Republic of the Philippines

Department of Health, Philippines

DEPARTMENT MEMORANDUM
NO. 2019- 0172

FOR: CENTER FOR HEALTH DEVELOPMENT DIRECTORS, CHIEF OF

HOSPITALS/ MEDICAL CENTERS/SANITARIA, COORDINATORS OF FOOD
AND WATERBORNE DISEASE PREVENTION AND CONTROL PROGRAM

SUBJECT : SUPPLEMENTAL GUIDELINES FOR THE IMPLEMENTATION OF

THE FOOD AND WATERBORNE DISEASE (FWBD) PROGRAM ORAL
REHYDRATION THERAPY (ORT) CORNER UTILIZING THE CLINICAL
PRACTICE GUIDELINES ON INFECTIOUS DIARRHEA

Department of Health, Philippnes

I. RATIONALE:

• The Food and Water Borne Disease( FWBD) Program is bringing back the Oral
Rehydration Therapy (ORT) Corner at the Rural Health Units ( RHUs)and other point-of-
care facilities for early management and treatment of diarrhea utilizing the FWBD Clinical
Practice Guidelines (CPG) on the hydration of patients with sign of diarrhea on an outside
patient basis.
• The restoration of ORT Corner intends to strengthen the health service delivery for prompt
response to diarrhea cases.
II. OBJECTIVES:
This Department Memorandum is issued to provide supplemental guidelines on the implementation of
Oral Rehydration Therapy ( ORT) Corners based on the FWBD-CPG.

III. SCOPE:
This issuance shall be applied to DOH Central Office, other relevant DOH Bureaus /Offices/ Units
and attached agencies , DOH CHDs and ARMM, health care facilities , health care providers,
medical societies and organizations, and all other institutions relevant for the nationwide
implementation of the FWBD Program.
 IV. GENERAL GUIDELINES
1. The FWBD- CPG shall be used as the primary guide for the hydration management of
diarrhea to be utilized by all health facilities.
2. Health facilities shall have a designated area or space, commodities and supplies for the
pre-implementation and implementation of ORT corners.
a. The ORT corner or a hydration area shall be placed primarily in public health
facilities , Outpatient Departments , Emergency rooms, Rural Health Units (RHU), school
clinics and other facilities with health providers that manage mild to moderate diarrhea.
b. A standardized capacity building program on the implementation of FWBD CPG and
the restoration of an ORT corner shall be provided to all health workers by the National
FWBD Program through the Centers for Health Development ( CHDs). This shall be
cascaded to the LGUs.
 c. CHDs shall provide capacity building , advocacy and health promotions while
Local Government Units shall allocate funds for the maintenance of the ORT corners
to include supply of ORS as a part of their regular service delivery.
d. All diarrhea cases ( Moderate to severe) that cannot be managed and treated
initially in the health facility shall be referred immediately to the nearest hospital for
further management. Other illness not related to diarrhea shall be treated
accordingly( e.g. cough, skin disease etc.)
e. Monitoring of ORT corner implementation shall be conducted at least once
every quarter utilizing FWBD Monitoring and Evaluation developed tool.
V. SPECIFIC GUIDELINES
1. DEHYDRATION ASSESSMENT
Clinical Parameters Indicative of Dehydration with Acute Infectious Diarrhea
1.1 In Children
1.Clinical findings indicative of dehydration include
abnormal Vital signs( tachycardia, tachypnea) depressed level of consciousness
depressed fontanels sunken eyes decreased or absent of
tears poor skin turgor prolonged capillary refill time
abnormal respiratory pattern decrease urine output
The parameters to assess the severity of dehydration in children are shown in Annex 1 (Annex 1.
Clinical manifestation of dehydration in children according to severity).
These parameters are unreliable for patients with severe malnutrition.
Use other parameters to distinguish malnutrition from dehydration.
1.2 In Adult
1.Clinical findings indicative of dehydration in adults include:
Fatigue lethargy
Thirst dry oral mucosa
Sunken eyes muscle weakness
Orthostatic hypotension poor skin turgor
Tachypnea prolonged capillary refill time
tachycardia cold and clammy skin

2.Laboratory parameters indicative of dehydration in adults include:

 Increased urine specific gravity( ≥1.010)
 Increase urine osmolality ( >800 mosm/kg)
 Increase serum osmolality (≥295 mosm/kg)
 Increased BUN/creatinine ratio( >20)
 metabolic acidosis ( (pH <7.35, HCO3<22 mmol/L
The clinical and laboratory parameters to assess the severity of dehydration in adults are in
Annexes 2 and 3.(Annex 2. Clinical manifestation of dehydration in adult according to
severity ;Annex 3.Other parameters used in assessing dehydration in adults)
3.Laboratory Parameters values ( see Annex 3) are appropriate for assessing severity of
dehydration if the patient has no fever.

