/eurheartj/ehy339
Unger et al. International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension, 75(6), 1334-1357. PMID:
32370572. 10.1161/HYPERTENSIONAHA.120.15026. 2020.
https://www.ahajournals.org/doi/epub/10.1161/HYPERTENSIONAHA.120.15026
Department of Health. Draft CSTs for Hypertension. N.d. Accessed December 14, 2023.
https://docs.google.com/presentation/d/1ArqWhDhR4GqXGj1F0G1h3n1kTQy0mKv_ZAE1O7lku-Y/edit#slide=id.g1be13ff716f_3_439
World Health Organization. WHO cardiovascular disease risk laboratory-based charts. N.d. Accessed December 16, 2023.
https://cdn.who.int/media/docs/default-source/ncds/cardiovascular-diseases/southeast-asia--corrected.pdf?sfvrsn=e7994290_0
World Health Organization. Guideline for the Pharmacological Treatment of Hypertension in Adults.; 2021. Accessed December 17, 2023.
https://iris.who.int/bitstream/handle/10665/344424/9789240033986-eng.pdf?sequence=1
National Institutes of Health. DASH Eating Plan. N.d. Accessed December 16, 2023.
https://www.nhlbi.nih.gov/education/dash-eating-plan
Department of Science and Technology. Pinggang Pinoy - Adults. N.d. Accessed December 16, 2023.
https://www.fnri.dost.gov.ph/images/sources/PinggangPinoy-Adult.pdf
World Health Organization. Guidelines on physical activity and sedentary behaviour. Published 2020. Accessed December 16, 2023.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719906/pdf/bjsports-2020-102955.pdf
World Health Organization. A healthy lifestyle - WHO recommendations. Published 2010. Accessed December 16, 2023.
https://www.who.int/europe/news-room/fact-sheets/item/a-healthy-lifestyle---who-recommendations
U.K. National Institute for Health and Care Excellence. Weight management: lifestyle services for overweight or obese adults.
Published 2014. Accessed December 16, 2023. https://www.nice.org.uk/guidance/ph53/chapter/4-considerations
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the
Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American
College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269-1324.
doi:https://doi.org/10.1161/hyp.0000000000000066
Uptodate. Nicardipine Drug information. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/nicardipine-drug-information?search=nicardipine&source=panel_search_result&selectedTitle
=1~85&usage_type=panel&kp_tab=drug_general&display_rank=1
Uptodate. Labetalol: Drug information. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/labetalol-drug-information?search=labetalol%20hypertensive%20urgency&source=search_res
ult&selectedTitle=2~149&usage_type=default&display_rank=2
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Major Depressive Disorder
is described as depressed mood or sadness, loss of interest or pleasure, feelings of guilt or low self-worth,
disturbed sleep or appetite, tiredness and poor concentration. These symptoms affect one’s ability to cope
with life, including ability to study or work.1 The Department of Health recognizes Major Depressive Disorder
(MDD) as one of the most common mental health conditions in the Philippines, occurring mostly in younger
adults, with one in every ten young adult Filipinos having MDD.2,3 It is estimated that MDD contributed to
0.95% of total DALYs among Filipinos.4 Because it predominantly affects young adults, MDD may also affect
community productivity and economic status. Moreover, MDD may also lead to death through suicide.
According to WHO, there is a substantial increase in the suicide rate of the Philippines in the past three
decades. The latest estimated mortality from suicide in the country was 2.5 per 100,000 in 2019, although the
WHO also recognized the possibility of underreporting due to religious beliefs and likely stigmatization of the
family1. All of these data emphasize that MDD has to be recognized and managed early and clinical and public
health interventions to safeguard mental health are necessary.
Table 23. Major Depressive Disorder Continuum of Care Overview
Major Depressive Disorder Overview
Risk Factors
Screening
Diagnosis
Pharmacologic
Treatment
Non-pharmacologic
management
Internal factors: female sex, history of anxiety, low self-esteem, Neuroticism
External factors: conduct disorder, substance use
Adverse life events: childhood sexual abuse, chronic medical conditions, disturbed
family environment, history of divorce, lifetime trauma, low educational status, low
social support, parental loss
Center for Epidemiologic Studies Depression Scale (CES-D) among ill adults and
caregivers
Patient Health Questionnaire-9 (PHQ-9) among healthcare workers
PHQ-2 among adults in the general population
Edinburgh Postnatal Depression Scale or PHQ-9 among pregnant adults
Diagnose depression among adults using the criteria from the Diagnostic and Statistical
Manual of Mental Disorders 5th Edition.
Additional laboratory tests: thyroid stimulating hormone, complete blood count, serum
electrolytes, and liver function test to rule out other medical conditions.
●
●
●
First-line:
Monotherapy using either non-pharmacologic interventions (e.g. therapy) or second
generation antidepressant (Escitalopram, Fluoxetine, Sertraline Venlafaxine, Bupropion,
Mirtazapine), or
Combination therapy using second generation antidepressant with CBT or interpersonal
psychotherapy
● Exercise monotherapy
● St. John’s Wort
● Bright light therapy
● Yoga
● Acupuncture
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Signs and Symptoms
●
●
Suspect depression among adults presenting with depressed mood, interest deficit (anhedonia),
changes in sleeping patterns (insomnia or sleeping more), guilt (worthlessness, hopelessness or
regret), energy deficit, concentration deficit, changes in appetite, psychomotor agitation or
retardation, and suicidality or self-harm.5
Consider depression particularly among adults with symptoms who have a past history of
depression or who have chronic comorbidities especially those with associated functional
impairment.6
Screening
●
●
●
Screen high-risk adults for depression using Center for Epidemiologic Studies Depression Scale
(CES-D) among ill adults and caregivers and using Patient Health Questionnaire-9 (PHQ-9) among
healthcare workers. (Strong Recommendation)7
Consider screening for depression among adults in the general population regardless of risk
factors for depression using PHQ-2 followed by PHQ-9 if depression is identified.5
(Recommended)8
Consider screening for depression among pregnant adults at least once during perinatal period
and at least once during four to eight weeks after delivery using Edinburgh Postnatal Depression
Scale or PHQ-9.5
Diagnostic Tests
●
Minimum at primary care. Diagnose depression among adults using the following criteria from the
Diagnostic and Statistical Manual of Mental Disorders 5th Edition 5,14:
A. Five (or more) of the following symptoms have been present during the same two-week period
and represent a change from previous functioning; at least one of the symptoms is either (1)
depressed mood or (2) loss of interest or pleasure.
NOTE: Do not include symptoms that are clearly attributable to another medical condition.
1) Depressed mood most of the day, nearly every day, as indicated by either subjective
report (eg, feels sad, empty, hopeless) or observations made by others (eg, appears
tearful). (NOTE: In children and adolescents, can be irritable mood.)
2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day (as indicated by either subjective account or observation).
3) Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of
body weight in a month), or decrease or increase in appetite nearly every day. (NOTE: In
children, consider failure to make expected weight gain.)
4) Insomnia or hypersomnia nearly every day.
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Diagnostic Tests
●
5) Psychomotor agitation or retardation nearly every day (observable by others, not merely
subjective feelings of restlessness or being slowed down).
6) Fatigue or loss of energy nearly every day.
7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick).
8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by
their subjective account or as observed by others).
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
C. The episode is not attributable to the direct physiological effects of a substance or to another
medical condition.
NOTE: Criteria A through C represent a major depressive episode.
NOTE: Responses to a significant loss (eg, bereavement, financial ruin, losses from a natural
disaster, a serious medical illness or disability) may include the feelings of intense sadness,
rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which
may resemble a depressive episode. Although such symptoms may be understandable or
considered appropriate to the loss, the presence of a major depressive episode in addition to the
normal response to a significant loss should also be carefully considered. This decision inevitably
requires the exercise of clinical judgement based on the individual's history and the cultural norms
for the expression of distress in the context of loss.
D. The occurrence of the major depressive episode is not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and
unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic or hypomanic episode.
NOTE: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are
substance-induced or are attributable to the physiological effects of another medical condition.
Specify:
With anxious distress
With mixed features
With melancholic features
With atypical features
With psychotic features
With catatonia
With peripartum onset
With seasonal pattern
Consider assessing adult patients with depression regarding ideation or intention for suicide or
self-harm.6
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Diagnostic Tests
●
Additional laboratory tests. Consider requesting laboratory tests as warranted, such as thyroid
stimulating hormone, complete blood count, serum electrolytes, and liver function test, to rule
out other medical conditions.5
Treatment
●
●
●
●
First Line. Provide interventions to adults after shared decision making with them and their
families as first line management6: (Recommendation for Use9); (Strong recommendation 10)
○ Monotherapy using either:
■ Non-pharmacologic interventions (such as behavioral therapy, cognitive
behavioral therapy (CBT), mindfulness based cognitive therapy, interpersonal
psychotherapy, psychodynamic therapies, or supportive therapy), or
■ Second generation antidepressant (such as Escitalopram 10mg tablet, Fluoxetine
30 mg capsule, Sertraline 50mg tablet, Venlafaxine 75 mg capsule, Paroxetine 20
mg tablet, Duloxetine 30 mg capsule, Vortioxetine 5 mg tablet, Bupropion 150 mg
tablet, or Mirtazapine 15mg tablet)
○ Combination therapy using second generation antidepressant with CBT or interpersonal
psychotherapy.
Provide pregnant adults at-risk for depression or those depressed with counseling interventions
such as CBT or interpersonal psychotherapy. (Recommended)11
Consider developing a safety plan among adults with depression who have self-harmed or at risk
of suicide.6,12
Other Non-Pharmacologic Options. Consider offering the following as adjunctive treatment such
as exercise monotherapy, St. John’s Wort, bright light therapy, yoga, or acupuncture to adults with
depression. (Conditional recommendation for use)9
Referral
●
Refer adults with severe symptoms, with marked or significant impairment on personal or social
functioning, self-neglect, or risk for self-harm or suicide, harm to others, those with personality
disorder or with psychotic symptoms, adults not responsive to treatment, or pregnant adults, to
the next level of care.6,10,11
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First Aid Measures and Basic Emergency Care
●
Assess the general status of the patient and provide urgent and appropriate medical care to adults
who have self-harmed or have attempted suicide prior to referral to the next level of care.12,13
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
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World Health Organization. Prevention and management of mental health conditions in The Philippines: The case for investment.
Published 2021. Accessed December 16, 2023.
https://www.who.int/docs/default-source/wpro---documents/countries/philippines/reports/investment-case-report-mental-healthphilippines-2021.pdf?sfvrsn=d0f436e7_9
Department of Health. Depression. HealthyPilipinas. N.d. Accessed December 16, 2023.
https://healthypilipinas.ph/health-a-z/depression
Puyat JH, Gastardo-Conaco MaC, Natividad J, Banal MA. Depressive symptoms among young adults in the Philippines: Results from a
nationwide cross-sectional survey. Journal of Affective Disorders Reports. 2021;3:100073.
doi:https://doi.org/10.1016/j.jadr.2020.100073
Institute for Health Metrics and Evaluation. GDB Compare. Published 2019. Accessed December 16, 2023.
https://vizhub.healthdata.org/gbd-compare/
Maurer DM, Raymond TJ, Davis BN. Depression: Screening and Diagnosis. American Family Physician. 2018;98(8):508-515. Accessed
December 17, 2023. https://www.aafp.org/pubs/afp/issues/2018/1015/p508.html
U.K. National Institute for Health and Care Excellence. Depression in adults: treatment and management. Published 2022. Accessed
December 16, 2023. https://www.nice.org.uk/guidance/ng222/chapter/Recommendations
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX): Screening for Mental Health and Addiction. Published 2021. Accessed December 16, 2023.
https://drive.google.com/file/d/1Nq-QO0UYMh0MiLWeKmO8CSdcuZyFdlbg/view
U.S. Preventive Services Task Force. Depression and Suicide Risk in Adults: Screening. Published 2023. Accessed December 16, 2023.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-adults
American Psychological Association. Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts. Published
2019. Accessed December 16, 2023. https://www.apa.org/depression-guideline/guideline.pdf
Qaseem A, Owens DK, Etxeandia-Ikobaltzeta I, Tufte J, Cross JT, Wilt TJ. Nonpharmacologic and Pharmacologic Treatments of Adults
in the Acute Phase of Major Depressive Disorder: A Living Clinical Guideline From the American College of Physicians. Annals of Internal
Medicine. 2023;176(2):239-252. doi:https://doi.org/10.7326/m22-2056
U.S. Preventive Services Task Force. Perinatal Depression: Preventive Interventions. Published 2019. Accessed December 16, 2023.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/perinatal-depression-preventive-interventions
U.K. National Institute for Health and Care Excellence. Self-harm: assessment, management and preventing recurrence. Published
2022. Accessed December 16, 2023.
https://www.nice.org.uk/guidance/ng225/chapter/Recommendations#involving-family-members-and-carers
UpToDate. Suicidal ideation and behavior in adults. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-adults?search=self%20harm&source=search_result&selecte
dTitle=5~150&usage_type=default&display_rank=5#
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington D.C.: 2013.
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Methamphetamine Use Disorder
Methamphetamine is an illicit psychostimulant that is smoked, snorted, injected or ingested orally that
causes the release and blocks the reuptake of neurotransmitters such as dopamine, norepinephrine, and
serotonin. Methamphetamine use disorder refers to the illicit use of methamphetamines that might involve
dependence and/or substance abuse 1,2. The estimated lifetime prevalence of substance and drug use
disorder among Filipinos was 1%3.
According to the latest available statistical analysis report of the Philippine Dangerous Drugs Board (2022),
Methamphetamine Hydrochloride in the form of shabu remains as the leading drug of abuse in the Philippines
seen as 92.06% of total admissions in their rehabilitation program3. Worldwide, amphetamine-type
stimulants such as methamphetamine are recorded as the fastest rising drug of abuse, with increasing use
recorded in Asia and Oceania1. Because of their symptoms, drug dependence, and or exacerbation of existing
other physical or psychological issues, heavy and frequent methamphetamine users eventually encounter
physical, familial, social, and economical issues in their lives due to lack of/altered functionality and
productivity.1,4
Table 24. Methamphetamine Use Disorder Continuum of Care Overview
Methamphetamine Use Disorder Overview
Signs and Symptoms
Acute changes in behavior, symptoms and signs of nervous system activation,
psychosis, delusions, or hallucinations, catatonia, symptoms of abstinence
syndrome, may present with cognitive changes
Screening
Use of standardized tools one a year during annual check-up
-Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), National
Institute on Drug Abuse (NIDA)
-Prenatal Risk Overview (PRO) for pregnant adults
Diagnosis
Non-pharmacologic
management
Urine screening tests, including confidentiality of records, conducted in
accordance with RA 9165 “Comprehensive Dangerous Drugs Act of 2002.”
