HEALTH Initial Report on Increasing Incidence of Diarrhea Cases in Barangay Culamdanum, Bataraza March 31, 2011 “Only when the last tree has died, the last river has been poisoned and the last fish has been caught, only then will man realize that money cannot be eaten” --- from a native Indian

1. HEALTH
“Only when the last tree has died,
the last river has been poisoned
and the last fish has been caught,
only then will man realize that money cannot be eaten”
--- from a native Indian
Skin lesions suffered by a kid from Sitio Tagdalongon, Brgy. Rio Tuba
Skin lesions suffered by a kid from Sitio Tagdalongon, Brgy. Rio Tuba

2. Skin lesions suffered by a kid from Sitio Tagdalongon, Brgy. Rio Tuba
Masamang Epekto sa Kalusugan
“Only when the last tree has died,
the last river has been poisoned
and the last fish has been caught,
only then will man realize that money cannot be eaten”
--- from a native Indian

3. Skin lesions suffered by a kid from Sitio Tagdalongon, Brgy. Rio Tuba
Skin lesions suffered by an adult from Sitio Tagdalongon, Brgy. Rio Tuba
“Only when the last tree has died,
the last river has been poisoned
and the last fish has been caught,
only then will man realize that money cannot be eaten”
--- from a native Indian

4. Initial Report on Increasing Incidence of Diarrhea Cases
in Barangay Culamdanum, Bataraza
On March 31, 2011, the Provincial Health Office received a report from Dr.
Mabutas, Municipal Health Officer of the Municipality of Bataraza, concerning deaths
due to diarrhea. Dr. Juan Mabutas asked for supply of ORS, IV fluid and antibiotics
which was immediately prepared and given to Ms. Emmy Asgali, nurse of Bataraza,
who was in Puerto Princesa attending the FHSIS Data Validation.
On April 3, 2011, an investigating team composed of Dr. Louie Ocampo, Ms.
Lorna Loor (Surveillance Officer), Mr. Arnold Flores (Sanitary Inspector) and Ms.
Jemadeth Cervancia (CHD Surveillance Officer) travelled to Bataraza to assist the Rural
Health Unit staff. Together with the RHU staff, the team went to Barangay Culandanum
where cases came from. The team arrived in Culandanum at 2 PM. A young adult male
was seen with moderate signs of dehydration, and was treated accordingly. The
Barangay Captain and the midwife assigned in the area were interviewed. They
reported that the most affected area was Apad-apad which is four hours (on foot) away
from the barangay health station of Culandanum. Since it was already past two PM, the
Barangay Captain suggested delaying the hike in the mountain of Apad-apad until the
next day for security reasons.
On April 4, 2011, the Sanitary Inspectors of PHO and MHO, a Medical
Technologist, and some residents of Barangay Culandanum headed by the Barangay
Captain hiked going to Apad-apad to collect water sample and check on the status of
the village where deaths were reported.
With the help from Riotuba Nickel Mining (RTN) group headed by Dr. Mia, a
camp was set-up in a school at Sitio Linao which is nearest to Apad-apad which would
serve as half-way treatment center. Initially, a 45-year-old male came in with severe
dehydration. IV fluids were immediately started. Then, another one female adult, and a
two-year-old male came in with signs of moderate dehydration, and they were managed
accordingly. One male infant with mild signs of dehydration was also seen and given
ORS treatment. Upon arrival of the group who went to Apad-apad, they have brought
with them another two patients (one elderly female and a 12-year-old male). Both of
them showed signs of severe dehydration, and fluid resuscitation was immediately
initiated. A male adult who survived the outbreak was also brought down by the group to
shed light on the events that happened to his family and tribe. At the end of the day, all
(5) patients were transferred to RTN Hospital for further evaluation and management.