4.Skin turgor is best assessed at the

 anterior forearm
 anterior thigh
 anterior chest
 subclavian area
 sternum

5. Capillary refill time should be assessed with the examiner ‘s middle finger at the same
level as the patients heart.
 2. DEHYDRATION MANAGEMENT
2.1 In Children
1. For Breast feeding infants, breast feeding shall be continued in addition to hydration therapy
2. Carbonated , sweetened , caffeinated and sports drinks are not recommended for fluid replacement
3.Check child from time to time during rehydration to ensure the ORS is being taken satisfactorily
and that signs of dehydration are not worsening. Evaluate child ‘s hydration status at least hourly
4. Recommended management according to level of dehydration is shown in Annex 4.
( Annex 4. Recommended management for children with acute infectious diarrhea according to
level of dehydration).
The Algorithm for fluid resuscitation is shown in Annex 2A and Annex 2B.
 2.2. In Adult
1. The recommended management for dehydration in adults is summarized in Annex 5.
( Annex 5. Recommended management for adults according to degree of dehydration)
2. Sports drinks and soda are NOT recommended to replace losses.
3. For calculations of maintenance fluid rate, it is suggested to use the actual or estimated body
weight. However , the ideal body weight should be used for overweight or obese patients.
4. Elderly patients and those at risk of fluid overload( patients with heart failure or kidney disease)
should be referred to a specialist for individualized fluid management.
 5. Recommendations for type of fluid:
5.1. PLRS, a chloride- restrictive IVF, is the fluid of choice for hydration and fluid resuscitation
of patients with diarrhea. If PLRS is not available plain normal saline solution may still be used.
5.2 During initial resuscitation , hourly monitoring of vital signs, mental status, peripheral
perfusion , and urine output must be done . The subsequent frequency of monitoring should be
based on the clinician’s judgement.
5.3 The routine use of albumin , hydroxyethyl starch (HES), dextran, or gelatin for fluid
resuscitation of dehydrated patients is not recommended.( Refer to Annex 6. Algorithm for initial
assessment of dehydration in adult patients)
NOTE: Patients with signs/ mild dehydration shall be initially assessed and managed initially with ORS
if tolerated . If after assessment , patient’s conditions has improved , he is advised to go home with
proper instructions.
However, patient condition does not improve , and does not respond to ORS, or condition worsens; the
patient should be referred to the nearest hospital for further management.
3. CRITERIA FOR ADMISSION
3.1. In Children
3.1.1. Children with acute infectious diarrhea who have any of the following signs and
symptoms should be admitted:
• Based on clinical history : unable to tolerate fluids , suspected electrolyte abnormalities ,
or conditions for safe follow up and home management are not met
• Based on physical findings: altered consciousness, abdominal distention , respiratory
distress , or hypothermia ( temperature <36 ◦C)
3.1.2. Children with acute infectious diarrhea who have any of the following co existing
medical conditions should be admitted:
• Co existing infections such as pneumonia meningitis /encephalitis or sepsis
• Moderate to severe malnutrition
• Suspected surgical condition
3.2. In Adult
3.2.1. Presence of any of the following clinical history and physical findings warrant admission
• Poor Tolerance
• Moderate to severe dehydration
• Acute kidney Injury
• Electrolyte Abnormalities
• Unstable comorbid conditions( e.g. uncontrolled diabetes, congestive heart failure, unstable coronary
artery disease, chronic kidney disease, chronic liver disease , immunocompromised conditions)
• Frail or elderly ( ≥60 years old) patients
• Poor nutritional status
• Patients with unique social circumstances ( living alone , residence far from a hospital)
VI. ORT CORNER OPERATIONAL GUIDELINES
A. Function of ORT Corner
1. Assessment & classification of children with diarrhea;
2. Oral rehydration therapy with ORS;
3. Administration of first dose of Zinc tablets ( 20mg or 10mg);
4. Administration of Vitamin A (200,000/100,000IU);
5. Counselling on continued diarrhea treatment of the child at home
B. COMPONENT OF AN ORT CORNER
1.Space Location
Health facility shall have designated area or space within main entry points
(e.g., OPD, ER, Ward) where patients with diarrhea disease are assessed
classified , treated and counselled.
2. ORT Corner Equipment , Commodities and Supplies
(Refer to Annex 7 ORT Corner Equipment , Commodities and supplies)
