Legal basis, policy linkage, and prior issuances
- The Order is issued in line with the goal of better health outcomes under AO No. 2005-0023, reflected through malaria morbidity and mortality reduction targets.
- The Order revises the anti-malaria drug policy previously established under AO No. 129-A s. 2002 requiring further study before adoption nationwide of artemisinin-based combination therapy (ACT).
- The Order is framed as the updated diagnostic and treatment policy and guidelines responding to the further-study requirement under AO No. 129-A s. 2002.
- The Order rescinds Administrative Order 19, s. 1996, AO 129 s. 2002, and all other orders and related issuances inconsistent with its provisions.
Policy declaration and guiding objectives
- The Malaria Control Program aims for the reduction of malaria morbidity by at least 70% and mortality by 50% in the 26 category A provinces.
- The Malaria Control Program aims to declare more malaria-free provinces and prevent the recurrence of malaria in malaria-free provinces.
- The policy targets reversing the malaria incidence trend by 2015.
- The revised policy shifts the first-line drug treatment of falciparum malaria from CQ + SP combination to AL combination.
Guiding principles for implementation
- The implementation of the revised policy and guidelines is subject to continuous review and evaluation by technical experts.
- Efficacy studies must be regularly undertaken, and effective diagnosis and treatment approaches in other countries must be reviewed for possible adoption.
- Diagnosis and treatment must be implemented under a primary health care approach, including community participation and the mobilization of barangay health workers and other community volunteers and groups.
- Malaria diagnostic and treatment services must be made available and accessible to all, especially vulnerable groups such as pregnant women, infants, indigenous peoples, and soldiers.
- Diagnostic and treatment services must be integrated with other health services across levels of care, and included in protocols of relevant programs in malaria-endemic areas.
- Effective implementation must be supported through information campaigns, adequate and timely arrival of drugs and supplies, training of health providers, and quality assurance.
- Adoption requires multi-sectoral collaboration among national DOH offices and attached agencies, other national government agencies, LGUs, and participation of the private sector and development partners/donor community.
Scope of application and covered entities
- The Order applies to all national, regional and local government offices, public and private health facilities, NGOs, development partners, and other stakeholders whose functions and activities contribute to prevention and control of malaria nationwide.
Definitions governing diagnosis and treatment
- Combination Therapy is defined as the combination of two schizontocidal drugs with independent modes of action and unrelated biochemical targets in the parasite, including:
- Artemisinin-based combination therapy (ACT): artemisinin derivatives combined with another schizontocidal drug.
- Quinine + AL or QN + doxycycline/tetracycline/clindamycin.
- Confirmed Malaria means malaria diagnosis confirmed by either:
- Microscopy: demonstration of parasites in a Giemsa-stained blood film, the gold standard, or
- Rapid Diagnostic Test (RDT): a rapid dipstick that has passed quality control, detecting parasite antigens in human blood and deployable in remote areas.
- Direct Observed Therapy (DOT) is daily intake of the prescribed antimalarial drugs supervised and observed by a health worker or treatment partner for the complete duration of treatment.
- Health Worker/Practitioner includes physicians, nurses, midwives, barangay health workers, and malaria microscopists trained in malaria diagnosis and treatment.
- Malaria Microscopists are Medical Technologists or barangay microscopists trained by DOH-MCP-RITM accredited malaria microscopy training programs or other WHO accredited centers.
- Malaria Treatment Failure is clinical deterioration or recurrence with asexual parasitaemia within 28 days post-treatment, after correct dosage of anti-malarial treatment, with or without symptoms.
- Severe Malaria is due to dysfunction of organ systems secondary to high parasitemia and untreated infection, sequestration of infected red blood cells, and anaemia, with clinical syndromes including coma, respiratory distress, severe anaemia, renal failure, disseminated intravascular coagulation, hypoglycemia, and metabolic acidosis.
- Uncomplicated Malaria is a febrile condition with any malaria species detected in a peripheral blood film and absence of severe disease and signs of multidrug-resistant P. falciparum, which may be accompanied by severe headaches and chills followed by a drenching sweat.