Assess using the Diagnostic and Statistical Manual of Mental Disorders 5th
Edition
Urine testing (+) to undergo confirmatory testing using gas chromatography/
mass spectrometry
First Line Therapy. Psychosocial therapy using contingency management with or
without other behavioral interventions, such as: individual or group therapy,
intensive outpatient therapy, cognitive behavioral therapy, or motivational
interviewing for 3 weeks, taking patient preference and availability of treatment.
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Signs and Symptoms
●
Consider methamphetamine (MAP) use disorder among adults who use methamphetamine, in
various ways including orally, smoked, snorted, or dissolved in liquids, accompanied by clinical
manifestations such as the following1,4:
○ Acute changes in behavior (e.g., increased energy and alertness, decreased need for
sleep, euphoria, increased sexuality, grinding teeth, itching, disorganized thinking, etc.)
○ Symptoms and signs of nervous system activation (e.g., sweating, gastrointestinal
symptoms, pupillary dilatation, increased heart rate)
○ Psychosis, predominantly paranoia, persecutory delusions, auditory, visual, and tactile
hallucinations
○ Catatonia
○ With or without cognitive changes
○ Symptoms of abstinence syndrome in individuals who discontinue MAP (e.g., anhedonia,
irritability, poor concentration, hyperphagia, insomnia or hypersomnia, psychomotor
agitation or retardation).
Screening
●
●
Screen adults for methamphetamine use disorder using standardized tools, such as Alcohol,
Smoking, and Substance Involvement Screening Test (ASSIST), National Institute on Drug Abuse
(NIDA), or for pregnant adults using Prenatal Risk Overview (PRO), at least once a year during
annual check-up. (Strong Recommendation5) (Recommended6)
Urine screening tests, including confidentiality of records, shall be conducted in accordance with
the provisions of the Republic Act No. 9165 “Comprehensive Dangerous Drugs Act of 2002”.
Diagnostic Tests
●
Minimum at primary care.
○ Diagnose methamphetamine use disorder among adults using the criteria from the
Diagnostic and Statistical Manual of Mental Disorders 5th Edition.1,4,11
■ A problematic pattern of amphetamine-type substance, cocaine or other
stimulant use (eg, methamphetamine use) leading to clinically significant
impairment or distress, as manifested by two or more of the following within a
12-month period:
● Methamphetamine is often taken in larger amounts or over a longer
period than was intended
● There is a persistent desire or unsuccessful efforts to cut down or
control methamphetamine use
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Diagnostic Tests
A great deal of time is spent in activities necessary to obtain
methamphetamine, use methamphetamine, or recover from its effects
● Craving, or a strong desire or urge to use methamphetamine
● Recurrent methamphetamine use resulting in a failure to fulfill major role
obligations at work, school, or home
● Continued methamphetamine use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the effects of
methamphetamine
● Important social, occupational, or recreational activities are given up or
reduced because of methamphetamine use
● Recurrent methamphetamine use in situations in which it is physically
hazardous
● Continued methamphetamine use despite knowledge of having a
persistent or recurrent physical or psychological problem that is likely to
have been caused or exacerbated by methamphetamine
● Tolerance*
● Withdrawal*
* These criteria are not considered to be met for those taking methamphetamine solely
under appropriate medical supervision, such as for attention deficit hyperactivity
disorder or narcolepsy.
○ Adults who screened positive in urine testing shall undergo confirmatory testing using
gas chromatography/ mass spectrometry and shall be conducted with confidentiality in
accordance with the provisions of the Republic Act No. 9165 “Comprehensive Dangerous
Drugs Act of 2002.”
Assess for other psychiatric comorbidities (e.g., depression, anxiety, psychosis, potential for
self-harm, personality disorders), other substance use, medical comorbidities, and cardiovascular
risk.
Other Laboratory Tests. Consider requesting laboratory tests as warranted to evaluate other
medical conditions (e.g., electrocardiogram).1,4,
●
●
●
Treatment
●
●
First Line Therapy. Consider providing psychosocial therapy using contingency management with
or without other behavioral interventions, such as individual or group therapy, intensive
outpatient therapy, cognitive behavioral therapy, or motivational interviewing, taking patient
preference and availability of treatment. (Weak Recommendation7);8
○ Consider continuing psychosocial treatment for up to one year for adults who responded8
Other Non-Pharmacologic Treatment. Consider active group involvement on community-based
drug rehabilitation programs (e.g.Katatagan, Kalusugan, at Damayan ng Komunidad), using peer
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Treatment
●
●
linkage or 12-step facilitation therapy, to adults in early recovery, or following relapse. (Weak
Recommendation7)
Add-on Pharmacologic Treatment. Consider pharmacologic treatment, such as bupropion 450
mg once a day or mirtazapine 30 mg once a day, in addition to psychosocial interventions, to
adults with suboptimal response 8 to 12 weeks after initial treatment.8
Special considerations. Treatment may commence in Drug Treatment and Rehabilitation Centers
designated by the Dangerous Drug Board (DDB) for individuals who voluntarily submit for
treatment and rehabilitation for drug dependency, according to the provisions of Republic Act No.
9165 “Comprehensive Dangerous Drugs Act of 2002.9
Referral
●
Refer adults suspected of methamphetamine intoxication presenting with diaphoresis,
hypertension, tachycardia, severe agitation, psychosis, delirium or in coma, hyperthermia,
symptoms of metabolic acidosis, or in shock to higher level facilities.10
First Aid Measures and Basic Emergency Care
●
●
Provide immediate first aid measures and basic emergency care to adults suspected of
methamphetamine intoxication depending on the signs and symptoms of the patient10 and refer
immediately to higher level of care:
○ For agitated patients, consider benzodiazepines using Midazolam 5 to 10 mg
Intramuscularly (IV) or 2.5 to 5 mg Intravenously, Lorazepam 2 to 4 mg IV, or Diazepam 5 to
10 mg IV, repeated every 10 minutes as needed. Avoid physical restraints.
○ For hypertension and tachycardia, consider benzodiazepine doses as above. Consider
using a calcium channel blocker to decrease the heart rate and the blood pressure (e.g.
Diltiazem). Avoid beta-blockers.
○ For hyperthermia, consider benzodiazepine doses as above. Antipyretics are not
recommended. Additionally, provide evaporative cooling measures or cooling blankets.
○ For hypovolemia, give fluid resuscitation using isotonic saline coupled with regular fluid
monitoring.
Consider cardiovascular complications (e.g., myocardial ischemia/infarction, valvular dysfunction,
aortic rupture/dissection) in patients presenting with signs and symptoms such tachycardia,
hypertension, and chest pain10.
○ Administer basic emergency care and facilitate immediate referral and transfer of these
patients to higher levels of care.
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References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
UpToDate. Methamphetamine use disorder: Epidemiology, clinical features, and diagnosis. Published 2023. Accessed December 16,
2023.
https://www.uptodate.com/contents/methamphetamine-use-disorder-epidemiology-clinical-features-and-diagnosis?topicRef=10687
8&source=see_link#
Paulus MP, Stewart JL. Neurobiology, Clinical Presentation, and Treatment of Methamphetamine Use Disorder. JAMA Psychiatry.
2020;77(9). doi:https://doi.org/10.1001/jamapsychiatry.2020.0246
Dangerous Drugs Board. 2022 Statistical Analysis. Published 2022. Accessed December 16, 2023.
https://ddb.gov.ph/2022-statistical-analysis/
Klega AE, Keehbauch JT. Stimulant and Designer Drug Use: Primary Care Management. American Family Physician. 2018;98(2):85-92.
Accessed December 17, 2023. https://www.aafp.org/pubs/afp/issues/2018/0715/p85.html
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX): Screening for Mental Health and Addiction. Published 2021. Accessed December 16, 2023.
https://drive.google.com/file/d/1Nq-QO0UYMh0MiLWeKmO8CSdcuZyFdlbg/view
U.S. Preventive Services Task Force. Unhealthy Drug Use: Screening. Published 2020. Accessed December 16, 2023.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening
United States Department of Veteran Affairs. Clinical Practice Guideline for the Management of Substance Use Disorders. Published
2021. Accessed December 16, 2023. https://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPG.pdf
UpToDate. Stimulant use disorder: Treatment overview. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/stimulant-use-disorder-treatment-overview
Republic Act No. 9165 “Comprehensive Dangerous Drugs Act of 2002”
UpToDate. Methamphetamine: Acute intoxication. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/methamphetamine-acute-intoxication?topicRef=82952&source=see_link#
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington D.C.: 2013.
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Infectious
Diseases
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Community Acquired Pneumonia (CAP)
is an acute infection of the pulmonary parenchyma acquired outside the hospital. The clinical manifestation
of community-acquired pneumonia (CAP) can vary widely, encompassing mild cases with symptoms like fever
and a productive cough, to more severe instances marked by respiratory distress and sepsis. Due to the
diverse range of clinical features it presents, CAP is considered in the differential diagnosis of nearly all
respiratory conditions1. Locally, pneumonia in general is the seventh leading cause of morbidity in the
Philippines. Based on the 2022 FHSIS data, the incidence of pneumonia is at 180.87 per 100,000 population2.
Pneumonia remains one of the top causes of mortality among Filipinos with about 5% of deaths attributable
to it. This guide mainly focuses on the management of low-risk CAP.
Table 25. Community-Acquired Pneumonia Continuum of Care Overview
Community Acquired Pneumonia Overview
Risk Factors
●
●
●
●
●
●
Prevention
Pneumococcal vaccination in eligible patients
Hand hygiene and respiratory protection (e.g., masking) , smoking cessation (See
General Wellness and Preventive Measures for general guidance)
Pneumocystis jiroveci prophylaxis in patients living with HIV
Not applicable
Screening
Diagnosis
Pharmacologic
Treatment
Non-pharmacologic
management
Older Age
Chronic comorbidities
Viral respiratory infections
Impaired airway protection (e.g., stroke, seizure, drug or alcohol use, dysphagia)
Smoking, vaping, or alcohol overuse
Crowded living conditions, low income settings, environmental toxin exposures
Minimum at Primary Care. Clinical diagnosis and risk assessment through history and
PE.
Gold standard for etiologic diagnosis: culture
For Low Risk CAP without comorbidities:
Amoxicillin 500mg-1g thrice a day for 5-7 days
Low Risk CAP with stable comorbidities:
β-lactam with β-lactamase inhibitor combinations (BLIC e.g. Co-amoxiclav 500/ 125mg
thrice a day for 5-7 days) or second generation cephalosporins (e.g. Cefuroxime 500mg
twice a day for 5-7 days) with or without extended macrolides (Azithromycin 500mg once
a day OR clarithromycin 500mg twice a day for 3-5 days)
● Smoking Cessation
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Signs and Symptoms
●
Consider community acquired pneumonia among adults presenting with acute symptoms
including cough, breathlessness, and fever.3
Diagnostic Tests
●
●
●
Minimum at primary care. Determine and classify the severity of pneumonia among adults during
history and physical examination using validated clinical prediction tools1,3,4 such as Pneumonia
Severity Index (PSI) or Confusion, Respiratory Rate, Blood Pressure and Age (CRB65). (PSI - Strong
recommendation; Conditional recommendation4)
○ Risk stratification of patients with CAP
■ CAP Low-risk: normal vital signs, no coexisting or stable comorbidities, with
CRB-65 score 0, PSI Score class I to II
■ CAP Moderate-risk: with oxygen saturation of <92%, CRB-65 score 1 to 2, PSI
Score class III
■ CAP High-Risk: with respiratory failure requiring mechanical ventilation, with
sepsis requiring vasopressor support, altered mental status, unstable vital signs,
CRB-65 score score 3 to 4, PSI Score class IV to V
Other laboratory tests.
○ Request rapid influenza molecular assay among adults with pneumonia in cases wherein
there is a high influenza activity in the community (Strong recommendation4)
○ May consider requesting for chest radiography among adults with pneumonia5
Tests at higher level care. Transfer adults with moderate and severe pneumonia to a hospital for
further diagnostic work-up, which can include the following depending on the clinical indication:
○ Sputum gram stain and culture 3,4 (Strong recommendation 4)
○ Complete blood count5
○ Urine testing for pneumococcal antigen (Strong recommendation4)
○ Serum biomarkers such as Procalcitonin or C-Reactive Protein4,5,7
○ Other imaging such as chest computed tomography scan or chest ultrasound5
Treatment
●
First Line. Initiate empiric antimicrobial therapy within 4 hours of establishing diagnosis:
○ For adult patients without comorbidities or history of antibiotic therapy within 3 months:
Amoxicillin 500 mg to 1 g capsule three times a day for 5 to 7 days4,6,8 (Strong
recommendation4)
○ For adult patients with comorbidities such as chronic diseases, diabetes mellitus,
alcoholism, cancers, or asplenia, and those with risk factors for methicillin resistant
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Treatment
●
Staphylococcus aureus or Pseudomonas aeruginosa, or with history of antibiotic therapy
within 3 months 4,8:
■ Amoxicillin/ Clavulanate 500/125mg capsule three times a day for 5 to 7 days, or
■ Ampicillin/ Sulbactam 375 to 750 mg every 12 hours for 5 to 7 days, or
■ Cephalosporins such as: Cefpodoxime 200 mg two times a day or Cefuroxime 500
mg two times a day or Cefaclor 500 mg three times a day for 5 to 7 days, with or
without
● Macrolide such as Azithromycin 500 mg once a day or Clarithromycin
500 mg two times a day for 3 to 5 days, or
● Doxycycline 100 mg two times a day for 3 to 5 days
Alternative Therapy. Consider the following as alternative therapy:
○ For adult patients without comorbidities or history of antibiotic therapy within 3 months:
■ Doxycycline 100 mg twice a day for 5 days 4,6 (Conditional recommendation4), or
■ For adults with penicillin allergy or when the local pneumococcal resistance is
<25%: Macrolide such as Azithromycin 500 mg D1 then 250 mg daily, or
Clarithromycin 500 mg twice a day for 5 days (Conditional recommendation4)
○ For adult patients with comorbidities such as chronic diseases, diabetes mellitus,
alcoholism, cancers, or asplenia, and those with risk factors for methicillin resistant
Staphylococcus aureus or Pseudomonas aeruginosa, or with history of antibiotic therapy
within 3 months, consider Fluoroquinolones such as Moxifloxacin, Levofloxacin,
Gemifloxacin or Nemonoxacin.4,8
Prophylaxis
●
Prophylaxis. Prescribe trimethoprim-sulfamethoxazole double strength oral tablet
(160mg/800mg) once a day for Pneumocystis pneumonia prophylaxis to the following adults with
HIV:
○ Adults with severe or advanced HIV clinical disease (WHO stage 3 or 4). (Strong
recommendation9)
○ Adults with HIV regardless of CD4 count with active tuberculosis disease. (Strong
recommendation9)
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Referral
●
Refer adults with pneumonia who are hypotensive, exhibiting respiratory distress, in
cardiopulmonary failure, with sepsis, with moderate to severe pneumonia, those who are not
improving with antibiotic therapy, worsening symptoms, or unable to take oral antibiotics to
higher levels of care.4, 6
First Aid Measures and Basic Emergency Care
●
●
Consider supplemental oxygenation using a non rebreather mask for adults who appear clinically
ill or hypoxic with pulse oxygen saturation <90 percent.10
Facilitate immediate transfer of patients presenting with septic shock.