3. Information , Education and Communication Materials.
3.1 Flip chart on “Pagtatae”
3.2 Poster on “ Pagtatae”
3.3 ORT Corner Operational Guidelines
3.4 Clinical Practice Guidelines on Acute Infectious
Diarrhea Pocket Guide Booklet
4. Human Resource
1. Ensure availability of ORT Corner Commodities , supplies and data tools;
2. Collect, analyze and submit timely diarrhea disease data and facility reports;
3. promote diseases surveillance;
4. Maintain all the ORT corner equipment ;
5. Ensure correct sick child management
6. Counsel mother on when to return ( Danger signs);
7.Correct sick child management( Assess, Classify & Treat)
 8.Counsel on Home treatment:
8.1. Give extra fluids- ORS and recommended home fluids;
8.2 Give extra feeding during and after diarrhea , and extra exclusive breast feeding if
age , <6 months
8.3 Give Zinc tablets as per the HCWs instructions
8.4 When to return if no improvement( Danger Signs)
5. Monitoring and Evaluation Tools Checklist at Facility ( Annex 8 & 9)
1. The ORT Registration
2.ORT data summary sheet
3. Supervision checklist
4. Graphical display of monthly cases of diarrhea and classifications
5. ORT Corner guidelines & M &E document
6. Sick Child recording forms
7.Referral & counter referral forms
VI.ROLES AND RESPOSIBILITIES
1. Disease Prevention and Control Bureau( DPCB)
The DOH- DCPB through the Food and Waterborne Disease ( FWBD) Program shall oversee the
implementation of the policy and guidelines. They shall undertake the following tasks:
1.1 Oversee the distribution of ORT Corner Supplies through the CHDs;
1.2 Coordinate with EB for efficient data gathering and recording . Data analysis shall be jointly
done with EB; and
1.3 Monitor and evaluate the implementation together with the region, provincial /city/municipal
health offices and other concerned technical partners. Provide recommendations for immediate actions.
2. Environmental Related Disease Division ( ERDD)
Environmental Health shall focus on the prevention of diarrhea and containment of possible cholera
outbreak through provision of safe water , safe food , hygiene promotion, messages and
environmental sanitation activities.
2.1 Prevention
2.1.1. Provide technical assistance to the regions and LGUs to comply with the provisions and
requirements of the Sanitation Code in the Philippines;
2.1.2. Formulate policies , guidelines and standards in promoting increase access to safe water and
sanitation services;
2.2 Containment
2.2.1. Lead the case investigation and assessment together with the other member of the investigating
team when clustering is observed.
2.2.2 Submit an assessment / investigation report including recommendations to the local and
regional health facilities.
2.2.3. Implement control measures together with local officials and environmental health staff.
3. Epidemiology Bureau ( EB)
3.1. Use the data of the line list to enhance PIDSR especially on he diarrhea case definitions; and
3.2. Ensure the reporting of diarrhea cases and use of ORT from the implementers to the region
and national offices through the RESU.
4. Health Promotion and Communication Services
4.1. Develop Information , Education and Communication (IEC) materials on food and waterborne
disease appropriate to the situation.
4.2. Advocate to seek early consultation at health facilities and include messages to promote on the
use of ORT corner.
4.3. advocate for safe food preparation / handling , transport , storage and consumption.
5. Centers for Health and Development ( CHDs)
5.1. Disseminate the policy and guidelines of ORT corner implementation at the health facilities
and evacuations centers;
5.2.Orient the health workers on the use of ORT corner in partnership with the FWBD program
and EB;
5.3.Provide the needed supplies to the concerned health workers / implementers;
5.4. Ensure timely submission of the FWBD form listing on diarrhea/ cholera cases through the
RESU to EB;
5.5 Integrate the monitoring visits;
5.6. Coordinate with the provincial the Provincial /City / Municipal Health Office to:
5.6.1 Conduct orientation / training of concerned staff on the use of ORT corner;
5.6.2. Advocate with municipalities/cities to adopt and support the use of ORT corner;
5.6.3 Support the quality assurance system of ORT corner ;and
5.6.4. Provide timely report to the region using the PIDSR reporting system.
 5.6.5. Coordinate with the Rural Health nits to;
a. Implement the use of ORT corner for screening and early diagnoses of cholera
cases;
b. Ensure proper storage of ORT corner commodities to ensure longer shelf life;
and
c. Ensure timely submission of diarrhea cases using PIDSR reporting system
including ORT corner data.