Diagnosis standards and treatment regimens
- Malaria diagnosis must be performed using:
- Microscopy as the gold standard where functional laboratories exist at all times, with maintained microscopy standards through a quality assurance system, and
- Rapid Diagnostic Test (RDT) kits that have passed quality control tests in these situations:
- when there is no microscopy center,
- when the client requires more than 2-hours travel to the nearest microscopy centers (such as inaccessible coastal or island areas),
- in areas where there are outbreaks, and
- in selected hospitals without a trained microscopist in an emergency situation.
- Artemether-Lumefantrine (AL) combination is the first line medicine for treatment of confirmed uncomplicated and severe Plasmodium falciparum, replacing CQ + SP combination.
- If AL is not available:
- Quinine (QN) must be used in combination with either tetracycline or doxycycline or clindamycin (QN + T/D/C x 7 days) as second-line treatment, whether the patient is conscious or unconscious, and in case of treatment failure.
- For severe malaria when the patient is unconscious and the facility lacks capacity to adequately manage the patient (e.g., no naso-gastric tube or intravenous therapy), Artesunate (AS) suppository must be introduced pending transfer to the next level of care.
- ACT can be used for all Plasmodium species and mixed infections.
- Anti-malarial drugs must be selected based on WHO pre-qualifications or Good Manufacturing Procedures (GMP) certifications.
Treatment mode, referral, drug and logistics obligations
- Direct Observed Therapy (DOT) must be adopted for all patients, and the first 3-day doses of AL must be supervised by a trained health worker, BHW, or treatment partner.
- Patients must receive immediate referral when necessary, with pre-referral treatment using appropriate anti-malarials administered by trained health workers, especially for:
- severe malaria cases, and
- patients who are pregnant and children below 5 years old.
- Competent health care providers must conduct diagnosis and treatment, and re-orientation and re-training must be conducted, especially in endemic areas.
- Adequate and quality drugs and other logistics must support diagnosis and treatment.
- The DOH shall provide national requirements of anti-malarial medicines, while laboratory supplies are a shared responsibility between DOH-Centers for Health Development (CHDs) and LGUs.
- Anti-malarial drugs must be made available to all public and private health facilities.
- Upon effectivity, remaining unexpired stocks of sulfadoxine-pyrimethamine (SP) must be used before shifting to AL.
- The compliance and adherence of all concerned entities to the revised policy and guide must be monitored on a regular basis.
Reporting systems and surveillance integration
- Malaria cases must be appropriately recorded and reported using the Philippine Malaria Information System (PhilMIS).
- Where PhilMIS has not been introduced or is not yet functional, the Field Health Service Information System (FHSIS) must be used.
- PhilMIS and FHSIS must be mainstreamed under Philippine Integrated Disease Surveillance and Response (PIDSR).
Roles and responsibilities by entity
- DOH-National Center for Disease Prevention and Control (NCDPC) leads management and execution of the revised policy and guidelines.
- CHDs must cascade and adapt the policies and general guidelines in their respective catchment provinces, cities, and municipalities.
- Professional societies, NGOs, and private sectors must be mobilized through formation of national, regional, and local coalitions to ensure malaria prevention and control nationally and in their assigned areas.
Department of Health at national level
- The DOH-NCDPC must disseminate the revised policy and advocate adoption among stakeholders.
- The DOH-NCDPC must coordinate installation/advocacy of essential management systems (including staff development program, logistics management, reporting system, quality assurance, and surveillance system).
- The DOH-NCDPC must conduct orientation and/or training of CHD officials and staff when necessary.
- The DOH-NCDPC must coordinate timely procurement and distribution of quality anti-malarial drugs based on an allocation list prepared by CHDs.
- The DOH-NCDPC must ensure quality assurance of diagnosis (microscopy and RDTs) and treatment with collaboration among BFAD, RITM, and WHO.
- The DOH-NCDPC must identify and select sentinel sites for therapeutic efficacy surveillance with CHDs and LGUs.
- The DOH-NCDPC must lobby and advocate for additional resources using the comprehensive financing strategy designed by the Health Policy Development and Planning Bureau.
- The DOH-NCDPC must review updated diagnostic and treatment guidelines as needed.