○ Provide intravenous fluid resuscitation using crystalloids while awaiting/facilitating
transfer (Strong Recommendation11)
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
UpToDate. Overview of community-acquired pneumonia in adults. Published 2023. Accessed December 16, 2023.
https://www.uptodate.com/contents/overview-of-community-acquired-pneumonia-in-adults
Department of Health. FHSIS - August 2022. Published 2022. Accessed December 16, 2023.
https://doh.gov.ph/sites/default/files/publications/FHSIS_2022_Aug.pdf
U.K. National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. 2023.
https://www.nice.org.uk/guidance/cg191/chapter/recommendations#lower-respiratory-tract-infection
American Thoracic Society and Infectious Diseases Society of America. Diagnosis and Treatment of Adults with Community-acquired
Pneumonia: An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. 2019.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812437/
UpToDate. Clinical evaluation and diagnostic testing for community-acquired pneumonia in adults. Published 2023. Accessed
December 16, 2023.
https://www.uptodate.com/contents/clinical-evaluation-and-diagnostic-testing-for-community-acquired-pneumonia-in-adults?topi
cRef=117561&source=see_link#
U.K. National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. Published 2019.
Accessed December 16, 2023. https://www.nice.org.uk/guidance/ng138/chapter/Recommendations
UpToDate. Procalcitonin use in lower respiratory tract infections. Published 2022. Accessed December 16, 2023.
https://www.uptodate.com/contents/procalcitonin-use-in-lower-respiratory-tract-infections?sectionName=Community-acquired%2
0pneumonia%20in%20hospitalized%20patients&topicRef=7032&anchor=H3117849100&source=see_link#H3117849100
Chou CC, Shen CF, Chen SJ, et al. Recommendations and guidelines for the treatment of pneumonia in Taiwan. Journal of Microbiology,
Immunology and Infection. 2019;52(1):172-199. doi:https://doi.org/10.1016/j.jmii.2018.11.004
World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring:
recommendations for a public health approach. www.who.int. Published July 16, 2021. Accessed December 16, 2023.
https://www.who.int/publications/i/item/978924003159
UpToDate. Approach to the adult with dyspnea in the emergency department. Published 2022. Accessed December 16, 2023.
https://www.uptodate.com/contents/approach-to-the-adult-with-dyspnea-in-the-emergency-department?topicRef=1436&source=s
ee_link#H4139199473
Philippine Society for Microbiology and Infectious Diseases. Clinical Practice Guidelines for Sepsis and Septic Shock. Published 2020.
Accessed December 16, 2023. https://drive.google.com/drive/folders/1hNd6ImqyCqiPw1p1hHBA6jytGgLWLsC0
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Coronavirus Disease (COVID-19)
is a disease caused by the SARS-COV-2 virus. It spreads mostly through respiratory droplets but may also
undergo airborne transmission, particularly during aerosol-generating procedures or AGPs (e.g., intubation,
nebulization). Causing a pandemic and a declaration of public health emergency (PHE) in 2020, COVID-19
eventually affected millions of Filipinos, prompting nation-wide health system and service delivery changes.
The clinical manifestation of this COVID-19 infection ranges from asymptomatic infection, to mild disease
commonly presenting with fever, cough, tiredness and loss of taste or smell, to severe disease presenting
with difficulty of breathing, neurologic changes, and cardiovascular symptoms such as chest pain1. In the
initial phase of the pandemic, without vaccines and proven treatments, COVID-19 was difficult to manage,
leading to disproportionately high mortality among affected individuals. As scientific evidence was
generated worldwide, safe and efficacious vaccines and medications were developed, and effective
non-pharmacologic interventions (NPIs) were utilized. These led to the successful control of the pandemic
and eventual lifting of its global PHE status on May 5, 2023 by the WHO2, followed by the Philippines on July
21, 2023 through Proclamation No. 297. As of December 12, 2023, COVID-19 has affected 4,127,769 Filipinos,
with a case fatality rate of 1.6%3. Continuing success in the prevention and control of COVID-19 entails
collaborative multisectoral and multidisciplinary efforts.
Table 26. COVID-19 Continuum of Care Overview
COVID-19 Overview
Risk Factors
Prevention
Screening
Anyone can be infected but the following increase the risk of transmission4:
● Longer exposure to an infected person
● Shorter distance from an infected person
● Exposure to a symptomatic person
● Coughing, singing, shouting, or breathing heavily due to exertion
● Poor ventilation or air filtration
Risk Factors for severe disease:
● Increasing age: older adults are more likely to get sick and hospitalized
● Immunocompromised /immunodeficient and pregnant individuals
● Presence of comorbidities/underlying health conditions (e.g., obesity, chronic
obstructive pulmonary disease)
Prevention of severe disease: Vaccination with primary series and updated boosters
Prevention of transmission of the virus:
● Masking especially in crowded, enclosed, and poorly ventilated spaces
● Observance of proper hand hygiene
● Adherence to national and local public health protocols
7-day symptom-based test
Diagnosis
Minimum at Primary Care. Rapid antigen test (RAT)
Gold standard: Reverse transcription polymerase chain reaction (RT-PCR)
Pharmacologic
Treatment for
outpatients
For mild-moderate disease in non-hospitalized patients with high risk of progression,
within 5 days of symptom onset:
● First-line: Nirmatrelvir + Ritonavir (Paxlovid) , dosing depends on renal function5
● Normal or mildly decreased renal function (eGFR ≥ 60 mL/min): 300
mg Nirmatrelvir + 100 mg Ritonavir BID PO x 5 days
● Moderately decreased renal function (eGFR 30-59 mL/min): 150 mg
Nirmatrelvir + 100 mg Ritonavir BID PO x 5 days
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Severely depressed renal function: not recommended by
manufacturer
● Alternative: Remdesivir 200 mg as a single dose on day 1, followed by 100 mg
once daily on days 2 and 3. Initiate as soon as possible after COVID-19 diagnosis
and within 7 days of symptom onset5
● Alternative: Molnupiravir 800 mg every 12 hours orally for 5 days; initiate as
soon as possible after COVID-19 diagnosis, and within 5 days of symptom onset5
After initiating treatment with molnupiravir, if hospitalization is
●
required, completion of 5-day course is at the health care provider's
discretion
Supportive treatment: Give supportive treatments to address the patient’s symptoms
● Antipyretics for fever
● Analgesics for headache, myalgia
● Antitussives for cough
● Advise the following:
● Oral hydration
● Advise adequate rest and sleep
● Home or facility for non-hospitalized patients
●
Non-pharmacologic
management
Signs and Symptoms
●
●
Consider the presence of COVID-19 in adults presenting with the following symptoms 1:
○ Most common symptoms: fever, chills, sore throat
○ Less common symptoms: muscle aches and heavy arms or legs, severe fatigue or
tiredness, runny or blocked nose, or sneezing, headache, sore eyes, dizziness, new and
persistent cough, tight chest or chest pain, shortness of breath, hoarse voice, numbness
or tingling, appetite loss, nausea, vomiting, abdominal pain or diarrhea, loss or change of
sense of taste or smell, difficulty sleeping
COVID-19 and influenza are both respiratory diseases. It is difficult to distinguish COVID-19 from
influenza by symptoms alone. If clinically indicated and/or necessary for surveillance,
simultaneous testing for COVID-19 and influenza may be done 4.
Screening
●
Utilize a 7-day symptom-based test to determine the probability of possible COVID-19 infection
among asymptomatic adults. (Strong recommendation6)
○ The 7-day symptom-based test includes assessment for the development of the following
in asymptomatic individuals with history of exposure to a confirmed case or who are close
contacts:
■ Fever (≥ 38 degrees Celsius) AND cough (WHO Case Definition for ILI7) OR
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Screening
Acute onset of 3 or more of the following: fever, cough, generalized
weakness/fatigue, headache, myalgia, sore throat, coryza, dyspnea,
nausea/diarrhea/anorexia
Close contacts are defined as individuals who experienced the following 8:
■ Interacted with a person with COVID-19 within one meter for more than 15
minutes
■ Had direct physical interaction with probable or confirmed COVID-19 case
■ Had interaction with a person with COVID-19 without wearing protective
equipment
Avoid using rapid antigen testing for screening purposes in asymptomatic patients (Weak
recommendation 6)
■
○
○
Diagnostic Tests
●
●
●
Minimum at primary care.
○ Consider testing symptomatic patients with rapid antigen tests (RAT) for the diagnosis of
COVID-19 (Weak recommendation6)
○ In the setting of an outbreak, consider testing using RAT for the diagnosis of COVID-19,
provided the all of the following conditions are met (Weak recommendation 6):
■ Individuals are in the early phase of illness (≤ 7 days from symptom onset) AND
■ RAT kits use have sensitivity of ≥80% and specificity of ≥97%
○ Advise symptomatic individuals to use self-administered RAT if able, provided all of the
following conditions are met (Strong recommendation6):
■ Ease of collecting samples is ensured;
■ Ease of interpretation is ensured;
■ Test kits have passed flex studies; AND
■ Symptoms have been present for ≤ 7 days.
○ In individuals whose RAT is negative but are highly suspected to have COVID-19, request
for RT-PCR to confirm diagnosis, if available.
Gold standard. RT-PCR remains the gold standard in confirming the diagnosis of COVID-19.
However, it is not widely available in primary care settings and is more costly.
Determine and classify the severity of COVID-19 among symptomatic individuals using the
following criteria to guide management:
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Diagnostic Tests
Table 27. Severity Classification of COVID-196
Classification
Criteria
Mild COVID-19
●
●
No pneumonia or desaturation#
Acute onset of fever and cough or any three (3) or more of the following:
○ Fever
○ Cough
○ Coryza
○ Sore throat
○ Diarrhea
○ Anorexia/nausea/vomiting
○ Loss of sense of smell or taste
○ General weakness/body malaise/fatigue
○ Headache
○ Myalgia
Moderate
COVID-19
●
With pneumonia* BUT no difficulty of breathing or shortness of breath, RR < 30
breaths/min, oxygen saturation# >/= 94% at room air
OR
Without pneumonia but with risk factors for progression: elderly (60 years old
and above) and/or with comorbidities
●
Severe COVID-19
●
With pneumonia* and ANY one of the following:
○ Signs of respiratory distress
○ Oxygen saturation# < 94% at room air
○ Respiratory rate of ≥30 breaths/minute
○ Requiring oxygen supplementation
Critical COVID-19
●
With pneumonia* and ANY one of the following:
○ Impending respiratory failure requiring high flow oxygen, non-invasive or
invasive ventilation
○ Acute respiratory distress syndrome
○ Sepsis or shock
○ Deteriorating sensorium
○ Multi-organ failure
○ Thrombosis
*Pneumonia – evidence of lower respiratory disease during clinical assessment (e.g. cough, fever plus
crackles) and/or imaging (CXR, ultrasound, CT scan)
#Proper recording of the O2 saturation: finger should be inserted in the oximeter for about 10-20
seconds; patient should be still and not talking.
●
Other tests.
○ Obtain baseline peripheral oxygen saturation using a calibrated pulse oximeter.
○ Consider requesting a chest-x ray to facilitate rapid triage, infection control, and clinical
management in the following types of patients (Weak recommendation6):
■ Patients who have mild COVID-19 but at risk of progression [e.g., elderly (60 years
old and above) and/or with comorbidities]
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Diagnostic Tests
●
■ Patients with moderate-severe COVID-19
■ Patients with symptoms of at least 5 days duration
○ Consider testing for other differentials e.g. influenza, if clinically indicated.
○ Consider requesting for basic laboratory tests (e.g. BUN, Creatinine) if planning to
administer Nirmatrelvir + Ritonavir (Paxlovid).
Tests at higher level care. Transfer adults with moderate-severe COVID-19 for further diagnostic
work-up, clinical management, and monitoring. Additional tests in higher levels of care may
include the following:
○ More advanced imaging tests (e.g., CT Scan)
○ Laboratory tests: CBC, BUN, CRP, LDH, Ferritin, D-Dimer, etc.
Treatment
●
●
●
The following are the treatment options for outpatients with mild-moderate COVID-19.
First Line.