For your guidance and strict compliance.

By the Authority of Secretary of Health

Myrna C. Cabotaje, MD, MPH, CESO III
Undersecretary of Health
Public Health Services Team
 ANNEX 1
CLINICAL MANIFESTATIONS OF DEHYDRATION IN CHILDREN
ACCORDING TO SEVERITY
Parameters No signs of dehydrations Mild to Moderate dehydration Severe dehydration

Fluid Deficit ( %body Infant < 5% 5-10% > 10%

weight)
Child 3% 6% 9%
Condition Well alert Restless, Irritable Lethargic, unconscious

Thirst Drinks normally, not Thirsty, drinks eagerly Drinks poorly, not able to drink
thirsty

Fontanel/ Eyes Normal Slightly depressed / slightly sunken Sunken

Tears Present Present or decreased No tears

Cutaneous Perfusion/Capillary Refill < 2 seconds Around 2 seconds >3 seconds

Time

Respiratory Normal Deep , may be rapid Deep and rapid

2mo-5yrs breath /min ≥50
>12mo-5yrs: breath/min ≥ 40
Skin Pinch Goes back quickly Goes back slowly Goes back very slowly

History of Urine Output Normal Decreased (<0.5 ml/kg/hr in 8hrs) Minimal ( <0.3ml/kg/hr in 16hrs) or
none ( no urine output in 12hrs)
( Reference : Philippine Clinical Practice
Guidelines on Acute Infectious Diarrhea
Pocket Guide Booklet, 2019)
 ANNEX 2B
CLINICAL MANIFESTATION OF DEHYDRATION IN ADULTS ACCORDING TO SEVERITY
PARAMETERS MILD MODERATE SEVERE DEHYDRATION
DEHYDRATION DEHYDRATION
Fatigue +/- + +
Thirst +/- + +
Sunken eyes - + +
Blood Pressure Normal Orthostatic hypotension Shock
Respiratory rate Normal 21-25 ≥25
(breath per minute)
Heart rate ≥80 ≥100 Faint or thread pulse
(beats per minute)
Peripheral circulation Warm extremities Cold clammy skin
Level of consciousness Alert Lethargic Coma or stupor
Oral mucosa Moist Dry
Muscle weakness None Mild to Moderate Severe
Skin Turgor ≤2 seconds > 2 seconds
Capillary refill time ≤2 seconds > 2 seconds
Urine output( ml/kg/hr) ≥0.5 < 0.5
• ( Reference : Philippine Clinical Practice Guidelines on Acute Infectious Diarrhea Pocket Guide Booklet, 2019)
 ANNEX 3
OTHER PARAMETERS USED IN ASSESSING DEHYDRATION IN ADULT
Parameters Mild Dehydration Moderate Dehydration Severe Dehydration
Body Weight Reduction of 3-5 %
Change Of body weight in ≤ 7 days or
Increase of 3-5% of body
weight in ≤ 7 days as an
indication that a person was Change of > 5 % of body weight
dehydrated before
rehydration

Urine Specific Gravity ≥ 1.010 ≥ 1.020

Urine Osmolality >800
(mosm/kg)
BUN/ Creatinine Ratio >20
Metabolic Acidosis
(pH <7.35, HCO3 - - +
<22 mmol/L

