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

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

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

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.

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

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.

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

HEALTH EFFECTS OF NICKEL

byyRebecca Green F.I.M.F.

Consultant to the Nickel Institute

FORMS TO BE CONSIDERED

• Ni metal dusts – usually insoluble• Partially soluble Ni saltsy

nickel oxides, sulphides, carbonate• Soluble Ni salts

nickel sulphate, nickel chlorideThis presentation will mainly consider the healthThis presentation will mainly consider the health

effects of soluble nickel salts.

MOBILITY & EXCRETIONMOBILITY & EXCRETION

• Ni metal dusts • Little transport away from absorption siteNi 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

b d 200 d

• NiSO4, NiCl2

body ~200 days

• Transported around body to all organsNiSO4, NiCl2• Excreted via kidney after ~28hrs. May stay

in lungs for years

ACUTE & CHRONIC EXPOSURE

• Acute exposure usually• Acute exposure usually• One-off• Relatively high dose• Relatively high dose

• Chronic exposure usually• Chronic exposure usually• Over a long period of time – months or

yearsy• Relatively small dose, (though not

necessarily)

ROUTES OF EXPOSURE

• Inhalation – breathing in dust, fume & mistsg

• Ingestion (oral) – by mouthg ( ) y

• Dermal (skin/eyes) – skin or clothingDermal (skin/eyes) skin or clothing contamination

EFFECTS OF ACUTE Ni INHALATION

– death (Ni dust) after 90 min exposure1 reported casep

– asthma (fumes), an electroplater who later ( ), pdeveloped Ni dermatitis

EFFECTS OF CHRONIC Ni INHALATIONEFFECTS 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”)lung”)

• Asthma• Rhinitis & sinusitis• Rhinitis & sinusitis• Damage to septum of nose• Loss of or reduced sense of smell• Loss of or reduced sense of smell

EFFECTS OF Ni INGESTIONEFFECTS OF Ni INGESTION

• AcuteAcute– 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 sensitisedmay provoke dermatitis in sensitised

individuals (e.g. diet high in Ni)– no others reported in humansp

EFFECTS OF SKIN EXPOSURE TO NICKEL

• Acute– Eyes: conjunctivitis, floods of tears– Skin: contact dermatitis.To develop skin must first be sensitised by contact AnyTo develop, skin must first be sensitised by contact. Any

subsequent contact then results in dermatitis.• Chronic

Eyes: none reported in humans– Eyes: none reported in humans– Skin: contact dermatitisLittle reported evidence of transport throughLittle reported evidence of transport through

system for Ni absorbed through skin.

OTHER HEALTH EFFECTS OF Ni ABSORPTION

• Immune System• Immune System– May over stimulate immune system

Nervous System• Nervous System– Symptoms reported in acute exposures

G ti Eff t• Genetic Effects– Some evidence of genetic damage

• Reproduction, Embryotoxicity, Teratogenicity– No reliable human data available

IN SUMMARYIN SUMMARY

Main effects of acute Ni absorption through:Inhalation

– death (1case)th i it ti f i t t t– asthma, irritation of upper respiratory tract

Skin & Eyes– conjunctivitis running eyes– conjunctivitis, running eyes– dermatitis

Ingestiong– death (1case)– vomiting, giddiness, palpitations, lassitude, cough

IN SUMMARY

Main effects of chronic Ni absorptionMain effects of chronic Ni absorption• Exposure by Inhalation

Risk significantly increased at levels >1mg/m3Risk significantly increased at levels >1mg/m3 (soluble) & 10mg/m3 (less/insoluble)

– increased risk of cancersincreased risk of cancers– long term damage to the respiratory tract– asthmaasthma

IN SUMMARYIN SUMMARY

Main effects of chronic Ni absorptionp• Exposure by Ingestion

– no long term effects reportedno long term effects reported

• Exposure through the Skin & Eyes• Exposure through the Skin & Eyes– Dermatitis (Ni itch)

NiCl is more potent sensitiser than NiSO– NiCl2 is more potent sensitiser than NiSO4

REFERENCES

• R. Von Burg, Journal of Applied Toxicology, vol 17(6), 425-431(1997)

• International Programme on Chemical Safety, EnvironmentalInternational Programme on Chemical Safety, Environmental Health Criteria 108, Nickel, World Health Organization Geneva, 1991

• Toxicological Profile for Ni, 2005, Dept. of Health & HumanToxicological Profile for Ni, 2005, Dept. of Health & Human Services, Atlanta, USA

• Priority Substances List Assessment Report, Nickel and its Compounds, 1994, Minister of Supply and Services, CanadaCo pou ds, 99 , ste o Supp y a d Se ces, Ca ada

• Toxicological Profile and Related Health Issues (for Physicians), 2001, Regional Niagara Public Health Department, Canada