○ For symptomatic individuals with mild-moderate COVID-19, with risk factors for
progression to severe disease5, and within 5 days from symptom onset, offer Nirmatrelvir
+ Ritonavir (Paxlovid) (Strong recommendation 6);
■ Risk factors for progression based on studies on Nirmatrelvir + Ritonavir include:
≥60 years of age; BMI >25 kg/m2; cigarette smoking; immunosuppressive disease
(including HIV infection with CD4 cell count <200mm3 and viral load <400
copies/mL) or prolonged iatrogenic immunosuppression; chronic lung,
cardiovascular, kidney, or sickle cell disease; hypertension; diabetes; cancer;
neurodevelopmental disorders or other medically complex conditions; or
medical-related technological dependence
■ Adjust dosing based on renal function5:
■ Normal or mildly decreased renal function (eGFR ≥ 60 mL/min): 300 mg
Nirmatrelvir + 100 mg Ritonavir BID PO x 5 days
■ Moderately decreased renal function (eGFR 30-59 mL/min): 150 mg
Nirmatrelvir + 100 mg Ritonavir BID PO x 5 days
■ Severely depressed renal function: not recommended by manufacturer
Alternatives to Nirmarelvir + Ritonavir. Consider offering the following treatments depending on
the patient’s characteristics and drug availability:
○ For symptomatic individuals with mild-moderate COVID-19 with at least 1 risk factor* for
progression to severe disease, consider offering Remdesivir5 (Weak recommendation
6
);
■ Risk factors for progression based on studies on Remdesivir include: ≥60 years
old, hypertension, cardiovascular or cerebrovascular disease, diabetes mellitus,
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Treatment
●
obesity (BMI≥30), immune compromise, chronic mild or moderate kidney disease,
chronic liver disease, chronic lung disease, current cancer, or sickle cell disease
■ Remdesivir 200 mg as a single dose on day 1, followed by 100 mg once daily on
days 2 and 3. Initiate as soon as possible after COVID-19 diagnosis and within 7
days of symptom onset5
○ For symptomatic individuals with moderate COVID-19 who are non-oxygen-requiring and
with at least 1 risk factor for progression, consider offering Molnupiravir (Weak
recommendation6):
■ Risk factors for progression based on studies on Molnupiravir include: age >60
years, active cancer, chronic kidney disease, chronic obstructive pulmonary
disease, obesity, serious heart conditions or diabetes mellitus
■ Molnupiravir 800 mg every 12 hours orally for 5 days; initiate as soon as possible
after COVID-19 diagnosis, and within 5 days of symptom onset.5
● After initiating treatment with molnupiravir, if hospitalization is
required, completion of the 5-day course is at the health care provider's
discretion.
Symptom management. Provide supportive therapy (e.g. antipyretic, analgesic, mucolytics, etc.)
to help address the symptoms of the patient.
Non-pharmacologic Interventions
●
Infection prevention and control measures. Ensure the observance of proper infection
prevention and control (IPC) measures:
○ For healthcare workers. Observe standard precautions for all patients including the
following9:
■ Hand hygiene through proper handwashing or by using an alcohol-based hand rub
and respiratory hygiene.
■ Use appropriate PPE.
● Use well-fitting medical masks in healthcare facilities especially in areas
of known or suspected community or cluster transmission (Strong
recommendation9).
■ Observe proper cleaning, disinfection, and healthcare waste disposal according
to IPC protocols
■ Also apply transmission-based precautions when indicated (e.g., when
performing aerosol-generating procedures among patients with suspected or
confirmed COVID-19, perform the procedure in an adequately ventilated room and
use appropriate PPE (e.g. N95/FFP2 respirator or equivalent)9
○ For patients. Advise to wear a medical mask. Advise hand and respiratory hygiene9.
○ For the community.
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Non-pharmacologic Interventions
Encourage the community members to wear face masks for preventing COVID-19
in crowded, enclosed, and poorly ventilated spaces (Strong recommendation6).
■ Encourage vaccination against COVID-19 (Strong recommendation6)
Ventilation.
■ Encourage the use of natural ventilation, including the opening of doors,
windows, and use of electric fans in indoor spaces, if possible and safe to do so
(Strong recommendation6).
Isolation. Immediately isolate individuals with suspected, probable or confirmed
COVID-19.9
■ Advise patients to self-isolate in well-ventilated, ideally single rooms and
accessible bathrooms. If patients are cohorted in isolation facilities, ensure bed
space of at least 1 meter apart9.
■ Ensure availability of home monitoring kit (e.g. thermometer, pulse oximeter,
etc.)
■ Observe the following updated masking and isolation protocols in accordance
with DOH Department Circular 2023-0324:
■
○
○
Patient Characteristics
Masking
Isolation
Quarantine
Asymptomatic but
confirmed COVID-19
Wear a
well-fitted mask
for 10 days
Not applicable
Not needed
Confirmed COVID-19 case
with mild symptoms OR
individuals with acute
respiratory symptoms
(suspected/probably
COVID-19)
Wear a
well-fitted mask
for 10 days
Home isolation for 5 days from onset of
signs and symptoms OR until
afebrile/fever-free for at least 24 hours
without using antipyretics (e.g.,
Paracetamol) and with improvement of
respiratory symptoms, whichever is earlier
* duration of isolation may be shorted upon
the advice of the healthcare provider
Not applicable
Confirmed COVID-19 case
with moderate to severe
symptoms, OR
immunocompromised
individuals with COVID-119
Wear a
well-fitted mask
for 10 days
Isolation for at least 10 days from onset of
signs and symptoms following the advice
of the attending physician, including
whether to be admitted to a healthcare
facility
Not applicable
●
General advice. Advice all patients to observe the following:
○ Get adequate rest and sleep.
○ Be adequately hydrated.
○ Symptom monitoring
○ Do pulse oximetry monitoring at home.
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Non-pharmacologic Interventions
○
Use telemedicine modalities for communicating with healthcare providers for medical,
psychosocial and mental health support
Referral
●
Refer all individuals with manifestations of severe and critical COVID-19 or progressive disease to
higher level facilities (i.e. through the DOH National Patient Navigation and Referral Center
(NPNRC) through 1555 and select option (2) for immediate and proper assessment as well as
corresponding management and interventions)
First Aid Measures and Basic Emergency Care
●
●
●
Facilitate immediate transfer of patients presenting with the following symptoms to higher level
facilities1:
○ Difficulty breathing, especially at rest, or inability to speak in sentences
○ Confusion, drowsiness, or loss of consciousness
○ Neurologic deficits (e.g., loss of speech or movement)
○ Persistent chest pain or pressure
○ Cold clammy skin or cyanosis
Administer supplemental oxygenation using a low-flow system (ie, up to 6 L/minute) via nasal
cannula10 in patients with mild desaturations, while awaiting transfer to a higher level facility,
provided adequate IPC measures are observed.
Balance the benefit and safety of administering high-flow oxygen (e.g. via oxygen mask) and
nebulization to patients with suspected, probable, or confirmed COVID-19, given the risk of
aerosolization.
References
1.
2.
3.
4.
5.
World Health Organization. Coronavirus Disease (COVID-19). N.d. Accessed December 16, 2023.
https://www.who.int/health-topics/coronavirus#tab=tab_3
World Health Organization. WHO Director-General's opening remarks at the media briefing. Published 2023. Accessed
December 16, 2023.
https://www.who.int/news-room/speeches/item/who-director-general-s-opening-remarks-at-the-media-briefing--5-may-2023
Department of Health. COVID-19 Tracker. Published 2023. Accessed December 12, 2023.
https://doh.gov.ph/covid19tracker
U.S. Centers for Disease Control and Prevention. Understanding Exposure Risks. Published 2022. Accessed
December 12, 2023. https://www.cdc.gov/coronavirus/2019-ncov/your-health/risks-exposure.html
UpToDate. COVID-19: Management of adults with acute illness in the outpatient setting. Published 2023. Accessed
December 12, 2023.
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Omnibus Health Guidelines ver. 2023 | 182
6.
7.
8.
9.
10.
https://www.uptodate.com/contents/covid-19-management-of-adults-with-acute-illness-in-the-outpatient-setting
?search=paxlovid&source=search_result&selectedTitle=2~52&usage_type=default&display_rank=1
Philippine Society for Microbiology and Infectious Diseases. Philippine COVID-19 Living Recommendations. Published
2023. Accessed December 12, 2023. https://www.psmid.org/philippine-covid-19-living-recommendations-3/
World Health Organization. WHO surveillance case definitions for ILI and SARI. Published 2014. Accessed December
12, 2023.
https://www.who.int/teams/global-influenza-programme/surveillance-and-monitoring/case-definitions-for-ili-andsari
Department of Health. COVID-19 FAQS. Published May 2021. Accessed December 12, 2023.
https://doh.gov.ph/COVID-19/FAQs.
World Health Organization. Clinical Management of COVID-19: living guideline. Published 2023. Accessed December
12, 2023. https://app.magicapp.org/#/guideline/j1WBYn/section/L0bmdE
UpToDate. COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive
ventilation, and intubation). Published 2023. Accessed December 12, 2023.
https://www.uptodate.com/contents/covid-19-respiratory-care-of-the-nonintubated-hypoxemic-adult-supplementa
l-oxygen-noninvasive-ventilation-and-intubation?search=covid-19%20oxygen%20supplementation&source=search_
result&selectedTitle=1~150&usage_type=default&display_rank=1#
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Dengue
is a mosquito-borne infection transmitted by Aedes aegyptii or Aedes albopictus. The wide range of
manifestations of dengue include asymptomatic infection, mild febrile illness, to multi-organ failure. Dengue
is an important cause of morbidity and mortality in the country, with 220,705 cases reported in 2022, which
is 182% higher than the cases in 2021, and a case fatality rate of 0.3%, which is 182%.1 Prevention, early
detection, and timely administration of interventions, including simple and inexpensive hydration, are critical
in reducing mortality and morbidity.2
Table 28. Dengue Continuum of Care Overview
Dengue Overview
Risk Factors
●
●
●
Prevention
Screening
Diagnosis
Treatment
Environmental factors leading to increased dengue transmission:
crowding/population density, human mobility, access to reliable water source,
water storage practices
Lack of vector control activities in the community
Previous dengue infection - increased risk of developing severe disease
Enhanced 4S Strategy (DOH Administrative 2018-0021)
Avoidance of mosquito bites (See General Wellness and Preventive Measures for
general guidance)
Not applicable
●
●
Minimum at Primary Care. Clinical diagnosis and risk assessment through history and
PE; Dengue NS1 rapid diagnostic test (RDT) (first-line for confirmation); Dengue IgM/IgG
RDT (alternative)
First-line for dengue without warning signs: oral rehydration solution
Adjunctive therapy: papaya (Carica papaya) leaf extract or juice preparations
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Signs and Symptoms
●
●
●
Suspect Dengue infection in a patient presenting with fever plus any two of the following3,4:
○ Nausea/vomiting
○ Rash
○ Headache, eye pain, muscle ache, or joint pain
○ Leukopenia
○ Positive tourniquet test
Dengue with warning signs of severe infection includes the clinical presentation above and in
addition of any of the following:
○ Abdominal pain or tenderness
○ Persistent vomiting
○ Clinical Fluid accumulation
○ Mucosal bleeding
○ Lethargy or restlessness
○ Hepatomegaly of > 2 cm
○ Increase in hematocrit concurrent with rapid decrease in platelet count
Severe dengue infection includes infection with at least one of the following:
○ Severe plasma leakage leading to: shock; fluid accumulation with respiratory distress
○ Severe bleeding (as evaluated by clinician)
○ Severe organ involvement: AST or ALT ≥ 1000 units/L; impaired consciousness; organ
failure
Screening
●
Not applicable
Diagnostic Tests
●
Minimum at primary care. Perform complete history taking and physical examination in all
patients presenting with symptoms of Dengue.
○ Assess the following clinical parameters to determine if the patient should be referred to
a hospital for inpatient management (Strong recommendation5):
■ Signs and symptoms:
● Vomiting/persistent vomiting
● Abdominal pain/tenderness
● Lethargy/restlessness
● Mucosal bleeding
● Impaired consciousness
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Diagnostic Tests
●
●
● Hepatomegaly
● Acute renal failure (e.g., Urine Output <0.5 mg/kg/hr)
■ Presence of comorbidities:
● Pregnancy
● Obesity
● Others (cardiac, renal, hematologic, pulmonary)
○ Perform NS1 rapid diagnostic test (RDT) to confirm the diagnosis of dengue infection in
individuals presenting within at least 3 days of symptom onset (Strong recommendation5).
■ Alternative: Request for combined Dengue NS1/IgM/IgG RDT to confirm the
diagnosis, if available (Strong recommendation5).
■ If the patient presents more than 5 days from the onset of symptoms, request for
Dengue IgM/IgG RDT (Strong recommendation5).
Additional tests at baseline. Request for CBC with platelet count, liver function tests (AST, ALT) ,
and coagulation tests (PT, PTT).
○ Consider transferring patient for in-hospital management if any of the following
laboratory parameters are present (Weak recommendation5):
■ Increased hematocrit with or without decrease in platelet count
■ Elevated transaminases
■ Impaired PT or PTT
■ Thrombocytopenia
Tests for monitoring. Consider requesting CBC daily or every 3 days to monitor disease
progression, as clinically indicated (Good Practice Statements5):
○ Depending on volume status, urine output, temperature, ability to tolerate feeding,
presence of warning signs
○ Discontinue CBC monitoring when the patient is already in the recovery phase (e.g.,
increasing platelet count trends, 48 hours afebrile, adequate urine output, and improved
sense of well-being/appetite).
Treatment
●
●
First-line therapy. Give oral rehydration solution (ORS) to all patients with probable or confirmed
dengue fever.5
Adjunctive therapy.
○ Consider giving papaya (Carica papaya) leaf extract or juice preparations as a supplement
○ to standard therapy (Strong recommendation5).
○ Avoid giving the following:
■ Acid suppressants (Strong recommendation - Against5)
■ Guava (Psidium guajava) preparations (Strong recommendation - Against5)
■ Tawa-tawa (Euphorbia hirta) preparations (Weak recommendation - Against5)
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Referral
●
●
Refer patients with confirmed or suspected Dengue to a hospital for inpatient management if the
following danger/warning signs are present:
○ Vomiting/persistent vomiting
○ Abdominal pain/tenderness
○ Lethargy/restlessness
○ Mucosal bleeding
○ Impaired consciousness
○ Hepatomegaly
○ Acute renal failure (e.g., Urine Output <0.5 mg/kg/hr)
○ Increased hematocrit with or without decrease in platelet count
○ Elevated transaminases
○ Impaired PT or PTT
○ Thrombocytopenia
Ensure IV access is present and provide IV fluid resuscitation in patients with confirmed or
suspected hypotension or in shock while awaiting or facilitation transfer.
References
1.
2.
3.
4.
5.