• ( Reference: Philippine Clinical Practice Guidelines on Acute Infectious Diarrhea Pocket Guide Booklet, 2019)
 ANNEX 4
RECOMMENDED MANAGEMENT FOR CHILDREN WITH ACUTE INFECTIOUS DIARRHEA ACCORDING TO LEVEL OF
DEHYDRATION

No dehydration Mild to Moderate dehydration Severe dehydration

Oral rehydration solution ( ORS) is Reduced osmolality ORS is Rapid intravenous rehydration
recommended to replace ongoing recommended to replace ongoing is recommended with plain
losses losses Lactated Ringer’s (LR) solution or
0.9 % Sodium Chloride ( with or
If commercial ORS is not If oral rehydration is not feasible without 5% glucose)
available , homemade ORS may be administration of ORS via
given ( 4-5 teaspoons of sugar and nasogastric tube is preferred over
1 teaspoon of salt in 1 liter of clean IV hydration
drinking water

( Reference : Philippine Clinical Practice Guidelines on Acute Infectious Diarrhea Pocket Guide Booklet, 2019)
 ANNEX 5
RECOMMENDED MANAGEMENT FOR ADULTS ACCORDING TO DEGREE OF DEHYDRATION

Oral rehydration solution is recommended at 1.5- 2 times the estimated amount of volume deficit plus
Mild dehydration concurrent gastrointestinal losses
Moderate dehydration 500 to 1,000 ml of plain Lactated Ringers solution ( PLRS) in the first 2 hours is recommended.

Once hemodynamically stable, give

• 2-3 ml/kg/hour PLRS for patients with actual or estimated body weight of < 50 kg
• 1.5-2 ml /kg/ hour PLRS for patients with actual or estimated body weight of > 50 kg.
• Use ideal body weight for overweight or obese patients

Replace ongoing losses volume per volume with PLRS boluses or ORS ( if tolerated).
Severe dehydration 1,000 to 2,000 ml of PLRS within the first hour is recommended

Once hemodynamically stable , give

• 2-3 ml/kg/hour PLRS for patients with actual or estimated body weight of < 50 kg
• 1.5-2ml/kg/hour PLRS for patient with actual or estimated body weight of > 50 kg
• Use ideal body weight for overweight or obese patients

Replace ongoing losses volume per volume with PLRS boluses. ORS is not recommended since patients with
severe dehydration may have compromised mental status and therefore have high risk for aspiration.

( Reference : Philippine Clinical Practice Guidelines on Acute Infectious Diarrhea Pocket Guide Booklet , 2019)
 ANNEX 6.
ALGORITHM FOR INITIAL ASSESSMENT OF DEHYDRATION IN ADULT PATIENTS

Initial Assessment

Does the patient have any 1 of the 4

Indicators necessitating fluid resuscitation

Proceed to Algorithm for

Fluid Resuscitation ( refer Can the patient meet his fluid
to Figure 1 and / or electrolyte needs enterally?

Outpatient management YES

(volume /volume replacement NO
with ORS)
Refer to Hospital for
further Management and treatment
( Reference : Philippine Clinical Practice Guidelines on Acute Infectious Diarrhea Pocket Guide Booklet, 2019)
 ANNEX 10
DEFINITION OF TERMS

1. Acute Diarrhea – is the passage of 3 or more loose , watery or bloody stools from an
immunocompetent person’s normal baseline in a 24 hour period, with a duration of less than 14
days. ( CPG, 2018)
2. Acute Gastroenteritis – The acute inflammation of the stomach and intestines associated with acute
diarrhea accompanied by other clinical features suggesting enteric involvement and may be caused
by chemical toxins, stress or infectious agent
3. Acute Infectious diarrhea – is suspected if a patient present with passage of 3 or more loose ,
watery or bloody stools within 24 hours that may be accompanied by any of the following
symptoms: nausea, vomiting, abdominal pain , and fever . ( CPG, 2018)
4. Capillary refill time – is time required for return of color after application of blanching pressure to
a distal capillary bed.
5. Dehydration – Loss of water and dissolved salts from the body, occurring for instance as a result of
diarrhea. ( WHO, 2006)
 ANNEX 10
DEFINITION OF TERMS