- The DOH-NCDPC must monitor CHD performance in ensuring compliance and adherence by LGU providers (public and private) to the revised policy and guidelines.
- The Procurement Division/Material Management Division must procure all anti-malarial commodities and ensure proper storage and timely distribution/delivery to end-users.
- The National Epidemiology Center (NEC) must provide accurate, timely, and complete data for policy decisions, strategic actions, and resource prioritization.
- The NEC must enhance/mainstream FHSIS and PhilMIS as the source for tracking malaria cases into PIDSR.
- PhilHealth must review, as necessary, a benefit package for malaria diagnosis and treatment for both in-patient and out-patient care based on actuarial feasibility.
Centers for Health Development (CHD)
- CHDs must disseminate and provide orientation/training to CHD staff on the revised policy and advocate adoption in their localities.
- CHDs must maintain quality assurance and internal control teams to ensure compliance with standards for confirmed malaria diagnosis.
- CHDs must ensure anti-malarial drug availability by facilitating distribution according to the allocation list, augmenting laboratory supplies, monitoring utilization quarterly, maintaining stock levels for outbreak/emergency situations, and maintaining Giemsa-stained preparation/production centers in strategically located areas.
- CHDs must mobilize additional resources to strengthen implementation.
- CHDs must formulate and implement advocacy plans to generate stakeholder support, particularly local officials.
- CHDs must ensure timely reporting and surveillance.
- CHDs must investigate adverse reactions to medicines and submit appropriate reports to the national office.
- CHDs must monitor implementation by public and private providers in their regions.
Local Government Units (LGUs)
- Provincial/City Health Office (P/CHO) must orient/train private and public health workers; advocate for adoption and implementation; provide counterpart funding; allocate anti-malarial drugs and laboratory supplies and monitor utilization.
- P/CHO must ensure proper storage and availability at dispensing facilities (accredited hospital pharmacies open 24/7) and require regular inventory of stocks.
- P/CHO must ensure systems for health human resource development, logistics management, reporting, surveillance, and other systems support efficient implementation.
- P/CHO must ensure quality assurance and control systems are in place for diagnosis and treatment.
- P/CHO must ensure weekly follow-up smears of positive cases in provincial and district hospitals, and where feasible for one month post-treatment or longer if necessary.
- P/CHO must investigate adverse reactions and report them to CHD and the regional BFAD.
- P/CHO must ensure timely reporting and surveillance and monitor implementation in public and private facilities, especially hospitals.
- Rural Health Units must implement the revised policy and guide; provide medicines for ADRS and report to the PHO; provide laboratory confirmation of diagnosis; perform weekly follow-up smears for one month post-treatment or longer if necessary; ensure proper storage and inventory; conduct training for midwives, BHWs, and volunteers with counterpart support; collect/analyze/submit reports using PhilMIS where applicable; implement information and education campaigns; and conduct and analyze client compliance surveys.
- Barangay Health Workers (BHWs)/Barangay Microscopists and Other Volunteers must conduct case finding and supervise treatment; directly observe intake of first-line anti-malarial medicines of positive cases; mobilize communities for personal protection measures and early diagnosis; report/refer adverse reactions immediately; perform weekly follow-up smears for one month post-treatment or longer if necessary; and submit updated reports regularly.
- Regional, Provincial and District Hospitals must provide services according to quality assurance protocols and guidelines and must make anti-malarial drugs available to private practitioners.
PhilMAM and other NGOs
- Philippine Movement Against Malaria (PhilMAM) and other collaborating NGOs must support implementation of the revised diagnostic and treatment policy and guide.
- Implementing partners must provide support in health service delivery when trained in diagnosis and treatment of malaria in partnership with LGUs or the community.
- Implementing partners must provide IEC message development and promote an enabling environment linking health systems with communities and increasing political support.
- Implementing partners must undertake social marketing strategies to increase participation of communities and LGUs in prevention and control of malaria.
- Implementing partners must assist in mobilizing resources for additional medicines and laboratory supplies.
Repeal and effectivity
- Administrative Order 19, s. 1996, AO 129 s. 2002, and all other inconsistent orders and related issuances are rescinded.
- The Order takes effect immediately (January 13, 2009).