Philippine Star. Philippines logs 220,705 dengue cases in 2022. Published January 17, 2023. Accessed December 16, 2023.
https://www.philstar.com/nation/2023/01/17/2238093/philippines-logs-220705-dengue-cases-2022
World Health Organization. Handbook for clinical management of dengue. Published 2012. Accessed December 16, 2023.
https://www.who.int/publications/i/item/9789241504713
World Health Organization. Dengue guidelines, for diagnosis, treatment, prevention and control. Published 2009. Accessed December
16, 2023. https://www.who.int/publications/i/item/9789241547871
UpToDate. Dengue virus infection: Clinical manifestations and diagnosis. Published 2022. Accessed December 16, 2023.
https://www.uptodate.com/contents/dengue-virus-infection-clinical-manifestations-and-diagnosis?search=severe%20dengue&sour
ce=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Department of Health. Clinical Practice Guideline on the Diagnosis, Management and Prevention of Dengue for Adult and Pediatric
Filipinos. Published 2023. Accessed December 16, 2023.
https://drive.google.com/file/d/1dsYIHm4UibfyP7FyFJeWsRQ5jXMZZNJp/view
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Human Immunodeficiency Virus - Acquired
Immunodeficiency Syndrome (HIV AIDS)
is a retrovirus that destroys cell-mediated immunity, leading to immunodeficiency. It is usually acquired
through sexual intercourse, exposure to infected blood, or perinatal transmission. It remains a major global
public health issue, with countries like the Philippines reporting increasing trends in new infections.1,2
Incidence has risen to 411% from 2012 to 2023, with the increase in cases noted among the 15 - 24 year old
age group.1
The Philippines has yet to meet its target on viral load suppression, with the country reaching 94% in 2021
(DOH, 2021). By 2025, 95% of all people living with HIV (PLHIV) should have a diagnosis, 95% of those should
be taking lifesaving antiretroviral treatment (ART) and 95% of PLHIV on treatment should achieve a
suppressed viral load for the benefit of the person’s health and for reducing onward HIV transmission.2 This
section contains updated recommendations on effective health technologies across the continuum of care
to achieve this target.
Table 29. HIV-AIDS Continuum of Care Overview
HIV-AIDS Overview
Risk Factors
Prevention
Screening
Diagnosis
Treatment
Men who have sex with men
Transgender women and heterosexual men
Women who have sexual partners with undiagnosed or untreated HIV infection
People who inject drugs (PWID)
Safe and responsible sexual and reproductive health practices (See General
Wellness and Preventive Measures for general guidance and Family Planning
Section for Barrier method and other pericoital contraceptives )
● Antigen/antibody immunoassays
● Rapid diagnostic test kit
Minimum at Primary Care. Combinations of antigen/antibody immunoassays or rapid
diagnostic test kit
First-line:
● Dolutegravir (DTG) - based regimens with nucleoside reverse transcriptase
inhibitor (NRTI) backbones
● Efavirenz with NRTI backbone
Second line:
● Boosted protease inhibitors in combination with an optimized NRTI backbone
● DTG in combination with an optimized NRTI backbone of previously on a non-DTG
regimen
●
●
●
●
●
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Signs and Symptoms
●
●
Primary HIV infection may be asymptomatic or cause nonspecific symptoms.3
Consider HIV infection on adults at risk for HIV (among men who have sex with men, transgender
women and heterosexual men, women who have sexual partners with undiagnosed or untreated
HIV infection, sharing of infected needles for PWID, presenting with the following3, 4;:
○ Constitutional symptoms (e.g. fever, fatigue, and myalgia),
○ Adenopathies (i.e. axillary, cervical, and occipital nodes)
○ Oropharyngeal findings (e.g. sore throat with ulcers)
○ Gastrointestinal symptoms (e.g. nausea, diarrhea, anorexia, weight loss)
○ Neurologic findings (e.g. headache)
○ Generalized rash (i.e. pink to red macules)
Screening
●
Encourage voluntary HIV testing, especially among adults at risk . Written informed consent from
the person taking the test must be obtained before HIV testing.5
○ Screen adults for HIV infection with approved antigen/antibody immunoassays or rapid
,
diagnostic test kits. (Strong recommendation 6 7)
●
HIV self-testing, with rapid diagnostic test kits, should be offered as an approach to HIV testing
services (Strong recommendation11)
Diagnostic Tests
●
●
●
Minimum at Primary Care. Perform three consecutive tests using combinations of
antigen/antibody immunoassays or rapid diagnostic tests to diagnose HIV infection.4
Gold Standard. Confirm negative or indeterminate results with HIV-1 nucleic acid test3,6 (Strong
recommendation6)
Additional Tests. Request for the following tests during initial patient visits, to assist in the
selection of antiretroviral (ARV) or pre-exposure prophylactic drug regimens, and monitor for
treatment failure or toxicity, as appropriate. Refer to higher level facilities for testing if these are
not available at primary care.
○ Plasma HIV RNA (viral load) (Evidence A)8.
○ CD4 cell count for identifying advanced HIV disease (Evidence A)8
○ Complete blood count; chemistry profile, including glucose, blood urea nitrogen and
creatinine, liver enzymes and bilirubin, urinalysis, and serologies for hepatitis A, B, and C
viruses (Evidence A)8
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Diagnostic Tests
Serum lipids at baseline
Age-appropriate TB symptom screening4
Pregnancy testing4
Syphilis testing4
HLA-B*5701 test (if abacavir is being considered) (Evidence A)8
Genotypic drug-resistance testing (Evidence A)8
For patients who have HIV RNA levels <1,000 copies/mL, viral amplification for drug
resistance testing should still be performed; however, it may not always be successful
(Evidence B)8
○ Depression screening for adults living with HIV using validated screening tools
(conditional recommendation)4.
Clinical Staging. Classify diagnosed patients according to the WHO clinical staging of HIV to guide
management9
Monitoring. Refer to Section 4.7 of the WHO Consolidated Guidelines for monitoring the response
to ARV.4
○
○
○
○
○
○
○
●
●
Treatment
●
Pharmacologic Therapy. Offer antiretroviral treatment (ART) to all patients diagnosed to have HIV
infection after thorough clinical and laboratory evaluation.4
○ First-line. Offer the following first-line regimens to eligible patients (strong
recommendation).
■ Tenofovir Disoproxil Fumarate (TDF) + lamivudine (3TC) + Dolutegravir (DTG) 300
mg once daily, 150 mg twice daily or 300 mg once daily, 50 mg once daily
■ TDF + Emtricitabine (FTC) + DTG 300 mg once daily, 200 mg once daily, 50 mg
once daily
■ TDF + 3TC (or FTC) + EFV 400 mg, 300 mg once daily, 150 mg twice daily or 300
mg once daily, 400 mg once daily
■ Second Line. Offer the following second-line regimens if the patient manifests
with symptoms of drug toxicity, adverse reactions, or treatment failure with
first-line regimens: boosted protease inhibitors in combination with an optimized
nucleoside reverse-transcriptase inhibitor backbone (Strong recommendation);
DTG in combination with an optimized nucleoside reverse-transcriptase inhibitor
backbone of previously on a non-DTG regimen (Conditional recommendation)4
● Adults on TDF + 3TC (or FTC) + DTG be shifted to Zidovudine (AZT) + 3TC +
Atazanavir/ritonavir [(ATV/r) or Lopinavir/ritonavir (LPV/r)] or AZT + 3TC
+ darunavir/ritonavir (DRV/r) [or raltegravir (RAL) + LPV/r)]
● Adults on TDF + 3TC (or FTC) + EFV be shifted to AZT + 3TC + DTG or AZT +
3TC + ATV/r (or LPV/r or DRV/r) in cases of clinical or immunological
failure or non-suppression of viral load (viral load >1000 copies/mL)
● Adults on AZT + 3TC +EFV be shifted to TDF + 3TC (or FTC) + DTG or TDF +
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Treatment
3TC (or FTC) + ATV/r (or LPV/r or DRV/r)
Start ART as soon as possible within two weeks of initiating TB treatment, regardless of
CD4 cell count (Strong recommendation).4
■ Immune reconstitution inflammatory syndrome (IRIS) is a paradoxical
inflammatory syndrome occurring within 4 to 8 weeks following ART initiation
among people living with HIV newly started on ART, after re-initiation of ART, or
after a change to a more effective ART regimen in patients who fail to achieve
viral suppression10.
● Symptoms depend on the existing opportunistic infection, but patients
responding to TB treatment may have worsening of pulmonary
symptoms, X-ray findings that suggest worsening of TB disease,
enlarging lymph nodes causing airway obstruction, or meningeal
symptoms.
● IRIS is usually accompanied by an increase in CD4 count and/or a rapid
decrease in viral load
● Monitor the presence of symptoms of tuberculosis or other opportunistic
infections (e.g. cryptococcal infections, herpes zoster, hepatitis B or C,
Kaposi sarcoma)
● Initiate appropriate treatment for the underlying condition and continue
ART.
Nonpharmacologic Interventions.
○ Offer counseling for adults living with HIV on the potential benefits and risks of disclosing
their HIV status to others and empowered and supported to determine whether, when,
how and to whom to disclose (Conditional recommendation)4
○ Inform adults living with HIV on the Undetectable = Untransmittable (U=U) principle,
whereby maintaining a plasma HIV RNA (viral load) of <200 copies/mL, including any
measurable value below this threshold value, with ART prevents sexual transmission of
HIV to their partners (Evidence A)8
○ Advise mothers living with HIV to breastfeed for at least 12 months and continue
breastfeeding for up to 24 months or longer (similar to the general population) while being
fully supported for ART adherence (Strong recommendation)4
○ Advise the correct and consistent use of condoms with condom-compatible lubricants
(Strong recommendation)4
○
●
Chemoprophylaxis
●
Pre-exposure prophylaxis
○ Start pre-exposure prophylaxis (PrEP) containing TDF [(e.g (TDF 300 mg + FTC 200 mg;
tenofovir alafenamide-emtricitabine (TAF-FTC)] daily for 90 days for adults at substantial
risk for HIV infection, as applicable, following the 2+1+1 approach before each sexual
activity (strong recommendation). It should be taken as long as the risk of infection
exists.4;11
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Chemoprophylaxis
Offer the dapivirine vaginal ring for adult women at substantial risk of HIV infection, to be
worn for 28 days (Conditional recommendation)4
○ Offer long-acting cabotegravir 600 mg IM once monthly for two doses (3 mL) (Conditional
recommendation)12;11
Post-exposure prophylaxis.
○ Start adults on a TDF + 3TC + DTG or TDF + FTC + DTG regimen within 72 hours after
exposure to HIV for 28 days (Strong recommendation)4;13
○ Offer ATV/r, DRV/r, LPV/r and RAL as alternative third drug options for PEP (Conditional
recommendation).4
Prophylaxis for opportunistic infections
○ Provide co-trimoxazole prophylaxis to all people living with HIV with active TB disease
regardless of CD4 cell count (Strong recommendation)4
○ Provide TPT for PLHIV without active TB disease (Strong recommendation)4
○
●
●
Referral
●
Refer people living with HIV4 to higher levels of care or qualified healthcare providers if they:
○ have advanced HIV disease (defined as WHO stage 3 or 4 or a CD4 count <200 cells/mm3).
○ are in need of social support services for palliative care.
Palliative Care
●
●
Administer pain medications appropriate for the adult’s condition.14
Provide appropriate basic palliative for people living with HIV, as appropriate. All health–care
providers should be trained in at least basic palliative care working at the primary care or
community level who care for people living with HIV4
References
1.
2.
3.
4.
5.
6.
Department of Health. HIV/AIDS & ART Registry of the Philippines. Epidemiology Bureau. Published 2023.
https://www.ship.ph/wp-content/uploads/2023/06/EB_HARP_March_AIDSreg2023.pdf
World Health Organization. HIV and AIDS. 2023. https://www.who.int/news-room/fact-sheets/detail/hiv-aids
UpToDate. Acute and early HIV infection: Clinical manifestations and diagnosis. 2023.
https://www.uptodate.com/contents/acute-and-early-hiv-infection-clinical-manifestations-and-diagnosis?search=hiv&source=searc
h_result&selectedTitle=1~150&usage_type=default&display_rank=1
World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring:
recommendations for a public health approach. 2021. https://www.who.int/publications/i/item/9789240031593
Republic Act No. 11166, “Philippine Aids Prevention and Control Act of 1998”
U.S. Preventive Services Task Force. Human Immunodeficiency Virus (HIV) Infection: Screening. 2019.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/human-immunodeficiency-virus-hiv-infection-screening#f
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Omnibus Health Guidelines ver. 2023 | 192
7.
8.
9.
10.
11.
12.
13.
14.
ullrecommendationstart
University of the Philippines National Institutes of Health - Institute of Clinical Epidemiology. Philippine Guidelines on Periodic Health
Examination (PHEX) Phase 3: Screening for Infectious Diseases. Published 2023.
https://drive.google.com/file/d/1up5YnRyy6S5YpTsGgRoZHo4XDCOSrjR7/view
HHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and
Adolescents with HIV. 2023.
https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf
World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection:
recommendations for a public health approach, 2nd Ed. 2016. https://www.who.int/publications/i/item/9789241549684
Brust et al. Management of Immune Reconstitution Inflammatory Syndrome (IRIS). 2021.
https://www.hivguidelines.org/guideline/hiv-iris/
UpToDate. HIV pre-exposure prophylaxis. 2023.
https://www.uptodate.com/contents/hiv-pre-exposure-prophylaxis?search=hiv%20pre%20exposure%20prophylaxis&source=search
_result&selectedTitle=1~150&usage_type=default&display_rank=1#
World Health Organization. Guidelines on long-acting injectable cabotegravir for HIV prevention. 2022.
https://www.who.int/publications/i/item/9789240054097
UpToDate. Management of nonoccupational exposures to HIV and hepatitis B and C in adults. 2023.
https://www.uptodate.com/contents/management-of-nonoccupational-exposures-to-hiv-and-hepatitis-b-and-c-in-adults?search=hi
v%20post%20exposure%20prophylaxis&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#
World Health Organization. WHO Model List of Essential Medicines for Children - 8th list. 2021.
https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2021.03
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Infectious Diarrhea
The burden of diarrheal diseases is estimated to be 3.6% of the total DALYs worldwide. Based on the Field
Health Information (DOH) report, acute watery diarrhea (AWD) ranked seventh among the top leading causes
of morbidity, affecting 76.3 per 100,000 population.1 In resource-limited settings, crowding, poor sanitation,
and microbiologic origins such as Campylobacter, Salmonella, Shigella, Escherichia, Vibrio, and human
immunodeficiency virus are the risk factors and causative agents of infectious diarrhea, respectively.2
Appropriate prevention, diagnosis, and management of infectious diarrhea are necessary to reduce the risk
of outbreaks, prevent complications, and prevent the development of antimicrobial resistance.