5. Observations and Initial Findings:
1. The diarrhea outbreak is located in Barangay Culandanum mainly affecting the
village of indigenous people in Apad-apad.
2. Affected individuals are member of the Palaw-an indigenous people.
3. Patients manifested symptoms of profuse watery diarrhea, abdominal pain and
vomiting.
4. Fast progression of symptoms and rapid deterioration of patient’s condition from
the onset of initial symptoms to severe dehydration and sudden death.
5. Affected individuals sourced drinking water from a shallow-dug well beside a
stream.
6. A high suspicion of cholera and a contaminated water source
7. None of the affected individuals consulted a health provider and given any form
of treatment prior to demise.
8. None of the deaths was seen by a health provider.
9. Seven cases of diarrhea with varying degree of dehydration were seen during the
investigation (April 3-4, 2011). Six of them came from Apad-apad , and one from
Bato which is another sitio of Culandanum.
10. Fifteen deaths were reported and verified by the member of the tribe who
survived the outbreak.
11. Eleven out of 15 deaths (73%) are children less than 5 years old.
Name of Patients who Died on March 27, 2011 Sex/Age
1. Armina Gangan 24/F
2. Joselina Gangan 1/F
3. Esrade Enyong 4/M
4. Morsaden Enyong 2/F
5. Sijun Enyong 2/M
6. Kolab Enyong 3/M
7. Bedina Enyong 3/F
Name of Patients who Died on March 28, 2011
8. Norlito Kundong 3/M
9. Nolina Kundong 4/F
10. Toto Sibubo 15/M
11. Emban Das 50/F
Name of Patients who Died on March 30, 2011
12. Tulina Busnol 15/F
13. Nuasin Sipla 1/F
Name of Patients who Died on April 1, 2011
14. Nene Limabo 3/F
15. Toto Limabo 2/M

6. Actions Taken:
1. Coordination with involved agencies and the community.
2. Barangay assembly with local officials, RHU staff, and RTN group was
conducted.
3. Planning of activities and spot mapping were carried out.
4. Focused and culturally-appropriate information and education campaign was
initiated
5. Seven patients with varying degree of dehydration were seen and managed
accordingly. Five were transferred to RTN Hospital and two were sent home after
observation.
6. Water sample taken from the identified water source
7. Rectal swab and stool specimens were taken from patients for confirmation of
suspected cholera outbreak.
8. Water chlorination was instructed and demonstrated to the indigenous people
9. ORS, IV fluids, Hyposol, Aquatabs and antibiotics given to affected individuals
10. Mortality was verified and counter-checked from different sources
11. Barangay Captains forewarned of possible spread of infection particularly to
communities being supplied by the identified stream/river
12. RHU was advised to station a vaccinating team at least every month at Sitio
Linao which is more accessible to indigenous people than the health center in
Culadanum.
Plans:
1. The “survivor” together with local residents will go to the cave where the other
members of the tribe are now staying. He will persuade the affected ones to
come down at the treatment camp for proper care.
2. Continuous education of the captured patients.
3. The treatment camp will stay operational and serve these patients for another 1-2
days or until the outbreak is deemed controlled.
4. The PHO and CHD staff (Lorna, Arnold, Jemadeth) together with Dr. Mabutas
and RTN group will stay at the treatment camp until the outbreak is declared
controlled.
Recommendations:
1. Provision of safe water supply specifically for the indigenous people. A stream
was identified and suggested by the Barangay Captain as a possible source of
water. A system of pipes is to be installed to supply communities down the
stream.

7. 2. Institutionalize a health education program which is culturally-sensitive and
appropriate focusing on the indigenous people.
3. Encourage members of the indigenous people to engage in health activities of
RHU such as inviting them to be involved as BHW or BNS.
4. Proactive response of RHU in possible outbreaks particularly in the rainy
seasons. Heightening level of alert of all health personnel for rising cases of
diarrhea during rainy seasons to institute timely and appropriate response.
5. “Adopt-a-community” program to be implemented in areas where indigenous
people reside. This is to ascertain that an “adopter” RHU health personnel
ensures implementation of health programs in this community and monitoring of
diseases and possible outbreaks. The “adopter” will also serves a direct linkage
of the indigenous community to the RHU and other involved agencies.
Prepared by:
Louie R. Ocampo, MD, CFP, MPH
Chief
Division of Planning, Research, Monitoring and Surveillance

8. HEALTH EFFECTS OF NICKEL
by
y
Rebecca Green F.I.M.F.
Consultant to the Nickel Institute

9. FORMS TO BE CONSIDERED
• Ni metal dusts – usually insoluble
• Partially soluble Ni salts
y
nickel oxides, sulphides, carbonate
• Soluble Ni salts
nickel sulphate, nickel chloride
This presentation will mainly consider the health
effects of soluble nickel salts.