6. Diarrhea – three ( 3) episodes of loose watery stool per day

7. Homemade ORS – composed of 4-5 teaspoon of sugar and 1 teaspoon of salt in 1 liter of clean
drinking water
8. Oral Rehydration Salts – is a balanced glucose – electrolyte mixture used as a drug for the treatment
of clinical dehydration throughout the world . ( WHO, 2006)
9. Oral Rehydration Therapy – includes rehydration and maintenance fluids with oral rehydration
solutions (ORS) , combined with continued age appropriate nutrition . The administration of fluid by
mouth to prevent or correct the dehydration that is a consequence of diarrhea ( WHO, 2006)
10. Oral Rehydration Therapy Corner – are a well developed, low resource method to provide
rehydration on an outpatient basis in designated areas in health facilities staffed by health workers who
have been specially trained in diarrhea management. ( USAID, 2016)
11. Rehydration – the correction of dehydration
 ANNEX 9
MONITORING AND EVALUATION TOOL FOR FWBD PROGRAM REGIONAL COORDINATORS
Indicator Definition Target Remarks
% of health facilities A designated space in the health facility equipped 100% Proposed to be present in all
with functional with essential supplies ( e.g. Oresol , water health facility integrated with
ORT dispenser, cups, mixer and water) and used for other infectious disease ( e.g.,
corner managing client with diarrhea Dengue, leptospirosis)

% of health facilities Refer to the proportion of health facilities with at At least 1 staff trained Also proxy for determining the
with competent least 1 staff trained ( either a doctor , nurse, ( either a doctor, proportion of FWBD cases
staff trained midwife) on the FWBD CPGs and laboratory nurse, midwife) on given appropriate
on FWBD capacitation the FWBD CPGs management/treatment
CPGs

Mortality Number of people who died due to diarrhea among 25 % Age -. Cause- and case- specific
rate due to the total population over 100,000 population Reduction per year
Diarrhea

Morbidity Number of people who fell ill due to diarrhea 25 % Age- , cause- and case- specific
rate due to diarrhea among the total population over 100,000 population Reduction per year
 ANNEX 8
HEALTH FACILITY CHECKLIST ON ORT CORNER
 ANNEX 7
COMPONENT OF AN ART ORT CORNER
A. EQUIPMENT
Item Item
Bucket for storing cups and spoon Infection prevention bucket with lids
• A. EQUIPMENT (No. 3 disinfecting , 1st rinse, final rinse)
At least 2 clear plastic jugs- Calibrated At least 6 cups, 50ml= 100ml, 100-200ml
Calibrated
Comfortable chairs/bench/seats for client Hand washing facility with tap

At least spoons- teaspoons and stirring spoons Safe water source & storage containers ( at
least 40 liters- 2 No. 20 Liter Jerricans)
Weighing scale Table for mixing ORS
Timing device or wall clock Wash Basin
Waste Bucket Water Heating equipment
Local available demonstrative measuring
materials
 ANNEX 7
COMPONENT OF AN ART ORT CORNER
B. COMMODITIES
Item Item
Chlorine for disinfection Soap for handwashing
ORS Sachets Safe , clean water
Zinc Tablets,20mg Thermometer
Vitamin A ( 200,000; 100,000 IU caps) Diarrhea wall chart
Azithromycin, cotrimoxazole, Assessment forms and ORT Registers
Ciprofloxacin, Metronidazole,
Erythromycin, Doxycycline , and
Chloramphenicol for Dysentry, Amoeba and Cholera

CPG on Acute Infectious Diarrhea pocket guide booklet IEC posters for diarrhea disease
 ANNEX 7
COMPONENT OF AN ART ORT CORNER
C. SUPPLIES
Item/ Equipment checklist Minimum Quantity
Tea spoons 12
Table spoons 12
Stirring spoon 1
Small plastic cups ( 50- 100 ml & 100- 200 ml) 12
1 liter Calibrated measuring jars ( pitcher) 2
Table Trays 2
Wash Basins 2
Water heating equipment ( stove , water heater) 1
Waste Basket 1
Wall Clock 1
Table – for mixing ORS 1
Bencher/ chair(s) 6
Weighing scale 1
Hand Washing Facility/ Point 1
Safe water source 1
Maraming salamat po!