Table 30. Infectious Diarrhea Continuum of Care Overview
Infectious Diarrhea Overview
Risk Factors
Prevention
Screening
Diagnosis
Treatment
Nonpharmacologic
Management
Consumption of contaminated food or water
Travel to an endemic area or an area with outbreak
Observance of hand hygiene and infection control practices, hygiene and sanitation in
the household and community, in line with the Water, Sanitation and Hygiene (WASH)
Strategy (See General Wellness and Preventive Measures)
Immunization for select groups
Salmonella screening in food handlers who had a recent bout of diarrhea
Minimum at primary care: History-taking and PE, including assessment of degree of
dehydration
Gold Standard: Stool culture only for severe cases of acute diarrhea and only during
outbreaks of enteric infections
First Line: Adequate oral hydration with reduced osmolarity oral rehydration
salts/solutions (ORS)
Adjunctive therapy: Racecadotril
Limit antibiotic use to suspected or confirmed cases of Cholera, Shigella,
Non-typhoidal Salmonellosis, and Amoebiasis
Hand hygiene
Avoidance of open defecation
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Signs and Symptoms
●
Suspect acute infectious diarrhea among adult patients presenting with the following:
○ a passage of 3 or more loose, watery, or bloody stools within 24 hours that may be
accompanied by any of the following: nausea, vomiting, abdominal pain, or fever. (Strong
Recommendation1)
Screening
●
Salmonella. Consider screening food handlers for Salmonella after a bout of acute diarrhea. (Good
Practice Statement1)
Diagnostic Tests
●
●
●
●
Minimum at primary care. Perform history-taking and physical examination.
○ Assess for dehydration. Ascertain and classify the degree of dehydration among adults
with acute infectious diarrhea during physical examination by assessing the following:
(Strong Recommendation1)
■ Mild dehydration: With or without fatigue or thirst; normal BP, respiratory rate
(RR), pulse rate (PR), warm extremities, alert, moist oral mucosa, normal skin
turgor and capillary refill time (CRT) ≤ 2 seconds, urine output (UO) ≥ 0.5
mg/kg/hr, body weight (BW) reduction 3-5% in ≤ 7 days OR increase of 3-5% BW in
≤ 7 days after rehydration
■ Moderate dehydration: With fatigue, thirst, sunken eyes, orthostatic
hypotension, increased RR (21-25), increased pulse rate (≥ 100), cold, clammy skin,
lethargy, dry oral mucosa, mild-moderate muscle weakness, skin turgor >2
seconds and CRT >2 seconds, UO <0.5 ml/kg/hr, BW reduction of >5%
■ Severe dehydration: Clinical parameters similar to moderate dehydration but
accompanied by hypovolemic shock (BP <90/60 mmHg), tachypnea (RR ≥ 25),
faint or thready pulses, coma or stupor, and severe muscle weakness
Request for stool examination only when suspecting parasitic infection or in the presence of
bloody diarrhea. (Strong Recommendation1)
Gold Standard: Stool Culture. Request stool cultures only for severe cases of acute diarrhea and
only during outbreaks of enteric infections, within 3 days from the symptom onset and before
administration of antibiotics. (Strong Recommendation1)
Additional laboratory tests. Consider requesting for additional tests depending on clinical
indication or suspicion:
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Diagnostic Tests
○
○
When suspecting complications of acute diarrhea such as moderate to severe
dehydration, acute kidney injury, or electrolyte imbalance: CBC, Urinalysis, Serum
Electrolytes, BUN, Creatinine, serum bicarbonate (Strong Recommendation1)
■ Increased urine specific gravity (≥1.010), increased urine osmolality (>800
mosm/kg), increased serum osmolality (≥295 mosm/kg), increased
BUN/creatinine ratio (>20), Metabolic Acidosis (pH<7.35, HCO3 <22 mmol/L).
During suspected outbreaks of cholera or shigella: rapid diagnostic tests (Strong
Recommendation1)
Treatment
●
●
●
●
●
First line therapy. Give ORS 1.5 to 2 times the estimated volume deficit to adult patients with mild
diarrhea. (Strong Recommendation1)
○ If commercial ORS is not available/accessible, teach patients and their caregivers to
prepare homemade ORS: 4-5 teaspoons sugar plus 1 teaspoon salt in 1 liter of clean
drinking water (sterilized or boiled)
When not to give antibiotics. Empiric antibiotic treatment is not recommended for adults with
acute infectious diarrhea with the following clinical features: mild to moderate dehydration,
non-bloody stools, and symptoms less than 3 days. (Strong Recommendation1)
When to give antibiotics. Prescribe the following antibiotics to adults suspected or confirmed to
have acute infectious diarrhea caused by the following organisms:
○ Cholera: prescribe Azithromycin 1 gram tablet orally as single dose or Ciprofloxacin 500
mg tablet orally twice a day for 3 days (Strong Recommendation1)
○ Shigella: prescribe Azithromycin 1 gram tablet orally as single dose or Ciprofloxacin 500
mg tablet orally twice a day for 5 days (Strong Recommendation1)
○ Non-Typhoidal Salmonella: prescribe Ciprofloxacin 500 mg tablet orally twice a day for 5
days (Strong Recommendation1)
○ Amoebiasis: Prescribe Metronidazole 500-750 mg tablet orally three times a day for 10
days (Strong Recommendation1)
Supportive Therapy. Consider giving Racecadotril 100 mg capsule 3 times a day to adults as
adjunctive therapy to shorten duration of diarrhea. (Weak Recommendation1)
Non-pharmacologic management:
○ Hygiene and sanitation. Advise all patients and household members regarding the
following:
■ Observe hand hygiene to reduce the transmission of organisms that cause
diarrhea. (Strong Recommendation1)
■ Avoid open defecation practices. (Strong Recommendation1)
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Referral
●
Refer to higher level of care patients with acute infectious diarrhea with the following (Strong
Recommendation1):
○ Poor tolerance to oral rehydration
○ Moderate to severe dehydration
○ Acute kidney injury
○ Electrolyte abnormality
○ Unstable comorbid conditions
○ Poor nutritional status
○ Unique social circumstances
○ Elderly or at risk of fluid overload (e.g., heart failure, kidney disease)
References
1.
2.
Department of Health. Clinical Practice Guidelines on the Management of Acute Infectious Diarrhea in Children and Adults. Published
2019. Accessed December 14, 2023. https://drive.google.com/drive/folders/1m-e_DkAucR9O_U58IrK2nCVnhYT3bFj9
UpToDate. Approach to the adult with acute diarrhea in resource-limited settings. Published 2023. Accessed December 14, 2023.
https://www.uptodate.com/contents/approach-to-the-adult-with-acute-diarrhea-in-resource-limited-settings?search=infectious%2
0diarrhea&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=5#H77501856
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Leptospirosis
is a zoonosis coming from direct or indirect contact with the pathogenic spirochetes of the genus Leptospira
from domesticated and wild animals. Sources of infection come from water, soil and/or surfaces
contaminated with infected urine or tissues. Upon contact, the bacteria may enter through cuts and
abrasions in the skin or mucosal surfaces; the conjunctiva; or by inhalation of droplets or aerosols of fluid
containing leptospires. After penetrating intact mucous membranes or epithelium, leptospires enter the
bloodstream and are rapidly carried to all parts of the body.1
In the Philippines, leptospirosis contributes to around 0.2% causes of morbidity in 2020.2 Leptospirosis
tends to occur frequently in urban flood-prone areas such as Metro Manila. More and more frequent
outbreaks of leptospirosis in the Philippines are expected to occur with increasing number of flood
prone-areas and increasing occurrence of flooding due to heavy rainfall, rapid urbanization (dramatic
increase in populations), deforestation, poor road and disaster risk reduction infrastructures among many
other factors1.
Table 31. Leptospirosis Continuum of Care Overview
Leptospirosis Overview
Risk Factors
Prevention
Screening
Diagnosis
Pharmacologic Treatment
Wading or swimming in floods- with or without wounds
Ingestion of flood/ contaminated water
Residing in a flood-prone area
Contact with animal fluids especially carcass
Avoid wading/swimming in floods, ingestion of flood/contaminated water (See
General Wellness and Preventive Measures)
Pre-and post-exposure prophylaxis:
● Pre-exposure prophylaxis: Doxycycline 200 mg orally once a week, to
begin 1 to 2 days before exposure and continued throughout the period
of exposure, for short-term exposures
● Post-exposure prophylaxis.
Mild Risk: Doxycycline 200 mg single dose, immediately within 24 to 72
hours from exposure
Moderate Risk: Doxycycline 200 mg once daily for 3-5 days to be started
immediately within 24 to 72 hours from exposure
High Risk: Doxycycline 200 mg once weekly until the end of exposure
Not applicable
Minimum at primary care: Clinical history-taking, physical examination.
Gold Standard: PCR or culture of blood during the first 4 to 6 days of symptoms,
or urine after the first week of illness
First Line: Doxycycline 100 mg tab twice daily orally for 7-10 days
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Signs and Symptoms
Suspect leptospirosis among patients presenting with:
● Acute febrile illness of at least 2 days, and
● With two or more of the following symptoms: myalgia, calf tenderness, conjunctival suffusion,
chills, abdominal pain, headache, jaundice, or oliguria, and
● With risk factors including: wading or swimming in floods, with or without wounds, ingestion of
flood/ contaminated water, residing in a flooded area, contact with animal fluids especially
carcass.1
Screening
●
Not applicable
Diagnostic Tests
●
●
●
Minimum at primary care. Perform thorough clinical history-taking and physical examination. A
high index of suspicion and early recognition is needed for initiation of treatment to prevent
complications and mortality.1
○ Classify leptospirosis as anicteric (mild) or moderate to severe(icteric):
■ Mild (anicteric) Leptospirosis: stable vital signs, anicteric sclera, no jaundice,
with good urine output, no meningismus, no dyspnea, no tachypnea, no bleeding,
no hemoptysis, not in sepsis, and can take oral medications
■ Moderate-Severe (Icteric) Leptospirosis: unstable vital signs, with jaundice,
icteric sclera, abdominal pain, nausea, vomiting and diarrhea, with oliguria or
anuria, bleeding, meningismus, with sepsis, altered mental status, hemoptysis or
difficulty of breathing
Gold Standard. Request for PCR or culture of appropriate clinical specimens depending on the
timing of the illness as follows: blood during the first 4 to 6 days of symptoms, or urine after the
first week of illness3. Confirmation with the gold standard may not always be available at primary
care; hence, a high index of clinical suspicion is necessary to prompt appropriate management.
Additional laboratory tests at primary care.
○ Request for Complete Blood Count with Platelet Count, Urinalysis, Blood Urea Nitrogen,
Creatinine, ALT and AST among adults with mild leptospirosis1.
○ Consider requesting a serologic test (e.g. microscopic agglutination test) to confirm
○
leptospiral infection if PCR and culture are not available.1
Other tests should be requested for inpatients or patients with complications, depending
on the clinical indication.
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Treatment
●
●
●
First line therapy. Doxycycline 100 mg tab twice daily orally for 7-10 days 1,4
Alternative. Consider either of the following antibiotics as an alternative to the first line
management if with contraindications (e.g., allergy) to first-line therapy:
○ Amoxicillin 500mg four times a day or 1 g every 8 hours orally1
○ Azithromycin 1g initially followed by 500 mg once a day for the next 2 days or 500 mg once
a day for 3 days 1,4
Treatment in Pregnancy. For pregnant adults, consider prescribing azithromycin 500 mg orally
once daily for three days or amoxicillin (25 to 50 mg/kg in three equally divided doses for seven
days.4
Chemoprophylaxis
●
●
Pre-exposure prophylaxis
○ Consider prescribing Doxycycline 200 mg orally once a week, to begin 1 to 2 days before
exposure and continued throughout the period of exposure, for adults with short-term
exposures such as those who intend to visit highly endemic areas including travelers,
soldiers, or adults who engage in water-related recreational and occupational activities,
disaster relief workers deployed to flooded or post-typhoon areas 1,5.
Post-exposure prophylaxis. This also requires prior consultation with a physician. Depending on
the risk exposure, consider prescribing the following1,5:
○ Mild Risk: adults with single exposure, non-mucosal or no breaks in the skin: Doxycycline
200 mg single dose, immediately within 24 to 72 hours from exposure
○ Moderate Risk: adults with mucosal exposure, presence or wound: Doxycycline 200 mg
once daily for 3-5 days to be started immediately within 24 to 72 hours from exposure
○ High Risk: adults with repeated or continuous exposure: Doxycycline 200 mg once weekly
until the end of exposure1
○ Pregnant women: Amoxicillin 500 mg/tablet - 1 tablet twice a day for 3 days. If allergic to
amoxicillin, may give erythromycin 250 mg/tablet twice a day for 3 days5.
Referral
●
Refer patients suspected of having moderate to severe (icteric) leptospirosis who present with
the following signs and symptoms to higher level of care1
○ Unstable vital signs
○ Jaundice/ icteric sclerae
○ Abdominal pain, nausea, vomiting or diarrhea
○ Oliguria or anuria
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Referral
○
○
○
○
○
Bleeding
Meningismus/ meningeal irritation/ nuchal rigidity,
Altered mental status, seizures
Difficulty of breathing or hemoptysis
Sepsis
First Aid Measures and Basic Emergency Care
●
Administer the following first aid measures to adults prior to referral to next level of care1:
○ Loading dose of Penicillin G 1.5 million units IV divided in 6 hours or Ceftriaxone 1gm IV
○ Fluid resuscitation, as warranted, to adults using balanced crystalloids/ NSS at 20ml/kg/h
or 500ml of crystalloids within 15- 30 minutes
References
1.
2.
3.
4.
5.
Department of Health. DOH Guidelines for Leptospirosis for Hospitals. Published 2019. Accessed December 14, 2023.
https://drive.google.com/drive/folders/1pxQDWu3H1rmtGlXhJB2G1ZA1x09DREgk
Department of Health. 2020 Philippine Health Statistics. Published 2020. Accessed December 14, 2023.
https://doh.gov.ph/sites/default/files/publications/2020PHS_FINAL_PDF.pdf
UpToDate. Leptospirosis: Epidemiology, microbiology, clinical manifestations, and diagnosis. Published 2023. Accessed
December 14, 2023.
https://www.uptodate.com/contents/leptospirosis-epidemiology-microbiology-clinical-manifestations-and-diagnosis?search=l
eptospirosis&source=search_result&selectedTitle=1~84&usage_type=default&display_rank=1#H6
UpToDate. Leptospirosis: Treatment and prevention.Published 2023. Accessed December 14, 2023.
https://www.uptodate.com/contents/leptospirosis-treatment-and-prevention/print
Department of Health. DOH DM 2023-0309: Guidelines on the Prevention, Control, Management, and Surveillance of
Leptospirosis.Published 2023. Accessed December 14, 2023.
https://drive.google.com/file/d/1rjEaSd-2_wWckYQipCJPRtxnn5v55cQe/view
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Tinea Infection
is a fungal infection more commonly called “ringworm” due to its classic appearance of circular,
erythematous, pruritic rash. Fungal skin diseases contributed to about 0.17% of total DALYs among Filipinos
in 2019.1 Tinea infection has a specific name depending on the part affected, such as tinea pedis for foot,
tinea cruris for groin, tinea capitis for scalp, and tinea corporis for other parts of the body.2 Though tinea
infection is not included in the WHO fungal priority pathogens list 20223, it is common in the country. In a
study conducted by Handog, E. and Dayrit, J. in 20054, it is found that fungal infections rank as second
leading cause of dermatology consultation with tinea corporis (22.63%), tinea cruris (16.7%), and tinea pedis
(16.38%) belonging to the most frequently encountered cases.