10. MOBILITY & EXCRETION
• Ni metal dusts • Little transport away from absorption site
• Excreted via faeces. May stay in body for
years
• NiO, NiS • Some transport away from absorption site
• Excreted via kidney & faeces. ½ life in
body 200 days
b d ~200 d
• NiSO4, NiCl2 • Transported around body to all organs
• Excreted via kidney after ~28hrs. May stay
in lungs for years

11. ACUTE & CHRONIC EXPOSURE
• Acute exposure usually
• One-off
• Relatively high dose
• Chronic exposure usually
• Over a long period of time – months or
y
years
• Relatively small dose, (though not
necessarily)

12. ROUTES OF EXPOSURE
• Inhalation – breathing in dust, fume & mists
g
• Ingestion (
g (oral) – by mouth
) y
• Dermal (skin/eyes) – skin or clothing
contamination

13. EFFECTS OF ACUTE Ni INHALATION
– death (Ni dust) after 90 min exposure
1 reported case
p
– asthma (fumes), an electroplater who later
( ), p
developed Ni dermatitis

14. EFFECTS OF CHRONIC Ni INHALATION
• Increased risk of cancer in
– lung, specially soluble species, >1mg/m3
– nasal, dust & partially soluble species
– stomach, 1 study of UK electroplaters
• Non-malignant lung damage (like “miner’s
lung”)
• Asthma
• Rhinitis & sinusitis
• Damage to septum of nose
• Loss of or reduced sense of smell

15. EFFECTS OF Ni INGESTION
• Acute
– Death, 2 yr old ingested 570mg Ni/Kg BW
– Nausea vomiting giddiness lassitude
Nausea, vomiting, giddiness, lassitude,
palpitations, headache, cough. Recovery
within 8 days.
y
• Chronic
– may provoke dermatitis in sensitised
individuals (e.g. diet high in Ni)
– no others reported in humans
p

16. EFFECTS OF SKIN EXPOSURE TO NICKEL
• Acute
– Eyes: conjunctivitis, floods of tears
– Skin: contact dermatitis.
To develop, skin must first be sensitised by contact Any
develop contact.
subsequent contact then results in dermatitis.
• Chronic
– Eyes: none reported in humans
– Skin: contact dermatitis
Little reported evidence of transport through
system for Ni absorbed through skin.

17. OTHER HEALTH EFFECTS OF Ni
ABSORPTION
• Immune System
– May over stimulate immune system
• Nervous System
– Symptoms reported in acute exposures
• G
Genetic Effects
ti Eff t
– Some evidence of genetic damage
• Reproduction, Embryotoxicity, Teratogenicity
– No reliable human data available

18. IN SUMMARY
Main effects of acute Ni absorption through:
Inhalation
– death (1case)
– asthma, irritation of upper respiratory tract
th i it ti f i t t t
Skin & Eyes
– conjunctivitis running eyes
conjunctivitis,
– dermatitis
Ingestion
g
– death (1case)
– vomiting, giddiness, palpitations, lassitude, cough

19. IN SUMMARY
Main effects of chronic Ni absorption
• Exposure by Inhalation
Risk significantly increased at levels >1mg/m3
(soluble) & 10mg/m3 (less/insoluble)
– increased risk of cancers
– long term damage to the respiratory tract
– asthma

20. IN SUMMARY
Main effects of chronic Ni absorption
p
• Exposure by Ingestion
– no long term effects reported
• Exposure through the Skin & Eyes
– Dermatitis (Ni itch)
– NiCl2 is more potent sensitiser than NiSO4

21. REFERENCES
• R. Von Burg, Journal of Applied Toxicology, vol 17(6), 425-
431(1997)
• International Programme on Chemical Safety, Environmental
Health Criteria 108, Nickel, World Health Organization Geneva,
1991
• Toxicological Profile for Ni, 2005, Dept. of Health & Human
Services, Atlanta, USA
• Priority Substances List Assessment Report, Nickel and its
Co pou ds, 99 ,
Compounds, 1994, Minister o Supp y a d Se ces, Ca ada
ste of Supply and Services, Canada
• Toxicological Profile and Related Health Issues (for Physicians),
2001, Regional Niagara Public Health Department, Canada