Table 32. Tinea Infection Continuum of Care Overview
Tinea Infection Overview
Risk Factors
●
●
●
●
●
●
●
Weakened immune system (e.g. diabetes)
Use of public showers or locker rooms
Athletes particularly those in contact sports
Wearing tight shoes
Excessive sweating
Obesity
Close contact with infected human or animal
Prevention
Screening
Diagnosis
Observance of proper personal hygiene (See General Wellness and Preventive Measures)
Not applicable.
Minimum at Primary Care. History and physical examination
Gold standard. Fungal culture.
Pharmacologic
Treatment
First Line: topical antifungal once or twice a day for 1-2 weeks
Alternative: oral antifungal for extensive lesions, or refractory response to topical
antifungal
Non-pharmacologic
management
●
●
●
Avoid sharing towels or clothes.
Avoid occlusive footwear or clothing
Avoid walking barefoot in pools or public showers.
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Signs and Symptoms
●
Consider tinea infection among adults presenting with pruritic rashes on various areas of the
body such as5,6:
○ Tinea pedis: pruritic, erythematous and scaly lesions on the foot, usually on the interdigits
appearing as maceration or scales between the toes and is often caused by walking
barefoot in locker rooms, swimming pools or communal spaces, or by using occlusive
footwear.
○ Tinea corporis: appearing as a pruritic, circular, erythematous patch with scales and with
central clearing on various parts of the body, and is often transmitted by direct skin
contact or fomites.
○ Tinea cruris: manifesting as pruritic, erythematous scaly patch with central clearing
usually starting on the medial thigh and is more common among males, or those who
sweat profusely, obese adults, with diabetes mellitus or adults with immunodeficiency.
Diagnostic Tests
●
●
●
Minimum at primary care
○ Diagnose tinea infections through history and physical examination of the affected
areas5,6
Gold Standard
○ Consider requesting fungal culture to confirm the diagnosis of tinea among adults6
Additional Tests
○ Consider potassium hydroxide (KOH) preparation on skin scrapings from the affected
areas.5,6
Treatment
●
Pharmacologic Therapy
○ First line: Consider topical anti-fungal preparations once or twice a day for 1 to 2 weeks
for localized infections6:
■ Azoles:
● Clotrimazole 1% cream, ointment, or solution
● Econazole 1% cream or foam
● Ketoconazole 2% cream, gel or foam
● Luliconazole 1% cream
● Miconazole 2% cream, ointment, solution, or powder
● Oxiconazole 1% cream or lotion
● Sertaconazole 2% cream
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Treatment
●
● Sulconazole 1% cream or solution
■ Allylamines
● Naftifine 1% or 2% cream or gel
● Terbinafine 1% cream or spray solution
■ Benzylamine: Butenafine 1% cream
○ Alternative: Consider oral anti-fungal preparations for extensive lesions, or those with
refractory response to topical anti-fungal6:
■ Terbinafine 250 mg tablet, 1 tablet daily for 1 to 2 weeks
■ Itraconazole 200 mg tablet twice a day for 1 week
■ Fluconazole 150 to 200 mg tablet once weekly for 2-6 weeks
■ Griseofulvin 250 mg tablet, 4 tablets a day for 4-8 weeks
Nonpharmacologic
○ May advise adult patients with tinea to avoid sharing towels or clothes, avoid occlusive
footwear or clothing, and avoid walking barefoot in pools or public showers.5,6
References
1.
2.
3.
4.
5.
6.
Institute of Health Metrics and Evaluation. GBD Compare. Published 2019. Accessed December 15, 2023.
https://vizhub.healthdata.org/gbd-compare/
U.S. Centers for Disease Control and Prevention. About Ringworm. Published 2021. Accessed December 15, 2023.
https://www.cdc.gov/fungal/diseases/ringworm/definition.html
World Health Organization. WHO fungal priority pathogens list to guide research, development and public health action. Published
2022. Accessed December 15, 2023. https://www.who.int/publications/i/item/9789240060241
Handog EB, Dayrit JF. Mycology in the Philippines, Revisited. Nippon Ishinkin Gakkai Zasshi. 2005;46(2):71-76.
doi:https://doi.org/10.3314/jjmm.46.71
UpToDate.
Dermatophyte
(tinea)
infections.
Published
2023.
Accessed
December
16,
2023.
https://www.uptodate.com/contents/dermatophyte-tinea-infections?search=tinea&source=search_result&selectedTitle=1~118&
usage_type=default&display_rank=1#H2696183692
Kovitwanichkanont T, Chong AH. Superficial fungal infections. Australian Journal of General Practice. 2022;48(10). Accessed
December 17, 2023. https://www1.racgp.org.au/ajgp/2019/october/superficial-fungal-infections
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Tuberculosis, Pulmonary
is a lung infection caused by Mycobacterium tuberculosis, which can be transmitted through the air by
infected individuals, mainly through coughing. Pulmonary Tuberculosis (PTB) manifests in two disease states
- latent tuberculosis infection (LTBI) and acute tuberculosis disease, with drug-resistant strains posing a
global health challenge. In 2022, approximately 10.6 million people worldwide developed TB. Notably, the
Philippines is one of the eight countries contributing to two-thirds of global TB cases. Although in contrast,
the country, along with India and Indonesia, collectively accounted for ≥ 60% of the global reductions in the
number of newly diagnosed TB in 2020 and 20211. PTB remains a priority public health problem and the goal is
to align with the Sustainable Development Goals to reduce global TB incidence by 80% and a 90% reduction
in TB deaths by 2030. However, the prevalence rate for the Philippines is still at 638 per 100,000 population in
2022. The country is aiming to contribute to the endeavors of reducing the prevalence rate globally to only
less than 10 per 100,000 population in 20351.
The scope of this section is limited to drug-susceptible and drug-resistant pulmonary tuberculosis and does
not include specific management for the different forms of extrapulmonary TB.
Table 32. Pulmonary Tuberculosis Continuum of Care Overview
Pulmonary Tuberculosis Overview
Risk Factors
Prevention
Screening
Diagnosis
Pharmacologic
Treatment
Structural risk factors: Urban poor/homeless communities, Geographically Isolated and
Disadvantaged Areas (GIDA), Indigenous populations, Migrants, Refugees, Prisons and
penitentiary institutions, Internally displaced and other marginalized groups
Occupational risk factors: Current and former workers in workplaces with silica exposure,
miners, Health care workers
Clinical risk factors: TB prevalence in the general population is 100/100,000 population is
higher, Untreated fibrotic lesions seen on chest x-ray, Diabetes mellitus, History of TB,
Chronic lung disease, Smoking/vaping, Alcohol use disorder, Substance use disorder,
Malnourishment, Pregnancy, Immunocompromising condition (e.g. organ transplant, renal
failure, dialysis)
Cough etiquette and respiratory hygiene (See General Wellness and Preventive Measures)
Chemoprophylaxis: TB Preventive Treatment (TPT) to all eligible contacts of TB patients
Minimum at primary care: Systematic screening using: symptom screen tool, chest x-ray or
molecular WHO-recommended rapid diagnostic test, alone or in combination
Alternative: Chest x-ray with computer-aided detection (CAD-AI) software, Xpert MTB/RIF
Minimum at primary care: Sputum Xpert MTB/RIF or Xpert Ultra
Gold Standard: TB culture with phenotypic drug susceptibility test (DST)
First Line for Drug-susceptible Pulmonary TB: Regimen 1: 2HRZE/4HR comprised of:
Isoniazid (H), Rifampicin (R), Ethambutol (E), Pyrazinamide (Z)
First Line for Drug-resistant Pulmonary TB: Depending on the resistance patterns,
regimen may vary as Standard Short All Oral Regimen (SSOR), Standard Long All Oral
Regimen for fluoroquinolone susceptible (SLOR FQ-S), SLOR for fluoroquinolone resistance
(SLOR FQ-R) that may be comprised of:
Group A: Levofloxacin, Moxifloxacin, Bedaquiline, and Linezolid
Group B: Clofazimine, and Cycloserine
Group C: Ethambutol, Delamanid, Pyrazinamide, and Prothionamide
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Signs and Symptoms
●
Suspect pulmonary tuberculosis among adults with:
○ Any of the following symptoms: cough > 2 to 3 week’s duration or wheezing,
lymphadenopathy, fevers, night sweats, unexplained weight loss, or
○ Relevant epidemiologic factors: history of prior TB infection or disease, known or
possible TB exposure for at least 2 weeks, and/or past or present residence in or travel to
an area where TB is endemic2.
Screening
●
●
Minimum at primary care. Consider conducting systematic screening using a symptom screen
tool, and/or chest x-ray for adults with signs and symptoms, or those with the following risk
factors (conditional recommendation)2:
○ Subpopulations with structural risk factors (urban poor communities, homeless
communities, GIDA, indigenous populations, migrants, refugees, internally displaced
persons and other marginalized groups) (conditional recommendation)3 ;
○ Adults living with HIV (strong recommendation)3;
○ Household contacts and other close contacts of individuals with TB disease (strong
recommendation)3;
○ Prisons and penitentiary institutions (strong recommendation)3
○ Current and former workers in workplaces with silica exposure (strong recommendation)3;
and
○ In settings where the TB prevalence in the general population is at least 100/100,000
population, such as the Philippines, consider screening among adults with clinical risk
factors for TB who are either seeking health care or who are already in care (conditional
recommendation)3:
■ Untreated fibrotic lesions seen on chest x-ray
■ Diabetes mellitus (DM)
■ History of TB
■ Chronic lung disease
■ Smoking
■ Alcohol use disorder
■ Substance use disorder
■ Malnourishment
■ Pregnancy
■ Immunocompromising condition (e.g. organ transplant, renal failure, dialysis)
■ Health care workers
Alternative screening tests.
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Screening
○
○
Consider requesting chest x-ray with computer-aided detection (CAD-AI) software
programs in place of human readers for interpreting digital chest x-rays as an alternative
for screening and triage of TB disease for adults. (Conditional recommendation4)
Consider requesting Xpert MTB/RIF as additional screening test for TB in high-risk groups
(Conditional recommendation4)
Diagnostic Tests
●
●
●
Minimum at Primary care. Request for Sputum Xpert MTB/RIF or Xpert Ultra as initial diagnostic
test for TB and rifampicin-resistance detection in sputum for adults. (Strong recommendation5)
Gold standard. Consider requesting the TB confirmatory and gold standard, TB culture with
phenotypic drug susceptibility test (DST) for the definitive diagnosis and drug resistance testing
for TB2.
Additional tests. The following may be requested when clinically indicated and/or when available
programmatically:
○ Alternative tests. Consider requesting the following as alternative, as indicated:
■ AFB sputum smear microscopy and culture, if Chest X-ray is suggestive of TB in
the lungs or airways2;
■ Sputum Truenat MTB or MTB Plus as an initial diagnostic test, alternative to
smear microscopy or culture, for Adults with signs and symptoms of pulmonary
TB. (Conditional recommendation5);
■ Loop-mediated isothermal amplification (TB-LAMP) as an alternative to sputum
smear microscopy for diagnosing TB or a follow-on test to smear microscopy in
adults (Conditional recommendation5);
○ Drug susceptibility testing. Consider requesting the following as additional or alternative
test to culture-based phenotypic DST (Conditional recommendations5):
■ Sputum Truenat MTB-RIF Dx as an initial test for rifampicin resistance for adults
with signs and symptoms of pulmonary TB and a Truenat MTB or MTB Plus
positive result;
■ Low complexity NAAT for the detection of isoniazid and second-line TB agents
resistance (Conditional recommendation);
■ Moderate complexity automated nucleic acid amplification test (NAAT) for
detection of TB and resistance to rifampicin and isoniazid;
■ High complexity reverse hybridization-based NAATs for the detection of
pyrazinamide resistance;
■ First-line line-probe assay (LPAs) for the detection of rifampicin and isoniazid
resistance in adults with a sputum smear-positive specimen or a cultured isolate
of Mycobacterium tuberculosis complex;
■ Second-line LPAs for the detection of fluoroquinolones and second-line
injectable drug resistance in adults with confirmed MDR/RR-TB.
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Diagnostic Tests
○
○
○
Consider requesting sequence-based testing such as pyrosequencing, Sanger
sequencing, and next generation sequencing for adults with pulmonary TB to determine
genetic identity of a particular mycobacterial mutation and predict drug resistance2.
Consider requesting lateral flow urine lipoarabinomannan assay for HIV-positive adults in
outpatient settings with signs and symptoms of TB or seriously ill, and irrespective of
signs and symptoms of TB and with a CD4 cell count of less than 100 cells/mm3
(Conditional recommendation5).
Drug Toxicity Monitoring
■ Conduct liver function tests (serum transaminases and bilirubin) as baseline prior
to initiation of treatment, and monthly evaluation of symptoms of hepatitis
among adults, and pregnant women with TB disease or TB infection2.
■ Assess baseline platelet count and serum creatinine of adult patients receiving
rifampin, in addition to the hepatic enzyme evaluation prior to the initiation of
therapy6.
■ Consider conducting periodic monitoring of adverse effects of antituberculous
drugs through the following tests, as appropriate7:
● Creatinine clearance
● Physical Examination maneuvers such as but not limited to, visual acuity
and red-green color discrimination, and brief peripheral neuropathy
screening.
● Renal function
● Electrolytes (potassium, calcium, magnesium)
● Audiology testing and evaluation for tinnitus and vestibular toxicity
● Thyroid stimulating hormone
● Psychiatric symptom monitoring (depression and mood changes). Refer
to the Screening for Anxiety, and Depression section.
● Complete blood count
● Electrocardiogram
Treatment for Active Disease
●
Pharmacologic Therapy.
○ First-line regimens for drug-susceptible TB
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Treatment for Active Disease
Give the six-month treatment Regimen 1: 2HRZE/4HR for all adults with
drug-susceptible TB (Strong recommendation8) with either of the following
eligibility criteria9:
● New or retreatment with the following Xpert results:
○ MTB, RIF Sensitive,
○ MTB, RIF indeterminate
● New pulmonary TB patient with positive SM/TB LAMP or clinically
diagnosed, and:
○ Xpert not done
○ Xpert result is MTB not detected
■ Recommended daily doses for 2HRZE/4HR in adults8;10:
● Isoniazid (H): 4 - 6 mg/kg, 300 mg formulation
● Rifampicin (R): 8 - 12 mg/kg, 300 mg formulation
● Ethambutol (E): 15 - 25 mg/kg, 400 mg formulation
● Pyrazinamide (Z): 20 - 30 mg/kg, 500 mg formulation
First-line regimens for drug-resistant TB
■ Depending on the TB resistance patterns, give the following treatment regimen
for adults with confirmed drug-resistant TB:
● Regimen 3: Standard Short All Oral Regimen (SSOR) for MDR-TB and
RR-TB eligible to SSOR, give, 4-6 months: Linezolid (Lfx) - Bedaquiline
(Bdq) - Clofazamine (Cfz) - Prothionamide (Pto) - Ethambutol (E) Pyrazinamide (Z) - High dose Isoniazid (HdH) [Bdq shall always be given
for 6 months] for 4-6 months; or Linezolid - Clofazamine (Cfz) Pyrazinamide (Z) - Ethambutol (E) for 5 months.
● Regimen 4: Standard Long All Oral Regimen for FQ Susceptible (SLOR
FQ-S) for MDR-TB and RR-Tb eligible to SLOR (no FQ resistance), give
Levofloxacin (Lfx) - Bedaquiline (Bdq) - Linezolid (Lzd) - Clofazamine (Cfz)
for 6 months; or Levofloxacin (Lfx) - Linezolid (Lzd) - Clofazamine (Cfz) for
12 - 14 months.
● Regimen 5: Standard Long All Oral Regimen for FQ Resistance (SLOR
FQ-R) for MDR-TB and RR-TB eligible to SLOR (with FQ resistance), give 6
Months: Linezolid (Lzd) - Bedaquiline (Bdq) - Delamanid (Dlm) Clofazamine (Cfz) - Cycloserine (Cs) for 6 months; or 12 - 14 Months:
Linezolid (Lzd) - Clofazamine (Cfz) - Cycloserine (Cs) for 12 - 14 months.
● Recommended daily doses of anti-TB medicines for treatment of
multidrug-resistant TB for adults8;10:
○ Group A - Levofloxacin: no weight-based dosing proposed, usual
upper daily dose of 1.5g, 250 mg formulation; Moxifloxacin: no
weight-based dosing proposed, usual upper daily standard dose
of 400 mg, 400 mg formulation; Bedaquiline: no weight-based
dosing proposed, usual upper daily dose of 400 mg, 100 mg
■
○
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Treatment for Active Disease
○
○
formulation; Linezolid: no weight-based dosing proposed, usual
upper daily dose of 1.2 g, 600 mg tab formulation.
○ Group B - Clofazimine: no weight-based dosing proposed, usual
upper daily dose of 100 mg, 50 mg or 100 mg formulation;
Cycloserine: 10 - 15 mg/kg, 250 mg formulation.
○ Group C - Ethambutol: 15 - 25 mg/kg, 400 mg formulation;
Delamanid: no weight-based dosing proposed, usual upper daily
dose of 200 mg, 50 mg formulation; Pyrazinamide: 20 - 30
mg/kg, 500 mg formulation; Prothionamide: 15 - 20 mg/kg, 250
mg formulation.
Second-line regimens for drug-susceptible TB
■ Consider giving a four-month drug-susceptible pulmonary TB treatment regimen
of isoniazid, rifapentine, moxifloxacin and pyrazinamide: 2HPMZ/2HPM to adults
with body weight >40 kg, including those who are also HIV-positive with CD4
count of >100 cells/mm3 (Conditional recommendation11)
● The following criteria excludes the adult patient in receiving the
2HPMZ/2HPM regimen:
○ Patients with < 40 kg of weight
○ Patients with severe extrapulmonary TB
○ PLHIV with a CD4 of < 100 cells/mm3
○ pregnant , breastfeeding and postpartum women
Second-line regimens for drug-resistant TB
■ Consider giving a 6-month treatment regimen consisting of bedaquiline,
pretomanid, linezolid (600 mg) and moxifloxacin (BPaLM) to adults with
MDR/RR-TB and in whom resistance to fluoroquinolones has been excluded
(Conditional recommendation11).
■ Consider the use of the 9-month all-oral regimen in patients with MDR/RR-TB and
in whom resistance to fluoroquinolones has been excluded (Conditional
recommendation11).
■ Consider giving rifampicin, ethambutol, pyrazinamide and levofloxacin, with or
without isoniazid for 6 months, for adults with confirmed rifampicin-susceptible,
isoniazid-resistant tuberculosis (Hr-TB) (Conditional recommendation4).
■ Consider preparing an Individualized Treatment Regimen by constructing at least
4–5 likely effective drugs for adults undergoing retreatment MDR-TB and/or with
RR-TB cases (not eligible to SSOR nor SLOR)9.
■ Consider giving longer regimens (18 - 20 months) comprised of all Group A agents
and at least one Group B agent for adults with multidrug- or rifampicin-resistant
tuberculosis (MDR/RR TB). Throughout the remainder of the treatment, a
minimum of three agents should be maintained, even if bedaquiline is
discontinued. If only one or two agents from Group A are utilized, both agents
from Group B should be included. In cases where a regimen cannot be formulated
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Treatment for Active Disease
●
●
solely with agents from Groups A and B, agents from Group C are introduced to
complete the treatment (Conditional Recommendation11).
■ Longer treatment regimens may be used in the following situations11:
● Additional resistance to key medicines of the BPaLM/BPaL regimen
(except moxifloxacin) or the 9-month oral regimen.
● Lack of response to shorter treatment regimens
● Drug tolerance to the component medicines of the BPaLM/BPaL regimen
(except moxifloxacin) or 9 months shorter all-oral treatment regimen.
● Pregnant and lactating women who could not benefit from the 9-month
shorter all-oral regimen because of certain clinical conditions
■ Consider the following recommendations for the composition of longer
treatment regimens for adults:
● Should be included (Strong recommendation11): Levofloxacin or
moxifloxacin ; Bedaquiline; Linezolid
● May be included (Conditional recommendation11): Clofazimine and
cycloserine or terizidone; ethambutol; Delamanid; Pyrazinamide;
Imipenem-cilastatin or meropenem; amikacin (if adequate adverse
reactions are ensured to be monitored, may be replaced by streptomycin
if amikacin is not available); ethionamide or prothionamide, and
p-aminosalicylic acid (if bedaquiline, linezolid, clofazimine or delamanid
are not used or if better options to compose a regimen are not possible)
● Not to be included: Kanamycin and capreomycin (Conditional
recommendation11); clavulanic acid (Strong - Against use11)
Other pharmacologic therapies. Offer as clinically appropriate12.
○ Ancillary medicines for the management of drug side effects (antiemetics, antacids,
pyridoxine, potassium replacement, thyroxine, medicines for psychiatric conditions, etc.);
○ Medicines for the management of possible comorbidities (cotrimoxazole, antiretroviral
drugs, metformin)
Non-pharmacologic Therapy
○ Nutrition buildup.
■ Assess and provide counseling based on nutritional status of all adults with active
TB (Strong recommendation13). This includes the provision of nutritional
sustenance on patients under treatment for faster healing and recovery, or the
rendering nutritional advice to identify appropriate food for the patient’s
condition, as well as fostering healthy eating habits and practices9.
○ Provide health education and counseling for adults on TB treatment, including smoking
cessation
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Preventive Treatment for Contacts
●
Offer TB Preventive Treatment (TPT) to all eligible contacts of TB patients.
○ Either a tuberculin skin test (TST) or interferon-gamma release assay (IGRA) can be used
to test for Latent TB Infection (Strong Recommendation14)
○ Give TPT to adults who are in contact with a person with TB who are found not to have
active TB by an appropriate clinical evaluation or according to the eligibility criteria set by
the National Tuberculosis Program:
a. Offer TPT to the following risk groups once active TB is ruled out. Tuberculin Skin
Test (TST) or interferon-gamma assays (IGRA) are not required prior to TPT
initiation in these patients:
● PLHIV aged 1 year or older
● Individuals 5 years and older with other TB risk factors and who are
household contacts of bacteriologically confirmed pulmonary TB
b. Offer TPT to the following risk groups upon ruling out TB infection using TST or
IGRA:
● Household contacts of bacteriologically confirmed pulmonary TB cases
who are 5 years and older with no other risk factors for TB.
● Close contacts of bacteriologically confirmed pulmonary TB
● Any of the following patients: receiving dialysis, preparing for an organ or
hematological transplantation, patients initiating anti-TNF treatment,
those with silicosis.
○ Tuberculosis preventive treatment options:
■ Regardless of HIV status:
● 6 or 9 months of daily isoniazid (6H, 9H) or 3-month regimen of weekly
rifapentine plus isoniazid (3HP)14:
○ 6H, 9H: daily isoniazid (5 mg/kg/day) for 6 or 9 months
○ 3HP: weekly rifapentine (150 mg) plus isoniazid (300 mg) [or
Isoniazid + Rifapetine FDC 300mg/300mg] regimen for 3 months
● Offer 1-month daily rifapentine plus isoniazid (1HP) or 4 months daily
rifampicin (4R) as alternative regimens (Conditional recommendation14).
● 1HP: daily rifapentine (600 mg/day) plus isoniazid (300 mg/day) for one
month (28 doses)
● 4R: daily rifampicin for four months 10 mg/kg/day, not to exceed 600 mg
daily
■ Offer 36 months daily isoniazid preventive treatment for adults living with HIV
who have an unknown or a positive LTBI test and are unlikely to have active TB
disease, irrespective of ART status, degree of immunosuppression, TB treatment
history and pregnancy status (Conditional recommendation14).
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Referral
●
Refer to following adult TB patients to higher levels of care:
○ With presumptive severe forms of extrapulmonary tuberculosis (such as TB meningitis,
disseminated TB and osteoarticular TB)
○ With presumptive DR-TB
○ With other comorbidities such as Severe Acute Malnutrition and Human
Immunodeficiency Virus Infection13
○ With altered or depressed mental status or seizures, including status epilepticus
○ Adults suspect of antituberculous drug toxicity such as: hepatotoxicity, dermatologic
effects, severe systemic reactions, QT prolongation, neurotoxicity, ototoxicity and
nephrotoxicity, hematologic effects, ophthalmic toxicity, musculoskeletal and endocrine
effects, among others.
References
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2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
World Health Organization. Global Tuberculosis Report. Published 2023. Accessed December 14, 2023.
https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2023
UpToDate. Diagnosis of pulmonary tuberculosis in adults. Published 2022.Accessed December 14, 2023.
https://www.uptodate.com/contents/diagnosis-of-pulmonary-tuberculosis-in-adults?search=pulmomary%20tuberculosis%20r
eferral&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
World Health Organization . WHO consolidated guidelines on tuberculosis - Module 2: screening – systematic screening for
tuberculosis disease. Published 2021. Accessed December 13, 2023. https://tbksp.org/en/node/1274
World Health Organization. WHO consolidated guidelines on tuberculosis - Module 5: management of tuberculosis in children and
adolescents. Published 2022. Accessed December 14, 2023. https://www.who.int/publications/i/item/9789240046764
World Health Organization. WHO consolidated guidelines on tuberculosis - Module 3: diagnosis: rapid diagnostics for tuberculosis
detection. Published 2021. Accessed December 13, 2023. https://tbksp.org/en/node/4
UpToDate. Rifamycins (rifampin, rifabutin, rifapentine). Published 2022. Accessed December 13, 2023.
https://www.uptodate.com/contents/rifamycins-rifampin-rifabutin-rifapentine?search=tuberculosis%20toxicity&source=searc
h_result&selectedTitle=9~150&usage_type=default&display_rank=9#H9
UpToDate. Antituberculous drugs: An overview. Published 2022. Accessed December 14, 2023.
https://www.uptodate.com/contents/antituberculous-drugs-an-overview?search=tuberculosis%20drug%20toxicity&source=se
arch_result&selectedTitle=1~150&usage_type=default&display_rank=1#H2636671244
World Health Organization. WHO operational handbook on tuberculosis: module 4: treatment: drug-resistant tuberculosis
treatment. Published 2020. Accessed December 14, 2023. https://www.who.int/publications/i/item/9789240006997
Department of Health. National Tuberculosis Program - Manual of Procedures, 8th Edition. Published 2020. Accessed December
14 2023. https://ntp.doh.gov.ph/download/ntp-mop-6th-edition/
Department of Health. Philippine National Formulary. DOH Pharmaceutical Division. Published 2019. Accessed December 14, 2023.
https://drive.google.com/file/d/1QA05jVfoQu7DJZihMRx5Mq53TobWTwah/view
World Health Organization. WHO consolidated guidelines on tuberculosis - Module 4: treatment: drug-susceptible tuberculosis
treatment. Published 2022. Accessed December 14, 2023. https://www.who.int/publications/i/item/9789240048126
International Union Against Tuberculosis and Lung Disease. Management of Tuberculosis: A Guide to Essential Practice.
Published 2019. Accessed December 14, 2023. https://theunion.org/sites/default/files/2020-08/TheUnion_Orange_2019.pdf
World Health Organization. WHO consolidated guidelines on tuberculosis - Module 6: Nutritional care and support for TB patients
Book traversal links for Module 6: Nutritional care and support for TB patients. Published 2013. Accessed December 14, 2023.
https://tbksp.org/en/node/704
World Health Organization. WHO consolidated guidelines on tuberculosis - Module 1: tuberculosis preventive treatment. Published
2020. Accessed December 14, 2023. https://tbksp.org/en/node/
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National Practice Guidelines
Program Products
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The Omnibus Health Guideline: Rollout
Guide ver. 1. 2023
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Quick Guide on the Adoption and
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Guidelines and Other Case Management
Protocols for Local Health Systems
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Sample Clinician Support Tool (CST) for
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Link to Sample Hypertension CST
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